chapter 25- Dorsal and lumbar spine and backpain Flashcards
Spinal problems commonly present with..
- Axial pain or stiffness
- Neurological symptoms- leg pain (sciatica), weakness or sensory disturbance
- Deformity (kyphosis, scoliosis, lordosis)
What systemic symptoms should you ask about if patient presents with lower back pain
- Cough, dyspnoea, haemoptysis
- Appetite, abdominal pain, bowels
- Urine retention, dysuria, frequency, nocturia
- Gynae: periods/ dyspareunia
- Loss of weight
MacNab’s classification of back pain?
- Viscerogenic: peptic ulcers, gall bladder, pamcreas, renal disease, pelvic inflammatory disease
- Vasculogenic
- spondyogenic
- Neurogenic
- Psychogenic
Classification of spondyogenic low back pain (originating in the spine)
- Traumatic - Fracture
- Inflammatory- tuberculosis or pyogenic osteomyelitis
- Degenerative- degenerative disk disease with or without herniation, spondylolisthesis
- Metabolic- osteoporosis or osteomalacia may cause back pain with out without fracture
- Neoplastic: beneign or malignant
Common site of degenerative spondylolisthesis
- due to facet degeneration and typically at L4/L5
What is the site of lytic listhesis
- between superior and inferior articular facets, often occuring at the L5/S1 level
Management of spondylothesis
General lumbar rehabilitation including weight loss and strenthening of the abdominal musculature and improvement of general fitness
if conservative measures fail and disability is significant, spinal fusion may be undertaken.
Radiograph findings in pyogenic spondylodiscitis
- disk space narrowing with erosions of adjacent end-plates, areas of sclerosis and bony destruction, vertebral body collapse and kyphosis in advanced disease
commonest organism causing pyogenic spondylodiscitis
S. Aureus
Treatment of pyogenic spondylodiscitis
Iv antibiotics–> oral for 6 weeks
Surgery is large abcess and especially when associated with neurological compromise
Factors that contribute to hyperextension of the spine
- extrinsic loading
- intrinsic loading
- weak abdominal muscles
- Fixed flexion of the hips
- high heels
Features of mechanical back pain
- back worse than legs- usually not below the knees
- aggravated by activity
- Relieved by rest
- Relieved by flexion of the lumbar spine
- No peripheral weakness or altered sensation
Common levels of disk herniation
- L4 and L5
- L5 and S1
Clinical features of neurogenic backache
- Legs may be worse than back
- relieved by moving about
- not relieved by rest
- pain on flexion of lumbar spine
- Distal:root tension: SLR and bowstring; femoral stretch test
- Root compression: neurological deficit
Neurological findings with L 3-4 herniation
Root involved: L4 Motor weakness: quads Sensory loss: medial calf Reflex lost: knee jerk Positive stretch test: femoral stretch test
Neuro findings with L4-5 herniation
Root involved: L5
Motor weakness: foot and ankle dorsiflexion
Sensory loss: lateral calf and dorsal 1st web space
Reflex lost: medial hamstring jerk
Positive stretch test: straight leg raising test and bowstring test
Neuro findings with L5- S1 herniation
Root involved: S1
Motor weakness: Foot and ankle plantar flexion
Sensory loss: lateral border of foot especially lateral malleolus
Reflex lost: ankle jerk
Positive stretch test: straight leg raising test and bowstring test
what may aggravate sciatica
coughing, sneezing or straining
when to refer acute lumbar pain and sciatica
- bladder or bowel dysfunction
- marked muscle weakness
- Progressive neurological degeneration
- failure to respond to acute phase of management
- Recurrent attacks of sciatica despite good long term maintenance therapy
management of acute lumbar pain and sciatica
- rest
- medication: NSAIDS and analgesia
- Surgery
what does post op management for disc herniation entail?
Physiotherapy for:
- Maintenance exercises in the immediate post op phase
- re educatin of activities of daily living
- strengthening of abdominal muscles
- Stretching exercises of all limb and trunk muscles
- improve general fitness
Treatment of recurrent and chronic back ache
- abdominal muscle exercises
- Activities of daily living- evaluate, modify and/or avoid
- General fitness
- education
- temporary financial aid
- surgery (fusion)
red flags for lower back pain
-age: < 20 or > 55
-violent trauma
-Constant, progressive, non-mechanical pain
-Thoracic pain
History of previous cancer
-Steroids
-systemically unwell
-Weight loss
-persisting severe restriction of lumbar flexion
-Widespread neurological signs and symptoms
-Structural deformity
