MIDTERM #1--WEEK 7 Flashcards
______________:
The presence of specific sign(s) or symptom(s) suggesting with almost certainty that the target condition is present
Pathognomonic
Test __________ is the ability of a test to correctly identify those with the disease (true positive rate)
sensitivity
Test ______ is the ability of the test to correctly identify those
without the disease (true negative rate)
specificity
Example: If 100 without a disease are tested, 90 have a negative result; the test has 90% specificity
Differential Diagnoses =
“ALL THE CONDITIONS THAT APPEAR ______”
Example: A patient with back & leg pain differential diagnoses may include: Disc herniation Facet syndrome Muscular strain SI Joint injury Piriformis syndrome
SIMILAR
______ ________: “A working
hypothesis formulated from significant items in history and physical findings, a tentative diagnosis; or a working diagnosis.”
Clinical Impression
Selected Disorders of the Lumbar Spine
____% of all adults will suffer from an episode of LBP at some time in their life
2nd only to the common cold as a cause of lost days at work
One of the most common reasons for visits to a doctor’s office or emergency department
80
Selected Disorders of the Lumbar Spine
Good news: most LBP is uncomplicated with recovery in about ____ weeks
Estimated 90% will self-resolve within ___-_____months
— Not so good news: 10% of patients do NOT return to normal function even after 2 months
Pose the greatest challenge to practitioners Enormous economic burden on society
NOTE: cLBP is the MOST common cause of disability in Americans younger than ____ years
6
1–2
45
Selected Disorders of the Lumbar Spine
Encouraging News:
~____% of Americans with LBP seek chiropractic care
• Evidence on clinical effectiveness supports the use of manipulation for acute LBP and helps resolve symptoms and restore function of chronic LBP
40
Selected Disorders of the Lumbar Spine
In total,_______% of workers who initially visited a surgeon underwent surgery, in contrast to only 1.5% of those who first consulted a chiropractor
42.7
Selected Disorders of the Lumbar Spine
- Disc disruption: _____%
- Facet involvement:___-______%
- Compression fracture: 4%
- Spondylolisthesis: 3%
- Malignant Neoplasm: 1%
- Ankylosing Spondylitis: 0.3% • Spinal Infection: 0.01%
39
15-40
Selected Disorders of the Lumbar Spine
LBP Etiology continued…….
• Spinal Stenosis - common in older population
coupled or enhanced by ___________ processes
• Sacroiliac (SI) Joint
• Other (Prostate, Aneurysm, kidney, female reproductive organs )
degenerative
Selected Disorders of the Lumbar Spine
Mechanical LBP (97%)
• Muscle/Ligament
– ______/_________, MFPS, fibromyalgia
• Bone/Joint
–_________ syndrome, arthritis, fracture, osteoporosis spondylolisthesis
• Nerve
– Compression/irritation (lateral, central canal), disc, inflammation
Strain/sprain,
Facet
Selected Disorders of the Lumbar Spine
Spinal pain is multifaceted, involving structural, biomechanical, biochemical, medical, and psychosocial influences that result in dilemmas of such complexity that treatment is often _______ or __________”
difficult
ineffective
Selected Disorders of the Lumbar Spine
Non-Spinal/Visceral Disease (___%)
• Aortic aneurysm
• Pelvic organs
– Prostatitis, pelvic inflammatory disease, endometriosis
• Renal organs
– Nephrolithiasis (kidney stones),pyelonephritis
(infection of the kidney and the ureters)
• Gastrointestinal system
– Pancreatitis, cholecystitis
2
Selected Disorders of the Lumbar Spine
Anatomy of the IVD
Centralportion:
The _____ _______which is composed of cells from the primitive notochord
• Outerportion:
The _____ ______composed of concentric layers of intertwined annular bands - resist forces placed on the lumbar spine
• Subdivided into:
Inner fibers, connected to the cartilaginous endplate
Outer Sharpy fibers, attached to the VB
nucleus pulposus
annulus fibrosis
Selected Disorders of the Lumbar Spine
ALL and PLL further strengthen the disc space
• ____ resists forces applied in extension
stronger ligament than the PLL
• The _____ resist flexion forces
Strongly attaches to the annulus fibrosis
Frequently is torn in cases of free fragment disc herniation
ALL
PLL
Selected Disorders of the Lumbar Spine
There is a distinction between an ______ disc and a degenerated disc
Although unfortunately, often considered synonymously
Difficult to differentiate changes that occur solely due to aging from those that might be considered pathological
Degeneration = _________
aging
Disease
Selected Disorders of the Lumbar Spine
The Aging Disc
ALL discs undergo age related changes
Age related changes occur in ALL collagenous tissue starting at ______
• Can be accelerated by ______
birth
trauma
Selected Disorders of the Lumbar Spine
Normal Disc Aging
• 1st changes occurs in the nucleus
Changes from soft gel into an mix of fibrous lumps with softer materials adjacent to endplates
Produce fewer proteoglycans therefore,
Water content _________
Accelerated by oxidative stress from ________ compromise
Tissue more brittle, prone to injury
• ________=physically stiffer
decreases
nutritional
Dehydrated
Selected Disorders of the Lumbar Spine
The strength of the lumbar disc is related to the fluid and proteoglycan content of the disc (Proteoglycan is a ___________)
hydrophilic
Selected Disorders of the Lumbar Spine
Disc Properties
_______ = Gradual deformation of the disc when under a constant load. Loading expresses ___% of water from disc during the day – most of water loss is from ________
• Non-degenerated disc:creep is very SLOW
• Injured disc:Creep/deformation can be RAPID–more vulnerable to prolapse – less able to recover
Creep
20
nucleus
Selected Disorders of the Lumbar Spine
Disc Degeneration
Very common in humans but, NOT an inevitable consequence of ______
Aging, apoptosis, abnormalities in collagen, vascular changes, loads placed on the disc, and abnormal proteoglycans, loss of disc nutrition
• May lead to loss of height of motion segment with concomitant changes in biomechanics of segment.
