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MM II > Lumbar Spine Exam > Flashcards

Lumbar Spine Exam Flashcards

1
Q

For the 2021 Revision of LBP CPG, what differentiates “acute” versus “chronic”

A

Acute < 6 wks of sxs

Chronic > 6 wks

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2
Q

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?

A
  1. STarT Back Screening tool
  2. Orebro MSK Pain Questionnaire
  3. OSPRO -Yellow flag tool
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3
Q

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?

A
  1. Oswestry Disability index (ODI)
  2. Roland-Morris Disability Questionnaire (RMDQ)
  3. Pt Specific Functional Scale (PSFS)
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4
Q

What are the 5 subgroup classifications for ACUTE LBP?

A

Acute LBP w/…
1. Movement Coordination Impairments

  1. Related cognitive or affective tendencies
  2. Mobility deficits
  3. Related (referred ) LE pain
  4. Radiating pain
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5
Q

What are the 3 subgroup classifications for CHRONIC LBP?

A

Chronic LBP w/…
1. Movement coordination impairments

  1. Radiating pain
  2. Generalized pain
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6
Q

If a pt scores 3 or less on the start back, what does that indicate?

A

Low risk (of disability)

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7
Q

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?

A

Medium risk (of disability)

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8
Q

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?

A

High risk (of disability)

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9
Q

What does the OREBRO test for?

A

likelihood to have future disability that interferes with employment

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10
Q

What is the MCID for OREBRO?

A

12

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11
Q

What is the OSPRO used for?

A

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

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12
Q

What 3 categories are included in the OSPRO?

A
  1. Negative mood
    • depression
    • state-trait anxiety
    • state-trait anger
  2. Fear avoidance
    • FABQ
    • Pain catastrophizing
    • Kinesiophobia
    • Pain anxiety
  3. Postive affect/coping
    • Pain self-efficacy
    • self-efficacy for rehab
    • chronic pain acceptance
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13
Q

Describe the interpretation for score ranges on the ODI?

A

Low/minimal disability = 0-21%

Mod = 21-40%

Severe = 41-60%

Crippled = 61-80%

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14
Q

What is the MCD for the ODI?

A

11%

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15
Q

what is the range that the Roland-Morris Disability Questionnaire is out of?

What does 0 indicate?

what is the MCD?

A

0-24%

0 = no disability

MCD = ~5% depending on pop

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16
Q

What is the MCD for PSFS (average score, not single activity score)?

A

2 points

(3 if single activity score)

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17
Q

Name the SINSS in order

A

Severity
Irritability
Nature
Stage
Stability

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18
Q

Define severity

A

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”)

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19
Q

Define irritability

A

ease in which sxs are produced and time it takes to settle

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20
Q

define nature

A

type and extent/degree of injury/illness

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21
Q

define stage (SINSS)

A

acute, sub-acute, chronic, acute on chronic etc

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22
Q

Define stability (SINSS)

A

how are sxs changing? better/worse/same? stable/unstable?

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23
Q

What are LBP risk factors?

A

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

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24
Q

There is a favorable natural history of acute LBP. 30-60% of people recover in ___ week(s)

A

1 week

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25
Q

There is a favorable natural history of acute LBP. 60-90% of people recover in ___ week(s)

A

6 weeks

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26
Q

There is a favorable natural history of acute LBP. 95% of people recover in ___ week(s)

A

12 weeks (3 mo)

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27
Q

According to a 2009 study, what is the greatest predictor of whether someone will have spinal surgery?

A

of surgeons in local pop

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28
Q

Of pts with LBP, what % have mechanical LBP?

A

97%

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29
Q

Of pts with LBP, what % have a visceral disease that is causing the pain, leading you to referring them?

A

2%

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30
Q

What are 4 general visceral disease categories that could be the reason your pt has LBP?

A
  1. Abdominal Aortic Aneurysms (AAA)
  2. GI diseases
  3. Disease of pelvic organs
  4. Renal disease
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31
Q

What % of patients with LBP have a nonmechanical spinal condition that isn’t a visceral disease?

A

1%

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32
Q

What potential nonmechanical and non-visceral conditions can be the reason for a pt’s LBP?

A
  1. Neoplasia
  2. Inflammatory arthritis
  3. Infection
  4. Paget’s disease (bone breakdown)
  5. Scheuermann’s disease (vertebral endplate ~kyphosis)
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33
Q

What interview questionnaire info would you expect for a pt with a bone related tumor?

A
  1. Constant pn not affected by position or activity, worse at night & worse w/ WBing
  2. Age > 50
  3. Hx of cancer
  4. Failure of conservative intervention (within 30 days)
  5. Unexplained weight loss
  6. no relief w/ bed-rest
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34
Q

T or F: Cauda Equina Syndrome is a neurological emergency!

