L5 Lumbar Spine Pathologies Flashcards
types of disc herniation
intra spongy nuclear herniation
protrusion ->
extrusion ->
sequestration
clinical presentation of herniated nucleus pulposus (HNP)
occurs gradually over time and starts asymptomatic
starts with back pain then progress to LE, then neuro involvement
types of HNP protrusion
can either have spinal nerve root involvement or not
intra spongy nuclear herniation
nucleus is displaced into vertebral body through the endplate of cartilage causing schmorl’s nodes
MOI of intra spongy nuclear herniation
mod to severe flexion trauma like fall into flexion
grades of intra spongy nuclear herniation
1: subchondral fracture into vertebral body
2: small cracks in endplate
3: crack where a piece of bone has shifted
4: crack where a piece of bone has shifted and disc material is forced through the crack
protrusion without spinal nerve root involvement
displacement of nuclear material beyond normal confines of inner annulus
creates bulge in outer annulus but no nuclear material escapes
protrusion without spinal nerve root involvement MOI
cumulative effect of months/years of forward bending and lifting, seated/flexion posture
protrusion without spinal nerve root involvement clinical presentation
general loss of spinal mobility, especially in extension
decline in general fitness
decreased disc nutrition
leg pain indicating larger protrusion
sitting is the worst position
protrusion without spinal nerve root involvement typical patient
30-50
male
early: complains of back/buttock/thigh pain
relief from sitting by standing and walking
UL referral pain to the leg
gradual pain onset
occupation/activity with flexed lumbar spine
clinical exam for protrusion without spinal nerve root involvement
posture: slumped, flexed L/S
lateral shift
flattening of lordosis
normal neuro exam
involved segments tender (central PAIVMs tender)
limited extension ROM
protrusion with spinal nerve root involvement
nucleus pulposus bulging but contained in annulus and PLL
bulge is large enough that it impinges upon/irritates the inferior nerve root
relation of lateral shift to disc bulge: which direction does the patient shift?
HNP lateral to nerve root: patient shifts to opposite side of bulge
HNP medial to nerve root: patient shifts towards the side of bulge
protective scoliosis
protrusion with spinal nerve root involvement clinical presentation
same as HNP with addition of positive neuro s/s: myotomal strength loss, decreased reflexes, loss of sensation, + SLR
attempts to fix lateral shift may increase peripheralization of symptoms
gradual worsening
HNP extrusion
nuclear material moves outside the disc and breaks through the annular fibers
progression of a disc protrusion
PLL still touching disc
occupies space in the spinal canal
extrusion symptoms
worse pain than protrusion
more irritable
harder to alleviate due to mechanical and chemical irritation of spinal nerves
- mechanical lesion taking up space causing nerve compression
- disc contents interact with glial cells to initiate inflammatory response (chemical)
HNP Sequestration
nuclear material escapes into the spinal canal as a free fragment
HNP Sequestration s/s
peripheral s/s will be predominant
reduction in pressure on the annular wall may reduce LBP from disc bulge but worsen peripheral symptoms due to space occupying lesion
healing of HNP sequestration
body can lyse and get rid of the sequestration over time
however, over the time it takes to heal the sequestration could continue to damage spinal nerves it is compressing
leads to potentially lasting radicular symptoms
lumbar radiculopathy vs radicular symptoms
radiculopathy is neuro signs including reduced DTR, clinical weakness, N/T, etc
radicular pain is pain down the leg, could just be referred
degenerative disc disease
nucleus pulposus is dehydrated
this causes narrowing of the intervertebral space, slackening of the spinal ligaments from decreased disc height, weakening of annular rings, and approximation of facet joints
examination findings of DDD
xray imaging showing decreased height and black/dehydration
tenderness segmentally
active and passive motion restriction
facet joints vulnerable to impingement
disc more vulnerable to herniation
facet joint referred pain area
posterior thigh
facet impingement MOI
sudden unguarded movement into ext, SB, and/or rotation
little or no trauma, just sudden movement
causes pinching of the facet meniscus
s/s of facet impingement
eased by rest
aggravated by movement
locked protective position
AROM reduced in 3/6 ranges
end range pain
ipsilateral SB and contralateral rotation limited
single segment tender to palpation
facet joint sprain
similar to impingement
more severe injury or progression of repetitive facet impingement
history of moderate to severe trauma
early on conservative treatment and longer healing time
causes of facet hypomobility
ligament tear
muscle tear
contusion
impingement
Z joint subluxation
s/s of facet joint hypomobility
UL back pain
certain movements aggravate pain
end range pain with combined motion and AROM
PPIVMs and PAIVMs
facet hypermobility
distinction made by end feel of PPIVM/PAIVM
facet joint OA
degenerative joint disease DJD
cartilage braekdown in facets
causes increased motion at facet
lumbar spine OA prevalance
40-85%
DJD process in spine
calcific deposits around periphery of facet joints
hyaline cartilage wears away
thickening synovial lining/capsule
thickening of subchondral bone
spondylosis
nonspecific term: refers to degeneration of disc, vertebral body, facet joints
3 stages of spondylosis
dysfunction: includes disc tears and hypermobility of the synovium, microtrauma results and can result in herniation
instability: once disc herniates, capsule and ligaments slacken
stabilization: osteophytes and bony changes occur, stenosis can occur, creating chronic issues
clinical instability in low back
increased translation of spinal segment during flex/ext movement or SB
difficult to assess due to static xray images
found catching on central PAs
excess motion
inconsistent symptoms
s/s of clinical instability in the low back
recurrent back pain
