HNP and Low Back Pain 1/21 Flashcards
Spondylosis
bone spurs
spondylolysis
pars fracture
spondylolisthesis
anterior deviation
what are most often cause of lower back pain?
Psoas/Illiacus muscle
osteomyelitis
infection of vertebrae
MI
can have referred pain to lower back
Aortic Abdominal Aneurism
pulsatile mass can be detected in periumbilical/epigastric region
Major causes of pain from GI system?
constipation
flatus = gas
necrotizing enterocolitis
perforation
L4/L5 herniation
Would affect L5 nerve root
If pain is above knee
primarily direct injury to a specific area:
- Most likely a non-specific muscular or ligamentous injury
- Somatic Dysfunction
- Degenerative Disease
- Fracture
- Spondylolysis
pain radiates below the knee
- 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
Cauda Equina syndrome
- 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
Radiculopathy
nervous like symptoms due to : Herniated Nucleus Pulposus Tumor Exostoses Spinal stenosis Infection Conditions that compromise intervertebral foramen, canal, disc
What can lead to decrease in the size of the intervertebral foramen?
Arthritis Ligament hypertrophy Disc degeneration Muscle imbalance Tissue quality SD
What do GAG’s do?
- 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
Aging and vertebral disc degeneration:
- 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
Protruded disc
type of disc herniation where the annulus remains intact
Extruded disc
disc herniation through the annulus but posterior longitudinal ligament maintains disc within vertebral space
sequestered disc
- disc herniation where annulus is free to roam the spinal canal
- can cause AI disorder
Where do most disc herniations occur?
- 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
Where does L4 go?
- 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
Where does L5 go?
- 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
S1?
- herniation at L5/S1
- peroneal/ fibular muscles: eversion
- Achilles reflex
- lateral side of foot parasthesia
where do disc herniations normally occur?
- 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
causes of pain in HNP?
- mechanical compression of nerve root
- chemical mediators: such as inflammatory agents
- irritation of highly innervated posterior longitudinal ligament
Why do we do OMT to treat HNP?
- 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
Acute HNP
- 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
Subacute/Chronic HNP
- May use direct treatments with care (Personally I would still shy away from direct techniques if at all possible)
- Patient normally tolerates more
Treatment for HNP
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.
paracentral disk herniation
- will result in posterior herniation to the side
- causes unilateral symptoms