A

T

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35
Q

What should you do for a pt with suspected Cauda Equina Syndrome?

A

Refer immediately to physician/ortho spine surgeon/neurosurgeon/local ED!

**surgery = most successful within 72 hours from onset

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36
Q

Cauda equina syndrome is often assoc w/ nontraumatic massive midline post disc herniation. What spinal segments are most common for CES to occur?

A

L4-5 > L5-S1 > L3-4

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37
Q

what are the consequences of delayed treatment for cauda equina syndrome?

A

pt may differ from long-term loss of B&B, sexual function

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38
Q

What are risk factors for cauda equina syndrome?

A
  1. LB injury w/ central disc herniation
  2. central canal stenosis
  3. spinal fx
  4. ankylosing spondylitis
  5. TB
  6. Pott’s disease
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39
Q

What diagnostic findings would suggest that a pt has CES?

A
  1. Urinary retention (cannot void) –> most Sn & Sp!
  2. Unilat/bilat sciatica
  3. Unilat/bilat motor/sensory deficits
    • SLR test (reproduction of radicular sxs in LE 20-70 deg hip flex)
  5. Sensory deficit: buttocks, post-sup thigh, perianal region (“saddle”)
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40
Q

What info would you expect from a history for a pt with a suspected back-related infection?

A
  1. Recent infection (UTI, skin etc)
  2. IV drug user/abuser
  3. Concurrent immunosuppressive disorder (HIV, TB etc)
  4. Reports of fever, malaise, swelling
  5. Limited mobility
41
Q

What info would you expect from a history for a pt with a suspected SPINAL COMPRESSION FX?

A
  1. Hx of trauma (MVA, fall from height, direct blow to spine)
  2. Hx of minor trauma for osteoporotic or elderly individuals (falls, heavy lifts)
  3. Age >75
  4. Prolonged use of corticosteroids
  5. Inc pn w/ WBing
42
Q

What is an Abdominal Aortic Aneurysm (AAA)?

A

= abdominal aortic vessel distension of 3 cm or more (risk of rupture increases as diameter approaches 5-6 cm)

*most common 60+

43
Q

What are 6 risk factors for AAA?

A
  1. Age (>)
  2. Male (5-6x more common)
  3. Hx of smoking (3-5x)
  4. DM
  5. Hx of CAD and hypercholesterolemia
  6. Family hx of AAA
44
Q

How would you expect a pt with a suspect AAA present clinically?

A
  1. back pn = most common! (referral pn)
  2. can present as abdominal, groin, or buttock pn
  3. Pn inc w/ general activity, but not w/ spinal movement (not mechanical to spine)
    -Inc w/ CV load, but not
    specific
  4. Insidious onset & may progress slowly or quickly
  5. May complain of early satiety (feeling full), weight loss, nausea
45
Q

What would you include in your exam of a pt with a suspected AAA?

A
  1. Palpation - AA diameter
  2. Bounding mass (not just pulse) = indicative of rupture
  3. Auscultation for bruit (vascular sound assoc w/ turbulent blood flow)
46
Q

What 2 factors would INCREASE your suspicion of AAA?

A
  1. Sxs NOT realted to mvmt stresses
  2. Abdominal girth <100 cm (40 in)
47
Q

What are S&S of digestive/GI system disorders?

A
  1. difficulty swallowing
  2. heartburn & indigestion
  3. specific food intolerances
  4. changes in appetite
  5. Bowel dysfunction
  6. Abdominal distension
  7. fevers/chills/sweats/ nausea
  8. rebound tenderness
  9. pn relieved by sitting forward in flexed posture (pancreatic etiology)
  10. colicky abdominal pn
48
Q

What digestive organs can refer to the region of the low back?

A
  1. stomach, small intestine, large intestine/colon, prostate, kindey, bladder
49
Q

What interview info would you expect from a pt with suspected ACUTE LBP w/ movement coordination impairments?

A
  1. Acute exacerbation of RECURRING LBP, commonly assoc w/ referred LE pn
  2. sxs often incl: numerous episodes of LBP and/or LB-related LE pn in recent yrs
50
Q

What interview info would you expect from a pt with suspected ACUTE LBP w/ MOBILITY DEFICITS?

A
  1. acute LBP, buttock, or thigh pn (<6wks)
  2. onset of sxs often linked to recent unguarded/awk mvmt or position
51
Q

What interview info would you expect from a pt with suspected ACUTE LBP w/ RELATED (REFERRED) LE PAIN?

A
  1. LBP commonly assoc w/ referred buttock, thigh, or leg pn, that worsens w/ FLEX activities & sitting
  2. numerous LB-related LE pn episodes
52
Q

what physical exam data would help to rule in ACUTE LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?

