Lumbar Spine Exam Flashcards
For the 2021 Revision of LBP CPG, what differentiates “acute” versus “chronic”
Acute < 6 wks of sxs
Chronic > 6 wks
According to the LBP Decision tree, to understand the pt’s LBP experience, you want to assess for pain related psychology distress. What are 3 options for doing so?
- STarT Back Screening tool
- Orebro MSK Pain Questionnaire
- OSPRO -Yellow flag tool
According to the LBP Decision tree, to understand the pt’s LBP experience, you want to collect baseline outcome assessment info. What are 3 options for doing so?
- Oswestry Disability index (ODI)
- Roland-Morris Disability Questionnaire (RMDQ)
- Pt Specific Functional Scale (PSFS)
What are the 5 subgroup classifications for ACUTE LBP?
Acute LBP w/…
1. Movement Coordination Impairments
- Related cognitive or affective tendencies
- Mobility deficits
- Related (referred ) LE pain
- Radiating pain
What are the 3 subgroup classifications for CHRONIC LBP?
Chronic LBP w/…
1. Movement coordination impairments
- Radiating pain
- Generalized pain
If a pt scores 3 or less on the start back, what does that indicate?
Low risk (of disability)
If a pt scores 4 or more on the start back, but their sub score (Q5-9) is 3 or less, what does that indicate?
Medium risk (of disability)
If a pt scores 4 or more on the start back, but their sub score (Q5-9) is 4 or more, what does that indicate?
High risk (of disability)
What does the OREBRO test for?
likelihood to have future disability that interferes with employment
What is the MCID for OREBRO?
12
What is the OSPRO used for?
Yellow flag assessment tool that can be used to determine full-length questionnaire score estimates or ID “yellow flags”
OSPRO = Optimal Screening for Prediction of Referral and Outcome
What 3 categories are included in the OSPRO?
- Negative mood
- depression
- state-trait anxiety
- state-trait anger
- Fear avoidance
- FABQ
- Pain catastrophizing
- Kinesiophobia
- Pain anxiety
- Postive affect/coping
- Pain self-efficacy
- self-efficacy for rehab
- chronic pain acceptance
Describe the interpretation for score ranges on the ODI?
Low/minimal disability = 0-21%
Mod = 21-40%
Severe = 41-60%
Crippled = 61-80%
What is the MCD for the ODI?
11%
what is the range that the Roland-Morris Disability Questionnaire is out of?
What does 0 indicate?
what is the MCD?
0-24%
0 = no disability
MCD = ~5% depending on pop
What is the MCD for PSFS (average score, not single activity score)?
2 points
(3 if single activity score)
Name the SINSS in order
Severity
Irritability
Nature
Stage
Stability
Define severity
Intensity of sxs and extent that they limit normal activity
ex. pain scale, functional limitations (“I can bend over and touch toes but it hurts a little when I do”)
Define irritability
ease in which sxs are produced and time it takes to settle
define nature
type and extent/degree of injury/illness
define stage (SINSS)
acute, sub-acute, chronic, acute on chronic etc
Define stability (SINSS)
how are sxs changing? better/worse/same? stable/unstable?
What are LBP risk factors?
Mod-strong evidence for:
1. smoking (2x more likely)
2. spending > 1hr/day in vehicle (2x)
3. spending > 1 hr/day in activity w/ vibratory forces (mowers, saws, etc.) (5x)
4. full-term pregnancy w/ vaginal delivery (3x)
Weak evidence:
1. Repetitive heavy lifting
2. obesity & poor conditioning
There is a favorable natural history of acute LBP. 30-60% of people recover in ___ week(s)
1 week
There is a favorable natural history of acute LBP. 60-90% of people recover in ___ week(s)
6 weeks
There is a favorable natural history of acute LBP. 95% of people recover in ___ week(s)
12 weeks (3 mo)
According to a 2009 study, what is the greatest predictor of whether someone will have spinal surgery?
of surgeons in local pop
Of pts with LBP, what % have mechanical LBP?
97%
Of pts with LBP, what % have a visceral disease that is causing the pain, leading you to referring them?
2%
What are 4 general visceral disease categories that could be the reason your pt has LBP?
- Abdominal Aortic Aneurysms (AAA)
- GI diseases
- Disease of pelvic organs
- Renal disease
What % of patients with LBP have a nonmechanical spinal condition that isn’t a visceral disease?
1%
What potential nonmechanical and non-visceral conditions can be the reason for a pt’s LBP?
- Neoplasia
- Inflammatory arthritis
- Infection
- Paget’s disease (bone breakdown)
- Scheuermann’s disease (vertebral endplate ~kyphosis)
What interview questionnaire info would you expect for a pt with a bone related tumor?
