L-spine 2 Flashcards
What is lumbar spinal stenosis
disc degeneration in aging population
arthritic changes to lumbar vertebrae and facet joints
thickening of ligamentum flavum
narrowing of the spinal canal and nerve root canals
compression of neural structures
Osteoarthritic spine shows
osteophytes
narrowed disc spaces
How do movements affect pain in lumbar stenosis
Worse with lumbar extension
Better with leaning forward (makes disc spaces larger)
Clinical manifestations of lumbar stenosis are
50+ y/o insidious onset Low back and leg pain (morning stiffness in low back, radiates to LE) Claudication with walking Shopping cart sign \+/- numbness and tingling
What is NOT common with lumbar stenosis
weakness!
although they can have some foot drop with prolonged walking
What does a neuro exam in lumbar stenosis typically look like
Normal!
Few will have sensory changes
motor deficits are usually mild, and hard to differentiate between age related changes
Explain Vascular claudication
cramping, tightness relief w/ standing Bruits (low blood supply) Absent pulses Shiny skin Hair loss
Explain neurogenic claudication
numbness, aching, sharp relief w/ siting flexed occasional atrophy and weakness *Back pain Limited ROM to spine
What imaging diagnoses lumbar stenosis
Radiographs (XR)
MRI
-narrowed disc spaces, narrowing of spinal canal
What is Spondylolithesis
Forward movement of one vertebrae on top of another
Can occur commonly during growth spurt
What are the degrees of Spondylolithesis
1: <25% translation
2: <50% translastion
3: <75% translation
4: 100% translation
(talking about degrees of slippage)
How do you treat Spondylolithesis
APAP (not inflammatory process!) NSAIDS (caution in long term use 2/2 metabolism in kidneys), Opioids (breakthrough pain) Weight loss PT Epidural injections Laminectomy, vertebral fusion
What does this scenario describe:
17 y/o varsity presents w/ b/l low back pain, initially left sided but gradually worsening over 3 months. Pain worse w/ activity and constant. No night Sx. Ibuprofen helps take the edge off. Recently started spring lifting program and football drills
PE: No antalgic gait, pain w/ standing or flexion, scoliosis, or kyphosis. Negative straight leg and seated slump test. L1-L5 dermatomes, myotomes and reflexes symmetric b/l. Positive stork test on right
Spondylosis!
A defect in the pars interarticularis of lumbar vertebrae (ex: a fracture)
Typically no neuro or radiculopathy Sx
W>M
What is the stork test
Have pt balance on one leg, extend, and turn towards lifted leg (side you are testing). You stand behind them for support. Test both sides
Extension tests
Facet joints!
If they are inflamed or rubbing, it will cause pain
What can cause fracture of the interarticularis pars
Overloading with load bearing, upright, and weight bearing activities
Trunk extension/hyperextensino
Extension and rotation (why we use the stork test!)
What sports are high risk for Spondylosis
classic ballet Gymnastics Figure skating Football linemen Diving
What symptoms indicate we should be concerned about spondylosis
Pain persists
Can progress to spondylolithesis (forward movement of one vertebrae on another)
How can you evaluate Spondylosis
Plain XR: Lateral view (most sensitive) Lateral Oblique (most specific), or AP view
Lateral oblique view of Spondylosis will show
Scotty dog defect!
On this view, you see a dog shape on every vertebrae. But the affected one has a line in it for the fracture, that makes it look like the collar on a scotty dog
What can cause a stress reaction
Repetitive mechanical stress (trunk extension and rotation)
What is the pathology behind a stress reaction
Maladaptive response to repetitive stress; Osteoclasts>Osteoblasts so bone remodeling accelerates
-Must r/o bone pathology as cause!*
What stimulates osteoblasts
weight bearing activity
growth
fluoride
electricity
What inhibits osteoblasts
No chronic weight bearing chronic malnutrition alcoholism chronic disease normal aging hypercortisolism
What Inhibits withdrawal of osteoclasts (ex promotes growth)
weight bearing
estrogentestosterone
calcitonin
adequate vitamin D and calcium
What stimulates withdrawal of osteoclasts (ex bone breakdown)
no weight bearing space travel hyperPTH Hypercortisol hyperthyroid estrogen deficiency (menopause) testosterone deficiency acidosis myeloma lymphoma normal aging not enough calcium intake
Stress reactions lead to
Microfractures
Initiation of inflammatory response
bone stress injury causing stress fracture
How do you grade stress reactions
I: periosteal edema
II-III: varying severity bone marrow edema
IV: cortical fracture line
What imaging does a stress reaction warrant
MRI!
after an MRI you can get a bone scan which will show black spots where affected
How do you treat stress reactions/Spondylosis
Activity restrict 1-4 wks
PT during week 5-12 (work on core strength and LE flexibility)
Gradually return to activity during wk 9-12
Full activity after wk 12
Consider brace
When would surgery be an option for Spondylosis
Grade III-IV spondylolithesis (75%+)
