Lumbar Pathologies and Assessment Flashcards
Tests for instability of the spine?
- 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)
Tests for herniated nucleus pulposis or lumbar radiculopathy?
- 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)
What are the five components for Cook’s Clinical Prediction Rule for Lumbar Stenosis?
- Bilateral symptoms
- Leg pain worse than back pain
- Pain during walking/standing (extension)
- Pain relief upon sitting (flexion)
- Older than 48 years
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?
Pain in back/buttocks
Better with extension, worse with flexion
Myotomes seldom affected
Dermatomes not affected
With facet joint involvement where is the pain worst? What movement makes it better or worse? How are myotomes and dermatomes affected?
Pain is in back/buttocks
Flexion makes it better, extension worse
Myotomes seldom affected
Dermatomes not affected
With lumbar stenosis (intermittent neurogenic claudication) where is the pain worst? What movement makes it better or worse? How are myotomes and dermatomes affected?
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
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?
Pain worse in leg, usually below the knee
Better with extension, worse with flexion
Myotomes commonly affected
Pain in dermatomes
What things should one observe for lumbar pathologies?
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)
History to take for lumbar pathologies
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.
Nerve roots for femoral nerve?
L2, L3, L4
Nerve roots for common peroneal nerve?
L4, L5, S1
Nerve roots for tibial nerve ?
L4, L5, S1, S2, S3
Nerve roots for obturator nerve?
L2, L3, L4
What nerves does the sciatic nerve branch into?
Tibial nerve and common peroneal nerve
What are the symptoms of osteoarthritis? What joints in the spine are we talking about usually?
- 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
What is spondylosis?
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
What are the three main causes of spondylosis?
- Disc dessication
- Tearing of annulus
- Facet joint degeneration
Describe disc dessication
- 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
Describe tearing of annulus
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.
Describe facet joint degeneration
Increased laxity of the facet joints and fibrillation of the articular cartilage lining these joints can lead to “facet joint syndrome”
Describe stage 1 of DDD or spondylosis
• 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.
Describe stage 2 of spondylosis (DDD)
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).
Describe stage 3 of spondylosis (DDD)
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.
What are the risk factors for spondylosis?
- Smoking (affects collagen and blood supply)
- Hereditary
- Obesity
- Repetitive postures/movements – especially heavy physical labour, prolonged sitting or flexed postures
- Trauma