LUMBAR SPINE Pathologies Flashcards
1
Q
Vertebral Fracture
A
Clinical Presentation
- History of significanttrauma
- Focal spinal pain
- Pain or tenderness on palpation (midline)
- Pain that is worse on sitting, standing or ambulating
- Development of neurological deficits such as weakness, numbness, and tingling
- Most clinically relevant fractures occur from T10 – L2
Types of Fractures
- Compression fracture - anterior column
- Burst Fracture - anterior and posterior column
- Flexion Distraction ‘Chance or seatbelt’ Fracture - Anterior, Posterior, Middle columns
- Fracture Dislocation
2
Q
Low Back Pain ‘Cancer’
A
Clinical Presentation
- Back pain
- Bone pain - especially at night
- Possible radicular symptoms
- 50% of have sensory and motor dysfunction
- >50% have bowel and bladder dysfunction
- Complete or incomplete paraplegia
Common sources of metastatic spread
- Prostate
- Breast adenocarcinoma
- Lung adenocarcinoma
- Renal cell carcinoma
- Gastric carcinoma
3
Q
Low Back Pain ‘Infection’
A
Clinical Features
- Features of acute infection:
- Signs and symptoms in the early stages of the disease may beminimal
- Insidious onset
- Pain
- Rigidity at the site of infection
- Neurological deficit
- Epidural abscess may be present
- Pathological fracture
- Focal tenderness
- Muscle spasm
Risk Factors
- Immuno-compromised individuals
- Individuals with comorbid conditions (20)
- Intravenous drug users
- Malnutrition
- Age
- Male gender
- Recent surgery
- Renal failure
- Rheumatological diseases
4
Q
Cauda Equina Syndrome
A
Definition
- Syndrome characterised by a variety of red flag symptoms:
- Severe low back pain (83%)
- Saddle and/or genital sensory disturbance
- Bladder, bowel and sexual dysfunction
- Sciatica (90%):
- Commonly bilateral – May be absent with L5/S1 with inferior discsequestration
Clinical Presentation
- Rapid onset severe LBP without previous history of spinal problems(70%)
- Acute bladder dysfunction with a history of low back pain and/orsciatica
- Chronic backache with sciatica with gradually progressing CES often with canalstenosis
Clinical Examination
- Urinary dysfunction
- Assess:
- Pelvic and lower limb sensation
- BL radiculopathy: check for neurological deficit in legs (RED FLAGS)
- SLR, reflexes, power, and sensation
- S1,2 and 3 dermatomes
- Bladder function changes w/ control?
- Urinary/fecal incontinence, perineal anesthesia?
5
Q
Low Back Pain Inflmmatory Arthritis
A
Clinical Features
- Redness
- Swollen, tender, warm joint
- Joint pain
- Jointstiffness
- Loss of joint function
- Morning stiffness:
- >30 minutes
- Symptoms improve slighty with exercise
- Swelling is common
Non-Inflmmatory Arthritis
- Morning stiffness:
- <30 minutes
- Symptoms are typically worse after activity
- Swelling may or may not be present
6
Q
Lumbosacral Rediculopathy
A
Casuses
- Compression
- Tethering
- Over stretching
- Transection
- Ischemia
- Infiltration
- Chemical radiculitis
Common conditions that lead to radiculopathy
- Disc Herniation (90% of the time)
- Osteophytes
- Spinalstenosis
- Trauma
- Diabetes
- Epidural abscess
- Epidural metastases
- Nerve sheath tumors
- Guillain-Barre syndrome
- Herpes Zoster(Shingles)
- Lyme disease
- Cytomegalovirus
- Idiopathic neuritis
Clinical Features
- Low back pain?
- Distal pain and paresthesia in an area of skin supplied by a single spinal segment (dermatome)
- Radiating pains that may be aggravated by movement
- Leg pain is typically worse than the associated back pain
- Pain can be sharp, burning, cold, lancinating, electric and is often well-defined in a band like pattern
- Pain can radiate into the leg below the knee and into the foot and toes in a dermatomal distribution
- Muscle weakness in a muscle/s supplied by a single spinal segment (myotome)
- Decreased or absent deep tendon reflexes (DTR)
- Muscle fasiculations (chronic cases)
- Muscular atrophy (chronic cases)
NOTE: Radicular pain that does not respond to, or is exacerbated by lying down is suggestive of inflammatory, neoplastic, or other non-mechanical pathology
7
Q
L1 Radiculopathy
A
Clinical Features
- Sensory abnormalities:
- Pain, paresthesia, and sensory loss in the inguinal area
- Associated weakness:
- Mild loss of hip flexor strength
- DTRs normal
- Imaging may be required to elicit the cause of the lesion/disease
8
Q
L2 Radiculopathy
A
Clinical Features
- Sensory abnormalities:
- Pain, paresthesia, and sensory loss in the anterolateral thigh area
- Associated weakness:
- Hip flexor weakness
DDx.
