L/S Presentations pt 2 Flashcards
what is a possible cause of internal disc disruption?
End-plate frx causing discogenic pain
what are Schmorl’s nodes?
nucleus infiltrates vertebral body as a result of blood extruded from interosseous veins in marrow space
discogenic pain may result from what 2 types of injuries?
- rotatry injury
- end-plate injury
what is the cause of discogenic pain?
- following trauma the nucleus is less able to bind water/withstand pressure
- annulus must accept more loading
- disc loses height
- excessive loading on facet joints (tripod effect)
- osteophyte formation
what is the difference between a disc bulge, herniation, extrusion, and sequestered?
- bulge → more than 50% of disc in periphery
- symmetrical
- asymmetrical
- herniation → a protusion of less than 50% of disc
- broad based
- focal
- extrusion → the bulging has a neck narrower than the distal portion of the bulge
- sequestration → material comes away from rest of disc
herniation locations can be classified as being in ______ or ________
- axial plane zones
- sagittal plane-levels
list the axial plane zones
- anterior
- extra-foraminal
- forminal
- subarticular
- central
list the sagittal levels
- suprapedicular
- pedicle level
- intrapedicular
- disk level
what is the difference between somatic referred pain, radicular pain and radiculopathy?
- somatic → altered pain perception in CNS
- radicular → pain related to nerve root irritation
- radiculopathy → conduction block of motor and sensory axons
what are some potential causes of radiculopathy?
- foraminal stenosis (e.g. osteophyte, etc.)
- epidural disorder
- meningeal disorder
- neurolgical disorder
- impingement by disc herniation
T/F: you can’t have radicular pain without a radiculopathy
FALSE
may occur with or w/o a radiculopathy
what is the expected history for radicular pain?
- Acute → trauma (twisting/lifting injury common)
- Insidious → progressively more distal as health condition progresses
describe the symptomology for radicular pain
- shooting/lancing pain traveling along nerve root distribution
- “band-like”
- pain with activities that close neuroforamen
- pain w/twisting/extension activities
in someone with radicular pain, what would you expect to find during a physical exam?
- visual inspection → lateral shift possible
- painful/limited ROM w/motions that compress foramen or place tensile load on nerve root
- foraminal stenosis → ROM extension/rotation/lateral flexion
- disc bulging → variable
- Test:
- Slump test
- SLR
- Well Leg Raise
- Tenderness/turgor w/guarding in paraspinals
what are some causes of central stenosis?
- Z-joint hypertrophy (related to arthropathy)
- Bulging Disc
- Thickening/ossification of ligamentous structures
- Spondylothesis
describe the symptoms of central canal stenosis
- possible cuada equina symptoms
- UMN and LMN signs
- Pain increases w/prolonged walking/standing
- Pain relieved with sitting/walking with UE support (walker, shopping cart)
- Pain in legs (posterior lower legs especially) > lower back
- bilateral > unilateral
physical exam findings for central canal stenosis
- visual inspection → diminished lumbar lordosis
- painful/limited extension and lateral flexion ROM
- both passive and active
- improves w/flexion
- shortened hip flexors and lengthened hip extensors
- neuro signs
what are some causes of lateral canal stenosis?
- loss of disc height with degenerative processes
- Z-disc hypertrophy
- Disc bulging
- Spondylothesis
describe the symptoms of lateral canal stenosis
- LMN symptoms
- increased pain with prolonged standing/walking
- pain relief with sitting, walking w/UE support (walker, shopping cart)
- LBP and LE pain
- unilateral (bilateral if present bilaterally)
physical exam findings for lateral stenosis
- visual inspection → diminished lumbar lordosis
- painful/limited extension and lateral flexion AROM and PROM
- commonly improves w/flexion
- Neuro signs
- myotomes
- dermatomes
- hyporeflexia
- other signs consistent with degenerative Z-joint arthropathy
what is Z-joint pain?
a degenerative osteoarthropathy
referred pain in buttock and thigh, though pattern not reliable (may occur below knee or as far as foot)
what are some potential etiologies for Z-joint pain?
osteoarthrosis
spondyloarthropathy
often secondary with DDD/disc spondylosis
what are the symptoms of Z-joint pain?
