lumbar presentations Flashcards
LBP CPGs were created with an impairment-based classification system in mind. The classifications are:
-Acute LBP with___deficits.
-Acute/Chronic LBP w/ movement ___
-Acute LBP w/ related ___ pain
-Acute/Chronic w/ ___ pain
Acute/Chronic w/ related ___/___
- mobility
- movement coordination
- relate (referred)
- radiating
related cog/affective
Excessive mobility in the spine or other joints + hx of previous episodes are prognostic indicators for ___pain, not chronic.
recurrent
Many of the prognostic indicators for chronic LBP relate to cog factors such as fear/low expectations, distress/depression, and passive coping style. What are 2 more physical indicators?
symptoms below the knee and high-intensity pain
Back pain is pretty prevalent in cancer pts- hence, asking re Hx is important. What are the common metastasis origins? (Think lead kettle minus 1)
prostate, breast, lung, and kidney
epidural abscesses occur when when bacteria is carried to the space by the blood but it’s often misdx—about___% of the time.
50%
Vertebral osteomyelitis and epidural abscesses are often concomitant and similar in that they both present in focal back pain and have nervey s/s but how do HPI differ?
EA: likely to occur after a fall-not always though
VM:Hx of infection (esp bladder)
what physical examination findings would support a dx of vertebral osteomyelitis?
fever, local tenderness, agg w/ percussion, neurologic s/s (cord/root),
confirmed via lab tests
what physical examination findings would support a dx of epidural abscess?
local/focal back pain, radicular s/s, paralysis
Henschke’s 4 Rules for spine fx (think osteoporosis )
age >70 years
significant trauma
prolonged corticosteroid use
sensory alt
Roman’s 4 rules for spine fx (think stress or osteoporosis)
age>52, no leg pain, BMI </=22, doesn’t exercise reg, female
spondylolysis is a fatigue fracture of the ___ that can be acquired, congenital or developmental. A majority of them are at level___
pars interarticularis; L5
Define a flail segment.
a bilat pars defect w/ attached multifidi
what are some demographic factors related to spondylolysis & spondylolisthesis
Greatest slip in ages 10-15
sports w/ repetitive ext (diving,gymnastics ,weight lifting, etc)
risk + high grade slip in women>men
spondylolysis & spondylolisthesis aggravating fx
extension activities, rotation
what physical examination findings would support a dx of spondylolysis & spondylolisthesis?
neurologic s/s
focal p!
excessive lordosis w/ possible step-off deformity
hamstring tightness?
+instability and spring test
»often decreased flex/ext via imaging as opposed to instability
When observing spondylolysthesis, we know that CT and MR’s are better than X-rays for confirming the dx. With these images, we are looking for a “______” (think puppy lol)
scotty dog sign WITH a collar
This medically/procedurally contracted condition most commonly results from bacterial infection secondary to a discography.
iatrogenic discitis
____ or _____ can be complications of iatrogenic discitis.
sepsis or epidural abscess
Three primary sources of discogenic pain are:
iatrogenic discitis, torsion/rotary injury, internal disc disruption
Falling, repetitive jumping and/or picking up heavy objects (multifidi stress) can lead to axial compression on the vertebral endplates and ultimately fx+ ___ (think nucleus leakage)
schmorl’s nodes
Schmorl’s nodes can indicate an interaction between the nucleus pulposus and the body, there is potential for _____of the nucleus matrix (inflammation present) or ____of the pH (inflammation absent). Either way it’s a bad time to be a nucleus.
degradation, lowering
Internal disc disruption is typically a result of these two MOI:
rotary or end plate injury
The 4 main consequences of an IDD are that:
*The nucleus is less able to bind ___(thus can’t withstand pressure as well) and relies more on ___.
*Discs lose height and may extend to form herniations.
*“_____ effect “as facet joints take on more load.
*_______formation.
water
annulus
“tripod effect”
osteophyte formation
this is not considered a herniation, but instead a _____. It involves between 50-100% of the disc circumference.
bulging disc
Herniation:
This _____ herniation is considered to be _____ because it involves 25-50% of the disc.
protrusion; broad based
Herniation:
This _____ herniation is considered to be _____ because it involves <25% of the disc.
protrusion; focal
Herniation:
This herniation is considered to be _____ because of its shape.
an extrusion
Herniation:
This herniation is considered to be _____ because of it’s free fragment.
sequestered
In the same way the the disc can migrate in the transverse plane to impact SC or nerve roots, it can also move ___/____
superiorly/inferiorly
talk through torsion MOI step by step.
