Lumbar Part 2

Question 1

Disc Lesion with

Radiculopathy

Answer 1

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

Question 2

Crossed Femoral

Stretching Test

Answer 2

Performed like FNTT except that symptoms occur in contralateral limb that is being tested

Question 3

Positive Crossed Femoral

Stretching Test

Answer 3

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

Question 4

Favorable prognostic factors of positive outcome with conservative intervention with lumbar disk herniation

Answer 4

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

Question 5

Unfavorable prognostic factors of positive outcome with conservative intervention with lumbar disk herniation

Answer 5

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

Question 6

Neutral prognostic factors of positive outcome with conservative intervention with lumbar disk herniation

Answer 6

degree of SLR
response to bed rest
response to passive care
gender
age

Question 7

Questionable prognostic factors of positive outcome with conservative intervention with lumbar disk herniation

Answer 7

actual size of lumbar disc herniation
canal position of lumbar disk herniation
spinal level of lumbar disk herniation
lumbar disk herniation material

Question 8

Painful arc for disk herniation:

Answer 8

30-60 degrees

Question 9

PT management of disk herniation:

Answer 9

Management with McKenzie method and lumbar stabilization program along with HEP

Question 10

Medical management of disk herniation:

Answer 10

medications and/or surgery such as discectomy, laminectomy, decompression, fusion, and lumbar artificial disc replacement

Question 11

Facet Syndrome or

Z-Joint Dysfunction

Answer 11

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)

Question 12

Facet Syndrome or

Z-Joint Dysfunction Management:

Answer 12

Mobilizations and/or SMT
Postural education
Correction of muscle imbalances
Core stabilization exercises
Medical approach may include injections

Question 13

Primary spinal stenosis:

Answer 13

congenital narrowing

Question 14

Secondary or acquired spinal stenosis:

Answer 14

Degenerative (hypertrophy of articular process, disc degeneration, ligamentum flavum hypertrophy, spondylolisthesis)
Fracture/trauma
Post-operative (post-laminectomy)
Ankylosing spondylitis
Tumors

Question 15

Who is spinal stenosis most common in?

Answer 15

65 years or older

Question 16

Diagnostic Utility of Patient History for Identifying Lumbar Spinal Stenosis

Answer 16

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

Question 17

Spinal stenosis signs and symptoms:

Answer 17

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

Question 18

CPR Diagnosis of

Lumbar Spinal Stenosis (LSS)

Answer 18

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)

Question 19

Diagnosis of LSS if:

Answer 19

Seven or higher on scoring system

Question 20

LSS likely NOT present if:

Answer 20

Two or lower on scoring system

Question 21

Neurological signs and symptoms of spinal stenosis:

Answer 21

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

Question 22

Spinal Stenosis

Neurological Testing

Answer 22

Vibration
pin prick
weakness
absent reflexes
Rhomberg
thigh pain with 30 seconds of extension

Question 23

Spinal stenosis management:

Answer 23

Management with therapeutic exercise including postural education, stretching, core stabilization, and aerobic conditioning
Medical approach may involve medications, injections and/or surgery

Question 24

What percentage of spinal stenosis patients have resolution without treatment

Answer 24

30%

Question 25

Type I Spondylolisthesis (dysplastic):

Answer 25

Congenital abnormality in upper sacrum or neural arch of L5, allowing displacement

Question 26

Type II Spondylolisthesis (isthmic):

Answer 26

A lytic or fatigue fracture of pars, or elongated but intact pars, or acute fracture of pars

Question 27

Type III Spondylolisthesis (degenerative):

Answer 27

Secondary to degenerative arthrosis of z-joints or discovertebral articulation

Question 28

Type IV Spondylolisthesis (traumatic):

Answer 28

Secondary to fractures in area of neural arch other than pars

Question 29

Type V Spondylolisthesis (pathologic):

Answer 29

In conjunction with bone disease (e.g. Paget’s disease, osteoporosis)

Question 30

Type VI Spondylolisthesis (iatrogenic):

Answer 30

Occurs above or below a spinal fusion

Question 31

Epidemiology of Spondylolisthesis

Answer 31

Two most common types are isthmic, occurring in younger patients and degenerative, occurring in older patients

Question 32

When is the incidence of onset of type II spondylolisthesis?

Answer 32

adolescence, figure skaters, high jumpers

Question 33

Grade 0 Spondylolisthesis

Answer 33

normal

Question 34

Grade 1 Spondylolisthesis

Answer 34

1-25%

Question 35

Grade 2 Spondylolisthesis

Answer 35

26-50%

Question 36

Grade 3 Spondylolisthesis

Answer 36

51-75%

Question 37

Grade 4 Spondylolisthesis

Answer 37

76-100%

Question 38

Symptoms and Signs | Spondylolisthesis

Answer 38

asymptomatic or LBP worse with extension | pain worsened w/activity, relieved with rest

Question 39

Subtle signs of Spondylolisthesis:

Answer 39

hamstring tightness, hyperlordosis, and palpable step defect of SP

Question 40

What do patients with a grade 3 or greater spondylolisthesis have:

Answer 40

symmetric transverse skin furrow and hyperlordosis along with anterior pelvic tilt

Question 41

Intervention for spondylolisthesis depends on:

Answer 41

presenting symptoms

Question 42

Interventions for spondylolisthesis

Answer 42

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

Question 43

Surgical referrals for what grades?

Answer 43

III and IV

Question 44

Who is pirifomis most common amoung?

Answer 44

active (athletes, runners, etc) and those who sit a great deal

Question 45

Signs and symptoms of piriformis syndrome?

Answer 45

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

Question 46

Six cardinal features of Piriformis Syndrome:

Answer 46

(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)

Question 47

When is aggressive stretch and massage of piriformis indicated?

Answer 47

If muscular spasm and tightness suspected etiology

Question 48

Diagnostic Utility of History for Identifying Ankylosing Spondylitis

Answer 48

``` 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 ```

Question 49

Ankylosing | Spondylitis Signs and Symptoms:

Answer 49

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

Question 50

Ankylosing | Spondylitis Management:

Answer 50

Gentle mobilization/manipulation, stretching, and postural and breathing exercises Monitor cardiac and pulmonary function

Question 51

Multiple Myeloma Signs and Symptoms:

Answer 51

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

Question 52

Metastatic Carcinoma Signs and Symptoms

Answer 52

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

Question 53

Where are METS most commonly from in metastatic carcinoma?

Answer 53

breast, lung and kidney

Question 54

Infectious Spondylitis Symptoms and Signs:

Answer 54

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

Question 55

What size is considered aneurysm?

Answer 55

greater than 3.8 cm

Question 56

What does urine test reveal in patients with multiple myeloma?

Answer 56

Bence-Jones proteins

Question 57

Where is AAA usually?

Answer 57

b/w L2 and L4