9- Lumbar II Flashcards
What pathology is typically presented as:
- LBP and leg pain below knee
- Hx of LBP that resolved
- Changes in reflexes, muscle weakness, and sensation (MRS)
- Numbness/tingling in specific dermatome
- Special tests such as SLR, WLR, and Braggard’s +
Disc lesion with radiculopathy
What tests can be used to assess for disc lesion with radiculopathy?
- SLR/Lasegue Test (Crossed, Well-Leg Raise/Fajersztajn, seated)
- Braggard’s sign
- Bowstring Test (Cram, Popliteal Pressure)
- Slump Test
- Femoral Nerve Traction Test (crossed)
Where is the pain located with an L3-4 disc herniation (4th lumbar nerve root)?
Lower back, hip, posterolateral thigh, anterior leg
Where is the numbness located with an L3-4 disc herniation (4th lumbar nerve root)?
Anteromedial thigh and knee
Where is the weakness with an L3-4 disc herniation (4th lumbar nerve root)?
quadriceps
Where is the atrophy with an L3-4 disc herniation (4th lumbar nerve root)?
quadriceps
Where is the reflex diminished with an L3-4 disc herniation (4th lumbar nerve root)?
knee jerk diminished
Where is the pain located with an L4-5 disc herniation (5th lumbar nerve root)?
over sacroiliac joint, hip, lateral thigh and leg
Where is the numbness located with an L4-5 disc herniation (5th lumbar nerve root)?
lateral leg, web of great toe
Where is the weakness with an L4-5 disc herniation (5th lumbar nerve root)?
dorsiflexion of great toe and foot, difficulty walking on heels, foot drop
Where is the atrophy with an L4-5 disc herniation (5th lumbar nerve root)?
Minor
Where is the reflex diminished with an L4-5 disc herniation (5th lumbar nerve root)?
changes uncommon (absent or diminished posterior tibial reflex)
Where is the pain located with an L5-S1 disc herniation (1st sacral nerve root)?
Over sacroiliac joint, hip, posterolateral thigh, and leg to heel
Where is the numbness with an L5-S1 disc herniation (1st sacral nerve root)?
back of calf, lateral heel, foot and toe
Where is the weakness with an L5-S1 disc herniation (1st sacral nerve root)?
plantar flexion of foot and great toe may be affected, difficulty walking on toes
Where is the atrophy with an L5-S1 disc herniation (1st sacral nerve root)?
gastrocnemius and soleus
Where is the reflex diminished with an L5-S1 disc herniation (1st sacral nerve root)?
ankle jerk diminished or absent
Where is the lumbar disc pain referral pattern?
L3/L4 and L4/5 on the front of the thigh, L4/5 and L5/S1 on the back of the thigh
Natural history of radiculopathy and disk herniation not quite as favorable as for simple LBP…………but still excellent with ~_____% of patients recovering in first 2 weeks and _____% recovering in 6 weeks.
50%
70%
How should lumbar disc herniations be managed?
McKenzie method and lumbar stabilization program with HEP
If centralization of pain occurs during a McKenzie exercise program, what does this mean?
good response to PT can be anticipated
What is the diagnosis for a patient that presents with:
- Patient usually presents with well-localized LBP with some hip/buttock or leg pain above knee
- Onset after simple misjudged movement or arising from flexed position
- Absence of neurological deficits and nerve root tension signs/tests
- AROM provokes pain (flexion/extension)
- Hypomobility with PPIVM and/or PPAIVM (spring testing)
Facet Syndrome or Z-Joint Dysfunction
What is the typical management for patients with facet syndrome or Z-joint dysfunction?
- mobilizations and/or SMT
- postural education
- correction of muscle imbalances
- core stabilization exercises
- medical approach may include injections
What age group is spinal stenosis common?
elderly > 65 yo
What is primary spinal stenosis?
Congenital Narrowing
What is secondary spinal stenosis caused by?
degeneration, fracture/trauma, post-operative, ankylosing spondylitis, tumors
What can degenerative secondary spinal stenosis be caused by?
- hypertrophy of articular processes
- disc degeneration
- ligamentum flavum
- hypertrophy
- spondylolisthesis
When do patients with spinal stenosis report pain occurs and relief occurs?
onset of leg pain with walking and relief after resting 20 min or by maintaining a flexed posture
What tests can be positive with neurological involvement in spinal stenosis?
Romberg, Urine incontinence, Inability to maintain extended or erect posture
What should happen to a spinal stenosis patient when extending?
Exacerbates pain
LSS can be diagnosed if a patient scores what on the scoring system?
7 +
LSS is likely not present if a patient scores what on the scoring system?
2 -
What are the predictor variables/ scoring system for LSS?
- age 60-70 or >70
- symptoms > 6 mo
- symptoms improve with flexion
- symptoms improve with extension ( -2)
- symptoms exacerbated while standing up
- intermittent claudication +
- urinary incontinence
How many patients have resolution of symptoms without intervention that have LSS?
many (about 30%)
What does PT management of LSS involve?
- therapeutic exercise
- postural education
- stretching
- core stabilization
- aerobic conditioning
What is Type I (dysplastic) spondylolisthesis caused by?
congenital abnormality in upper sacrum or neural arch of L5, allowing displacement
What is Type II (isthmic) spondylolisthesis caused by?
a lytic or fatigue fracture of pars, elongated but intact pars, or acute fracture of pars
What is Type III (degenerative) spondylolisthesis caused by?
secondary to degenerative arthrosis of z-joints or discovertebral articulation
What is Type IV (traumatic) spondylolisthesis caused by?
secondary to fractures in area of neural arch other than pars
What is Type V (pathologic) spondylolisthesis caused by?
in conjunction with bone disease (Paget’s disease, osteoporosis)
What is Type VI (iatrogenic) spondylolisthesis caused by?
occurs above or below a spinal fusion
What are the titles for Types I-VI for spondylolisthesis?
I dysplastic II isthmic III degenerative IV traumatic V pathologic VI iatrogenic
What are the two most common types of spondylolisthesis?
isthmic (younger) and degenerative (older)
What is the Meyerding Grading for spondyolisthesis?
Grade 0 (normal) Grade 1 (1-25%) Grade 2 (26-50%) Grade 3 (51-75%) Grade 4 (76-100%)
What are some subtle signs associated with grades 1 and 2 spondylolisthesis?
hamstring tightness, hyperlordosis, palpable step defect of SP
Which test can be used to indicated active spondylitic defect or facet syndrome?
Stork Test
How is the stork test done? what does it do physiologically?
- stand on one leg and extend
- extension compresses SPs and ilopsosas pulls anteriorly on vertebrae creating a shear force on the pars
What are some signs of a patient with grade 3 or greater spondylolisthesis?
symmetric transverse skin furrow and hyperlordosis along with anterior pelvic tilt… hamstring tightness may be significant
When should the spine be investigated to rule out spinal cord lesions or CES?
if hyperreflexic or UMN signs appears (clonus, Babinski, etc.)
Which muscles should be stretched in cases of spondylolisthesis? Why?
rectus femoris and iliopsoas to decrease anterior pelvic tilting
When are patients with spondylolisthesis reffered for surgical consult?
grades III and IV (segment unstable or nerve compression)
