Lumbar spine Flashcards
Defining characteristics of cauda equina syndrome
Risk factors: herniated discs, acute rapid onset, lumbar stenosis, chronic/gradual onset, spinal surgery
Presentation: back pain with saddle anesthesia, bowel and bladder disturbances, unilateral symptoms progressing to bilateral, alternating leg pain, presence of new motor weakness, greater than 50 years old
Signs and symptoms of cauda equina
Bowel and bladder disturbances, alternating leg pain, saddle anesthesia, unilateral/bilateral radicular pain dermatome and myotome changesWhy is acute or extreme and rapid onset of lower back pain in adults older than 50 a red flag
Why is acute or extreme and rapid onset of lower back pain in adults older than 50 a red flag
Large discs typically do not cause issues in older adults. Suspect cauda equina syndrome
Fracture of lumbar spine risk factors
Severe trauma
female
Advanced age: > 65 years old female > 75 years old male previous spinal fracture especially with low impact
Frequent use of corticosteroids (75 mg over for three months)
cancer
osteoporosis
severe falls
What is the vertebral compression fracture CPG
Female
Greater than 70 years
Significant trauma in younger old populations
Prolonged corticosteroid use
3/4 equals 100% specificity
What are signs that you would look for an exam to encourage referral to imaging? What Type of imaging?
Use of CPG in addition to:
midline tenderness to palpation (can be below fracture area) neurological signs
spinal deformity
contusion or abrasion if sustained from fall
X-ray with lateral view MRI to differentially diagnose fracture between metastatic disease or myeloma
What risk factors would you suspect with spinal malignancy?
Age over 50, history of cancer (not a risk factor in isolation)
Which organs metastasized to the spine
PBKTL prostate breast kidney thyroid liver
What are signs and symptoms of spine metastasis
Severe pain that comes and goes
Night pain
Systematically unwell
Thoracic pain
Greater than 5% body loss over six months
Neurological signs
Spinal tenderness
Weird feeling in legs with altered sensations
Lab tests: ESR and hematocrit
What are the normal ranges for ESR
Under 50 years old: less than 15-20 Over 50 years old: less than 20-30
How much weight loss is suspicious of cancer?
weight loss of five per cent or more in six months
Risk factors for a spinal infection, what signs or symptoms would you see?
Risk factors: Immunosuppression, surgery, IV drug use, social environmental risk factors: homelessness, prison, or work exposure, tuberculosis history or recent or pre-existing infection
Signs and symptoms include: fatigue, spine pain, neuro symptoms, infection symptoms get worse instead of wax/waning wiht maliganacy
Differentiate between malignancy using ESR, see reactive proteins normal white count does not rule out a spinal infection
What are the four main treatment selections based off the treatment based classification for lower back pain
Traction
Specific Exercise
Stabilization
Manipulation
Which patients benefit from manipulation according to the CPG
No symptoms distal to the knee symptom
Onset <16 days low
Fab Q score <19
Lumbar hypomobility
Hip internal rotation >35° for at least 1 hip
Which patients benefit from Specific exercise according to the CPG
Directional preference
Symptoms that centralize or peripheralize with lumbar range of motion
Symptoms distal to butt
> 50 years old
Which patients benefit from Stabilization according to the CPG
Patients younger than 40 greater
General flexibility (postpartum SLR range of motion >91°
Instability catch or aberrant movement
+ Prone instability test
Which patients benefit from traction according to the CPG
Signs and symptoms of nerve root compression: Crossed SLR test
No movements centralize
Symptoms peripheralize with flexion AND extension
According to the treatment selection based on the lumbar TBC what is the cascade of events for intervention selection
Symptom modulation treatment criteria for selection
> movement control
> functional optimization
Which patients can be classified under the symptom modulation category for the lumbar interventions CPG
High Irritability
ODI greater than 40
7 out of 10 pain
High disability
Volatile symptoms
Which patients can be classified under the movement control category for the lumbar interventions CPG
Moderate Irritability
ODI greater than 21-40
3-6 out of 10 pain
moderate disability
stable symptoms
Which patients can be classified under the functional optimization category for the lumbar interventions CPG
low Irritability
ODI greater than 0-20%
1-3 out of 10 pain
low disability
Controlled symptoms
Which interventions are appropriate for the symptom modulation patient category
Directional preference
Manipulation mobilization
Traction
Active rest (encourage active participation without fearful wording pain under 24 hours is consideration for acuity)
Which interventions are appropriate for the movement control patient category
Sensory motor exercises
Stabilization exercises
Flexibility exercises
(think nerve glides)
Which interventions are appropriate for the functional optimization patient category
Strength and conditioning
work/sport specific exercises
aerobic exercise
general fitness
What are defining characteristics of disc herniation with nerve root involvement
Positive straight leg raise test with referred pain
Dermatomal pain at location in accordance to nerve roots Corresponding sensory or motor weakness
3/4 present
How do you distinguish intravertebral disc pain from facet joint pain
IVD Will have centralizing pain,
Facet joint pain will have no relief with rest and possible centralization
What are defining characteristics of spondylolisthesis
Intravertebral slip via palpation or inspection
Segmental hyper mobility with motion testing
Positive leg extension test in elderly
What are defining characteristics of Spinal stenosis
Age over 48
Bilateral symptoms
leg pain > lower back pain
pain with walking and standing
relief with sitting
What is the SI joint cluster of tests
Laslett rules
3/5 positive:
distraction
compression
thigh thrust
gaensleans
sacral thrust
Other cluster
TTP at PSIS
no centralization
Characteristics of disc herniation with nerve root involvement
Corresponding nerve root sensory and motor weakness
Positive SLR with referred pain
Dermatomal pain at location in accordance to nerve root
Characteristics of spondylolisthesis
Intravertebral slip via palpation or inspection
segmental hypermobility with motion testing
+ leg extension test and elderly
Which myotomes are tested with toe and heel walking
L4,5 Ankle dorsiflexion (L4,L5) Great extension (L5)
S1 Ankle PF (L5,S1)
According to the 2021 LBPCPG what are the recommendations for ACUTE low back pain
Active education should be provided not passive
include 1:1 biopsychosocial factors for pain
Self management techniques such as remaining active and pacing with back protection techniques.
