Week 1- L-spine Common Clinical Presentations Flashcards
Classifications of LBP.
- Acute or Subacute LBP with Mobility Deficits
- Acute, Subacute, or Chronic LBP with Movement Coordination Impairments
- Acute LBP with Related (Referred) Radiating LE Pain
- Acute, Subacute, or Chronic LBP with Radiating Pain
- Acute or Subacute LBP with Related Cognitive or Affective Tendencies
- Chronic LBP with Related Generalized Pain
What are (3) prognostic indicators for development of recurrent LBP?
- Hx previous episodes.
- Excessive spine mobility.
- Excessive mobility in other joints.
What are the (5) prognostic indicators for development of chronic LBP?
- Presence of symptoms below the knee.
- Psychosocial distress or depression.
- Fear of pain, movement, and re-injury or low expectations of recovery.
- Pain of high intensity.
- Passive coping style.
- ______ _____ Pain: Area bordered by transverse line from T12 – S1.
- ______ _____ Pain: Area bordered by vertical lines through PSISs and horizontal lines through S1 and sacrococcygeal joints .
- Lumbar Spine Pain
- Sacral Spine Pain
LBP Prevalence:
- Mechanical = ___%
- Non-mechanical spinal conditions = ___%
- Visceral = ___%
- Mechanical = 97%
- Non-mechanical spinal conditions = ~1%
- Visceral = 2%
Common Clinical Presentations List, (11)
- Neoplasms
- Infection
- Spondyloarthropathies
- Vertebral Body Fracture
- Spondylolysis & Spondylolysthesis
- Discogenic Pain (discitis and internal disc disruption)
- Radicular pain/ radiculopathy
- Lumbar Stenosis
- Zygapophysial Joint Pain
- Muscle Pain
- L-Spine Surgeries
Neoplasms:
- What is the presenting complaint in 90% of neoplasm patients?
- What are the (4) most common sites of metastasis?
- Back pain
- Breast, Lung, Prostate, Kidney
What may be found during a patient interview/Hx with Neoplasms? (6)
- PMH includes cancer
- Progressive
- Fatigue
- Weight Loss
- Smoking
- Pain Complaints
Common pain complaints found with patients with Neoplasms:
- Persistent
- Not alleviated with “________”
- Worse at _______
- _________ symptoms
- Persistent
- NOT alleviated with “bed rest”
- night
- Neurological
Neoplasm Physical Examination:
- ____-_______ presentation
- Age > ___
- Anemia
- Neurological signs
- non-mechanical
- Age > 50`
Infection:
- Vertebral osteomyelitis is misdiagnosed in ____% of cases and has an average delay of _____ months in diagnosis.
- _______ ________ is a hematogenous spread of bacteria into epidural space that occurs in 10% of spine infections. Misdiagnosis rate is estimated at 50%.
- 33.7%, 2.6 months
- Epidural Abscess
What may be found during a patient interview/Hx with Infection (Vertebral Osteomyelitis)? (6)
- Often traced to other sources of infection (bladder most common)
- At risk patients (immunocompromised or DM)
- Weight loss
- Fatigue
- Fever
- Neurological Symptoms
Patients with Vertebral Osteomyelitis often complain of local, focal back pain that is worse with _________ loading and improves with __________ position.
- mechanical
- recumbent
Vertebral Osteomyelitis Physical Examination:
- Fever
- ______ tenderness
- Aggravated with local __________
- __________ signs
- Lab tests important for Dx
- local
- percussion
- Neurological
Epidural Abscess is often concomitant with vertebral osteomyelitis and can present similar to mechanical _________ pain.
-radicular
Fractures:
- What are the (3) divisions of fracture classifications.
- Vertebral fractures increase mortality and is a predictor for subsequent vertebral fractures (__-__x) and hip fracture (__x).
- Anterior Column, Middle Column, Posterior Column
- vertebral fracture (4-5x), hip fracture (3x)
What are the (3) Types of Fractures in the TLICS Classification System?
