Lumbar Part 2 Flashcards
Disc Lesion with
Radiculopathy
Patient complains of LBP and leg pain below knee….may be sudden onset after bending and/or twisting
previous hx of LBP that resolved
changes in reflexes, muscle weakness, sensation
numbness, tingling in specific dermatome
Special tests such as SLR, WLR and Braggard’s positive
Crossed Femoral
Stretching Test
Performed like FNTT except that symptoms occur in contralateral limb that is being tested
Positive Crossed Femoral
Stretching Test
Pain in groin and hip that radiate along anterior medial thigh (L3 nerve root) and pain extending to to mid-tibia (L4) indicate positive test for mid-lumbar nerve root tension
Favorable prognostic factors of positive outcome with conservative intervention with lumbar disk herniation
absence of crossed SLR
spinal motion in extension that does not reproduce leg pain
relief or 50% reduction in leg pain within first 6 wks of onset
self employed
educational level greater than 12 yrs
absence of spinal stenosis
limited psychosocial issue
progressive return of neurological deficit with 12 wks
Unfavorable prognostic factors of positive outcome with conservative intervention with lumbar disk herniation
positive crossed SLR leg pain produced with spinal extension lack of 50% reduction in leg pain within first 6 wks of onset overbearing psychosocial issues worker's comp educational level less than 12 years concomitant spinal stenosis cauda equina progressive neurological deficit
Neutral prognostic factors of positive outcome with conservative intervention with lumbar disk herniation
degree of SLR response to bed rest response to passive care gender age
Questionable prognostic factors of positive outcome with conservative intervention with lumbar disk herniation
actual size of lumbar disc herniation
canal position of lumbar disk herniation
spinal level of lumbar disk herniation
lumbar disk herniation material
Painful arc for disk herniation:
30-60 degrees
PT management of disk herniation:
Management with McKenzie method and lumbar stabilization program along with HEP
Medical management of disk herniation:
medications and/or surgery such as discectomy, laminectomy, decompression, fusion, and lumbar artificial disc replacement
Facet Syndrome or
Z-Joint Dysfunction
well-localized LBP with some hip/buttock or leg pain above knee
Onset after simple misjudged movement or arising from flexed position
Absence of neurological deficits and nerve root tension signs/tests
AROM provokes pain (flexion/extension)
Hypomobility with PPIVM and/or PPAIVM (spring testing)
Facet Syndrome or
Z-Joint Dysfunction Management:
Mobilizations and/or SMT Postural education Correction of muscle imbalances Core stabilization exercises Medical approach may include injections
Primary spinal stenosis:
congenital narrowing
Secondary or acquired spinal stenosis:
Degenerative (hypertrophy of articular process, disc degeneration, ligamentum flavum hypertrophy, spondylolisthesis) Fracture/trauma Post-operative (post-laminectomy) Ankylosing spondylitis Tumors
Who is spinal stenosis most common in?
65 years or older
Diagnostic Utility of Patient History for Identifying Lumbar Spinal Stenosis
age over 65 pain below knees pain below buttocks no pain when seated sever LE pain symptoms improved when seated worse when walking numbness poor balance
Spinal stenosis signs and symptoms:
Often over age 50 years complaining of leg and back pain
Pain may be unilateral (lateral canal stenosis) or bilateral (central canal stenosis) and often diffuse
May complain of onset of leg pain with walking and relief after resting 20 minutes or by maintaining a flexed posture
CPR Diagnosis of
Lumbar Spinal Stenosis (LSS)
age 60-70 (2 points
age over 70 (3)
symptoms over 6 months (1)
symptoms improve when bending forward (2)
symptoms improve when bending backwards (-2)
symptoms exacerbated while standing up (2)
intermittent claudication (1)
urinary incontinence (1)
Diagnosis of LSS if:
Seven or higher on scoring system
LSS likely NOT present if:
Two or lower on scoring system
Neurological signs and symptoms of spinal stenosis:
Neurological deficits may be apparent yet cross-dermatomal and other nerve root boundaries
Normal peripheral pulses
Positive Romberg test and possible urine incontinence
↓ lumbar extension and difficulty standing or lying in erect position
Spinal Stenosis
Neurological Testing
Vibration pin prick weakness absent reflexes Rhomberg thigh pain with 30 seconds of extension
Spinal stenosis management:
Management with therapeutic exercise including postural education, stretching, core stabilization, and aerobic conditioning
Medical approach may involve medications, injections and/or surgery
What percentage of spinal stenosis patients have resolution without treatment
30%
Type I Spondylolisthesis (dysplastic):
Congenital abnormality in upper sacrum or neural arch of L5, allowing displacement
Type II Spondylolisthesis (isthmic):
A lytic or fatigue fracture of pars, or elongated but intact pars, or acute fracture of pars
Type III Spondylolisthesis (degenerative):
Secondary to degenerative arthrosis of z-joints or discovertebral articulation
Type IV Spondylolisthesis (traumatic):
Secondary to fractures in area of neural arch other than pars
Type V Spondylolisthesis (pathologic):
In conjunction with bone disease (e.g. Paget’s disease, osteoporosis)
Type VI Spondylolisthesis (iatrogenic):
Occurs above or below a spinal fusion
Epidemiology of Spondylolisthesis
Two most common types are isthmic, occurring in younger patients and degenerative, occurring in older patients
When is the incidence of onset of type II spondylolisthesis?
