Lumbosacral pathophysiology Flashcards
1
Q
Number of people off work daily in the U.S.
A
10,000,000
2
Q
Number of working days lost in GB annually
A
15,000,000
3
Q
Missed days cost U.S. industries….
A
14 billion each year
4
Q
____% of the cases with LBP account for ___% of the cost to the industry
A
25%; 90%
5
Q
The incidence rate of LBP in sedentary workers is the ___ as in those doing heavy labor
A
same
6
Q
Group most affected by LBP in the US
A
Truck Drivers
7
Q
Is there a correlation between x-ray and symptomology?
A
moderate correlation, not much
8
Q
Attacks of acute LBP start at about age ___
A
25
9
Q
Attacks of LBP become significant by age___
A
35
10
Q
Attacks of acute LBP peak between the ages of _____
A
40-45
11
Q
Percent of people with LBP better in one week
A
40%
12
Q
Percent of people with LBP better in one month
A
86%
13
Q
Percent of people with LBP better in two months
A
92%
14
Q
Percent of back pain that is recurrent
A
90%
15
Q
Percentage of recurrent LBP patients that develop sciatica
A
40%
16
Q
Visceral Disease
A
Originates in the internal organs
Deep, dull, achey, and often diffuse
Less likely to be influenced by movement
Atypical presentation with movement exam
17
Q
Kidney referral
A
Lumbar spine, lower and upper abdomen
18
Q
Ureter Referral
A
Groin Upper abdomen Suprapubic Medial proximal thigh TL spine
19
Q
Bladder referral
A
TL spine
Sacral apex
Suprapubic area
20
Q
Prostate Referral
A
Sacral Spine
Suprapubic
Testes
21
Q
Uterus Referral
A
Sacral and TL spine
Primarily L5/S1
22
Q
Ovaries and Testes Referral
A
Lower abdomen and Sacral Spine
23
Q
Pancreas referral
A
TL Spine and upper abdomen
24
Q
Duodenum referral
A
Mid and Lower T spine
25
Gallbladder referral
TL spine
| Right inferior angle of scapula
26
Colon referral
Upper sacral spine
Suprapubic
Left lower abdominal quadrant
27
Herniation of the IVD
Not synonymous with, but related to DDD
| 60 y/o+ individuals more likely to be DDD, slow onset
28
Herniations predominant in
Younger males
29
Likelihood of disk herniations at varying levels
L4/5 > L5/S1 > L3/4 > L2/3 > L1/2
30
Disk Protrusion
Annular fibers intact
A) localized annular bulge-usually laterally
B) Diffuse annular bulge-usually posterior
31
Disk Prolapse
Annular fibers disrupted
| Nucleus has migrated through the inner laminar layers, still contained
32
Disk Extrusion
Annular fibers disrupted
| Nucleus has broken through the outermost layer
33
Disk Sequestration
Annular fibers disrupted
| Nucleus separate from disk/ now in spinal and/or intervertebral canals
34
Clinical features of IVD herniation
```
Dramatic onset of symptoms
-fragmentation mouse
Onset often a day or two after activity
Acute sciatica
Muscle spasm with deviation
AROM flexion/extension limited
```
35
Nerve root irritation and conduction evidence
Dermatomal/myotomal testing
Radiographs often not helpful but does rule out other
MRI/CT/Myelography useful
36
Myelography is ___ as accurate as ____
76%; CT/MRI
37
Derangement 1
Central or symmetrical pain across L4/L5
Rarely buttock or thigh pain
No deformity
38
Derangement 2
Central or symmetrical pain across L4/L5
With or w/o buttock or thigh pain
With deformity of flat spine
39
Derangement 3
Unilateral or asymmetrical pain across L4/5
With or without buttock or thigh pain
No deformity
40
Derangement 4
Unilateral or asymmetrical pain across L4/5
With or without buttock or thigh pain
Deformity of lateral shift
41
