Lumbar Spine Conditions (Week 1 Module) Flashcards
Lumbar spine conditions
Lumbar fractures (spinal compression due to osteoporosis or traumatic)
Spondylolysis/spondylolisthesis
Lumbar degenerative disk disease (OA)
Lumbar disk herniation
Sacroiliac joint dysfunction
Scoliosis
Ankylosing spondylitis
Lumbar muscle strain
Lumbar radiculopathy
Lumbar spinal stenosis
Spinal compression fracture–Osteoporosis or Traumatic
Vertebral body compression fracture that results in collapsing or crushing bone
Typically occurs at thoracic and thoracic lumbar junction
Affects: osteoporotic postmenopausal women, elderly men, people on long-term steroid meds, younger people after trauma/fall landing on buttocks or feet
Spondylolysis/Spondylolisthesis
Pathophysiology: Spondylolysis is fracture of pars interarticularis, usually in lumbar spine (L5/S1) and occurs in 5% of population; Spondylolisthesis occurs if progresses to point where vertebral body above slips forward onto one below (can also occur due to degenerative disk disease), spondylolisthesis can be stable or unstable (slippage changes with flexion/extension)
Clinical presentation: lower back pain over L5, hamstring tightness, use CR and CT
Management/prognosis: NSAIDs, muscle relaxants, surgical fusion if extreme, stretching, correct lifting, strengthening abs/back; patients often fine without surgery, but is sometimes required especially if unstable spondylolisthesis
Lumbar Degenerative Disk Disease (OA)
Pathophysiology: intervertebral disk undergoes normal aging and loses flexibility/shock absorbing function (nucleus pulposus dehydrates/more collagen and more pressure on vertebral endplates causes sclerosis and osteophytes and tears in annulus fibrosis); altered alignment of spine causes articular cartilage covering superior/inferior articulating processes to degenerate (osteoarthritis of joints)
Clinical presentation: back pain as disks degenerate, midline area pain with movement/weight bearing and if facet joints involved then with back extension, loss of lumbar lordosis
Management/prognosis: NSAIDs, opioids, weight loss, strengthen abs and back; disease will progress with age of more trauma
Lumbar disk herniation
Pathophysiology: microtears in annulus fibrosis cause inflammation and allows nucleus pulposus to go through the tear (posterolaterally b/c of repeated flexion of lumbar spine); herniation directly, or due to inflammation, compresses nerve roots (cervical radiculopathy) or spinal cord (cervical myelopathy) (however, remember NO SPINAL CORD below L2, just cauda equina)
Clinical presentation: low back pain midline and/or in lumbar paraspinal muscles worse with movements, if nerve root compressed then radiating pain to butt/thigh/lower extremity, if disk compresses thecal sac, compression of cauda equina can cause bowel/bladder incontinence, weakness, decreased muscle tone, loss of sensation/reflexes in leg, Straight Leg Raise test (reproduce LEG pain by elevating leg)
Management/prognosis: NSAIDs, opioids, muscle relaxants, corticosteroid injection, relaxation/ROM exercises, ice/heat; most resolve within 6 weeks of conservative treatment unless have nerve/spinal cord compression
Note: disk herniation much more common in lumbar region because more weight there
Sacroiliac joint dysfunction
Pathophysiology: caused by change in integrity of sacroiliac ligaments (shortened/tight, lax, uneven/fused joint surfaces, imbalance of musculature surrounding SI joint)
Clinical presentation: low back/butt pain increases with walking, standing, weight-bearing, pain may be reproducible with palpation, leg length test, FABER test (positive is pain with hip external rotation, flexion, abduction)
Management/prognosis: NSAIDs, ice/heat, strengthening exercises, steroid injection; good prognosis for those treated early but chronic/debilitating otherwise
Scoliosis
