Low Back Pain Eval Flashcards
Percentage of American adults who will experience at least one serious episode of LBP
- 84%
LBP economic cost
- $100 billion/year
Patients who have best recovery from LBP
- Pts who have high expectations for recovery *psychosocial variables are stronger predictors of long-term disability than anatomic findings found on imaging studies
LBP Red Flags
- Fracture - Tumor - Infection - Cauda Equina Syndrome
Suspicion for fracture
- >70 years, female, premature menopause/lack of hormone replacement - Recent trauma - Hx of hyperthyroidism, Cushing’s, Addison’s, Osteoporosis - Sedentary lifestyle
Suspicion for Cancer
- Night pain (unrelieved by change of position) - Unexplained weight loss - Prior or family history of cancer - Changes in bowel &/or bladder function/control
Suspicion for Cauda Equina Syndrome
- Sciatica (pain stops at knee) - B/L leg weakness/numbness - Difficulty walking - Urinary retention or overflow incontinence - New onset of unexplained constipation
Signs of Surgical Emergency
- Cauda Equina syndrome - Saddle anethesis - Decreased anal sphincter tone - Bowel or bladder symptoms - Sciatica w/ rapidly progressing motor weakness/neurologic deficit(s) *usually assoc. w/ massive central disc herniation
Transitional vertebra
- Congenital anomaly in which there is a naturally occurring articulation or bony infusion b/w the transverse processes of L5 and sacrum, but there is still a small remnant disc space b/w - Type II means one or both transverse processes appear to form a diarthrodial joint w/ sacrum but no bony fusion - Type IV means that there is a type II on one side and a complete bony fusion on the opposite
Spondylosis
- Arthritis of the spine. Seen radiographically as disc space narrowing and arthritic changes of the facet joint
Spondylolisthesis
- Anterior displacement of a vertebra on the one beneath it. A radiologist determines degree of slippage upon reviewing spinal x-ray. Slippage graded I-IV
Spondylolisthesis Grading
- Grade I: 1-25% slip (does not require surgery) - Grade II: 26-50% slip (“) - Grade III: 51-75% slip (surgery if persistent and disabling symptoms) - Grade IV: 76-100% slip (“)
Spondylolysis
- A fracture in the in the Pars interarticularis where the vertebral body and the posterior elements, protecting the nerves are joined, In a small percent of the adult pop., there is a developmental crack in one of the vertebrae (usually at L5)
Spinal stenosis
- Local, segmental, or generalized narrowing of the central spinal canal by bone or soft tissue elements, usually bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum
Radiculopathy
- Impairment of a nerve root, usually causing radiating pain, numbness, tingling or muscle weakness that corresponds to a specific nerve root
Sciatica
- Pain, numbness, tingling in the distribution of the sciatic nerve, radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle
Cauda Equina Syndrome
- Loss of bowel and bladder control and numbness in the groin and saddle area of the perineum, assoc. w/ weakness of the lower extremities - Can be caused by abnormal pressure on the bottom-most portion of the spinal canal and spinal nerve roots, related to either bony stenosis or a large herniated disc
Schmorl’s Nodes
- Herniation of the nucleus pulposus into the adjacent end plate - Seen in approx 20% of MRI studies in pts w/o back pain - Assoc. w/ degenerative changes in the lower back - Not an independent risk factor for back pain
Uncomfortable back extension causes
- Think deg disc disease
- Spondylosis
- Hypertrophy of lumbar zygopophyseal (facet) joints
- Hypertrophy of ligamentum flavum
Neurogenic vs. Vascular pain chart
Lumbar Synovial Cyst
- Mimics a herniated disc in that it will cause pain to shoot down the nerve root from its origin
Tarlov cyst
- Sacral perineural cysts
