Lumbar Spine Pathologies Flashcards
Name the Lumbar Vertebrae Anatomical Landmarks
Vertebral Body
Neural Canal
Pedicle - between vertebral body and transverse process
Lamina - between transverse process and spinous process
Spinous process
Transverse Process
Mammillary Process - posterior and lateral aspect of the transverse process to increase surface area for muscle attachment
Superior and Inferior articular facets
What anatomical features are specific to the Lx?
Spinous process - projects horizontally backwards and have a thick posterior border
Vertebral canal is triangular,
Larger than thoracic but smaller than cervical
Spinal cord becomes the cauda equina at L1&2
Transverse processes are short and project laterally
What are the Lx Red Flags?
Constant progressive night pain
Saddle anaesthesia
Bowel or bladder incontinence or retention
Visceral disease
History of Cancer
Unexplained weight loss
Systemic illness or infection
Fever
Prolonged steroid use
IV drug abuse
Advanced age
History of trauma
Deformity
Bilateral radiculopathy
Problems with sexual function
What are the Cauda Equina Symptoms?
Todd 2017
Red Flags Backpain Bilateral radiculopathy Sphincteric problems Perineal sensory changes Urinary disturbance
White flags
Saddle anaesthesia
Bladder and bowel innocence or retention
What are the functions of the Lumbar Spine?
Bear weight of the body
Large intervertebral discs for shock absorption
Lumbar vertebrae are larger to absorb stress of lifting and carrying
What is specific about the Lumbar Facet Joints?
Due to direction limit movement
Superior face inwards and inferior face outwards
What are the 2 different joints in the Lx?
Joints of the vertebral bodies to the intervertebral discs - Cartilaginous joints that have limited movement.
Facet joints - synovial joints.
What movements do the facet joint facilitate?
Flexion, extension, side flexion.
Limits rotation
How would someone with a facet joint strain/dysfunction present in the subjective?
Revel's Criteria Age >65 Pain relief by lying down Flexion eased pain Sitting, hyperextension and extension with rotation increased pain
Absence of centralisation Absence of trauma Lack of radicular features Pain tends to stay above the knee Localised unilateral pain
What does increased pain on coughing or sneeze
Disc pathology
What type of pathology does trauma or centralisation suggest?
Disc pathology
What is centralisation?
Patient has limb pain, they then complete the same movement repetitively and the pain goes from the limb to the spine
What are the objective findings of a facet joint problem?
Reduced ROM
Doing specific movements aggravated pain
Increased stiffness by unilateral pressure over the facet joint
Unilateral Muscle Spasm
Pain eased in flexion
Pain in extension, lateral flexion or rotation to the ipsilateral side
Extension combined with rotation most aggravating movement
What ligaments are in the Lx?”
Anterior longitudinal ligament - runs along the anterior part of the vertebral bodies
Posterior longitudinal ligament - runs along the posterior part of the vertebral body
Ligamentum flavum - runs between the lamina and adjacent vertebrae
Supraspinous ligament - connects tips of the spinous processes
Interspinous ligaments - between spinous processes
Intertransverse ligaments - between transverse processes
Can you differentiate between the Lx ligaments?
No
What are the anatomical components of the intervertebral discs?
Nucleus pulposus - centrally
Annulus fibrosus - surrounds the nucleus pulposus
Cartilage end plates - between the disc and vertebral body
What is the structure of the nucleus pulposus?
Its soft and contains high amounts of water
Posteriorly in the Lx and centrally in the Cx and Tx
What is the structure of the annulus fibrosus?
Series of annular bands (like a tree trunk) that surround the nucleus
Fibrocartilogenous collagen bundles
In Lx denser anteriorly and weakest posteriolaterally
In which direction does a disc prolapse in the Lx?
Posteriolaterally
Which positions cause the most pressure on the disk?
Sitting forward
What happens to the discs with ageing?
Loss of disc height
More collagen content in the annulus fibrosus
Loss of water in the nucleus pulposus
How does disc herniation occur due to age?
Annulus fibrosus weakens which leads to cracks and herniation of the nuculeus pulposus
What is spondylosis?
Loss of disc height or osteophyte formation that causes narrowing and compression of the nerve root
How would someone with a disc injury (spondylosis) present?
Discogenic pain - where disc has been injured and becomes a nociceptive source
Centralisation
Loss of extension
High sens, low spec
What subjective indicators may suggest centralisation?
If the patient says they when they do things for a long time e.g. painting the ceiling, walking for a while, up hills (extension) and the pain goes from the back of their leg
What are the subjective indicators of disk herniation with sciatica?
Poor correlation between MRI and symptoms
Follows dermatomal pattern
Pain to coughing, sneezing, bracing due to an increase in intra abdominal pressure
Feeling of coldness in the legs
What are the neurodynamic tests for disk herniation with sciatica or radiculopathy?
