Lumbar Assessment Flashcards
1
Q
Red Flags
A
- Age of onset <20 or >55 years
- Violent trauma, e.g. fall from height, RTA
- Constant, progressive, non-mechanical pain
- Thoracic pain
- PMH – Carcinoma
- Systemic steroids
- Drug abuse, HIV
- Systemically unwell
- Unexplained weight loss
- Persisting severe restriction to lumbar flexion
- Widespread neurology
- Structural deformity
- TB
If there are suspicious clinical features, and if pain has not settled in 6/52’s further investigations should be considered.
2
Q
Cauda Equina symptoms
A
Definite red flags:
- Bilateral radiculopathy (loss/diminished strength, feeling of touch or reflexes)
- Progressive neurological deficits in the legs
- Widespread (>one nerve root) or progressive weakness in the legs and/or gait disturbance.
Possible red/white flags:
- Unspecified urinary disturbance (any new change in bladder function but with preserved control)
- Loss of anal sphincter tone/faecal incontinence
- Saddle anaesthesia about the anus, perineum or genitals
- Erectile dysfunction or changes in sexual function
Definite white flags:
- Urinary retention or incontinence
- Faecal incontinence
- Perineal anaesthesia
3
Q
Infection symptoms
A
- General feeling unwell
- High temperature (fever)
- IVDU (intravenous drug use)
- Recent surgery / open wounds
4
Q
Cancer signs
A
- Previous Hx of cancer in themselves or family
- Unexplained weight loss
- Non- mechanical, constant pain
- Night sweats
- Generally feeling unwell
5
Q
Fracture signs
A
- Major trauma (motor vehicle accident, fall from height)
- Minor trauma or strenuous lifting in an older or osteoporotic patient
- Constant pain, worse on weight bearing
- Swelling/ bruising
- Steroid use
- Osteoporosis/ osteopenia
6
Q
Inflammatory Disorders (Ankylosing spondylitis etc.) signs
A
- Gradual onset
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement/tendionpathies/aches
- Iritis, skin irritation (psoriasis), colitis, urethral discharge
- Family history
7
Q
Myelopathy (Central cord compression in cervical (most common), thoracic or lumbar (rare) spine) signs
A
- Neck, arm, leg or lower back pain
- Tingling, numbness or weakness
- Difficulty with fine motor skills, such as writing or buttoning a shirt
- Increased reflexes in extremities or the development of abnormal reflexes
- Difficulty walking (ataxic gait)
- Loss of urinary or bowel control
- Issues with balance and coordination
8
Q
SQs
A
- Bladder and bowel dysfunction- bladder retention and bowel incontinence are signs of Cauda equina
- Sacral numbness - Sign of Cauda equina
- Gait disturbances/ataxia, knees or ankles giving way - sign of severe motor weakness
9
Q
Observation
A
- Gait:
- Excessive weight bearing through one leg
- Antalgic gait,
- Positive Trendelenberg,
- Posture during gait
- Postural alignment noting any asymmetry – scoliosis/kyphosis/flattened thoracic region
- CoG
- Adaptive postures- Pain avoidance, guarding/bracing
- Muscle tone/bulk
10
Q
Neurological testing
A
If pain referred below the crease of the buttocks then neurological testing is indicated
-
Myotomes (look for weakness not pain)
- L2: Hip flexion
- L3: Knee extension
- L4: Dorsiflexion
- L5: Great toe extension
- S1: Eversion, contract buttock, knee flexion
- S2: Knee flexion, toe standing
-
Reflexes
- Knee Jerk (L3-4, Femoral Nerve)
- Ankle Jerk (S1-2, Tibial Nerve)
- Dermatomes
Neurodynamics:
- Slump test: sciatic nerve and above
- Patient in sitting-ask patient to slump chin to chest and sump thoracic spine forward. Physio will apply a gentle force through the patients thoracic spine and neck. Patient is asked to extend their knee to point of discomfort is posterior leg. Release pressure on thoracic spine and ask patient to extend neck. Relief from discomfort in posterior of leg indicates a positive sign of neural tension on sciatic nerve.
- Straight leg raise: sciatic nerve and branches
- With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient’s leg while the knee is straight and slightly medially rotated. Lift until discomfort in posterior leg- sensitise by ankle dorsiflexion or cervical flexion.
- SID - sural nerve INV + DF
- PIP - peroneal nerve INV + PF
- TED - tibial nerve EVE + DF
- PKB - femoral nerve
11
Q
AROM and PPIVM
A
Movements:
- Forward flexion (facet joints opening)
- Lateral Flexion (+ contralateral pelvic rotation)
- Extension (facet joints closing)
- Rotation in sitting (limited due to facet joint orientation)
- Quadrant testing- lateral flexion with forward flexion or extension
- PPIVMS: Passive physiological movements-flexion, extension and rotation
What are we looking for?
- Quality, range (record distance from floor to fingernails), end feel, =/- overpressure
Why might we look at shoulder elevation?
- Associated T. spine ext & side flexn
- Muscle length: scalenii ant rot towards, SF away; mid SF away; post rot away, SF towards; SCM
12
Q
Muscle tests
A
Length tests:
- lat dorsi, thomas test (hip flexors), hamstring/glutes
Strength tests:
- hip flexors, rec fem, glutes, hamstrings, upper limbs, whole kinetic chain
Motor control tests:
- squat (double leg and single), lunge, step up, one leg stand (trendelenburg), physiological movements (change tempo)
13
Q
PAIVMS
A
- Posterior/Anterior (PA) with cephalad (angle more cephalad the more upper Lx) - helps Lx ext by opening inferior facet joint
- Unilateral
- Transverse glide
Maitland Joint Mobilization Grading Scale: R>P or P>R
Usually painful or provocative
SIN = dosage
14
Q
Palpation
A
- Muscle tone
- Bulk
- Pain provocation
- Hyperalgesia (hypersensitivity)
15
Q
Functional Assessment
A
- Sit to stand
- Step ups/down
- Picking something off floor
- On and off the bed
