Lecture 3 - The Lower Back

Question 1

How many processes do the vertebrae have and what are they?

Answer 1

7
2 x superior articular processes
2 x inferior articular processes
2 x transverse processes
1 x spinous process

Question 2

What are the 3 joints to know about in the spine

Answer 2

Zygopophyseal/facet joint - synovial joint between the superior articular facet and the inferior articular process of neighbouring vertebra

Secondary cartilaginous joint - fibrocartilage joint between vertebral bodies, typically known as discs

Costovertebral joint - synovial joint connecting ribs with their corresponding thoracic vertebrae

Question 3

What are the qualities of lumbar vertebrae

Answer 3

Kidney/bean shaped vertebral bodies
Large to absorb shock/for load-bearing
Level of lumbar rotation is limited to 5-13 degrees due to inward orientation of the superior articular processes

Question 4

Give the qualities of the lumbar vertebrae/how to identify them on palpation

Answer 4

L5 = 30 degrees up from PSIS’s
L4 = Go to apex of iliac crest and follow round
L5 and T12 = small and round
L4 and L1 = quadrilateral
L3 = Longest vertebrae

Question 5

What are the two groups of back muscles with 3 muscles in each, what action do they do and what are the relevant muscles?

Answer 5

Erector spinae muscles - extensors
- Longissimus
- Iliocostalis
- Spinalis

Transversospinales muscles - extensors

• Mortifidus
• Rotatores
• Semispinalis

Question 6

What are the extensors of the back?

Answer 6

Erector spinae
Transversospinalis
Quadratus lumborum

Question 7

What are the flexors of the back?

Answer 7

Internal and external obliques
Rectus abdominis
Psoas major and psoas minor

Question 8

What are the main side flexors of the back?

Answer 8

Internal and external obliques
Quadratus Lumborum
Unilateral transversospinales

Question 9

Why do stiff muscles cause pain?

Answer 9

Pull on bones irritating periosteum which is the membrane covering the bone rich with nerve and blood supply

Continually contracted/stiff muscles = achy

Restricts movement of joints meaning synovial fluid doesn’t move around joints

Question 10

Why is breathing relevant to lower back pain

Answer 10

Apical breathing can put strain on the levator scapulae muscles due to overuse

Accessory muscle overuse can cause soreness (this includes the obliques, serratus posterior and latissimus dorsi)

Tightness/soreness of muscles that attach to the ribs can reduce lateral expansion.

Question 11

Give a list of additional symptoms that might raise red flags around cancer

Answer 11

Generally unwell
Sudden unexplained weight loss
History of cancer
Night/persistent pain
Thoracic Pain
Usually non-mechanic presentation

Question 12

What are the key symptoms of cauda equina?

Answer 12

Perineal/bladder/bowel/genital changes
Urinary retention/overflow incontinence
Severe bilateral radicular pain and lower back pain
Ejaculation issues

Question 13

What are the signs of infection in the back?

Answer 13

Generally unwell
Redness and heat
Bony tenderness + overlying soft tissue lesions
Recent infection
Immunosupressed
Severe pain
Night/persistent pain
Blood tests consistent with sepsis - ESR, CRP and neutrophil count

Question 14

What blood test results indicate inflammation/infection

Answer 14

Higher erythrocyte sedimentation rate (red blood cells settle to the bottom of the test tube settling further due to additional proteins caused by inflammation)

Higher CRP count (increased c-reactive protein count)

Question 15

Give warning signs of spinal fracture

Answer 15

Major trauma in fit and young people or minor trauma in elderly
Severe distress and movement restriction
Bony tenderness
Structural deformity
Prolonged use of corticosteroids
Pain is sudden onset and excruciating - eased by lying

Question 15

Give warning signs of inflammation

Answer 15

Early morning stiffness lasting longer than 30 minutes
Blood test results indicative of inflammation
Inflammatory patterns i.e. pain eases with activity, worsens into the evening
Restricted spinal movements
Pain alternates sides and impacts sacroiliac joints and buttocks
Sternocostal pain and reduced chest expansion
History of inflammation in other joints or areas for example inflammatory bowel syndrome or psoriasis

Question 16

What is axial spondyloarthritis?

Answer 16

Axial spondyloarthritis has two divisions and is inflammatory arthritis in the spine or the sacroiliac joint:
- Ankylosing spondylitis = able to be viewed on x-ray
- Non-radiographic axial spondyloarthritis = unable to be viewed on x-ray

Question 17

What is a radiculopathy?

