Lumbar Medical Diagnosis

self-limiting problem

a problem that goes away on its own

types of medical/pathoanatomical dx

1. disc lesions

2. radiculopathy

3. degenerative disc disease

4. degenerative joint disease

5. spinal stenosis

6. cauda equina

7. spondylolysis/spondylolisthesis

8. anklyosing spondylitis

9. soft tissue injury

lumbar disc lesions

• most common L4/5 and L5/S1

• more common posterolateral than posterior

• usually affects the nerve root below (L4/5 disc = L5 nerve root)

• central HNP or spinal tumor can cause Cauda Equina Syndrome

acute presentation of lumbar disc pathology

• highly variable → depends on size and position of protrusion

• can range from mild intermittent pain to constant incapacitating pain as well as leg symptoms

• can have some neurological signs

acute radiculopathy/radiculitis

nerve root becomes inflamed causing local edema which leads to further compression

• intermittent pressure leads to paresthesia and pain in the dermatome (radiculitis)

• more continuous pressure causes ischemia with loss of nerve conduction producing anesthesia, muscle weaknesss, and diminished DTRs (radiculopathy)

foraminal stenosis

• caused by any condition that reduces size of foramen, leading to nerve root involvement

• may be HNP or facet enlargement due to swelling or osteophytes

acute radiculopathy signs and symptoms

• unilateral, dermatomal, distal > proximal

• constant and severe in acute stage

• pain > at night

• movement limited

acute intervention - radiculopathy

initial care → for pain: repeated extension or flexion

• bedrest 24-48 hours/med/ice

• trial of maual traction

• monitor neuro with each visit

• should show improvement in 7-10 days

• as sx decrease, response should guide intervention

subacute intervention - radiculopathy

add AROM, gentle mobility exercises painfree (NWB) and without reproducing sx → attempt to obtain centralization

chronic intervention

continue AROM, address regional impairments, restore mobility/stability/motor control/endurance

• altered neural tissue mobility may or may not be present or mechanosensitivity related to edema, inflammation, ischemia, soft tissue restrictions

degenerative diseases of the lumbar spine

• degenerative disc disease

• degenerative joint disease

• lumbar spinal stenosis

• spondylolithesis and spondylolysis

DDD

discs get old and lost their weight → push out

DJD

arthritis → normal wear and tear → can create bone spurs

does lumbar DJD/DDD always have sx

NO it may not

DDD/DJD

• pain, stiffness, radiculopathy, canal stenosis

• trauma or degeneration

• lateral stenosis

• central/lumbar spinal stenosis

lateral (foraminal) stenosis

lateral degeneration causing the foramen to narrow, which irritates spinal nerves causing radiculopathy

lumbar spinal stenosis

= central spinal stenosis = posterior degeneration (the vertebral canal is narrowed and the cauda equina can be irritated)

lumbar spinal canal stenosis - congenital

abnormally small canal

lumbar spinal canal stenosis - acquired

DDD, thickening of ligamentum flavum, spondylolisthesis, post laminectomy, neoplasm

lumbar spinal canal stenosis - combination of congenital and acquired

degenerative changes may result in a critical decrease in available space → cauda equina produces the sx of neurogenic claudication

neurogenic claudication

nerve causing cramping

signs and sx of neurogenic claudication

• age > 65, more males than females

• history of LBP several years

• unilateral or bilateral LE sx

• weakness, burning, N/T, radiates distally

• leg pain > back pain

• pain below buttock

• may or may not have neuro sx: weakness, impaired sensation, decreased DTRs, saddle anesthesia, bowel/bladder retention

neurogenic claudication intervention

impairment based → will fit more than 1 classification

neurogenic claudication aggravating factors

prolonged extension → walking downhill (compensate by flexing forward, slowing gait, leaning on objects like shopping cart)

neurogenic caludication easing factors

no pain with sitting or flexion, eases slowly with flexion/sitting/squat

how do both neurogenic and vascular claudication present

both can present as bilateral leg pain with walking

vascular claudication is a sx of what

= a sx of peripheral artery disease

vascular claudication signs and sx

• > 50

• pain in buttocks, calves, thighs → radiates proximally wth cramping, aching, squeezing

