NMS 2 Exam 3 Flashcards
Type 1 Spondylolisthesis
-Dysplastic
-Congenital defect in neural arch or sacrum
Type 2 Spondylolisthesis
-Isthmic
-Lytic: Stress fracture in pars
-Acute: Fracture in Pars
Type 3 Spondylolisthesis
-Degenerative
-Degenerative arthrosis of regional lumbar anatomy
Type 4 Spondylolisthesis
-Traumatic
-Fracture of neural arch other than pars
Type 5 Spondylolisthesis
-Pathologic
-Occurs as a result of bone pathology
Lumbar Myelopathy
-Compression of the spinal cord causing neurologic dysfunction (gait disturbance, pathologic reflexes, muscle weakness, and/or numbness)
Causes of Lumbar Myelopathy
Degenerative changes, central disc herniations, autoimmune disorders, hernias, cysts, hematomas and spinal tumors
Symptoms of Lumbar Myelopathy
-Leg/Lower back pain
-Tingling, numbness or weakness
-Increased reflexes in the extremities
-Difficulty walking
-Loss of urinary or bowel control
-Issues with balance and coordination
Lumbar Radiculopathy
-IVF compresses the nerve root as it exits the vertebrae
-Can cause compressive or inflammatory lesions
-Compressive: Space occupying lesion
-Inflammatory: Reaction leading to sensitivity
Examples of Lumbar Radiculopathy
Disc herniations, degenerative changes and expansile lesions
Risk factors of Lumbar radiculopathy
Degenerative, repetitive lifting/twisting, chronic overloading, prior trauma, poor posture, muscle imbalance, congenital defects, family history, lack of exercise, poor core strength
Lumbar Spinal Stenosis
Narrowing of the lumbar vertebral spinal canal with possible subsequent neural compression (neurogenic claudication)
Neurogenic claudication
Cramping/weakness in legs
Stenosis: Clinical Presentation
-Elderly undergoing extensive degenerative changes
-Discomfort is generally local as dull/achy pain
-Pain worse with extension and extercise
-Pain better with rest and flexion
-Most common at L5/S1
Central Canal Disc Lesion
-Compressed the spinal cord in the cervical and thoracic regions, compresses the cauda equina in the lumbar region
-Myelopathy and cauda equina syndrome
-Central, paracentral, lateral
IVF disc lesion
Compresses the nerve root as it exits the vertebrae
-Radiculopathy
-Medial/Lateral
Types of Disc Lesions
-Contained (intact annular fibers): Protrusion, Subannular extrusion
-Non-Contained (disruption of annular fibers): Transannular, Sequestered
Progression of Disc Lesions
-90% of patients have resolution of symptoms within 3 months of onset
-Nearly complete recovery, although flareups can occur
-75% of herniations resolve spontaneously within 6 months due to resporption of herniated material
At what point should we be looking at surgery for a disc lesion if conservative care isn’t working
Approximately 8-12 weeks
Lumbar Facet Syndrome
LBP d/t inflammation or degeneration of the facet joint or joint capsule often aggravated by hyperlordosis or extension movements
-Peak incidence in 40-50 years old
Lumbar Facet Syndrome: Presentation
-Dull, achy LBP w/ some sharp, acute episodes
-Insidious (degenerative)/Sudden (trauma)
-Pain worse with prolonged standings/lumbar ext
-Pain better lying supine, sitting or lumbar flexion
Causes of stenosis
-Primary causes: Anything that alters size/shape of the canal, usually during the developmental years
-Secondary causes: Degenerative changes or any condition that invades or compromises the space
Grade 1 Sprain/Strain
-Mild swelling/point tenderness over ligament
-No bruising
>10% fiber damage
-Mild stretch, no instability
(-) stretch tests, mild pain at extreme ROM
-Recovery: 2-14 days
Grade 2: Sprain/Strain
-Mild to moderate swelling
-Large spectrum injury that can include partial tearing
-11-90% fiber damage
-Mild to moderate instability may be demonstrated
-Recovery: 14 days to 2 months
Grade 3: Sprain/Strain
-Severe deep bruising/swelling
-Complete tearing of multiple ligaments, muscles, and joint capsules
-Marked instability
-Almost complete loss of ROM
-Recovery: 1-3 months
Lumbar Sprain/Strain: Presentation
-LBP, stiffness, or muscle spasms
-Prior history of back injury
-Limited ROM in low back d/t pain
-Pain better with rest, heat and non-weight bearing
-Pain is aggravated by activity and lifting
-Know specifics of techniques and MOI
Coccygodynia
-Ongoing pain syndrome around the coccyx
