4 - Selected Lumbar Pathology

Osteoarthritis - age demographic

most common in pts 45+

Osteoarthritis - pts typically have Hx of

LBP

Osteoarthritis - presentation

- stiff in AM, pain inc during day

- pain not well localized (cant pinpoint)

- does not radiate to leg (past buttock)

OA - observations

postural changes consistent w overall degeneration

~ arthritis affects facet joints --> loading with inc extension painful = flattened lordosis

OA - neuro findings

none usually present

OA - function

reduced overall motion with exception to flexion

- may req repeated motions to provoke symp if not in acute exacerbation

~ flex is reserved bc nothing is compressed

OA - palpation

palpable degenerative changes

~ abnormal/bumpy

OA - special tests

non-specific

- compression may be positive

OA - segmental mobility

consistently reduced throughout region

degenerative spinal stenosis - age demographic

most common in 65+

degenerative spinal stenosis - Hx of

LBP

what structures are often involved in degenerative spinal stenosis?

- bulging disc anteriorly

- facet hypertrophy posterioly

- thickening of ligamentum flavum

- spinal cord is compressed overtime bc less space in canal

degenerative spinal stenosis is commonly preceded by:

activities that involved extension

what are activites that aggravate degenerative spinal stenosis? relieves?

- aggravated by walking; standing for long periods of time can worsen symp

- relieved by sitting

why is degenerative spinal stenosis "seasonal"?

Often involves an activity that aggravates the condition

- Ex: going backpacking on vacation = Inc anterior tilt bc of inc stride length can create enough repeated pressure --> inc symptoms

- Ex: gardening --> In spring --> constantly reaching up (extension) in quadruped position

- Can create enough sustained extension to agg. condition

how does walking aggravate degenerative spinal stenosis?

epeated anterior pelvic tilt --> closes space

- Long stride length is often the problem

how does sitting relieve degenerative spinal stenosis?

puts you in neutral/post tilt (stops anterior pelvic tilt)

what is a hallmark for degnerative spinal stenosis?

neurogenic claudication

~ Ex: prolonged walking --> legs start to hurt bc of cord compression

~ Bilateral leg pain

~ Happens bc of neuro problem

degenerative spinal stenosis - observation

- flattened lumbar lordosis accompanied by adaptive changes

degenerative spinal stenosis - posture overtime

- Sequence of decreased --> reversed lordosis

- Increased flexion

degenerative spinal stenosis - neuro findings

- Neurogenic claudication

- May have other neurologic symptoms consistent with compression of SC or nerve roots depending on severity.

degenerative spinal stenosis - function

extension reproduces symptoms

- grossly reduced extension

- SB sometimes reproduces sx

- flexion relieves symptoms

degenerative spinal stenosis - palpation

may note degenerative changes

degenerative spinal stenosis - special tests

- compression positive

- Van Gelderens test for diff neurogenic vs vascular claudication

Van Gelderens test

- Bicycle in upright until sx appear.

- Cont bicycling in flexed position

- Symptoms will resolve in case of neurogenic claudication

neurogenic claudication is

positional - bilateral leg pain

vasular claudication is

based on oxygen demand - bilateral leg pain

- Creating enough O2 demand in LE for blood (inc exercise) --> vascular system can't supply it (requirement cant be met) --> pain in LE muscles

- Occurs when there is a blockage higher in chain (between heart and LE)

- Serious problem --> want to refer immediately to physician

degenerative spinal stenosis - segmental mobility (PPIVMS)

globally reduced segmental mobility consistent w degenerative conditions

Clinical/Segmental Instability - symptoms

- inconsistent symptoms

- repeated episodes of feeling unstable

- minor aching after episodes

- clicking/cluncking

Clinical/Segmental Instability - observation

hinging or wedging may be present

Clinical/Segmental Instability - function

excessive active ROM

- inability to return from full flexion normally

~ Flexion past end ROM (flexing too far at that segment) --> will walk up their thighs w hands

~ Will relieve moment arm

~ Tries to be in closed packed position before coming up (inc lordosis)

Clinical/Segmental Instability - palpation

pressure during palpation may generate symptoms

Clinical/Segmental Instability - special tests

nonspecific

Clinical/Segmental Instability - segmental mobility present

- shearing may be present

- may note hypermobilities

Facet Joint Dysfunction - onset is often described as

"locking up"

- associated w flexion activity & onset of acute pain when return to upright

Facet joint dysfunction: pain

- constant and severe after onset

- slowly decreases w time

Facet joint dysfunction: Hx

of similar episodes in the past

Facet joint dysfunction: MOI

- Hypermobile segment stretches facet joint capsule

- During flexion: facet joint capsule is fully elongated

- return to standing: capsule does not "retract" with sufficient elasticity to reposition capsular structures, structures are extruded or entrapped

facet joint dysfunction - observation

possible spasm, lack of willingness to move

facet joint dysfunction - neurological

not usually present

- pseudo-radiculopathy may be present

facet joint dysfunction - function

all mvmt painful

- patten varied

- resisted motions increase pain

facet joint dysfunction - palpation

spasm often in paraspinal and multifidus

facet joint dysfunction - special tests

none specific

facet joint dysfunction - segmental mobility

- hypomobile bc of spasm

- FOLLOWED by hypermobility segmentally when sx resolve

Spondylolisthesis is most common at what segment?

L5/S1

Spondylolisthesis - age demographic

- adolescents 15-20

- degenerative older population

Spondylolisthesis is most common in what gender?

Women > Men

Spondylolisthesis - palpation

step may be palpated

- Palpate - one spinous process "steps up"

- Spinous process of L5 is left behind but body is slipped anteriorly

- L4 spinous process moves anteriorly

Spondylolisthesis - what motion exacerbates symptoms?

extension

Spondylolisthesis - when does neural signs show?

if neurological structures compromised

Spondylolisthesis - shearing

is excessive