Counsel and favorable and natural history of acute lower back pain
According to the 2021 LBPCPG what are the recommendations for CHRONIC low back pain
Education should not be standalone or passive
PNE must be done with manual therapy or exercise
Active treatment is better than standalone education
Which treatments were performed following the manip CPG study
Treatment:
manips: SI,Chicago/ Million dollar roll sidlying rotational manipulation
Exercise: pelvic tilts
How can you distinguish radiculopathy from mononeuropathy
Radiculopathies will have symptoms lumbar/spine
Radiculopathy will follow nerve root pattern for sensation and motor changes
If severe enough weakness will show up later
Hip flexion nerve root
L2-L3
Knee extension nerve root
L 2,L3 ,L5
Ankle dorsiflexion nerve roots
L4, L5
Great toe extension nerve roots
L5
ankle plantarflexion nerve roots
L5 S1
knee flexion nerve roots
L4, L5, S1, S2
What nerve roots contribute to the plantar reflex
L2,3,4
Also known as the babinski reflex
What nerve roots contribute to the achlles reflex
S1 S2
What is an aggravating factor and what is involved with femoral nerve neuropathy
Weak hip flexion if entrapment is above inguinal ligament
Motor and sensory changes
Pain with hip extension
What is an aggravating factor and what is involved with saphrenous nerve neuropathy
Sensory changes only
What is an aggravating factor and what is involved with obturator nerve neuropathy
sensory changes, very small over medial thigh
Weakness after exercise
pain with Adductor stretch
What is an aggravating factor and what is involved with lateral femoral cutaneous femoral nerve neuropathy
Compression of midsection via belt clothing or weight
No motor symptoms
Only sensory loss over anterior lateral thigh
What is an aggravating factor and what is involved with peroneal nerve injury?
which nerve root can it mimic and how to differentiate it? how to distinguish deep peroneal
Ankle plantar flexion and inversion will be affected
Can look like L5 radic.
Muscles not innervated by L5 and not peroneal N.:
Glutes, posterior tibialis, hamstrings (but not short head of biceps) will be spared
If deep peroneal is affected eversion is spared only sensory changes between toes one and two occur
How to distinguish L3/4 neuropathy from femoral mononeuropathy
L3/4 radic: Positive straight leg raise (Sciatic N has L3/4 contributions), posterior tib, Glute med/min, adductor weakness
How can you differentiate saphenous neuropathy from L4 radiculopathy
L4 will have pain with lumbar movement, motor changes to post tib, glute med/min, adductor magnus and will have quad weakness
Deep peroneal nerve muscle innervation.
Anterior muscles of leg. Tibialis anterior extensor digitorum extensor hallicus longus and tertius
Sensory function: Supplies the triangular region of skin between the 1st and 2nd toes
Superficial peroneal nerve muscle innervation
Motor impulses to the peroneus longus and peroneus brevis muscles, every and plantar flexion
Sensory information from the anterior leg and almost the entire foot dorsum
What structure is the only direct dynamic check of anterior shear forces of L5/S1
Deep erector spinae
What muscles place tension across the thoraco lumbar fascia
Deep erector spinae, gluteus maximus, minimus, transverse abs
What are type 1, 2 and three spinal mechanics
Type 1 neutral mechanics vertebral rotation and sidebending happen in opposite directions in a neutral spine position
Type 2: non- neutral mechanics during flexion and extension, vertebral rotation and side bending happened to the same side
Type 3: spinal motion in one plain reduces the amount available in other planes
Cholecystitis pain referral
Right lower thoracic/lower lumbar region
Pancreatitis pain refferal
Left posterior shoulder and upper trap
Penetrating duodenal ulcer pain refferal
Midline thoracolumbar junction
Not perforated duodenal ulcer which refers to right posterior shoulder
Liver pathology pain referral
right anterior shoulder
L5 dermatome myotome
Dermatome: lateral aspect of leg, dorsum of foot, medial half of sole, first, second, and third toes
Myotome: Extensor hallucis, hamstring and calf atrophy
S1 dermatome myotome reflex
D: toes 4 and 5
M: gastroc
R: achilles tendon
L4 dermatome myotome reflex
D: big toe
M: Tibialis anterior
R: (patellar tendon)
s2 dermatome myotome reflex
D: leg posterior thigh and plantar calcaneus
M: hamstring,
R: lateral hamstrings
C7
Dermatome: digits 2-4
Myotome: triceps
Reflex: triceps
C8
Dermatome: medial forearm
Myotome: none
Reflex: noen
C5
Dermatome: middle deltoid
Myotome: biceps
Reflex: biceps
spondylolisthesis
Forward slipping movement of the body of one of the lower lumbar vertebrae on the vertebra or sacrum below it
Step off deformity
Pars inticularis deformity
Treatment: Stabilization exercises
C6
Dermatome: thumb
Myotome: wrist extensors
Reflex: brachioradilais
Which body position increases intravertebral disc pressure the most
sitting, not standing
what do the internal obliques do
right oblique = trunk rotation to the right
hip flexion
L2 L3
Knee extension
L2 L3 L4
ankle DF
L4 L5
Big toe extension
L5
Ankle Plantar flexion
L5 S1
Knee flexion
L5 S1 S2
