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Clinical Medicine PT-517 > Lumbosacral pathophysiology > Flashcards

Lumbosacral pathophysiology Flashcards

1
Q

Number of people off work daily in the U.S.

A

10,000,000

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2
Q

Number of working days lost in GB annually

A

15,000,000

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3
Q

Missed days cost U.S. industries….

A

14 billion each year

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4
Q

____% of the cases with LBP account for ___% of the cost to the industry

A

25%; 90%

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5
Q

The incidence rate of LBP in sedentary workers is the ___ as in those doing heavy labor

A

same

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6
Q

Group most affected by LBP in the US

A

Truck Drivers

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7
Q

Is there a correlation between x-ray and symptomology?

A

moderate correlation, not much

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8
Q

Attacks of acute LBP start at about age ___

A

25

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9
Q

Attacks of LBP become significant by age___

A

35

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10
Q

Attacks of acute LBP peak between the ages of _____

A

40-45

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11
Q

Percent of people with LBP better in one week

A

40%

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12
Q

Percent of people with LBP better in one month

A

86%

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13
Q

Percent of people with LBP better in two months

A

92%

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14
Q

Percent of back pain that is recurrent

A

90%

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15
Q

Percentage of recurrent LBP patients that develop sciatica

A

40%

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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

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17
Q

Kidney referral

A

Lumbar spine, lower and upper abdomen

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18
Q

Ureter Referral

A 
Groin
Upper abdomen
Suprapubic
Medial proximal thigh
TL spine
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19
Q

Bladder referral

A

TL spine
Sacral apex
Suprapubic area

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20
Q

Prostate Referral

A

Sacral Spine
Suprapubic
Testes

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21
Q

Uterus Referral

A

Sacral and TL spine

Primarily L5/S1

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22
Q

Ovaries and Testes Referral

A

Lower abdomen and Sacral Spine

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23
Q

Pancreas referral

A

TL Spine and upper abdomen

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24
Q

Duodenum referral

A

Mid and Lower T spine

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25
Q

Gallbladder referral

A

TL spine

Right inferior angle of scapula

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26
Q

Colon referral

A

Upper sacral spine
Suprapubic
Left lower abdominal quadrant

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27
Q

Herniation of the IVD

A

Not synonymous with, but related to DDD

60 y/o+ individuals more likely to be DDD, slow onset

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28
Q

Herniations predominant in

A

Younger males

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29
Q

Likelihood of disk herniations at varying levels

A

L4/5 > L5/S1 > L3/4 > L2/3 > L1/2

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30
Q

Disk Protrusion

A

Annular fibers intact
A) localized annular bulge-usually laterally
B) Diffuse annular bulge-usually posterior

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31
Q

Disk Prolapse

A

Annular fibers disrupted

Nucleus has migrated through the inner laminar layers, still contained

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32
Q

Disk Extrusion

A

Annular fibers disrupted

Nucleus has broken through the outermost layer

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33
Q

Disk Sequestration

A

Annular fibers disrupted

Nucleus separate from disk/ now in spinal and/or intervertebral canals

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34
Q

Clinical features of IVD herniation

A 
Dramatic onset of symptoms
-fragmentation mouse
Onset often a day or two after activity
Acute sciatica
Muscle spasm with deviation
AROM flexion/extension limited
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35
Q

Nerve root irritation and conduction evidence

A

Dermatomal/myotomal testing
Radiographs often not helpful but does rule out other
MRI/CT/Myelography useful

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36
Q

Myelography is ___ as accurate as ____

A

76%; CT/MRI

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37
Q

Derangement 1

A

Central or symmetrical pain across L4/L5
Rarely buttock or thigh pain
No deformity

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38
Q

Derangement 2

A

Central or symmetrical pain across L4/L5
With or w/o buttock or thigh pain
With deformity of flat spine

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39
Q

Derangement 3

A

Unilateral or asymmetrical pain across L4/5
With or without buttock or thigh pain
No deformity

