MSK 1 Lumbar

Lumbar pain

Pain, muscle tension, or stiffness below the costal margin and above the inferior gluteal folds, with or without leg pain

Acute lumbar pain

Subacute lumbar pain

1–3 months

Chronic lumbar pain

3 months; NIH definition also includes pain on at least half the days during the past 6 months

Non-specific low back pain (NSLBP)

Low back pain without a recognizable specific pathology

LBP — symptom or disease?

A symptom, not a disease

How common is NSLBP?

85% of patients with LBP are diagnosed with non-specific LBP

NSLBP clinical presentation

Variable; may include pain, mobility deficits, weakness, soft-tissue tightness, and ROM loss

Goal with NSLBP examination

Find the concordant pain, identify priority impairments, and match treatment to them

NSLBP pathogenesis

May involve pathoanatomical and biopsychosocial factors, maladaptive coping, deconditioning, and altered pain mechanisms

NSLBP acute classification

NSLBP subacute classification

6–12 weeks

NSLBP chronic classification

12 weeks

Mechanical/tissue-based spinal pain

Symptoms are usually predictably aggravated or relieved by movement, posture, or load

Non-mechanical spinal pain

Pain cannot be consistently reproduced, changed, or reduced during the mechanical exam

Major non-mechanical spinal pathologies

Cancer, cauda equina syndrome, vertebral fracture, infection, and myelopathy

Major mechanical/tissue-based conditions

NSLBP, radiculopathy, disc herniation, stenosis, instability, spondyloarthropathy, and sprain/strain

Predictors of LBP chronicity

Nerve-root pain/specific pathology, severe acute pain, work-related beliefs, psychological distress, psychosocial factors, compensation, and time off work

Time off work and prognosis

Longer time off work decreases the probability of returning

General non-mechanical signs/symptoms

Night pain, cancer history, trauma, bowel/bladder dysfunction, poor bone density, fever/infection, and psychosocial factors

Red flag screening

History/examination findings that may indicate serious pathology

History of cancer + unexplained weight loss

Highly specific combination for concern about spinal cancer

Spinal cancer findings to recognize

Older age, night pain, unexplained weight loss, rest pain, urinary retention, and history of cancer

Cauda equina syndrome (CES)

Compression of cauda equina nerve roots disrupting LE motor/sensory function and bladder function

CES — UMN or LMN?

Lower motor neuron syndrome

Major CES findings

Rapid symptoms, back pain, urinary retention, loss of sphincter tone, sacral sensation loss, and LE weakness/gait loss

CES urinary retention

Major red flag; slide reports 90% sensitivity

CES sacral sensation loss

Major red flag; slide reports 85% sensitivity

CES rapid symptom progression

Symptoms developing within 24 hours are a major concern

Suspected CES action

Urgent medical referral

Vertebral fracture risk factors

Trauma, older age, osteoporosis, and corticosteroid use

Spinal infection risk factor emphasized

Immunocompromised/immunosuppressed patient

Spinal infection presentation

Fever >100

5°F, night pain, extreme tenderness, chills, reduced appetite, fatigue, drug abuse, and immunosuppression

Examples of spinal infections

Osteomyelitis, disc infection, infective myositis, meningitis, post-surgical infection, and intraspinal abscess

Myelopathy

Pathological condition from incursion or compression of the spinal cord

Causes of myelopathy

Trauma, degenerative changes, disc herniation, and tumor

Myelopathy signs/symptoms

UMN signs, bowel/bladder dysfunction, dysphagia/dysarthria, ataxic gait, LE weakness before UE weakness, and diffuse/non-dermatomal numbness

Myelopathy clinical prediction rule

Ataxic gait, +Hoffman, +inverted supinator, +Babinski, and age >45

Bilateral neurological symptoms should make you think of what?

Myelopathy or stenosis rather than a typical unilateral radiculopathy

Lumbar radiculopathy

Pain/symptoms caused by compression or irritation of lumbar nerve roots

Possible causes of radiculopathy

Foraminal narrowing, mobility deficits, disc herniation, or spondylopathy

Radiculopathy requires what two components?

