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MSK Practical Exam > Lumbar Spine Pathologies > Flashcards

Lumbar Spine Pathologies Flashcards

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1
Q

Name the Lumbar Vertebrae Anatomical Landmarks

A

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

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2
Q

What anatomical features are specific to the Lx?

A

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

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3
Q

What are the Lx Red Flags?

A

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

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4
Q

What are the Cauda Equina Symptoms?

A

Todd 2017

Red Flags
Backpain
Bilateral radiculopathy
Sphincteric problems
Perineal sensory changes
Urinary disturbance

White flags
Saddle anaesthesia
Bladder and bowel innocence or retention

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5
Q

What are the functions of the Lumbar Spine?

A

Bear weight of the body

Large intervertebral discs for shock absorption

Lumbar vertebrae are larger to absorb stress of lifting and carrying

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6
Q

What is specific about the Lumbar Facet Joints?

A

Due to direction limit movement

Superior face inwards and inferior face outwards

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7
Q

What are the 2 different joints in the Lx?

A

Joints of the vertebral bodies to the intervertebral discs - Cartilaginous joints that have limited movement.

Facet joints - synovial joints.

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8
Q

What movements do the facet joint facilitate?

A

Flexion, extension, side flexion.

Limits rotation

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9
Q

How would someone with a facet joint strain/dysfunction present in the subjective?

A 
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
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10
Q

What does increased pain on coughing or sneeze

A

Disc pathology

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11
Q

What type of pathology does trauma or centralisation suggest?

A

Disc pathology

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12
Q

What is centralisation?

A

Patient has limb pain, they then complete the same movement repetitively and the pain goes from the limb to the spine

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13
Q

What are the objective findings of a facet joint problem?

A

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

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14
Q

What ligaments are in the Lx?”

A

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

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15
Q

Can you differentiate between the Lx ligaments?

A

No

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16
Q

What are the anatomical components of the intervertebral discs?

A

Nucleus pulposus - centrally

Annulus fibrosus - surrounds the nucleus pulposus

Cartilage end plates - between the disc and vertebral body

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17
Q

What is the structure of the nucleus pulposus?

A

Its soft and contains high amounts of water

Posteriorly in the Lx and centrally in the Cx and Tx

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18
Q

What is the structure of the annulus fibrosus?

A

Series of annular bands (like a tree trunk) that surround the nucleus

Fibrocartilogenous collagen bundles

In Lx denser anteriorly and weakest posteriolaterally

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19
Q

In which direction does a disc prolapse in the Lx?

A

Posteriolaterally

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20
Q

Which positions cause the most pressure on the disk?

A

Sitting forward

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21
Q

What happens to the discs with ageing?

A

Loss of disc height

More collagen content in the annulus fibrosus

Loss of water in the nucleus pulposus

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22
Q

How does disc herniation occur due to age?

A

Annulus fibrosus weakens which leads to cracks and herniation of the nuculeus pulposus

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23
Q

What is spondylosis?

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A

Loss of disc height or osteophyte formation that causes narrowing and compression of the nerve root

24
Q

How would someone with a disc injury (spondylosis) present?

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A

Discogenic pain - where disc has been injured and becomes a nociceptive source

Centralisation

Loss of extension

High sens, low spec

25
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
26
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
27
What are the neurodynamic tests for disk herniation with sciatica or radiculopathy?
Slump Straight Leg Raise High Sens, Low Spec
28
When is a MRI useful in Lx pain?
Red flags Severe nerve root compression
29
What model is important to consider with Lx pain patients?
Biopsychosocial model
30
How can you differentiate between specific and non-specific back pain?
Exclude the specific causes
31
What is sciatica?
Neuropathic leg pain secondary to compressive spinal pathology e.g. spondylosis Pain involves the sciatic nerve
32
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
33
What are the subjective questions should you ask regarding sciatica?
Sitting, standing or walking posture Specific occupation function regarding biomechanics
34
What dictates the structure of the objective assessment?
Severity and irritability
35
What position is spondylolisthesis most painful?
Extension
36
What position is most painful for a disc injury?
Sitting for long periods
37
What is a typical of patients with stenosis?
Can only walk for a period of time before getting stenotic symptoms down the leg
38
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?
39
What are orange flags?
Psychiatric status e.g. suicidal, severe depression
40
What are pink flags?
Positive attitudes, good motivation, etc.
41
How does anxiety and depression affected Lx pain?
Amplify pain
42
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
43
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
44
What type of exercise is effective for LBP?
Group exercise programme e.g. bio-mechanical, aerobic, mind-body or a combination Make patient specific
45
What type of manual therapy is effective for LBP?
Spinal mobilisations Soft tissue techniques (massage) Combined with exercise and psychological therapy
46
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
47
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
48
What should you not offer?
Orthotics Traction Acupuncture Electrotherapy
49
What is the main predictor of chronicity?
Psychological factors
50
What is and spondylolisthesis?
Vertebrae slips forward due to complete fracture of the pars interarticularis
51
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
52
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
53
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
54
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
55
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
56
What type of Lx pain is Spondylolisthesis and facet joint pathologies?
Regional non-specific mechanical back pain
57
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

MSK Practical Exam (11 decks)

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