Disc space __________ is NOT normal = Degeneration
aging
narrowing
Selected Disorders of the Lumbar Spine
—Etiology: Disc Degeneration—
One of the primary causes of disc degeneration is thought to be failure of the _______ supply to the disc cells
• Can be affected by several factors that affect the blood supply to the vertebral body such as:
_____________appear to lead to a significant increase in disc degeneration
Long-term _______or lack of it appears to have an effect on movement of nutrients into the disc, and thus on their concentration in the tissue
nutrient
Atherosclerosis
exercise
Selected Disorders of the Lumbar Spine
Disc Degeneration
3 phases of progressive degenerative
changes in the annulus nuclear complex:
- ___________:= Circumferential and radial tears
- __________:= Internal disruption and disc resorption
- _________:= Osteophytes and traction spurs. Can lead to stenosis
Dysfunction
Instability
Restabilization
Selected DISORDERS of the Lumbar Spine
Pathomechanical Disc Degeneration
1–• _________ tears = From shear stresses from loading in bending and torsion
2–• ___ _____ = Circumferential avulsions of the peripheral annulus with sclerosis and osteophytosis of the adjacent bone
3–• Internal disc disruption =Inward buckling
4–• Radial fissures = Starting from the inner annulus sometimes progressing to the outer margins of disc so,
5–• NP material can then _________ resulting in disc prolapse = Protrusion, extrusion or sequestration
Circumferential
Rim lesions
escape
Selected Disorders of the Lumbar Spine
Disc degeneration alters disc height and the mechanics of the rest of the spinal column.
Possibly adversely affecting behavior of other spinal structures such as _____ and ligaments
• Associated with _______ and disc herniation or prolapse
Long term:
• Can lead to _____ _______, a major cause of pain and disability in the elderly
• Apophyseal joints adjacent to discs subject to abnormal loads and eventually develop osteoarthritic changes
muscles
sciatica
spinal stenosis
Selected Disorders of the Lumbar Spine
2 phases of IVD prolapse/herniation:
- ________ __________= Displaced nuclear material causing the outer annulus to bulge
- ________ _________= Nuclear material escapes from the disc.
***________ most often occurs on the posterior or posterolateral aspect of the disc partially due to arrangement of the annular fiber bundles appear. Directs the herniation toward the exiting and traversing nerve roots.
Annular Protrusion
Nuclear Extrusion
Herniation
Selected Disorders of the Lumbar Spine
Disc Herniation
1—__________ Disc– Nucleus protrudes through inner but NOT the outer layer of the annulus
(outer annular fibers intact)
2---\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Disc – Nuclear material penetrates completely through annulus (annular fiber ruptured) • Beneath the PLL • Penetrate the PLL or • Sequestered
Contained
Non-Contained
Selected Disorders of the Lumbar Spine
—Lumbar Disc Herniation / Prolapse—
1—Bulge:
- Mild displacement of the annular fibers probably due to a slight nuclear displacement
- Involves at least ___% of the circumference of the disc, but may involve up to 100%-
The ____ is intact. Bulge may be caused by disc degeneration, response to loading or angular motion, or even a normal variant.
50
PLL
Selected Disorders of the Lumbar Spine
—Lumbar Disc Herniation / Prolapse—
2–Protrusion:
– A focal outcropping of the annulus
– The fibers of the annulus are thinned with some tearing
– The _______ moves through the ‘tears’ usually in a posterior direction
– PLL is intact
nucleus
Selected Disorders of the Lumbar Spine
—Lumbar Disc Herniation / Prolapse—
3—___________:– Rupture of the annular fibers so that the nuclear material emerges through the annulus
– NP remains confined by the PLL
Extrusion
Selected Disorders of the Lumbar Spine
Clinical Consideration
Patients with severe back pain and sciatica are almost 3 times as likely to have a disc _______
On MRI examination of the lumbar spine, many people without back pain have ____ _____ or _________ but NOT extrusions
extrusion
disk bulges
protrusions
Selected Disorders of the Lumbar Spine
—Lumbar Disc Herniation / Prolapse—
4—______________:
– PLL is disrupted and the nucleus protrudes into the epidural space
– Displaced disc tissue is expelled from disc and is no longer attached to it.
***The _____ and ______ of disc herniation DOES NOT correlate with the degree of patient pain, disability, or suffering
Sequestration
size
severity
Selected Disorders of the Lumbar Spine
Disc Lesion – Immune Response?
RECALL: NP has no blood supply – segregated from immune system
Herniated disc material causes an _______ reaction due to the release of irritating substances and/or an autoimmune inflammatory reaction
inflammatory
***Immune inflammatory response causes further degradation
• Result:herniation & irritation or compression of nerve root.
