lumbar spine Flashcards
risk factor of low back pain
low educational status, stress, anxiety, depression, job dissatisfaction, low levels of social support in the workplace
T/F female>man experience low back pain
T
most common form of low back pain is
is NON-SPECIFIC (~90%), meaning the pathoanatomical cause of pain cannot be determined
what is mechanical low back pain
= pain arises intrinsically from the spine (discs, facets, soft tissue
Acute LBP can be triggered by
physical factors (lifting awkwardly), or psychosocial factors (being fatigued, frustrated) or a combo of the two
low back pain can be accompanied by several disease like? and what do you want to rule out
Want to rule out conditions affecting L/S epidural abscess, compression fx, spondys, malignancy, cauda equina)
Radicular pain, radiculopathy or spinal canal stenosis
which structure can be a source of pain with low back pain
Intervertebral disc, facet joints, muscle, bone, fascial structures, and organs within the abdominal cavity
Also influences by psychological factors such as stress, depression and/or anxiety
Recommendation for by the American College of radiology is not to do imaging for LBP within the first _weeks UNLESS red flags are present
6
what are the red flag that would required imaging within the first 6 week of complain of LBP
Recent substantial trauma or milder trauma in those over 50
Weight loss or fever with no known cause, immunosuppression
A previous cancer diagnosis, IV drug use, or osteoporosis
Being over 70 years old
Focal neurological deficit with progressive or disabling symptoms
Lumbar Spine Subjective Screening
mechanical lifting
pain location and timing: backlog or both
effect of sitting, standing, walking
effect of fast/slow, uphill/downhill walking
effect of cough,sneeze,valsava
bed type and sleeping position
painful locking or catching with lumbar spine motion
what is cauda equina syndrome
progressive motor or sensory loss, new urinary retention or overflow incontinence, new fecal incotinence
differential diagnosis of mechanical low back pain
lumbosacral muscle/strain sprain
lumbar spondylosis
disk herniation
spondylolysis
vertebral compression fracture
spondylolisthesis
spinal stenosis
what is lumbar stenosis
narrowing of vertebral space (worse in flexion)
what is lumbar spondylosis
(degenerative disc disease)- begins in 20’s, overall OA and stenosis
stress fx or complete fx of the pars interarticularis
s/s spondylolisthesis
Spondylolisthesis- 90% at L5/S1, excessive lordosis, postural ache, mm spasm, tight psoas and hamstrings
Gradual onset that is worsened by activity involving hyperextension or rotation of the L/S
Radiculopathy can occur with progressive foraminal stenosis
what is ankylosing spondylitis
inflammatory disorder of spine (synovial lining), morning stiffness, pain with exercise, leading to decrease vertebral movement (fusion)
with time can cause some of the bones in the spine to fuse
Affecting ROM within the spine
most common cause of radicular pain from back to buttock
evoked from inflamed or lesioned dorsal root or its ganglion
Generally occurs from back to buttock into the leg in a dermatomal distribution
Disc herniation most common cause
what is radiculopathy
Radiculopathy- impairs the conduction down a spinal nerve or its root
Affecting sensory changes (numbness), motor fibers (weakness), and possible reflexes
can radicular pain occurs without radiculopathy
yes
is it possible to make a distinction among the patterns of L4, L5, S1 radicular pain
no except if radiculopathy is associated with radicular pain
which type of disc herniation is most popular and worse with what
Posterior herniations most common
Worse with forward flexion
May have neurological signs at specific nerve root level
Pain increases with intrathecal pressure increase
common complain of facet joint syndrome
Pain off to the side
May or may not have radicular symptoms (will terminate above knee), often radiating to thigh or groin
Pain inc with hyperextension, rotation and lateral bending and walking uphill
Exacerbated when waking up or sitting for long periods (stiffness
if you have pain with hyperextension, rotation, side bending , pain exacerbated when waking up or sitting for too long what could you have
facet joint syndrome
lumbar stenosis can be caused by
inflammatory/scar tissue after spine surgery, disc herniation, thickening of ligaments, osteophytes etc.