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40
Q

Derangement 4

A

Unilateral or asymmetrical pain across L4/5
With or without buttock or thigh pain
Deformity of lateral shift

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41
Q

Derangement 5

A

Unilateral or asymmetrical pain across L4/5
With or w/o buttock or thigh pain
Pain below the knee
No deformity

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42
Q

Derangement 6

A

Unilateral or asymmetrical pain across L4/5
With or w/o buttock and or thigh pain
Pain below the knee
Deformity of lateral shift

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43
Q

Derangement 7

A

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

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44
Q

Disc Degeneration (DDD)

A 
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
Q

Schmorl’s Nodes

A

Cartilage end plate weakness

Common but with minimal clinical significance

46
Q

DDD pathogenesis

A

Interrelation of IVD disease and posterior facet joint disease
Posterior facet compression
Decreased foraminal opening
Ligamentous laxity

47
Q

Degenerative Joint Disease

A

Most common in the spine
Not uncommon, but not normal
Increased incidence in more mobile segments of the spine

48
Q

DJD Etiology

A

Weak trunk muscles
Smokers 3x more likely
Fall, MVA, sports injury, poor lifting mechanics
Infection and neoplasm

49
Q

Segmental narrowing

A

Late stage in DDD, segment now stiff and stable
Loss of ROM and stiffness in back
Radiographs helpful for narrowing and osteophyte formation

50
Q

Segmental narrowing leads to…

A

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
Q

Spinal Stenosis

A

Bony narrowing of the spinal canal either centrally or in its lateral recesses including the intervertebral foramen
-Congenital vs acquired

52
Q

Central Spinal Stenosis

A

Cauda equina compression
S2,3,4 nerve roots
Bowel incontinence

53
Q

Lateral spinal stenosis

A

Nerve roots compressed

54
Q

Spinal Stenosis etiology

A
  • Annular protrusion of the disc
  • Osteophyte
  • Ligamentum flavum folding or bulging
  • Subperiostial thickening over the vertebral body and laminar arch
  • Congenital narrowing
  • DJD
55
Q

Spinal stenosis or intermittent claudication?

A

Stationary bike vs treadmill testing

Stenosis wont have symptoms on bike

56
Q

Flaccid bladder

A

Flaccid bladder is S2,3,4 issues

57
Q

Stenotic syndome has a ___ sensitivity to neurogenic claudication

A

60%

58
Q

Sensitivity of leg pain ____ in patients with disk disease and spinal stenosis

A

94%

59
Q

Extension decreases spinal canal ____ in degenerative spine vs ____ in normal spine

A

67%;9%

60
Q

Segmental hyperextension

A

Chronic, intermmittent LBP (Lumbago)
Local or referred to buttocks
Worse with extension, better with flexion
Radiographs help

61
Q

Segmental Hyperflexion

A

Often associated with herniated disc or DDD
May be relieved by extension
Radiographs help

62
Q

Clinical features of segmental instability

A
  • 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
Q

MOI instability

A

more likely to be traumatic than hypermobility

64
Q

Level of function instability

A

Less than with hypermobility

65
Q

AROM w/ weightbearing instability

A

Less with instability

66
Q

PIVM weightbearing vs non w/ instability

A

Less motion when weightbearing than when non-weight bearing

67
Q

Neurological tests Instability

A

More positives with instability

68
Q

Palpation Instability

A

More movement with instability

69
Q

Segmental hyperextension may lead to..

