Approach to Thoracolumbar Complaint Flashcards
Spina Bifida
- birth defect that occurs when the spine and spinal cord don’t form properly
- type of neural tube defect
Spina Bifida: Etiology/Risk Factors
- Family Hx of neural tube defects
- Folate deficiency
- DM
- Increased body temperature
- Obesity
- Medications
Meningo
refers to the lining of the vertebral canal
Myelo
refers to the spinal cord itself
Cele
means something is bulging out
Spina Bifida Occulta
- “occulta” means hidden
- most common type
- small gap in one or more vertebrae
- generally asymptomatic
Meningocele
- sac of fluid comes through an opening in the babys back
- small gap in the spine, but no opening or sac on the back
- spinal cord and the nerves usually are normal
Myelomeningocele
- most severe type
- spinal canal is open along several vertebrae in the lower or middle back
- membranes and spinal nerves push through this opening at birth, forming a sac on the babys back, typically exposing tissues and nerves
- baby prone to life-threatening infections and may cause paralysis and bladder and bowel dysfunction
Scoliosis
- lateral curve of the spine greater than 10 degrees with vertebral rotation
- majority of cases are idiopathic
- females are 5-10x more likely to progress to severe disease
- if both parents have this then kids are 50xs more likely to require treatment than general population
What is the most common form of scoliosis?
Adolescent Idiopathic Scoliosis
Signs of Scoliosis
- shoulder height difference
- posterior scapula
- crease/skin fold at waist
- leg lengths typically unequal
Special Test for Scoliosis
Adams Forward Bend Test
(+ test = spinal rotation and rib hump)
Scoliometer
- used to quantify the spinal curve and rotation
- used to determine who needs radiography
Cobb Angle
- necessary for dx of scoliosis
- angle between the most tilted vertebra above the apex and the most tilted vertebra below the apex
- angle is greater than or equal to 10 degrees
Scoliosis Red Flags
- onset before age 8
- severe pain
- rapid curve progression >1 degree per month
- unusual left thoracic curve (convex to the left)
- neurological deficits or findings (midline hairy patch = spina bifida)
Short Leg Syndrome
- discrepancy in leg lengths resulting in chronic leg and back pain
- tends to tilt the pelvis down on one side placing abnormal stress on the muscles and spine
- two types: anatomical, functional
Anatomical Short Leg
when one leg is longer and can be corrected with a heel lieft in the shoe of the short leg
Functional Short Leg
an apparent short leg although structurally both legs are the same length when measured
Compression Fractures
- type of fracture or break in your vertebrae
- can cause the vertebrae to collapse, making them shorter in height
- collapse can also cause pieces of bone to press on the spinal cord and nerves, decreasing the amount of blood and oxygen that gets to spinal cord
What population are compression fractures most common in?
Elderly females
What is the most common cause of compression fractures?
Osteoporosis
Low Back Pain
- highest prevalence in 45-64 YO age group
- 95% recovery in 12 weeks
- majority of pain is mechanical
- fifth most common reason for all physician visits
Acute Low Back Pain
- one of the most common reasons for adults to see a physician
- pain is often self-limited and resolves with little intervention
- defined as 6-12 weeks of pain between the costal angles and gluteal folds that may radiate down one or both legs (sciatica)
- often nonspecific and therefore cannot be attributed to a definite cause
Lumbosacral Strains
- injury to either a muscle or tendon
- caused by twisting or pulling a muscle or tendon, also could be caused by a single instance of improper lifting
- chronic strains usually result from overuse after prolonged, repetitive movement of the muscles and tendons
Lumbosacral Sprains
- stretching or tearing of a ligament
- typically occurs after a fall or sudden twist, or blow to the body that forces the joint out of its normal position
Ligament injuries lead to:
Degenerative Arthritis
How does Osteoarthritis typically begin?
