Lumbar Spine

What % of low back pain is non-specific

90%

What % of lumbar extension and what % of lumbar flexion + lateral flexion are lost as we age

80%; 50%

True or False: As we age, there is increased ligamentous laxity but can also be ligamentous calcification

True

What is “SINSS”?

Severity
Intensity
Nature
Stage
Stability

What is MCID for Numeric Rating Scale? Oswestry?

2 points
10 points

Why perform an evaluation?

Assess pain related physical and psychological distress
Collect baseline information

What should the physical exam look like for LB?

Inspection
Palpation
ROM
MMT
Endurance testing
Special testing
Gait
Balance
Segment Mobility

What are 3 signs that a neural component is contributing to a patient’s back pain?

- Reproduction of familiar symptoms
- Contralateral motion asymmetry
- Symptoms change with distant component

What physical exam findings can point to possible malignancy/tumor?

- Constant, nonmechanical pain
- Worse at night or with WB
- Neurologic signs

What physical exam findings can point to possible spinal infection?

- Deep constant pain
- Fever, malaise, swelling
- Spinal rigidity / decreased mobility

What physical exam findings can point to possible cauda equina syndrome?

- Saddle/perineal sensory loss
- LE neurological deficits
- weakness of dorsiflexion, toe extension, plantarflexion

What physical exam findings can point to possible spinal fracture?

- Focal point tenderness
- Marked tenderness with palpation
- Increased pain with weight bearing
- Local edema

What physical exam findings can point to possible abdominal aortic aneurysm?

- Abnormal aortic/iliac pulses
- Abnormal bruit

What is Spondyloarthritis?

A group of inflammatory rheumatic conditions that primarily affect the spine and sacroiliac joints, causing pain and stiffness (predominantly axial or peripheral involvement)

What is Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

Pathologic calcification of the spine resulting in intersegmental fusion

What is Arterial Claudication?

Spine related causes of LE symptoms that worsen with exertion and ease with rest

True or False: Organ referrals such as prostatitis, endometriosis, and ovarian cysts can present or cause LBP

True

What would Polynephritis present as?

Fever
Flank Pain
Costovertebral angle tenderness

What would Nephrolithiasis present as?

Sudden, sharp, cramping pain (colicky pain)
Possibly accompanied by hematuria, nausea, and vomiting

What are some GI disorders that can cause organ referral that cause LBP?

Pancreatitis
Appendicitis
IBS

What are the 7 “LBP with Spine-Related Leg Symptoms” categories?

- Lumbar Radiculopathy
- Lumbar Radiculopathy from disc herniation
- Lumbar Radicular Pain
- Neurogenic Claudication
- Dynamic lumbar instability from Spondylolisthesis
- Deep Gluteal Pain Syndrome
- Somatic Referred LE Pain

What is Lumbar Radiculopathy?

Compression or irritation of a lumbar spinal nerve root, causing radiating pain, numbness, tingling, or weakness along the nerve’s distribution

True or False: For Lumbar Radiculopathy dermatomal deficits are more predicative of the associated nerve root

False; myotomal

In Lumbar Radiculopathy what could be compressing the nerve root?

Tumor
Infection
Somatic Tissues

What is PT Management for Lumbar Radiculopathy?

- Symptom control (acute first 6 weeks)
- Centralization
- Exercises in directional preference
- Progress to strength training and neural mobility based on soft tissue healing principles and patient response

Where can Lumbar Radiculopathy from Disc Herniation occur?

Centrally
Paracentrally (most common)
Far Laterally

What do far lateral disc herniations often affect?

Exiting nerve roots

True or False: Individuals with Lumbar Radiculopathy from Disc Herniation often report worse symptoms at the night

False; morning

What is the PT Management of Lumbar Radiculopathy from Disc Herniation?

- Patient counseling
- Directional preference exercises
- Exercise therapy
- Traction (short term benefit)
- Neural mobilizations
- Manual therapy

What % of patients with Lumbar Radiculopathy from Disc Herniation recover in 12 weeks.

60-80%

What is Lumbar Radicular Pain?

Pain that radiates from the low back into the leg along the distribution of a lumbar spinal nerve root.

What are common signs/symptoms of lumbar radicular pain?

- Nerve root inflammation
- Numbness
- Tingling
- Muscle weakness
- Loss of reflexes
- Symptoms may not follow a specific dermatomal pattern.

What is lumbar radicular pain typically described as?

Lancinating pain that occurs in a narrow band (<3 inches wide) and may be non-dermatomal

How may lumbar radicular pain be described?

Electric, burning, stabbing, and unpredictable pain

What would physical exam look like for lumbar radicular pain?

Reduced neural mobility without signs of neurological conduction deficits

What is Neurogenic Claudication?

Intermittent compression of nerves in lumbar canal or foramina

For individuals >48 with Neurogenic Claudication, are symptoms worse in the LE’s or low back?

LE’s (aggravated by standing or ambulation but ease with sitting)

Difference in Neurogenic Claudication vs Arterial Claudication?

Neuro = worse stand/walk/extension, better sitting (flexion)
Arterial = worse stand/exertion, better stopping activity regardless position

What are some physical exam findings for individuals with Neurogenic Claudication?

- Stooped posturing
- Wide based gait
- Reduced sensation
- Hyporeflexia
- Myotomal weakness at affected levels

True or False: In individuals with Neurogenic Claudication, neurological symptoms typically improve with prolonged ambulation

False; worsen

What is dynamic lumbar instability from spondylolisthesis?

Excessive or abnormal movement between lumbar vertebrae due to vertebral slippage, causing spinal instability and potentially pain or neurological symptoms

How is Dynamic Lumbar Instability from Spondylolisthesis diagnosed?