*****It had been suggested by recent studies that the herniation does NOT regress back into the annulus, but actually shrinks from resorption, desiccation, and phagocytosis!!
Selected Disorders of the Lumbar Spine
_____% of lesions are to L4-L5 or L5-S1
Classic Presentation and Symptoms
– Sudden onset of back pain with sharp pain into the leg past the knee, to the foot
– Usually follows twisting or bending injury
– Often a past Hx of several bouts of LBP that resolved
– Pain is made worse with coughing, bearing down, sneezing
• Signs
– Pain with palpation, splinting, edema, spasm
98
Know
Selected Disorders of the Lumbar Spine
L5-S1 Disc
• \_\_\_\_% probable if 3 S1 signs are present: 1. Pain projection into the S1 area • sciatic 2. Pathologic achilles DTR 3. Sensory deficit in S1 dermatome
86
Selected Disorders of the Lumbar Spine
L4-L5 Disc • \_\_\_\_\_% probable if 3 L5 signs are present: 1. Ext. Hallicus weakness 2. Pain projection into the L5 area • posterolateral thigh/calf 3. Sensory deficit of L5 dermatome
87%
Selected Disorders of the Lumbar Spine
Characteristics of Disc Injuries
1--Bulge – Pain increases with flexion – Flexion is limited – No radicular pain – Neuro exam is negative – X-rays are negative – Probably \_\_\_\_\_\_\_\_\_
asymptomatic
Selected Disorders of the Lumbar Spine
Characteristics of Disc Injuries
2--Protrusion – Pain \_\_\_\_\_\_\_\_\_ with flexion – All ROM limited to some degree – Somatic and/or radicular pain – Antalgia – Neuro exam may be normal or be deficit – X-ray: decreased disc angle or decreased lordosis or decreased lumbosacral angle
increased
Selected Disorders of the Lumbar Spine
Characteristics of Disc Injuries
3---Extrusion – Pain increases with flexion – Radicular and somatic \_\_\_\_\_\_\_\_\_ pain – Antalgia – (+) Dural Tension Signs – Hard Neurological Signs (abnormal) – MRI evident – X-ray same as protrusion
referred
Selected Disorders of the Lumbar Spine
Characteristics of Disc Injuries
4—Sequestration
– Back pain history that suddenly Changes to predominantly leg pain
– Early dural tension signs that may have disappeared
Unrelenting paresthesia/pain
– MRI
– Posterior migration of the free fragments:
______ __________ syndrome
(rare/immediate referral)
Cauda Equina
Selected Disorders of the Lumbar Spine
Lower Vs. Upper Lumbar Nerve Root Pathology
______ ________: : (L4), L5, S1, S2, S3
______ _________: L2, L3, L4
Sciatic Nerve
Femoral Nerve
Selected Disorders of the Lumbar Spine
Imaging and Special Testing
1–Do NOT reveal herniation; but do help exclude other conditions
(eg. fracture, cancer, infection)
2–NOTE: consider whether disc herniation
is ______ OR ________ to nerve root
medial or lateral
Selected Disorders of the Lumbar Spine
Epidural STEROID Injections
- Used in attempt to relieve back and lower limb pain associated with disc conditions with or without nerve root involvement
- Typically used when patient has primary leg pain or pain that is too _______ for less invasive management
- Early patient satisfaction reported – diminishes over time
- Complications exist
- Limited evidence about how well injections actually work and limited agreement on when they should be used
severe
***In the absence of: loss of bowel or bladder control and of progressive neurological deficit most patients are suitable for 2-3 month trail of conservative management before proceeding with surgery
Selected Disorders of the Lumbar Spine
Suspicion of cauda equina syndrome or __________ neurological deficits warrant surgical consultation to avoid progressive or irreversible neurological deficits
progressive
Select Disorders of the Lumbar Spine PART 2
Lumbar Stenosis—Common and complex degenerative disorder in the aging population
WHAT ARE THE 2 TYPES??
Central Stenosis
Foraminal Stenosis
Select Disorders of the Lumbar Spine PART 2
Foraminal Stenosis
IVF Stenosis = Reduction in size of the space at the IVF due to: – \_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ – \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ – Tumor – Osteophytes
Disc Herniation
Spondylolisthesis
***Spondylolisthesis is a condition in which a bone (vertebra) in the spine slips out of the proper position onto the bone below it.
Select Disorders of the Lumbar Spine PART 2
Central Stenosis
Cause:= Bony or soft tissue encroachment often at ______ ________.
multiple levels
Select Disorders of the Lumbar Spine PART 2
Central Stenosis CAUSES X 2
1—____________— Trefoil shape of canal or short pedicles
2—-_________ (most common)—– IVD prominence posteriorly, bony outgrowths, degenerative spondylosisthesis or hypertrophied &/or calcified lig. flavum, HYPERtrophied articular facets, tumor, postoperative (consequence of decompression surgeries eg. laminectomies)
*** Neurologic deficits may cross dermatomal and
other nerve root boundaries
Congenital
Acquired
Select Disorders of the Lumbar Spine PART 2
Central Stenosis: Classic Presentation and Symptoms
- Over ___ YOA with LBP and unilateral or bilateral (MC) leg pain
- Leg complaints usually come on after _______ and relieved by stooping over or by resting for 15-20 min
- Going up stairs and bicycling are NOT as provocative
- Flexion theoretically opens up the canal and IVF taking pressure off neural structures
50
walking
Select Disorders of the Lumbar Spine PART 2
___________________= A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.
CLAUDICATION
Select Disorders of the Lumbar Spine PART 2
____________________ = is a collection of symptoms resulting from LUMBAR spinal stenosis, or the lower back.
1–Positional – relief with forward bending
2–Walking: pain pattern not fixed
3–Pain: Proximal to distal (thigh vs. calf)
4–Cycling is better vs. walking
5–Peripheral pulses: normal
6– narrowing of the spinal canal in the lower back.