Ligament weakness
Wolfs Law
bones respond to stress by making new bone
Osteoarthritis
- age-related degeneration of the spine due to encroachment on the spinal canal with potential for radiculopathy and myelopathy
- often related to formation of OA growths on the bone (osteophytes)
- Presentation: pain, stiffness, occasional numbness
Spondylolysis
- defect in par interarticularis (often unilateral) w/o anterior displacement of the vertebral body
- can lead to small stress fxs in the vertebrae that can weaken the bones so much that one slips out of place – spondylolisthesis
- very common cause of low back pain in children and people under 26 years of age
- pain typically spreads across lower back and might feel like muscle strain, worse with vigorous activity and with spine extension
How is Spondylolysis diagnosed?
“Collar of Scotty Dog”
- dx made with oblique view of lumbar spine
- fx of par interarticularis is described as “Collar of Scotty Dog” usually at L5/S1
Spondylolisthesis
- vertebral body slips in relation to the one below at pars interarticularis (usually between L5/S1)
- bone may press on nerve and cause pain
- most common cause of back pain in teens
- sxs often begin during the teen-age growth spurt
- if slipped vertebrae is pressing on nerve, will have pain/numbness spreading down leg to the foot which is often worse when standing
- usually the leg pain is worse than the back pain
- pain improves with rest or when spine is flexed
How is Spondylolisthesis diagnosed?
On palpation of lumbar spinous process there is a “Step Off” sign
Ankylosing Spondylitis
ossification of the annulus fibrosus in the lumbar spine resulting in the formation of marginal syndesmophytes in a gradually ascending pattern (“bamboo spine”)
Spinal Stenosis
- narrowing of the spaces within your spine
- can put pressure on nerves
- most often in lower back and neck
Degenerative Lumbar Stenosis is common in:
Elderly adults (esp adults over 50 years old)
Neurogenic Claudication
- combination of low back pain, numbness, and motor weakness that starts or intensifies on standing or walking and is eased by sitting or lying down
- common in patients with lumbar spinal stenosis
Spinal Stenosis: Clinical Presentation
- low back pain
- difficult walking
- changes in urinary functions
- root sxs such as numbness, burning and feeling of heaviness in legs
Progression of Disc Degeneration and Herniated Disc
(1) Primary ligament weakness
(2) Deteriorating disc
(3) Outside edges of disc become cracked and torn
(4) High pressure scenarios can cause disc center to leak out
(5) Leads to decreased disc height
(6) Causes ligaments to become weakened
(7) Joint becomes more unstable and more likely to herniate
Spinal Disc Disease
- progressive degeneration of the spinal discs in conjunction with osteophyte formation; disc changes result in disc space narrowing and bulging or herniation of the degenerative nuclear contents
- most common in individuals ages 70+
- has similar sxs as an acute herniation but a chronic onset
Herniated Disc (Nucleus Pulposus)
- fragment of the disc nucleus is pushed out of the annulus into the spinal canal through a tear or rupture in the annulus
- discs that this happens to are typically in an early stage of degeneration
Herniated Disc: Clinical Presentation
- arm or leg pain, numbness or tingling, weakness
- pain originating from lumbar spine that radiates down the leg into the foot
- sharp burning pain - electric quality
- weakness in affected myotome (decreased reflexes)
Referred Pain: Spine Structures (muscles, ligaments, facets, discs)
refer pain to the thigh region, but rarely below the knee
Referred Pain: Sacroiliac Joint
refers pain to the thigh but can also radiate below the knee
Referred Pain: Lumbar Root (irritation, impingement, compression)
- pain results in more leg pain than back pain
- L1-L3 nerve roots
- L4-S1 nerve roots
L1-L3 Nerve Root Impingement/Compression
Pain radiates to the hip and/or thigh
L4-S1 Nerve Root Impingement/Compression
Pain radiates below the knee
Herniation at L4/L5:
L5 nerve root impinged
Herniation at L5/S1:
S1 nerve root impingement
L4
Patellar Reflex
L5
great toe sensation, heel walk
S1
Achilles reflex, toe walk
Sciatica
- symptom
- pain emerging from the lower back that is felt along the distribution of the sciatic nerve in the LE
- frequently attributed to disc herniation
- # 1 reason of this is ligamentous laxity in SI joint
Sacroiliitis
- inflammation of one or both of your SI joints
- Sxs: pain in butt or low back that can radiate down both legs, prolonged standing or stair climbing worsens the pain
What test is used to dx Sacroiliitis?
