3 - Lumbar Spine Exam and Eval Considerations, and Selected Lumbar Pathologies

in addition to normal exam and eval, what should we also consider?

- risk for complicated course of treatment

- any signs of serious pathology

what is considered a complicated course of lumbar spine?

- lower back pain that is persistent, severe, and accompanied by additional symptoms

- S/S: numbness, weakness in legs, bladder dysfunction, or significant functional limitations, often req extensive diagnostic evaluation

- complex Tx plans making it difficult to manage compared to simple muscle strain or mild back pain

Risk factors for adverse prognosis or complicated course LBP (10)

- genetics

- Possibly age, over 40 or 50

- Education and socioeconomic class

- race

- Physical workload - especially driving with vibration

- Pain radiating to leg (sciatica)

- Smoking

- Obesity

- Psychosocial factors

- Comorbidities

indicators of serious pathology (4)

- neurological findings over multiple levels

- unexplained wt loss, night pain (not affected by position)

- bowel/bladder dysfunction (cauda equina)

- unexplained abdominal pain and backache

when is a neurological finding over multiple levels NOT AN INDICATOR for serious lumbar pathology

Except at L4/L5 OR central disc protrusion

Indicators of LBP not related to low back

- doesn't fit pattern

- unable to reproduce or affect symptoms

types of Lumbar IVD (interventricular disc) lesions (3)

- Prolapse

- extrusion

- sequestration

IVD prolapse

NP bulges to strain but not escape outer AF and PLL

~ bulging disk

IVD Extrusion

Nuclear material remains attached but escapes AF and/or PLL to bulge posteriolaterally into intervertebral foraminal space

~ some disc material exposed

~ inflammatory response, chemical reactions to remove NP in spaces

IVD Sequestration

Nuclear material escapes disk and becomes free fragment in intervertebral foraminal space

- indiv MIGHT feel better compared to extrusion

Prognosis is ____. what is the %?

good

- 50% recover in 2 wk

- 70% recover in 6wks.

IVD: When may surgery be indicated?

After 4-6 wks if symptoms persist

IVD lesions: 10-40% complain of symptoms _______ (before/after) surgery

AFTER

IVD Lesions: what % may have resolution of symptoms over time with conservative tx?

66% (2/3)

prognosis for IVD lesions improves with what other factors? (3)

- >50% leg pain reduction in 6wks

- no spinal stenosis

- progressive return of neurologic deficit within 12 wks

prognosis for IVD lesions worsen with what factors? (4)

- less leg pain reduction in 6 wks

- progressive neurologic deficit

- spinal stenosis

- positive crossed SLR

other factors affecting the prognosis of IVD lesions: (3)

- educational level

- workers comp

- psychosocial issues

Peak incidence of IVD lesions

30 - 55 yo pts

does IVD lesions typically have acute or delayed onset?

delayed onset

- might feel sharp strain, pop, "crick"

- Will start developing more symptoms the next day

MOI for lumbar IVD lesion often involves what 3 things?

- sustained or repeated lifting

- bending and rotation

What aggravates lumbar IVD lesions? (3)

- sitting - may wt shift or stand to relive symptoms

- flexion

- sometimes extension

what is the pain pattern for lumbar IVD lesions? (during the day)

- acute on arising

- resolves w movement

- worsens as day progresses

80% of IVD lesions affect what nerve root levels?

L4 OR L5 nerve root

what disc levels are commonly herniated in IVD lesions? 80% - 90% of IVD lesions affect

- L4-L5 disc

- L5-S1 disc

10% of IVD hernations are

L1-2 and L3-4

Lumbar IVD lesions - radiculopathy

- radiculopathy in 95% sensitive for IVD lesion BUT only 88% specific

Observations in pts w/ lumbar IVD lesion

- possible pelvic shift

- SB away from involved side (occasionally toward)

- noticeable flexion w/ central bulge (rare)

- slight flexion if nerve root is involved

if a patient is right side bent with pain on the left, what is the location of the lesion?

lateral lesion

- lateral = away

if a patient is left side bent with pain on the left, what is the location of the lesion?

- medial lesion (TOWARD)

Neuro findings for lumbar IVD lesion

- decreased sensation, DTR

- weakness w NR involvement

- change in pain as NR compression resolves (numbness v pain)

- centralization of symptoms

centralization is

symptoms moving from distal to proximal (good sign)

what is better, numbness or pain?

Can get worse as NR compression resolves - numbness --> progression --> worsening pain

- better if numbness resolves to pain

APR w/ lumbar IVD lesion

- gross limitations in ROM

- flex and SB toward painful side is common

- extension past neutral may be painful (esp acute)

- may note deviations during flexion

IVD lesion APR - resistive may be painful due to

valsalva effect

what motion typically painless with IVD lesions?

rotation - doesn't change foraminal space

Palpation of lumbar IVD lesion?

- Segmental changes - bc segmental innervation

- Spasm of quadratus

- paraspinals

- segmental spasm of multifidus

Special tests for Lumbar IVD lesion

- Valsalva positive

- Compression (heel slam)

- SLR

- Crossed SLR

- Slump (reverses lordosis)

- Heel Toe Walking (functional or quick test)

heel toe walking indicates

anterior tib and gastroc --> may not elicit weakness

- Walk on tip-toes - look for heel of affected side drifting down (nerve weakness)

- Then walk on heel - toe will start to drift downward on last few steps

Segmental mobility PPVIM w/ lumbar IVD lesion

- positive shear test at segment

- regional hypermobility

- distant hypomobility

- acute gaurding may limit mobility testing