Lumbar II Flashcards
Questions to ask when forming differential diagnosis
. How severe symptoms are
. Is there traumatic anatomic damage
. Is there serious underlying medical condition
. DO symptoms have progressing neurologic involvement
. Is patient child, elderly, or high risk
Non mechanical differential diagnoses for back pain
. 1% . Neoplasia . Infection . Inflammatory arthritis . Metabolic bone disease
Referred pain differentials of low back pain
. GI
. GU/reproductive
. cardiovascular
Mechanical differentials for LBP
. Sprains . Somatic dysfunction . Fracture . Spondylolsis . Facet syndrome . Spinal stenosis . Disc issues . Congenital . Instability . 97% of cases
Characteristics of mechanic LBP
. Assoc. w/ bending/twisting
. Better w/ rest
. Pain varies w/ motion, position
. Assoc. w/ dec. range of motion, muscle spasm, trigger points in muscle, tendinitis or joint inflammation
. Strongest predictor of future mechanical LBP is history of previous mechanical LBP
Strain
Tendon inflammation
Sprain
Ligament back pain
Only consider xrays for mechanical LBP if ____
. Patient over 50
. There is additional medical info that raises suspicion for organic disease
T/F don’t treat X-ray, adults will have radiographic findings but are asymptomatic
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Consider non-mechanical/systemic disease as underlying cause of LBP if _____
. Abnormal vitals . History of cancer . Spinal infection . Prolonged steroid use . history of IV drug use . UTI . Unexplained weight loss . Old . Night pain or sweats . No pain relief w/ rest . Failure to respond to standard therapies . Osteoporosis . immunocompromised . Rheumatologist disorders
WHen to consider diagnostic imaging and laboratory tests
. Young patients under 18 . Patients over 50 . Trauma . Neurological deficit . Fever . Unexplained weight loss . Cancer history . Drug use history
Bat wing deformity
. Enlargement of 1 or both transverse processes of L5
Sacralization of L5
. Partial or complete fusion of 5th lumbar vertebra w/ sacrum
. Causes fewer moving lumbar segments that inc. mechanical stress at remaining lumbar levels
Lumbarization of S1
. Partial or complete separation of S1 from sacrum
. Patient functionality has 6 lumbar vertebrae
. Causes lumbo-sacral instability
Spina bifida
. Most common birth defects w/ incidence os 1-2 cases/1000 births
. Incomplete closing of embryonic neural tube
. Vertebra overlying spinal cord not formed and remained infused and open
.most common areas: lumbar and sacral
. Detected during pregnancy by testing mother’s blood (AFP screening) or detailed fetal ultrasound
Spina bifida occulta
. Mildest form . Hairy patch on skin . Dark spots or birth marks . Red/purple spot on back composed to blood vessels . Dimpling in back . Less skin color than other areas
T/F disc repair is less efficient than other tissues
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Lumbar disc disease
. Compromised disc causes LBP
. Causes: multifactorial from wear and tear, trauma, or genetic causes
. Due to low energy injury of disc that progresses w/ time
. At least 30% people from 30-50 have some degree of disc degeneration
. Routine finding after 50 y/o
Disc bulge mechanics
. Flexing forward motions inc. lumbar intradiscal pressure
. Repetitive/excessive force causes bulging/herniation in thinner post. Or posterolateral wall
. Invades space by nerve root
. Neurological signs may be present
Radicular pain
. Annular tearing, compression of nerves or root sleeve from arthritic spurs or degenerating joints
. Most common it L4-5, L5-S1
Radiculopathy considerations
. Consider MRI/surgical consult if they have significant neurologic deficits
. Surgery if large disk protrusion, spinal cord compression, worsening neuro deficits
. Contraindication for OMM (soft tissue finer, no HVLA or rotational maneuvers)
Neurologic signs assoc. w/ LBP
. Motor loss
. Sensory loss
. Loss of deep tendon reflex
Heeel walking checks which nerve root?
L4, ankle dorsi flexion
Tow walking checks which nerve root?
. Ankle plantarflexion
. S1
What nerve root is checked by great toe extension
L5
Bragard test
. Modification of SLR involving dorsi flexion of ankle
. Has reticular symptoms when leg is raised or when ankle is doriflexed
Contralateral straight leg test (contralateral laseque)
. Lift leg on uninvolved side
. Reproduces symptoms in involved side legs
. More specific than SLR but less sensitive for radiculopathy
Nachlas test
. Differentiates btw femoral nerve, disc disease, radicular symptoms, lumbar ligamentous strains. And SI pathology
. Patient prone w. Knee bent until heel approaches ipsilateral butt
. Affects L2-3 and L3-4 discs and stretches lumbar nerve roots irritating femoral nerve
. If no symptoms, lift thigh off table w/ knee flexed and hold 1 min to stress lumbar dura (pos. If symptoms seen in but and post. Thigh)
. If pain in ant. Thigh it is pos. For tight quads and stretching for femoral nerve (Ely’s test)
Screening tests done first for lumbar somatic dysfunction
. Standing structural exam . AROM . Standing flexion test . Pelvic side shift . Seated flexion . Modified Thomas test and prone psoas tests
Lumbar segmental motion
. Sagittal plane
. Extension more than flexion bc of lumbar lordosis
. Considerably less rotation and sidebending
. Limited at L1-4 sue to z-joint shapes
. L5 permits more rotations due to it’s facet joints
Lumbar segmental motion testing
. Prone or seated (prone easier, seated can assess flexion/extension)
. Use same naming as thoracic
Prone lumbar segmental motion testing
. Rotate segments L and R
. Sidebending: apply lat. translation R and L
. Flexion and extension: downward pressure over spinous process
. Resistance to pressure is flexed, excess freedom is extension
. Patient also can prop themselves up using elbows to test extension, laying flat is flexed
Seated lumbar segmental motion testing
. Similar to thoracic
. Important bc many LBP patients cannot lie prone
Disc L3-4 root, reflex, muscles, and sensation
. L4 root
. Patellar reflex
. Ant. Tibialis muscles
. Medial leg and foot
L4-5 disc root, reflex, muscles, and sensation
. L5
. No reflex
. Extensor hallucis longus
. Lat. leg and dorsum of foot
L5-S1 disc root, reflex, muscles, and sensation
. S1
. Achilles reflex
. Proneus longus and brevis muscles
. Lat. foot sensation