7–Dermatomal/Myotomal
8–Radiographs for stenosis may reveal canal widths
of less than 15mm (10 -12 mm =relative stenosis,
Neurogenic Intermittent Claudication
Select Disorders of the Lumbar Spine PART 2
___________________ = stops quickly when you rest, even in the standing position. By comparison, pain due to spinal stenosis is related to body position and may continue for as long as you remain standing. Bending forward or sitting down usually relieves the pain, but even then the pain of spinal stenosis does not stop as quickly as pain resulting from insufficient blood flow. Caused by atherosclerosis of the iliofemoral vessels
– Peripheral vascular disease (PVD)
Vascular Claudication
Select Disorders of the Lumbar Spine PART 2
Vascular Claudication = commonly associated with:
• Impotence in men
• Dystrophic skin changes (nail atrophy, alopecia)
• Foot pallor or cyanosis
• Decreased or ________ peripheral pulses
• Relief with rest
• NOT effected by changes in ___________
• Pain in the gastrocnemius
absent
posture
Select Disorders of the Lumbar Spine PART 2
Management of L/S Stenosis
1—Surgical consult indicated if patient has intolerable symptoms (leg and back pain) and shows ______ neurological deficits
2— Surgery is rarely performed otherwise – unless, pt is
NOT responding to an aggressive and comprehensive
trial of conservative management first
severe
Select Disorders of the Lumbar Spine PART 2
Facet syndrome— is a syndrome in which the zygapophysial joints (synovial diarthroses, from C2 to S1) cause back pain. 55% of facet syndrome cases occur in ________ vertebrae, and 31% in _______. Facet syndrome can progress to spinal osteoarthritis, which is known as spondylosis.
cervical
lumbar.
Select Disorders of the Lumbar Spine PART 2
Lumbar Facet Syndrome
- A ______ AND ________ injury of the richly innervated articulating facets of the lumbar spine
- Characterized by LOCAL and/or ______ pain arising from the zygapophseal joints
rotational and compression
referred
Select Disorders of the Lumbar Spine PART 2
Lumbar Facet Syndrome = _______ is the most common location.
– Transitional
– Joints more coronal
– Site of most weight bearing
– Center of gravity passes through the vertebrae
***Pain decreases with flexion and increases
with extension!!
L5/S1
Select Disorders of the Lumbar Spine PART 2
Lumbar Facet Syndrome……………Possible Causes:
– Richly innervated facet and it’s capsule may be source of pain
– Entrapped meniscoid (synovial folds) may become entrapped or pinched and cause pain
– Inflamed joint surface
– Degeneration in older adults
– Faulty posture may be contributing factor
– Trauma, microtrauma
KNOW
Select Disorders of the Lumbar Spine PART 2
Tropism = Joint tropism = Joint asymmetry: a turn in the orientation of the facet.
Congenital anomaly
• Occurs in ___% to ___% of the population
• L4/L5 and L5/S1 facets are the M/C location
– Although this must alter the biomechanics at that segmental level, it has NOT been demonstrated to cause
an increase in LBP
– May cause you to alter your CMT
21 - 37%
Select Disorders of the Lumbar Spine PART 2
Facet Syndrome Management– Particularly responsive to ____! It is proposed that manipulation may free the
entrapped meniscoid OR causes reflex mediated
changes that diminish spasm and pain.
CMT
Select Disorders of the Lumbar Spine PART 2
Facet Syndrome:
- Lacks neurologic findings and nerve root tension signs
- Lacks pain below the ____
- Facet syndrome has dull achy pain that stops before the knee with Kemp’s and SLR
- Radiographs of facet syndrome may reveal signs of facet imbrication
knee
Select Disorders of the Lumbar Spine PART 2
Lumbar Sprain/Strain
• \_\_\_\_\_\_\_\_: an injury to a ligament; stretch or tear • \_\_\_\_\_\_\_\_\_: an injury to a muscle – Muscle belly – Tendon – Musculotendinous junction (M/C site)
Sprain
Strain
Select Disorders of the Lumbar Spine PART 2
Lumbar Sprain/Strain———-Grade I (mild)
___ _______ of the muscle or ligament with little or no outright tearing of the fibers.
• There is NO hemorrhage, minimal swelling or edema and palpable tenderness.
• Slight laxity is possible with a sprain, but unlikely to be palpable by the doctor
Mild stretching
Select Disorders of the Lumbar Spine PART 2
Lumbar Sprain/Strain—–Grade II (moderate)
- There is tearing of the fibers of the muscle or ligaments. This tearing is less than 100% of the fibers.
