Lumbar Pathologies and Assessment

Question 1

Tests for instability of the spine?

Answer 1

• Instability Catch Test (have them bend forward and back up)
• Passive Lumbar Extension Test (lift legs of patient)
• Prone Instability Test (Patient lifts legs off floor while examiner presses down on low back. Pain relieved by lifting legs)

Question 2

Tests for herniated nucleus pulposis or lumbar radiculopathy?

Answer 2

• Well Leg Raise (patient supine, raise well leg until symptom reproduction of opposite leg)
• Straight Leg Raise (patient supine, raise affected leg until point of symptom production)
• Slump Test (spinal flexion with overpressure, then extend knee and dorsiflex, then neck flexion and assess, take neck off flexion)
• Femoral Nerve Tension Test (examiner hand on PSIS and then bend affected knee into flexion, then can add hip extension and ankle or head movements)

Question 3

What are the five components for Cook’s Clinical Prediction Rule for Lumbar Stenosis?

Answer 3

1. Bilateral symptoms
2. Leg pain worse than back pain
3. Pain during walking/standing (extension)
4. Pain relief upon sitting (flexion)
5. Older than 48 years

Question 4

With disc herniation, spondylosis or sprain/strain where is the pain worst? What movement makes it better or worse? How are myotomes and dermatomes affected?

Answer 4

Pain in back/buttocks

Better with extension, worse with flexion

Myotomes seldom affected

Dermatomes not affected

Question 5

With facet joint involvement where is the pain worst? What movement makes it better or worse? How are myotomes and dermatomes affected?

Answer 5

Pain is in back/buttocks

Flexion makes it better, extension worse

Myotomes seldom affected

Dermatomes not affected

Question 6

With lumbar stenosis (intermittent neurogenic claudication) where is the pain worst? What movement makes it better or worse? How are myotomes and dermatomes affected?

Answer 6

Pain worse in leg, usually below the knee

Pain better with rest and sitting (flexion), worse with walking (extension)

Myotomes commonly affected

Pain in dermatomes

Question 7

With nerve root irritation (usually caused by disc-herniation) where is the pain? What movement makes it better or worse? How are myotomes and dermatomes affected?

Answer 7

Pain worse in leg, usually below the knee

Better with extension, worse with flexion

Myotomes commonly affected

Pain in dermatomes

Question 8

What things should one observe for lumbar pathologies?

Answer 8

a. Gait
b. Standing posture
c. Spinal curvatures
i. Lumbar lordosis (excessive? Flattened? Where?) – Segmental specific?
ii. Thoracic kyphosis (excessive? Flattened?)
iii. Lateralshift?
iv. Step deformity?
d. Position of pelvis (neutral pelvis = ASIS slightly lower than PSIS)

Question 9

History to take for lumbar pathologies

Answer 9

a. MOI: insidious or traumatic. First occurrence or episodic?
b. Where is the pain located? Is it back dominant or leg dominant?
i. Where in the back or leg(s) is it located?
ii. Have the patient mark out the pain/symptoms.
c. Describe nature of pain
i. Type? –burning, sharp, achy, pins/needles
ii. Any correlation to time of day? – worse in am/pm
iii. Any correlation to activity? –worse with sitting, standing, walking?
iv. Are the symptoms worse with postures or transitions?
d. Any increase in pain with coughing, sneezing or laughing (increase in intrathecal pressure)?
e. Any bowel or bladder changes.

Question 10

Nerve roots for femoral nerve?

Answer 10

L2, L3, L4

Question 11

Nerve roots for common peroneal nerve?

Answer 11

L4, L5, S1

Question 12

Nerve roots for tibial nerve ?

Answer 12

L4, L5, S1, S2, S3

Question 13

Nerve roots for obturator nerve?

Answer 13

L2, L3, L4

Question 14

What nerves does the sciatic nerve branch into?

Answer 14

Tibial nerve and common peroneal nerve

Question 15

What are the symptoms of osteoarthritis? What joints in the spine are we talking about usually?

Answer 15

• Generalized stiffness and pain (especially am). Noticeable increase with changes in weather (barometric pressure).
• Improvements with movement, worse with inactivity.

Loss of joint space can result in…

• Radiculopathy: subsequent sensory and/or motor disturbances, such as pain, paresthesia, or muscle weakness in the limbs

Generally talking about facet joints

Question 16

What is spondylosis?

Answer 16

Degenerative Disc Disease (aka Spondylosis):a term used to describe the “normal” age related changes and sometimes trauma induced changes in intervertebral discs and associated vertebrae

Question 17

What are the three main causes of spondylosis?

Answer 17

1. Disc dessication
2. Tearing of annulus
3. Facet joint degeneration

Question 18

Describe disc dessication

Answer 18

1. The replacement of the hydrophilic polysaccharides within the nucleus pulposuswith fibrocartilage resulting in…
   a. Decreased flexibility of the disc
   b. Decreased shock absorbing ability.
   c. Decreased disc height therefore narrowing the distance between the vertebrae.
   d. Less fibres posteriorly than anteriorly

Question 19

Describe tearing of annulus

Answer 19

Tiny tears or cracks in the outer layer (annulus) of the disc allows the nucleus to escape through the tears or cracks in the capsule, causing the disc to bulge, break open (rupture), or break into fragments.

Question 20

Describe facet joint degeneration

Answer 20

Increased laxity of the facet joints and fibrillation of the articular cartilage lining these joints can lead to “facet joint syndrome”

Question 21

Describe stage 1 of DDD or spondylosis

Answer 21

• Stage 1: “Early degeneration” involves increased laxity of the facet joints, fibrillation of the articular cartilage and intervertebral discs display grade 1-2 degenerative changes.

