week 5 Flashcards
radiculopathy aka pinches nerve
injury or damage to nerve roots in the area
they leave the spine that may result in pain, loss of sensation and/or motor function depending on the severity of symptoms
acute vs chronic low back pain
acute low back pain (LBP) - up to 12 weeks
chronic LBP - 3 months or greater
lumbago
often refers to acute back pain or a strain, typically to either the quadratus lumborum muscle or the paraspinal muscles
sciatica
often used to describe lumbosacral radiculopathy, more specifically pain distributed along the sciatic nerve (L4, L5, S1, S2, S3)
types of low back pain
- LBP due to MSK disorders
- LBP due to systemic diseases affecting the spine
- LBP due to visceral diseases
- LBP due to disorders of the musculoskeletal structures
- Nonspecific (mechanical) back pain
- Specific MSK back pain: clear relationship between anatomic abnormalities
seen on imaging and symptoms
a. Lumbar radiculopathy due to herniated disc, osteophyte, facet
hypertrophy, or neuroforaminal narrowing
b. SpinalStenosis
c. Cauda equina syndrome - LBP due to systemic disease affecting the spine
- Serious and emergent (requires specific and often rapid treatment)
a. Neoplasms
b. Infection
- Serious but nonemergent (requires specific treatment but not urgently).
a. Osteoporotic compression fracture
b. Inflammatoryarthritis - LBP due to visceral disease (serious, requires specific and rapid diagnosis and treatment) - could involve the pelvis, renal structures, GI structures, etc.
acute LBP with radiculopathy
- mechanical
- degenerative
- inflammatory
- oncologic
- infectious
Mechanical;;
**Spinal fracture
**Lumbar disc herniation
**Cauda equina syndrome
Piriformis syndrome, Iliotibial band syndrome
Degenerative;;
**Spinal stenosis
Spondylosis, Spondylolisthesis
Facet arthropathy, Pseudoclaudication
Inflammatory;;
Sacroiliitis
Greater trochanter bursitis Ankylosing spondylitis
Oncologic;;
***Spinal neoplasms (most commonly metastatic)
Infectious;;
Vertebral lesion (***infection, e.g. epidural abscess)
***= red flags
red flag findings in low back pain
fecal or urine incontinence
saddle anesthesia
unexplained fever and weight loss
Focal neurological deficit, progressive or disabling symptoms
No improvement after 6 weeks of conservative management
–> recent infection
–> cancer history
–>high LR+
cauda equina syndrome (LBP)
L3-L5 nerve roots
Mostly from lumbar disc herniation
-urinary and fecal incontinence
-saddle anesthesia
spinal malignancy: metastases (LBP)
whereis the most common cancer to metastasize from?
Tumors from other primary cancers: breast, lung, prostate, renal, GI, thyroid
-weight loss, back pain, sensory loss
vertebral fracture (LBP)
Mostly from osteoporosis (low bone density from drugs, anorexia, meds, falls)
Back pain worse with standing/walking, rarely radiculopathy
Vertebral infection: osteomyelitis (LBP)
Via staphylococcus aureus
Back pain, fever, sensory loss, weakness or radiculopathy
why you shouldn’t image LBP
Initial imaging is not indicated in the majority of patients with low back pain.
- due to very high prevalence of abnormal neuroimaging findings even in asymptomatic patients
- conservative management for 6 weeks is typically recommended before considering imaging (radiography, MRI, CT)
- UNLESS presenting with severe symptom intensity (causing diability) or red flag findings for conditions that require timely diagnosis to prevent serious consequences (e.g. cauda equina syndrome, malignancy, fracture and infection)
best imaging for LBP
MRI
then CT if cant do
then plain radiographs (X-ray) for malignancy or fracture or osteroperosis
3 categories of radicular symptoms
- Mild radiculopathy is considered a sensory loss and pain without motor deficits
- Moderate radiculopathy is the sensory loss or pain with mild motor deficits
- Severe radiculopathy is considered sensory loss and pain with marked motor deficits.
