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Spine MSK > Lumbar Spine Common Presentations > Flashcards

Lumbar Spine Common Presentations Flashcards

1
Q

Prognostic Indicators for development of RECURRENT PAIN

A
  • Hx of previous epsodes
  • Excessive spine/joint mobility
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2
Q

Prognostic Indicators for development of
CHRONIC LB PAIN

A
  • Presence of symptoms below the knee
  • Psychosocial distress or depression
  • Fear of pain, movement, and re-injury or low expectations of recovery
  • Pain of high intensity
  • A passive coping style
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3
Q

What is the most commonly presenting complaint for spinal cancer?

A

Back pain

90% of patients

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4
Q

When ruling in/out spinal cancer screening, what are two components fo the patient interview/history that are important indicators for cancer screening?

A

PMH cancer, pain no alleviated with bed rest

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5
Q

Vertebral Osteomyelitis Patient Interview/Hx

A
  • Often traced to other source of infection (dental abscess, pnm, BLADDER)
  • Increased risk:
    • Immunocompromised patients
    • DM
  • Weight Loss
  • Fatigue
  • Fever
  • Neurologic Symptoms
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6
Q

Vertebral Osteomyelitis Pain Complaints

A
  • Local, focal back pain
  • Worse with mechanical loading
  • Improves with recumbent position
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7
Q

Vertebral Osteomyelitis Physical Examination

A
  • Fever
  • Local tenderness
  • Aggravated with local percussion
  • Neurologic signs (cord/root)
  • Lab tests important for diagnosis
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8
Q

Epidural Abscess are often misdiagnosed and are associated with:

A
  • DM
  • Chronic Renal Failure
  • IV drug misuse
  • Alcoholism
  • Cancer
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9
Q

Epidural abscess commonly occurs with:

A

vertebral osteomyelitis

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10
Q

Epidural abscess progression:

A

Local, focal back pain → radicular S&S → paralysis

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11
Q

🚩 Red Flags associated with Vertebral Fractures

A
  • Older age
  • Significant trauma
  • Corticosteroid use
  • Contusion/abrasion
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12
Q

Roman Clinical Prediction Rules

A
  • Age >52Y
  • Absence of leg pain
  • BMI </=22
  • Does not exercise regularly
  • Female gender
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13
Q

Henschke Vertebral Fracture Rules

A
  • Age >70Y
  • Significant trauma
  • Prolonged corticosteroid use
  • Sensory alterations from trunk down
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14
Q

Spondylolysis occurs commonly with what motions?

A

Repetitive microtrauma:
- Extension
- Side-bending
- Lateral flexion
- Rotation

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15
Q

Spondylolysis most commonly occurs at

A

L5

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16
Q

Spondylolisthesis could be a flail segment when:

A

there is a bilateral pars defect with attached multifidus

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17
Q

The greatest slippage of vertebrae occurs when?

A

10-15 YO

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18
Q

On imaging, what would show spondylolisthesis?

A

“Scotty Dog with a collar”

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19
Q

Spondylolisthesis History

A
  • Prevalence up to 43% in athletes (rep. motions): gymnastics, diving, weight lifting)
  • High grade slippage 2x greater in GIRLS > boys; and 4x greater in women > men
  • Greater risk among adolescents
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20
Q

Symptoms of Spondylolithesis

A
  • Localized LBP
  • Worse with extension activities (prolonged standing)
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21
Q

Physical Exam Findings for Spondylolithesis

A
  • Include neurologic testing
  • Visual inspection: excessive lumbar lordosis
  • Possible step-off deformity (SP)
  • Pain with lumbar EXT, rotation (IPSI = lumbar flexion)
  • “Hamstring tightness” (could be protective mechanism to counteract excessive lumbar lordosis)
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22
Q

Spondylolithesis Special Tests/Mobility

A

(+) Instability testing
Spring testing at involved segments

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23
Q

Iatrogenic discitis is extremely painful and commonly occurs due to

A

discography

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24
Q

Internal Disc Disruption is often due to a

A

Rotary injury

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25
Q

What is the weakest portion of an IV disc?

