Lumbar Spine Syndromes Flashcards by Kelliane Tambe

describe lifetime prevalence of LBP

60-80%

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LBP risk factors

Sedentary occupations,
Work involving lifting, bending, awkward postures & physically demanding,
Smoking,
Obesity,
Low levels of PA,
Low socioeconomic status

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trauma and degenerative causes of LBP

Facet Jt arthrosis
Spondylosis
Spinal Stenosis
PIVD
#, ligt sprain, muscular strain
Spondylolysis
Spondylolisthesis,
Ankylosing vertebral hyperostosis

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Inflammatory causes of LBP

Ankylosing Spondylitis
Rheumatoid Arthritis

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Metabolic causes of LBP

Paget’s Disease
Osteoporosis
Osteomalacia

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Describe classification system of LBP

For pathology based models use maitland assessment
symptom based mode e.g leg pain vs leg pain only
movement dysfunction e.g. O Sullivan Sahrmann
risk stratification model e.g. keele startback

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describe mechanical low back pain

somatic pain in muscles and joints
muscle imbalance

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postural types

Swayback
Hyper-lordotic / Kypho-lordotic
Flatback
Kyphosis
not Dowager’s hump
Flat upper back
FHP – forward head posture
Scoliosis

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features of lordotic posture

increased lumbar lordosis, anterior pelvic tilt & hyperextended knees.

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list the muscles that become elongated and weak in lordotic posture

Anterior abdominals
Hamstrings may lengthen initially BUT may eventually shorten to compensate where posture is longstanding

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list the muscles that become short and overactive in lordotic posture

Low back musculature
Hip flexors

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features of kypho-lordotic posture

increased lumbar lordosis and thoracic kyphosis. Pelvis anteriorly tilted & most forwardly placed body segment.

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muscles in kypho-lordotic posture that become elongated and weak

Neck flexors
Upper erector spinae
External Oblique

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list the muscles that become short and overactive in kypho-lordotic posture

Sub-occipital neck extensors
Hip flexors

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features of sway back posture

long kyphosis with pelvis most anterior body segment & flat low lumbar area. Hip joint moves anterior. Pelvis neutral & Hips & knees hyperextended.

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list the muscles that become elongated and weak in sway back posture

Single joint hip flexors
External Oblique
Thoracic extensors
Neck flexors

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list the muscles that become short and overactive in sway back posture

Low back musculature short but not strong

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features of flat back posture

loss of lordosis with pelvis in posterior tilt.

list the muscles that become elongated and weak in flat back posture

Single joint hip flexors

list the muscles that become short and overactive in flat back posture

Hams
Maybe abdominals

describe clinical pattern of acute locked back pain

subjective assessment
sudden onset - from sudden movement
may hear a click
spontaneous recovery 1-2/52

objective
observation - pt stuck in flexion or contralateral side flexion is position of ease
all movements of pain e.g extension ispilateral side flexion, regional spasms

describe pathophysiology discogenic low back pain

Stage 1 –
Protrusion – circumferential annular tearing – posterolateral radial fissure produced

Stage 2 –
Prolapse – Nucleus escapes further into annulus & AF protrudes

Stage 3 –
Extrusion –Nucleus escapes beyond annulus completely

Stage 4 –
Sequestration – Nuclear material exits disc & becomes detached

clinical pattern of discogenic low back pain

causes 90% radicular pain or can cause referred pain
subjective ax
work requiring prolonged lumbar flexion
cumulative e.g. desk job micro trauma or traumatic e.g. lifting injury
central or unilateral LBP and or leg pain
WB/compression painful

objective
observation - loss of lordosis due to spasm
gait avoid WB through leg on painful side
lateral shift
ROM - lumbar flexion most limited
PAVIM provocative PA midline cause shear stress to disc

contributing factors to LBP

Genetic Predisposition - Fam Hx
Macro overload –
Twist / sudden high loading IN flexion
Trauma / fall on buttocks / RTA
Micro overload –
Repetitive Lifting / bending / twisting
Occupation
Manual work e.g. nursing, construction, assembly line workers
Sustained sitting postures e.g. desk job