-Pain around the sacrococcygeal articulation
-Acute or chronic
-May have history of a sit down fall
-Pain with sitting or sit to stand
-Pain relieved by walking
-Pain with palpation/ROM
Segmental instability
Reversible, hypomobile segments that respond well to manipulation
Segmental Instability
Reversible, hypomobile segments respond well to manipulation
Vascular claudication
-Narrowing or blockage of an artery
-X-Rays may show arteiosclerosis
Use of bracing
Only use if severe, to help stabilize lumbar spine
(Not sure on time)
DDD/DJD
-Progressive loss of articular fibrocartilage and reactive changes to the joint margins and subchondral bone
-DJD is the most common form of joint disease and leading cause of disability with elderly
Primary DJD
-Idiopathic
-Abnormal biomechanics or posture
-Genetic disposition
-Metabolic causes
Secondary DJD
-Usually following joint trauma
-Equal gender distribution
-Childhood anatomic abnormalities
-Joint trauma or fracture
-Obesity
-Repetitive action/joint motion
Phases of Degeneration (Kirkaldy-Willis Degenerative cascade)
-Phase 1 (Dysfunctional Phase)
-Phase 2 (Unstable Phase)
-Phase 3 (Stabilization Phase)
Phase 1: Dysfunctional Phase
-Circumferential tears in outer annulus
-Nucleus pulposis loses water and proteoglycan content
Phase 2: Unstable Phase
-Loss of mechanical integrity, internal disc disruption, resorption and loss of disc height
-Leading to segmental instability
Phase 3: Stabilization Phase
Further disc resorption, disc space narrowing, endplate destruction, osteophyte formation
-Possible discogenic pain results
What is the most common spondy
L5
What is the most common disc
L4
Who is spondy more common in
Females, 40+ yoa
Ankylosing Spondylitis is more prevalent in
Males (4:1) in their 20s
Ankylosing Spondylitis
Chronic, inflammatory disorder of the axial skeleton resulting in formation of new bone at the t of ligaments and tendons
AS Diagnosis
Young males who have: Back pain and stiffness for 3 months, progressive chest pain and stiffness, limited chest expansion, Radiographic changes at SI joint and spine
Reactive Arthritis
Disease associated with the trial of urethritis, conjunctivitis, and arthritis
Who is reactive arthritis more common in
-Young males 9-15:1
Psoriatic Arthritis
Seronegative spondyarthropathy usually associated with psoriasis
Enteropathic Arthritis
Arthritis symptoms that develop with people that have ulcerative colitis or crohns disease
Rheumatoid Arthritis
Chronic systemic inflammatory disease resulting in symmetrical joint pain and swelling as well as subsequent destruction of the affected joints
Who is Rheumatoid Arthritis more common in
Females (3:1)
How much is life expectancy shortened with RA
-Men: 7 years, females: 3 years over 35 yoa
Osteitis Condensans Illii
Mild back pain and UL/BL sclerosis of the lower portion of the SI joint
Who is osteitis condensans more common in
Females 9:1; More common giving birth
Osteitis Pubic
Painful condition around the pubic symphysis
DISH
Diffuse overproduction of bone throughout the spine and possibly extraspinal sites
Who is DISH more common in
-Males (2:1)/Caucasians
Prevalence of lumbar ligament sprains/strains
60% of back injuries
-30-50 years old
Recovery times of lumbar sprains/strains
Muscle: 6-8 weeks
Ligaments: 12 weeks to 6 months
Prevalence of Lumbar Facet Syndrome
15-40% of LBP cases
-Peak incidence: 40-50 years old
Acute vs. Chronic Lumbar Facet Syndrome
Acute: Spinal Manipulation/Conservative Care
Chronic: Spinal Distraction
Myofascial Pain Syndrome
Chronic pain disorder that occurs after multiple muscle contractions
-Can be caused by sleep issues, stress, anxiety, fibromyalgia
Lumbar Instability
Loss of normal biomechanical function between two adjacent vertebrae resulting in increased or abnormal motion or static malposition
-Most common between 15-50 years old
Types of Instability
Generalized: May be genetic and use multiple joints
Segmental: Easier to adjust
Surgery: Very unstable
Functional: Chronic/muscle imbalances requiring conditoin and proprioceptive retraining
Structural: Difficult to reverse, unstable end ROM
Lumbar Disc Herniation
Tear or rupture of fibrocartilaginous material, that surrounds IVD
-Age 25-45
-1/3% of cases
-Male 3:2
Which of the following spondylolisthesis types is due to a boney pathology?
