Lumbar Spine (Part 2) Flashcards
Where does L3/L4/L5 disc pain refer to?
the anterior thigh region
Where does L4/L5/S1 disc pain refer to?
posterior thigh region
__% of patients with lumbar disc herniation recover within the first 2 weeks and __% recover within 6 weeks
50
70
Disc herniation symptoms are ____ to the knee
distal
Facet syndrome symptoms are ____ to the knee
proximal
What are the signs of facet syndrome?
- Absence of neurological deficits and nerve root tension signs/tests
- flexion/extension AROM provokes pain
- Hypomobility with PPIVM and/or PPAIVM (spring testing)
Spinal stenosis is more common in those __ years of older
65
What signs and symptoms are sensitive to spinal stenosis?
- age greater than 65
- pain below the butt
- pain that is worsened with walking
- poor balance
What 6 neurological tests are specific to spinal stenosis?
- vibration deficit
- pin prick deficit
- weakness
- absent Achilles reflex
- abnormal Rhomberg test
- thigh pain with 30 seconds of extension
What are the 7 predictor variables for the diagnosis of lumbar spinal stenosis?
- age 60-70
- symptoms present > 6 months
- symptoms improve when bending forward
- symptoms improve with bending backward
- symptoms exacerbated while standing up
- intermittent claudication present
- urinary incontinence
Based on the clinical prediction rule a score greater than _ indicates a meaningful shift in the probability that the patient DOES lumbar spinal stenosis
7
Based on the clinical prediction rule a score less than _ indicates a moderate shift in the probability that the patient does NOT lumbar spinal stenosis
2
What percentage of spinal stenosis patients have resolution of symptoms without intervention?
30%
How are spondylolisthesis types classified?
according to causation
What causes Type I spondylolisthesis?
dysplastic
Describe type I spondylolisthesis
Congenital abnormality in upper sacrum or neural arch of L5, allowing displacement
What causes Type II spondylolisthesis?
isthmic
Describe type II spondylolisthesis
A lytic or fatigue fracture of pars, or elongated but intact pars, or acute fracture of pars
What causes Type III spondylolisthesis?
degeneration
Describe type III spondylolisthesis
Secondary to degenerative arthrosis of z-joints or discovertebral articulation
What causes Type IV spondylolisthesis?
trauma
Describe type IV spondylolisthesis
Secondary to fractures in area of neural arch other than pars
What causes Type V spondylolisthesis?
pathology
Describe type V spondylolisthesis
In conjunction with bone disease (e.g. Paget’s disease, osteoporosis)
What causes Type VI spondylolisthesis?
iatrogenic
Describe type VI spondylolisthesis
Occurs above or below a spinal fusion
What spondylolisthesis grades are the most common?
II and III
Type II (isthmic) spondylolisthesis occurs in ____ patients, whereas type III (degenerative) spondylolisthesis occurs in ____ patients spondylolisthesis
younger
older
The incidence of spondylolisthesis increases from 4.4% at age 6 to _ by adulthood
6%
Only __% of patients with grade II spondylolisthesis develop symptoms
50
MeyerdingGrading
Grade 0 = \_\_\_\_\_ Grade 1 = _-\_\_% Grade 2 = \_\_-\_\_% Grade 3 = \_\_-\_\_% Grade 4 = \_\_-\_\_%
Normal
1-25%
26-50%
51-75%
76-100%
Symptoms associated with spondylolisthesis are worsened with what movement?
extension
What are subtle signs of grades 1 and 2 spondylolisthesis?
- hamstring tightness
- hyperlordosis
- palpable step defect of SP
What test may indicate active spondylitic defect or facet syndrome?
stork test/one-leg standing lumbar extension test
What are the signs of patients with grade 3 or greater spondylolisthesis?
- symmetric transverse skin furrow
- hyperlordosis
- anterior pelvic tilt
- significant hamstring stiffness
What does intervention for spondylolisthesis depend on?
presenting symptoms, rather than degree of slip
Describe conservative treatment for spondylolisthesis
- pelvic positioning initially to provide symptomatic relief
- followed by an active lumbar stabilization program and stretching (rectus femoris and iliopsoas muscles) to decrease anterior pelvic tilting
What is the course of treatment for grades III and IV spondylolisthesis?
surgery
Sciatica is most common in what patient population?
Active people and those who sit frequently
It is estimated that __ million Americans suffer from LBP and sciatica annually
80
List the 3 most common causes of sciatica from most to least common
1) occupational causes
2) trauma
3) improper lifting mechanics, gluteal injections, lipomas, and unusual furniture
What are patient complaints of sciatica?
unilateral buttock and posterior leg pain and paresthesia
True or False
Neurological deficits are common in patients with sciatica
False
What movements may increase sciatica related pain?
Resisted ER or passive IR
What are the 6 cardinal features of piriformis syndrome?
1) History of trauma to sacroiliac and gluteal regions
2) Pain in region of SIJ, greater sciatic notch, and piriformis muscle, extending down lower limb and causing difficulty in walking
3) Acute exacerbation of symptoms by lifting or stooping
4) Palpable, sausage-shaped mass over piriformis muscle
5) Positive SLR test
(6) Gluteal atrophy
If pririformis syndrome is due to muscular spasm and/or tightness what is the conservative treatment regimen? If conservative fails?
aggressive stretching and massage of the muscle
local anesthetic block to muscle
When is ankylosing spondylitis onset usually?
mid 30s
What are the symptoms of ankylosing spondylitis?
- loss of lumbar lordosis
- increased thoracic kyphosis
- decreased chest expansion
What are the 2 special tests to help diagnose ankylosing spondylitis?
- chest expansion test
- modified Schober’s test
Describe a positive chest expansion test
2.5 cm below the average is considered abnormal
Describe a positive modified Schober’s test
If the difference is less than 5 cm it is considered abnormal
What is the treatment protocol for ankylosing spondylitis?
Gentle mobilizations (grade 5 contraindicated), stretching, and postural and breathing exercises
Describe the complaints associated with multiple myeloma
50 years old with complaints of persistent LBP unrelieved by rest and typically worse at night and may be associated with rib pain
What do radiographs reveal in multiple myeloma?
Osteopenia with lytic lesion in spine, ribs and skull (“punched out” or “rat-bite” lesions)
True or False
Multiple myeloma is similar to metastasis in that it effects the posterior elements of the spine, such as the pedicles
False
Where are the most common METS related to metastatic carcinoma from?
breast, lung, and kidney
If a patient is unresponsive to conservative care for __ month(s) it is highly suggestive of cancer, especially in patients greater than 50 years
1 month
What do radiographs revel in metastatic carcinoma?
osteolytic process (missing or “one-eyed” pedicle) or osteoblastic (ivory vertebrae)
Osteolytic process may increase serum ____ levels
calcium
Osteoblastic process may increase alkaline _______ levels
phosphatase
Describe the symptoms associated with infectious spondylitis
- deep back pain made worse with pressure or percussion of SP’s
- fever
- difficulty sleeping d/t pain
Does infectious spondylitis involve the disc, vertebral body, or both?
Both
What do radiographs revel in infectious spondylitis?
bony lysis followed by sclerosis in the vertebral bodies
What is the most common finding in asymptomatic abdominal aneurysm patients?
pulsatile mid or upper abdominal mass
What do radiographs revel in abdominal aneurysm?
enlarged calcific margin of aorta
Where do the majority of AAA’s occur?
Between L2 and L4
An expansion greater than __ cm is considered an aneurysm
3.5
When is surgical consult for a AAA required?
when the expansion is greater than 4-6 cm