A
  1. sxs reproduced mid-range motions that worsen w/ end-range
  2. sxs reproduced provocation of involved lumbar segment(s)
  3. observable mvmt coordination impairments of LB region w/ FLEX/EXT, or ADLs
  4. Diminised trunk/pelvic region mm strength/endurance
  5. mobility deficits of thorax & hips (may be present)
  6. HYPERmobility of lumbar/sacroiliac (may be present)
53
Q

what physical exam data would help to rule IN ACUTE LBP w/ RELATED COGNITIVE OR AFFECTIVE TENDENCIES?

A
  1. suggests presence of fear-avoidance, pn catastrophizing, or depression (with high scores of related questionnaires)
54
Q

what physical exam data would help to rule IN ACUTE LBP w/ MOBILITY DEFICITS

A
  1. Lower TS or LS ROM limitations
  2. LB and LB-related LE pain reproduced w/:
    • end range spinal
      motions
    • provocation of involved
      lower TS or LS segments
55
Q

What physical exam data would help to rule OUT ACUTE LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?

A
  1. adequate L/R passive SLR (80deg) and thorax rot (80deg) mobility
  2. normal trunk flexor (DL lower test), trunk extensors (sorenson test), lateral abd and hip abd (side plank), hip & thigh mm performance (SEBT)
56
Q

What physical exam data would help to rule OUT ACUTE LBP w/ MOBILITY DEFICITS?

A
  1. Combined end-range spinal motions (quadrant) w/ OP is PAIN FREE
  2. Unable to produce LBP/LE pn w/ provocation of lower TS or LS segments (ie. end-range UPAs)
57
Q

what physical exam data would help to rule IN ACUTE LBP w/ RELATED (REFERRED) LE PAIN?

A
  1. LBP & LE pain that can be CENTRALIZED & DIMINISHED w/ positioning, manual procedures, and/or repeated movements
  2. Lateral trunk shift, reduced reduced lumbar lordosis, lim lumbar ext,
  3. findings assoc w/ movement coordination impairments are commonly present
58
Q

What interview info would you expect from a pt with suspected ACUTE LBP w/ RADIATING PN?

A
  1. acute LBP w/ assoc radiating (narrow band of lancinating) pn in involved LE
  2. LE pareethesia, numbness, weakness may be reported
59
Q

what physical exam data would help to rule IN ACUTE LBP w/ RADIATING PN?

A
  1. sxs reproduced w/ MID-range and worsen w/ END-range spinal mobility, LLT/SLR, and/or slump test
  2. signs of nerve root involvement (sensory, strength, reflex deficits) - may be present
60
Q

What 5 factors are included in the CPR for a positive response to manipulation for LBP?

A
  1. Sxs <16 days
  2. No sxs distal to knee
  3. FABQWK <19 (higher score = greater fear avoidance beliefs)
  4. Hip IR >35 deg
  5. Lumbar HYPOmobility
61
Q

T or F: basically everyone who have CLBP will have mvmt coordination impairments?

A

T

62
Q

What interview info is expected for a pt with suspected CHRONIC LBP W/ MOVEMENT COORDINATION IMPAIRMENTS?

A

Chronic, recurring LBP that is commonly assoc w/ referred LE pn

63
Q

What physical exam findings would help you rule IN CHRONIC LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?

A
  1. LBP and/or LB-related LE pn that worsens s/ sustained END-range movements
  2. Observable mvmt coordination impairments of LB w/ FLEX/EXT, ADLs/recreational activities
  3. Diminished trunk/pelvic region mm strength/endurance
  4. Mobility deficits of thorax and hips (may be present)
  5. Signs of LS segmental or sacroiliac HYPERmobility (may be present)
  6. General ligamentous laxity
64
Q

What physical exam findings would help you rule OUT CHRONIC LBP w/ MOVEMENT COORDINATION IMPAIRMENTS?

A
  1. adequate L/R passive SLR (80deg) and thorax rot (80deg) mobility
  2. 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)

65
Q

What indictates “hypermobile” based on the beighton score?

A

4 or more out of 9

66
Q

What is included in the 2007 CPR for stabilization (old name)/Movement coordination classification?

A
  1. younger age <40
  2. greater general flexibility
  3. “instability catch” or aberrant movements (during flex/ext)
    • findings for prone instability test
67
Q

what is normal lumbopelvic rhythm?

A

head/upper trunk –>
pelvis shifts back –>
spine full ROM –>
pelvis ant tilt –>
lengthen post LE mm

68
Q

What is gower’s sign?

A

walk up legs w/ hands (aberrant motion seen w/ patients w/ movement coordination impairments)

69
Q

What exam measures would you include for a pt with suspected movement coordination impairments?

