LBP with Radiating Pain Flashcards
What is the proposed underlying cause of this condition?
- Herniated Nucleus Pulposus
- Lateral Foraminal Stenosis
- Central Canal Stenosis
Pathoanatomy
With LBP with Radiating pain, what two conditions can affect the HNP?
Degenerative Changes to the Annulus Fibers
- Prolonged exposure to hypo- or hyper- loading correlates with disc degeneration
- Degeneration and weakening of the annulus allows the nucleus material to bulge and migrate outside the annulus margins
Failure in the integrity of annulus fibrosis integrity
- Sudden unguarded movement, often flexion with torsion
- Protrusion or herniation into the neural canal, intervertebral foramen or lateral to the foramen
With McNab’s Surgical Classification for HNP, what are the 2 types of DisK Protrusion?
- Type 1: Localized Annular bulge
- Type 2: Diffuse Annular bulge
With McNas’s Surgical Classification for HNP, what are the 3 types of Disk Herniations?
- Type 1: Prolapsed Nucleus (push though annular fiber)
- Type 2: Extruded Nucleus
- Type 3: Sequestered Nucleus (Comes out and breaks off)
This is more universally known
How does the American Academy of Orthopedic Surgeons (AAOS) classify discogenic presentations?
As:
- Degeneration
- Bulge
- Protrusion
- Extrusion
–Subligamentous
–Transligamentous
–Sequestered
With LBP with Radiating Pain, what is Lateral Foraminal Stenosis?
(Nerve Root)
A condition that is the result of a space-occupying lesion in the intervertebral foramen
A combination of factors may cause this including:
- Degenerative changes (Spondylosis)
–Facets
–Interberteral disk
- Spondylolisthesis
What does Lateral Foraminal Stenosis result in? What movements make this worse?
- Lateral Foraminal Stenosis results in unilateral radiating LE pain.
- Its made worse by further closure of the foramen, such as doing lumbar extension and ipsilateral sidebending
With LBP with Radiating Pain, what is Central Canal Stenosis?
(Spinal cord and/or Cauda Equina)
- Can present as UMN up to L2
Space occupying lesion of the central spinal canal
A combination of factors may cause this including:
- Degenerative changes (Spondylosis)
- Spondylolisthesis
What does Central Canal Stenosis result in? What movements make this worse?
- Central Canal Stenosis results in bilateral LE pain
- Made worse by further narrowing of the central canal like during lumbar extension requierd for walking
What system, structure, pain mechanism, and phases of healing are unique to patients with LBP with Radiating Pain?
System
- Neuromusculoskeletal
Structure
- Nerve Root and Disk (if HNP)
Pain Mechanism
- Neuropathic (nerve root), Nociceptive (disk)
Phase of healing
- Disk/Annulus tear: 10/12 weeks
- Nerve: 2-3 mm/day
What are common subjective reports with HNP?
May be gradual or immediate onset of local and/or somatic referred LBP and lancinating LE pain
What are common subjective reports with Lateral Foraminal Stenosis?
Gradual onset of worsening lancinating Unilateral LE pain
What are common subjective reports with Central Canal Stenosis?
Gradual onset of worsening lancinating Bilateral LE pain
What are the Agg/Ease factors of HNP?
Agg
- Lumbosacral flexion
–Sitting and bending forward
- Positions of the lower quarter that tensions the nerve root
–Sciatic nerve lower limb tissue tension positions of the LE
Ease
- Lumbosacral extension
–Standing and walking
- Position of the lower quarter that reduce tensions of the nerve root
–Positioning opposite SLR or Slump Test
What is the 24hr pain behavior with HNP?
Morning
- Sleeping in flexion or in a LE position that tensions the nerve root, may wake up with leg pain
- May have difficulty coming up into full lumbar extension initially
Noon to evening
- Sx may vary throughout the day depending on the patients activities
Night
- Sleeping in flexion or in a LE position that tensions the nerve root, they may wake up with leg pain
- Neuropathic pain is often worse at night
- May have distured sleep
What are the Agg/Ease factors of Lateral Foraminal and Central Canal Stenosis?
Agg (Peripheralization of Radicular Sx)
- Lumbar Extension
–Standing and walking
- Positions of the lower quarter that tensions the nerve root
–Sciatic nerve lower limb tissue tension positions of the LE
Ease (Centralization of Radicular Sx)
- Lumbosacral flexion
–Sitting and bending forward
- Position of the lower quarter that reduce tensions of the nerve root
–Positioning opposite SLR or Slump Test
What is the 24hr pain behavior for Lateral Foraminal and Central Canal Stenosis?
Morning
- Sleeping in lumbar extension or in a LE position that tensions the nerve root, they may wake up with leg pain
Noonn to evening
- Sx will vary throughout the day depending on the patient’s activities
Night
- Sleeping in lumbar extension or in a LE position that tensions the nerve root, they may wake up with leg pain
- Neuropathic pain is often worse at night
- May have disrupted sleep
What should take place in the Neurological Examination?
DTR’s
- Quads, and Achilles
Dermatomes
- L3-S1
- Sharp/Dull
Myotomes
- L3-S1
During the Movement and Provocation examination, what would you see with Active ROM?
ROM limitations and Sx provocation will depend on individual patient presentation
- Extension loss
- Centralization
The movements and positions that result in peripheralizing or centralizing leg pain should be noted and will depend on whether the patinet has a disc herniation or stenosis.