- Constant pn not affected by position or activity, worse at night & worse w/ WBing
- Age > 50
- Hx of cancer
- Failure of conservative intervention (within 30 days)
- Unexplained weight loss
- no relief w/ bed-rest
T or F: Cauda Equina Syndrome is a neurological emergency!
T
What should you do for a pt with suspected Cauda Equina Syndrome?
Refer immediately to physician/ortho spine surgeon/neurosurgeon/local ED!
**surgery = most successful within 72 hours from onset
Cauda equina syndrome is often assoc w/ nontraumatic massive midline post disc herniation. What spinal segments are most common for CES to occur?
L4-5 > L5-S1 > L3-4
what are the consequences of delayed treatment for cauda equina syndrome?
pt may differ from long-term loss of B&B, sexual function
What are risk factors for cauda equina syndrome?
- LB injury w/ central disc herniation
- central canal stenosis
- spinal fx
- ankylosing spondylitis
- TB
- Pott’s disease
What diagnostic findings would suggest that a pt has CES?
- Urinary retention (cannot void) –> most Sn & Sp!
- Unilat/bilat sciatica
- Unilat/bilat motor/sensory deficits
- SLR test (reproduction of radicular sxs in LE 20-70 deg hip flex)
- Sensory deficit: buttocks, post-sup thigh, perianal region (“saddle”)
What info would you expect from a history for a pt with a suspected back-related infection?
- Recent infection (UTI, skin etc)
- IV drug user/abuser
- Concurrent immunosuppressive disorder (HIV, TB etc)
- Reports of fever, malaise, swelling
- Limited mobility
What info would you expect from a history for a pt with a suspected SPINAL COMPRESSION FX?
- Hx of trauma (MVA, fall from height, direct blow to spine)
- Hx of minor trauma for osteoporotic or elderly individuals (falls, heavy lifts)
- Age >75
- Prolonged use of corticosteroids
- Inc pn w/ WBing
What is an Abdominal Aortic Aneurysm (AAA)?
= abdominal aortic vessel distension of 3 cm or more (risk of rupture increases as diameter approaches 5-6 cm)
*most common 60+
What are 6 risk factors for AAA?
- Age (>)
- Male (5-6x more common)
- Hx of smoking (3-5x)
- DM
- Hx of CAD and hypercholesterolemia
- Family hx of AAA
How would you expect a pt with a suspect AAA present clinically?
- back pn = most common! (referral pn)
- can present as abdominal, groin, or buttock pn
- Pn inc w/ general activity, but not w/ spinal movement (not mechanical to spine)
-Inc w/ CV load, but not
specific - Insidious onset & may progress slowly or quickly
- May complain of early satiety (feeling full), weight loss, nausea
What would you include in your exam of a pt with a suspected AAA?
- Palpation - AA diameter
- Bounding mass (not just pulse) = indicative of rupture
- Auscultation for bruit (vascular sound assoc w/ turbulent blood flow)
What 2 factors would INCREASE your suspicion of AAA?
- Sxs NOT realted to mvmt stresses
- Abdominal girth <100 cm (40 in)
What are S&S of digestive/GI system disorders?
- difficulty swallowing
- heartburn & indigestion
- specific food intolerances
- changes in appetite
- Bowel dysfunction
- Abdominal distension
- fevers/chills/sweats/ nausea
- rebound tenderness
- pn relieved by sitting forward in flexed posture (pancreatic etiology)
- colicky abdominal pn
What digestive organs can refer to the region of the low back?
- stomach, small intestine, large intestine/colon, prostate, kindey, bladder
What interview info would you expect from a pt with suspected ACUTE LBP w/ movement coordination impairments?
- Acute exacerbation of RECURRING LBP, commonly assoc w/ referred LE pn
- sxs often incl: numerous episodes of LBP and/or LB-related LE pn in recent yrs
What interview info would you expect from a pt with suspected ACUTE LBP w/ MOBILITY DEFICITS?
- acute LBP, buttock, or thigh pn (<6wks)
- onset of sxs often linked to recent unguarded/awk mvmt or position
What interview info would you expect from a pt with suspected ACUTE LBP w/ RELATED (REFERRED) LE PAIN?
- LBP commonly assoc w/ referred buttock, thigh, or leg pn, that worsens w/ FLEX activities & sitting
- numerous LB-related LE pn episodes
what physical exam data would help to rule in ACUTE LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?
- sxs reproduced mid-range motions that worsen w/ end-range
- sxs reproduced provocation of involved lumbar segment(s)
- observable mvmt coordination impairments of LB region w/ FLEX/EXT, or ADLs
- Diminised trunk/pelvic region mm strength/endurance
- mobility deficits of thorax & hips (may be present)
- HYPERmobility of lumbar/sacroiliac (may be present)
what physical exam data would help to rule IN ACUTE LBP w/ RELATED COGNITIVE OR AFFECTIVE TENDENCIES?