A

-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)

70
Q

What interview info is expected for a pt with suspected CHRONIC LBP W/ RADIATING PN?

A
  1. Chronic, recurring, mid-back and/or LBP w/ assoc radiating pn & potential sensory, strength, or reflex deficits in involved LE
  2. LE paresthesias, numbness, weakness (may be reported)
71
Q

What physical exam findings would help you rule IN CHRONIC LBP w/ RADIATING PN?

A
  1. sxs reproduced w/ MID-range & worsen w/ END-range spinal mobility, lower limb tension/SLR, slump
  2. signs of nerve root involvement (sensory, strength, or reflex deficits) may be present
72
Q

What 3 fundamental biomechanical functions must nerve be capable of?

A
  1. Withstanding tension
  2. Sliding
  3. Withstanding compression
73
Q

What are contraindications and precautions of neurodynamic assessment?

A

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

74
Q

What is the meaning behind the acronym “TED SID PIP”

A

Used in neurodynamic testing to isolate sensitization of specific nerves:

TED: Tibial (Ev + DF)
SID: Sural (Inv + DF)
PIP: Peroneal (Inv + PF)

75
Q

What interview info is expected for a pt with suspected CHRONIC LBP W/ GENERALIZED PN?

A
  1. LBP and/or LB-related LE pn w/ sxs duration > 3 mo
  2. suggested presence of fear-avoidance beliefs. pain catastrophizing, depression
76
Q

How can you rule out CLBP w/ Generalized pn?

A

scores on psychosocial subscale of start back total to 0

77
Q

T or F: only ~15% of LBP can be given a specific pathoanatomical dx

A

T

78
Q

What does spondylosis mean?

A

= spine is abnormal

“osis” = problem/abnormal

typicall means degenerative OA of vertebral jts

79
Q

what is spondylitis?

A

inflammation of vertebral jts

80
Q

what is spondylolysis?

A

defect of a vertebrae; defect in the pars interarticularis of the the vertebral arch

“lysis” = loosen/break down

81
Q

what is spondylolisthesis?

A

forward displacement of a vertebra; often after fx

“listhesis” = slippage

82
Q

what spinal mvmt is typically aggravating for a pt with symptomatic disc-involved back pn?

A

flexion

83
Q

what spinal mvmt is typically relieving for a pt w/ symptomatic disc-involved back pn?

A

extension

84
Q

What are 4 types of disc injuries?

A
  1. degeneration/protrusion: disc bulges post w/o annulus rupture
  2. 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

3.extrusion: annulus perforated; discal material moves into epidural space (can be source of chemical irritant for lumbar n roots)

  1. sequestration: discal fragments outside disc, sig disruption of passive disc structures
85
Q

What is the most common level of disc herniation/prolapse?

A

L4/5

86
Q

What clinical presentation would you expect for someone with LSS?

A

-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
87
Q

What 5 factors are included in Cook’s CPR for LSS?

A
  1. Pn during walking/standing
  2. Pn relief upon sitting
  3. Age > 48
  4. B LE sxs
  5. Leg pn > back pn

(4/5 findings: Sp 98%)

88
Q

Differentiate btwn Neurogenic claudication and vascular claudication

A

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

89
Q

An ABI score of < what # indicates increased likelihood of PAD?

A

< 1.0

90
Q

Where does inflammation related to Ankylosing spondylitis start?

A

Sacrum! (SIJ)

91
Q

T or F: Ankylosing spondylitis is an autoimmune condition?

A

T

92
Q

How do the early vs advanced stages of Ankylosing spondylitis differ?

A

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

93
Q

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.

A

age onset </= 40

*if pt w/ LBP is 20-30’s, you should always be thinking re: AS as differential dx

94
Q

What 5 pt hx factors would you potentially expect for someone w/ AS?

A
  1. pn NOT relieved by rest/lying down
  2. back pn at night
  3. morning stiffness >30 min
  4. pn/stiffness RELIEVED by exercise

5 Age of onset </= 40 yrs (Sn 1.0)

95
Q

T or F: ossification of annulus fibrosus, facet jts, ALL, interspinal ligs can occur with AS?

A

T

96
Q

What is FACET SYNDROME?

A

pn/inflammation in facet jt, capsule, or surrounding tissues due to trauma, degenerative change, and/or nerve irritation

97
Q

When is strain highest on facet jts?

A

end-range extension

98
Q

What spinal. movement is relieving for pts with facet syndrome?

A

flexion (opening)

*ext = aggravating (closing)

99
Q

what would you expect for a neuro screen for a pt with facet syndrome?

A
  • myotomes seldom affected
  • sensory/dermatomes NOT affected

MM II (6 decks)

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