- Patients with HNPs will have Sx with lumbar flexion and centralized lumbar extension
- A HALLMARK of patients with HNP is they initially have a significant loss of extension that will rapidly restore once they perform repeated or sustained lumbar extension
- Patients with Stenosis of leg Sx with extension and centralization with flexion based movements. This will occur either bilaterally or unilaterally depending on the type of lumbar stenosis
During the Movement and Provocation examination, what would you see with PIVM?
- Hypomobility and Sx reproduction at the involved segments
- Possible hyper- or hypomobility at adjacent segments
- For patients with disc herniations, the PIVM assessment may reveal segmental reproduction in the lumbar spine and LE
- For patients with stenosis, the involved segements may be hypomobile or in cases of an unstable spondylosthesis, could be hypermobile and can elicit local and distal Sx reproduction
What test are part of the Neurodynamic Testing?
These are mostly for HNP, although they can reproduce both lateral foraminal and centtral canal stenosis
- Straight Leg Raise (SLR)
- Cross Straight Leg Raise
- Slump Test
- Femoral Nerve Tension Test (Ely’s Test)
What was the Diagnostic Cluster developed to determine which patients have Lumbar Spinal Stenosis?
Cooks Cluster (Lumbar Spinal Stenosis)
- Bilateral Sx
- Leg pain > Back pain
- Pain during standing and walking
- Pain relief upon sitting
- Age >48 years old
What is LSS?
A common degenerative condition associated with narrowing of the spinal canal or nerve root canals caused by degenerative arthritic changes of the facet joints and intervertebral disks
With patients with LBO with Radiating Pain, what is the clinical importance of performing the Two Stage Treadmill Test with those with Lumbar Spinal Stenosis?
We must determine the cause of Sx for those who have bilateral LE pain with walking and reduces with sitting
They may have:
- Neurogenic Claudication: Pain, paresthesia, and cramping of the LE brought by walking and relieved by sitting. This should be more affected by the position of the spine during the LE exertion. A positive test results for neurogenic is a demonstration of greater tolerance for walking in an inclined position, which places the spine in flexion
or
- Vascular/Intermittent Claudication: From peripheral vascular disease. This must be screened before a diagnosis of spinal stenosis can be made. This should be only affected by the level of LE exertion and the demands of blood flow to the LE muscles
Why might LSS result in leg Sx?
Due to compression on the vertebral venous plexus from multi-level stenosis that creates venous pooling and congestion and leads to ischemic pain and fatigue in the LE during walking
What movement is typically limted with LSS? What movement alliviates pain?
- Spinal Extension is commonly limited
- Sitting or assuming a spinal flexion (forward bent) position often
What are the 7 Hx items that can be used to help Diagnose LSS?
- Leg or buttock pain while walking
- Flex forward to relieve Sx
- Feel relief when using a shopping cart or bicycle
- Motor or sensory disturbances while walking
- Normal and symmetric foot pulses
- LE weakness
- LBP
What is the Clinical Course and Prognosis of LBP with Radiating Pain?
- Self-limiting with a favorable prognosis with resolution of Sx occuring weeks to month
- 70-90% of patinets exerience improvement without surgery
- Most patients will see Sx improvement over time
- Sx centralixation is a Positive prognositic indicator
- Spontaneous resolution of disk herniations are common
- Motor and sensory deficits will improve at different rates
- patients should be monitored for several progressive neurological dysfunction
What are Interventions recommended by the clinical practice guidelines for patients in the Acute stage?
Classification, Education, Exercise, Manual Therapy
Classification
- Mechanical Dx and Therapy or Treatment-based classification
Education
- Advice to remain active, pursue an active lifestyle, and self-management
- Favorable natural Hx of acute LBP
Exercise
- Trunk strengthening, endurance, and specific trunk activation training
Manual Therapy
- Neural tissue mobilization
- Thrust and non-trust manipulation and soft tissue mobilization to reduce pain and disability
What are Interventions recommended by the clinical practice guidelines for patients in the Subcute stage?
Classification, Education, Exercise, Manual Therapy
Classification
- Mechanical Dx and Therapy or Treatment-based classification
Education
- Advice to remain active, pursue an active lifestyle, and self-management
- Favorable natural Hx of subacute LBP
Exercise
- Trunk strengthening, endurance, and specific trunk activating training
Manual Therapy
- Neural tissue mobilization
- Thrust and non-trust manipulation and soft tissue mobilization to reduce pain and disability
What are Interventions recommended by the clinical practice guidelines for patients in the Chronic stage?
Education, Exercise, Manual Therapy
Classification
- Mechanical Dx and Therapy or Treatment-based classification
Education
- Advice to remain active, pursure an active lifestyle, and self-management
- pain neuroscience education
Exercise
- Trunk strengthening, endurance, specific trunk activation and movement control training
Manual Therapy
- Neural tissue mobilization
- Thrust and non-trust manipulation and soft tissue mobilization to reduce pain and disability
With Interventions, what is the Mechanical Dx and Therapy (MDT) for patients with LBP with Radiating Pain?
- Assessment and treatment utilizing the patients directional prefernce for Sx centralization
- Disk related conditions often respond to extension-oriented program (Mckenzy)
- Stenosis related conditions often respond to flexion-oriented program (William’s Flexion exercises)
What is the Cluster for Lumbar Traction or Positional Distraction, in the Prone position?
- Radicular LE pain
- Signs of nerve compression (DTR, Myotomes, Dermatomes)
- Peripheralization of Sx with extension
- (+) Crossed SLR (45°)
