clinical syndromes lumbar spine Flashcards
what is LBP?
low back pain is defined as pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or w/o leg pain
what is acute LBP?
-duration of an episode of low back pain persisting for less than 6 weeks
what is sub acute LBP?
-LBP persisting between 6-12 weeks
what is chronic LBP?
LBP persisting for 12+ weeks
describe the epidemiology and prevalence of LBP
-experienced at any age
-more prevalent in women
-increased prevalence with age up to 80 yrs
-highest number of LBP cases occurs at Aage 50-55 years
what is the most common presentation of LBP?
non specific low back pain
is recurrence likely?
yes - 70-80&
what does the global burden of disease state about LBP?
that is causes more global disability than any other condition
what are examples of non specific mechanical LBP risk factors?
-sedentary occupations
-work involving lifting, bending, awkward postures etc
-smoking
-obesity
-low socioeconomic status
-psychological factors
what are examples of physical causes of LBP- divided into trauma & degeneration and inflammatory?
- trauma and degeneration
-ligament spain
-muscle strain
-fracture
-spondylolysis
-spondyloisthesis
-facet joint athropathy
-spondylosis
-spinal stenosis - inflam
- ankylosing spondylitis
-RA
what are metabolic causes of LBP?
-pagets disease
-osteoporosis
-osteomalacia
what infections can cause LBP?
-TB
-pygenic osteitis of spine
-tumours
what are examples of mechanical causes of LBP?
-deep gluteal pain syndrome
-hypermobility
what are the common systemic arthritis disorders affect young people (less than 20 years)?
-juvenile arthritis
-septic arthritis
what are common arthitic disorders in middle aged (aged 20 +)?
-ankylosing spondylitis
-RA
-enteropathic arthropathies
-reiters syndrome
-psoriatic arthritis
what is the most common arthritic disorder affecting older pts (>55 years)?
- OA
what is an example of a masqueraders?
abdominal aortic aneurysm - can present with LBP
masqueraders= something that may present as LBP, but it actually something much more serious
if you think a red flag disorder is present, what do you do?
refer them to appropriate service for further investigation etc
what is a “specific” diagnosis according to the MSK clinical translation framework?
-a MSK disorder that refers to a disorder where pain and symptoms can be directly attributed to a biological process associated with the MSK system
-EG RA, stress fractures , tendon ruptures
how is LBP classified into systems?
-can be pathology / tissue based model
-it can be symptom base model eg LBP or LB and leg pain
-movement dysfunction model
define mechanical LBP
Mechanical low back pain is the most common type of LBP, characterized by pain that varies with physical activity and position. It typically originates from the spine’s mechanical structures, such as muscles, ligaments, intervertebral discs, or facet joints
-more often comes with muscle + muscle imbalance
what are examples of some muscles in the neck and back that can be overactive?
SCM
-pectoralis
-upper trapezius
-rectus femurs and iliopsoas
-thoraco-lumbar extensors
what can postural type of the patient help identify?
muscle imbalances and weakness
what does lordotic mean?
increased lumbar lordosis
anterior pelvic tilt
hyperextended knees
what can be weak and elongated with lordotic postures?
- anterior abdominals
-hamstrings can be elongated initially
what can be short and overactive for lordotic postures?
-low back musculature
-hip flexors
what are kypho-lordotic postures?
-increased lumbar lordosis and thoracic kyphosis
-pelvis is anteriorly tilted and most forward bodily placed segment
what can be weak and elongated vs short and overactive in kyphosis lordotic postures?
elongated and weak
- neck flexors
-external oblique
-upper erector spinae
short and overactive
-hip flexors
-sub-occipital neck extensors
what is sway back posture?
-long kyphosis with pelvis most anterior body segment and flat low lumbar area
-hip joint moves anterior
-pelvis neutral and hips and knees are hyperextended
what are examples of elongated and weak muscles with swag back posture?
-external oblique muscles
-thoracic extensors
-neck flexors
-hip flexors
what is a flat back?
loss of lordosis with pelvis in posterior tilt
what muscles are elongated and weak for flat back posture?
single joint hip flexors
what muscles are short and overactive with flat back posture?
-hams
-maybe abdominals
what is acute locked back?
sudden and severe inability to move the spine, often due to muscle spasm, joint dysfunction, or disc-related issues
what is the clinical pattern of acute locked back?
-sudden onset- sudden movement, may or may not have click
-patient is stuck in flexion
-all movements bring pain and could be spasm
-there can be a spontaneous recovery 1-2 weeks
what can cause acute locked back?
-disc injury / prolapse
-meniscoid entrapment in facet joint
describe the pathology of discogenic LBP
stage 1: protrusion: annular fibrosis tear
stage 2: prolapse- nucleus escapes further into the annulus and the AF protrudes
stage 3: escape - nucleus escapes beyond the AF completely
stage 4: sequestration - nucleus has exited the disc and has travelled somewhere - serious! but rare
describe the clinical pattern with discogenic LBP
-5% of all LBP - 90% of radicular pain
-age 30-55 years
-more common in males
-work hx: prolonged lumbar flexion or sitting at desk etc or sometimes a macrotrama
-most commonly affects L4/5 or L5/S1
-most often resolves in 6-8 weeks
-central or unilateral LBP / leg pain
-WB compression is painful
-loss of lordosis due to spasm
-lumbar flexion most limited
does discogenic LBP reoccur?
yes
what can happen with lumbar flex and ext with discogenic pain?
-flexion may peripheralise pain (ie into the legs)
-extension may centralise the pain - ie in the back
are PAIVMS provocative for discogenic LBP?
yes
what happens with nociception with a person who’s disc injury is stimulated?
pain can spread from back- thigh - lower leg
referred pain vs radiculopathy
radiculopathy
causes: compression or irritation of spinal nerve eg herniated disc or spinal stenosis
symptoms: numbness, P+N’s, weakness, sharp shooting pain that follows nerve root
pain pattern: radiates along a nerve pathway eg LB- down back of leg etc
neurological signs: may include reflexes, muscle weakness & sensory changes along the nerve root
Referred pain
cause: pain from a structure eg muscle, joint etc that is perceived in a different location due to shared neural pathways
symptoms: deep aching pain with no p+n’s, numbness etc
pain pattern: more diffuse (doesn’t follow a dermatomal pattern)
neuro: no change with reflexes etc
eg shoulder pain from a rotator cuff issue can be felt in the upper arm
what are examples of contributory factors to discogenic LBP?
-fam hx
-macro-overload - twist or sudden high loading in flexion
-microoverload - repetitive lifting, bending twisting etc
-occupation - manual work - nursing, construction etc
what is a radiculopathy?
back and leg pain due to compression / irritation to nerve root
- may also have pins and needles or numbness
-burning or shooting pain
what can cause a radiculopathy?
-prolapsed IV disc
-foraminal stenosis eg degeneration, tumours, osteophytes
-epidural disorders eg infections
meningeal disorders - cyst of nerve root sleeve
what would you expect with L3-L4 radiculopathy?
-weak quads and tip ant
-patellar jerk reflex
-sensory loss in medial knee and shin
-pain and anterior thigh
what would you expect in neuro exam of L4-5 radiculopathy?
-EHL weakness
-1st toe sensory loss
-pain in posterior thigh and lateral calf
what would you expect in a neuro exam with a L5-S1 radiculopathy?
– weak gastrocs
- achilles reflex
-pain in back of thigh and calf
