The Thoracic and Lumbar spine Flashcards
Red flags: Metastatic Spinal Cord compression
- Referred back pain is band-like
- Escalating pain
- Heavy legs
- Lying flat increases back pain
- Agonising pain
- Gait disturbances
- Sleep disturbed
Red flags: Multiple Myeloma
- Dull ache and pain on palpation- back, ribs or pelvis
- Tiredness
- Extreme thurst
- Blurred vision
- Bone fragility: fracture, cord compression
Spinal infection (Tuberculosis,Osteomyelytis, Discitis)
-Weight loss
-Loss of appetite
-Localised spinal pain
-Extreme night sweats
-Fevers
-Malaise
- Continuous pain
Red flags: Spondyloarthropathy
Less than 45 years with
- Spinal pain reduces with activity
- Waking on second half of night
- Buttock pain
- Stiffnes in morning for more than 45 mins
- Swollen fingers
- Red eyes
- Psoriasis
Red flags: Osteoporotic Compression fracture
- Sudden severe back pain
- Pain worse on standing/walking/change of position
- Relieved by resting
Red flags: CES
- Loss of sensation in saddle area
- Altered sexual function
- Bilateral leg pain
- Bladder or bowel changes
Red flags: AAA
- Abdominal pain
- Palpable, pulsatile mass
- Passing out, SOB
- Severe low back pain/ flank pain worse on exertion
What is Lumbar Spine Radiculoathy?
Compression of the nerve roots which exit the spine at level L1-S4
Incorporates sciatica as the nerve roots that make up the sciatic nerve are affected too
What can cause compression of nerve roots to cause lumbar radiculopathy?
- Herniated discs
- Spondylolisthesis (vertebrae slips)
- Lumbar stenosis (narrowing of vertebral canal)
- Trauma
- Cancer
- OA
Signs and symptoms of lumbar radiculopathy
- Unilateral or bilateral leg pain into lower limb
- Lower back pain often present
- Positive straight leg raise
- Neurological deficits: numbness, tingling, myotomal weakness, changed sensation
What is Lumbar spondylolisthesis /restrolisthesis
Spondylolisthesis (forward movement of a vertebrae)
Retrolisthesis (backward movement of vertebrae)
Causes and risk factors of Lumbar spondylolisthesis /restrolisthesis
- Trauma
- Fracture
- Arthritis
- Tumour
Symptoms of Lumbar spondylolisthesis /restrolisthesis
- Can be asymptomatic
- LBP with or without leg pain and neuro symptoms
- Descriptions of catching pain during movement
- Noticeable step in the lumbar spine on palpation
What is lumbar spine stenosis? Risk factors?
Narrowing of the spinal canal and is characterized by symptoms being relieved by forwards flexion and worsened with extention
Risk factors:
- Age e.g age related changes
- Females are more likely
Causes of lumbar spine stenosis
- Congenital stenosis and spondylolisthesis
- Lateral recess and foraminal stenosis
- Central spine stenosis (causing neuro claudication)
- OA, RA
- Trauma/injury to spine
- Tumour
Symptoms of Lumbar spine stenosis
-Present with LBP with or without leg pain
-Neurological symptoms with leg pain being the most prominent symptom
-Describe walking and standing as a cause for their symptoms
-Relieved by forward flexion
Management of Lumbar spin conditions
Advice - GP, heat treament, sleeping with pillow between legs, return to normal activity, avoid bed rest
Reassurance (usually settles within 4-6weeks)
Symptoms not going or getting worse
Physio: manual therapy, exercise, spinal mobs, massage
Referral for pain meds (nerve root blockers)
Consider neurosurgery
Research: Raymond Ostelo
- Exercise therapy for complaints longer than 6-8wks
- all advice above recommended plus exercise if leg pain is most dominant symptom
What is non-specific LBP
Lower back pain that can’t be attributed to a specific pathoanatomical structure and has a mechanical pattern
Risk factors for LBP
Obesity
Physical inactivity
Occupational factors
Depression and other psychological conditions
Lifestyle
Red flags for LBP
Cauda equina
Spinal fracture
Cancer
Infection
Signs and symptoms of mechanical LBP
- Mechanical in nature
- Pain local to lumbar but can radiate in a non-dermatomal distribution into hip, buttock, LL
- Pain associated with pins and needles but NO dermatomal or myotomal deficit
Management of mechanical LBP
Advice: GP for pain relief, avoid bed rest, encourage activity
Reassurance: not usually structure damage, usually resolves in a period of weeks
All backed up by evidence
Failure to improve within 4 weeks or at risk of chronic:
Physio: exercise, spinal mobs, manipulation or massage
Pain management service
All backed up by evidence as well as psychosocail interventions
Research: Chris Mayer et al
What is thoracic spine pain
Difficult to distinguish the pathoanatomical origin of non-specific thoracic pain
Causes of non-specific thoracic spine pain
- Muscle strain (overuse/sport)
- Postural
- Vertebral fracture
- Structural abnormalities
- Degenerative changes
Thoracic spine is most common area for bone metastases. What are the most common primary cancer that can spread to the spine
- Breast cancer
- Prostate cancer
- Lung cancer
- Myeloma
Risk factors of non-specific thoracic spine pain
- Postural changes
- Increased back pack weight
- Poorer mental health
- White collar workers
Signs and symptoms of non-specific thoracic spine pain
- Aggravated by movements, postures, activities
- Usually pain local to the thoracic spine
- Referred pain to ribs, chest and arms
- Visceral referral from non MSK conditions e.g cardiac
- No associated motor deficit
- Pain may be reproduced with movement in the opposite direction
- Tenderness on palpation of intervertebral joints
Management of non-specific thoracic spine pain
(0-12 weeks)
Advice: GP, encourage activity, change positions regularly
Physio: stretch, strength, ROM, postural exercise, manual therapy
Reassurance usually resolves in a few weeks
(more than 12 weeks)
Provide MDT pain management programme
Pain clinic
Research: NLM, Marco Risetti et al
- Exercise and education was found to be beneficial in the short term, and long term treatment of TSP.
- Manual techniques (spinal manipulation, spinal mobilisation and soft tissue mobilisation) only as short term treatment.
A multimodal treatment with these and some psychosocial management was shown to be beneficial
What are the red flags to look out for in lumbar and thoracic assessments?
- Cauda Equina
- Metastatic cord compression
- Multiple myeloma
- Spinal infection
- Spondyloarthropathy (ankylosing arthritis)
- Osteoporotic stress factor
- AAA
Signs and symptoms of spinal fracture of lumbar spine (red flag)
Sudden onset of severe central spine pain - relieved by lying down
Major trauma, minor trauma
Structural deformity (e.g a step)
Point tenderness over a vertebral body
