clinical syndromes - lumbar spine Flashcards
define LBP
pain and discomfort localised below the costal margin and above the inferior gluteal folds +/- leg pain.
acute <6 weeks
sub acute 6-12 weeks
chronic 12 weeks or more
LBP risk factors
LBP Risk Factors Sedentary occupations, Work involving lifting, bending, awkward postures & physically demanding, Smoking, Obesity, Low levels of PA, Low socioeconomic status Psychological factors
possible causes LBP
physical
Trauma & Degeneration #, ligt sprain, muscular strain Spondylolysis Spondylolisthesis, Ankylosing vertebral hyperostosis Scheuermann’s disease Facet Jt arthrosis Spondylosis Spinal Stenosis PIVD Inflammatory Ankylosing Spondylitis Rheumatoid Arthritis
metabolic
Paget’s disease
OP
osteomalacia
Infections TB Pyogenic Osteitis of spine Tumours Postural LBP Piriformis Syndrome Hypermobility Masqueraders E.g. Vascular lesions - AAA
classification systems
Pathology / tissue based model e.g. Maitland
Can a pathoanatomic diagnosis be made for LBP?
Symptom based model e.g. LBP vs. LB + leg pain vs. leg pain only. Acute vs. Chronic LBP
Movement dysfunction model e.g. O’Sullivan, Sahrmann
Used by physios primarily
Risk Stratification model e.g. Keele Startback algorithm
postural LBP
somatic pain - muscles joints
muscle imbalance
weak muscles lower stabilisers of scapulae lumbosacral erector spine gluteus maximus
tight muscles
cervical erector spinae
upper traps
levator scap
thoracolumbar
erector spinae
hamstrings
postural types
Swayback Hyper-lordotic / Kypho-lordotic Flatback Kyphosis not Dowager’s hump Flat upper back FHP – forward head posture Scoliosis
lordotic
increased lumbar lordosis, anterior pelvic tilt & hyperextended knees.
ELONGATED & WEAK:
Anterior abdominals
Hamstrings may lengthen initially BUT may eventually shorten to compensate where posture is longstanding
SHORT & OVERACTIVE:
Low back musculature
Hip flexors
kyphosis lordotic
increased lumbar lordosis and thoracic kyphosis. Pelvis anteriorly tilted & most forwardly placed body segment.
ELONGATED & WEAK:
Neck flexors
Upper erector spinae
External Oblique
SHORT & OVERACTIVE:
Sub-occipital neck extensors
Hip flexors
sway back
= long kyphosis with pelvis most anterior body segment & flat low lumbar area. Hip joint moves anterior. Pelvis neutral & Hips & knees hyperextended.
ELONGATED & WEAK: Single joint hip flexors External Oblique Thoracic extensors Neck flexors
SHORT & OVERACTIVE:
Low back musculature short but not strong
flat back
loss of lordosis with pelvis in posterior tilt.
ELONGATED & WEAK:
Single joint hip flexors
SHORT & OVERACTIVE:
Hams
Maybe abdominals
acute locked back
sudden onset often on return flexed position \+/- pain pt stuck in flexion all movements pain + regional spasm meniscoid entrapment in facet joint / subluxation acute disc prolapse natural history : spontaneous recovery.
disc pathology
stage 1 protrusion
circumferential annular tearing - posterolateral radial fissure produced
stage 2 prolapse - nucleus escapes further into annulus and AF protrudes
Stage 3 - extrusion - nucleus escapes beyond annulus completely
stage 4 - sequestration - nuclear material exits disc and becomes detached.
prolapsed IV disc
CLINICAL PATTERN Central or unilateral LBP +/- leg pain WB / compression painful gait: avoid WB through leg on painful side sitting / bending \+/- lateral shift Loss of lordosis due to spasm Lumbar flexion most limited: pain may ‘peripheralise’ Extension: pain may ‘centralise’ PAIVMs provocative > PPIVMs PA (↓) midline = shear stress to disc
primary pain zones:
Primary pain zones: low back (including hip/buttock), proximal leg (thigh), and lower leg (below the knee).
Distal extent of pain produced depending on intensity of noxious stimulus
Pain consistently reproduced in same order – back thigh lower leg
lateral shift of pelvis PIVD
sciatic list indicates displacement of the position of the upper trunk relative to the pelvis
lateral shift = shoulders level relative to the pelvis
factors PIVD
CONTRIBUTORY FACTORS Genetic Predisposition Macro overload – Twist / sudden high loading IN flexion Trauma / fall on buttocks / RTA Micro overload – Repetitive Lifting / bending / twisting Occupation Manual work e.g. nursing, construction, assembly line workers Sustained sitting postures e.g. desk job
radiculopathy
Back & leg pain resulting from compression / irritation to nerve root i.e. RADICULAR PAIN, with evidence of nerve function loss.
Paraesthesia / numbness
Myotomal weakness
Burning, shooting pain in dermatomal innervation field
(+) Neurodynamic tests
Leg pain reproduced & limited range in SLR
Find Mechanical interface
Identify problematic IVF
racidulopathy neuro exam
slide 31
nerve dysfunction
2 factors
Mechanical – impairment of microcirculation intraneural edema ISCHAEMIA
Chemical – chemical mediators decrease nociceptor firing threshold (e.g. disc prolapse)
External compression alone won’t cause pain if compression happens slowly
until inflammation has also occurred –
DRG is exception – is more sensitive
causes of radiculopathy
FORAMINAL STENOSIS DEGENERATION: Osteophytes from disc / facet jts VERTEBRAL CYSTS & TUMOURS etc. EPIDURAL DISORDERS Lipoma, angioma Infections MENINGEAL DISORDERS Cysts of nerve root sleeve NEUROLOGICAL DISORDERS Diabetes Neural cysts & tumours
cauda equina syndrome
Clinical pattern – B&B changes Saddle paraesthesia / anaesthesia Gait difficulty Neuro exam? SURGICAL EMERGENCY – DECOMPRESSION Greater time compressed greater chance of nerve damage
