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MSK PT > Lumbar Pathology > Flashcards

Lumbar Pathology Flashcards

1
Q

what hydrophilic properties of the disc change with degeneration

A

decrease in proteoglycans and increase in collagen in NP and AF

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2
Q

with degeneration, the disc becomes more __ and less ____

A

more fibrous
less flexible

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3
Q

how is the disc’s ability to transmit forces affected with degeneration

A

less able to transmit vertical load and shear forces

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4
Q

what type of fissuring occurs with degeneration

A

circumferential

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5
Q

with degeneration, what happens to the disc height?

A

relative increase due to structures around it becoming weaker

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6
Q

what happens to the disc height with degradation

A

decreases - loss of height

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7
Q

describe the order of susceptibility to compression overload

A
  1. end plate (weakest)
  2. VB
  3. disc
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8
Q

describe the pathology of disc degradation, starting with excessive compression

A

compression -> end plate fx -> NP exposed to blood -> inflammatory process ->NP loses water and height -> decreased ability to resist loads -> more load to AF -> radial fissure of AF -> herniation

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9
Q

what are the 4 stages of disc herniation (in order)

A

protrusion
prolapse
extrusion
sequestration

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10
Q

what happens with protrusion

A

disc bulge without rupture of AF

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11
Q

what happens with prolapse

A

only outer layers of AF contain nucleus (still intact)

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12
Q

what happens with extrusion

A

AF is perforated and discal materials move to epidural space

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13
Q

what happens with sequestration

A

discal fragments from AF and NP are disconnected

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14
Q

which stages of HNP are you likely to see symptoms of radiculopathy

A

extrusion and sequestration

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15
Q

describe the clinical presentation of someone with an end plate fx

A
  • some MOI/incident
  • acute pain/spasm lasting few days to 3 wks
  • negative SLR
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16
Q

describe the clinical presentation of protrusion and prolapse

A
  • LBP and/or hip/upper leg referred pain
  • pain with increase in intradiscal pressure (cough, sneeze, sitting, bending, etc.)
  • negative SLR
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17
Q

describe the clinical presentation of extruded and sequestrated disc

A
  • LBP
  • pain with increase in intradiscal pressure
  • true sciatica (radicular pain)
  • (+ )SLR
  • severe pain (prob did not move for a week or so)
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18
Q

describe the referral pattern for disc

A
  • extensive referral
    back -> thigh -> leg
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19
Q

what causes radiculopathy

A

compression or block of n root

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20
Q

describe the symptoms of radiculopathy

A
  • paresthesia (dermatome)
  • myotomal weakness
  • hypo-reflexia
  • may or may not have radicular pain
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21
Q

Lateral HNP is more likely to cause ______ while central HNP is more likely to cause _____

A

lateral = radiculopathy
central = myelopathy

NOT only causes and NOT every case

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22
Q

what is radicular pain

A

lancinating pain, traveling along the length of LE (2-3 inches wide)

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23
Q

what is the most common cause of radicular pain

A

HNP -> inflammation of n (dorsal root or ganglion)

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24
Q

radicular pain only occurs in what types of nerves?

A

unhealthy

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25
Q

what does somatic referred pain feel like?

A

dull, aching, gnawing, or expanding pressure

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26
Q

a disc pathology located at L4-5 will affect what nerve roots

A

L5 NOT L4 - will affect the one below

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27
Q

CT and MRI are abt equally accurate for dx ______

A

HNP and stenosis

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28
Q

when is imaging recommended?

A

in the absence of systemic diseases/red flags, not until after 6 wks of failed conservative therapy

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29
Q

narrowing of the spinal canal or IV foramen causing a nerve pinching

A

spinal stenosis

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30
Q

describe the clinical presentation of a pt with spinal stenosis

A
  • persistent pain (mild to mod) in butt
  • limping
  • lack of feeling in LE (claudication)
  • decreased walking/standing ability (feel better w/ flexion)
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31
Q

describe the ROM findings for spinal stenosis

A

usually WNL but stiff in all directions

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32
Q

for pts with spinal stenosis, is there a MOI?

A

no, usually a gradual/insidious onset

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33
Q

a thickened ligamentum flavum or osteophytes in spinal canal can cause what type of stenosis

A

central stenosis

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34
Q

describe the different presentation of central and lateral stenosis

A

central - bilat, neurogenic claudication or pain in butt, thigh, leg
lateral - unilat, may have radiculopathy and radicular pain

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35
Q

what are 2 degenerative causes of stenosis

A

osteophytes
thickened ligamentu flavum

36
Q

other than degenerative causes, what things can cause stenosis

A
  • HNP + another congenital or acquired
  • spondylolisthesis
  • post-trauma
  • post-op
37
Q

what are the 2 most common causes of n root entrapment

A

HNP and lateral recess stenosis

38
Q

s/s of radiculopathy

A
  • paresthesia (dermatome)
  • fatigable weakness (myotome pattern)
  • hyporeflexia
  • may or may not have radicular pain
  • sensory loss (dermatome)
39
Q

what dx imaging tool is best for N root entrapment

A

MRI

40
Q

what are the 2 types of instability

A

end zone and neutral zone

41
Q

how does end zone instability occur

A

loss of PASSIVE restraints to motions with loss of active NM control - disc, capsule, ligament injury

42
Q

how does end zone instability present?