- Meralgia Paresthetica
- Femoral neuropathy
- Upper lumbar plexopathy
9
Q
L3 Radiculopathy
A
Clinical Features
- Sensory abnormalities:
- Pain and paresthesia in the thigh and knee
- Associated weakness:
- Hip flexors
- Hip adductors
- Kneeextensors
- Reflex abnormalities:
- Patellar reflex may be depressed or absent
DDx:
- Femoral neuropathy
- Obturatorneuropathy
10
Q
L4 Radiculopathy
A
Clinical Features
- Sensory abnormalities:
- Pain and paresthesia in the medial lowerlimb
- Associated weakness:
- Knee extension
- Hip adduction
- Ankle dorsiflexion
- Reflex abnormalities:
- Depressed or absent patella reflex
DDx:
- Lumbosacral plexopathy
- Saphenous neuropathy
11
Q
L5 Radiculopathy
A
Clinical Feartures
- Associated weakness
- Ankle dorsiflexion (‘Foot drop’)
- Great toe dorsiflexion
- Inversion
- Eversion
- Leg abduction
- Sensory abnormalities:
- Anterolateral leg and the dorsum and sole of thefoot
DDx:
- Peroneal neuropathy
- Lumbosacral plexopathy
- Sciatic neuropathy (nerve)
12
Q
S1 Radiculopathy
A
Clinical Features
- Associated weakness:
- Plantar flexion (highlighted during toe walking)
- Knee flexion
- Hip extension
- Sensory abnormalities:
- Lateral foot and outer aspects of the sole of the foot
- Reflex abnormalities:
- Absent or depressed Achillesreflex
DDx:
- Sciatic neuropathy
- Lower lumbosacral plexopathy
13
Q
Disc Degeneration
- Annular Tear
- Disc Buldge
- Disc Herniation
- Disc Extrusion
- Disc Sequestration
- End plate degeneration (Schmorles nodes)
A
Clinical Presentation
- Sudden abrupt pain often precipitated by bending over or lifting
- Radiculopathy may be present without back pain
- Cauda equnia syndrome (CES) with large central herniations
- Localized axial back pain
- Pain on movement:
- Flexion
- Lateral flexion
- Cough, sneeze, valsalva (CSV)
- Pain with prolonged sitting
- Can cause referred pain down the legs:
- Ill-defined, intolerable, deep ache
- Unilateral or bilateral
14
Q
Spondylosis
- Loss of disc height, osteophyte growth, facet joint degeneration, alteration to the inert structures (i.e., ligaments) in the adjacent region
A
Clinical Presentation
- Back pain does not correlate well with imaging findings
- Changes associated with normal ageing are not painful per se
- Neurological compromise due to spondylosis becomes more prevalent with increasing age
- Compromise to the (1) central or (2) lateral recess or (3) IVF increase the likelihood of neurological deficit
Spondylotic vertebral changes:
- Osteophyte growth
- Cartilage loss and osteoarthritic change in the facet joints
- Thickening and buckling of the ligamentum flavum
Biomechanical changes:
- Increased force through facet joints:
- Normal = 33% compressive load which can progress up to 70% in combination with IVD degeneration
- Synovitis → widening and instability → bony hypertrophy → spinal stenosis
- Decreased load on anterior vertebralbodies
Biomechnical changes may lead to increase in inflammatory markers to the area and vasodilation causing sensitisation of the are
15
Q
Lumbar Stenosis
- Clinical syndrome of buttock or lower extremity pain, which may occur with or without back pain
- Associated with reduced available space for the neural and vascular elements of the lumbar spine secondary to changes in the central or foraminal canal
A
Clinical Presentation
- Starts gradually and slowly progresses
- Somatic back pain and stiffness associated with spondylosis
- May be exacerbated by trauma or physical activity
- Radiculopathy or ‘sciatic’ pain (95% of cases): specific NR leg pain and paresthesias (L5 most common)
- Neurogenic claudication (91% of cases): thecal sac is compressed, nonspecific NR distribution
- Bilateral symptoms (42% of cases):
- Symptoms can be unilateral
- Sensory alterations (70%)
- Motor loss (33%)
- Wide-based gait
- Fatigue
- Reduced lumbar lordosis with exaggerated thoracic kyphosis
- Pain increased with walking
- Pain with extension
- Pain relieved by flexion
16
Q
Neurogenic Claudication
A
Clinical Presentation
- Can be unilateral or bilateral
- Symptoms are brought on by walking
- Discomfort in the thighs, calves and feet when walking (pain and paresthesia)
- However, pain radiating distal to the knee is not required, it can present with pain solely in the gluteals
- Weakness, tiredness and heaviness in the legs that gradually increases and causes the patient to stop
- Symptoms are not typically present at rest and will disappear with rest/sitting down
- After a few minutes rest the patient is generally ready to walk again
- Leaning forward or pushing a grocery cart (relief)
- Neurological exam is typically normal
Intermittent vascular claudication
- symptoms overlap significantly with neurogenic claudication
- although pain may begin distally near the ankle and moves proximally and may include signs of diminished distal pulses, hairless extremities, or frank ulceration…
