Lumbar Viva Questions Flashcards
- Can you outline some potential hypotheses for this patient?
Non-specific mechanical lower back pain
Spinal Stenosis
Spondylosis
Spondylolysis
Spondylolysthesis
Disc herniation
Facet joint problem
- What red flags specific to the Lx spine?
Hx of cancer
Unremitting night pain
Unexplained weight loss
Cauda equina
Saddle anaesthesia
Bladder and bowel incontinence or retention
Long term steroid use
IV drug use
Systemic illness or infection
Fever
Visceral disease
Hx of trauma
Deformity
Change in sexual function
Bilateral radiculopathy
Impaired sensation, anal tone, urinary disturbance
Advanced age
- What are the most important aspects of the physical examination and why?
Severity and irritability
> 1 month is subacute phase, would expect some healing by now = psych
Main thing to work out, is it psych driven or neurological driven
Petty 2010 stated if symptoms go bellow the ischial tuberosity or the patient has neurological symptoms = need to do a neurological assessment
If neurological assessment is negative, then re-assure the patient of this
Look at how the patient moves, are they moving from the hips and not the Lx because of anxiety
Can they flex? Try in different positions e.g. knee hugs in supine, seated knee flexion
- The neurological assessment and neurodynamic testing you did was negative. Does this affect your differential diagnosis and if yes what is your new primary diagnosis?
Non-nerve root issue
Pain down posterior thigh, issue with the sciatic nerve
Smart et al., 2012
If there is a loss of sensation and weakness, does not follow a dermatomal or myotomal pattern but reflexes are -ve = nerve trunk pain
If no change in sensation, no neurological weakness and -ve reflexes - somatic referred pain from a nociceptive pain from the Lx
- Slump test is used to examine the nerual mechanosensitivity of the nervous system. How does it do this ad what are its strengths and weaknesses?
It sequentially loads the nervous system and assesses its ability to distribute load
Used to differentiate between neural and non-neural structures
Strengths = Functional, does the patient get pain in sitting?
Weakness = more provocative than SLR
- What are some important psychological factors that present with this case that you need to be aware of? And how would they influence your assessment and treatment
NICE guidelines state that eduction, reassurance, encouragement of patient to continue with activities of daily living and aerobic exercise
Breathing technique has been shown to decrease anxiety
Cognitive behavioural therapy and refer if needed
Severity and irritability
- Appropriate outcome measures?
STart Back Tool - high sens, spec and reliability
Assess’ patients risk (9 questions)
Low risk - reassurance, education, encouragment
Moderate risk - reassurance, education, encouragment and physical therapy intervention
High risk - Refer for psychological treatment (cognitive behavioural therapy) and physical therapy intervention
Oswestry Disability Index - level of disability with tasks of daily living
SF-36 - anxiety, depression, general health
- What advice would you give to this patient regards to their current circumstances?
NICE Guidelines Education Heat Encourage to continue with activities of daily living and remain active Strength and ROM exercises Control pain NSAIDs Reassure Imaging not effective
- Nociceptive pain, peripheral neuropathic pain or central sensitisation?
Smart et al., 2012
Nociceptive pain - sensitisation of the peripheral nerves
Localised pain
Aggravating and easing factors are in proportion with the pain
Pain in proportion with tissue damage
Usually acute
Follows a normal anatomical pattern
Pain reduced with NSAIDs
Pain with movement and theres easing postures
Peripheral neuropathic pain - direct injury to the nerve that causes neurological symptoms
Nerve root pain - Compression or inflammatory reaction in the nerve root that causes dermotomal and myotomal pain
Nerve trunk pain - Injury to the nerve distal of the nerve root. -ve reflexes, may have change in sensation and weakness but is not dermotomal and myotomal.
Usually both are high severity and irritability
Central sensitisation - Sensitisation of the central nervou system
Aggravating and easing factors are out of proportion to the injury
Tissue damage may not be present
Pain does not follow a normal anatomical distribution
Hyperalgesia and/or allodynia
Night pain
Pain is out of proportion to the tissue damage
NSAIDs are unaffective
Pain does not resolve when the tissue damage is healed
Usually chronic
Somatic referred pain - pain referral from a nociceptive source
Centralisation - phenomenon where the patients distal leg pain with go centrally with repeated movements. No set amount of reps, use subjective indicators
