Specific low back pain

define: specific low back pain, what percentage of pain does it make up?

pain and other symptoms caused by specific pathophysiological cause, cause can be identified

makes up 10% of pain

define: herniated disc

displacement of disk material (annulus, nucleus, or both) beyond the normal perimeter of the disc

in what direction are most herniated discs?

posterolaterally

in what age groups, sex, and spinal levels do herniated discs occur?

common in 20-50 year olds, higher occurence in men, 95% occur at L4/5 or L5/S1 levels

what increases the risk of having a herniated disc?

professions requiring heavy lifting, weight-bearing sports, non-ideal postures, obesity, smoking

in what postures is disc pressure greatest?

bending over in sitting or standing, look at charts on slide 8

what are some lifting tips if someone has a herniated disc?

keep back straight, bend knees to lift, team lift, use lifting equipment, check the load, don’t bend and twist

what is a classical symptom of a herniated disc? does this mean that they have a herniated disc?

classical symptom: neurogenic pain, (radicular pain or sciatica), may be totally asymptomatic

define: sciatica

pain in sciatic nerve distribution, inappropriately used to describe any back and leg pain

define: radiculopathy

pain of nerve root origin, more specific to motor and sensory changes in nerve root

what are some ways you can decrease disc pressure, how does the body react when having a herniated disc?

ease pressure by lying, body does protective muscle spasms, paraspinal tenderness, and positive neruomeningeal signs

how does a persons posture look with a herniated disc? how is it named?

lateral shift, named according to position of shoulders relative to hips,

which is worse, contralateral or ipsilateral shift with a herniated disc?

ipsilateral shift is not very common and has worse prognosis

what symptoms does herniated disc have mechanical vs. inflammatory? what responds to remove material?

mechanical and inflammatory symptoms, macrophages respond and seek to remove material

define: protrusion, extrusion, and sequestration

protrusion: prolapse contained in that it remains covered by a layer of annulus

extrusion: breaches covering layer, but remains in contact with rest of nucleus

sequestrian: prolapsed material loses continuity with material still within disc

when is imaging necessary for a herniated disc? what imagins are discs not visible on? how many weeks should you let go by before getting imaging

progressive or severe neurological deficits, discs are not visible on x-ray, 4-6 weeks requires a CT or MRI if things are not getting better

do disc herniations need surgery? what is happening at the cellular level with disc herniations?

vasy majority do not need surgery, fragment dehydrates and its proteoglycans deteriorate

combined macrophages remove material

how long does recovery normally take? what are exercises these patients with herniated discs can do?

recovery usually in 6 weeks, exercises in directional preference, lateral shift correction

when is surgery required for a disc herniation?

for major neurological deficits with no response to conservative management and imaging confirmed nerve root compression and corresponding sciatic syndrome

define: spinal stenosis

narrowing of the spinal canal and or nerve/root canal and intervertebral foramina

in what population is spinal stenosis common in?

generally degenerative(leading indication for lumbar surgery in patients greater than 65, disk height is lost with aging

what is a proposed pathology of spinal stenosis?

increased pressure disrupts neural blood supply, this venous congestion increases venous pressure and accumulation of toxic metabolities

what are some signs and symptoms of spinal stenosis?

discomfort in lumbar spine, buttocks, thighs, may be poorly localized, unilateral or bialteral

what are exacerbating and relieving factors for spinal stenosis?

exacerbated by extension, relieved by flexion, commonly known as the “shopping cart sign”

when thinking about anatomy what are some signs that they have spinal stenosis?

increased lordosis, reduced hip flexor length (iliposoas and rectus femoris) weak glutes and core

is imaging needed for spinal stenosis?

imaging is not required initially, first line of treatment is activity modification analgesia and physical therapy

true or false: exercise helps with spinal stenosis, if so what are some exercises that are sometimes used

false; exercise evidence is sparse

postural exercises, hip flexor, lumbar stabilization, positioning through posterior pelvic tilt

what are the majority of the exercises that are supposed to help with spinal stenosis?

flexion exercises, abdominal, glute me

is surgery a fix all with spinal stenosis?

no symptoms will often recur after several years,

define: spondylolysis

defect in pars interarticularis (concave lateral part of the lamina connection superior and inferior facets

what is the etiology of spondylolysis?

congenital or acquired defect, acquired is due to a bone stress injury

in what activites and what body position are spondylolysis common in?

activites requiring hyperextension and rotation, or repetitive combined flexion and extension

gymnasts more common in females, divers, weightlifters, criquet, cheerleading

what are some symptoms of spondylolysis?

usually asymptomatic, LBP exacerbated, may radiate into buttock, relieved by rest, persistent and night pain is uncommon, rearely have neuropathic symptoms

what are the signs and tests that can be used to test for spondylolysis?

no definitive test, most common sign is limited painful extension, stork test can sometimes be helpful, second most common sign is hamstring tightness

what does imaging show about sponylolysis?

x-rays often negative, not visible until there is bone defect

what does spondylolysis look like on an xray

broken neck scotty dog

what should someone do with symptomatic spondylosis

6-12 weeks spinal bracing to limit motion and stress on pars, activity modification: cessation of aggraving activites, especially those invovling hyperextension of the spine

define: spondylisthesis

forward translation of a vertebrae and the spine above it relative to the vertebra below

what are the mechnics of a spondylolisthesis?

superior surface of sacrum angulated downwards, creates a shear force at lower lumbar spine

what does grading refer to and how many different grades are there?

the degree of slippage as a percentage of teh distance the anteriorly translated vertebral body has moved forward relative to the superior endplate of the vertebrae below

5 different grades

what are the 2 most common types of spondylolisthesis?

isthmic and degenerative

what does an isthmic spondylolisthesis mean?

need bilateral pars defect for slippage; not all patients with bilateral defects develop slippage

what is degenerative spondylolisthesis?

not related to pars defect, usually due to long standing intersegmental instability, also, abnormalities of ligamentous and structures

what is teh correlation of symptoms and grades? what is the most common complaint?

little correlation between degree of slip and symptoms, most common complaint=LBP, symptoms are variable

what type of neuropathic pain is common?

referral past the knee, more common with larger slips, resulting from lateral recess stenosis,

what is the intervention with spondylolisthesis?

depends on severity of slip, surgery is indicated for immature patients with greater than 50% slippage because they are at greater risk for progression

what are some activites that can help with conservative management?

decrease extension stresses, strengthen elements to promote antilordotic posture, flexibility to stretch spinal extensors