lumbar presentations

Question 1

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 ___/___

Answer 1

1. mobility
2. movement coordination
3. relate (referred)
4. radiating
   related cog/affective

Question 2

Excessive mobility in the spine or other joints + hx of previous episodes are prognostic indicators for ___pain, not chronic.

Answer 2

recurrent

Question 3

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?

Answer 3

symptoms below the knee and high-intensity pain

Question 4

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)

Answer 4

prostate, breast, lung, and kidney

Question 5

epidural abscesses occur when when bacteria is carried to the space by the blood but it’s often misdx—about___% of the time.

Answer 5

50%

Question 6

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?

Answer 6

EA: likely to occur after a fall-not always though

VM:Hx of infection (esp bladder)

Question 7

what physical examination findings would support a dx of vertebral osteomyelitis?

Answer 7

fever, local tenderness, agg w/ percussion, neurologic s/s (cord/root),

confirmed via lab tests

Question 8

what physical examination findings would support a dx of epidural abscess?

Answer 8

local/focal back pain, radicular s/s, paralysis

Question 9

Henschke’s 4 Rules for spine fx (think osteoporosis )

Answer 9

age >70 years
significant trauma
prolonged corticosteroid use
sensory alt

Question 10

Roman’s 4 rules for spine fx (think stress or osteoporosis)

Answer 10

age>52, no leg pain, BMI </=22, doesn’t exercise reg, female

Question 11

spondylolysis is a fatigue fracture of the ___ that can be acquired, congenital or developmental. A majority of them are at level___

Answer 11

pars interarticularis; L5

Question 12

Define a flail segment.

Answer 12

a bilat pars defect w/ attached multifidi

Question 13

what are some demographic factors related to spondylolysis & spondylolisthesis

Answer 13

Greatest slip in ages 10-15
sports w/ repetitive ext (diving,gymnastics ,weight lifting, etc)
risk + high grade slip in women>men

Question 14

spondylolysis & spondylolisthesis aggravating fx

Answer 14

extension activities, rotation

Question 15

what physical examination findings would support a dx of spondylolysis & spondylolisthesis?

Answer 15

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

Question 16

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)

Answer 16

scotty dog sign WITH a collar

Question 17

This medically/procedurally contracted condition most commonly results from bacterial infection secondary to a discography.

Answer 17

iatrogenic discitis

Question 18

____ or _____ can be complications of iatrogenic discitis.

Answer 18

sepsis or epidural abscess

Question 19

Three primary sources of discogenic pain are:

Answer 19

iatrogenic discitis, torsion/rotary injury, internal disc disruption

Question 19

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)

Answer 19

schmorl’s nodes

Question 20

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.

Answer 20

degradation, lowering

Question 21

Internal disc disruption is typically a result of these two MOI:

Answer 21

rotary or end plate injury

Question 22

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.

Answer 22

water
annulus
“tripod effect”
osteophyte formation

Question 23

this is not considered a herniation, but instead a _____. It involves between 50-100% of the disc circumference.

Answer 23

bulging disc

Question 24

Herniation: This _____ herniation is considered to be _____ because it involves 25-50% of the disc.

Answer 24

protrusion; broad based

Question 25

Herniation: This _____ herniation is considered to be _____ because it involves <25% of the disc.

Answer 25

protrusion; focal

Question 26

Herniation: This herniation is considered to be _____ because of its shape.

Answer 26

an extrusion

Question 27

Herniation: This herniation is considered to be _____ because of it's free fragment.

Answer 27

sequestered

Question 28

In the same way the the disc can migrate in the transverse plane to impact SC or nerve roots, it can also move ___/____

Answer 28

superiorly/inferiorly

Question 29

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 ___

Answer 29

1. posterior 1/3 of disc, z-joint 2. z-joint (both blanks) 3. tearing of annulus

Question 30

While initial trauma is still a factor regardless , pain from disc pathologies can be ___or ___

Answer 30

acute or chronic

Question 31

Pain descriptions for disc pathology are usually: (think type, frequency and location)

Answer 31

dull and constant ache thats recurrent and worsens in intensity over time central but not well localized

Question 32

Aggravating fx of disc pathology include: (hint: R.E.A.D. the room, my back hurts!)

