Lumbar Flashcards
Schobers test
A test used to assess decrease in lumbar flexion, typically seen in ankylosing spondylitis
- The patient stands upright with their feet together.
- The examiner locates the lumbosacral junction, which is typically the midpoint between the dimples of Venus (sacral dimples) at the level of the posterior superior iliac spines (PSIS).
- The examiner marks a point 10 cm above and a point 5 cm below the lumbosacral junction along the midline of the spine.
- With the patient in a forward-flexed position (bending forward), the distance between the two marked points is measured using a measuring tape or ruler.
- The examiner records the distance between the two points in centimeters.
*In individuals with normal lumbar spine mobility, the distance between the two marked points increases when the patient bends forward. A normal increase in distance (i.e., greater than or equal to 5 cm) indicates normal lumbar spine mobility.
*In individuals with decreased lumbar spine mobility, such as those with ankylosing spondylitis or other spinal conditions, the distance between the two marked points may increase by less than 5 cm or may not increase at all during forward flexion, indicating restricted lumbar spine mobility.
Ankylosing Spondylitis
Chronic inflammatory arthritis that primarliy affects the spine but other joints can be involved, inflammation of the intervertebral discs and joints in spine and pelvis
Causes: Genetics, Strongly associated with HLA-B27 gene, immune system dysfunction, environmental factors
S&S: Back pain, stiffness, fatigue, eye inflammation, breathing difficulties, reduced mobility, loss of appetite, weight loss
Multiple Sclerosis
Chronic autoimmune disease that affects the central nervous system. The immune system mistakenly attacks tthe myelin sheath leading to inflammation, demyelination and nerve damaga
Causes: Autoimmune disorder, genetics, environmental factors (Vit D defficiency, Smoking)
S&S: Faitgue, Numbness of weakness (SIngle or multiple limbs on one side of the body), Double blurred or loss of vision, sensory disturbances (tingling, Pricking, pain sensations) Coordination and balance problems, Muscle stiffness and spasm, Bladder and bowel dysfuntion, cognitive changes (memory, concentration)
Types of MS
Relapsing-remitting MS: Most common form, characterised by period of relapse followed by periods of remission
Primary progressive MS: Gradual worsening of symtpoms without periods of remission
Secondary Progressive MS: Begins as relapsing-remitting MS and eventually transitions to a progressive form of the disease
Progressive-relapsing MS: A rare form of characterised by a steady worsening of symptoms with occasional relapses
Myelopathy
Disease process of the spinal cord, leading to dysfunction or impairment of spinal cord function
Causes: Trauma, vascular disorder, infection, inflammation, tumours
Types: cervical< thoracic, Lumbar
S&S: Progressive weakness or numbness of extremities starting in hands/feet and origressive upwards. Changes in coordination, spasticity or rigidity, sensory disturbances, tingling, loss of sensation, bowel and bladder dysfunction, pain and paralysis.
Radiculopathy
Pinched nerve or irritated nerve as it leaves the spinal canal
S&S
-A distinctive pattern due to the nerve root/s involvement:
-Pain: sharp, shooting, burning, lancinating following dermatomal pattern/s
-One or more: parasthesia, dysesthesia, hyperesthesia, hypoesthesia, etc dermatomal pattern
-Myotomal weakness +/- atrophy
-Deep tendon reflex/s or absent
Lumbar herniation’s occurs 15 x more frequent cervical herniations
56% of adults have evidence of lumbar disc bulging
20-35% of working age adults have asymptomatic disc herniation
80% lifetime LBP prevalence, with 2-5% incidence of symptomatic disc herniation with nerve root involvement
Non specific Low Back Pain (NSLBP)
Lifetime prevalence 50-85%
Point prevalence 6-35%
10-50% of the population report pain in the last year, 21-39% in the past month.
to prevalence is equal
suffer more disabling LBP, more non-disabling LBP
Peak age of prevalence: 40 years and between 50-60 years
Disabling LBP is most common in 35-54 year olds
Smoking, obesity (high BMI), sedentary life style & leisure activities, alcohol use, psychological distress, catastrophising, fear avoidance
avoidance, depression
Lumbar sprain or strains (assumed involvement 70%)
Disc Herniation
Spinal Stenosis
Spondylolysis (Pars Articularis, young gymnasts extremely common)
Compression Fracture
Quada Equina syndrome
Red Flag
The cauda equina is a collection of nerves at the end of the spinal cord that control movement and sensation in the legs, bladder, and anus.
