Lumbar Spine Flashcards
What is the lifetime prevalence of LBP?
85%
What are indications for low back surgery?
-Cauda Equina Syndrome
-Trauma resulting in gross instability
-Stable Fractures
-Herniated Disc
-Spinal Stenosis
What are the emergent surgical conditions for low back pain?
-Cauda Equina Syndrome
-Trauma resulting in gross instability
What is a spinal decompression surgery?
Removal of bone or neural material suspected to be impinging upon nerves
What is left for stability with a laminectomy?
Just facets, unless hardware included
What should be limited s/p discectomy?
-Bending
-Twisting
-Sitting >30 minutes
What should be limited with laminectomy?
-Bending
-Twisting
-Sitting
All “as tolerated”
What is a typical exercise program for weeks 2-4 after lumbar decompression?
-Ankle Pumps
-Quad, Glute, Ham sets
-SAQ
-LAQ
-Midline stabilization
-Treadmill as tolerated
What manual therapy may be used after lumbar decompression surgery?
Soft Tissue Mobilization
What positioning and postural education should be performed after lumbar decompression?
-Use Lumbar roll
-Neutral posture
At what point to initiate lifting exercises with an individual after spinal decompression surgery?
5-12 weeks, progress from 0 to 15-20#
What is the goal timeframe for returning an individual back to prior level of function after spinal decompression surgery?
6 months
What are the dos and don’ts of total disk replacement?
-No rotation of the lumbar region for the first 3 weeks
-No curving of the lumbar region for the first 6 weeks
-No intense ab exercises for 6 weeks
-No participation in competitive sports for the first 6 months
-Avoid lifting, twisting, and hyperextending for the first 6 weeks
-Try to keep back straight
-Can swim after 6 weeks
-Can jog after 6 weeks
-Can drive after 2 weeks
What is the evidence for activity restriction after lumbar disc surgery (nucleoplasty)?
No evidence activities need to be restricted; wait 4-6 weeks for intensive exercise programs
What is the most common cancer to metastasize to the lumbar spine?
Prostate
What are medical screening questions for cancer/back-related tumor?
-Prior hx
-Neurologic symptoms
-Unexplained weight loss
-Not improved over 1 month
-Age >50
-No relief with bed rest
-Insidious onset
What are signs of back-related spinal infection?
-LB, flank, or pelvic pain
-Local tenderness over spinal process with percussion
-Concurrent infection or drug use
-Fever
What are the items indicitive of cauda equina syndrome?
-Urine retention
-Saddle anaesthesia
-Sensory or motor deficits in the feet
What are features of a spinal compression fracture?
-Major trauma
-Pain and tenderness
-Age >50
-Female
What are signs of an abdominal aortic aneurysm?
-Midline lower thoracic/lumbar pain
-Palpable pulsating abdominal mass
-Patient unable to find a comfortable position
-History of cigarette smoking
-Positive family history
-History of AAA or vascular atherosclerotic disorders
Palpable mass in the abdomen wound indicate performing what next?
Ascultating for a bruit or chaotic sounding blood flow
What are key factors of ankylosing spodylitis?
-Morning stiffness >30 minutes
-Improvment in LBP with exercise but not rest
-Night pain during second half of night only
-Alternating buttock pain
What items would clue you in that back pain is musculoskeletal in origin and not GI related?
-worse with coughing, sneezing, taking a deep breath
-Bending, sitting, lifting, twisting, or turning over in bed make the pain feel worse
-No change in bowel habit
-No change with eating certain foods
-No weight change
To question whether renal or urinary disorders may be contributing to low back pain, what questions to ask?
-Do you have trouble with urination?
-Any changes in urine color, initiation of stream, incontinence, flow changes (in frequency, urgency, output, volume, retention, pain).
What are the 3 subsystems coordinating for spinal stability?
-Passive/Spinal column
-Active/Spinal muscles
-Control/Neural
Spinal stability contributes to?