- Compression
- Translation
- Distraction
Compression Fractures (“Traditional”):
- Stable injury involving the ______ column.
- Common mechanism is axial loading in what position?
- A compression ______ fracture involves the anterior and middle columns and makes up 15-20% of all major vertebral body fractures.
- Where is a compression burst fracture most common? What is of concern with burst fractures?
- Compression burst fractures come from high axial force in what position?
- anterior
- flexed position
- burst
- T/L Junction, neural involvement
- flexed
Translation/Rotation Fractures:
- Associated with what common MOIs?
- Involves ________ and _____ forces.
- Horizontal displacement of one T/L vertebral body on another.
- Facet joints are intact but __________.
- Fall from height or heavy object falling on body with bent trunk.
- torsion and shear forces
- dislocated
Distraction Fractures:
- Separation in the ________ axis.
- Anterior & posterior ligaments, anterior & posterior bony structures, both.
- Potential Frx to __________ elements.
- vertical
- posterior
What are some red flags for vertebral fracture? (4)
- Older age
- Significant trauma
- Corticosteroid use
- Contusion/abrasion
Henschke Cluster Items for Vertebral Frx. (4)
- Age > 70 years
- Significant trauma
- Prolonged corticosteroid use
- Sensory alterations from the trunk down
Roman Cluster Items for Vertebral Frx. (5)
- Age >52
- No presence of leg pain
- BMI = 22
- Does not exercise regularly
- Female
Spondylolysis:
- Fatigue fracture of ____________.
- What are the (3) proposed mechanisms?
- What is a flail segment?
- 90% of Spondylolysis at ___ level.
- pars interarticularis
- Acquired (repetitive microtrauma), Congenital, Developmental
- Bilateral pars defect with attached multifidi.
- L5 level
Spondylolisthesis:
- Anterior slip of the vertebrae following bilateral __________.
- What are the grades?
- Greatest slippage occurs between __-__ years old. Why?
- Often reduced ______ observed with flex/ext radiographs (rather than instability).
- spondylosis
- Grade 1=0-25%, Grade 2=25-50%, Grade 3=50-75%, Grade 4=75-100%
- 10-15 years old, bone is not ossified
- ROM
What populations are at increased risk for Spondylolysis and Spondylolisthesis? (3)
- Athletes (repetitive extension)
- girls (2x), women (4x)
- Adolescents
Patients with Spondylolysis or Spondylolisthesis have localized LBP, which is worsened with ________ activities.
-extension
Spondylolysis and Spondylolisthesis Physical Examination:
- Include __________ testing
- Visual Inspection: _________ lumbar lordosis
- Possible __________ deformity
- Pain with lumbar ________/_________
- “Hamstring tightness” has been proposed
- ________ testing & _______ testing at involved segment (if administered)
- neurological
- excessive
- step-off
- extension/rotation
- instability testing & spring testing
Discogenic Pain (Internal Disc Disruption):
- Involves an _______ fracture.
- Common MOI is axial ___________.
- May involve possible Schmorl’s nodes, what is this?
- May progressively degredate the matrix.
- end-plate fracture
- compression
- Extrusion of the IV disc nuclear material through the endplate, with displacement of this material into the adjacent vertebral body.
Discogenic Pain (IDD):
- Following ______ or __________ injury.
- Nucleus less able to withstand pressure and _______ must accept more loading.
- Discs lose height leads to excessive loading on facet joints, and _________ formation.
- rotary or end-plate injury
- Annulus
- osteophyte
Bulging disc involves ___-___% of circumference.
-50-100%
- What is Somatic Referred Pain?
- What is Radicular Pain?
- What is Radiculopathy?
- Somatic Referred Pain = Altered pain perception in CNS.
- Radicular Pain = Pain related to nerve root irritation.
- Radiculopathy = Conduction block of motor and sensory axons.
Is Radicular Pain acute or chronic?
Both
- Acute: Trauma (twisting/lifting injury common)
- Insidious: Progressively more distal as health condition progresses.
How do patients describe Radicular Pain?