- Clinically, there is an appreciable inflammatory response (swelling, tenderness, heat), hemorrhage, and usually protective muscle spasm or splinting.
- Produces a _____ of the joint
laxity
Select Disorders of the Lumbar Spine PART 2
Lumbar Sprain/Strain—Grade III (severe)
1—–100% of the ligament or muscle fibers are torn
2—-Clinically: severe pain, diffuse hemorrhage gross swelling, complete loss of muscle function and severe spasm of the surrounding musculature in the acute phase.
• Grade III sprains create laxity and possible functional instability
– _____ ______ must be present for this less likely sprain
Major trauma
Select Disorders of the Lumbar Spine PART 2
Lumbar Sprain/Strain——Healing Time
- Minor: Resolves in ~1-2 week
- Moderate: ~___-____ weeks
- Severe: ~5-10 weeks = Severe Sp/St may require surgery and postoperative rehabilitation
3-4
Select Disorders of the Lumbar Spine PART 2
Spondylolisthesis–Slippage of one vertebra on another
Classifications X 5
– Type I: ________ = Congenital abnormality in sacrum or neural arch
– Type II:______ = Lytic or fatigue fracture of the pars interarticularis
• Elongated but intact pars
• Acute fracture of the pars
Dysplastic
Isthmic
*** Spondylolysis only refers to the separation of the pars interarticularis (a small bony arch in the back of the spine between the facet joints), whereas spondylolisthesis refers to anterior slippage of one vertebra over another (in the front of the spine).
**Can have a spondylolysis without spondylolisthesis
Select Disorders of the Lumbar Spine PART 2
Spondylolisthesis Classifications X 5
– Type III:___________ = Secondary to long standing arthrosis
– Type IV: ________ = Fractures other than the neural arch
– Type V: Iatrogenic = Above or below a spinal fusion
Degenerative
Traumatic
Select Disorders of the Lumbar Spine PART 2
Spondylolisthesis
• 2 most common types:
1–– Isthmic: Patient with stress fracture of the pars
interarticularis (spondylolysis) or an elongated pars
90% at ____
2–– Degenerative: Older patient with degenerative
slippage, usually at _____
L5
L4
Select Disorders of the Lumbar Spine PART 2
Spondylolisthesis—–Isthmic Spondylolisthesis
- Most Common type
- ____ is weakest part of neural arch
- Repetitive flexion and extension motion creating fracture
- Increased incidence in athletes (eg. gymnastics, weight lifting, and football)
- ____% at L5
- Majority of slippage occurs in children under age of ___
- Lysthesis—- most likely to occur in patients with weakness in iliolumbar ligament and TPs not well developed
Pars
90
10
Select Disorders of the Lumbar Spine PART 2
Degenerative Spondylolisthesis—• A degenerative disc leads to instability and the_______ facet subluxates.
• The axis of rotation shifts from the vertebral
body/disc to the ______
**• 3 F’s: Female, Forty, Fourth Lumbar (L4)
inferior
facets
Select Disorders of the Lumbar Spine PART 2
Spondylolisthesis —- Grading
Divide the sacrum or vertebra below into 1/4ths
• Each slip of the 1/4 is considered a grade:
– Grade 1 & 2: stable
– Grade 3 & 4: require surgical consultation
Meyerding Grading System
Grade I: 1-24% Grade II: 25-49% Grade III: 50-74% Grade IV: 75%-99% slip. Grade V: Complete slip (100%), known as spondyloptosis
Disorders of the SI Joint and Pelvis
Sacroiliac Joint Syndromes
- A pain syndrome presenting with pain over 1 sacroiliac joint, which may be accompanied by _____ _______ to the buttock, groin, and leg
- Caused by dysfunction or lesion to the joint
referred pain
Disorders of the SI Joint and Pelvis
Causes x 3
1—___% of SIJ syndrome cases from a one time traumatic event
2— ___% due to repetitive injury
3— 35% had idiopathic/spontaneous onset
44
20
Disorders of the SI Joint and Pelvis
SI Joint Syndrome
• SI joints can cause LBP
• No standard pain referral pattern (Schwarzer)
• Local aching, burning or dull pain (pain can be sharp at times)
• Point tenderness or pain on motion palpation
• NO radiation of pain above L__
• Can refer pain to buttocks, posterior or lateral thigh, groin or anterior pelvis
L5
Disorders of the SI Joint and Pelvis
Examples of SIJ Orthopedic Tests X 7
Gaenslen’s Test Lewin-Gaenlen’s Test Yeoman’s Test Nachlas Test Pelvic Rock Test Hibb’s Test Sign of the Buttocks
KNOW
Disorders of the SI Joint and Pelvis
SI Joint Sprain Management——-Acute =
• SIJ belt
• Cautious CMT (avoid increased stretch to ligaments)
• Ice
• Core stabilization
KNOW
Disorders of the SI Joint and Pelvis
Sacroiliitis—-• Inflammation to the _____
– Attempt to determine cause
• Infection, arthritide, etc…
– Treatment directed at cause
SIJ
Disorders of the SI Joint and Pelvis-Piriformis Syndrome
• Buttock pain with or without ______ ________
pain secondary to injury or contracture of
the Piriformis muscle (spasm or strain)
• May mimic ____________