- Nerve root cyists found most commonly in the sacral roots, arising b/w the covering layer othe perineurium and the endoneurium near the dorsal root ganglion
- Mayi complain of low back pain w/ neurological claudication (pain)
L1 lumbosacral myotome
- Femoral nerve
*Iliopsoas (hip flexion)
L2 lumbosacral myotome
- Femoral nerve
*Iliopsoas (hip flexion)
*Quadriceps (knee extension)
- Obturator nerve
*Hip adductors
L3 lumbosacral myotome
- Femoral nerve
*Iliopsoas (hip flexion)
*Quadriceps (knee extension)
- Obturator nerve
*Hip adductors
L4 lumbosacral myotome
- Femoral nerve
*Iliopsoas (hip flexion)
*Quadriceps (knee extension)
- Obturator nerve
*Hip adductors
L5 lumbosacral myotome
- Peroneal nerve
*Ankle dorsiflexion (tibialis anterior)
*Ankle eversion (peroneus muscles)
- Tibial nerve
*Ankle inversion (tibialis posterior)
- Superior gluteal nerve
*Hip abduction (gluteus medius)
*Leg internal rotation (tensor fascia latae)
S1 lumbosacral myotome
- Inferior gluteal nerve
*Hip extension (gluteus maximus)
- Sciatic nerve
*Knee flexion (hamstrings)
- Tibial nerve
*Ankle plantar flexion
S2 lumbosacral myotome
- Inferior gluteal nerve
*Hip extension (gluteus maximus)
- Sciatic nerve
*knee flexion (hamstrings)
- Tibial nerve
*Ankle plantar flexion
L1 nerve root lesions pain, sensory loss, weakness and assoc. stretch reflex loss
- Pain: inguinal region
- Sensory loss: inguinal region
- Weakness: rarely hip flexion
- Stretch reflex loss: None
L2, 3, 4 nerve root lesions pain, sensory loss, weakness and assoc. stretch reflex loss
- Pain: back, radiating into anterior thigh, and at times medial lower leg
- Sensory loss: anterior thigh, occasionally medial lower leg
- Weakness: hip flexion, hip adduction, knee extension
- Stretch reflex loss: patellar tendon
L5 nerve root lesions pain, sensory loss, weakness and assoc. stretch reflex loss
- Pain: back, radiating into buttock, lateral thigh, lateral calf and dorsum foot, great toe
- Sensory loss: lateral calf, dorsum foot, web space b/w first and second toe
- Weakness: hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion
- Stretch reflex loss: semitendinosus/semibranosus (internal hamstrings) tendon
S1 nerve root lesions pain, sensory loss, weakness and assoc. stretch reflex loss
- Pain: back, radiating into butt, lateral or posterior thigh, posterior calf, lateral or plantar food
- Sensory loss: posterior calf, lateral or plantar aspect of foot
- Weakness: hip extension, knee flexion, plantar flexion of the foot
- Stretch reflex loss: achilles tendon
S2, 3, 4 nerve root lesions pain, sensory loss, weakness and assoc. stretch reflex loss
- Pain: sacral or butt pain radiating into the posterior aspect of the leg or the perineum
- Sensory loss: medial butt, perineal, and perianal regions
- Weakness: may be minimal, with urinary and fecal incontinence as well as sexual dysfunction
- Stretch reflex loss: bulbocavernosus, anal wink
L-4 Nerve Root
- Tibialis anterior (deep peroneal nerve)
- Difficulty walking on heels (also L5 root)
- Diminished patellar reflex (asymmetric)
- Sensory loss medial aspect of the lower leg/ankle/foot
L-5 Nerve Root
- Motor to extensor hallucis longus, extensor digitorum longus and brevis and gluteus medius
- Weakness of ankle and great toe dorsiflexion
- L5 muscle stretch reflex- medial hamstring tendons
- Sensory loss to lateral leg and dorsum of foot
S-1 Nerve Root
- Motor to peroneus longus/brevis; gastrocnemius,soleus and gluteus maximus
- Difficulty walking on toes
- Weakness of plantar flexion of the foot
- Diminished achilles reflex (asymmetric)
- Sensory loss lateral and plantar aspect of the foot/ankle
T10-T11 Autonomics- sympathetics
- Kidneys, gonads, upper ureter, adrenals
T12-L2 Autonomics-Sympathetics
- Lower ureters, uterus, vagina, clitoris, vas deferens, prostate, bladder, urethra, fallopian tubes, seminal vesicles, sphincter, trigone
