Module 4 Lumbar Spine Assessment Flashcards
Back pain in children is common, becoming more common as they get older.
What is most common cause and when should we be concerned.
Spondylolysis with or without spondylolithesis was the most common diagnosis
Back pain lasting more than a few days or responding poorly to chiropractic management requires careful investigation.
List 6 differential diagnosis for paediatric back pain
-scheuermans disease
-Infection/ inflammatory (tuberculosis spondylodiscitis
-inflammatory arthritis
osteoid osteoma
osteoporosis blastoma
Aneurysmal bone cyst
osteoid sarcoma
Ewing sarcoma
Disc bulge and herniation
-In adolescents, disc herniation is more commonly traumatic than degenerative
-Usually sudden and occurs after a significant extension of the spine.
-might also be associated with excess loading, resulting in herniation or degeneration
-most of the time, single level only L4-L5 is affected
What do you see?
- A 12 yr old- elongated L5 pars interticularis (arrow) with grade III spondylolisthesis of L5 over S1
- 15 yr old boy. Spondylolysis of L5 (arrow) with grade 1 spondylolisthesis of L5 over S1
Traumatic Spondylolysis and Secondary spondylolisthesis
tell me a bit about it ‘
How about its natural history?
-usually cause by repetitive micro-trauma esp young athletic boys Typically with hyperextension sports eg soccer, dancing, gymnastics
-seldom history of sever trauma
-Most commonly affected area is the lower lumbar spine, mainly L5.
Most common age is 10-15 yeas
-CT is best
Development of spondylolisthesis never occurred with unilateral defects, and when present, progression of slippage was most pronounced during adolescent growth spurt and slowed each decade after.
-When bilateral pars defects are present, progression to spondylolisthesis occurs 70% of patients
Radiographic assessment of Spondylolisthesis
How do we grade them
What is the presentation?
Physical exam reveals:
-Grade1- translation up to 25%
-Grade 2- 26-50%
-Grade 3- 51-75%
Grade 4- 76-100
Grade 5>100% (spondyloptosis)
> 50% are considered unstable
Presentation:
-Aching low back pain made worse with hyperextension and relieved by rest
-radicular symptoms and postural spinal deformity are more common in high grade spondys
Physical exam reveals:
-hyperlordotic posture
-lumbosacral tenderness
-palpable step off
Pain on hyperextension
Hamstring contracture is common and when sever can produce gait disturbance characterised by crunching, a short stride length, and incomplete swing phase.
Ring Apophyseal Fracture
What is it?
How does it present
how do you confirm diagnosis
Fracture of the posterior vertebral end plate
-m.c seen in lumbar spine, mainly the inferior rim of L4
-Very commonly results in LBP and sometimes sciatica
-Frequently seen along with disc degeneration and disc herniation that usually does not protrude belying dissociated bone fragment
-almost all affected patients are involved in sports secondary to repetitive or acute trauma.
-best diagnostic modality is CT
Disc degeneration
Genetics play a role- what are the 3 types of genes that affect DGD
DD is clinically symptomatic process that frequently, but not exclusively, us linked premature or pathologic ageing.
Initial degenerative alterations even occurr in early infantile discs
Sometimes seen at end of puberty when there has been a rapid growth process which has led to a signifiant increase of diffusion distances within the disc.
Diagnosis is best made by MRI
pain isn’t always present
there are 3 groups pf genres that related to LDDS
-Genese related to the structure of IVD
-Genese related to production of the degradation enzymes or cytokines for the extracellular matrix
-Genes related to connective tissues, such as bone and other tissue
Scheueremann’s Disease
Why does it happen
What is it characterised by?
-Due to repetitive trauma where the nucleus polyposis migrates through the cartilaginous layer between the vertebral body and the ring apophysis resulting in its avulsion.