A. Type 5
B. Туре 4
C. Type 3
D. Type 2
E. Type 1
A. Type 5
Which of the following is NOT a potential cause of lumbar myelopathy?
A. Spinal tumor
B. Herniated disc
C. Bone spurs
D. All of these are potential causes of myelopathy
D. All of these are potential causes of myelopathy
Cauda equina syndrome is usually caused by:
A. an autoimmune disorder
B. a massive lumbar disc prolapse
C. diabetes mellitus
D. a large compression fracture
B. a massive lumbar disc prolapse
Most lumbar discs resolve spontaneously within
A. 6 weeks
B. 12 weeks
C. 1 year
D. 6 months
D. 6 months
Exercises for piriformis syndrome are aimed at:
A. strengthening the core
B. relaxing the piriformis
C. stretching the low back musculature
D. strengthening the pelvic floor
B. relaxing the piriformis
Which of the following can cause neurological changes?
A. Diabetes mellitus
B. Pernicious anemia
C. Alcoholism
D. B12 deficiency
E. Heavy metal toxicity
F. All the above
F. All the above
A low back brace should be used:
A. during the acute phase
B. throughout the entirety of treatment
C. if there is a fracture
D. only for the first 24 hours
A. during the acute phase
LI4 s a very common trigger point for gastrointestinal, headache, pregnancy complaints ommon trigger point for gastrointestinal and low back pain. Where is this point located?
A. Base of the 5th metatarsal
B. PSIS’s
C. Web of the thumb
D. Midway between the sacrum and greater trochanter
C. Web of the thumb
If a patient has symptoms of vascular claudication, x-rays may show:
A. lumbar stenosis
B. cauda equina syndrome
C. pars fracture
D. arteriosclerosis
D. arteriosclerosis
Segmental instability is:
A. chronic
B. genetic
C. highly unstable
D. reversible
D. reversible
Which of the following conditions would you want to obtain motion films (such as flexion extension views) before treating conservatively?
A. Lumbar strain/sprain
B. Lumbar instability
C. Piriformis syndrome
D. Coccygodynia
B. Lumbar instability
The nucleus pulposis has migrated beyond the dimensions of the vertebral body but the nuclear fibers are still intact it is called:
A. protrusion
B. sub annular extrusion
C. transannular extrusion
D. sequestered
B. subannular extrusion
If L5 has completely slipped of the sacrum it is called:
A. spondyloptosis
B. spondylolisthesis
C. spondylosis
D. spondylarthritis
A. spondyloptosis
A 25-year-old female presents with dull achy low back pain that radiates into her glutes. She states it has been progressively worsening for about 5 years. She used to be a competitive gymnast and stopped when the back pain developed. The pain is worse with extension. What do you suspect the diagnosis to be?
A. Lumbar strain/sprain
B. Piriformis syndrome
C. Lumbar disc herniation
D .Spondylolisthesis
D .Spondylolisthesis
A 29-year-old female presents with intense coccygeal pain following labor and delivery. She delivered the first child 4 months prior and has had progressively worsening discomfort since. She has difficulty sitting for prolonged periods and difficulty with transitioning from sitting to standing. What do you suspect the initial injury was?
A. Coccygeal fracture
B. Sacral fracture
C. Pelvic ligament sprains
D. Hemorrhoids
A. Coccygeal fracture
What is the best system ot evaluate the degree of slippage for a spondylolisthesis?
A. George’s line
B. Ullman’s line
C. Meyerding’s scale
D. Cobb’s angle
C. Meyerding’s scale
The most common type of L4 spondylolisthesis is
A .Traumatic
B. Isthmic
C.Dysplastic
D. Degenerative
D. Degenerative
Which of the following would be an example of a dysplastic spondylolisthesis?
A .DJD
B . Trauma
C .Spina Bifida
D . Scoilsis
C .Spina Bifida
Most common segment for a spondylolisthesis to occur is
A. L2
B. L3
C. L4
D. L5
D. L5
Patient presents with saddle paresthesia and bowel/bladder incontinence. What should your next step in treatment be?
A. Adjust with focus on the low back and pelvis
B. Electrical stimulation for 10 minutes
C. Core rehabilitation program
D. Refer to the ER for emergency decompression
D. Refer to the ER for emergency decompression
A patient presents with saddle paresthesia and bowel/bladder incontinence. What doyou suspect the diagnosis to be?
A. Myelopathy
B. Cauda Equina Syndrome
C. Radiculopathy
D. Vascular Claudication
B. Cauda Equina Syndrome
Gait disturbances, pathological reflexes, muscle weakness, and numbness in the extremities are all signs of ________ compromise.
