Lumbar Spine Syndromes Flashcards
describe lifetime prevalence of LBP
60-80%
LBP risk factors
Sedentary occupations,
Work involving lifting, bending, awkward postures & physically demanding,
Smoking,
Obesity,
Low levels of PA,
Low socioeconomic status
trauma and degenerative causes of LBP
Facet Jt arthrosis
Spondylosis
Spinal Stenosis
PIVD
#, ligt sprain, muscular strain
Spondylolysis
Spondylolisthesis,
Ankylosing vertebral hyperostosis
Inflammatory causes of LBP
Ankylosing Spondylitis
Rheumatoid Arthritis
Metabolic causes of LBP
Paget’s Disease
Osteoporosis
Osteomalacia
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
describe mechanical low back pain
somatic pain in muscles and joints
muscle imbalance
postural types
Swayback
Hyper-lordotic / Kypho-lordotic
Flatback
Kyphosis
not Dowager’s hump
Flat upper back
FHP – forward head posture
Scoliosis
features of lordotic posture
increased lumbar lordosis, anterior pelvic tilt & hyperextended knees.
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
list the muscles that become short and overactive in lordotic posture
Low back musculature
Hip flexors
features of kypho-lordotic posture
increased lumbar lordosis and thoracic kyphosis. Pelvis anteriorly tilted & most forwardly placed body segment.
muscles in kypho-lordotic posture that become elongated and weak
Neck flexors
Upper erector spinae
External Oblique
list the muscles that become short and overactive in kypho-lordotic posture
Sub-occipital neck extensors
Hip flexors
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.
list the muscles that become elongated and weak in sway back posture
Single joint hip flexors
External Oblique
Thoracic extensors
Neck flexors
list the muscles that become short and overactive in sway back posture
Low back musculature short but not strong
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
