Low back notes Flashcards
what should you screen for when assessing LBP?
severe trauma fever or recent bacterial infection saddle anesthesia severe or progressive neurological complaints bladder dysfunction unexplained weight loss prior history of cancer IV drug use or immunosuppression pain that is worse at night
what questions should you ask with someone who has LBP
Trauma? Mechanism? Severity? is there leg pain? are leg complaints worse with coughing, sneezing or straining at the stool? weakness in legs with activity? difficulty with urination or defecation? adominal pain? weight loss? level of pain and functional capacity?
what do you do if there are signs of cauda equine?
refer for neurological evaluation
fracture, infection or cancer indicates what?
radiographs
if the clinical, radiographic or labs indicate tumor, infection or fracture, what should you do?
sent for medical evaluation and management
what do you do with patients that appear to have a mechanical cause of pain?
managed conservatively for one month
if unresponsive, further testing or referral for second opinion
what is the most sensitivty indicator for cauda equina syndrome?
urinary retention/overflow incontinence
low back pain due to cancer potential indicators
>50 previous history of cancer unexplained weight loss failure to respond to conservative care pain unrelieved by bed rest
low back pain due to spinal infection potential indicators
history of UTI urinary catheter injection of drugs skin infections fever (highly specific)
ominous conditions for older patients
sudden onset of pain with coughing, sneezing or sudden lfecion unassociated with radicular complaints should warrrant a search for potential compression fracture
signs and symptoms of LBP from a disc
pain travelling below the knee
paresthesia or numbness
history of recurrent episodes of back pain without leg pain
30-50 yo
may report twisting injury accompanied by immediate leg pain
younger patients with a disc lesion have pain when?
sitting
less with standing or walking
older patients with leg pain is more likely to have?
a compression insult of the nerve root due to various forms of stenosis
more difficulty with walking or standing because of the compressive effect
selected disorders of low back
disc lesion facet syndrome canal stenosis spondylolisthesis aneurysm
signs/symptoms of disc lesion with radiculopathy
30-50 yo
patient complains of low back and leg pain below knee
sudden onset from bending &/or twisting maneuver
several bouts of LBP that resolved
NR inflammed but not always compressed
what does herniated disc material cause?
release of irritating substances or initiates an autoimmune inflammatory reaction
when the ___ is compressed, frank neurological signs usually become evident
nerve root
98% of all disc lesions are at?
L4/5
L5/S1
weakness of dorsiflexion of great toe and numbness on lateral side of lower leg suggests
L5 NR lesion
L4 disc
L5 disc
S1 NR
absent achilles relfex, numbness on the back of the calf, lateral foot or torrom of the foot, weakness on plantar flexion of great toe or foot
what is a reliable nerve root sign?
SLR when positive for reproduction of leg pain below 45 degrees of elevation
valsalva
slump
what is a strong confirmation of a disc lesion
positive well leg raiser
braggard’s
when is confirmation of MRI or electrodiagnostic studies used for a disc lesion?
within the first 4 weeks if severe, unrelenting pain or progressive neurological signs
what are good ways to adjust people with disc lesions?
flexion disraction
blocking
activator
make sure ot tell them exactly what could happen
in the C spine, midline disc herniations create?
myelopathies
midline disc herniations are usually from?
spinal cord pathology
lateral disc herniation in the C spine compresses?
nerve below (C5 disc herniates C6 root)
midline/paracentral disc herniation compresses what in the L spine?
NR below
L5 disc compresses S1 NR
foraminal disc herniation in the L spine involves?
NR at the same level
L5 disc herniation compresses L5 root
high intensity zone
area of high signal intensity on T2 weighted MR images of the disc, usually referring to the outer annulus
may reflect fissure or tear of the annulus
signs/symptoms of L5/S1 disc lesion
affects the S1 NR
pain projection to the S1 area
pathological achilles relfex
sensory deficit in teh S1 dermatome (posterior-lateral leg and lateral foot)
weak plantar flexion (peroneus longus)
difficulty with toe walking (peroneus brevis)
signs/symptoms of L4/L5 disc lesion
affects the L5 NR
extensor hallucis weakness
pain projects in the L5 area
sensory deficit in the L5 dermatome (anterior lateral lower leg and top of foot)
weak dorsiflexion of foot/difficulty with heel walking (ext. digitorum) (weak dorsiflexion suggest L4 or L5), primarily L5
L4 NR (L3-4 disc) DTR
patellar reflex
S1 NR (L5-S1 disc) DTR
achilles
L4 NR (L3-4 disc) motor exam
ankle dorsiflexion (primarily L5)
L5 NR (L4-5 disc) motor exam
great toe dorsiflexion (extensor hallucis longus)
S1 NR (L5-S1 disc) motor exam
ankle plantar flexion (gastroc-soleus comprex)
L4 NR (L3-4 disc) sensory exam
medial malleolus
L5 NR (L4-5 disc) sensory exam
dorsal 1/3 metatarsophalangeal joint
S1 NR (L5-S1 disc) sensory exam
lateral heel
weak knee extension and hip adduction
L3
foot inversion may suggest
L4 involveement
weak ankle dorsiflexion may be present suggests either?
L4-5 involvement
foot drop or “stomping foot”
L5 involvement
weakness of ankle dorsiflexion, toe extension and flexion, foot inversion and eversion, hip abduction
L5 involvement
weakenss of plantar flexion, knee flexion, hip extension
S1 involvement
pain or sensory loss in medial foreleg or medial lower leg
L4 involvement
pain in lteral thgh, lower leg and dorsum of foot
L5 involvement
sensory loss on anterolateral leg, first toe, and dorsum of foot suggests
L5 involvement
pain in posterior thigh, calf or heel suggests
S1 involvement
sensory loss of lateral foot, ankle, heel, toes, or sole
S1 involvement
abnormal patellar relfex
L4 involvement
asymmetric internal hamstring relfex
L5 involvement
abnormal achilles tendon reflex
S1 involvement
disc lesion lateral ro NR give s the patient what posture?
antalgic lean away
disc lesion medial to NR gives the patietn what posture?
antalgic lean toward
central disc lesion gives patient what posture?
flexed antalgic posture
patient will complain of what with facet syndrome?
well localized LBP with some hip/buttock or leg pain above the knee
onest of facet syndrome
sudden after a timple miss judged movement or arising from a flexed position
what is the source of pain for facet syndrome?
facet and its capsule
what can help you differentiate between a facet and a disc problem?
abscence of neurological deficits, absence of NR tension signs/tests, pain is rather localized with Kemp’s test and when reproduced with SLR does not extend below the knee
radiographic evidence may include facet imbrication
what radiographic lines help determine a facet problem?
hadlye’s S curve, disc angle greather than 15 degrees
describe signs and symptoms of canal stenosis
patients are often in their 50s or older
back and leg pain. pain can be unilateral and bilateral and is often diffuse
complain of onset of leg complaints with walking (claudication) and relief after resting 15-20 minutes or by maintaining a flexed posture
when does canal stenosis get better?
flexed posture
how does canal stenosis occur?
bony or soft tissue encroachment
multiple levels of stenosis usually involves?
leg complaints
what are the different types of stenosis?
congenital
pedicogenic
acquired stenosis
acquired stenosis can be due to?
osteophytes
degenerative spondylolisthesis
hypertrophied ligamentum flavum