LBP education
Disease education:
- Provide reassurance:
- low likelihood of serious pathology
- most cases are self-limited and resolve with conservative management
in 6-8 weeks
- Stay active (moderate level) and return to normal activities as soon as
possible; avoid bed rest and aggravating movements
- Pain management includes nonpharmacologic (physiotherapy) and
pharmacologic options
What they need to look out for:
- Symptoms persisting for over six weeks may benefit from additional interventions (e.g. injections)
- Red Flag symptoms that warrant an immediate emergent evaluation and potential surgical consultation
cauda equina sydrome
cause?
which nerve roots?
signs
testing done
L3-L5 nerve roots
Mostly from lumbar disc herniation
-urinary and fecal incontinence
-saddle anesthesia
MRI
spinal malignancy; metastases
cause
symptoms
testing
Tumors from other primary cancers: breast, lung, prostate, renal, GI, thyroid
-weight loss, back pain, sensory loss
MRI or xray
vertebral fracture
cause
symptoms
testing
Mostly from osteoporosis (low bone density from drugs, anorexia, meds, falls)
Back pain worse with standing/walking, rarely radiculopathy
CT
vertebral infection: osteomyeltiis
cause
symptoms
testing and treatment
Via staphylococcus aureus
Back pain, fever, sensory loss, weakness or radiculopathy
MRI, CRP, ESR
*antibiotics
what is osteomyletitis
vertebral infection
which bacteria causes osteomyelitis
staphylococcus aureus
which nerve root is most common for LBP with radiculopathy
L5 nerve roots (L4-L5)
symptoms of LBP w radiculopathy
- Pain; tingling, electric, burning, sharp
o Paresthesia, radiating to lower limbs, numb (anesthesia), muscle weakness, absent ankle and knee reflexes - Symptoms: fever, malaise, weight loss, early morning stiffness, muscle spasms
risk factors for LBP w radiculopathy
- Risk factor: heavy lifting and twisting; repetitive stress trauma
what makes LBP w radiculopathy betta or worse
- Pain worse with weight bearing, stand, walk, cough, strain bowels, forward flexion of L spine
- Better with: extension of L spine, recumbent position
key history to consider for LBP
- Key history: malignancy, bacterial infections, spinal tap or epidural, corticosteroid use, social or psychologic distress
4 stages of disc herniation
- degeneration
- prolapse.
- extrustion
- sequestration
how long for disc herniation to get better
- Usually relief in 6-12 weeks without treatment
tests for disc herniation (2)
- Diagnosis: straight leg raise ( and well leg raise) and hancock rule
o Hancock rule:
Dermatomal pain location
Sensory deficit
Reduced reflex
Motor weakness
disc herniation definition and symptoms
- Displacement of intervertebral disc (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space
- Paresthesia, sensory changes, loss of reflexes
which disc herniation has the best prognosis with treatment
sequestration ; 96% regression, 43% disappearance
which disc herniation has the worst prognosis with treatment
bulging disc ; regression 13%, complete disappearance 11%
bulging disc description
loss/damage of annular fibers allows nucleus pulposus to shift without herniation
herniated disc- protrusion/ prolapse definition
focal distension of the disc
-annulus fibrosis remains intact
herniated disc- extrusion definition
nucleus palposus breaks through annulus fibrosis
-remains in the disc
herniated disc- sequestration definition
-nuclus palposus breaks through annulus fibrosis and is discplaced from the side of extrusion
-subtype of extrustion
L3-L4 disc (L4 nerve root)
reflex
motor exam
sensory exam
Patellar
Ankle dorsiflexion
Medial malleolus
L4-L5 disc (L5 nerve root)
reflex
motor exam
sensory exam
None but Asymmetric hamstring reflex
Great toe dorsiflexion
Dorsal third metatarsophalangeal joint
L5-S1 disc (S1 nerve root)
reflex
motor exam
sensory exam
achilles
Ankle plantar flexion
Lateral heel
spondylosis vs spinal stenosis vs spondylolysis vs spondylolisthesis
- spondylosis: an umbrella term for age-related degeneration of the spinal column (often involves degenerative disc disease and facet arthropathy)
- spinal stenosis: narrowing of the spinal canal, neural foramen and lateral recess which can lead to compression of the nerve roots and neurogenic claudication
o most commonly due to spinal osteoarthritis (degeneration of the vertebral bodies, joints and foramina due to “wear and tear”)
- spinal stenosis: narrowing of the spinal canal, neural foramen and lateral recess which can lead to compression of the nerve roots and neurogenic claudication
- spondylolysis: weakness or stress fracture through the pars interarticularis
- spondylolisthesis: the slippage of one vertebral body with respect to the adjacent vertebral body
main cause of spinal stenoniss
spinal osteoarthritis
what is spinal stenosis
narrowing or spinal canal
spondylolysis is to what part
pars interarticularis
sponylolisthesis
slippage of a vertebral body
age for spinal stenosis
60+
because of spinal osteoarthritis
what motion is diagnostic for spinal stenosis
lumbar extension
which 2 spondylos go together
50-75% of bilateral spondylolysis will have spondylolisthesis
