Lumbar pathologies Flashcards
What are the three main branches for LBP?
- serious or systematic pathology
- malignancies, systematic inflammatory disorders, infections
- 1-2% - LBP with specific pathology
- fracture, disc prolapse with radicular pain, type1 Modic changes, spondylolisthesis (x-rays)
- 5-10% - non-specific LBP
- no pathoanatomical diagnosis that correlates with clinical presentation
- 90%
What are the red flags with LBP? x7 (not exhaustive)
~ timely referral to other services - initial LBP may worsen > 1-4% Pt have spinal # and less than 1% have cauda equina syndrome
- medical hx > ca
- high impact trauma
- neurology > weakness/reflex changes
- bladder and bowel dysfunction > saddle anaesthesia
- continuous or progressive non-mechanical pain (pain is not affected by movement e.g. IA)
- systematically unwell (affected whole body)
- unexpected weight loss > -5% in 1/12
What is spondylosis? (SL)
spondylo = spine
osis = abnormal/disease
- a degenerative condition - bony overgrowths (osteophytes) at anterior, lateral, occasionally posterior aspects of the inferior and superior edges of the vertebral body
- often due to aging > progressive wear and tear
Who does spondylosis present in? How might it present?
- equal in male and female
- can present in all ages > most common is those over 40 (80%) though 20-29 y/olds may present degenerative changes in x-ray (3%)
- an asymptomatic population
- gradual onset pain in LB
- aggravated by acute episodes of intense activity
- present with stiffness/limited movement
- POE found by Pt > unloaded/non WB
How can spondylosis be managed?
- surgical or non-surgical treatment e.g. physio;
- mobilisation
- manipulation
- massage
- TENS
- Lx supports
- Pt education
AGGs and EASEs of spondylosis?
AGGs - acute intense activity
EASEs - positions of ease, non WB
What is spondylolysis? (SLL)
spondylo = spine
lysis = split
- a fracture of pars interarticularis (between the inferior and superior articular processes)
- can be one side or both sides of the vertebrae
- “scotty dog #” evident on x-ray
Who does SLL present in? What is its cause?
- affects 6-8% people
- usually appears in first or second decade of life, specifically young athletic population, fairly common
- frequency increasing with age until 20 years > no prevalence with age past this
- uncertain genetic tendency
- likely affected by repetitive stress > stress # from repetitive mechanical loading, particularly in extension and rotation around L5 (80-95%)
How might a Pt present with SLL? aggs and eases
- gradual onset focal LBP
- may have recorded local trauma in MHx
- increased pain on extension or rotation (agg)
- eased by rest
On examination:
- hyper-lordotic
- greater LBP on extension
- neuro is normal
- ‘dip’ on Maitland mobilisation
How might SLL be managed? (same as spondlyolisthesis)
- NSAIDs (non-steroidal anti-inflammatory drugs) to relive pain e.g. ibuprofen
- surgical fusion (last resort)
- de-stress injury: break from activity, avoid extension, use a brace, improve ROM and power imbalances (hip flexors/hamstrings > pelvic tilt), core stabilisation
- diagnose early > rest > rehab
- avoid fear of movement, educate Pt (not a ‘broken spine’), remain positive
- when appropriate to engaged with ADL, sport
What is spondylolisthesis?
spondylo = spine
listhesis = slip forward (thesis is something you put forward as an argument/theory)
- anterior slippage L4 on L5 OR L5 on S1 (pars interarticularis separates allowing vertebrae to move forward out of position)
- spondylolisthesis is a progression of SLL
- 5 types;
I - congenital SLL, II - isthmic SLL (growth spurt), III - degenerative (50yrs +), IV - traumatic SLL, V - pathologic SLL
Who is mostly likely to present with spondylolisthesis?