Cauda equina syndrome (CES) occurs when the nerves in the cauda equina are compressed or damaged
Men in the 4th and 5th decades of life are most prone to CES 2nd to disk herniations
CES is the 1st symptom of disc herniation
S&S:
Radicular pain - back, buttocks, perineum (saddle area), genitalia, thighs, leg.
Loss of sensation: often tingling or numbness in the saddle area.
Weakness: in legs, often asymmetric.
Bladder/bowel/sexual dysfunction: incontinence/retention of urine; incontinence of faeces; impotence/loss of ejaculation or orgasm.
Loss of reflexes: knee/ankle reflexes may be diminished, as may anal and bulbocavernosus
Posterior Facet Syndrome
Facet joint is bearing weight
facet joint load occurs through contact of the tip of the inferior articular process with the pars of the vertebra below. The overloaded facet then causes posterior rotation of the inferior articular process, resulting in stretching of the joint capsule
Normally the facet joints do not have a weight bearing
function, but with disc space narrowing, as with aging
and disc disease, the joint may be required to bear as
much as 70% of the axial compressive forces
In back extension, the facets along with the intervertebral discs absorb a compressive load.
History:
Dull aching LBP referring to buttock & posterior thigh, usually not past knee.
May also have sharp catchy localised low back pain.
Onset maybe sudden and patient may relate it to trauma such as twisting
Examination:
Active/passive ROM restricted and may reproduce pain.
No objective sensory or motor deficits (unless the facet or IVD lesions cause irritation to the nerve root)
Detectable abnormal movements - abnormal muscle contraction changes in movement patterns
Aggravated by movement especially hyperextension, lateral flexion and rotation (Kemp’s test – See practical book).
Disc Degeneration
Disc degeneration by the age of 50 years very prevalent, 85%–95% of adults show evidence of disc degeneration.
High prevalence in the asymptomatic population.
Up to 30% of young healthy adults with no back pain have disc degeneration on MRI scan.
Degenerative changes of the lumbar spine occur most frequently in the L4/L5 disc space seconded by the L5/S1 disc space. These disc spaces are the point of maximal force of transmission of the weight of the upper part of the body to the pelvic girdle.
Disc Degeneration Stages
1. Recurrent rotational strains
2. Circumferential annular tears
3. Coalesce to form radial tears
4. Internal disc disruption: Lots of tears, passing through all parts of the disc
5. Loss of disc height: Nucleus loses H20
6. Generalised peripheral disc bulge:
7. Disc resorption: Chemical, structural changes
8. Osteophytes
DDD Symptoms
-low-grade continuous but tolerable pain that will occasionally flare (intensify) for a few days or more
-LBP made worse with sitting, since in the seated position the lumbosacral discs are loaded 3x more than standing.
-Certain types of activity will usually worsen the LBP, especially bending, lifting and twisting.
-Walking, and even running, may actually feel better than prolonged sitting or standing.
-Patients will generally feel better if they can change positions frequently, and lying down is usually the best position since this relieves stress on the disc space.
Risk factors for DDD
Age: 30s or 40s
Genetic predisposition
Smoking - 3-4 x higher risk of developing DDD
Inactivity
Athletes micro trauma
Back injury macro trauma
Piriformis syndrome
Piriformis syndrome is a condition which is believed to result from nerve compression at the sciatic nerve by the piriformis muscl
