Lumbar Spine Common Presentations Flashcards
Prognostic Indicators for development of RECURRENT PAIN
- Hx of previous epsodes
- Excessive spine/joint mobility
Prognostic Indicators for development of
CHRONIC LB PAIN
- Presence of symptoms below the knee
- Psychosocial distress or depression
- Fear of pain, movement, and re-injury or low expectations of recovery
- Pain of high intensity
- A passive coping style
What is the most commonly presenting complaint for spinal cancer?
Back pain
90% of patients
When ruling in/out spinal cancer screening, what are two components fo the patient interview/history that are important indicators for cancer screening?
PMH cancer, pain no alleviated with bed rest
Vertebral Osteomyelitis Patient Interview/Hx
- Often traced to other source of infection (dental abscess, pnm, BLADDER)
- Increased risk:
- Immunocompromised patients
- DM
- Weight Loss
- Fatigue
- Fever
- Neurologic Symptoms
Vertebral Osteomyelitis Pain Complaints
- Local, focal back pain
- Worse with mechanical loading
- Improves with recumbent position
Vertebral Osteomyelitis Physical Examination
- Fever
- Local tenderness
- Aggravated with local percussion
- Neurologic signs (cord/root)
- Lab tests important for diagnosis
Epidural Abscess are often misdiagnosed and are associated with:
- DM
- Chronic Renal Failure
- IV drug misuse
- Alcoholism
- Cancer
Epidural abscess commonly occurs with:
vertebral osteomyelitis
Epidural abscess progression:
Local, focal back pain → radicular S&S → paralysis
🚩 Red Flags associated with Vertebral Fractures
- Older age
- Significant trauma
- Corticosteroid use
- Contusion/abrasion
Roman Clinical Prediction Rules
- Age >52Y
- Absence of leg pain
- BMI </=22
- Does not exercise regularly
- Female gender
Henschke Vertebral Fracture Rules
- Age >70Y
- Significant trauma
- Prolonged corticosteroid use
- Sensory alterations from trunk down
Spondylolysis occurs commonly with what motions?
Repetitive microtrauma:
- Extension
- Side-bending
- Lateral flexion
- Rotation
Spondylolysis most commonly occurs at
L5
Spondylolisthesis could be a flail segment when:
there is a bilateral pars defect with attached multifidus
The greatest slippage of vertebrae occurs when?
10-15 YO
On imaging, what would show spondylolisthesis?
“Scotty Dog with a collar”
Spondylolisthesis History
- Prevalence up to 43% in athletes (rep. motions): gymnastics, diving, weight lifting)
- High grade slippage 2x greater in GIRLS > boys; and 4x greater in women > men
- Greater risk among adolescents
Symptoms of Spondylolithesis
- Localized LBP
- Worse with extension activities (prolonged standing)
Physical Exam Findings for Spondylolithesis
- Include neurologic testing
- Visual inspection: excessive lumbar lordosis
- Possible step-off deformity (SP)
- Pain with lumbar EXT, rotation (IPSI = lumbar flexion)
- “Hamstring tightness” (could be protective mechanism to counteract excessive lumbar lordosis)
Spondylolithesis Special Tests/Mobility
(+) Instability testing
Spring testing at involved segments
Iatrogenic discitis is extremely painful and commonly occurs due to
discography
Internal Disc Disruption is often due to a
Rotary injury
What is the weakest portion of an IV disc?
end-plate
Loss of disc height requres exessive loading on what jonts?
Facet Joints (Tripod effect)
What motion is most painful for internal disc disruption?
Flexion
Symptoms of IDD
- Sudden onset w/trauma or gradual/progressive onset.
- Recurrent episodes, worsening in intensity each episode.
- Central lumbar area or can be difficult to localize (focal or diffuse)
- Pain
- Dull, constant, aching
- Activities that stress outer annulus or increase compressional load on disc (coughing, straining, sitting)
- Multi-directional trunk motions, component)
- Worse:
- End range (esp. including a flexion limitation)
- First getting up after periods of recumbency or sitting,
- Over course of day
- Improves with activity (standing, walking)
- Radicular SxS (if bulge/herniation is present and affecting spinal nerve(s)).
Physical Exam IDD
- Imaging: high prevalence rates in asymptomatic populations (20-30%)
- Visual: Lateral shift or other postural abnormalities
- Multi-directional P/AROM pain and limitations
- Can be a directional preference with repeated motions (observe for centralization +/- peripheralization with repeated motions)
- Pain with spring testing (CPAs)
- Radicular LMN signs (if bulge/herniation is present and affecting spinal nerve(s))
- SLR Test (more indicative of radicular s/s)
A bulging disc involves how much of the circumference of the disc?
50-100% if circumference
Symmetrical or asymmetrical
Type of disc herniation
Protrusion or Extrusion
Types of Protruded Discs
Broad-based: 25-50% (90-180º)
Focal: <25% (<90º)
Extrusion Types
Narrower neck
Sequestered free fragment
What is the kinematics behind a torsion injury?
