Lumbar Spine

what is the most prevalent pain complaint?

lower back pain

what are risk factors associated with back pain?

smoking, obesity, age, female, physically strenuous or sedentary work, psychologically strenuous work, job dissatisfaction

how many pairs of facet joints in lumbar spine? what movement is most restricted? CPP? capsular pattern? how much of the axial load do normal discs carry?

5

rotation

extension

side flexion and rotation are equally limited followed by extension

20-25%, if degenerated up to 70%

function of the intervertebral disc

shock absorber and holds vertebra together

allows movement between bones

separates the vertebra and allows nerve root passage through the IV foramen

annulus fibrosis criss cross and resist torsion

nucleus pulposus is 85-90% water and decrease to 65% with age

does the IVD have nerve supply?

no, except the peripheral annulus

IVD receives nutrition by diffusion

what are pain sensitive structures around the IVD?

anterior and posterior longitudinal ligaments, vertebral body, nerve root, cartilage of facet joint

what is the vertebral end plate?

important structure that borders the IVD

portion of the endplate that is nearest the IVD is composed of fibrocartilage where it binds to the nuclear and annular regions

portion that is nearest the vertebral body is mostly hyaline cartilage

this area is believed to be the weak link when the IVD is exposed to trauma

how does lumbar degenerative disease occur?

strongly linked to genetic factors

progression is from environmental factors

injury to outermost annulus or subchondral bone adjacent to injured vertebral end plate can trigger LBP

protrusion, prolapse, extrusion, sequestration

protrusion - disc bulges posteriorly without rupture

prolapse - only the outermost fibers of the annulus contain the nucleus

extrusion - the annulus is perforated and disc material moves into the epidural space

sequestration - discal fragments from the annulus and nucleus escape. may put pressure on spinal cord or cauda equina

what are outcome measures for lumbar?

oswestry modified disability index

FABQ

PSFS

patient history

age

disc problems 15-40 yrs

ankylosing spondylitis 18-45 years

osteoarthritis/spondylosis >45 yrs

malignancy >50 yrs

occupation - strenuous occupations, truck drivers, sitting

mechanism of injury for lumbar pathology

lifting - force on disc (10x weight lifted)

pressur eon discs vary with position

prolonged sitting

predisposing factors - poor sitting posture, frequently bending forward, heavy lifting, and working in stooped over positions for long periods of time

sites and boundaries of symptoms

radiation - dermatome

deep, superficial, burning pain

acute <3-4 weeks, subacute up to 12 weeks, chronic >3 months

worsening, unchanging or improving

coughing, sneezing increases intrathecal pressure

what does pain after rest indicate?

ankylosing spondylitis

how does mechanical pain usually present?

increased with certain activities, decreased with others. often relieved at rest

discogenic pain is increased with

prolonged sitting especially in flexion

pain in AM, PM, or as day progresses

OA pain is worse in Am and relieved with activity

painful arc is common with?

disc pathology

what suggests nerve root involvement?

paresthesia

what are symptoms of cauda equina syndrome?

retention of urine, incontinence with bowel and saddle anesthesia. myelopathy

what are possible red flags?

thoracic pain

fever and unexplained weight loss

bowel and bladder dysfunction, saddle anesthesia

CA

othe rmedical illness, trauma

progressive neurological deficit

disturbed gait

gae <20, >55

night pain or pain at rest

CA metastases to spine usually comes from

breasts, prostate, lung, kidney, thyroid

T/F most single positive red flags significantly increase the likelihood of serious disease.

does not

what are yellow flags?

psychosocial factors can indicate chronicity and disability

negative attitude - feeling tha tback pain is harmful or disabling

fear avoidance behaviors - decrease activity level

expectation of passive rather than active treatment

depression, low morale, social withdrawal, financial problems

what should you observe in exam?

body type, gait, attitude, willingness to move

posture - lumbar lordosis, sitting, standing, lateral shift

shoulders are level - arms equal distance from trunk

neutral pelvis - ASIS slightly lower than PSIS, iliac crests and ASIS same height

what landmarks should be aligned when observing posture from side view?

ear lobe, acromion, iliac crest high point

what should you observe about posture in anterior posterior view

symmetry of scapula, step deformity spondylolisthesis, hair patch (spina bifida), skin markings (neurofibromatosis), scoliosis

what is pelvic crossed syndrome?

effect of muscle imbalance in the pelvis

weakness in abdominals and glute max

tight muscles in hip flexors and back extensors

multifidus weakness, hamstring tightness

causes increased lumbar lordosis

what to observe in examination of lumbar spine?

active movements - pt standing

differences in ROM

overpressure in sustained posture

repeated movements

SLS stance Trendelenburg sign

willingness to move and deviation during movement

what is peripheral joint clearing

clearing the hip, knee, ankle via P/AROM

SI joint by palpating SI and sacral spine, PSIS should drop with hip flexion, SI provocation tests

what are myotomes for lumbar spine

L2 - hip flexion

L3 - knee extension

L4 - ankle dorsiflexion

S1 - ankle plantarflexion (standing)

S1 - ankle eversion

L5 - toe extension

S1 - hip extension

S1-S2 - hamstring

what is normal value for active motion of the lumbar spine?

flexion of 40-60º, T12-S1 tape measure should be 7-8 cm

extension - 20-35º standing or prone

side bending - 15-20º standing or sitting

where does most of the motion occur in lumbar spine?