• CV risk factors

• worse with walking → set distance to see how long sx come on

• eases rapidly with standing still

• no neuro symptoms

• peripheral pulses usually present

• no change in sx with lumbar position

2 stage treadmill tests

differentiates b/w vascular claudication

• compare level walking vs walking on 15% incline

  • measure time until sx produced or exacerbated

  • neurogenic feels better when walking on incline

lumbar spinal stenosis diagnostic support tool

1. bilateral symptoms

2. leg pain > back pain

3. pain during walking/standing

4. pain relief upon sitting

5. age > 48 years

lumbar spinal stenosis: PT vs surgery

PT (6 weeks) had similar outcomes as decompression surgery among patients with LSS who were surgical candidates

LSS: PT intervention

manual therapy with body weight supported treadmill walking and exercise improved at 6 weeks and maintained improvement at 1 year

• also BWS treadmill, cycling, heat, traction, flexion

cauda equina syndrome

surgical emergency!!!

• large central disc herniation at L5-S1 entrapping nerve supply to bowel and bladder

• may also be due to inflammatory or neoplastic disease

cauda equina intervention

• immediate referral to orthopedic surgeon/neurosurgeon

• if not treated within 48 hours, outcome is poor → LE neuro impairment, lifelong bowel and bladder problems

signs and symptoms of cauda equina syndrome

• saddle anesthesia/perianal area

• urinary retention

• fecal incontinence due to loss of sphincter tone

• onset may be sudden or over hours to 1-2 days

• mixed LMN signs (uni or bi) → multiple levels, weakness, decreased/absent DTRs

spondylolysis

stress fx involving pars interarticularis (between the superior and inferior facet)

spondylosis

lumbar spine degeneration → general term

spondylolisthesis

when spondylolysis defect is bilateral, a separation of anterior and posterior elements may occur → stress fx worsens to a frank fx and slippage occurs

spondylolisthesis most common site

L5-S1

signs and symptoms of spondylolithesis

• most common in 10-15 yo, activities with ext (swimming, gymnastics, football)

• sx can be mild and overlooked

• can occur in older population due to DJD

• hurts with extension

• neg neuro signs

• better with rest

• most heal with conservative tx

PT intervention of spondylolithesis

• response to repeated movement guides exam and intervention

• stabilization → motor control

• neural posture education

• may need to avoid heavy labor and vigorous physical activity

• if conservative tx fails, fusion may be necessary

ankylosing spondylitis

= bamboo spine

• type of rheumatoid arthritis

• autoimmune, chronic inflammatory spondyloarthropathy → may progress to ossification of everything

• can result in systemic multi-system disease (fatigue, CVD, lung, kindey, eye)

signs and sx of anklyosing spondylitis

• insidious onset 15-40 yo, M > F

• blood test for HLA-B27

• loss of lumbar lordosis, increased thoracic kyphosis, eventual stooped-over position

• mobility loss is bilateral and symmetric

• most LOF within first 10 years

• assess chest expansion (< 2.5 cm at 4th intercostal space)

HLA-B27

blood test for anklyosing spondylitis → highly indicative of caucasian with AK but not as high for african americans or those with a mediterranean background

clinical prediction rule for ankylosing spondylitis

1. morning stiffness > 30 mins

2. improvement in back pain with exercise but not rest

3. nocturnal awakening (2nd half of the night)

4. alternating buttock pain

*if ¾ criteria present = +LR of 12.4

ankylosing spondylitis intervention

• maintain mobility of the spine as long as possible

• mainstay → prone with ext, breathing, address flexion contracture, aquatic therapy for breathing and ext

mainstay

daily moderate exercise (land or water)

pharmacological intervention for ankylosing spondylitis

1st line NSAIDS, TNF-blockers

soft tissue injuries and/or pain

• ligament injury → sprains and tears

• tendon injury → strains and tears

• muscle injury → strains and tears, trigger points

when should you use TBC/CPG Dx

>6-8 weeks and into chronic timeframe

active trigger point

hyper-irritable nodule located within a taut band of skeletal muscle

primary trigger point

main complaint of pain

latent trigger point

pain only with excessive stimulation/palpation; not the pt recognized pain

secondary trigger point

located in synergistic and antagonistic muscles