Clinical pattern of radiculopathy

back pain and leg pain caused by compression or irritation of nerve root paraesthesia or numbness myotomal weakness burning, shooting pain in dermatomal innervation field NDT - leg pain reproduced in SLR

If patient has low back pain and some burning shooting pain in anterior thigh pain. With reduced deep tendon reflex of patella and myotomal weakness of quads and tibialis anterior and loss of sensation of medial knee and skin. what does the patient have

radiculopathy in disc level L3-L4

If patient has low back pain and some burning shooting pain in posterior thigh pain and lateral calf pain. With no reduced deep tendon reflex and myotomal weakness of extensor hallucis longus and loss of sensation of 1st toe. what does the patient have

radiculopathy of L4-L5

If patient has low back pain and some burning shooting pain in posterior thigh pain and posterior calf pain. With reduced deep tendon reflex of achilles tendon and myotomal weakness of peroneii and gastroc and loss of sensation of lateral foot and heel. what does the patient have

radiculopathy L5-S1

Causes of radiculopathy

DISC HERNIATION FORAMINAL STENOSIS DEGENERATION: Osteophytes from disc / facet jts VERTEBRAL CYSTS & TUMOURS etc. EPIDURAL DISORDERS Lipoma, angioma Infections MENINGEAL DISORDERS Cysts of nerve root sleeve NEUROLOGICAL DISORDERS Diabetes Neural cysts & tumours

clinical pattern of cauda equina syndrome

bowel and bladder disturbance saddle paraesthesia/anaesthesia gait difficulty

what would be assessed in a suspected cauda equina patient

assess the following actions to see the possible aggravating activities and how they relate to the suspected pathological structure Sitting Sit to stand after prolonged sit Standing Walking Driving Cough / sneeze Turning in bed Running Lifting Bending to put on shoes & socks

how does the nucleus propulsus change with age

Proteoglycan content ↓ - 30% by age 60 PG composition changes ↑ Collagen content

how does the IVD structure change with age

NP dries & becomes solid & granular  less able to WB  more WB direct to AF. NP & AF coalesce. AF may develop cracks Overall disc is stiffer  more resistant to deformation but less able to recover from creep.

how does the vertebral body change with age

Disc height maintained  any trunk height loss due to ↓ VB height End-plate thins & bows into VB ↓ bone density due to loss of trabeculae

how does the facet joint change with age

Subchondral bone thickens Gross thickening & cartilage irregularity Osteophytes develop along capsule & Ligt Flavum attachments

spondylosis

disc degeneration - annulus bulges, height is lost osteophyte develop circumferentially reactive changes in surrounding tissue facet joints may become hyperextended IV foramen reduce osteophyte

clinical pattern of spondylosis

subjective LBP and/or leg pain pain worse in EOD stiffness worse in am Objective PAVIM hypo not reactive unless very acute potential sequelae - narrow IVF, radiculopathy

facet joint arthropathy clinical pattern

usually secondary to disc degeneration subjective pain pain lateral can radiate below knee but most commonly in gluteal region, thigh, or groin objective Pain STS after prolonged sitting, standing or hyperextension ease with flexion physical - central PA, NAD, unilateral PA painful

spinal stenosis

SPONDYLOSIS / FACET JOINT ARTHROSIS  canal stenosis canal volume minimal in extension  flexion is POE Fowler’s position (90:90) Potential sequelae Neurogenic claudication Bicycle test

spondylolysis

a bilateral defect in pars interarticularis probably due to genetics, congenital weakness and micro or macro trauma.

spondylolisthesis

bilateral defect in pars interarticularis and leads to a forward slip

clinical pattern of spondylolisthesis

Extension most painful +/- step deformity PAIVM – pain & ‘reactive’

red flags to identify - indications of serious spinal pathology

Significant trauma Fever Unexplained weight loss Severe, unremitting night pain Hx of Ca Thoracic Pain IV Drug use or Steroid use Progressive neurological deficit Disturbed gait, saddle anaesthesia Bladder or bowel dysfunction