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518 Spine > L5 Lumbar Spine Pathologies > Flashcards

L5 Lumbar Spine Pathologies Flashcards

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1
Q

types of disc herniation

A

intra spongy nuclear herniation

protrusion ->
extrusion ->
sequestration

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2
Q

clinical presentation of herniated nucleus pulposus (HNP)

A

occurs gradually over time and starts asymptomatic
starts with back pain then progress to LE, then neuro involvement

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3
Q

types of HNP protrusion

A

can either have spinal nerve root involvement or not

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4
Q

intra spongy nuclear herniation

A

nucleus is displaced into vertebral body through the endplate of cartilage causing schmorl’s nodes

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5
Q

MOI of intra spongy nuclear herniation

A

mod to severe flexion trauma like fall into flexion

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6
Q

grades of intra spongy nuclear herniation

A

1: subchondral fracture into vertebral body
2: small cracks in endplate
3: crack where a piece of bone has shifted
4: crack where a piece of bone has shifted and disc material is forced through the crack

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7
Q

protrusion without spinal nerve root involvement

A

displacement of nuclear material beyond normal confines of inner annulus
creates bulge in outer annulus but no nuclear material escapes

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8
Q

protrusion without spinal nerve root involvement MOI

A

cumulative effect of months/years of forward bending and lifting, seated/flexion posture

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9
Q

protrusion without spinal nerve root involvement clinical presentation

A

general loss of spinal mobility, especially in extension
decline in general fitness
decreased disc nutrition
leg pain indicating larger protrusion
sitting is the worst position

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10
Q

protrusion without spinal nerve root involvement typical patient

A

30-50
male
early: complains of back/buttock/thigh pain
relief from sitting by standing and walking
UL referral pain to the leg
gradual pain onset
occupation/activity with flexed lumbar spine

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11
Q

clinical exam for protrusion without spinal nerve root involvement

A

posture: slumped, flexed L/S
lateral shift
flattening of lordosis
normal neuro exam
involved segments tender (central PAIVMs tender)
limited extension ROM

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12
Q

protrusion with spinal nerve root involvement

A

nucleus pulposus bulging but contained in annulus and PLL
bulge is large enough that it impinges upon/irritates the inferior nerve root

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13
Q

relation of lateral shift to disc bulge: which direction does the patient shift?

A

HNP lateral to nerve root: patient shifts to opposite side of bulge
HNP medial to nerve root: patient shifts towards the side of bulge
protective scoliosis

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14
Q

protrusion with spinal nerve root involvement clinical presentation

A

same as HNP with addition of positive neuro s/s: myotomal strength loss, decreased reflexes, loss of sensation, + SLR
attempts to fix lateral shift may increase peripheralization of symptoms
gradual worsening

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15
Q

HNP extrusion

A

nuclear material moves outside the disc and breaks through the annular fibers
progression of a disc protrusion
PLL still touching disc
occupies space in the spinal canal

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16
Q

extrusion symptoms

A

worse pain than protrusion
more irritable
harder to alleviate due to mechanical and chemical irritation of spinal nerves
- mechanical lesion taking up space causing nerve compression
- disc contents interact with glial cells to initiate inflammatory response (chemical)

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17
Q

HNP Sequestration

A

nuclear material escapes into the spinal canal as a free fragment

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18
Q

HNP Sequestration s/s

A

peripheral s/s will be predominant
reduction in pressure on the annular wall may reduce LBP from disc bulge but worsen peripheral symptoms due to space occupying lesion

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19
Q

healing of HNP sequestration

A

body can lyse and get rid of the sequestration over time
however, over the time it takes to heal the sequestration could continue to damage spinal nerves it is compressing
leads to potentially lasting radicular symptoms

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20
Q

lumbar radiculopathy vs radicular symptoms

A

radiculopathy is neuro signs including reduced DTR, clinical weakness, N/T, etc
radicular pain is pain down the leg, could just be referred

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21
Q

degenerative disc disease

A

nucleus pulposus is dehydrated
this causes narrowing of the intervertebral space, slackening of the spinal ligaments from decreased disc height, weakening of annular rings, and approximation of facet joints

