Lumbar Flashcards
Cancer and back-related tumor
Prior hx cancer Sp = 0.98, +LR = 28.7
Clinical judgment consistent with malignancy Sp = 0.98
Neurologic symptoms Sp = 0.97
Unexpected weight loss Sp = 0.94
Sensitive factors:
Age>= 50, unexplained weight loss, previous cx hx, or failure to improve over 1 mo. Sn = 100, -LR = 0.6
Spinal infection
Clinical features
LBP, flank, or pelvic pain
Local tenderness over spinous process with percussion
Concurrent infection or drug use
Fever
Gold standard for dx is MRI due to excellent sensitivity and specific
Cauda equina syndrome
Clinical features
Urinary retention* (very high sensitivity and specificity). Sp = 0.90, Sn = 0.95, +LR = 18, -LR = 0.11
Saddle anesthesia
Sensory or motor deficits in feet (L4-S1)
Spinal compression fracture
Clinical features
Major trauma
Age > 50
Female
Pain & tenderness
Abdominal aortic aneurysm
Palpable pulsating abdominal mass, can be associated with ripping sensation
Can often be palpated just left of umbilicus
Patients often experienced rapid, severe onset of groin pain that occurs with LBP
Ankylosing spondylitis
Clinical features
Morning stiffness > 30min
Improvement in LBP with exercise but not with rest
Night pain during second half of night
Alternating buttock pain
3/4 signs present => Sp = 0.97, +LR = 12.4
HLA-B27 lab values positive in vast majority of patients with ankylosing spondylitis, high c reactive protein, increased risk of autoimmune conditions
Most common age 13-45
Will likely also see limited chest expansion, limited sidebending
Cluster questions to ID abdominal pain of musculoskeletal origin
Cluster 1:
Does coughing, sneezing, or taking deep breath make pain worse?
Do activities such as bending, lifting, twisting, or turning in bed make pain worse?
Has there been any change in your bowel habit since onset of symptoms?
Cluster 2:
Does eating certain foods make your pain worse?
Has your weight changed since symptoms started?
Depression common risk factors
Current or past history of major depression
Family history of major depression
History of MI, CA, CVA, substance abuse, obesity, CHF, dementia, DM
currently suffering from significant loss or change in social status
Pregnant or post partum
Fatigue or sleep disturbance, fatigue, or weight change
Women > men
Chronic pain or 2+ chronic diseases
Screening questions for depression
One “yes” answer: 96% Sn, 57% Sp
Over the past 2 weeks, have you felt down, depressed, or hopeless?
Over the last 2 weeks, have you felt little interest or pleasure in doing things?
Lumbar manipulation clinical prediction rule
*symptom duration < 16 days
*Prone hip IR > 35deg
Lumbar segmental hypomobility
No symptoms distal to knee
FABQ work subscale < 19
4/5 conditions met were strong predictors of success with manipulation
*Clinical features with highest +LR
Lumbar treatment based classification
Mobilization/manipulation
Stabilization
Specific exercise (directional preference)
Traction -> interdisciplinary mgt
Misc
Lumbar
Malignancy red flag screening
Does not improve with rest (Most sensitive Sn = 0.9)
Previous history of cancer (most specific +LR = 15)
Age> 50
Unexplained weight loss > 10% in 6 months
Failure to improve after 1 mo therapy
Absence of all factors confidently rules out malignancy. Sn = 100%
Fever
LBP clinical feature
High specificity for spinal infection but only moderate sensitivity
Absence of fever does not significantly lower odds of spinal infection but presence of fever is suspicious of infection
Corticosteroids
LBP clinical feature
Fairly high specificity for compression fx. +LR=12
Advanced age, history of trauma, in addition to corticosteroid use should increase suspicion of fx
Urinary retention
LBP clinical feature
Very high sensitivity to rule out spinal cord compression when not present (Sn = 0.9, -LR = 0.1)
Very high specificity for ruling in spinal cord compression if present
SLR vs contralateral SLR
SLR has relatively high sensitivity for disc herniation, but limited specificity. Also is more relevant for lower lumbar spine
Contralateral SLR has relatively good specificity, but limited sensitivity
SIJ cluster test
Gaenslen
Patrick’s (FABER)
compression
Distraction
Thigh thrust test
Prognostic factors for recurrent low back pain
1) history of previous LBP episodes
2) excessive spine mobility
3) excessive mobility in other joints
Pronostic factors for developing chronic pain
1) presence of symptoms below the knee
2) psychological distress or depression
3) fear of pain, movement, reinjury, or low expectations of recovery
4) pain of high intensity
5) passive coping style
Kehr’s sign
Pain referred to left shoulder with palpation of abdomen when patient is lying down with legs elevated.
Can indicate ruptured spleen, ectopic pregnancy, or GI bloating/gas
Sub-group for benefit with lumbar traction
Pt with leg pain or signs of nerve root compression
Symptoms peripheralize with extension
Positive crossed SLR (high specificity test)
Leg symptoms that increase with activity that is otherwise not mechanical
Possible peripheral artery disease. Test for ABI or pedal pulses
ABI norms
Normal > 1.0
Mild disease 0.8-0.9
Moderate disease 0.5-0.8
Severe disease < 0.5
McKenzie approach
Postural syndrome
Symptoms tend to arise due to prolonged static positioning, alleviated when pt is not in that position or when participating in movement/activity
Tx includes education, postural corrections, restoring lumbar lordosis, avoiding prolonged stress on tissues
Mckenzie approach
Dysfunction classification
Pain results from deformation of structurally impaired tissue, or adaptive shortening
Pain is intermittent- tends to be produced at end range of restricted movement
Tx: repeated movement into dysfunction or direction that produces pain to encourage tissue remodeling
McKenzie approach
Derangement classification
Aka directional preference where repeated movement causes relative improvement of symptoms. Symptoms can either be local or referred
Tx: repeated movements to decrease pain, centralize symptoms
Panjabi theory
Spinal stability theory. includes a relatively more mobile “neutral zone” in the mid-range of movement, and an “elastic zone”at end-range that has more internal resistance
Panjabi subsystems of spinal stability
Passive system, comprised of vertebral bodies, facet joints, IVD, joint capsules, spinal ligaments
Active system, consisting of muscles and tendons
Neural system, which receives afferents from structures in active and passive subsystems to regulate spine stability
Cancers with a high chance of spinal metastasis
Prostate
Breast
Kidney
Thyroid
Lung
Central stenosis most common level
L4-L5
Brown-Sequard syndrome
Clinical presentation
Ipsilateral weakness or paralysis and contralateral sensory loss, resulting from spinal tumor or hemisection of spinal cord
Lumbar instability clinical presentation
May see gower’s sign
Clinical prediction rule indicating spinal stabilization approach:
Age < 40
SLR > 90deg
Aberrant motions during AROM (painful arc, etc)
+ Prone instability test
Traction parameters
Acute initial traction: static traction 5- 10 minutes.
Afterwards: 60 second hold/ 20sec rest @ 40- 60% body weight for 12 minutes
**Conflicting evidence states clinician should not use..
Laslett’s cluster test for SI
Thigh thrust (most sensitive)
Distraction test (most specific)
Compression test
Sacral thrust test
Gaenslen’s test
If at least 3/5 positive Sp =0.78, +LR=4.3
Compression test can be replaced by FABER test but results and diagnostic statistics are the same
Lumbar stenosis clinical cluster
Bilateral symptoms
Pain with walking/standing
Pain relief with sitting
Leg pain greater than back pain.
Age > 48 years old