Question 22

Describe stage 2 of spondylosis (DDD)

Answer 22

Stage 2: “Lumbar instability” at the effected level(s) develops due to laxity of the facet capsules, cartilage degeneration and grade 2-3 degenerative disc disease.

Segmental Instability: definedas loss of motion and segmental stiffness such that force application to that motion segment will produce greater displacements than would occur in a normal structure (Frymoyer1985). Mechanical testing suggests the intervertebral disc is most susceptible to herniation at this stage (Adams 1982).

Question 23

Describe stage 3 of spondylosis (DDD)

Answer 23

Stage 3: “Fixed deformity” results from repair processes such as facet and peri-discalosteophytes effectively stabilising the motion segment. There is advanced facet joint degeneration (or “facet joint syndrome”) and grade 3-4 disc degeneration.

Possible altered spinal canal dimensions (spinal stenosis) due to fixed deformity and osteophyte formation.

Question 24

What are the risk factors for spondylosis?

Answer 24

• Smoking (affects collagen and blood supply)
• Hereditary
• Obesity
• Repetitive postures/movements – especially heavy physical labour, prolonged sitting or flexed postures
• Trauma

Question 25

What is a herniated disc? What directions does a disc usually herniate?

Answer 25

an abnormal bulge or extrusion of the nucleus pulposus.

• Tears are almost always postero-lateral in nature
• Disc can bulge or rupture posterior central as well or up/down into the vertebral endplate (schmorl’s nodules)

·This tear in the disc ring may result in the release of inflammatory chemical mediators, which may directly cause pain, even in the absence of nerve root compression.

Question 26

What is sequestration of a disc?

Answer 26

Disc breaks off and floats around in spinal canal. Most painful but quick recovery. Once a disc exits its capsule the body does not recognize it as self so antibodies will come and clear it up.

Question 27

Symptoms of a disc herniation?

Answer 27

• Undefined pains in the extremities.
• Sciatica.
• Sensory and/or motor changes: numbness, tingling (dermatomal), muscular weakness (myotomal), paresthesia, and changes in reflexes.
• Symptoms typically worse with flexion activities and improved with extension.

Question 28

What is Cauda Equina Syndrome? What are the sn/sx? (on exam!)

Answer 28

Occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Usually from a disc bulge that is large or centrally located. The cause is usually a disc herniation in the lower region of the back. Other causes include spinal stenosis, cancer, trauma, epidural abscess, and epidural hematoma.

• Lower extremity pain, weakness, numbness that may involve perineum and buttocks
• Associated with bladder and bowel dysfunction.
• Occurs bilaterally, often multisegmental.

Question 29

What is intermittent neurogenic claudication? What are the symptoms?

Answer 29

Spinal stenosis (narrowing of the spinal canal)

Characterized by:

• Lower limb numbness, weakness, diffuse or radicular leg pain
• Associated with paresthesia bilaterally
• Weakness and/or heaviness in buttocks radiating into lower extremities with walking or prolonged standing.
• Radiculopathy (with or without radicular pain): objective signs such as weakness, loss of sensation and of reflex.

Question 30

What is spondylolisthesis? What is the most common vertebra?

Answer 30

Forward displacement of a vertebra.

Usually fifth lumbar vertebra

Question 31

What are symptoms of spondylolisthesis?

Answer 31

• A general stiffening of the back and a tightening of the hamstrings. Generalized low back pain.
• An individual may also note a “slipping sensation” when moving into an upright position. Sitting and trying to stand up may be painful and difficult.
• A possible leaning-forward or semi-kyphotic.
• A “waddle” may be seen in more advanced causes, due to compensatory pelvic rotation due to decreased lumbar spine rotation.
• A result of this change in gait is a noticeable atrophy in the gluteal muscles due to lack of use.
• Other symptoms may include tingling and numbness. Coughing and sneezing can intensify the pain.

Question 32

What is the most common cause of spondylolisthesis?

Answer 32

Fracture.

Superior vertebra slides anteriorly on the one below.

Find the Scotty dog, little Scottish terrier…At top of head, ear of dog is the facet joint of the vertebra above. Front legs facet joint of one below

Part that connects superior to inferior facet gets a fracture.

Can be born with this. Does not have to be bilateral. But most likely because of a break or fracture. If you are not born with this there has to be some kind of trauma.

Question 33

What posture relieves spondylolistheses? Worsens? Which sinew channel is involved?

Answer 33

These will be better with flexion rather than extension. Respond kind of like stenosis but also have generalized stiffness in back and tightening of the hamstrings.

Hamstrings major clinical diagnosis, usually bilaterally and really stiff low back and they respond more to flexion: might want to consider a “spondy”

When moving from flexion up into extension may have a “slipping” sensation.

Sheers vertebrae anteriorly on the one below it. Leg sensations will usually go down past the knees with this as well. (SI joint will usually not go down past knees)

Lumbar lordosis may flatten out because they like to flex through upper back.

UB sinew channel, gastroc then glutest o straighten out back. If back does not like extension your glutes will stop firing as much. Waddle is due to atrophy of glute muscles.

Question 34

What are the red flags for back pain?

Answer 34

1. Unrelenting/constant pain, night pain
2. Bowel and Bladder changes: Retention, frequent urination, leakage.
3. Saddle area paresthesia.
4. Bilateral sciatica past the knees

Question 35

What sinew channel should you look at for stenosis?

Answer 35

Kidney

Question 36

What sinew channel should you look at for facilitated segments, neuropathic pain, sciatica, disc bulge?

Answer 36

Bladder