A. vascular
B. peripheral nerve
C. Cord
C. Cord
Which imaging modality is considered the gold standard for diagnosing disc herniations?
A. X-ray
B. MRI
C. CT
D. PET scan
B. MRI
If a disc herniation is classified as contained, it means:
A. the annular fibers are disrupted
B. the nucleus pulposis is sequestered
C. the nucleus pulposis is extruding
D. the annular fibers are intact
D. the annular fibers are intact
A disc herniation at L2 will affect what nerve root?
A. L1
B. L2
C. L3
D. L4
C. L3
A patient with a lateral disc herniation will typically have antalgic _________
A. in forward flexion
B. in extension
C. toward the lesion
D. away from lesion
D. away from lesion
Myelopathy and cauda equina syndrome are caused by compression in the:
A. IVF
B. vertebral canal
C. transverse foramen
D. inguinal canal
B. vertebral canal
True or False: An inflammatory lesion and a compressive lesion can occur together.
True
An inflammatory lesion is related to:
A. the location of a herniation
B. the reaction of a herniation
C. the size of a herniation
D. the level of a herniation
B. the reaction of a herniation
A compressive lesion is related to:
A. the location of a herniation
B. the reaction of a herniation
C. the size of a herniation
D .the level of a herniation
C. the size of a herniation
Multidirectional instability is likely due to
A. Genetic factors
B. muscle imbalance
C. surgery
D. congenital structural anomalies
B. muscle imbalance?
Would you adjust a patient with lumbar instability?
A. Yes, but avoiding the unstable segments.
B. Yes, full spine adjusting is fine in patients with this condition.
C. Yes, but only using activator protocol.
D. No, adjusting is contraindicated in these patients.
A. Yes, but avoiding the unstable segments.
Surgery to relieve pressure on the cord for those with lumbar canal stenosis is typically a
A. fusion
B. disc replacement
C. laminectomy
D. bone graft
C. laminectomy
Lumbar canal stenosis is generally worse with
A . rotation
B . lateral flexion
C . extension
D . flexion
C . extension
Cramping and pain in the legs of a patient with lumbar canal stenosis is called
A. Vascular claudication
B. Neurogenic claudication
C. Intermittent claudication
B. Neurogenic claudication
Which of the following substances are affecting by aging and lead to decreased tensile strength and diminished nutrient supply to cartilage?
A. Collagen
B. Proteoglycan
C. Elastin
D. A and B
E. A and C
F. All of the above
D. A and B
Degenerative joint disease is most common inwhich of the following joints?
A.Axial skeletal joints
B. Appendicular skeletal joints
C. Weight bearing joints
D. non-weight bearing joints
C. Weight bearing joints
The leading cause of disability in the elderly is:
A. Lumbar stenosis
B. Degenerative joint disease
C. Osteoarthritis
D. Diabetes mellitus
B. Degenerative joint disease
Rarely, surgery may be required for patients with piriformis syndrome to release the
A. tendinous bands of the piriformis
B. tight fibers of the Sacro tuberous ligament
C. compressed sciatic nerve
D. tight fibers of the sacroiliac ligament
A. tendinous bands of the piriformis
A 35-year-old female presents to the clinic with chronic tingling and pain down the back of her right leg. She works as a receptionist and has difficulty sitting during work. During your exam you note she has a significant internal rotation restriction of her right hip. What is the most likely diagnosis?
A.Piriformis syndrome
B.Lumbar spinal stenosis
C. Sciatica
D .Lumbar myelopathy
A.Piriformis syndrome
Primary sciatica affects the sciatic nerve via where secondary sciatica affects the sciatic nerve via
A.direct irritation, muscle tension
B. underlying neurologic changes, direct irritation
C . muscle tension, underlying neurologic changes
D . direct irritation, muscle tension
B. underlying neurologic changes, direct irritation
Myofascial pain syndrome is characterized by:
A. Pain
B. neurological changes
C. fibromyalgia
D. trigger points
D. trigger points
What chiropractic treatment is very beneficial in preventing progression of disease in patients with lumbar facet syndrome?
A. Flexion distraction
B. Early manipulation
C. TENS therapy
D. Core rehabilitation
A. Flexion distraction
A 44-year-old male presents to your clinic following an injury at work. He was picking up a box and didn’t bend his Knees. He states he “moved too quickly” and had spasming immediately in his lower back. Now he can barely move due to intense muscle spasm pain. He states that heat has made ti better. What is the most likely diagnosis?
A.Lumbar facet syndrome
B. Lumbar stenosis
C. Lumbar sprain/strain
D. Sciatica
C. Lumbar sprain/strain
