Lumbar

Question 1

Cancer and back-related tumor

Answer 1

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

Question 2

Spinal infection
Clinical features

Answer 2

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

Question 3

Cauda equina syndrome
Clinical features

Answer 3

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)

Question 4

Spinal compression fracture
Clinical features

Answer 4

Major trauma
Age > 50
Female
Pain & tenderness

Question 5

Abdominal aortic aneurysm

Answer 5

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

Question 6

Ankylosing spondylitis
Clinical features

Answer 6

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

Question 7

Cluster questions to ID abdominal pain of musculoskeletal origin

Answer 7

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?

Question 8

Depression common risk factors

Answer 8

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

Question 9

Screening questions for depression

Answer 9

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?

Question 10

Lumbar manipulation clinical prediction rule

Answer 10

*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

Question 11

Lumbar treatment based classification

Answer 11

Mobilization/manipulation
Stabilization
Specific exercise (directional preference)
Traction -> interdisciplinary mgt
Misc

Question 12

Lumbar
Malignancy red flag screening

Answer 12

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%

Question 13

Fever
LBP clinical feature

Answer 13

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

Question 14

Corticosteroids
LBP clinical feature

Answer 14

Fairly high specificity for compression fx. +LR=12

Advanced age, history of trauma, in addition to corticosteroid use should increase suspicion of fx

Question 15

Urinary retention
LBP clinical feature

Answer 15

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

Question 16

SLR vs contralateral SLR

Answer 16

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

Question 17

SIJ cluster test

Answer 17

Gaenslen
Patrick’s (FABER)
compression
Distraction
Thigh thrust test

Question 18

Prognostic factors for recurrent low back pain

Answer 18

1) history of previous LBP episodes
2) excessive spine mobility
3) excessive mobility in other joints

Question 19

Pronostic factors for developing chronic pain

Answer 19

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

Question 20

Kehr’s sign

Answer 20

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

Question 21

Sub-group for benefit with lumbar traction

Answer 21

Pt with leg pain or signs of nerve root compression
Symptoms peripheralize with extension
Positive crossed SLR (high specificity test)

Question 22

Leg symptoms that increase with activity that is otherwise not mechanical

Answer 22

Possible peripheral artery disease. Test for ABI or pedal pulses

Question 23

ABI norms

Answer 23

Normal > 1.0
Mild disease 0.8-0.9
Moderate disease 0.5-0.8
Severe disease < 0.5

Question 24

McKenzie approach
Postural syndrome

Answer 24

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

Question 25

Mckenzie approach
Dysfunction classification

Answer 25

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

Question 26

McKenzie approach
Derangement classification

Answer 26

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

Question 27

Panjabi theory

Answer 27

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

Question 28

Panjabi subsystems of spinal stability

Answer 28

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

Question 29

Cancers with a high chance of spinal metastasis

Answer 29

Prostate
Breast
Kidney
Thyroid
Lung

Question 30

Central stenosis most common level

Answer 30

L4-L5

Question 31

Brown-Sequard syndrome
Clinical presentation

Answer 31

Ipsilateral weakness or paralysis and contralateral sensory loss, resulting from spinal tumor or hemisection of spinal cord

Question 32

Lumbar instability clinical presentation

Answer 32

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

Question 33

Traction parameters

Answer 33

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..

Question 34

Laslett’s cluster test for SI

Answer 34

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

Question 35

Lumbar stenosis clinical cluster

Answer 35

Bilateral symptoms
Pain with walking/standing
Pain relief with sitting
Leg pain greater than back pain.
Age > 48 years old