Derangement 5
Unilateral or asymmetrical pain across L4/5
With or w/o buttock or thigh pain
Pain below the knee
No deformity
42
Derangement 6
Unilateral or asymmetrical pain across L4/5
With or w/o buttock and or thigh pain
Pain below the knee
Deformity of lateral shift
43
Derangement 7
Unilateral or asymmetrical pain across L4/5
With or w/o buttock and or thigh pain
Pain below the knee
Deformity of accentuated lumbar lordosis
44
Disc Degeneration (DDD)
```
Nucleus pulposis degenerates in spine
Water and chondroitin sulfate loss
Height of disc space decreases
Normal 60 years and >
Annulus fibrosis loses elasticity, becomes thin
```
45
Schmorl's Nodes
Cartilage end plate weakness
| Common but with minimal clinical significance
46
DDD pathogenesis
Interrelation of IVD disease and posterior facet joint disease
Posterior facet compression
Decreased foraminal opening
Ligamentous laxity
47
Degenerative Joint Disease
Most common in the spine
Not uncommon, but not normal
Increased incidence in more mobile segments of the spine
48
DJD Etiology
Weak trunk muscles
Smokers 3x more likely
Fall, MVA, sports injury, poor lifting mechanics
Infection and neoplasm
49
Segmental narrowing
Late stage in DDD, segment now stiff and stable
Loss of ROM and stiffness in back
Radiographs helpful for narrowing and osteophyte formation
50
Segmental narrowing leads to...
Posterior facet changes
AF bulging creates large osteophytes at bony margins
>60 y/o 90% present with this
May or may not be painful
51
Spinal Stenosis
Bony narrowing of the spinal canal either centrally or in its lateral recesses including the intervertebral foramen
-Congenital vs acquired
52
Central Spinal Stenosis
Cauda equina compression
S2,3,4 nerve roots
Bowel incontinence
53
Lateral spinal stenosis
Nerve roots compressed
54
Spinal Stenosis etiology
- Annular protrusion of the disc
- Osteophyte
- Ligamentum flavum folding or bulging
- Subperiostial thickening over the vertebral body and laminar arch
- Congenital narrowing
- DJD
55
Spinal stenosis or intermittent claudication?
Stationary bike vs treadmill testing
| Stenosis wont have symptoms on bike
56
Flaccid bladder
Flaccid bladder is S2,3,4 issues
57
Stenotic syndome has a ___ sensitivity to neurogenic claudication
60%
58
Sensitivity of leg pain ____ in patients with disk disease and spinal stenosis
94%
59
Extension decreases spinal canal ____ in degenerative spine vs ____ in normal spine
67%;9%
60
Segmental hyperextension
Chronic, intermmittent LBP (Lumbago)
Local or referred to buttocks
Worse with extension, better with flexion
Radiographs help
61
Segmental Hyperflexion
Often associated with herniated disc or DDD
May be relieved by extension
Radiographs help
62
Clinical features of segmental instability
- Chronic, intermmittent backache
- Increases w/ ativity
- Local or referred to buttocks
- Muscle splinting, guarding, and loss of function
- Often associated with positive neurological findings
- Radiograph helpful
63
MOI instability
more likely to be traumatic than hypermobility
64
Level of function instability
Less than with hypermobility
65
AROM w/ weightbearing instability
Less with instability
66
PIVM weightbearing vs non w/ instability
Less motion when weightbearing than when non-weight bearing
67
Neurological tests Instability
More positives with instability
68
Palpation Instability
More movement with instability
69
Segmental hyperextension may lead to..