Progressive narrowing of central or lateral spinal canal, causing compression of neurovascular structures
to have spinal stenosis you need to have less than _ mm diameter of spinal canal
Less than 10mm diameter of spinal canal (15-27mm normal)
common S/S of lumbar stenosis
Radiculopathy (motor weakness, parathesia, impairment of sensory nerves)
Central= often bilateral symptoms
Lateral=often lateral symptoms
Ease discomfort- trunk flexion, sitting, lying
Aggravate- standing, lumber extension
what is disco degeneration
Degradation within the disc of the nucleus pulposus with fissures (crack/split) in the annulus fibrosus
what can increase disc degeneration
diabetes
what is the General term for age related wear and tear of the bones, cartilage, ligaments and discs of the spine
spondylosis
spondylosis is typically characterized by
narrowing of the disc space or arthritis of the facet joints
main symptom of spondylosis
General neck pain and stiffness
Can be associated with radiculopathy
what is spondylolisthesis
Spondylolisthesis- anterior translation of the vertebral body relative to the other, and secondary to an abnormality of the pars interarticularis
what is the most frequent lumbar injury in adolescent
spondylolisis
spondulolisthesis occurs most commonly where
l5/s1
spondylolisthesis can affect load sharing how
Inc shearing forces
Higher sacral slope and pelvic tilt
Inc pressure on discs, facet joints, leading to degeneration
Muscle spasm of ES to protect
see the table of differential diagnosis of mechanical low back pain
postural muscle tend to respond how with low back pain
with tightness in the form of spasm or adaptive shortening
Examples: psoas, QL, Erector spinae
phasic muscle tend to respond how with low back pain injury
with atrophy
Examples: Abdominals, glutes
if you have difficulty sitting you may have
lumbar instability or muscle spam
what is discogenic pain
flexion for extend period of time
when performing SLR if the athlete have pain primarily in the back it would indicate what
Back pain primarily=most likely from disc herniation from pressure on the anterior theca of the spinal cord
when performing SLR if the athlete have pain primarily in the leg t would indicate what
Pain primarily in leg=pathology causing pressure on neurological tissues more laterally
what could indicate a positive slump test for neurmeningeal tract
If unable to extend knee fully, take tension off c-spine (extend it) and if knee is able to extend fully, the symptoms decrease then POSITIVE for tension in the neuromeningeal tract
slump test is more (sensitive/specific) than SLR
SLR is slightly more (sensitive/specifi) than slump test
sensitive, specific
what is the cross over sign/ well leg raise
If opposite leg to the affected leg is lifted and there is pain on the affected leg it is an indication of a space occupying lesion (e.g. herniated disc or inflammatory swelling)
cross over sign indicate what and if positive what would you want to ask
Typically indicates a rather large disc protrusion, and usually medial to the nerve root
If positive, ask question regarding bowel and bladder control
PKB test indicate what
Unilateral neurological pain in the lumbar area, buttocks or posterior thigh may indicate an L2 or L3 nerve root lesion
Test also stresses femoral nerve
Careful history and pain differentiation will help determine between tight quads or femoral nerve irritation
finding of quadrant test and what it is
Patient stands with examiner behind them
Patient extends the spine
Patient then side flexes and rotates to the side of pain
Position causes maximum narrowing of vertebral foreman and stress on the facet joint in which rotation occurs
+ve- radiation, local irritation, SI joint irriation
one leg standing (stork stance) trst
Patient stands on one leg and extends the spine while balancing on one leg
Repeat opposite leg
Positive test indicated by pain in back
Pars interarticularis stress fracture If fracture is unilateral, standing on ipsilateral leg causes more pain
how long do you hold the Mckenzie slide glide test
10-15s
what is pheasant test
Patient lies prone
With one hand the examiner applies pressure to the posterior aspect of lumbar spine
With the other hand, the examiner passively flexes the patients knees until the heels touch buttocks
If the hyperextension of the spine causes pain in the leg the test is considered positive and indicates unstable spinal segment
what is passive lumbar extension test
Patient prone and relaxed
Examiner passively lifts both extremities at same time to about 1 foot from bed
While maintaining lift, gently pull on legs
Positive: pt complains of strong pain in L/S, very heavy feeling
Pain disappears with returning to start position
H&I instability test positive
Positive for instability
Hypomobility
At least 2 of the movements into the same quadrant would be limited
Instability
One quadrant will be affected but by only one of the moves (i.e “H” movement or “I” movement)
what is type 1 dysfunction of lumbar
SB and rotation are opposite in neutral
multi-segmental (3+ vertebra) and adaptive
Restrictions found in “Neutral” (but are correct in Flex/Ext)
NSR(L)
NSR(R)
See a rotation in TPs in neutral
Left TP is anterior, right TP is posterior—what rotation is this?
Rotation is corrected in extension and flexion
what is type 2 dysfunction of lumbar
In flexion/extension with SB and rotation same
Single segmental and traumatic
Assess the L/S in neutral (pt prone). Place thumbs on TPs of lumbar segment you are looking at (example L4)
- Note if one thumb is more anterior then the other
- Example: R thumb is more anterior than L thumb than
left rotation of the L4 segment and if there’s more than 2 segment it multisegment so type one dysfunction
if 3 or more TP’s remain prominent prominent in neutral (but disappear during flexion AND extension) than a
neutral (type 1) dysfunction is present
if one segment is stuck in either flexion or extension a _ is present
If one segment is stuck in either flexion or extension, a non-neutral (Type II) dysfunction is present- FRS or ERS
if you palpate the lumbar spine TP and your left thumb is more posterior and right thumb is more anterior in neutral
when you sphinx, both thumb even out but when you go into child pose, the thumb return more posterior on the left and anterior to right what does it mean
ERS dysfunction because the vertebra love to be in extension and when you go into flexion it don’t want to so it doesn’t even ou