A

end-plate

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26
Q

Loss of disc height requres exessive loading on what jonts?

A

Facet Joints (Tripod effect)

27
Q

What motion is most painful for internal disc disruption?

A

Flexion

28
Q

Symptoms of IDD

A
  • Sudden onset w/trauma or gradual/progressive onset.
  • Recurrent episodes, worsening in intensity each episode.
  • Central lumbar area or can be difficult to localize (focal or diffuse)
  • Pain
    • Dull, constant, aching
    • Activities that stress outer annulus or increase compressional load on disc (coughing, straining, sitting)
    • Multi-directional trunk motions, component)
    • Worse:
      • End range (esp. including a flexion limitation)
      • First getting up after periods of recumbency or sitting,
      • Over course of day
    • Improves with activity (standing, walking)
  • Radicular SxS (if bulge/herniation is present and affecting spinal nerve(s)).
29
Q

Physical Exam IDD

A
  • Imaging: high prevalence rates in asymptomatic populations (20-30%)
  • Visual: Lateral shift or other postural abnormalities
  • Multi-directional P/AROM pain and limitations
    • Can be a directional preference with repeated motions (observe for centralization +/- peripheralization with repeated motions)
  • Pain with spring testing (CPAs)
  • Radicular LMN signs (if bulge/herniation is present and affecting spinal nerve(s))
    • SLR Test (more indicative of radicular s/s)
30
Q

A bulging disc involves how much of the circumference of the disc?

A

50-100% if circumference

Symmetrical or asymmetrical

31
Q
A
32
Q

Type of disc herniation

A

Protrusion or Extrusion

33
Q

Types of Protruded Discs

A

Broad-based: 25-50% (90-180º)
Focal: <25% (<90º)

34
Q

Extrusion Types

A

Narrower neck
Sequestered free fragment

35
Q

What is the kinematics behind a torsion injury?

A

Rotation begins in axis of rotation through posterior 1/3 of IV disc → force at contra facet joint → axis shifts to facet joint = shear and rotary loading

36
Q

Radicular Pain History

A

Acute: trauma (twisting/lifting)
Insidious: progressively more distal as health condition progresses

37
Q

Radicular Pain Symptoms

A
  • Shooting/lancing pain traveling along nerve root distribution
  • “Band-like”
  • Pain with activities that close the neuroforamen
    * Painful twisting/extension activities
38
Q

Physical Exam Findings for Radicular Pain

A
  • Visual inspection: lateral shift
  • Painful/limited ROM - compress foramen or place tensile load on nerve root.
    • Foraminal stenosis: ROM extension/rotation/lateral flexion
    • Disc bulging
  • Tenderness/turgor with guarding paraspinals
39
Q

Radicular Special Tests

A
    • Slump test
    • SLR test
    • Well leg raise test
40
Q

Potential Causes of Central Canal Degenerative stenosis

A
  • Z-joint hypertrophy
  • Bulging disc
  • Thickening/ossification of ligamentous structures
41
Q

What ligaments are the most commonly involved in central canal stenosis?

A

Ligamentum flavum
PLL

42
Q

Central Canal Stenosis History

A
  • Age >65 years
  • Chronic LBP: intermittent/recurrent, +/- hx of trauma
43
Q

Symptoms of Central Canal Stenosis

A
  • Possibly cauda equina symptoms
  • UMN or LMN symptoms in lumbosacral distributions (pending level)
  • Pain increases with walking/standing (prolonged)
  • Pain relieved with sitting, walking with UE support (walker/shopping cart)
  • Pain in legs (posterior lower legs esp) > lower back
  • Bilateral > Unilateral
44
Q

Physical Exam Central Canal Stenosis

A
  • Visual inspection: diminished lumbar lordosis
  • Painful/limited extension + lateral flexion ROM (P/AROM)
  • Improves with flexion
  • Shortened hamstrings*, lengthened hip flexors
  • Neurologic signs
45
Q

CPR for Lumbar Stenosis

A
  • Bilateral symptoms
  • Leg > back pain
  • Pain with walking/standing
  • Pain relieved with sitting
  • Age >48Y
46
Q

How many items from the lumbar stenosis CPR need to be positive to rule out?