Rotation begins in axis of rotation through posterior 1/3 of IV disc → force at contra facet joint → axis shifts to facet joint = shear and rotary loading
Radicular Pain History
Acute: trauma (twisting/lifting)
Insidious: progressively more distal as health condition progresses
Radicular Pain Symptoms
- Shooting/lancing pain traveling along nerve root distribution
- “Band-like”
- Pain with activities that close the neuroforamen
* Painful twisting/extension activities
Physical Exam Findings for Radicular Pain
- Visual inspection: lateral shift
- Painful/limited ROM - compress foramen or place tensile load on nerve root.
- Foraminal stenosis: ROM extension/rotation/lateral flexion
- Disc bulging
- Tenderness/turgor with guarding paraspinals
Radicular Special Tests
- Slump test
- SLR test
- Well leg raise test
Potential Causes of Central Canal Degenerative stenosis
- Z-joint hypertrophy
- Bulging disc
- Thickening/ossification of ligamentous structures
What ligaments are the most commonly involved in central canal stenosis?
Ligamentum flavum
PLL
Central Canal Stenosis History
- Age >65 years
- Chronic LBP: intermittent/recurrent, +/- hx of trauma
Symptoms of Central Canal Stenosis
- Possibly cauda equina symptoms
- UMN or LMN symptoms in lumbosacral distributions (pending level)
- Pain increases with walking/standing (prolonged)
- Pain relieved with sitting, walking with UE support (walker/shopping cart)
- Pain in legs (posterior lower legs esp) > lower back
- Bilateral > Unilateral
Physical Exam Central Canal Stenosis
- Visual inspection: diminished lumbar lordosis
- Painful/limited extension + lateral flexion ROM (P/AROM)
- Improves with flexion
- Shortened hamstrings*, lengthened hip flexors
- Neurologic signs
CPR for Lumbar Stenosis
- Bilateral symptoms
- Leg > back pain
- Pain with walking/standing
- Pain relieved with sitting
- Age >48Y
How many items from the lumbar stenosis CPR need to be positive to rule out?
0 items
How many items need to be present to rule in lumbar stenosis?
4 or 5 items
Lateral Canal Stenosis Causes:
- Loss of disc height w/degenerative process
- Z-joint hypertrophy
- Disc bulging
- Spondylolysthesis
Syptoms of Lateral Canal Stenosis
- LMN symptoms in lumbosacral distributions
- Pain increased with walking/standing (prolonged)
- Pain relieved with sitting, walking with UE support (walker/cart)
- LBP + LE pain
- Unilateral (bilateral if present bilaterally)
Physical Exam of Lateral Stenosis
- Visual inspection: diminished lumbar lordosis
- Painful/limited extension + lateral flexion ROM (passive and active)
- Commonly improves with flexion
- Neurologic signs
- Other findings consistent with degenerative z-joint arthropathy.
What are potential referral locations associated with degenerative osteoarthropathy?
- Buttock
- Thigh
- Knee
- Foot
What are symptoms of degenerative osteoarthropathy?
- Local/referred, unilateral LBP/buttock pain
- Aggravating factors consistent with MSK pattern of facet closing
- Relief with facet gapping positions/activities
Physical exam findings with degenerative osteoarthropathy
- P/AROM: painful/limited lumbar extension, ipsi lateral flexion, contralateral rotation, end-range flexion
- Muscle guarding lumbar erector spinae
- Possibly difficulty activating multifidi
- Performance test with cuff
- Pseudohypertrophy
- Painful spring testing/UPA
- Hypomobility with joint mobility testing (in any direction)
Acute Traumatic Z-joint pain potential cause
meniscoid entrapment - serves as an attached loose body
Acute J-joint Pain History
- Sudden onset, potentially Hx of trauma
- Possible “acute locked back”
Acute Traumatic Z-Joint Pain Symptoms
- Diminished pain in slight flexion position and positions that gap the z-joint
- Pain with extension activities greatest (closing of z-joint)
Acute Traumatic Z-joint pain Physical exam findings
- “Slouched” posture, potentially lateral shift
- Painful, limited ROM greatest with extension
- Painful spring testing/UPA
- Tender, guarded paraspinals
NM Instability History
- Recurrent exacerbations
- Feelings of instability
NM Instability Symptoms
- LBP is constant
- Catching and locking with trunk motion
- Clicking/clunking/popping noises
- Aggravated with prolonged positioned (sitting, standing), flexion motion, sudden trunk movements, returning to upright position from flexed position
Physical Exam Findings with NM Instability
- Aberrant motions (trunk AROM)
- Painful/limited: AROM (commonly flexion), returning from full motion (looks like Gower sign)
- Excessive motion (early)
- Paraspinal guarding/tenderness
- Hypermobility (joint mobility testing)
- Prone instability test
- Passive lumbar extension test
LBP and related health conditions can be associated with what changes in back musculature?
fatty infiltration and atrophy of multifidi
Pseudohypertrophy
CSA normal, fatty tissue occupies space within muscle.
How does pseudohypertrophy affect prognosis?
Worsens prognosis