• Possible PAIN patterns
– Groin
– Posterior thigh into calf and ankle or foot
– Exacerbated by activity, bowel mvnt, prolonged sitting, or rise from seated position
sciatic nerve
radiculopathy
Disorders of the SI Joint and Pelvis-Piriformis Syndrome
Anatomical Considerations:
O: Anterior surface of the lateral sacrum S2-S4 and sacrotuberous ligament
I: Greater trochanter (superior) – Gluteal nerves, sciatic nerve and gluteal vessels all pass ______ the greater sciatic notch with the piriformis muscle
Sciatic Nerve– Passes ______ piriformis or through muscle or divides through and below/above
through
below
Disorders of the SI Joint and Pelvis-Piriformis Syndrome
Causes: – SIJ dysfunction – Trauma – Prolonged \_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ or – Activities requiring internal rotation of leg with flexion
sitting postures
Disorders of the SI Joint and Pelvis-Piriformis Syndrome
Piriformis Syndrome Management
- ____ or myofascial release techniques are often helpful
- When acute, ___ modalities may help
- CMT for SI joint restriction
- Home stretching program
PIR
PT
Disorders of the SI Joint and Pelvis
Coccydynia / Coccygodynia = Irritation of the coccyx or sacrococcygeal junction with possible displacement of the __________
1—Etiology:
• Trauma: direct contusion or flexion sprain/anterior displacement or the rare extension injury from childbirth
coccyx
Disorders of the SI Joint and Pelvis
Coccydynia / Coccygodynia
Symptoms:- Local pain and soreness; pain on sitting
Signs:- Contusion/inflammation over coccyx, palpable tenderness
Treatment:
- CMT: internal vs. external
- Cryotherapy
- Anti-inflammatory therapy
- Donut pillow
know
Disorders of the SI Joint and Pelvis–Osteitis Pubis
aka: __________ ___________
Gracilis Syndrome
Disorders of the SI Joint and Pelvis–Osteitis Pubis
• Inflammation of the pubic symphysis
• Prevalence: athletes
• Etiology: acute trauma, genitourinary infection, pelvic surgery, pregnancy, arthritic conditions
• S/S: Ache or tenderness on palpation;
Pain with passive _______ or resisted ______
Management:
– Rest and time
– Modalities including _____or ____ may provide symptomatic relief
abduction
adduction
heat or ice
Arthritides and Red Flags —-Arthritis Classification
***Arthritis = conditions involving damage to the joints
EROSIVE x 3
a. \_\_\_\_\_\_\_\_\_\_\_ • Gout • Pseudogout • Hydroxyapatite deposit disease b. \_\_\_\_\_\_\_\_\_\_\_ Rheumatoid: • RA • JCA/Still’s Disease Seronegative: • Reiter’s Syndrome/Reactive Arthritis • Psoriatic • AS Connective Tissue: • Lupus Erythematosus • Scleroderma c. \_\_\_\_\_\_\_\_\_\_(septic)
Metabolic
Inflammatory
Infectious
Arthritides and Red Flags —-Arthritis Classification
***Arthritis = conditions involving damage to the joints
SCLEROTIC x 1 d. \_\_\_\_\_\_\_\_\_\_\_\_\_\_ • Primary (idiopathic) • Secondary (known factor/trauma) • Spinal • Erosive • DISH • Neuropathic Arthropathy
Osteoarthritis
***Theory: Barometric pressure falls before the arrival of wet, damp weather
• Bones, muscles, ligaments and tendons have to adjust by expanding
• When expansion occurs, sensitized nerves send out pain signals
Osteoarthritis / Degenerative Joint Disease
Pathogenesis: Abnormal biomechanics – cartilaginous erosion – sclerosis of subchondral bone – subchondral cysts – marginal osteophytes – variable synovial inflammation – Also, \_\_\_\_\_\_\_\_\_\_\_\_ distribution
asymmetric
*** Often will c/o morning stiffness that resolves after
~ 30 min, also stiffness following prolonged rest
Osteoarthritis / Degenerative Joint Disease
________–Degenerative changes to facet, discs and vertebral bodies
• Degenerative Disk Disease (DDD): Refers to back PN symptoms attributable to ___ degeneration
Spondylosis
IVD
Osteoarthritis / Degenerative Joint Disease
Seronegative Arthritides
Refers to a diverse group of musculoskeletal
syndromes linked by common clinical features
and common immunopathologic mechanisms
• Characterized by the ________ of Rheumatoid Factor (RF)
ex– Reiter’s/Reactive Arthritis
ex– Ankylosing Spondylitis
ex– Psoriatic Arthritis
absence
Osteoarthritis / Degenerative Joint Disease
Seronegative Arthritides
• Spontaneous exacerbations and _______
Wide range of non-articular features examples:
• inflammatory eye disease
• inflammatory bowel disease
• urethritis
Human Leukocyte Antigen B27–(+) HLA-B27
• Strongly associated with Seronegative Arthritides
• Ordered to help strengthen or confirm a suspected diagnosis.
remissions
Arthritides and Red Flags —-Ankylosing Spondylitis– is an inflammatory disease that can cause some of the vertebrae in your spine to fuse together. This fusing makes the spine less flexible and can result in a hunched-forward posture. If ribs are affected, it may be difficult to breathe deeply.