- young athletic teenagers
- children with growth spurts > most common reason for LBP in children
- females over 50 for degenerative > stress and weakness
Symptoms of spondylolisthesis? AGGs and EASEs
- AGG LBP pain in standing for for long periods
- pain in extension and rotation (easing in flexion or supine as POE and non WB)
pain may be radicular (nerve roots being compressed > narrowed foremen) - stiffness
- muscle spasms in hamstrings
- weakness/numbness/tingling in foot
What is are discogenic Lx pathologies? x4
~ originating from disc
~ degeneration and/or trauma
- disc bulge: disc goes beyond margin of endplates, nucleus is still contained within the annulus but only because the outermost fibres are holding it in
- disc protrusion: outer disc wall ‘distends’ beyond normal perimeter, nucleus gelatinous material ‘escapes’ tearing through annulus but still connected, impinges PLL
- disc herniation: annulus fibrous tears, nucleus pulpous forced beyond disc wall, compressing spinal nerve
- disc sequestration: herniation leading to nucleus material disrupting PLL, occupying the epidural space
What is the structure of intervertebral discs? x3
- nucleus pulposus - soft/gelatinous inner part of the IVD to resist compression
- annulus fibrosus - tough outer ring of fibrous tissue around the nucleus pulposus, resists torsional forces (twisting)
- two endplates - hyaline cartilage, separating vertebral bone from disc itself, preventing highly hydrated nucleus pulposus from bulging into near vertebrae
Most likely to have a discogenic condition?
- 33% of UK adults with LBP - 5% are discogenic
- males 2:1 30-50 years (though 20% of teens show changes)
- typically L4,L5,S1 region
What are discogenic signs/symptoms?
- can be very painful (or not) depending on what is compromised
- LBP
- LBP with sciatica (radicular) > paraesthesia (p+n, tingling), anaesthesia (loss of sensation) and dermatome, myotome changes
- usually one leg (suddenly or gradually and constant or intermittent)
- AGG: sitting, prolonged standing, flexing or rotation, sneezing/coughing
- EASED: walking, unloaded position, cryo/thermotherapy, painkillers
- surgery risk : benefit analysis
- physiotherapy
What is spondyloarthritis? (SpA)
spondylo = spine
arthritis = disease of the joint
- family of inflammatory rheumatic diseases similarly causing inflammation, pain and stiffness > of spine and pelvic joints
- SpA is axial and includes ankylosing spondylitis (AS) which is visible on x-rays and non radiographic axial spondyloarthritis, not visible on x-rays (others include psoriatic, reactive and enteropathic arthritis)
What is ankylosing spondylitis (AS)? a form of spondyloarthritis*
ankylos = fuse
spondy = spine
itis = inflammation
- chronic condition, familiar with HLA B27 antigen (cannot identify self/non self cells)
- inflammation entheses (ligament/tendon bone junction), calcium deposits in, around and between ligaments and IVD = ossification
Who may AS present in? How may it present?
- 0.1-2% of people
- 3x more common in females
- onset of symptoms between 20-40 years or late adolescence and early adulthood
- those carrying the gene HLA B27 are of higher risk
- insidious onset (slow and unrecognised)
- pain and stiffness in SIJ and gluteal region
- am stiffness easing after 30m, waking up second half of night
- pain and stiffness increases with inactivity (AGG) and EASEs with exercise
- involvement of peripheral joints, eyes (e.g. conjunctivitis), skin, and the cardiac and intestinal systems
- intermittent breathing difficulties due to a reduction in chest expansion
- fatigue, weight loss
How can AS be diagnosed or special tests used?
- imaging (can be seen in radiography) with decreased ROM
- Schober test - Lx flexion ROM Ax
- side flexion ROM
- chest excursion range
- tragus to wall test - ROM in cervical spine
- gaenslen test - spine knee tested over bed and other flexed into chest > reproduction of pain
How can AS be treated?
DRUGS:
- NSAIDs
- corticosteroids (anti-inflammatory)
- TNF inhibitor
- biphosphate > osteoporosis
PHYSIO:
- exercise
- lifestyle - flares and remissions
- education