Pathophysiology: lateral curvature of the spine primarily in thoracic/lumbar regions either C or S shaped and either dextroscoliosis (convex to pts right) or levoscoliosis (convex to pts left); idiopathic in adolescence and secondary to spondylolysis/spondylolisthesis, degenerative disk disease, spinal stenosis or compression fractures from osteoporosis in adults
Clinical persentation: no pain in adolescents, only in adults, asymmetry of spine more apparent as pt bends forward
Management/prognosis: once hits 20-30 degree curvature children have to wear brace and fixed surgically at 40 degrees; in adults, increased pain and deformity progresses
Ankylosing Spondylitis
Pathophysiology: ankylosing (joint fusion) spondylitis (spinal inflammation) is chronic seronegative spondyloarthropathy defined by axial (sacroiliac and spine) involvement and association with Class I HLA-B27 allele; sacroiliac joints get sacroilitis and pannus (granulation tissue) forms that erodes fibrocartilagenous joint resulting in ossification and bony fusion (ankylosis); enthesitis (inflammation where tendons and ligaments attach to bone)
Clinical presentation: low back pain due to sacroiliitis that is worse with rest, morning stiffness, enthesitis causes pain and stiffness, test for HLA-B27 but only 2-7% of HLA-B27 positive people develop AS and >90% of caucasians have HLA-B27, sacroiliac joints widen then sheets of ossification obscure joint completely, “bamboo spine” (squaring of vertebral bodies and fusion bc anterior/posterior longitudinal ligaments become calcified)
Management/prognosis: NSAIDs, physical therapy for good posture; ranges from mild to severe
Lumbar muscle strain
Pathophysiology: injury of muscle from incorrect exertion or overuse
Clinical presentation: acute onset of sharp, aching, throbbing pain at posterior back and butt worse with movement, loss of normal lumbar lordosis, pain reproducible with palpation, lack of flexibility due to muscle spasm
Management/prognosis: NSAIDs, ice acute, back brace, heat subacute, stretching; most cases recover spontaneously days to weeks
Lumbar radiculopathy
Pathophysiology: compression or injury to spinal nerve roots: (1) herniated intervertebral disk or osteophytes, (2) inflammatory process in surrounding soft tissues, most commonly tears in annulus fibrosis; L5 and S1 nerve roots most commonly affected (remember, by disks right ABOVE them)
Clinical presentation: paresthesia along dermatome, or movement deficit, antalgic gait, loss of reflexes/abnormal sensations along myotomes, affects gluteal region and lower extremity, sciatica (pain along distr of sciatic nerve), Straight Leg Raise Test, EMG for level of involvement
Management/prognosis: NSAIDS, antidepressants and anti-seizure meds, posture, lumbar traction, epidural corticosteroid injection, surgical removal of herniated disk/osteophytes; most symptoms resolve w/conservative treatment
Lumbar spinal stenosis
Pathophysiology: narrowing of lumbar spinal canal (disk herniation, osteophyte, hematoma, tumor, foreign body), can get compression of nerve roots or cauda equina
Clinical presentation: sometimes gradual onset back pain/stiffness, bowel/bladder incontinence if cauda equina compression, walk forward flexed (stooped), reduced muscle tone and reflexes in lower extremities, Straight Leg Raise Test, MRI to determine canal size and compression, usually causes bilateral symptoms and multilevel involvement (diff nerve levels)
Management/prognosis: NSAIDs, opioids, oral corticosteroid, epidural corticosteroid injection, decompression surgery; mild will improve, moderate will progress, surgery
For lumbar radiculopathy, what nerves cause pain change where?
L2-3: anterior/mid-thigh
L4: knee and medial malleoulus
L5: web between 1st and 2nd toe
S1: lateral malleolus
(Roots: Pain Location)
For lumbar radiculopathy, what nerves cause movement change where?
(Roots: Movements)
L2-4: knee extension and hip adduction
L5: ankle dorsiflexion and big toe extension
S1: ankle plantar flexion, knee flexion, hip extension