A

0 items

47
Q

How many items need to be present to rule in lumbar stenosis?

A

4 or 5 items

48
Q

Lateral Canal Stenosis Causes:

A
  • Loss of disc height w/degenerative process
  • Z-joint hypertrophy
  • Disc bulging
  • Spondylolysthesis
49
Q

Syptoms of Lateral Canal Stenosis

A
  • LMN symptoms in lumbosacral distributions
  • Pain increased with walking/standing (prolonged)
  • Pain relieved with sitting, walking with UE support (walker/cart)
  • LBP + LE pain
  • Unilateral (bilateral if present bilaterally)
50
Q

Physical Exam of Lateral Stenosis

A
  • Visual inspection: diminished lumbar lordosis
  • Painful/limited extension + lateral flexion ROM (passive and active)
    • Commonly improves with flexion
  • Neurologic signs
  • Other findings consistent with degenerative z-joint arthropathy.
51
Q

What are potential referral locations associated with degenerative osteoarthropathy?

A
  • Buttock
  • Thigh
  • Knee
  • Foot
52
Q

What are symptoms of degenerative osteoarthropathy?

A
  • Local/referred, unilateral LBP/buttock pain
  • Aggravating factors consistent with MSK pattern of facet closing
  • Relief with facet gapping positions/activities
53
Q

Physical exam findings with degenerative osteoarthropathy

A
  • P/AROM: painful/limited lumbar extension, ipsi lateral flexion, contralateral rotation, end-range flexion
  • Muscle guarding lumbar erector spinae
  • Possibly difficulty activating multifidi
    • Performance test with cuff
    • Pseudohypertrophy
  • Painful spring testing/UPA
  • Hypomobility with joint mobility testing (in any direction)
54
Q

Acute Traumatic Z-joint pain potential cause

A

meniscoid entrapment - serves as an attached loose body

55
Q

Acute J-joint Pain History

A
  • Sudden onset, potentially Hx of trauma
  • Possible “acute locked back”
56
Q
A
57
Q

Acute Traumatic Z-Joint Pain Symptoms

A
  • Diminished pain in slight flexion position and positions that gap the z-joint
  • Pain with extension activities greatest (closing of z-joint)
58
Q

Acute Traumatic Z-joint pain Physical exam findings

A
  • “Slouched” posture, potentially lateral shift
  • Painful, limited ROM greatest with extension
  • Painful spring testing/UPA
  • Tender, guarded paraspinals
59
Q

NM Instability History

A
  • Recurrent exacerbations
  • Feelings of instability
60
Q

NM Instability Symptoms

A
  • LBP is constant
  • Catching and locking with trunk motion
  • Clicking/clunking/popping noises
  • Aggravated with prolonged positioned (sitting, standing), flexion motion, sudden trunk movements, returning to upright position from flexed position
61
Q

Physical Exam Findings with NM Instability

A
  • Aberrant motions (trunk AROM)
  • Painful/limited: AROM (commonly flexion), returning from full motion (looks like Gower sign)
  • Excessive motion (early)
  • Paraspinal guarding/tenderness
  • Hypermobility (joint mobility testing)
  • Prone instability test
  • Passive lumbar extension test
62
Q

LBP and related health conditions can be associated with what changes in back musculature?

A

fatty infiltration and atrophy of multifidi

63
Q

Pseudohypertrophy

A

CSA normal, fatty tissue occupies space within muscle.

64
Q

How does pseudohypertrophy affect prognosis?

A

Worsens prognosis

Spine MSK (6 decks)

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