A

abnormal center of motion with enlarged neutral zone
- emphasis on abnormal motion rather than hypermobility

43
Q

describe neutral zone instability

A

during motion that occurs during normal posture, minimal resistance is offered by passive restraints - joints move too rapidly or too early from neutral zone even though strength of end restraints or range is normal

44
Q

defect in pars interarticularis connecting superior and inferior facets

A

spondylolysis

45
Q

what will you see in an exam that indicated spondylolisthesis

A

step deformity at segment above affected

46
Q

when does spondylolisthesis occur

A

when the VB of affected segment translates anteriorly

47
Q

describe the grading system for spondylolisthesis (grade 1-5)

A

Grade 1: 25% translation over segment below
Grade 2: 26-50%
3: 51-75%
4: 76-100%
5: > 100%

48
Q

which grades for spondylolisthesis require surgery for sure

A

3-5

49
Q

what radiograph view is needed to grade the slippage associated with spondylolisthesis

A

lateral view

50
Q

describe the clinical presentation of severe (grade 3-4) spondylolisthesis

A
  • SEVERE pain and leg pain (radicular or not)
  • often have neuro deficit
  • kyphotic L4-5 and L5-S1
  • pain increases with walking
51
Q

what radiographic view is required to see a pars interarticularis deficit

A

oblique view - neck of Scottie dog

52
Q

A unilateral pars interarticularis deficit is most commonly seen at which segment

A

L5

53
Q

when is surgery recommended for unilateral pars interarticularis

A
  • symptoms > 6 mo
  • non healing on CT
  • no disc degeneration on MRI
54
Q

what are some examples of causes of unilateral pars interarticularis deficit

A

people that do lots of twisting/rotation - especially in one direction
- golf, baseball

55
Q

describe the process of a unilateral pars interarticularis injury due to torsion forces starting with an excessive rotary force

A

excess rotary force ->
compression fx of subchondral bone on facet ->
neural arch is shorter after healing ->
increased rotation stress on disc ->
fx pars interarticularis (unilat) ->
facet joint capsule tears ->
AF circumferential tear

56
Q

what is acute locked back

A

segmental facet dysfunction

57
Q

describe the initial presentation of segmental facet dysfunction

A

sudden onset of pain on attempt extension from bent position

58
Q

what is the most likely underlying pathology of segmental facet dysfunction

A

instability associated with recurrent episodes

59
Q

describe the incident that a pt may describe for segmental facet dysfunction

A

usually an incident with excessive force (rotation)
- twist and fall, swing bat, MVA

can also be as simple as bend over to pick up a pencil

60
Q

describe the meniscal entrapment theory

A

the meniscoid covers the surface of the facet when the facet is gapped or exposed - when the pt tries to return to neutral position (ex: extend from a flexed position) the meniscoid gets stuck

61
Q

describe the 3 s/s of pt with segmental facet dysfunction

A
  • LBP with occasional radiating/referral pain to butt and posterior thigh
  • pain with hyperextension
  • paraspinal tenderness
62
Q

does a pt with segmental facet dysfunction have neurological signs

A

not usually

63
Q

where is the referral pattern for pts with segmental facet dysfunction

A

butt and maybe posterior thigh

DOES NOT usually refer below knee

64
Q

what should you do/look for after you get a pt with segmental facet dysfunction unstuck?

A

look for underlying instability

65
Q

what quadrant motions will you see in a pt with segmental facet dysfunction

A

restriction in 1 quad loss

66
Q

chronic inflammatory disease of unknow origin, first affecting spine and progressing to fusion of involved joints

A

AS

67
Q

who is AS most common in

A

males, < 30 yrs age

68
Q

most pts with AS have what ____

A

human leukocyte antigen B27 (HLA-B27) gene

69
Q

ASAS classification criteria for axial spondyloarthritis is used in what pts?

A

> 3 mo of back pain and age onset < 45

70
Q

what are the classification criteria for ASAS

A
  • sacroiliitis on imaging + >/= 1 SpA feature

OR

  • HLA-B27 + >/= 2 SpA features
71
Q

spinal fusion that occurs in AS is secondary to _____

A

syndesmophytes

72
Q

what 2 things will you see on a radiograph to indicate bamboo spine?

A
  • ossificaiton of AF
  • squaring of VB
73
Q

repetitive and abnormal afferent input from a pathological segment of spinal or visceral sources would converge on the same segment of spine

A

facilitated segment

74
Q

in the facilitated segment theory, the repeated input would decrease ______, making transmission impulse to the efferent segment ____

A

synaptic resistance
easier

75
Q

what is the outcome of facilitated segment

A

a lesser degree of afferent input would be able to have a greater efferent output

76
Q

facilitated segment - the affected nerve tends to _____ and fire ________

A

over-react
excessively

77
Q

6 s/s of facilitated segment

A
  • tender to palpation in referred area
  • brisk reflex
  • non-fatigable weakness
  • hypertonicity
  • hyper aesthesia
  • orange peel appearance (vasoconstriction)
78
Q

why does a facilitated segment have non-fatigable weakness

A

due to inhibition of n root

79
Q

enhancement in function of neurons and circuit in nociceptive pathway caused by increase in membrane excitability and synaptic efficacy in response to activity, inflammation and neural injury

A

central facilitation/sensitization

80
Q

central facilitation/sensitization - pain is no longer _____

A

protective

81
Q

what are 4 clinical manifestations of sensitization

A
  • allodynia
  • hyperalgesia
  • after sensation
    enhanced temporal summation
82
Q

pain can be elicited by normally innocuous stimuli

A

allodynia

83
Q

pain is exaggerated and prolonged in response to noxious stimuli

A

hyperalgesia

84
Q

what is after sensation?

A

after the stimuli is removed, pt still has pain

85
Q

what is enhanced temporal summation in relation to pain

A

after repeated stimuli, pain gets worse

MSK PT (7 decks)

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