With dynamic flexion-extension radiographs

What would clinical presentation look like for individuals with lumbar instability from spondylolisthesis?

- Increased lumbar lordosis
- Lumbar hypermobility with segmental testing
- painful catching sign with lumbar flexion***

What two tests are appropriate for Dynamic lumbar instability from spondylolisthesis?

Prone Instability Test
Passive Lumbar Extension Test

What is the “cluster” (4) for dynamic lumbar instability from spondylolisthesis?

- Apprehension sign
- Instability catch sign
- Painful catch sign
- Prone Instability test

What is deep gluteal pain syndrome?

Pain caused by compression or irritation of the sciatic nerve in the deep gluteal region, often causing buttock pain with possible symptoms into the leg.

When should we consider Deep Gluteal Pain Syndrome?

When the lumbar spine pain had been ruled out

What is somatic referred lower extremity pain?

pain felt in the lower extremity that originates from a spinal or musculoskeletal structure, rather than from the nerve root itself

True or False: Somatic Referred LE pain is not expected to follow a dermatomal pattern

False

What are some potential MSK causes of LBP?

- Strain/Sprain
- Myofascial Pain Syndrome
- Facetogenic
- Vertebrogenic
- Discogenic
- Spondylosis

What is LBP strain/sprain associated with?

Acute event

What are key features of myofascial pain syndrome?

Hyperirritable myofascial areas, muscular deconditioning and muscle inhibition

What is Myofascial Pain Syndrome?

A condition involving painful, sensitive areas in muscles and fascia, often associated with muscle tension, trigger points, weakness/deconditioning, and altered muscle activation

What is Facetogenic LBP?

Low back pain originating from the lumbar facet joints, often caused by irritation or degeneration of the facet joints.

What are the typical symptoms of facetogenic LBP?

Paravertebral pain without midline pain, with referred pain to the buttock, groin, or thigh that does not extend past the knee.

What movements typically reproduce facetogenic LBP?

Lumbar extension and ipsilateral sidebending

What is vertebrogenic low back pain?

Low back pain originating from the vertebral endplates, often associated with Modic endplate changes seen on MRI

What is discogenic low back pain?

Low back pain originating from the intervertebral disc, often due to disc degeneration or injury

What findings may suggest discogenic low back pain?

- Progressive worsening pain over the last 6 months
- Age >30
- History of repetitive bending and lifting.

What is spondylosis?

A stress reaction or stress fracture that can progress to a complete fracture of the pars interarticularis

In individuals with Spondylosis, is flexion or extension better tolerated?

Typically flexion

What are the 4 buckets for ACUTE LBP?

- Acute LBP with Mobility Deficits
- Acute LBP with Movement Coordination Impairments
- Acute LBP with Related/Referred LE Pain
- Acute LBP with Radiating Pain
- Acute LBP with Related Cognitive or Affective Tendencies

What is Acute LBP with Mobility Deficiits?

Acute LB, buttock or thigh pain that occurs following a recent unguarded/awkward movement or position

What is PT management for Acute LBP with Mobility Deficits?

- Manual therapy
- Mobilizations
- Mobility Exercises

What is Acute LBP with Movement Coordination Impairments?

Acute LB pain associated with impaired control or coordination of spinal movements, often due to altered muscle activation and poor movement patterns

How can symptoms be reproduced with Acute LBP with Movement Coordination Impairments?

Mid range motions, worse with end-range movements

What is PT Management for Acute LBP with Movement Coordination Impairments?

- Trunk activation training
- Trunk muscle strength training and endurance
- Manual therapy to thorax and hip
- Counseling on active lifestyle and activity participation

What is PT Management for Acute LBP with Related/Referred LE Pain?

- Interventions that promote centralization of symptoms (manual therapy, positioning, repeated movements, traction)
- Progress to stabilization exercises and strength training

What is PT Management for Acute LBP with Radiating Pain?

- Interventions that include neural mobilizations
- Thrust or non-thrust mobilizations
- Soft tissue mobilization
- Counseling

What is PT Management for Acute LBP with Related Cognitive or Affective Tendencies?

- PNE
- Physical activities such as aerobic exercise
- Counseling

Should they get imaging, if so what kind(s)?:

Acute LBP with or without radiculopathy

No

Should they get imaging, if so what kind(s)?:

Subacute or chronic LBP with or without radiculopathy. No red flags or prior management

No

Should they get imaging, if so what kind(s)?:

Subacute or chronic LBP with or without radiculopathy. Surgery or intervention candidate with progressive symptoms or following 6 weeks of medical management

Yes; MRI lumbar spine without IV contrast

Should they get imaging, if so what kind(s)?:

LBP with suspected cauda equina syndrome

Yes
MRI lumbar spine without and with IV contrast
MRI lumbar spine without IV contrast

Should they get imaging, if so what kind(s)?:

LBP with history of prior lumbar surgery and with or without radiculopathy. New or progressive symptoms/findings.

Yes
Radiography lumbar spine
MRI lumbar spine without and with IV contrast
MRI lumbar spine without IV contrast

Should they get imaging, if so what kind(s)?:

LBP with or without radiculopathy. One or more findings following low-velocity trauma, osteoporosis, elderly individual or chronic steroid use

Yes
Radiography lumbar spine
MRI lumbar spine without IV contrast
CT lumbar spine without contrast

Should they get imaging, if so what kind(s)?:

LBP with or without radiculopathy. One or more of following: suspicion of cancer, infection or immunosuppresion

Yes
MRI lumbar spine without and with IV contrast
MRI lumbar spine without IV contrast