Lecture 3 - The Lower Back Flashcards
How many processes do the vertebrae have and what are they?
7
2 x superior articular processes
2 x inferior articular processes
2 x transverse processes
1 x spinous process
What are the 3 joints to know about in the spine
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
What are the qualities of lumbar vertebrae
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
Give the qualities of the lumbar vertebrae/how to identify them on palpation
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
What are the two groups of back muscles with 3 muscles in each, what action do they do and what are the relevant muscles?
Erector spinae muscles - extensors
- Longissimus
- Iliocostalis
- Spinalis
Transversospinales muscles - extensors
- Mortifidus
- Rotatores
- Semispinalis
What are the extensors of the back?
Erector spinae
Transversospinalis
Quadratus lumborum
What are the flexors of the back?
Internal and external obliques
Rectus abdominis
Psoas major and psoas minor
What are the main side flexors of the back?
Internal and external obliques
Quadratus Lumborum
Unilateral transversospinales
Why do stiff muscles cause pain?
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
Why is breathing relevant to lower back pain
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.
Give a list of additional symptoms that might raise red flags around cancer
Generally unwell
Sudden unexplained weight loss
History of cancer
Night/persistent pain
Thoracic Pain
Usually non-mechanic presentation
What are the key symptoms of cauda equina?
Perineal/bladder/bowel/genital changes
Urinary retention/overflow incontinence
Severe bilateral radicular pain and lower back pain
Ejaculation issues
What are the signs of infection in the back?
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
What blood test results indicate inflammation/infection
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)
Give warning signs of spinal fracture
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
Give warning signs of inflammation
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
What is axial spondyloarthritis?
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
What is a radiculopathy?
A range of symptoms produced by a pinching of the nerve root
What is myelopathy
Myelopathy is any neurologic deficit related to the spinal cord
What is spinal stenosis
Radiculopathy caused by narrowing of the vertebral canal compressing the spinal cord
Give five examples of causes of spinal stenosis
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
Neuropathy
Pain related to the nervous system
What is spondylosis
Degenerative changes to bones and discs in the spinal column - most common cause is spinal osteoarthritis
What are the symptoms of peripheral neuropathy?
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
Give some causes of peripheral neuropathy
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
What are some ways to differentiate between peripheral and spinal neuropathy?
Sensation issues will follow dermatomal patterns if spinal and glove and sock pattern if peripheral
What are the 6 P’s for indication of PAD
Pain
Poikilothermal (inability to regulate temperature)
Pallor
Pulselessness
Paraesthesia
Paralysis
Give some things you might look for when you observe someone with lower back pain
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
What tests would you do in a neurological assessment for a patient with lower back pain
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)
Describe how you would test the myotomes
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
Describe how you would test dermatomes
Use cotton wool ball to test circumferentially or dermatomally
How do you test vascular function in the lower limb
Take popliteal, dorsal-pedal and tibialis posterior pulses looking for weak or non-existent pulse
What is a PPIVM
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
What is a PAIVM
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