Answer 17

A range of symptoms produced by a pinching of the nerve root

Question 18

What is myelopathy

Answer 18

Myelopathy is any neurologic deficit related to the spinal cord

Question 19

What is spinal stenosis

Answer 19

Radiculopathy caused by narrowing of the vertebral canal compressing the spinal cord

Question 20

Give five examples of causes of spinal stenosis

Answer 20

Osteophytes (bony spurs) formed due to an area of the spine becoming too mobile, the facet joint thickens in an attempt to stabilise this and this leads to bony spurs forming which can compress the spinal cord

Thickened ligaments - occurs over time

Herniated disk - the nucleus pulposus of the fibrocartilaginous disc between vertebral bodies protrudes into the vertebral canal

Tumours

Spondylolisthesis - a vertebral disc shifts anteriorly

Question 21

Neuropathy

Answer 21

Pain related to the nervous system

Question 22

What is spondylosis

Answer 22

Degenerative changes to bones and discs in the spinal column - most common cause is spinal osteoarthritis

Question 23

What are the symptoms of peripheral neuropathy?

Answer 23

if damage to sensory nerve:
- Numbness/tingling (paraesthesia)
- Stabbing/shooting/burning pain
- Balance/co-ordination issues

If damage to motor nerve:
- Muscle wasting and weakness

Question 24

Give some causes of peripheral neuropathy

Answer 24

Diabetes = main cause as high blood sugar damages nerves over time

Autoimmune diseases such as guillain-barre syndrome

Physical damage

Viral infections

Cancer

Toxins

Nutritional deficiency

Too much alcohol or certain other medications

Question 25

What are some ways to differentiate between peripheral and spinal neuropathy?

Answer 25

Sensation issues will follow dermatomal patterns if spinal and glove and sock pattern if peripheral

Question 26

What are the 6 P’s for indication of PAD

Answer 26

Pain
Poikilothermal (inability to regulate temperature)
Pallor
Pulselessness
Paraesthesia
Paralysis

Question 27

Give some things you might look for when you observe someone with lower back pain

Answer 27

Slapping of feet indicates foot drop which indicates radiculopathy

Increased kyphosis - Scheurrmann’s disease in adolescence

Decreased lumbar lordosis - indicates spinal stenosis

Diaphragmatic v apical breathing

Muscle bulk - trapezius, quadriceps, gastrocnemius, scapula muscles

Buttocks and knee creases

Ataxic gait - myelopathy

Increased gap between one hand and hip indicates pelvic tilt

Question 28

What tests would you do in a neurological assessment for a patient with lower back pain

Answer 28

Patella tendon reflex test
Achilles tendon reflex test
- Hyperreflexia indicates Upper motor neuron issue
- Hyporeflexia, weak or non-existent reflex can indicate lower motor neuron issue

Babinski - Run something (i.e. end of tendon hammer) down the lateral part of the foot from posterior to anterior and look for toes splaying (positive sign)

Clonus - rapid passive dorsiflexion and hold, if more than 3 beats, clonus indicated

Hoffman’s - flick middle finger rapidly, look for index finger and thumb pinching together (less reliable)

Question 29

Describe how you would test the myotomes

Answer 29

L2 - Resisted Hip flexion
L3 - Resisted knee extension
L4-5 Resisted knee flexion
L4 - Resisted dorsiflexion
L5 - Resisted toe extension
S1 - Resisted plantarflexion
S1 - Resisted eversion
Tiptoes, single legged on tiptoes and walking on tiptoes can also test S1

Question 30

Describe how you would test dermatomes

Answer 30

Use cotton wool ball to test circumferentially or dermatomally

Question 31

How do you test vascular function in the lower limb

Answer 31

Take popliteal, dorsal-pedal and tibialis posterior pulses looking for weak or non-existent pulse

Question 32

What is a PPIVM

Answer 32

Passive physiological intervertebral movement:
Put your fingers between the vertebrae and bring one or two legs to chest in order to bring about trunk flexion

Feel for quantity and quality of movement as well as if the patient feels pain

Question 33

What is a PAIVM

Answer 33

Passive accessory intervertebral movement:
Transverse glides of spinous processes
P-A glides of spinous processes

Feeling for quality of movement, stiffness, pain and can be used as treatment or assessment