- Shooting/lancing pain traveling along nerve distribution.
- “band-like”
- Pain with activities that close neuroforamen.
Radicular Pain Physical Examination:
- Visual Inspection: _______shift possibly
- Painful/ limited ROM with motions that __________ foramen or place tensile load on nerve root
- Potentially + _______, ______, and ______ ____ ______ tests
- Tenderness/ turgor with guarding paraspinals
- lateral shift
- compress
- Slump test +, SLR test +, Well Leg Raise test +
Spinal Stenosis:
- Stenosis is mainly degenerative, what does this mean?
- What are the symptoms?
- Will these patients have long tract signs?
- Mostly seen in older adults.
- LBP, bilateral involvment, UMN/LMN symptoms, posterior leg pain,diminished lumbar lordosis, extension ROM pain
- Yes (Hoffman’s, Babinski, Clonus)
- ______ Canal Stenosis is a narrowing of the vertebral canal and can cause impingement on neurological structures in vertebral canal. Makes up 65% of cases with L-spine stenosis.
- Hx includes age > __ years and _______ LBP
- Central Canal Stenosis
- age > 65, chronic LBP
Central Canal Stenosis Symptomology:
- Possible ______ ________ symptoms
- ____ or ____symptoms in lumbosacral distributions (pending level)
- Pain ___________ with walking/ standing (prolonged)
- Pain relieved with sitting, walking with UE support (walker, shopping cart)
- Pain in ______ (posterior lower legs especially) > lower back
- Cauda Equina
- UMN or LMN
- increases
- legs
Central Canal Stenosis Physical Examination:
- Visual Inspection: _________ lumbar lordosis
- Painful/Limited ________ and ___________ ROM (passive and active)
- Shortened hip ________, lengthened hip _________
- _________ signs
- diminished
- extension and lateral flexion
- shortened hip extensors, lengthened hip flexors
- neurological signs
Lateral Canal Symptomology:
- ____ symptoms in lumbosacral distributions
- Pain ________ with walking/standing (prolonged)
- Pain relieved with sitting, walking with UE support (walker, shopping cart)
- _____ and ___ pain (unilateral)
- LMN
- increases
- LBP and LE
Lateral Canal Physical Examination:
- Visual Inspection: __________ lumbar lordosis
- Painful/Limited ________ and ___________ ROM (passive and active)
- _________ signs
- diminished
- extension and lateral flexion
- neurological
Z-Joint Pain:
- Referred pain in _______ and _____, though pattern not reliable.
- What are a few potential etiologies?
- Often secondary with DDD/disc spondylosis
- buttock and thigh
- OA and Spondyloarthropathy
Z-Joint Pain Symptomology (Degenerate OA):
- Local/ referred, unilateral _______ and _________ pain.
- Aggravation with facet _______. Relief with facet _______.
- low back and buttock pain
- closing, gapping
Z-Joint Physical Examination (Degenerative OA):
- PROM/AROM: Pain/limited lumbar __________, ipsilateral ___________, contralateral __________, and end-range flexion.
- Muscle guarding lumbar erector spinae.
- Possibly difficulty activating ________.
- Painful spring testing/ UPA.
- ___________ with joint mobility testing.
- lumbar extension, ipsilateral lateral flexion, contralateral rotation
- multifidi
- hypomobility
Z-Joint Pain Symptomology (Acute Traumatic):
-Diminished pain in slight flexion position and positions that ____ the z-joint.
Pain with _________ activities greatest (closing of z-joint).
- gap
- extension
Z-Joint Pain Physical Examination (Acute Traumatic):
- “_______” posture, potential lateral shift
- Painful limited ROM greatest w/ _______
- Painful spring testing/ UPA
- Tender, guarded paraspinals
- “slouched” posture
- extension
- What is Meniscoid entrapment?
- During lumbar ______, meniscoid is drawn out of joint.
- During lumbar _______, it buckles and occupies space.
- When the soft tissue in between the joint capsule becomes trapped, and a ‘pinching’ or ‘catching’ sensation is experienced.