Characterised by
1. vertebral wedging
2. endplate irregularity
3. Narrowing of the disc space with or without disc herniation
4. Intravertebral disc herniation
These result in increased kyphosis of the spine.
Radiographs readily demonstrate the described findings
Spondylodiscitis - 2 types
2 types is
1. Nonspecific (nonpyogenic, traumatic)
2. Infectious (mainly bacterial)
In infectious a primary focus may e detected (eat, throat)
Spine infectious represents about 2-4$ of all osteomyelitis cases.
The diagnosis is often delayed and the mean age at diagnosis is 7.5 years.
There are 3 clinical forms according to ages.
- In patients less than 1 year of age there is a serious from with septicaemia
- The infantile form (1-4 years) is associated with stiff gait and limping
- After 4 years of age, spondylodiscitis is associated with back pain and has a benign course, more so in the younger.
Symptoms may include fever, malaise, weight loss, bone pain, irritability, and a refusal to walk.
What is this?
Spondylodiscitis
Bacterial spondylodiscitis in a 1.5-year-old child with fever and irritation
(A) Lateral spine radiograph shows narrowing of the L3-L4 disc space with lucencies at both endplates (circle).
(B) Sagittal T2W MR image. The involved vertebrae display slight increased signal.
A focus of significant increased signal is seen in the posterior aspect of the disc due to discitis (circle).
The rest of the disc is of abnormal low signal intensity when compared with other normal discs
A 15 year old girl presenting with sever diffuse back pain
Spondlodiscitis
The term “spondylodiscitis” means primary infection of the intervertebral disc by a pathogen, with secondary infection of neighboring vertebral bodies.
- Sagittal T2W MR image of the spine.
There is an abnormally high signal intensity of an upper lumbar vertebra (arrow), which is low on T1W images (not shown).
There is loss of height of the affected lumbar vertebral body.
The adjacent discs are preserved. - Tuberculous spondylitis was proven by biopsy.
What are the most common inflammatory arthritides
What is the best way to image these pathologies?
Seronegative spondyloarthropathies (SPA) are the most common inflammatory disorders that affect the thoracic and lumbar spine in the pediatric age group.
- These SPA include
1. Ankylosing spondylitis,
2. Psoriatic arthritis,
3. Reiter’s syndrome, and
4. Arthritis associated with inflammatory bowel disease. - The juvenile form of SPA occurs in patients who are less than 16 years of age and is characterized by the presence of sacroiliitis.
In all these SPA, disease of the spine (spondylitis) is a late gradual manifestation that follows sacroiliitis.
* Juvenile rheumatoid arthritis very rarely affects the spine or causes back pain.
* On imaging, findings of sacroiliitis may be delayed on radiographs.
* CT scan is a better modality to assess earlier changes.
* Bone marrow edema is readily seen by MRI, denoting very early inflammation
* In the spine, the findings are subtle with some erosions or sclerosis at the anterior vertebral corners.
* Facet joint involvement and vertebral squaring may occur.
NEOPLASTIC DISORDERS - sizzle these into your brain.
primary tumours of the thoracic and lumbar spine are very rare
clinical presentation of vertebral tumours is….
- Clinical presentation of vertebral tumors is back pain (86%) followed by neurological symptoms in 55% of patients.
The most common tumours are:
1. Osteoid osteoma
2. Osteoblastoma
3. Aneurysmal bone cyst(ABC)
4. Langerhans cell histiocytosis;
5. Ewing sarcoma
6. Leukemia
7. Lymphoma and metastases
What is the diagnosis
Give me some information on them
Osteoid osteoma (Benign)
Osteoid osteoma is mostly prevalent between 7 and 25 years of age (90% of the cases).
It is rare (3%) under the age of 5 years.29
Spinal osteoid osteoma occurs in 10 to 18% of all
cases.
It involves mainly the posterior elements. Vertebral bodies’ lesions are unusual
Spinal involvement by osteoid osteoma presents usually with painful scoliosis, mainly at night, which can be relieved by salicylates intake.
referred pain to the lower extremities may also occur.
