L/S Presentations pt 1

Question 1

List the impairment/functional-based classifications for lumbar spine disorders

Answer 1

1. A/SA LBP w/ Mobility Deficits
2. A/SA LBP w/Related Cognitive or Affective Tendencies
3. A/SA/C LBP w/Radiating Pain
4. A/SA/C LBP w/Movement Coordination Impairments
5. A LBP w/Related (Referred) Radiating LE Pain
6. Chronic LBP w/related generalized pain

Question 2

list some prognostic indicators for development of LBP

Answer 2

1. Hx previous episodes
2. excessive spine mobility
3. excessive mobility in other joints

Question 3

list some prognostic indicators for the developent of chronic LBP

Answer 3

1. presence of symptoms below the knee
2. pyschosocial distress or depression
3. fear of pain, movement, and re-injury or low expectations of recovery
4. pain of high intensity
5. a passive coping style

Question 4

LBP can be broken down to include what 2 areas?

Answer 4

1. Lumbar spine pain
   
   • area bordered by transverse line from T12-S1
2. Sacral spine pain
   
   • area bordered by vertical lines through PSISs and horizontal lines through S1 and sacrococcygeal joints

Question 5

List some common clinical presentations at the L/S

Answer 5

1. Neoplasms
2. Infection
3. Spondyloarthropathies
4. Vertebral Body frx
5. Spondylolysis and Spondylolysthesis
6. Discogenic Pain
   
   • Discitis
   • internal disc disruption (IDD)
7. Radicular pain/radiculopathy
8. Lumbar Stenosis
9. Zygapophysial Joint Pain
10. Muscle Pain
11. L-S surgeries

Question 6

what are common sites for metastasis for lumbar neoplasms?

Answer 6

• 16.5% from breast
• 15.6% from lung
• 9.2% from prostate
• 6.5% from kidney

Question 7

when suspecting a neoplasms what are you looking for in the patient interview?

Answer 7

1. PMH includes cancer
2. progressive in nature
3. fatigue
4. weight loss
5. smoking
6. Pain complaints:
   
   • persistent
   • not alleviated w/bed rest
   • worse at night
   • neurologic symptoms

Question 8

for a neoplasm, the physical exam may include what?

Answer 8

1. non-mechanical presentation
2. age > 50 yrs
3. anemia
4. neurologic signs
5. lab tests for confirmation

Question 9

list 2 types of infections that may occur at the L/S

Answer 9

1. Vertebral Osteomyelitis
2. Epidural abscess

Question 10

what is an epidural abscess?

Answer 10

haematogenous spread of bacteria into epidural space

occurs in 10% of spine infections

associated with DM, chronic renal failure, IV drug misuse, alcoholism, cancer

Question 11

what are likely findings during a patient interview in someone with vertebral osteomyelitis?

Answer 11

1. oftent traced to other source of infection (dental abscess, pneumonia, etc.)
   
   • bladder infection most common
2. Increased risk
   
   • immunocompromised pts
   • DM
3. Weight loss
4. Fatigue
5. Fever
6. Neurologic symptoms

Question 12

what would pain compliants look like in someone with vertebral osteomyelitis?

Answer 12

1. local, focal back pain
2. worse w/mechanical loading
3. improves w/recumbent position

Question 13

physical exam findings in vertebral osteomyelitis

Answer 13

1. Fever
2. Local tenderness
3. Aggravated w/local percussion
4. Neurologic signs (cord/root)
5. Lab tests important for dx

Question 14

what may increase the risk of an epidural abscess?

Answer 14

1. misdiagnosed vertebral osteomyelitis
   
   • they are common concomitants
2. 12-30% have a Hx of preceding trauma (fall, etc)

Question 15

what is the typical progression of symptoms with epidural abscesses?

Answer 15

1. local, focal back pain
2. radicular signs/symptoms
3. paralysis

Question 16

abdominal referrals may cause LBP, but viseral disease accounts for ____ of cases

Answer 16

2%

potential organs involved:

1. pelvic organs
2. kidneys
3. Aortic aneurysm
4. Gastrointestinal

Question 17

T/F: vertebral frxs are associated with increased mortality?