-Protection of spinal cord
-Upright posture
-Transmit weight to lower members
Spinal mobility contributes to?
-Acting as a shock absorber
-Provides motion for head and trunk
-Attachments for muscles and ligaments
How much fluid content of discs is lost each day?
25%
When is the load on zygapophysial joints the most?
With loaded lordotic posture
What is the lumbosacral angle?
Usually 30 degrees; angle of sacral base
What will increase shear forces at the lumbosacral joint?
Increased lumbar lordosis
How is vertebral motion described?
As the superior segment moving on the inferior and in the direction of the anterior surface of the vertebral body
According to Fryette’s laws of vertebral motion, in neutral, coupled motions are?
Opposite
Lateral flexion in one direction is accompanied by rotation to the other
According to Fryette’s laws of vertebral motion, in non-neutral, coupled motions are?
Same
Lateral flexion in one direction is accompanied by rotation to the same
With rotation, which side of the facet joint is gapped?
The ipsilateral side
What is important regarding the neuromuscular system and injury?
Failure to regain neuromuscular control may place the patient at risk for re-injury
If having pain at midrange, which structures to think of with pain?
Muscles
If having pain at end ranges, think of what structures with low back pain?
Passive structures
What is the order of the spondys from least to most pathological?
-losis
-Lysis
-listhesis
What things clue you into RA, Ankylosing SPonylitis, Psoriatic Arthritis, etc?
-Multiple joint issues
-Skin issues (psoriatic)
-Abnormal lab values (C-reactive protein and Erythrocyte sedimentation rate)
-Medications such as long term steroids, immunosuppresants
What are symptoms of cauda equina?
-B leg symptoms
-Saddle anesthesia
-Bowel/bladder changes
-May be vague or intermittent symptoms
What is an alternative to ankle dorsiflexion to screen the L4 myotome?
Ankle inversion
What is another way to screen the S1 dermatome besides ankle plantarflexion?
Hip Extension
Is a SLR sensitive or specific for a herniated nucleus pulposus?
Sensitive
Is a cross SLR sensitive or specific for herniated nucleus pulposus?
Specific
What do you need in addition to pain down the leg to be considered a radiculopathy?
One of dermatomal, myotomal, and reflex findings
What can cause pain mimicing radicular pain?
Facet joint pain (no myo, dermo, reflex findings)
What is the minimum to clear the hip with a low back patient?
-Observe gait
-PROM with overpressure
-Scour test
What has higher evidence? TBC or McKenzie?
TBC
What are the 3 rehabilitation approaches in the 2015 revision of the TBC?
-Symptom Modulation
-Movement Control
-Functional Optimization
How many visits does it take to reduce low back pain by 50% with manipulation?
2
In general, when to use manipulation with low back pain?
In acute cases unless not indicated
In general, when to use mobilization?
To address movement impairments, particularly stiff joints in aging patients
What has higher evidence for low back pain, Thrust or nonthrust mobliization or soft tissue mobilization?
Thrust or nonthrust mobilization
What level of evidence does dry needling have on low back pain?
C
What level of evidence does directional preference have?
A
What is actually the problem in individuals needing “spinal stabilization”?
Neuromuscular control
What happens with “spinal instability?”
When the deep muscles aren’t firing they way they should, the bigger muscles start to overreact
What does the multifidus do?
-Extension
-Control of anterior translation and rotatoin during flexion
What muscles fire with side lifts?
-Quadratus lumborum
-Multifidus
-External Oblique
-Internal Oblique
What are issues of the hip that generally go along with regional interdependence of back issues?
-Weak glute med
-Inhibited Glute Max
-Tight Rec FEm
-Tight Iliopsoas
-Tight Hamstrings
When is exercise given the highest evidence with low back pain?
Wtih chronic low back pain
Education gets what level of evidence for chronic low back pain?
A
What is the order of SIJ tests?
-if distraction and thigh thrust tests are negative
-then compression test
-If the compression test is negative, then the sacral thrust test