CT is the method of choice for diagnosis
What is the diagnosis
Give me some information on them
Osteoid osteoma (Benign)
Osteoid osteoma is mostly prevalent between 7 and 25 years of age (90% of the cases).
It is rare (3%) under the age of 5 years.29
Spinal osteoid osteoma occurs in 10 to 18% of all
cases.
It involves mainly the posterior elements. Vertebral bodies’ lesions are unusual
Spinal involvement by osteoid osteoma presents usually with painful scoliosis, mainly at night, which can be relieved by salicylates (Aspirin/ Nsaids) intake.
referred pain to the lower extremities may also occur.
CT is the method of choice for diagnosis
What is the diagnosis?
Tell me some information about the DX
- Osteoblastoma is a benign bone-forming lesion that has similar histopathology to osteoid osteoma
- It is however equal or larger than 1.5 to 2 cm in size.
- Osteoblastoma may be aggressive.
- In occurs before 30 years of age in 90% of the cases and is most commonly seen between 10 and 15 years of age
- One-third of all osteoblastomas occur in the spine with nearly all of them involving the posterior elements
- In the spine, it causes painful scoliosis. However, the pain is less frequent than in osteoid osteoma
What is the diagnosis?
tell me some information about it
Aneurysmal bone cyst (benign)
Patients with ABC usually present before 20 years of age.
* The spine is involved in about 11% of cases, occurring more at the lumbar level.
* The posterior elements are always involved with infrequent extension to the vertebral bodies or ribs.
* Spinal lesions frequently present with neurological symptoms.
* Pain is invariably present and either is localized in the back or is secondary to involvement of a nerve root or the cord
What is the diagnosis- give me some information on it
- Osteosarcoma is the most common malignant bone tumor in children and young adults, occurring mainly between 10 and 30 years of age
- However, it involves the vertebral column in only 4% of the cases (33.3% at the thoracic level and 32.3% at the lumbar level).
- Most commonly, vertebral osteosarcoma involves the posterior elements (79%) with variable extent into the vertebral body.
The lesion is confined only to the body in 21% of the cases. Two-level involvement occurs in 17% of the cases.
- Osteosarcoma is a destructive lesion with variable degrees of mineralization leading to a mixture of permeative lytic pattern and sclerosis
What is the diagnosis?
Give me some info on it
Ewing sarcoma is the second most common malignant bone tumor in children following osteosarcoma.
* The tumor presents mainly at 5 to 25 years of age and is uncommon before the age of 5.3
* In the spine, the tumor typically involves the vertebral body.
* In addition to back pain, neurological signs may be seen due to intraspinal extension.
* Systemic symptoms may also occur, including fever and malaise.
* The radiographic and CT scan findings include destructive, permeative, and sclerotic or mixed tumor
Diagnosis?
Ewing sarcoma
Describe what you see in the image and what the diagnosis is
- Leukemia is usually encountered in childhood and adolescents with the acute forms representing more than one-third of pediatric malignancies
- Radiographs show generalized decrease in bone density (which can be also either geographic permeative or moth-eaten)
What is the diagnosis?
tell me some information about it and describe what you see on the image?
Lymphoblastic Leukaemia
A cancer of the lymphatic system.
The lymphatic system is the body’s disease-fighting network. It includes the lymph nodes, spleen, thymus gland and bone marrow. The main types of lymphoma are Hodgkin’s lymphoma and non-Hodgkin’s lymphoma.
Symptoms include enlarged lymph nodes, fatigue and weight loss.
Treatment may involve chemotherapy, medication, radiation therapy and rarely stem-cell transplant.
- Spinal involvement can be secondary to both Hodgkin’s disease and Non-Hodgkin’s lymphoma
- In children it is the third most common primary malignant bone tumor and is seen more in Non-Hodgkin’s lymphoma
- The symptoms include back pain and neurological symptoms, depending on the extension within the spinal canal.