- suggests presence of fear-avoidance, pn catastrophizing, or depression (with high scores of related questionnaires)
what physical exam data would help to rule IN ACUTE LBP w/ MOBILITY DEFICITS
- Lower TS or LS ROM limitations
- LB and LB-related LE pain reproduced w/:
- end range spinal
motions - provocation of involved
lower TS or LS segments
- end range spinal
What physical exam data would help to rule OUT ACUTE LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?
- adequate L/R passive SLR (80deg) and thorax rot (80deg) mobility
- normal trunk flexor (DL lower test), trunk extensors (sorenson test), lateral abd and hip abd (side plank), hip & thigh mm performance (SEBT)
What physical exam data would help to rule OUT ACUTE LBP w/ MOBILITY DEFICITS?
- Combined end-range spinal motions (quadrant) w/ OP is PAIN FREE
- Unable to produce LBP/LE pn w/ provocation of lower TS or LS segments (ie. end-range UPAs)
what physical exam data would help to rule IN ACUTE LBP w/ RELATED (REFERRED) LE PAIN?
- LBP & LE pain that can be CENTRALIZED & DIMINISHED w/ positioning, manual procedures, and/or repeated movements
- Lateral trunk shift, reduced reduced lumbar lordosis, lim lumbar ext,
- findings assoc w/ movement coordination impairments are commonly present
What interview info would you expect from a pt with suspected ACUTE LBP w/ RADIATING PN?
- acute LBP w/ assoc radiating (narrow band of lancinating) pn in involved LE
- LE pareethesia, numbness, weakness may be reported
what physical exam data would help to rule IN ACUTE LBP w/ RADIATING PN?
- sxs reproduced w/ MID-range and worsen w/ END-range spinal mobility, LLT/SLR, and/or slump test
- signs of nerve root involvement (sensory, strength, reflex deficits) - may be present
What 5 factors are included in the CPR for a positive response to manipulation for LBP?
- Sxs <16 days
- No sxs distal to knee
- FABQWK <19 (higher score = greater fear avoidance beliefs)
- Hip IR >35 deg
- Lumbar HYPOmobility
T or F: basically everyone who have CLBP will have mvmt coordination impairments?
T
What interview info is expected for a pt with suspected CHRONIC LBP W/ MOVEMENT COORDINATION IMPAIRMENTS?
Chronic, recurring LBP that is commonly assoc w/ referred LE pn
What physical exam findings would help you rule IN CHRONIC LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?
- LBP and/or LB-related LE pn that worsens s/ sustained END-range movements
- Observable mvmt coordination impairments of LB w/ FLEX/EXT, ADLs/recreational activities
- Diminished trunk/pelvic region mm strength/endurance
- Mobility deficits of thorax and hips (may be present)
- Signs of LS segmental or sacroiliac HYPERmobility (may be present)
- General ligamentous laxity
What physical exam findings would help you rule OUT CHRONIC LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?
- adequate L/R passive SLR (80deg) and thorax rot (80deg) mobility
- normal trunk flexor (DL lower test), trunk extensors (sorenson test), lateral abd and hip abd (side plank), hip & thigh mm performance (SEBT)
(same as acute)
What indictates “hypermobile” based on the beighton score?
4 or more out of 9
What is included in the 2007 CPR for stabilization (old name)/Movement coordination classification?
- younger age <40
- greater general flexibility
- “instability catch” or aberrant movements (during flex/ext)
- findings for prone instability test
what is normal lumbopelvic rhythm?
head/upper trunk –>
pelvis shifts back –>
spine full ROM –>
pelvis ant tilt –>
lengthen post LE mm
What is gower’s sign?
walk up legs w/ hands (aberrant motion seen w/ patients w/ movement coordination impairments)
What exam measures would you include for a pt with suspected movement coordination impairments?
-Obs dynamic mvmts (walking, running, step down test, SEBT, etc)
-Aberrant motion assessment
-Modified trendelenburg test
-Prone PA segmental mobility
-PPIVM (passive physiological intervertebral motion)
-Sidelying PPIVMs
- Active SLR test/ pelvis force closure test
- Passive lumbar extension test
-Strength (hip abd, trunk flexors/ext, trunk power/endurance, lat abs, hip ext)
-Functional movement screen (rotatry stability)
What interview info is expected for a pt with suspected CHRONIC LBP W/ RADIATING PN?
- Chronic, recurring, mid-back and/or LBP w/ assoc radiating pn & potential sensory, strength, or reflex deficits in involved LE
- LE paresthesias, numbness, weakness (may be reported)
What physical exam findings would help you rule IN CHRONIC LBP w/ RADIATING PN?
- sxs reproduced w/ MID-range & worsen w/ END-range spinal mobility, lower limb tension/SLR, slump
- signs of nerve root involvement (sensory, strength, or reflex deficits) may be present
What 3 fundamental biomechanical functions must nerve be capable of?
