Mechanical Spinal Pain Syndromes Flashcards
What is the main complaint of spinal muscle strain?
Back/neck pain
Does not radiate to extremities
What are mechanical spinal pain syndromes?
Local disorders of the spine and are purely musculoskeletal diseases
Pain secondary to overuse, injury or deformity or normal anatomical structure
Characteristically exacerbated by certain activities and relieved by others.
What can cause spinal muscle strain?
Mechanical stress (overuse/over stretching) Prolonged abnormal posture
May be associated with structural leg length discrepancies >5mm
What are the clinical presentations/physical examination findings of spinal muscle strain?
Pain with resisted isometric contraction or passive stretching Tender on palpation Localised pain Hypertonic (muscle spasm) Normal neurological examination
What are the presentation of a ligamentous (supraspinous) sprain?
Pain with passive stretching (flexion)
What is the main complaint of lumbar spine strain?
Lower back pain
What are underlying causes of lumbar spine strain?
Trauma Repetitive mechanical stress Abnormal anatomy (scoliosis) Hyperlordosis
What causes the onset of pain in lumbar spine strain?
Flexion/extension
Contraction of injured muscles
Activity related
In what motions does pain occur in lumbar spine strain?
Stress > supporting structure’s ability to sustain
F(load) > ability of muscle to resist - transfer of force to ligaments
F(generated) > load (excessive movement exceeding limits)
What is the correlation between lumbar spine strain and hyperlordosis?
Increased angle of L5/S1 segment increases shear forces on disc
Approximation of articular surfaces, modifies function to weight bearing
Increased stress on supporting ligaments
What are the clinical presentations of lumbar spine strain?
Local or diffuse low back pain
May refer to buttock and posterior thigh
Non-dermatomal
What are the physical examination findings of lumbar spine strain?
Pain on resisted isometric contraction and passive stretching
Tenderness on palpation
Hypertonic
Describe the 3 categories of lumbar spine strain.
Mild:
Subjective pain with no objective findings
Recovery <3 weeks
What can cause cervical spine strain?
Trauma -> over stretching -> Protective spasm of surrounding muscles
Abnormal head posture
What is the result of the protective reflex recruitment of surrounding muscle?
Autonomic reflex
Decreased blood flow
Produces anaerobic conditions in injured muscle
What can cause muscle hypertonicity?
Trauma
Postural strain
Increased muscle tension
What are the extraneous factors affecting muscle tension?
Fatigue
Emotional stress (anger, anxiety, depression)
Pain
What is the main complaint of cervical spine strain?
Pain and associated headaches
What are the clinical presentations of a patient with cervical spine strain?
Pain in middle/lower part of posterior aspect of neck
May radiate to shoulders (scapular area), occipital area, chest wall
Rare Hx of injury
Dull aching pain
Exacerbated by neck motion, relieved by rest
Onset: awkward nights sleep, rapid head movement, coughing, sneezing
What are the physical examination findings of cervical spine strain?
Locally tender areas lateral to spine Loss of cervical motion Pain on resisted isometric contraction Passive ROM > active ROM Normal neurological examination
List management of back and neck strain.
Manual therapy Controlled physical activity Non-steroidal anti-inflammatory drugs Muscle relaxants Ice/heat (patients specific) Dry needling Rehabilitative exercises
What is posterior facet syndrome?
Pain originating from any structure integral to both function and configuration of facet joints
What are aetiologies of posterior facet syndrome?
Trauma
Degeneration
Faulty posture (hyperextension)
What are the clinical history findings of posterior facet syndrome?
Back pain radiating to groin, hip, buttock, leg (above knee)
Increased pain when sleeping on abdomen, sitting in upright position, lifting hands/arms above head, sneezing, coughing
Minor sensory changes (not true loss)
Subjective muscle weakness due to pain
Low back stiffness (AM/inactivity)
How would you provide treatment/management for posterior facet syndrome?
Manipulation Corrective exercise Postural Correction -pelvic tilt Strengthen abdominal wall Injection of anesthetic solution
What are the clinical features of cervical posterior facet syndrome?
Radiation to sub occipital region, shoulders and mid back (non-dermatomal)
Previous Hx of hyper extension injury or other trauma
What is the purpose of plain film x-rays on the c-spine?
Detect: Instability Gross fracture Abnormal lesions Osteoarthritis
What are the treatment modalities do cervical posterior facet syndrome?
Analgesic/anti-inflammatory medication
Heat/ice/massage
Manipulation/mobilisation
What is sacroiliac syndrome?
Pain in the lower lumbar/gluteal region die ton jury of the SI joint
What are the mechanisms of SI syndrome?
Axial loading/rotation
Pathological changes resulting in pain (nociceptive receptors)
What are the clinical presentations of SI syndrome?
Non-dermatomal referral patterns: buttocks, lower lumbar, groin, lower extremities
Pain over SI/PSIS
What movement will aggravate SI syndrome?
Forward flexion
Sitting (sit-stand maneuvers)
What position/movement can relieve SI syndrome symptoms?