- On imaging, radiographs and CT scan usually show destructive permeative lesions and rarely blastic lesions
A 6-year-old girl with known lymphoblastic leukemia. (A) Axial CT scan showing a permeative lesion of L3 vertebral body.
(B) Sagittal STIR MR image showing very high signal intensity of the involved L3 vertebra.
What is the aetiology of idopathic scoliosis?
- Abnormalities of visual, vestibular, proprioceptive and postural control involving the brain stem, cerebral hemispheres and corpus callosum have been identified
Involved children tend to show subtle changes in proprioception and vibratory sensation, suggesting that abnormalities of spinal cord posterior column function may have a causative role.
- Abnormal asymmetries of brain structure and function are found in AIS girls for each of cerebral hemispheres, brain stem and, in preliminary research for left thoracic AIS, on MR brain scans, reduced white matter density in the left internal capsule and corpus callosum
- The autonomic nervous system through its hypothalamic neuroendocrine control of puberty, menarche and skeletal growth contributes importantly to the pathogenesis of AIS.
Melatonin and its signaling pathway dysfunction and platelet- calmodulin dysfunction detected in AIS subjects involve the autonomic nervous system.
In AIS girls, autonomic nervous system activity was reported to be higher than controls
Motion palpation of the lumbopelvic spine
Tell me the 10 steps for the pelvis!
The Ten Steps for the Pelvis
- L5 Flexion and Extension
- SI Flexion
- SI Extension
- L5 Rotation
- L5 Lateral Flexion
- SI Internal and External Rotation
- S2-4 Flexion
- Coccyx
- Connective tissue
- Neurology and Compensation patterns
The Lumbar Spine
Also see video on phone.
- L5 Flexion and Extension
Interpretation
Loss of flexion: L5 or anterior sacrum Loss of extension: Posterior sacrum
Normal: Check innominates, pubis, sacral segments, lower extremities, upper cervical & cranial
- SI Flexion
Interpretation
When L5/S1 flexion is lost:
SI extension will be normal when L5 is subluxated. Proceed to step 4 to quantify the Y & Z-axis vectors.
SI extension will be impaired on the side of the anterior sacrum. Extension will be impaired at both SI’s when the sacrum is base anterior - SI Extension
Interpretation
When L5/S1 extension is lost:
SI flexion will be impaired on the side of the posterior sacrum.
Flexion will be impaired at both SI’s when the sacrum is base posterior - L5 Rotation
Interpretation
Impaired movement with right pelvic rotation implies a spinous right fixation and with left pelvic rotation a spinous left fixation - L5 Lateral Flexion
Define L5/S1 vectors in Z-axis rotation when there is loss of extension and normal SI movement
Interpretation
Impaired movement to either side implies an open wedge between L5 and S1 on that side - SI Internal and External Rotation
Define SI rotation when there is loss of flexion or extension with normal L5/S1 movement
Interpretation
Impaired internal rotation implies an external fixation (Ex) and impaired external rotation implies an internal rotation fixation (In) - S2-4 Flexion
Examine the individual sacral motion segments starting at S1/S2 and moving to S4/S5
Interpretation
Impaired movement in flexion implies posteriority of the lower component of the motion segment being examined. - Coccyx
Interpretation
Impaired movement in flexion implies posteriority of the lower component of the motion segment being examined. - Connective tissue
Examine the point specific connective tissue and muscle locations related to the vectors of kinesiopathology identified in steps 1-7.
Pain is indicated by an involuntary extensor response, spontaneous pupillary constriction, facial wincing, crying or a change in the pitch of the cry. - Neurology and Compensation patterns
Elicit the muscle stretch reflexes at L4 and S1 in addition to the perianal reflex and the cremasteric reflex in boys
Identify the compensation pattern associated with the subluxation vectors