Answer 32

-recumbency -end range rotation -activities that increase compression (sitting, coughing, etc) -day duration/ disk

Question 33

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)

Answer 33

multidirectional trunk ROM lim directional preference in rep motion (+centralization) +SLR test

Question 34

how might the HPI of radicular pain differ between someone who is acute vs chronic?

Answer 34

acute- likely trauma related to twisting or lifting chronic- insidious but feels like its peripheralizing as the condition progresses

Question 35

describe the symptomatology of radicular pain

Answer 35

shooting band-like pain that is aggravated with closing the foramen

Question 36

what physical examination findings would support a dx of radicular pain?

Answer 36

potential lateral shift and/or disc bulge, lim foramen closing, tenderness/turgor in paraspinals

Question 37

what special test findings would support a dx of radicular pain?

Answer 37

+ slump test +SLR +Well leg raise

Question 38

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)

Answer 38

thickening ligaments (potentially PLL), and spondylolisthesis

Question 39

this **calf** and sometimes thigh pain is common in over half of pts with L-spine stenosis.

Answer 39

neurogenic claudification

Question 40

list the common demographics for degenerative spinal stenosis

Answer 40

age >65, chronic LBP

Question 41

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

Answer 41

central canal degen spinal stenosis

Question 42

what physical examination findings would support a dx of degen spinal stenosis

Answer 42

diminished lumbar lordosis painful/lim ext + lat flex ROM that improves w/ flexion shortened HS/tight hip flex UMN/LMN s/s

Question 43

Our CPRs for lumbar stenosis note 4/5 factors are pretty helpful in CONFIRMING a dx. What are the 5 factors?

Answer 43

bilat s/s leg pain>back pain w/ walking and standing alleviating w/ rest age >48

Question 44

T/F: Similar to what occurs in other spinal regions, z-Joint pain typically refers to the buttock and thigh in reliable, defined patterns.

Answer 44

FALSE. honestly they can refer all the way to foot in some cases

Question 45

thes 3 pathologies are contributors to the development of degen z-joint pain

Answer 45

OA, spondyloarthropathy, DDD/disc spondylosis bonus: hx of prior injury can also relate

Question 46

what patient reports would encourage you to make acute z-joint OA part of your diff dx?

Answer 46

sudden oset and/or trauma acute "locked back" pain assoc w/ opening/closing z-joint space

Question 47

what components of your physical examination might cue you into an acute z-joint dx?

Answer 47

-slouched and potentially lat shifted posture -pain and lim ROM (worst w/ ext) -pain w/ spring testing /UPA -tender, guarded paraspinal

Question 48

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.

Answer 48

flexion: OUT ext: IN

Question 49

NM instability aka muscle imbalance often comes w/ recurrent hx. what other pt reports are characteristic of this dx?

Answer 49

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 )

Question 50

what physical examination findings would support a dx of NM instability?

Answer 50

aberrant and or lim trunk AROM joint or muscular hypermobility paraspinal guarding/tenderness

Question 51

what special tests would support a dx of lumbar NM instability?

Answer 51

Prone instability test passive lumbar ext test

Question 52

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.

Answer 52

back mice; needling and steroid injections

Question 53

LBP is often associated with fatty infiltration and atrophy of the ___. The typical conditions related to these morphologic changes include (3)

Answer 53

multifidi; post-op (fusion!), recurrent unilat LBP, chronic LBP

Question 54

Proposed rationale for why the likelihood of recurrent/ chronic LBP increases with fatty infiltration--in addition to worsening intervention prognosis-- is that...

Answer 54

there is an alteration in muscle recruitment potentially related to reflex inhibition.

Question 55

While a hx of low load, repetitive motions might prioritize trigger points in a differential diagnosis, the 3 requirements of an official dx are:

Answer 55

taut band twitch response local and referred tenderness