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22
Q

examination findings of DDD

A

xray imaging showing decreased height and black/dehydration
tenderness segmentally
active and passive motion restriction
facet joints vulnerable to impingement
disc more vulnerable to herniation

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23
Q

facet joint referred pain area

A

posterior thigh

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24
Q

facet impingement MOI

A

sudden unguarded movement into ext, SB, and/or rotation
little or no trauma, just sudden movement
causes pinching of the facet meniscus

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25
s/s of facet impingement
eased by rest aggravated by movement locked protective position AROM reduced in 3/6 ranges end range pain ipsilateral SB and contralateral rotation limited single segment tender to palpation
26
facet joint sprain
similar to impingement more severe injury or progression of repetitive facet impingement history of moderate to severe trauma early on conservative treatment and longer healing time
27
causes of facet hypomobility
ligament tear muscle tear contusion impingement Z joint subluxation
28
s/s of facet joint hypomobility
UL back pain certain movements aggravate pain end range pain with combined motion and AROM PPIVMs and PAIVMs
29
facet hypermobility
distinction made by end feel of PPIVM/PAIVM
30
facet joint OA
degenerative joint disease DJD cartilage braekdown in facets causes increased motion at facet
31
lumbar spine OA prevalance
40-85%
32
DJD process in spine
calcific deposits around periphery of facet joints hyaline cartilage wears away thickening synovial lining/capsule thickening of subchondral bone
33
spondylosis
nonspecific term: refers to degeneration of disc, vertebral body, facet joints
34
3 stages of spondylosis
dysfunction: includes disc tears and hypermobility of the synovium, microtrauma results and can result in herniation instability: once disc herniates, capsule and ligaments slacken stabilization: osteophytes and bony changes occur, stenosis can occur, creating chronic issues
35
clinical instability in low back
increased translation of spinal segment during flex/ext movement or SB difficult to assess due to static xray images found catching on central PAs excess motion inconsistent symptoms
36
s/s of clinical instability in the low back
recurrent back pain constant pain with catching/locking during exacerbation unprovoked episodes feeling unstable give way inconsistent symptoms, but aggravating factors include: sustained sitting or standing, semi flexed positions, forward bend, sudden movement, sneezing may have aberrant spinal movement
37
neutral zone of the spine
region of intervertebral motion in neutral posture where there is little resistance in the passive spinal column size of this zone changes with instability or low back pain treat with lumbar stab to reduce neutral zone to below painfree range basically if you have hypermobility or instability your neutral zone increases and goes beyond range of pain free motion, creates pain
38
Panjabi's spine stabilization principle
1. spinal column 2. spinal muscles 3. neuromuscular control spinal column and spinal muscles send proprioceptive input to brain, which sends afferent signals to muscles to activate, creating stability and movement in the spinal column
39
spondylolysis
defect/fracture of pars interarticularis near facet/neural arch of vertabrae vs spondylosis is degeneration
40
spondylolisthesis
defect of neural arch resulting in separation of anterior and posterior elements, anterior portion of vertebrae translates forward
41
most common location of spondylolisthesis
L5/S1
42
findings in spondylolysis and spondylolisthesis
spondylolisthesis: may feel a step off of spinous processes hyperlordosis pain with prolonged standing (exT) relief with sitting onset from athletic or physical activity as a child pain results from excess segmental motion/stress
43
grading of spondylolisthesis
I: 1-25% slippage II: 26-50 III: 51-75 IV: 76-100
44
symptoms associated with grades III and IV spondylolisthesis
likely will have cauda equina syndrome
45
nerve root compression cause
impingement or chemical irritation of the spinal nerve root often caused by HNP, congenital issue, tumor, fracture, or advanced DDD
46
s/s of nerve root compression