know
Rheumatoid Factor (RF) : • An autoantibody • Identified through blood test • Part of the usual disease criteria of Rheumatoid Arthritis
Arthritides and Red Flags —–Ankylosing Spondylitis
Classic Presentation:
• Young male ( 3 months)
• Relief with mild to moderate activity
• Fatigue is common
know
*** Progressive spinal stiffening and fusion
***Unpredictable course remission/relapse
Arthritides and Red Flags ——Ankylosing Spondylitis
With Progression: – Gradual stiffening – Loss of L/S \_\_\_\_\_\_\_\_\_ – Increase in T/S \_\_\_\_\_\_\_\_\_\_\_ – Cardiac and lung involvement possible – 50% have peripheral joint involvement: » Hips » Shoulders » Knees
lordosis
kyphosis
Arthritides and Red Flags ——Ankylosing Spondylitis
Radiographic Changes:
• Early changes seen in SI: _______
– ________, symmetric pseudo-widening, erosions and
sclerosis, eventual fusion
• Spine: marginal sclerosis, erosion of sup. and inf. margin
of ________ _________
– Squaring appearance
• Calcified spinal ligaments and annular fibrosis create
“_____ _______” sign & eventual fusion: Bamboo spine
• Radiographic changes may not be visible for 4-6
years AFTER onset
Saroiliitis
Bilateral
vertebral bodies
trolley track
Reiter’s Syndrome / Reactive Arthritis*
Classic Presentation:
• Young male
• Associated w/ venereal or dysenteric infection
• c/o LBP began after onset of urethritis, conjunctivitis, and ____ ________
Evaluation:
• Mechanical testing of ___ will usually increase PAIN!
—_______involvement, jt. space narrowing, erosive changes may be seen
skin lesions
SI
Unilateral
Reactive Arthritis
Diagnostic Tetrad:
- Polyarthritis affecting the knees and ankles __________ but SI is most common symptomatic joint (asymmetric sacroilitis)
- Urethritis
- Conjunctivitis (resolves w/n 1-2 d)
- Lesion (tongue, palate, penis or foot)
asymmetrically
Reactive Arthritis
Management:
• Primarily symptom relief/ anti-inflammatory
•______: used to treat underlying infection but does NOT change course of the disease
• Caution with CMT:
– Inflammatory; CMT to SI may aggravate
Antibiotics
Psoriatic Arthritis
• Psoriasis usually precedes _________
– Occasionally by as many as 5 - 20 y
– Can develops in the absence of detectable psoriasis
– __-___% of patients, arthritis appears BEFORE the psoriasis
• Affects 5-8% of patients with psoriasis
• MC in caucasians, 35-55 yoa (but can occur at any age)
• Men and women affected EQUALLY
• Labs: elevated ESR, (+) or (-) HLA-B27, (-) RF
– NOT diagnostic
arthritis
15-20
Psoriatic Arthritis–Spondylitis (with or without sacroiliitis)
(Spondylitis)— is an inflammation of the vertebra. It is a form of spondylopathy. In many cases spondylitis involves one or more vertebral joints as well, which itself is called _______
– Occurs in approx 5% of patients with psoriatic
arthritis, male predominance
– Sacroiliitis: if present, tends to be _____
– May appear radiologically without classic symptoms of morning stiffness in the lower back
– Vertebrae affected _________
spondylarthritis.
asymmetric
asymmetrically
Psoriatic Arthritis Management:
- Treatment is directed at controlling the ________process
- _______ is an important part of the total treatment to limit the pain, maintain mobility
inflammatory
Exercise
Initial LBP Assessment
Classify into 1 of 3 working categories:
1. Potentially serious spinal condition: _____,______ spinal fracture, or a major neurologic compromise, such as cauda equina syndrome, suggested by a red flag
- ______: back-related lower limb symptoms suggesting
lumbosacral nerve root compromise - __________ back symptoms: occurring primarily in the back and suggesting neither nerve root compromise nor a serious underlying condition
OR:
__________ pathology: (abdominal, pelvic, etc.) that can present as low back symptoms
tumor, infection,
Sciatica
Nonspecific
Non-spinal
Abdominal Aortic Aneurysm (AAA)
• Relatively common, potentially life-threatening
condition
• Ruptured AAA is the ___th-leading cause of death in the United States
• Incidence of 2-4% in the adult population
• MC in ________ males b/w 65 - 75 yoa
• 5:1 – 7:1 male predominance
• More frequent in men smokers
• Often have Hx of HTN
• _____________ is the M/C cause
• Between L2 - L4 is the M/C location
* Most are asymptomatic until they rupture/bleed
13
Caucasian
Atherosclerosis
Abdominal Aortic Aneurysm
Classic Presentation:
• Mild to severe abdominal or low back pain
– ______ _____ will have throbbing or aching
– Epigastric, flank, or low back pain, weakness
• May be associated complaint of leg pain with
exertion (Claudication)
Mild bleeding
Abdominal Aneurysm
• In asymptomatic patient:
- MC finding is _______ abdominal mass
- Auscultation may reveal a bruit
• Dissecting: – Ripping chest, upper back, and __________ pain that is very severe
• Ruptures:
– Exsanguinations, pulsating masses, pain may be worse with lying down (14%)
pulsatile
abdominal
Abdominal Aneurysm
Radiographs:
• Diameter exceeding 3.8 cm at the most