Standing or walking
Will SI syndrome present with any neurological findings?
No
What diagnostic tests can help identify that the SI joint is the pain generating tissue?
Laslett criteria: 2/5 positive tests
What are the tests in Lasletts criteria?
Distraction test Compression test Thigh thrust test Gaenslen's test Sacral thrust test
What are some of the treatment modalities for SI syndrome?
Muscle strengthening
Temporary use of lumbosacral support
Manipulation (altered gait/spine mechanics for improved mobility)
What is scoliosis?
Lateral curvature of the spine greater than 10 degrees
What is idiopathic scoliosis?
Structural curve with no clear underlying cause
Secondary cause identified by radiograph and clinical examination
How is scoliosis classified?
Based on age of detection:
Infantile (<3 years)
Juvenile (3-10 years)
Adolescent (10 year - skeletal maturity)
What are the risk factors of idiopathic scoliosis?
Age/Onset (time of diagnosis)
Magnitude of curve
Gender (f>m)
Future growth potential
How is idiopathic scoliosis classified?
Location of apex
Minor/major based on magnitude/flexibility
Compensatory or structural
At what levels would classify idiopathic scoliosis as thoracic?
T2-T11
At what levels would classify idiopathic scoliosis as thoracolumbar?
T12-L2
At what levels would classify idiopathic scoliosis as lumbar?
Distal to T12
How would you evaluate growth potential of idiopathic scoliosis?
Tanner stage (puberty growth) - peak curve progression in stage 2-3 Risser grade - estimation of remaining skeletal growth by bony fusion of iliac apophysis (0-5)
If a patient presents with a lateral cure of 10-19 degrees and Risser grade of 2-4 what is the risk of progression?
Low
If a patient presents with a lateral cure of 10-19 degrees and Risser grade of 0-1 what is the risk of progression?
Moderate
If a patient presents with a lateral cure of 20-29 degrees and Risser grade of 2-4 what is the risk of progression?
Low-moderate
If a patient presents with a lateral cure of 20-29 degrees and Risser grade of 0-1 what is the risk of progression?
High
If a patient presents with a lateral cure of >29 degrees and Risser grade of 2-4 what is the risk of progression?
High
If a patient presents with a lateral cure of >29 degrees and Risser grade of 0-1 what is the risk of progression?
Very high
When should a chiropractor refer a patient with idiopathic scoliosis?
When the curve exceeds 20 degrees
Includes X-rays every 6 months
What are treatment/management methods of idiopathic scoliosis?
Chiropractic can only provide symptomatic relief
Bracing/spinal surgery can alter natural history (prevent significant progression)
Curves >40 degrees may require surgery
What are red flags and require referral when diagnosis idiopathic scoliosis?
Left thoracic curve
Unusual pain
Abnormal neurology
What is Maigne’s syndrome?
Facet syndrome involving T12-L1 facet joints
What are the clinical presentations of Maigne’s syndrome?
Similar to PFJS
Referred pain in distribution of cluneal nerves, posterior rami of T12-L1 (level of iliac crest)
When is identification of degenerative disc disease on radiographs significant?
When it is indicative of instability, degenerative spondylolisthesis or spinal stenosis
Explain why a child is likely or unlikely to progress after diagnosis of idiopathic scoliosis.
Most of the progression of the lateral curve will occur during developmental stages (I.e during puberty)
The progression of the curve are also dependant on the magnitude of the curve and gender (f>m)
What are the 2 types of presentation of lateral entrapment syndrome?
As a result of instability or degeneration
Describe the mechanisms of lateral entrapment syndrome.
- Progressive degenerative changes in facet joints
- Loss of disc height
- Subluxation of facets
- Superior facet moves superiorly and anteriorly on inferior facet
- Impingement on pedicle above
- Narrowing of intervertebral foramen
What is another term of describing lateral entrapment due to instability?
Dynamic lateral entrapment
What type of pain is presented in patients with dynamic lateral entrapment?
Intermittent, postural/positional pain
What are two tests that can help identify a lateral entrapment?
Patient standing - runs hand down leg to back of knee
Pheasant sign - patient laying prone, with both knees flexed. Change in reflexes suggests unstable segment
What can cause entrapment due to degeneration?
Formation of osteophyte, disc degeneration (structural)
What is the main complaint of a patient with lateral stenosis?
Back pain and leg pain (leg > back)
What are the referral patterns of lateral stenosis?
Dermatomal referral patterns to buttock, trochanteric region, posterior thigh to knee (posterolateral aspect of calf to ankle)
Neurological symptoms - decreased myotomal/dermatomal (altered sensations)/reflex responses
Restricted movements
What are diagnostic tests used in physical examination for lateral stenosis?
Straight-leg raising test
Nerve root tension test
What are additional signs/tests for lateral stenosis in unstable phase?
Rotation of pelvis anteriorly when lying on affected side
same test in standing position (with assistant)
Patient lies prone and flexes knees until heels touch buttock