truw neuro presentation: s/s like clinical weakness, N/T, reduced DTR pain is deep and superficial, burning in one spinal nerve root distribution
47
somatic referred pain
deep, aching diffuse covers 2-3 dermatomes
48
lateral spine stenosis is...
nerve root compression
49
neuritis findings
inflammation causing impingement in intervertebral foramen + neuro exam insidious or onset with muscle and joint inflammation seen within a few days after severe injury
50
nerve root adhesion
nerve root is entrapped by scar tissue possible causes include spinal surgery or disc herniation
51
findings with nerve root adhesions
history of spine surgery or disc herniation period of complete recovery then insidious onset of spinal/referred pain absence of lumbar flexion in standing with no restriction in seated no signs of disc protrusion like sitting pain
52
congenital abnormalities in low back include:
spondlylolysis spondylolsthesis lumbarized sacral vertebrae: extra lumbar vertebrae sacralized lumbar vertebrae: extra sacral vertebrae and missing lumbar asymmetrical facet joints
53
spinal stenosis s/s
pain in lower back and leg(s) N/T in feet/legs decreased DTR motor weakness symptoms worse with walking relieved by rest and flexion
54
lumbar spinal canal stenosis is:
ischemia of lumbosacral nerve roots due to compression cutting off blood supply
55
main risk factor for spinal stenosis
age >50, more likely to have degenerative changes
56
formainal area changes with lumbar flexion/ext | %
derceases 20% in extension and increases 12% in flexion
57
cause of spinal stenosis
degeneration causing fibrosis of spinal ligaments that encroach of the circumferential area of the spinal canal
58
special tests for spinal stenosis
bike test: rule out intermittent claudication by putting patient in flexion on bike and see if they get claudication pain. Since they are flexed, the bike shouldn't provoke neurogenic claudication but will provoke IC 2. 2 part treadmill test: increase incline to create spinal flexion 3. Stoop test: if walking brings on symptoms, does stooping into flexion relieve them?
59
cauda equina causes
spinal stenosis, herniated lumbar disc fracture tumor infection inflammation traumatic injury arteriovenous malformation hemorrhage in spine postop surgical complication spinal anesthesia
60
cauda equina
compression of the lumbar and sacral nerve roots
61
cauds equina presentation
mixed UMN and LMN, more UMN in kids and LMN in adults urinary retention: doesn't feel sensation/urge to urinate urinary/fecal incontinence saddle anesthesia weakness/paralysis back/leg pain
62
ankylosing spondylitis
systemic inflammatory process causing joint sclerosis and ligament ossification starts in SI joints, then lumbar, thoraic, ribs
63
ankylosing spondylitis population
20-35 y/o more male>female
64
ankylosing spondylitis findings
present 3+ mo flattening of spinal curves + constitutional symptoms vague LBP and stiffness worse when waking eased by movement weeks/months aggravation episodes insidious onset w no MOI
65
coccyx injury MOI and s/s
fall onto coccys or in childbirth unable to sit on both buttcheeks due to tenderness internal and external may heal extended creating pressure point on end of coccyx
66
CPR for lumbar spine manipulation
1. FABQ <19 2. symptoms <16 days 3. no symptoms distal to knee 4. lumbar spine hypomobility 5. one hip with more than 35 degrees of IR
67
CPR for lumbar spine stabilization treatment
1. SLR > 90 degrees 2. + prone instability test 3. + aberrant movements 4. age < 40 y/o success most likely if 3+ present
68
CPR for ankylosing spondylitis
1. morning stiffness >30 min 2. back pain improves with exercise but not rest 3. wake up due to back pain in second half of night only 4. alternating buttock pain diagnosis likely if 3+ are present
69
CPR for lumbar spinal stenosis
2 - age 60-70 3 - age 70+ 1 - symptoms present 6+ mo 2 - symptoms improve with flexion -2 - symptoms improve withe ext 2 - symptoms exacerbated by standing 1 - + IC 1 - urinary incontinence diagnose if 7+ unlikely if 2 or less
70
anatomic sites of pain: spinal ligaments
innervated with nociceptive afferents chronic or acute pain
71
anatomic sites of pain: spinal muscles innervation for pain
highly innervated A delta (fast) C fibers (slow) lower threshold of firing for pain as compared to facet joint nerves

518 Spine (19 decks)

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