LBP and HNP Flashcards
localized LBP - mech w/p radiation below the knee
- non-specific muscular/ligamentous injury
- SD
- degen disc disease
- degen joint disease
- spondylolithesis
- fracture/spondlylolysis
localized LBP - mech with radiation below the knee
- cauda equina syndrome
- radiculopathy
- spinal stenosis
localized LBP - non-mech
- infection
- neoplasm
- inflamm
referred LBP
- GI disease
- renal disease
- gynecological
- vascular
- pyschological
relief only with complete immobility suggests what ddx?
- acute infection
- compression fracture (metabolic bone disease)
- pathologic fracture (tumor or infiltrative disease)
pain worsens with prolonged sitting suggests what ddx?
herniated disc
pain worsens with prolonged standing and extension suggests what ddx?
shopping cart sign - spinal stenosis
no position is comfortable suggests what ddx?
psychogenic pain - not well localized, follows no pattern, is constant, and patients can’t describe alleviating nor aggravating factors
radiating pain with extension suggests what ddx?
stenosis
radiating pain at rest suggests what ddx?
disc herniation
stiffness and pain upon waking suggests what ddx?
inflamm arthropathies
intense night time pain suggests what ddx?
bone tumors
red flags - would not treat these patients if these sx present
- bowel or bladder dysfx
- saddle anesthesia
- b/l weakness or numbness in legs
- acute neuro deficits in patients with cancer
- progressive or severe neuro deficit
- LBP along with a fever in a patient who uses IV drugs
yellow lights - gently treat patient during first visit if these sx present
pos straight leg raise test
latissimus dorsi
- originates in the thoracolumbar fascia, iliac crest, and spinous processes of lower 6 thoracic vertebrae
- inserts on intertubercular groove of humerus
- connects lumbar, thoracic, and pelvic regions to UE
- factor in cases of LBP combined with shoulder pain
quadratus lumborum
- origin: iliolumbar ligament and iliac crest
- inserts: L1-4 transverse processes and ant. surface of 12th rib
- considered a posterior inferior extension of the abdominal diaphragm
iliopsoas
- origin: vertebral bodies and anterior surfaces of transverse processes of lumbar spine
- inserts: lesser trocanter of femur
- often causes pain but inaccessible
sacro-iliac joint
- potential contributor to LBP
what compromises the intervertebral foramina and disc?
- arthritis
- ligament hypertrophy
- disc degen
- mm imbalance
- inherent tissue qualities
- SD
herniated nucleus pulposus - anatomy
intervertebral disc
- mostly water
- few pain fibers
- compression pressure balanced by hydrostatic forces
- annulus fibrosus and nucleus pulposus
disc herniations commonly occur in which direction?
posteriorly, paracentrally or parasagitally
- anterior longitudinal ligament much thicker and stronger than posterior
- posterior longitudinal ligament prevents central herniation
most common vertebral level for herniated disc?
L5-S1 and L4-5
- undergo most motion and stress
- posterior longitudinal ligament more narrow
why does disc herniation commonly affects the nerve root below?
- pedicles of the lumbar vertebra protect a nerve from being injured by the disc at its own level
clinical features of L4-5 herniated disc
- pain: over SI joint, hip, lateral thigh and leg
- numbness: lateral leg and first 3 toes
- weakness: dorsiflexion, walking on heel
- atrophy: minor
- reflex: internal hamstring reflex diminished or absent
clinical features of L5-S1 herniated disc
- pain: over SI joint, postero-lat thigh and leg to heel
- numbess: back of calf, lat heel, foot to toe
- weakness: plantar flexion, walking on toes
- atrophy: gastroc and soleus
- reflexes: ankle jerk diminished or absent
HNP risk factors
- occupational lifting
- bending or lifting
- prev hx of LBP
- age
- tobacco use
- ethanol use
HNP vs SD symptom distrib
- HNP: dermatomal pattern
- SD: glove-like distrib
HNP vs SD mm they affect
- HNP: hypertonic paraspinal mm and hypotonic lower limb mm and possible calf atrophy
- SD: hypertonic paraspinal and LE mm due to increased symp
HNP vs SD LBP that radiates
- HNP: down the back of the leg to the calf or foot
- SD: down buttocks and ant/post thigh, rarely below knee, groin pain due to irritation of ilioinguinal and iliohypogastric nn, psoas tightness that cause radiation pain to ant thight (irritate lumbar plexus)
HNP vs SD improvement of symptoms
- HNP: improve with rest
- SD: improve with activity
HNP may cause what that requires surgical emergency?
loss of bowel and bladder control
HNP tx
- rest
- cont anti-inflamm tx
- analgesics
- mm relaxants
- OMT
role of acute SD on radiculopathy
intervertebral foramen already compromised by a chronic process, acute SD can precipiate or aggravat symptoms
role of chronic SD on radiculopathy
chronic SD can alter mech forces on the disc
- type I SD: long paraspinals
- type II SD: short paraspinals
role of lumbar spine on whole body as unit - MSK model
- occupies 1/2 - 2/3 of post skeletal and myofascial wall of abdomen
- directly linked to thoracic and pelvic regions
- influences head and neck, UE and LE, and viscera
role of lumbar spine on whole body - resp/circulatory model
- located b/w 2 greater areas of stability, thus assoc with 2 junctional areas - thoracolumbar and lumbosacral junction
- these junctional areas are key for lymphatic and venous drainage and return
abdominal diaphragm attachment
- attaches from bodies of L1-3 to lower 6 ribs and xiphoid process
SD of L1-3 associated with?
flattened ineff diaphragm
what does flattened diaphragm cause?
- unable to develop eff, approp pressure gradients b/w thorax and abdomen –> decreased lymphatic flow and venous return (Batson’s Plexus) and increased abdominal and pelvic congestion
OMT tx - acute cases
- indirect tech better tolerated
OMT tx - subacute/chronic cases
- indirect tech fine but can incorp direct tech
when to do surgery
- neurologic deficit
- cont pain combined with 2/3 of the following: paresthesia, reflex changes, mm atrophy
- increase in intensity of symptoms despite conservative care
