Lumbar Flashcards
What are the 10 serious conditions that need to be considered in a lumbar pain presentation?
Myocardial ischaemia Aortic dissection Retroperitoneal haemorrhage Osteomyelitis Tuberculosis Discitis Abscess Neoplasia Fracture Cauda equina
What are the signs and symptoms of cauda equina?
- severe localized central LBP, maybe sharp / stabbing pain in LL
- bladder and bowel incontinence
- sexual dysfunction
- saddle paraesthesia
- motor and sensory deficit LL
What are the signs and symptoms of an aortic dissection?
(must be considered as a DD for lumbar pain in patients with CV risk factors, esp. elderly patients)
- sudden onset severe pain (ripping / stabbing / tearing quality), maybe present in chest / Tx / Lx
- SOB
- difficulty speaking
- loss of vision
- difficulty walking / unilateral paralysis
- mental state change (distress, anxiety, confusion)
- collapse
- pulsatile abdo mass
What are the signs and symptoms of a vertebral compression fracture?
- acute midline back pain (can range from asymptomatic to severe)
- pain agg. by standing / sitting and relieved by lying down
- loss of height
- kyphotic deformity of spine
- maybe radiculopathy / myelopathy
What are the red flags for lumbar pain that indicate a serious cardiovascular condition?
SOB / dyspnoea palpitations pallor sweating mental state changes nausea / vomiting - SSX agg by activity
Which 4 infectious conditions can cause lumbar pain?
Osteomyelitis
Discitis
Abscess
Tuberculosis
What are some PROMs that can be used to measure lumbar pain and function?
ODQ (Oswestry) - best for persistent severe disability
RMQ (Roland-Morris) - best for mild to moderate disability
Describe the condition of lumbar facet syndrome
- lumbar facet joints most common source of mechanical LBP in chronic cases, often contributes to NSLBP
Pathology:
- dysfunction of facet joints that can include irritation / oedema of facet joint and surrounding structures, facet sprain, degeneration, microtrauma, radiculopathy
- most common in L4/5 and L5/S1
- high level of chronicity
Mechanism:
- insidious: degeneration, microtrauma, overuse (esp. repetitive flexion / extension)
Presentation:
- dull aching LBP, sharp w/ agg. movement
Agg by:
- extension, rotation, ipsilateral SB
- returning to standing from a flexed position
- prolonged sitting, standing, walking
Rel by:
- lying supine with bent knees
- contralateral SB
- supported flexion (sitting or standing with weight on hands and elbows
- analgesics / NSAIDs
Findings:
- decreased Lx ROM w pain on movement, pain with local extension, ipsilateral SB, rotation
- decreased pain with contralateral SB, flexion
- pain returning to stand from forward flexion
- pain on palpation / PA springing of affected segment
- increased Lx lordosis (esp. in chronic cases - protective flexion position)
Prognosis: high level of chronicity, need to manage psychosocial factors and pain beliefs, maintain activity
What is the difference between spondylolysis and spondylolisthesis?
Spondylolysis: fracture of pars interarticularis between superior and inferior facets
Spondylolisthesis: anterior slippage of vertebrae (often caused by underlying pars fracture or degeneration of lumbar vertebrae and ligaments)
Describe the condition of SIJ dysfunction
- common presentation, contributes to 15-30% of mechanical LBP cases
Presentation:
- broad area of pain over sacrum and low back, maybe radiating to groin, glutes, greater trochanter, posterior thigh
- dull and aching pain
Classic triad:
- pain over SIJ
- tenderness over sacrospinous and sacrotuberous ligs
- pain reproduction over pubic symphysis
Agg by:
- prolonged sitting
- climbing stairs
- jogging
- lying one one side in bed
- forward flexion
Pathology:
- umbrella term for pathology of SIJ including degeneration of ligaments creating hypermobility instability, hypomobility
Risk factors: age, pregnancy, trauma, hypermobility or hypomobility, mm imbalances around hip, weak trunk and back mm, leg length discrepancies
What are risk factors for SIJ dysfunction?
- pregnancy
- hypermobility
- hypomobility
- leg length discrepancy
- mm imbalance (ext and int hip rotators, hip flexors and extensors, other hip mm)
- asymmetrical biomechanics
- age related degeneration
- trauma
- weak trunk and back mm
What is the classic triad of findings in SIJ dysfunction?
- pain over SIJ
- pain reproduced on springing of pubic symphysis
- tenderness over sacrospinous and sacrotuberous ligaments
In a presentation of lumbar facet sprain or facet syndrome, which movements aggravate and which movements relieve pain?
Agg by:
- extension
- rotation
- ipsilateral SB
- returning to stand from forward flexion
Rel by:
- forward flexion
- contralateral SB
What are risk factors for lumbar disc herniation?
- age related degeneration
- lumbar trauma
- obesity / pregnancy
- prolonged Lx flexion (desk work, driving, manual labour)
- typical mechanism of injury flexion with rotation
What are typical findings in a lumbar disc herniation?
Pain (can be asymptomatic):
- typically dull and diffuse with sharp aggravations
- may have radicular pain in LL and particularly sciatic nerve
Agg by:
- flexion
- prolonged sitting, standing
Findings:
- single level motor / sensory disturbance
- diminished Achilles or patellar reflex
- positive SLR
- positive Slump test
- pain on Lx flexion
Prognosis:
- SSX reduction 4-6/52
- resolution 3-6/12
- if radiculopathy: resolution 3-6/12
Which signs in a suspected lumbar disc herniation indicate a potential myelopathy?
Radiculopathy:
- single level motor / sensory disturbance
- diminished patellar / Achilles reflex
Myelopathy:
- multi level motor / sensory disturbance
- increased tone / spasticity
- hyperreflexia
- clonus
What are common causes of lumbar radiculopathy?
- disc herniation (most common)
- osteoperotic degeneration (may include osteophytic bone growths)
- facet joint sprain or syndrome
Which nerves provide cutaneous supply to the lumbar region?
dorsal rami of spinal nerves
What are the spinal nerve roots of the obturator, femoral and sciatic nerves?
Obturator and femoral L2-4
Sciatic L4-S3