A

Sprain or posterior subluxation

70
Q

Traction spur formation

A

Form of osteophyte

Susceptible now to injury which may create sprain of facet joints

71
Q

Spondylolysis

A 
Defect in pars interarticularis (Isthmus)
85% incidence at L5
15% incidence at L4
Etiology may be stress fx
Found in 10% of adults
72
Q

Spondylolysis incidence

A

Seldom found

73
Q

Eskimos incidence of spondylolysis

A

As high as 50%

74
Q

African American incidence of spondylolysis

A
75
Q

Spondylolysis most common in which sports

A

Gymnastics, Wrestler, football linemen, butterfly swimmers, weightlifting

76
Q

Imaging for spondylolysis

A

X-ray and bone scan

77
Q

Spondylolesthesis

A

Forward slippage of one vertebra and the remainder of the spinal column above it
-step deformity
Increased lumbar lordosis
Grades 1-4

78
Q

Step deformity

A

Stable if present when standing and lying down

79
Q

Most common spondylolesthesis level

A

L5/S1 followed by L4/5

80
Q

Grade I spondylolesthesis

A

25% of the body is forward

81
Q

Grade II spondylolesthesis

A

50% of the body is forward

82
Q

Grade III Spondylolesthesis

A

75% of the body is forward

83
Q

Grade I Spondylolesthesis treatment

A

Restrict aggravating activities
Co-Contraction trunk strengthening
Rest/NSAIDS/TLSO

84
Q

Grade II Spondylolysthesis treatment

A

X-rays every 4-6 months until end of growth

Same as grade I, or a posterior fusion

85
Q

Grade III spondylolysthesis treatment

A

Posterior fusion

86
Q

Myelography

A

Injection of dye into the spinal canal

Value is specificity

87
Q

CAT Scan

A

Indicated if trauma

Valuable diagnosing fx

88
Q

MRI

A

Go to test

89
Q

Bone scan

A

Used in inflammation and stress fx

90
Q

Microdiscectomy

A

Indicated if neurological deficit
Failure to respond to conservative measures of >6 weeks
Unrelenting pain, recurrent sciatica

91
Q

Decompression laminectomy

A

Indicated if severe disabling back or leg pain
Bowel or bladder involvement
Removal of posterior arch/ligamentum flavum and possibly a fusion

92
Q

Fusion

A

Indicated if instability due to degenerative changes, trauma, or same as laminectomy

93
Q

Instrumented fusions

A

Harrington rod
Pedicle Screw
Anterior and posterior approaches

94
Q

Interbody fusions

A

Titanium cages
Allograft bone
Bone morphogenic protein

95
Q

Cauda Equina Syndrome

A

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
Q

Micturition difficulty

A

Increased frequency
Overflow incontinence
Recent impotence

97
Q

Cauda Equina Syndrome symptom percentages

A

95% specificity for urinary incontinence
80% for unilateral or bilateral sciatica and sensory/motor deficits
75% for saddle anesthesia

98
Q

Ankylosing Spondylitis

A 
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
Q

Bamboo spine

A

Flexed thoracic posture

100
Q

Ankylosing Spondylitis intervention

A 
Nsaids (Indomethacin)
Education
Thermal modalities
PRE's
Swimming
101
Q

Sacroiliitis

A

Inflammation of the SI joint

A-P radiograph before CT scan

102
Q

Sacroiliac Osteomyelitis

A

Hematogeneous infection to SIJ
Pain over SI joint
Staph infection normally

103
Q

Paget’s Disease

A
  • Increased activity of osteoclastic and osteoblastic cells, bone marrow replacement by hypervascular fibrous tissue
  • Mosaic like disorganization of trabecular and cortical bone
104
Q

Paget’s Disease presentation

A

Rare before 40
Males=females
3-4% after 40 and up to 10% by 90
Lumbar spine 60% and sacral spine 45%

105
Q

Non-musculoskeletal symptoms paget’s disease

A 
Increased hat size
Hearing loss
Tinnitus
Vertigo
HA
CHF
Basilar invagination
106
Q

Paget’s disease exam reveals

A

Flat lumbar spine
Slow gait
Anterolateral bowing of the legs (Saber shin)

107
Q

Paget’s disease diagnosis

A

Bone deformities on x-ray

Elevated serum alkaline phosphate

108
Q

Paget’s disease treatment

A

NSAIDs
Hormone Calcitonin
Bisphosphonates

109
Q

Bisphosphonates

A

Bind to bone minerals to inhibit bone loss

Clinical Medicine PT-517 (10 decks)

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