Lumbar Flashcards
MRI findings associated with clinical symptoms
High intensity zone = associated with annular tear and discogenic pain
Modic sign = disruption of endplate with bone marrow edema
NOTE: centralization of symptoms is the only clinical test that increase the likelihood of discogenic pain
BOTTOM LINE: HIZ, endplate changes, and/or centralization of symptoms indicates disc problem
Metastatic cancer clinical cluster
Screening cluster Sn = 100% (5/5): History of cancer Unexplained weight loss Age greater > 50 or < 17 Failure to improve over predicted time interval
Also:
Night pain or pain at rest
Disc or vertebra infection clinical cluster
Immunosuppression
Prolonged fever with temperature> 100.4
History of IV drug use
History of recent UTI, cellulitis, or pneumonia
Other:
Acute pain and tenderness of spinous processes
Vertebral fracture clinical cluster
Clinical prediction rule: Age> 70 Female Significant trauma Prolonged use of corticosteroids
Other risk factors:
Mild trauma in age >50
Known history of osteoporosis
Abdominal aortic aneurysm clinical cluster
Pulsating mass in abdomen
Throbbing, pulsing back pain at rest or with recumbency (not relieved by change in position)
History of atherosclerotic vascular disease
Age >60
Other:
Male
Recently started weightlifting
Structures in degenerative disc disease that can produce pain
Outermost annulus
Subchondral bone adjacent to injured disc
Adjacent tissues
Factors influencing/not influencing the development of lumbar DDD
Genetics = strongly linked
No link:
Smoking
Physical loading
Age related degenerative changes
Loss of hydration in nucleus
Vertebral end plate disruption
Annulus disruption
- Peripheral rim lesions due to trauma
- Circumferential tears due to repetitive stress
- Radial fissures (primary structural anomaly associated with DD)
Treatment for lumbar DDD related to stage of disease (early, later, severe, diurnal changes)
Mild early stage = no additional treatment precautions
Later stage = avoid vigorous or sustained loading at endrage of trunk motion; stabilization through contraction of abdominal and multifidus muscles may improve tolerance
Moderate or severe = avoid long exposure to compression (prolonged sitting or lumbar flexion)
NOTE: increased disc volume in the morning may influence response of discs to load, especially flexion (avoid early morning lumbar flexion)
Cancers that metastasize to bone
PB KTLL
Prostate Breast Kidney Thyroid Lung Lymphoma
Contraindications to manipulation
Any pathology that leads to significant bone weakening - Bone malignancies - Bone infection/osteomyelitis - Osteomalacia Fracture Ligamentous instability Inflammatory arthritis Neurological compromise: - Cord compression - Cauda equina - Nerve root compression with increasing neurological deficit Vascular compromise: - Aortic aneurysm - Bleeding into joints Unclear diagnosis/reason for pain Patient does not want Patient positioning cannot be achieved
Precautions to manipulation
Spondylolisthesis Hypermobility Post-surgical joints Osteoporosis Benign bone tumors Signs of nerve root compression Pregnancy Long-term use of steroids Blood thinners
Potential complications of manipulation
Cauda equina
Disc herniation
3 step process for validating clinical prediction rules
Derive
Validate
Analyze
Levels of CPR validation
Level 1 = perspective study with multiple locations plus an impact study
Level 2 = one large or several smaller perspective studies
Level 3 = similar sample size and type of clinicians as derivation study
Level 4 = retrospective data, narrow population
Derivation study = identifying components of model
Types of clinical prediction rules
Diagnostic
Interventional
Prognostic
Visceral referral patterns
Pancreas = pain T3 to 10, upper abdominal pain and symptoms in R shoulder Breast = anterior pain radiates posteriorly to thoracic region and posterior shoulder; skin changes, palpable nodes or lumps Esophagus = anterior neck pain, difficulty swallowing Heart = thoracic, neck, jaw, L arm pain; activity increases symptoms
Characteristics of pulmonary symptoms
Difficulty breathing
Semi reclined position improves symptoms
Characteristics of cardiac symptoms
Acute
Unrelieved with position
Aggravated by activity
Kehrs sign
= acute tip of L shoulder due to presence of blood or other areas in the paratomial cavity when lying down and legs are elevated
- Ruptured spleen
- GI bloating/gas
- Ectopic pregnancy
Gallbladder (cholecystitis) signs
= inflammation of gallbladder
Right upper quadrant pain and tenderness
Right upper abdominal pain
Right scapular pain
Mid to lower thoracic pain
Renal/kidney system referral
Pelvic and low back
Proximal thigh
Left shoulder pain
Changes/problems with urination
Gastrointestinal referral patterns
Lower abdominal and centralized LBP
Heartburn, indigestion, and difficulty swallowing (upper GI)
Bloody diarrhea, fecal incontinence (lower GI)
Stomach referral pattern
Upper abdominal, middle and lower thoracic (T6-10)
Large intestine referral pattern
Buttocks, middle lumber spine or lower abdomen
Ankylosing spondylitis (clinical signs, CPR’s, diagnosis)
Clinical presentation:
Mobility limitations throughout the spine
Pain worse in second half of night or in AM
Pain increased on days without exercise
Most common joints affected (in order): Spine Shoulder Hip Knee
CPR: Alternating buttocks pain Morning stiffness > 30 min Improvement with exercise Awakening due to pain during second half of the night only
CPR: Age of onset < 40 Insidious onset Improvement with exercise No improvement with rest Pain a night with improvement on getting up
Diagnosis:
HLAB27
Radiographs
Rheumatoid arthritis (signs and symptoms, associated syndromes)
More distal symptoms (hands, feet, ankles) BUT not distal IP, only proximal IP joints Knee joint swelling Rapid onset Females Onset 40-50
Associated syndromes:
Feltys = causes recurrent infections
Sjogrens = dryness of eyes and mouth
Contraindications for spinal traction
Spinal infection
RA or other acute inflammatory joint disorder
Osteoporosis
Spinal cancer
Central spinal cord pressure (tumor, central HNP)
Precautions for spinal traction
Joint hypermobility
Acute inflammation
Claustrophobia or anxiety associated with traction
Cardiac or respiratory insufficiency
Pregnancy
Symptoms increase with traction / history of aggravation with traction
TMJ dysfunction for cervical using chin strap