distant calcified borders is diagnostic
• __-__ cm requires a consultation and ultrasound
• >6 cm usually requires surgery
• __-____ % survival rate for ruptures
• Smaller AAA’s, when surgery may not yet
be indicated, will be monitored over time
4–6
10 - 20
Cauda Equina
• Cauda equina is formed by nerve roots caudal to the level of spinal cord termination
– Average adult: cord terminates b/w 1st and ____ lumbar vertebrae
• Distal to this end of the spinal cord is a
collection of nerve roots,
(which have horsetail-like appearance) called
the cauda equina (Latin for horse’s tail)
Cauda Equina Syndrome is characterized by:
– Low back pain
– Unilateral or usually bilateral _________
– Saddle sensory disturbances
– _________ and _________ dysfunction
– Variable lower extremity motor and sensory loss
* Rare but serious: may be irreversible and
may be a surgical emergency
2nd
sciatica
Bladder and bowel
Cauda Equina Syndrome
• The most sensitive (90%) and specific (95%) indicator is _____ ________ that eventually leads to overflow incontinence
–Therefore, patients without ______ ______
are UNLIKELY to have cauda equina syndrome
– Other conditions cause urinary retention
• Saddle anesthesia
• Motor deficits
urinary retention
urinary retention
Metastatic Disease
• The spine is the 3rd MC site for cancer cells to metastasize, following the lung and the liver
– Approximately ___-____% of patients with systemic cancer will have spinal metastasis
• Spinal metastasis may be the initial
presentation in ___% of patients with systemic cancer
• Skeletal metastases is MC in adults > 50 yoa
60-70
10
Spinal Metastatic Disease • Primary sources for spinal metastatic disease include the following: – \_\_\_\_\_\_\_ - 31% – \_\_\_\_\_ - 24% – GI tract - 9% – Prostate - 8% – Lymphoma - 6% – Melanoma - 4% – Unknown - 2% – Kidney - 1% – Others including multiple myeloma - 13%
Lung
Breast
Metastatic Carcinoma
Classic Presentation:
• Pt c/o insidious onset of pain, persistent
• Worse at _____ and NOT mechanically affected
• Often a Hx of _____ ______ and fatigue
NOTE:
– Patient may be asymptomatic until late in course
of disease
– May become symptomatic after trauma due
to pathological weakness of the vertebrae
night
weight loss
Metastatic Carcinoma
Radiographs:
• Posterior vertebral collapse is suggestive
• May be ______ (one eyed pedicle, increased serum
calcium), or _________ (ivory white vertebra,
increased alk phos)
What to do:
• Immediate referral to oncologist (or GP)
osteolytic
osteoblastic
Multiple Myeloma
• Most common PRIMARY malignant tumor of
bone
• > 50 yoa
• ____% of patients have bone pain at presentation
• The lumbar spine is one of the MC sites of
pain
• C/O persistent back pain unrelieved by rest
– PN is worse at night
– may have associated rib pain
70
Multiple Myeloma
• Osteopenia (generalized)
• Hypercalcemia
• Anemia
• Renal disease
• Infection (often pneumonia) due to decreased
immunity
• _____ ________ proteins found on 24hr urine test
• Monoclonal (M) spiking on electrophoresis, increased IgG
Bence Jones
Multiple Myeloma
Radiographs:
• Will show ______, then “_____ _______”
lytic lesions involving the spine, ribs, and skull
– does NOT usually affect the posterior elements
Definitive Diagnosis:
• Bone marrow aspirate showing more then
20% plasma cells
osteopenia
punched out
Infectious Spondylitis
Classic Presentation:
No typical patient but some red flags include:
• Presents with a complaint of deep back pain
• History of a recent respiratory tract, urinary
tract, or skin ________ (or IV drug use or DM)
• Patient is antalgic
• Complains of ______ and difficulty sleeping due to pain
NOTE: pt is NOT always febrile
infection
fever
Infectious Spondylitis
- Deep pain made WORSE by percussion of SP
- Increased ESR, fever and WBC is variable
Bone: __________
Disc: Discitis
Osteomyelitis
Infectious Spondylitis
Two Types:
1. ________: staphylococcus (90%), streptococcus, & gram-negative organisms
• Involve more than one vertebra, may NOT involve the disc,
posterior elements rarely affected
2. ___________: tuberculosis (Pott’s disease),
brucella, or fungi
• Centers around L1, posterior elements may be involved
• 3-4 wk history to see on films
What to do? Refer for ortho consult (or to GP)
• Infection is spread via hematogenous routes
Pyogenic
Nonpyogenic
Mechanical vs. Non-mechanical LBP
In general:
Mechanical = Relief of symptoms–1 or more PN free–Can usually get some sleep–Able to mechanically reproduce the cc
Non-mechanical–No relief of symptoms–No pain free positions—May be worse at night—Unable to mechanically reproduce the cc
KNOW THE DIFFERENCE
Outcome Assessment Questionnaires
May prove to be even more reliable and
reproducible than clinical exam findings
2 most popular, valid and reliable for LBP:
- Oswertry Disability Index for LBP—Use for ________disability & comparison for future improvement
- Roland-Morris LBP Questionnaire
_______ ________=>greater disability
baseline
Higher score