L4-L5 and L5-S1

what to observe in AROM flexion?

differentiate lumbar, thoracic, hip motion

hypomobility

greater injury - greater loss of motion (disc)

instability - juddering on return to standing

bending knees - tight hamstring or nerve root involvement

painful arc of motion

if lateral flexion to the painful side increases symptoms, lesion is most likely _____.

intraarticular

disc patients deviate to/away from the painful side

away

what motions most likely exacerbate facet syndrome symptoms?

extension and rotation

flexion in standing takes place from ___ to ____.

flexion in lying takes place from ____ to ____.

top, bottom

bottom, top

can you test PROM on lumbar spine?

difficult ot perform because of body weight

if AROM is full, overpressure can be applied, safer to test end feel with accessory motion testing

may perform isometric tests sitting or MMT on abdominal and back extensor muscles in lying

what is considered a positive test for lumbar spine special tests?

reproducing pt’s symptoms

what is the most common neurological test for the lower limb?

slump test

what do you look for in the slump test

neurological test

look for reproduction of pt’s pathological sx, sciatic type pain, not just sx

what is the pt position for the slump test?

sitting on edge of table, pt leans forward examiner holds chin upright

neck flexion, knee extension, ankle dorsifllexion

what is the straight leg raise test?

passive test where each leg is tested individually

hip IR and adduction, SLR to pain, then lower slightly and add ankle DF then add neck flex

positive test is 35-70º

what is sensitizing?

stretching the dural tissue of the spinal cord

what is the prone knee bending test?

pt is prone, and passively flex knee as far as possible

stretches the femoral nerve, pain in anterior thigh

sx have to different than other side to be positive

what is the prone instability test?

pt prone over exam table, legs over edge with feet on floor. pain is assessed

examiner applies pressure to lumbar spine and pain is assessed again

pt then lifts legs off floor again and pressure is applied to lumbar spine

if pain is only produced in step one, then the test is positive for instability

what is passive accessory intervertebral motion (PAIVMs)?

vertebral mobs

assess motion, end feel, pain

PACVP

posterior anterior central vertebral pressure - apply pressure in spinous process

PAUVP

posterior anterior unilateral vertebral pressure

apply pressure on lamina or transverse processes

TVP

transverse vertebral process

fingers along side spinous process

what is radiculopathy and causes?

refers to sx or impairments related to a spinal nerve root (90% L5-S1)

damage may be caused by degenerative changes of vertebrae or disc protrusion

pts present with pain, sensory loss, weakness and reflex change

what is sciatica?

non-specific term used to describe a variety of leg and back sxs

usually refers to a sharp or burning pain radiating down from the buttock along the course of the sciatic nerve

spinal stenosis

typically patients >60 yrs

can be caused by degenerative arthritis - spondylosis

hallmark is neurogenic claudication - ambulation induced pain in the distal LE resolved with sitting or leaning forward

what is nonspecific LBP? prognosis? causes? primary complaints?

the patient has back pain the absence of a specific underlying condition that can be reliably identified

many may have MSK pain and often improves in a few weeks

any structure that has a nerve supply is capable of triggering the nociceptive process

pain is usually the prime concern of the pt

osteoarthritis

LBP, OA of facet joints of spine

pt >40 yrs may have OA of the hips as well

aggravated with activity decreases with rest. may lead to stenosis

what are other etiologies for LBP?

OA

piriformis syndrome - compression of sciatic nerve

SI joint dysfunction

scoliosis and hyperkyphosis

psychologic distress

pancreatitis, aortic aneurysm, etc

spondylosis

a general term for nonspecific degenerative changes in spine

spondylolysis

unilateral defect in the pars interarticularis

spondylolisthesis

forward displacement of one vertebra over another

osteoporosis

loss of bone mass that occurs with aging, disuse, hormonal or metabolic disorders or drug use

what population often present with spondylolysis?

line men, gymnasts, people with lots of LB extension

motions that reproduce sx of spondylolisthesis?

SB, rotation, closing down space (extension), better with flexion

*where you feel the step-off is at the level above where the fx is

what is ankylosis spondylitis? population? sx?

chronic polyarthritis leading to fusion of the SI and intervertebral joints

usually in males (35-45 yrs)

sx: morning stiffness, pain >3 mo, decreased chest expansion, early sclerosis of SI joint on X-ray

lumbar instability

implies that during movement there is brief loss of control. the segment may be structurally unstable

what causes radiculopathy? what is the most common area in the spine?

the disc between the 2 vertebra where the nerve root exits from

L5-S1 is most common site of problems because it bears more weight, increased stress and greater angle

what is spinal stenosis? sx?

narrowing of the spinal canal resulting in compression of neural tissue, congenital or degenerative (usually pt is >50 yrs)

sx: increased with standing, walking, extension. sx may be unilateral or bilateral. stenosis may be stable or progressive

neurogenic claudication

inflammation of the nerve emanating from spinal cord. the pt feels a painful cramping or weakness in the legs

what % of pts will have a serious systemic etiology?

1%

what are some serious systemic etiologies?

spinal cord or cauda equina compression

metastatic cancer

spinal epidural abscess - rare (fever, malaise)

vertebral osteomyelitis - risk increases with age and men more affected

spinal neoplasm - <1% of pts with LBP older than 50 yrs

spinal infections (often from other sites like UTI, indwelling catheters, IV drug use, skin lesions)

what are the types of spine pain?

acute, subacute, recurrent, chronic

know how to differentiate between LBP with mobility deficits, movement coordination impairments, referred/radiating pain, and cognitive or affective tendencies.