Mechanical compression/tension AND a chemically mediated inflammatory reaction

Lumbar radiculopathy presentation

LBP/hip/leg symptoms with numbness, tingling, paresthesia, and possibly weakness

Pattern of lumbar radiculopathy

Dermatomal/myotomal

Typical laterality of radiculopathy

Usually unilateral

LE weakness with radiculopathy

May indicate symptoms have progressed

Sciatica

Term commonly used for radicular pain/numbness involving the low back, hip, buttock, leg, or foot

Radiculopathy examination priority

Lower-quarter screen

Primary disc herniation

Disc protrusion, prolapse, extrusion, or sequestration in which disc material enters nerve-root or spinal-canal territory

Most common lumbar disc disorder

Posterolateral disc bulge/herniation

Why are posterolateral herniations common?

Posterior longitudinal ligament is centrally located and posterolateral annular laminae may be weaker

Disc herniation presentation

Back pain that may progress to radiating leg pain, radiculopathy, or referred pain

Disc herniation symptom pattern

May be dermatomal/myotomal

Disc herniation pain quality

Often deep and ill-defined

Disc herniation — flexion

Commonly worse with flexion and sitting

Disc herniation — positions that may improve symptoms

Walking, prone positioning, standing/moving

Disc herniation special tests

Slump and SLR may be positive

Disc herniation and centralization

Symptoms may centralize with the patient's directional preference

Disc herniation prevalence pattern

More common in patients <40 and heavy-lifting occupations

Does herniation size determine symptoms?

No; size alone does not reliably predict pain or failure of conservative care

How should lumbar imaging be interpreted?

In the context of the patient's clinical presentation

Disc abnormalities on imaging

Do NOT definitively diagnose the patient's source of symptoms

Important disc-language takeaway

Discs don't slip

Lumbar spinal stenosis

Narrowing of neural space centrally in the vertebral canal or laterally in the intervertebral foramen

Lumbar stenosis onset

Usually insidious

Typical stenosis history

Previous LBP that gradually worsens

Typical stenosis symptoms

Bilateral leg pain/paresthesia, heaviness, fatigue, or burning in the buttocks, thighs, calves, or feet

Stenosis aggravating factors

Standing and walking

Stenosis relieving factors

Sitting or lumbar flexion

Lumbar stenosis cluster

Bilateral symptoms, leg pain > back pain, pain with walking/standing, relief with sitting, age >48

Neurogenic claudication

Symptoms from neural/spinal compression that improve with lumbar flexion

Vascular claudication

Symptoms from vascular narrowing/peripheral ischemia that do NOT change with lumbar flexion

Key neurogenic vs vascular finding

Improvement with lumbar flexion supports neurogenic claudication

Spondylolysis

Unilateral or bilateral fracture defect of the pars interarticularis

Spondylolysis can lead to what?

Spondylolisthesis

Spondylolisthesis

Translation/shift of one vertebra relative to another

Grade I spondylolisthesis

Grade II spondylolisthesis

25–50% shift

Grade III spondylolisthesis

50–75% shift

Grade IV spondylolisthesis

75% shift

Spondylolisthesis population

Common in adolescent athletes; females > males

Spondylolisthesis presentation

Persistent LBP, paraspinal spasm, possible buttock/leg symptoms, neurological symptoms, and palpable step deformity

Step deformity

Observation associated with spondylolisthesis

Spondyloarthropathy may also be called

Spondylosis, degenerative disc disease, internal disc disruption, degenerative joint disease, or lumbar osteoarthritis

Spondyloarthropathy dominant impairment

Stiffness

Spondyloarthropathy morning symptoms

Pain/stiffness worse in the morning and improves within <1 hour after rising

Spondyloarthropathy pain quality

Deep aching pain

Spondyloarthropathy response to movement

Decreases with movement but may increase after extended activity

Spondyloarthropathy neurological findings

No significant neurological signs

Structural/pathoanatomical language with patients

Can increase beliefs that the body is vulnerable and reduce confidence with activity

Ankylosing spondylitis

Inflammatory arthritis affecting the spine and large joints

Typical AS demographic

Male predominance and <40 years old

AS onset

Insidious LBP

AS morning stiffness

1 hour

AS pain

Intermittent aching; may have sharp pain followed by aching

AS SI symptoms

Bilateral SI pain may refer into posterior thighs

AS neurological findings

Typically none

AS ROM

Restricted lumbar AROM and PROM

AS systemic symptoms

Fever, fatigue, weight loss, anemia, and cardiac symptoms