Slump
Straight Leg Raise
High Sens, Low Spec
When is a MRI useful in Lx pain?
Red flags
Severe nerve root compression
What model is important to consider with Lx pain patients?
Biopsychosocial model
How can you differentiate between specific and non-specific back pain?
Exclude the specific causes
What is sciatica?
Neuropathic leg pain secondary to compressive spinal pathology e.g. spondylosis
Pain involves the sciatic nerve
What would sciatica look like on a body chart?
P1 - Ache or stabbing unilateral pain in the Lx
P2 - Superficial intermittent ache down the leg
P2 only comes on when P1 has been painful
What are the subjective questions should you ask regarding sciatica?
Sitting, standing or walking posture
Specific occupation function regarding biomechanics
What dictates the structure of the objective assessment?
Severity and irritability
What position is spondylolisthesis most painful?
Extension
What position is most painful for a disc injury?
Sitting for long periods
What is a typical of patients with stenosis?
Can only walk for a period of time before getting stenotic symptoms down the leg
What are blue and black flags?
Blue - Occupational e.g. litigation, insurance, work status
Black - Socio-occupational e.g. work satisfaction, work conditions, do they enjoy work? how long have they worked there for?
What are orange flags?
Psychiatric status e.g. suicidal, severe depression
What are pink flags?
Positive attitudes, good motivation, etc.
How does anxiety and depression affected Lx pain?
Amplify pain
What is the STarT Back Tool
A stratified care screening tool that includes 9 questions (good sens and spec in primary care)
Low risk patients - minimal intervention and support self-management
Medium risk - Referral to physical therapy
High risk - Refer to psychologically informed physical therapy e.g. senior physio
What is effective self management for LBP?
Provide advice and information tailored to individuals needs and capabilities to help them self-manage
Information on the nature of LBP and sciatica
Encourage to continue with normal activities
What type of exercise is effective for LBP?
Group exercise programme e.g. bio-mechanical, aerobic, mind-body or a combination
Make patient specific
What type of manual therapy is effective for LBP?
Spinal mobilisations
Soft tissue techniques (massage)
Combined with exercise and psychological therapy
What is effective psychological therapy for LBP?
Refer if needed
Cognitive behavioural therapy (group or individual)
Promote and facilitate return to work and normal activities of daily living
What are the effective pharmacological interventions for LBP?
NSAIDs
Weak opioids e.g. paracetamol only if NSAIDs are contraindicated, not tolerated or ineffective
Do not offer paracetamol alone
What should you not offer?
Orthotics
Traction
Acupuncture
Electrotherapy
What is the main predictor of chronicity?
Psychological factors
What is and spondylolisthesis?
Vertebrae slips forward due to complete fracture of the pars interarticularis
What are the clinical features of spondylolisthesis?
Localised Lx pain
Increased pain with flexion and extension leading to reduced ROM
Increased pain on palpation
Narrowing leads to nerve root compression and symptoms down leg
Pain relieved lying supine
Hamstring spasm
Disturbances in coordination and balance
What is spinal stenosis?
Narrowing of the spinal canal
Caused by degeneration which can involve disc bulge, osteophyte formation and a thickened posterior longitudinal ligament
What are the clinical features of spinal stenosis?
Increase in pain with prolonged walking and standing with lumbar extension
Relieved by forward flexion and rest
Intermittent leg pain
Often unilateral radicular symptoms also weakness throughout entire leg
Upstairs walking is easier than downstairs walking
What are the clinical features of spondylolysis?
Actue or gradual onset
Possible history of trauma
Unilateral low back pain with radiation into buttock or proximal lower limb
increase in pain on extension, rotation and lateral flexion
Pain on hyperextension
Hamstring muscle spasm
Tenderness on palpation
Excessive Lx lordosis
Pain increased on single leg stance
Name 2 ways that the nerve root can be affected causing pain from a disc herniation
Physical compression of the nerve from the disc herniation
Disc herniation releases chemicals that cause inflammation of the nerve root
What type of Lx pain is Spondylolisthesis and facet joint pathologies?
Regional non-specific mechanical back pain
What are the general red flags?
Hx of Cancer
Constant progressive unremitting night pain
Unexpected weightloss
Alcohol and drug abuse
Long-term steroid use
IV drug use
Chemotherapy / Radiotherapy
Osteoporosis
Cardiac and circulatory problems
Cauda equina symptoms
Asthma
Epilepsy
Diabetes
Hx of trauma
Rheumatoid arthritis
5Ds and 3Ns - Diplopia, dysarthria, dysphagia, drop attacks, dizziness, nystagmus, numbness, nausea
Pregnancy
Poor general health
Anticoagulants
