LSP Flashcards
Common LSP Dx
Spinal stenosis Lumbar strain Spondylolistesis / lysis Herniated nucleus pulposus Cauda equina syndrome Pott's dz Compression fx
Spinal stenosis - in general
Congenital or acquired narrowing of the spinal canal
Usually worsening with age
>50yo
Distinguish by neurogenic vs. vascular claudication
Spinal stenosis - s/s
LBP & leg pain worse with extension
Leg pain with ambulation - dermatomal pattern
Leg weakness
Relief with lumbar flexion
Ask about night pain and bladder / bowel dysfunction
Spinal stenosis - exam
Increased leg pain with lumbar extension
Diminished reflexes
Decreased leg strength and sensation
SLR +/-
L4
Motor - tibialis anterior
Reflex - patellar
Sensation - medial ankle
L5
Motor - Extensor hallicus longus
Reflex - none
Sensation - top of foot
S1
Motor - Peroneus
Reflex - Achilles
Sensation - lateral ankle
Spinal stenosis - dx
Plain AP & lat x-rays
- DDD, Degenerative scoliosis, osteophyte formation or Degenerative spondylolisthesis
CT/Myelogram vs. MRI
Spinal stenosis - tx
LESI NSAIDs Sx decompression Refer - bladder / bowel incontinence - fail conservative tx
Herniated disc - in general
<50yo Acute onset of leg pain Pain usually dermatome specific L4-5 HNP most common Pain results from direct mechanical compression of nerve root or chemical irritation
Herniated disc - s/s
LBP & leg pain Worse with - sitting - bending - coughing / sneezing - twisting Difficult to remain in one position
Herniated disc - exam
Difficult to sit Increased leg pain with lumbar bending Positive SLR - sitting and supine Positive "bowstring sign" L3 femoral N. stretch test Decreased or absent reflex Decreased muscle strength Decrease sensation
Nerve Root - L4
Motor - Quads
Reflex - knee jerk
Sensation - anterior thigh
Nerve Root - L5
Motor - EHL (big toe)
Reflex - none
Sensation - Shin, top & medial foot
Nerve Root - S1
Motor - Ankle plantar flexion
Reflex - Achilles
Sensation - calf; lateral foot
Herniated disc - dx
X-rays
MRI scan***
Herniated disc - tx
PT LESI Taper dose prednisone NSAIDs Muscle relaxers Analgesics Nicotine abstinence Reassurance Sx
Herniated disc - when to refer
Cauda equina symptoms
Progressive neuro deficit
Paralysis
Failed conservative tx
Lumbar strain - in general
Repeated twisting or lifting heavy objects
May last a few days to 4 weeks
Annular tear may cause pain
Tendons, ligaments and muscles may be involved
Lumbar strain - s/s
LBP, may radiate to buttock
Difficulty standing straight
Lumbar strain - RF
Lifting Twisting Sitting for prolonged periods Poor fitness Smoking Operating Vibrating equipment
Lumbar strain - exam
Low back tenderness & spasm
Limited ROM
Normal reflexes and muscle strength
SLR produces LBP
Lumbar strain - dx
Plain x-rays usually not helpful
Atypical s/s, such as rest or night pain or trauma obtain x-rays
Lumbar strain - tx
Short course of NSAIDs Muscle relaxers Early PT No long term bed rest Avoid narcotics
Spondylotisthesis
“slip” or “listhesis”
Vertebral body slips in relation to one below
Defect in junction of lamina with pedicle (pars intra-articularis_ - Spondylolysis
Adolescent (L5-S1) vs. Degenerative (no pars defect)
Most likely a fatigue fx that fails to heal
Participation in gymnastics and football, may increase incidence
Degenerative slip secondary to DD found in older adults
Spondylotisthesis - s/s
May be asymptomatic
LBP with posterior leg radiation
Pain worse with standing and lumbar extension
Spondylotisthesis - exam
Diminished lumbar lordosis
Palpation - pain and “step-off” with spinous process of slipped vertebra
Lumbar pain with extension
Reflexes and MS usually normal
Spondylotisthesis - dx
X-ray - AP, lat, oblique view
Pars defect seen on oblique view (scotty dog) absent neck
CT scan
Bone scan
Spondylotisthesis - tx
PT Avoid aggravating activities Lumbar orthrosis Sx - degenerative slips Evaluate every 6 months with x-rays until growth complete
Compression Fx - in general
Osteoporosis related Occurs with or w/o trauma Acute onset of back pain May become multiple All heal in time (2 months) Feel better with brace (warm-n-foam, camp)
Compression Fx - tx
Kyphoplasty
Vertebroplasty
Kyphoplasty / vertebroplasty
1-3% neurologic complication
Reasonable choice for prolonged pain
Pott’s Dz
TB of the spine
Result in destruction of vertebral bodies
X-ray show vertebral ostolysis or compression fx
Tx - rest and anti-TB meds
Cauda Equina Syndrome - in general
Compression of causda equina roots
May result from large midline disc herniation
Occurs in only 2%
L4-5 most common
Cauda Equina Syndrome - s/s
Incontinence
Severe leg pain
Numbness
Difficulty walking
Cauda Equina Syndrome - dx
Emergent MRI
Cauda Equina Syndrome - tx
Sx
When to order x-rays
> 65yo
Hx of trauma
Pain lasting >4weeks
Hx of ca (MRI or bone scan)
When to order MRI
Loss of bladder/bowel control Neurological deficit Severe leg pain not responding to ESI Suspected malignancy (ca hx, night pain) Back pain for 4 months despite tx
“Hip pain”
Buttock - referred back pain
Groin - true hip joint pain
Lateral - trochanteric bursitis
Hx keys
What makes pain worse? Better?
Ca - constant, may be worse at night
Pain - increased by activity, relieved by rest
TRUE loss of bladder control
Exam keys
Decreased Knee Jerk - L3 or L4 Decreased EHL strentgth - L5 Decreased Ankle Jerk - S1 Beware - "breakaway weakness" or "cogwheeling" SLR- positive if it produces leg pain
Don’t forget other causes
Aortic aneurysm
Ca
Fx
DVT