- flexion
- extension
Neuromuscular Instability/Muscle Imbalance:
- _________ patterns between muscle groups that result in pain.
- What are the proposed pain generators? (2)
- Activation
- involved musculature (DOMS with excessive guarding), joint structures (aberrant loading patterns)
Neuromuscular Instability/Muscle Imbalance Symptomology:
- LBP is _________.
- ________/_______ with trunk motion.
- _______/_________ noises.
- Aggravated with _________ positions (sitting, standing), flexion motion, sudden trunk movements, returning to upright position from flexed position.
- constant
- Catching/locking
- Clicking/popping
- prolonged
Neuromuscular Instability/Muscle Imbalance Physical Examination:
- Aberrant motions (trunk AROM)
- Painful/ limited: AROM (commonly _______), returning from full motion
- Excessive motion
- Paraspinal guarding/ tenderness
- _______mobility (joint mobility testing)
- _________________Test and __________________ Test
- commonly flexion
- hypermobility
- Prone Instability Test and Passive Lumbar Extension Test
___________ AKA “back mice” is herniation of fat through posterior layer of thoracolumbar fascia. Innervated fat tissue is compressed during motions and places tensile load on fascia.
-Thoracolumbar Fascia Fat Herniation
What are the (3) main types of muscle pain?
- General Muscle Strain
- Diffuse Muscle Pain
- Muscle Spasm
Which type of muscle pain is controversial, especially with chronic LBP?
-Muscle Spasm
Which type of muscle pain involves a forceful stretch of contractile unit against contraction, has a common failure at the myotendinous junction, and provokes an inflammatory response?
-General Muscle Strain
Which type of muscle pain is likely ischemic in nature and happens with sustained muscle contraction compressing on vascular structures?
-Diffuse Muscle Pain
LBP and health related conditions associated with fatty infiltration and atrophy of _________. Fatty infiltration likely related to muscle disuse and spinal injury.
-multifidi
“The presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain (zone of reference) and a local twitch response.”
-They can be _______ or ________.
-Trigger Points
active or latent
What (3) things are needed for Dx of trigger points?
- Palpable band
- Local and referred tenderness
- Local twitch response
L-Spine Common Surgical Procedures. (7)
- Medial Branch Neurotomy
- Laminoforaminotomy
- Laminectomy
- Laminoplasty
- Discectomy
- Interbody Fusion
- Arthroplasty
- Tissues in neuroforamen compressing nerve tissue removed. (lamina, disc, hypertrophied ligaments, etc.)
- Under fluoroscopy.
- Open vs. minimally invasive.
-Laminoforaminotomy
- Radiofrequency ablation of medial branch of dorsal rami.
- Under fluoroscopy.
- Indicated for pain relief to address z-joint pain.
-Medial Branch Neurotomy
- Removal of the lamina. (Complete: removal of lamina & SP)
- Likely contributes to diminished stability.
-Laminectomy
- Reconstruction of posterior ring at lamina.
- Open door: bone graft from SP fixated on open side.
- Indications: multi-level spondylosis/ spinal stenosis.
- Increases space for cord.
- Posterior approach, removal/ thinning of lateral lamina.
-Laminoplasty
- Aspiration of nucleus via probe.
- Indications: HNP/ disc origin of symptoms.
-Percutaneous Discectomy
- Removal of disc that is compressing/ irritating the nerve root.
- Up to 90% success rate reported.
-Microdiscectomy
- Indications: stenosis.
- Reduces/ eliminates segmental motion/ stress on involved structures.
- TLIF (transforaminal lumbar interbody fusion): bone graft & titanium mesh placed into distracted IV space.
- ALIF (anterior lumbar interbody fusion): fixation with bone grafts, cages, dowels.
- Increased risk for subsequent degeneration of adjacent segments.
-Interbody Fusion
- Disc is removed and replaced with metal & plastic prosthesis.
- Restoration of motion.
- Avoidance of subsequent adjacent segment stress concentrations.
-Arthroplasty