FABER test – (+) = buttock pain
Piriformis Syndrome
injury to piriformis causes inflammation leading to swelling and pressure on sciatic nerve causing pain and referred pain
Hoover Test
- used to differentiate between leg paresis that has no definitive neurological pathology to that which has a definite, identifiable cause
- identifies functional weakness in LEs
Red Flag Sxs in Back Pain
TUNA FISH
- Trauma
- Unexplained weight loss
- Neurologic sxs
- Age >50
- Fever
- IVDU
- Steroid use
- Hx of cancer (prostate, renal, breast, lung)
Cauda Equina Syndrome
- large central disc herniation compressing the tail of the lumbar spine, causing compression of sacral nerve roots
- signs and sxs: pain similar to herniated disc (low back pain) that radiates down leg, numbness around the anus, loss of bowel or bladder control
- impingement of S2-4
**emergency surgery is imperative to avoid paralysis
Impingement of S2-4 causes:
- bowel dysfunction (decreased rectal tone)
- bladder dysfunction
- sexual dysfunction
- saddle anesthesia
When to Image for Low Back Pain:
Don’t do imaging within the first 6 weeks UNLESS red flags are present
FAIR Test
- Flexion, ADduction, Internal Rotation
- Indication: Piriformis Syndrome
- (+) Test = pain produced in sciatic/gluteal region
Thomas Test
- Indication: Hip flexor (iliopsoas) contraction
- (+) Test = inability to fully extend leg OR the other leg raises off the table
FABER Test
- Flexion, ABduction, External Rotation
- Indication: intra articular disorders, labral tear, sacroiliitis, bursitis, OA
- (+) Test = groin/anterior hip pain: iliopsoas bursitis, labral tear, OA; posterior hip pain: sacroiliitis
Positive Straight Leg Test
- Pain over lateral leg at 15-30 degrees: IT band contracture
- Neurologic pain between 30-60 degrees: lumbar disc herniation at L4-S1 nerve roots, lumbosacral radiculopathy, sciatic neuropathy
- Pain at >70 degrees: mechanical low back pain due to muscle strain or joint disease, pathology of hip or SI joints, tightness of hamstrings or gluteus maximus
Adam’s Forward Bend Test
- Indication: scoliosis
- (+) Test = functional: resolution of rib hump with sidebending; structural: persistence of rib hump with sidebending
- REMEMBER angle of trunk rotation (ATR) >7 degrees and Cobb Angle >10 degrees
Malingering (Factitious Disorder)
- patient misrepresents, stimulates or causes sxs of an illness even in absence of clear external reward
- can occur in Hoovers Test when patient isnt trying to lift the weak leg so feel absence of pressure in heel of good leg
3 Types of Posterior Lumbar Tender Points:
(1) PL 1-5 Spinous Process
(2) PL 1-5 Transverse Process
(3) Unique
Pelvic rotates ___ of spine
Opposite
OMT: PL 1-5 SP
- Torso: e-E Adduction RA (rotate away)
- Pelvis: e-E Adduction RT (rotate towards)
OMT: PL 1-5 TP
- Torso: E Sa RA
- Pelvis: E Sa RT
Muscle that shortens during treatment of PL 1-5 SP
Multifidus
Muscle that shortens during treatment of PL 1-5 TP
Intertransversarii
Upper Pole L5
- Location: superior medial surface of PSIS
- Treatment: E Add IR/ER
- Muscle shortened: iliolumbar ligament
Lower Pole L5
- Location: ilium just inferior to PSOS pressing superiorly
- Treatment: F Add IR
- Muscle shortened: posterior sacroiliac ligament
High Ilium Sacroiliac (HISI)
- Location: 2-3cm lateral to PSIS pressing medially towards PSIS
- Treatment: e-E Abd ER
- Muscle shortened: glut max
PL3 GLUT
- Location: 2/3 lateral from PSIS to tensor fascia latae
- Treatment: E Abd ER
PL4 GLUT
- Location: posterior margin of tensor fascia latae
- Treatment: E Abd ER
OMT: Psoas Major
F ST
OMT: Piriformis
F Abd ER