constant pain with catching/locking during exacerbation
unprovoked episodes
feeling unstable
give way
inconsistent symptoms, but aggravating factors include: sustained sitting or standing, semi flexed positions, forward bend, sudden movement, sneezing
may have aberrant spinal movement
neutral zone of the spine
region of intervertebral motion in neutral posture where there is little resistance in the passive spinal column
size of this zone changes with instability or low back pain
treat with lumbar stab to reduce neutral zone to below painfree range
basically if you have hypermobility or instability your neutral zone increases and goes beyond range of pain free motion, creates pain
Panjabi’s spine stabilization principle
- spinal column
- spinal muscles
- neuromuscular control
spinal column and spinal muscles send proprioceptive input to brain, which sends afferent signals to muscles to activate, creating stability and movement in the spinal column
spondylolysis
defect/fracture of pars interarticularis near facet/neural arch of vertabrae
vs spondylosis is degeneration
spondylolisthesis
defect of neural arch resulting in separation of anterior and posterior elements, anterior portion of vertebrae translates forward
most common location of spondylolisthesis
L5/S1
findings in spondylolysis and spondylolisthesis
spondylolisthesis: may feel a step off of spinous processes
hyperlordosis
pain with prolonged standing (exT)
relief with sitting
onset from athletic or physical activity as a child
pain results from excess segmental motion/stress
grading of spondylolisthesis
I: 1-25% slippage
II: 26-50
III: 51-75
IV: 76-100
symptoms associated with grades III and IV spondylolisthesis
likely will have cauda equina syndrome
nerve root compression cause
impingement or chemical irritation of the spinal nerve root
often caused by HNP, congenital issue, tumor, fracture, or advanced DDD
s/s of nerve root compression
truw neuro presentation: s/s like clinical weakness, N/T, reduced DTR
pain is deep and superficial, burning in one spinal nerve root distribution
somatic referred pain
deep, aching
diffuse
covers 2-3 dermatomes
lateral spine stenosis is…
nerve root compression
neuritis findings
inflammation causing impingement in intervertebral foramen
+ neuro exam
insidious or onset with muscle and joint inflammation
seen within a few days after severe injury
nerve root adhesion
nerve root is entrapped by scar tissue
possible causes include spinal surgery or disc herniation
findings with nerve root adhesions
history of spine surgery or disc herniation
period of complete recovery then insidious onset of spinal/referred pain
absence of lumbar flexion in standing with no restriction in seated
no signs of disc protrusion like sitting pain
congenital abnormalities in low back include:
spondlylolysis
spondylolsthesis
lumbarized sacral vertebrae: extra lumbar vertebrae
sacralized lumbar vertebrae: extra sacral vertebrae and missing lumbar
asymmetrical facet joints
spinal stenosis s/s
pain in lower back and leg(s)
N/T in feet/legs
decreased DTR
motor weakness
symptoms worse with walking
relieved by rest and flexion
lumbar spinal canal stenosis is:
ischemia of lumbosacral nerve roots due to compression cutting off blood supply
main risk factor for spinal stenosis
age >50, more likely to have degenerative changes
formainal area changes with lumbar flexion/ext
%
derceases 20% in extension and increases 12% in flexion
cause of spinal stenosis
degeneration causing fibrosis of spinal ligaments that encroach of the circumferential area of the spinal canal
special tests for spinal stenosis
bike test: rule out intermittent claudication by putting patient in flexion on bike and see if they get claudication pain. Since they are flexed, the bike shouldn’t provoke neurogenic claudication but will provoke IC
2. 2 part treadmill test: increase incline to create spinal flexion
3. Stoop test: if walking brings on symptoms, does stooping into flexion relieve them?
cauda equina causes
spinal stenosis, herniated lumbar disc
fracture
tumor
infection
inflammation
traumatic injury
arteriovenous malformation
hemorrhage in spine
postop surgical complication
spinal anesthesia
cauda equina
compression of the lumbar and sacral nerve roots
cauds equina presentation
mixed UMN and LMN, more UMN in kids and LMN in adults
urinary retention: doesn’t feel sensation/urge to urinate
urinary/fecal incontinence
saddle anesthesia
weakness/paralysis
back/leg pain
ankylosing spondylitis
systemic inflammatory process causing joint sclerosis and ligament ossification
starts in SI joints, then lumbar, thoraic, ribs
ankylosing spondylitis population
20-35 y/o
more male>female
ankylosing spondylitis findings
present 3+ mo
flattening of spinal curves
+ constitutional symptoms
vague LBP and stiffness
worse when waking
eased by movement
weeks/months aggravation episodes
insidious onset w no MOI
coccyx injury MOI and s/s
fall onto coccys or in childbirth
unable to sit on both buttcheeks due to tenderness internal and external
may heal extended creating pressure point on end of coccyx
CPR for lumbar spine manipulation
- FABQ <19
- symptoms <16 days
- no symptoms distal to knee
- lumbar spine hypomobility
- one hip with more than 35 degrees of IR
CPR for lumbar spine stabilization treatment
- SLR > 90 degrees
- prone instability test
- aberrant movements
- age < 40 y/o
success most likely if 3+ present
CPR for ankylosing spondylitis
- morning stiffness >30 min
- back pain improves with exercise but not rest
- wake up due to back pain in second half of night only
- alternating buttock pain
diagnosis likely if 3+ are present
CPR for lumbar spinal stenosis
2 - age 60-70
3 - age 70+
1 - symptoms present 6+ mo
2 - symptoms improve with flexion
-2 - symptoms improve withe ext
2 - symptoms exacerbated by standing
1 - + IC
1 - urinary incontinence
diagnose if 7+
unlikely if 2 or less
anatomic sites of pain: spinal ligaments
innervated with nociceptive afferents
chronic or acute pain
anatomic sites of pain: spinal muscles
innervation for pain
highly innervated
A delta (fast)
C fibers (slow)
lower threshold of firing for pain as compared to facet joint nerves
