Low Back Pain 12/2 Flashcards
Epidemiology of LBP
1.3 % of total office visit
Lifetime prevalence 80%
Leading cause of work related disability
Estimated 149 million work days lost per year in US
Total cost of LBP 100 billion to 200 billion per year in US
Patient comes in c/ o of LBP describes it as deep ache and in left buttock and radiates down the left thigh, patient reports pain is worse when sitting for longer than 15 min, and improves with walking
PE shows tender SI joint region, tender point 2/3 distance between ILA and left greater trochanter
What is your diagnosis?
Piriformis syndrome
What is the action of the piriformis muscle?
Hip external rotation (when hip is extended) and abduction (when hip is flexed)
What are some associations/PE findings of piriformis syndrome?
Associated with trauma or over use
Parenthesias down posterior aspect of thigh due to proximity to sciatic nerve
Straight leg raise positive but nonspecific
Aching pain in gluteal region (greater sciatic foramen) which increases after sitting for longer than 15-20 min
What is sacral diagnosis associated with piriformis syndrome?
Typical scrum is rotated anteriorly towards ipsilateral side on contralateral axis
Example: rights died piriformis usually causes L on L sacral torsion with compensatory rotation of lower lumbar vertebrae in opposite direction
Leads to ipsilateral physiologic short leg
What hip dysfunction is associated with piriformis syndrome?
Ipsilateral hip external rotation SD
Piriformis diagnosis nd treatment t ?
Diagnosis of exclusion
R/o other causes with PE, xRAY, and or MRI
TXT: OMT, PT (effective for majority cases) , consider appropriate analgesics, consider glucocorticoid injections or botulinum toxin injections , rarely surgery
Patient presents with RLQ abdominal pain that radiates to her lower back; characterized as sharp, cramping pain started 2 hours after returning from 50 mi bike ride. She is hunched over to the right and standing up makes pain worse. PE notes tender point 2/3 distance from ASIS to midline. Diagnosis ?
Psoas major syndrome
What physical exam findings associated with psoas syndrome ?
Hypertonicity of psoas musculature
Chronic psoas spasm that can cause persistent strain across lunbrsacral junction
L1 and L2 commonly flexed and rotated towards side of affected psoas - chronic psoas syndrome may have two type 1 SDs( 1 above and 1 below ) around the type 2 SD of L1/L2
L5 commonly in extension
Tenderpoint ipsilateral iliacus and contralateral piriformis
Treatment for psoas syndrome ?
OMT directed txt of SD in thoracolumbar junction and lumbosacral area
Stretching of hypertonic psoas muscle
pt presents of LBP for 2 months
Pain is located midline and he points to area of lumbosacral junction, describes pin as dull ache and worse as day progresses.
Denies radiation down leg. History reveal underwent total hip arthroplasty 6 months ago. Lumbar X-ray shows no disc space narrowing but reveal 6mm difference in iliac crest heights, left higher than the right, which way would tou expect the lumbar spine to be sidebent? Diagnosis?
Left sidebent
Short leg syndrome
What PE findings are associated with short leg syndrome?
Sacroiliac and lumbosacral joint pain and dysfunction - dull, midline lumbosacral aching, becomes way worse as day progresses
Sacral base unleveling
Often associated with scoliosis
Iliolumbar ligament is typically first structure to react to added stresss in lumbosacral area
Tender palpating at attachment on Iliad crest or L4 and L5 TP
What are somatic dysfunctions associated with short leg syndrome?
Lumbar spine is SB away and rotated towards the side of sacral base
Innominate rotated anteriorly on side of short leg OR rotated posteriorly on side of long leg
Pelvic side shift to the side of the longer leg
Foot on longer leg pronates with IR
What type of X-ray is used for measuring heights of iliac crest femoral heads and sacral base?
Standing postural X-ray
What are some treatment considerations a for short leg syndrome
Treat SD area first
Exercise for stretching asymmetric muscles
Heel lift therapy
Acute change in leg length = replace full discrepancy immediately *
Heel lift therapy
For short leg syndrome
Typically only treated if leg length discrepancy is greater than 5 mm
Max 1/4 Heel lift in shoe, 1/4 may be added to outside for total 1/2
May add the full 1/2 outside of shoe
Final life height should be 1/2 to 3/4 of measured discrepancy unless recent sudden cause apparent
What are some PE associated with spondylolysis / spondylolisthesis ?
Children - usually asymptomatic
Adolescent athlete typically has gradual onset of symptoms in acute / subacute spondylolysis, worse when participating in activities
Pain may radiate to buttocks or posterior thigh - more common in spondylolisthesis
What are the common SD assocIated with spondylolysis and spondylolisthesis?