- Withstanding tension
- Sliding
- Withstanding compression
What are contraindications and precautions of neurodynamic assessment?
Contraindications:
1. Recent neural surgery
2. Any condition where mvmt across the jts would be contraindicated (ie. fx)
Precautions:
1. highly irritable conditions
2. progressing radicular signs
3. recent neural injury
What is the meaning behind the acronym “TED SID PIP”
Used in neurodynamic testing to isolate sensitization of specific nerves:
TED: Tibial (Ev + DF)
SID: Sural (Inv + DF)
PIP: Peroneal (Inv + PF)
What interview info is expected for a pt with suspected CHRONIC LBP W/ GENERALIZED PN?
- LBP and/or LB-related LE pn w/ sxs duration > 3 mo
- suggested presence of fear-avoidance beliefs. pain catastrophizing, depression
How can you rule out CLBP w/ Generalized pn?
scores on psychosocial subscale of start back total to 0
T or F: only ~15% of LBP can be given a specific pathoanatomical dx
T
What does spondylosis mean?
= spine is abnormal
“osis” = problem/abnormal
typicall means degenerative OA of vertebral jts
what is spondylitis?
inflammation of vertebral jts
what is spondylolysis?
defect of a vertebrae; defect in the pars interarticularis of the the vertebral arch
“lysis” = loosen/break down
what is spondylolisthesis?
forward displacement of a vertebra; often after fx
“listhesis” = slippage
what spinal mvmt is typically aggravating for a pt with symptomatic disc-involved back pn?
flexion
what spinal mvmt is typically relieving for a pt w/ symptomatic disc-involved back pn?
extension
What are 4 types of disc injuries?
- degeneration/protrusion: disc bulges post w/o annulus rupture
- prolapse/herniation: disc bulges more significantly but outer fibers of annulus= intact
- Common levels of herniation:
L4/5>L5/S1>L3/4>L2/3>L1/2
- Common levels of herniation:
3.extrusion: annulus perforated; discal material moves into epidural space (can be source of chemical irritant for lumbar n roots)
- sequestration: discal fragments outside disc, sig disruption of passive disc structures
What is the most common level of disc herniation/prolapse?
L4/5
What clinical presentation would you expect for someone with LSS?
-LBP
-tension or weakness w/ walking or standing (and stairs)
- sxs extending into buttock, and/or 1 or both LE
- sxs improve w/ FLEX and SITTING
What 5 factors are included in Cook’s CPR for LSS?
- Pn during walking/standing
- Pn relief upon sitting
- Age > 48
- B LE sxs
- Leg pn > back pn
(4/5 findings: Sp 98%)
Differentiate btwn Neurogenic claudication and vascular claudication
NEUROGENIC CLAUDICATION
- pn in buttock/leg mm caused by nerve root compression
- walking on incline (flex) often dec sxs
- 2 stage treadmill test
VASCULAR CLAUDICATION
- pn in buttock/leg mm caused by poor arterial blood flow
- walking on incline/flex WON’T dec sxs
- ABI: < 1.0 = inc likelihood of PAD
- 5 P’s: inc Pallor, dec pulses, perishing (cold), pain, paresthesia, paralysis
An ABI score of < what # indicates increased likelihood of PAD?
< 1.0
Where does inflammation related to Ankylosing spondylitis start?
Sacrum! (SIJ)
T or F: Ankylosing spondylitis is an autoimmune condition?
T
How do the early vs advanced stages of Ankylosing spondylitis differ?
EARLY:
- B sacroilitis = early radiographic sign
- SIJ pn; chronic LBP
- back contour may appear norm but LS flex may be lim
ADVANCED:
- SIJ, LS, TS, ribs
- back straightened w/ “ironed out” appearance
What clinical sx of AS has a SEN of 1.0? Meaning that if it is neg, then you can be 100% positive to rule out AS.
age onset </= 40
*if pt w/ LBP is 20-30’s, you should always be thinking re: AS as differential dx
What 5 pt hx factors would you potentially expect for someone w/ AS?
- pn NOT relieved by rest/lying down
- back pn at night
- morning stiffness >30 min
- pn/stiffness RELIEVED by exercise
5 Age of onset </= 40 yrs (Sn 1.0)
T or F: ossification of annulus fibrosus, facet jts, ALL, interspinal ligs can occur with AS?
T
What is FACET SYNDROME?
pn/inflammation in facet jt, capsule, or surrounding tissues due to trauma, degenerative change, and/or nerve irritation
When is strain highest on facet jts?
end-range extension
What spinal. movement is relieving for pts with facet syndrome?
flexion (opening)
*ext = aggravating (closing)
what would you expect for a neuro screen for a pt with facet syndrome?
- myotomes seldom affected
- sensory/dermatomes NOT affected