adolescence, figure skaters, high jumpers
Grade 0 Spondylolisthesis
normal
Grade 1 Spondylolisthesis
1-25%
Grade 2 Spondylolisthesis
26-50%
Grade 3 Spondylolisthesis
51-75%
Grade 4 Spondylolisthesis
76-100%
Symptoms and Signs
Spondylolisthesis
asymptomatic or LBP worse with extension
pain worsened w/activity, relieved with rest
Subtle signs of Spondylolisthesis:
hamstring tightness, hyperlordosis, and palpable step defect of SP
What do patients with a grade 3 or greater spondylolisthesis have:
symmetric transverse skin furrow and hyperlordosis along with anterior pelvic tilt
Intervention for spondylolisthesis depends on:
presenting symptoms
Interventions for spondylolisthesis
pelvic positioning initially to provide symptomatic relief, followed by an active lumbar stabilization program and stretching (rectus femoris and iliopsoas muscles) to decrease anterior pelvic tilting
Surgical referrals for what grades?
III and IV
Who is pirifomis most common amoung?
active (athletes, runners, etc) and those who sit a great deal
Signs and symptoms of piriformis syndrome?
unilateral buttock and posterior leg pain and paresthesia
Resisted external rotation of hip or passive internal rotation of hip may increase pain
Palpation of piriformis muscle may cause referred pattern down back of leg
Neurological symptoms uncommon
Six cardinal features of Piriformis Syndrome:
(1) History of trauma to sacroiliac and gluteal regions
(2) Pain in region of SIJ, greater sciatic notch, and piriformis muscle, extending down lower limb and causing difficulty in walking
(3) Acute exacerbation of symptoms by lifting or stooping
(4) Palpable, sausage-shaped mass over piriformis muscle, during exacerbation of symptoms, which is markedly tender to pressure (this feature pathognomonic)
(5) Positive SLR test
(6) Gluteal atrophy (depending on duration of symptoms)
When is aggressive stretch and massage of piriformis indicated?
If muscular spasm and tightness suspected etiology
Diagnostic Utility of History for Identifying Ankylosing Spondylitis
Pain not relieved by lying down Back pain at night Morning stiffness greater than 30 mins Pain or stiffness relieved by exercise age onset 40 years or less
Ankylosing
Spondylitis Signs and Symptoms:
young male, CLBP and stiffness w/occasional radiation
Stiffness upon rising with some relief of complaints with mild to moderate activity
Global decrease in lumbopelvic ROM with gradual stiffening
Gradual loss of lumbar lordosis, increase thoracic kyphosis and decrease in chest expansion
Ankylosing
Spondylitis Management:
Gentle mobilization/manipulation, stretching, and postural and breathing exercises
Monitor cardiac and pulmonary function
Multiple Myeloma Signs and Symptoms:
Usually older patient (over 50 years age) with complaints of persistent LBP unrelieved by rest
Pain worse at night and may be associated with rib pain
Metastatic Carcinoma Signs and Symptoms
Patient is usually >50 years with insidious onset of pain that is persistent, worse at night and not mechanically affected
Often an Hx of previous cancer, weight loss and fatigue
Unresponsiveness to conservative care after one month highly suggestive of cancer, especially in patients >50 years
Where are METS most commonly from in metastatic carcinoma?
breast, lung and kidney
Infectious Spondylitis Symptoms and Signs:
deep back pain made worse with pressure or percussion of SP’s, fever, and difficulty sleeping d/t pain; may present with antalgia
History of recent respiratory or UTI, or IV drug use or diabetes
Infection involving both disc and vertebral body
Involved organisms include Staph, Strept and TB
What size is considered aneurysm?
greater than 3.8 cm
What does urine test reveal in patients with multiple myeloma?
Bence-Jones proteins
Where is AAA usually?
b/w L2 and L4