Psoas spasm or inhibition Iliacus dysfunction Flexed upper lumbar dysfunction Sacroiliac / sacral torsion dysfunction Innominate dysfunction
Treatments for spondylolysis and spondylolisthesis
OMT mostly indirect or ST
NO HVLA
Exercise focus on strengthening muscles and diminishing lordosis
Hamstring stretch
Postural improvement techniques
Avoid contact sports
Orthotics, braces, casts
Anti-inflammatory medication, muscle relaxants have limited role
Potential indications for surgery ie. progressive slippage, Neuro deficits, segmental instability with pain
Patient c/o pin right buttock radiates down posterior thigh for 1 week. No weka was in right leg, but lost balance a few times. Straight leg test is positive. Imagine shows lumbar spine herniation of spinal disc b/w L4 and L5. Protrusion of which anatomical structures is most likely causing patients sx?
Nucleus pulposus
What is the most common type of spinal disc herniation?
Posterolateral herniation
What are some PE findings / sx associated with spinal disc herniation?
—Sudden onset of LBP with bending or lifting or more gradual onset
- Most sx are caused by inflammation of nerve root, not by direct compression
- Radiculopathy
- straight leg positive
What disc are most commonly affected in spinal disc herniation?
L4-L5 and L5-S1
What are some causes of spinal disc herniation?
- microtrauma from rotational stresses predisposes the disc to damage
- sudden compressive or rotational force can cause tear in weakened nucleus pulposis
Treatment for spinal disc herniation
Most patients treat conservatively for acute sx ie rest a few days, ice , NSAIDs, steroids
Once acute phase has subsided consider OMT Targeted musculature and physical therapy
FPR technique useful if sx of radiculopathy
Indications for sx - intractable pain, progressive, or moderate to severe Neuro deficit
Diagnosis for spinal disc herniation
Clinical test of choice is MRI for confirmation
Patient pr3ents to ED for LBP radiates down her bilateral posterior thighs to level of the knee. Started 13 hours ago when she was helping move a couch and something “ tweaked wrong” in her back. She has not urinated or had a bowl movement t since this event. What is most likely to be found on PE?
Decreased pinprick sensation in perineum
Cauda equina syndrome
What some sx and PE findings for cauda equina syndrome?
- radicular pain
-paresthesia
-sensory loss in distribution of nerve roots
-bilateral lower extremity pain
-results in bowel or bladder dysfunction
-sensory loss of perineum (saddle anesthesia), decreased anal sphincter tone
MEDICAL EMERGENCY
What is the cause of cauda equina syndrome and txt ?
Spinal nerve root compression usually by a massive disk protrusion, fracture, or abnormal mass
Txt as MEDICAL EMERGENCY
Emergent management and surgical decompression within 48 hours or risk permanent neurological damage
Degenerative disc disease
Natural part of aging
By 49, 60% of women and. 80% of me have osteophytes and other changes indicative of degeneration
- lumbar spine particularly affected due to mobility and weight bearing responsibilities
-poor correlation with X-ray findings and degree of pain
-txt with OMT, PT, acetaminophen/NSAIDs
Spinal stenosis and causes
- narrowing of spinal canal Causes - herniated our bulging intervertebral disc - abnormal mass - osteophytes - scar tissue from previous surgery
Central vs lateral spinal stenosis
Central may result in neurogenic Claudication
Sx of spinal stenosis
Back pain frequently associated with radiculopathy
Pain exacerbated by standing and walking, relieved by sitting or lying down
Spinal stenosis diagnosis and txt
MRI
OMT offered relief of sx in 50% of patients
PT and aspirin / NSAIDs
Severe casa require surgery
Contraindications for OMT in LBP
- No HVLA vertebral tumor or cancer metastasis to spine ( can do other techniques as long as directly involved site is avoided)
- no HVLA Hx of osteoporosis
- no HVLA Acute lumbar disc herniation - relative contraindication
- Most types of direct txts for compression fx contraindicated except direct MFR
- no HVLA in acute phase rheumatiod arthritis affecting lumbar spine
Spinal curve compensation in aging?
Kyphosis
Spinal curve compensation in pregnancy?
Increased kyphosis and lordosis
Psoas strain causes what type of spinal curve compensation?
Loss of lordosis
What is compensated zink pattern?
L/R/L/R common
R/L/R /L uncommon
What is uncompensated zink pattern?
R/R/L/ L and others