- local/referred, unilateral LBP/buttock pain
- aggravating factors consistent w/MSK pattern of facet closing
- relief with facet gapping positions/activities
physical exam findings for Z-joint pain
- PROM and AROM pain and limited:
- lumbar extension
- ipsilateral lateral flexion
- contralateral rotation
- end-range flexion
- muscle guarding in lumber erector spinae
- possibly difficulty activating multifidi
- Painful spring testing/UPA
- hypomobility w/joint mobility testing
broad physcial exam findings for Z-joint pain
- “slouched” posture, potentially lateral shift
- painful limited ROM greatest with extension
- painful spring testing/UPA
- tender, guarded paraspinals
Hx for Z-joint Pain
sudden onset, potentially hx of trauma
possible “acute locked back”
symptoms of Z-joint pain
- diminished pain in slight flexion position and positions that gap the z-joint
- pain w/extension activities greatest
what is a meniscoid entrapment, and when may it occur?
may occur as a consquence of Z-joint pain (episdoe of acute locked back)
- during lumbar flexion the meniscoid is drawn out of joint
- during extension, it buckles and occupies space outside
- with distraction it can be realigned
what is neuromuscular instability/muscle imbalance?
- activation patterns between muscle groups that results in pain
- postural and phasic muscles
- trunk extensors and psoas major
- trunk flexors and hip extensors
- proposed pain generators
- involved musculature (DOMS w/excessive guarding)
- joint structures (aberrant loading patterns)
- remeber that the discoordination doesn’t cause the pain but the resultant pattern and muscled used hurt
Hx for neuromuscular instabilty/muscle imbalance
recurrent exacerbations
feelings of instability
symptoms of neuromuscular instability/muscle imbalance
- LBP constant
- catching and locking w/trunk motion
- clicking/clunking/popping noises
- aggravating with:
- prolonged positions (sitting, standing)
- flexion motion
- sudden trunk movements
- returning to upright position from flexed position
physical exam findings for neuromuscular instability/muscle imbalance
- aberrant motions (trunk AROM)
- painful/limited:
- AROM (commonly flexion)
- returning full motion (similar to Gower sign)
- Excessive motion
- paraspinal guarding/tenderness
- hypermobile (joint mobility testing)
- Tests:
- +prone instability test
- +passive lumbar extension test
what is a Thoracolumbar Fascia Fat Herniation?
AKA “back mice”
- herniation of fat through posterior layer of thoracolumbar fascia
- innervated fat tissue compressed as exit site during motions that place tensile loading on fascia
- palpabale subcutaneous nodule w/provocation of concordant pain
what are the different types of muscle pain that occur at the lower back?
- general muscle strain
- diffuse muscle pain
- muscle spasm
what is a general muscle strain?
- forceful stretch of contractile unit against contraction
- common failure at mytendinous junction
- provokes inflammatory response (source of pain)
- could be palpable at insertion site
- could occur with lateral flexion/combined rotation and lateral flexion
what is diffuse muscle pain?
- likely ischemic in nature related to guarding
- sustained muscle contraction leads to compression on vascular structures (limits blood supply and metabolite uptake)
- breakdown from secondary muscle cell death also irritant
T/F: muscle spasms are a controversial topic
TRUE
especially with chronic LBP
what morphological change can occur to back musculature due to LBP?
fatty infilitation of multifidi and atrophy of multifidi
can be due to post-op, recurrent unilteral LBP and chronic LBP
fatty infilitation likely related to muscle disuse and spinal injury (denervation)
T/F: fatty infiltrates may manifest as hypertrophy
TRUE
this may also alter recruitment due to reflex inhibition
impact of fatty infilitation on prognosis?
worsens prognosis and response to intervention
what are trigger points?
the presence of discrete focal tenderness located in a palpabale tuat band of skeletal muscles, which produces both referred regional pain and a local twitch response
potentially related to low-load sustained/repetitive contractions
the dx of a trigger point requires what?
- palpable band
- local and referred tenderness
- local twitch response
