HNP and Low Back Pain 1/21

Question 1

Spondylosis

Answer 1

bone spurs

Question 2

spondylolysis

Answer 2

pars fracture

Question 3

spondylolisthesis

Answer 3

anterior deviation

Question 4

what are most often cause of lower back pain?

Answer 4

Psoas/Illiacus muscle

Question 5

osteomyelitis

Answer 5

infection of vertebrae

Question 6

MI

Answer 6

can have referred pain to lower back

Question 7

Aortic Abdominal Aneurism

Answer 7

pulsatile mass can be detected in periumbilical/epigastric region

Question 8

Major causes of pain from GI system?

Answer 8

constipation
flatus = gas
necrotizing enterocolitis
perforation

Question 9

L4/L5 herniation

Answer 9

Would affect L5 nerve root

Question 10

If pain is above knee

Answer 10

primarily direct injury to a specific area:

1. Most likely a non-specific muscular or ligamentous injury
2. Somatic Dysfunction
3. Degenerative Disease
4. Fracture
5. Spondylolysis

Question 11

pain radiates below the knee

Answer 11

- normally due to nervous innervation 
Pain radiates below the knee:
1. Radiculopathy
2. Spinal Stenosis
3. ***Cauda Equina Syndrome (medical emergency)
4. Associated Piriformis Syndrome

Question 12

Cauda Equina syndrome

Answer 12

• compression of nerves from L1-S5 normally due to massive disc protrusion, fracture, or tumor that causes bowel or bladder dysfunction
• Medical Management and Surgical decompression required within 48 hours to prevent permanent neurological damage
• Check for saddle/perineum anesthesia and decreased anal sphincter tone (loss of bowel and bladder control) in suspected cases

Question 13

Radiculopathy

Answer 13

nervous like symptoms due to : 
Herniated Nucleus Pulposus
Tumor
Exostoses 
Spinal stenosis
Infection
Conditions that compromise intervertebral foramen, canal, disc

Question 14

What can lead to decrease in the size of the intervertebral foramen?

Answer 14

Arthritis
Ligament hypertrophy
Disc degeneration
Muscle imbalance
Tissue quality
SD

Question 15

What do GAG’s do?

Answer 15

• Negatively charged glycosaminoglycan molecules on proteoglycan chains attract fluid into the extracellular space
• help vertebral disc maintain water (the more negative the space, the more inhibitory pressure is created within the disk)
• Anulus fibrosis can adapt, but does not deform very much

Question 16

Aging and vertebral disc degeneration:

Answer 16

• age-related changes in discs begin in adolescence:
• Diminished blood flow to the disc
• Nucleus Pulposus gets smaller and more fibrotic during adult years and blood vessels disappear, cracks appear in the lamellae and annulus
• in the elderly, the annulus becomes stiff fibrocartilage and the nucleus pulposus has few viable cells

Question 17

Protruded disc

Answer 17

type of disc herniation where the annulus remains intact

Question 18

Extruded disc

Answer 18

disc herniation through the annulus but posterior longitudinal ligament maintains disc within vertebral space

Question 19

sequestered disc

Answer 19

• disc herniation where annulus is free to roam the spinal canal
• can cause AI disorder

Question 20

Where do most disc herniations occur?

Answer 20

• Most herniations occur in the Lumbar Spine
• More stress in the lumbar region compared to other regions of the spine
• Thoracic spine is protected from extreme motion by the thoracic cage, meanwhile the lumbar spine is left without boney connections to stabilize it.
• most commonly affected is S1 due to disc herniation from L5, and second most common is hernation from L4

Question 21

Where does L4 go?

Answer 21

• herniation of disk L3,4
• dermatome crosses over knee medially, and the medial side of the leg
• patellar tendon reflex lost
• medial portion of foot
• motor affected: tibialis anterior - INVERSION

Question 22

Where does L5 go?

Answer 22

• herniation of L4/5 disc
• lateral side of the leg
  (higher up in the spine starts anterior and superior, and then will rotate down.)
• there is no reflex
• extensors affected
• anterior portion of leg: extensor digitorum longus: flexion of foot

Question 23

S1?

Answer 23

• herniation at L5/S1
• peroneal/ fibular muscles: eversion
• Achilles reflex
• lateral side of foot parasthesia

Question 24

where do disc herniations normally occur?

Answer 24

• most often occur posteriorly, because the anterior long. ligament is thicker and stronger
• the post. long. lig. is at its narrowest in the lower portion of the spine
• results in the herniation occurring posteriorly or off to the side (paracentrally)
• keeps herniation from occurring anteriorly

Question 25

causes of pain in HNP?

Answer 25

1. mechanical compression of nerve root
2. chemical mediators: such as inflammatory agents
3. irritation of highly innervated posterior longitudinal ligament

Question 26

Why do we do OMT to treat HNP?

Answer 26

• SDs pre-dispose or aggravate radiculopathy when chronic processes are present within a disc
• SDs alter mechanical relationships which can change the forces directed toward the disc

OMT goals:

• Stabilize and decrease impingement locally
• Address any SD contributing to mechanical instability in the area
• Treat SDs that may have been created by the HNP
• Reduce viscerosomatic and Chapman’s reflexes
• Reduce sympathetic tone
• Improve lymphatic and venous drainage

Question 27

Acute HNP

Answer 27

• Indirect techniques (HVLA & MUSCLE ENERGY ARE CONTRAINDICATED, as is any technique that exacerbates symptoms)
• Patient may not tolerate much
• May need to treat areas distal to the herniation first

Question 28

Subacute/Chronic HNP

Answer 28

• May use direct treatments with care (Personally I would still shy away from direct techniques if at all possible)
• Patient normally tolerates more

Question 29

Treatment for HNP

Answer 29

treat affected extremities and sacrum/pelvis:

• Type II/Type I mechanics
• ribs and diaphragm (L1-L3)
• latissimus dorsi (seen in cases with low back pain associated with shoulder pain)
• quadratus lumborum: becomes hip stabilizer with weak gluteus medius, results in LBP
• Iliopsoas: results in majority of back pain coming in - due to people seated at most times, results in constant stretch of muscle and increased gamma gain.

Question 30

paracentral disk herniation

Answer 30

• will result in posterior herniation to the side

- causes unilateral symptoms