1. axis of rotation starts @ ____ and lim by _____
2. Forced rotation changes axis to ____ and the opp ____ rotates backwatds+ shearing force on disc
3. Shear + rotary loading > potential ___
- posterior 1/3 of disc, z-joint
- z-joint (both blanks)
- tearing of annulus
While initial trauma is still a factor regardless , pain from disc pathologies can be ___or ___
acute or chronic
Pain descriptions for disc pathology are usually: (think type, frequency and location)
dull and constant ache thats recurrent and worsens in intensity over time
central but not well localized
Aggravating fx of disc pathology include:
(hint: R.E.A.D. the room, my back hurts!)
-recumbency
-end range rotation
-activities that increase compression (sitting, coughing, etc)
-day duration/ disk
in a physical examination of someone with disc pathology, we might expect to see postural abnormality (ex lat shift), pain in CPAs, LMN s/s and (3)
multidirectional trunk ROM lim
directional preference in rep motion (+centralization)
+SLR test
how might the HPI of radicular pain differ between someone who is acute vs chronic?
acute- likely trauma related to twisting or lifting
chronic- insidious but feels like its peripheralizing as the condition progresses
describe the symptomatology of radicular pain
shooting band-like pain that is aggravated with closing the foramen
what physical examination findings would support a dx of radicular pain?
potential lateral shift and/or disc bulge, lim foramen closing, tenderness/turgor in paraspinals
what special test findings would support a dx of radicular pain?
+ slump test
+SLR
+Well leg raise
spinal stenosis is foraminal closing that is often described as degenerative. Structures that may contribute to this are: bulging discs, z joint hypertrophy (or osteophytes), ____(2)
thickening ligaments (potentially PLL), and spondylolisthesis
this calf and sometimes thigh pain is common in over half of pts with L-spine stenosis.
neurogenic claudification
list the common demographics for degenerative spinal stenosis
age >65, chronic LBP
A person notes they are experiencing: UMN (OR LMN) s/s, pain aggravated by prolonged positioning/relieved w/ recumbency or UE support and pain in both legs that > their LBP. What is at the top of your differential
central canal degen spinal stenosis
what physical examination findings would support a dx of degen spinal stenosis
diminished lumbar lordosis
painful/lim ext + lat flex ROM that improves w/ flexion
shortened HS/tight hip flex
UMN/LMN s/s
Our CPRs for lumbar stenosis note 4/5 factors are pretty helpful in CONFIRMING a dx. What are the 5 factors?
bilat s/s
leg pain>back
pain w/ walking and standing
alleviating w/ rest
age >48
T/F: Similar to what occurs in other spinal regions, z-Joint pain typically refers to the buttock and thigh in reliable, defined patterns.
FALSE. honestly they can refer all the way to foot in some cases
thes 3 pathologies are contributors to the development of degen z-joint pain
OA, spondyloarthropathy, DDD/disc spondylosis
bonus: hx of prior injury can also relate
what patient reports would encourage you to make acute z-joint OA part of your diff dx?
sudden oset and/or trauma
acute “locked back”
pain assoc w/ opening/closing z-joint space
what components of your physical examination might cue you into an acute z-joint dx?
-slouched and potentially lat shifted posture
-pain and lim ROM (worst w/ ext)
-pain w/ spring testing /UPA
-tender, guarded paraspinal
the insulating fat pads of the spine, ie: meniscoids, move ___ (into/out of) the joint during flexion and ____(into/out of) it during extension. After trauma, they can become highly irritable loose bodies.
flexion: OUT
ext: IN
NM instability aka muscle imbalance often comes w/ recurrent hx. what other pt reports are characteristic of this dx?
constant LBP, prolong position, quick movement, flexion
+ pop,lock and drop it!
(pop/clunk noises, locking/catching, painful flex /getting up from ‘dropping it’ lol )
what physical examination findings would support a dx of NM instability?
aberrant and or lim trunk AROM
joint or muscular hypermobility
paraspinal guarding/tenderness
what special tests would support a dx of lumbar NM instability?
Prone instability test
passive lumbar ext test
thoracolumbar fascia fat herniations, aka _____, present as innervated and palpable nodules in the posterior layer of the fascia.Rarely the ONLY issue, they can be treated with______ . They can also be asymptomatic.
back mice; needling and steroid injections
LBP is often associated with fatty infiltration and atrophy of the ___. The typical conditions related to these morphologic changes include (3)
multifidi;
post-op (fusion!), recurrent unilat LBP, chronic LBP
Proposed rationale for why the likelihood of recurrent/ chronic LBP increases with fatty infiltration–in addition to worsening intervention prognosis– is that…
there is an alteration in muscle recruitment potentially related to reflex inhibition.
While a hx of low load, repetitive motions might prioritize trigger points in a differential diagnosis, the 3 requirements of an official dx are:
taut band
twitch response
local and referred tenderness