Answer 17

TRUE

predictor for subsequent vertebral frx (4-5x) and hip frx (3x)

Question 18

the TLICS classification system for vertebral fractures is based off of what 3 things?

Answer 18

1. Morphology
2. Integrity of PLC
   
   • supraspinous, interspinous ligaments, ligamentum flava, z-joint capsules
3. Neurologic status

Question 19

what are the 3 morphologic descriptors in the TLICS classification system?

Answer 19

1. compression → vertebral body buckles under load to produce a compression/burst frx
2. translation/rotation → vertebral column is subjected to shear/torsional forces causing the rostral part of spinal column to translate/rotate w/respect to caudal portion
3. distraction → rostral spinal column becomes separated from caudal segement b/c of distraction forces

Question 20

what are the 2 subtypes of compression frxs?

Answer 20

1. Traditional
2. Burst

Question 21

describe traditional compression frxs

Answer 21

1. stable injury
2. invovles anterior column
3. common mechanism → axial loading in flexed position
4. Traumatic
   
   • high energy
   • osteoporotic

Question 22

describe burst compression frxs

Answer 22

1. anterior and middle column invovlement
2. 15-20% of all major vertebral body frxs
3. most common at T/L junction
4. potential neural involvment
5. vertebral segment subjected to high force axial (and/or flexion load)
   
   • MVC
   • falls from heights
   • high-speed sport injury

Question 23

describe rotation/translation frxs

Answer 23

1. associated w/fall from a height or heavy object falling on body w/bent trunk
2. torsion/shear force
3. horizontal displacement of one T/L vertebral body on another
4. dislocation → facet joints intact but dislocated

Question 24

describe distraction frxs

Answer 24

1. separation in the vertical axis
2. anterior and posterior ligaments, anterior and posterior bony structures both
3. potential frx to posterior elements

Question 25

list vertebral frx red flags

Answer 25

1. older age 2. sig trauma 3. corticosteroid use 4. contusion/abrasion

Question 26

List the Henschke cluster for vertebral frxs

Answer 26

1. Age \> 70 2. sig trauma 3. prolonged corticosteroid use 4. sensory alterations from trunk down

Question 27

list the components of the Roman cluster for osteoporotic vertebral compression frxs

Answer 27

1. Age \> 52 2. no presence of leg pain 3. BMI = 22 4. does not exercise regularly 5. female gender 4/5 = +LR 9.6

Question 28

what is spondylolysis?

Answer 28

fatigue frx of pars interarticularis proposed mechanism: 1. acquired → repetitive microtrauma w/extension or extension w/side-bending activities 2. congential 3. developmental

Question 29

90% of spondyloysis occur \_\_\_\_\_

Answer 29

at L5 level (L5/S1 \> L4/L5)

Question 30

what is spondylolythesis?

Answer 30

anterior slip of the vertebra following bilateral spondylolysis graded 1-4 via the percentage of body slipped

Question 31

describe the grades for spondylothesis

Answer 31

* I = 1-25% * II = 25-50% * III = 50-75% * IV = \>75% greatest slippage occurs between 10-15 y/o

Question 32

how would a spondylothesis show up on a radiograph?

Answer 32

"Scotty dog with collar" (on PA, lateral oblique radiographs) often, reduced ROM observed with flexion/extension radiographs (rather than instability)

Question 33

prevelance of spondylolysis and spondylothesis is higher in what population?

Answer 33

up to 43% in athletes 1. repetitive extension: gymnastics, diving, weight lifting 2. high grade slippage 2x greater in girls and 4x greater in women 3. greater risk among adolescents

Question 34

describe the symptomology of spondylolysis and spondylothesis

Answer 34

* localized LBP, worsened with extension activities

Question 35

what physical exam findings are expected with spondylolysis and spondylothesis?

Answer 35

1. include neurologic testing 2. visual inspection: excessive lumbar lordosis 3. possible step-off deformity 4. pain with lumbar extension, rotation 5. "hamstring tightness" has been proposed 6. + instability testing and spring testing at involved segment (if administered)