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