Sprain or posterior subluxation
70
Traction spur formation
Form of osteophyte
| Susceptible now to injury which may create sprain of facet joints
71
Spondylolysis
```
Defect in pars interarticularis (Isthmus)
85% incidence at L5
15% incidence at L4
Etiology may be stress fx
Found in 10% of adults
```
72
Spondylolysis incidence
Seldom found
73
Eskimos incidence of spondylolysis
As high as 50%
74
African American incidence of spondylolysis
75
Spondylolysis most common in which sports
Gymnastics, Wrestler, football linemen, butterfly swimmers, weightlifting
76
Imaging for spondylolysis
X-ray and bone scan
77
Spondylolesthesis
Forward slippage of one vertebra and the remainder of the spinal column above it
-step deformity
Increased lumbar lordosis
Grades 1-4
78
Step deformity
Stable if present when standing and lying down
79
Most common spondylolesthesis level
L5/S1 followed by L4/5
80
Grade I spondylolesthesis
25% of the body is forward
81
Grade II spondylolesthesis
50% of the body is forward
82
Grade III Spondylolesthesis
75% of the body is forward
83
Grade I Spondylolesthesis treatment
Restrict aggravating activities
Co-Contraction trunk strengthening
Rest/NSAIDS/TLSO
84
Grade II Spondylolysthesis treatment
X-rays every 4-6 months until end of growth
| Same as grade I, or a posterior fusion
85
Grade III spondylolysthesis treatment
Posterior fusion
86
Myelography
Injection of dye into the spinal canal
| Value is specificity
87
CAT Scan
Indicated if trauma
| Valuable diagnosing fx
88
MRI
Go to test
89
Bone scan
Used in inflammation and stress fx
90
Microdiscectomy
Indicated if neurological deficit
Failure to respond to conservative measures of >6 weeks
Unrelenting pain, recurrent sciatica
91
Decompression laminectomy
Indicated if severe disabling back or leg pain
Bowel or bladder involvement
Removal of posterior arch/ligamentum flavum and possibly a fusion
92
Fusion
Indicated if instability due to degenerative changes, trauma, or same as laminectomy
93
Instrumented fusions
Harrington rod
Pedicle Screw
Anterior and posterior approaches
94
Interbody fusions
Titanium cages
Allograft bone
Bone morphogenic protein
95
Cauda Equina Syndrome
Large midline disc herniation may compress cauda equina
~2% of patients with disc herniations
Micturition difficulty
LBP, leg pain, severe numbness and difficulty walking
Saddle parasthesias
Prompt surgical intervention
96
Micturition difficulty
Increased frequency
Overflow incontinence
Recent impotence
97
Cauda Equina Syndrome symptom percentages
95% specificity for urinary incontinence
80% for unilateral or bilateral sciatica and sensory/motor deficits
75% for saddle anesthesia
98
Ankylosing Spondylitis
```
Hereditary
15-40 y/o males
Slowly progressive LBP and stiffness
4:1 male to female ratio
Affects sacroiliac joint, ZJ, and CV joints
Bamboo spine
Radicular above knee
Increased pain with rest and decreased with activity
```
99
Bamboo spine
Flexed thoracic posture
100
Ankylosing Spondylitis intervention
```
Nsaids (Indomethacin)
Education
Thermal modalities
PRE's
Swimming
```
101
Sacroiliitis
Inflammation of the SI joint
| A-P radiograph before CT scan
102
Sacroiliac Osteomyelitis
Hematogeneous infection to SIJ
Pain over SI joint
Staph infection normally
103
Paget's Disease
- Increased activity of osteoclastic and osteoblastic cells, bone marrow replacement by hypervascular fibrous tissue
- Mosaic like disorganization of trabecular and cortical bone
104
Paget's Disease presentation
Rare before 40
Males=females
3-4% after 40 and up to 10% by 90
Lumbar spine 60% and sacral spine 45%
105
Non-musculoskeletal symptoms paget's disease
```
Increased hat size
Hearing loss
Tinnitus
Vertigo
HA
CHF
Basilar invagination
```
106
Paget's disease exam reveals
Flat lumbar spine
Slow gait
Anterolateral bowing of the legs (Saber shin)
107
Paget's disease diagnosis
Bone deformities on x-ray
| Elevated serum alkaline phosphate
108
Paget's disease treatment
NSAIDs
Hormone Calcitonin
Bisphosphonates
109
Bisphosphonates
Bind to bone minerals to inhibit bone loss
