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Spinal Disorders > Low Back Neurological Assessment > Flashcards

Low Back Neurological Assessment Flashcards

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1
Q

Leg and back pain with nerve involvement

A

Cord lesions - only upper lumbar lesions
Nerve root lesions - Include cauda equina
Peripheral nerve lesions - Sciatica, femoral, neuropathy)

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2
Q

Leg and back pain without nerve involvement

A

Deep referred pain - From Si and lumbar structures

Separat lesions - along the kinetic chain

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3
Q

Deep referred pain syndromes

A

irritated joints of muscles in the spine often feel pain in other areas despite no pinched or injured nerves

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4
Q

Sclerotomal pain

A

can come from any tissue with the same embryological origin

Pain is experienced from all of these tissues innervated by the same nerve or along sclerotomes

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5
Q

Sclerotogenous Referred Pain Patterns

A

From deep somatic tissue

Leads to:
Deep - aching, diffuse pain
Sclerotomal segmental pattern
Often more proximal than distal

Pain often spreads out over time. Referral territory grows. Pain may skip over regions

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6
Q

When patients have leg or arm symptoms with spinal pain one of the top priorities are _______ or not

A

Neuropathic

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7
Q

The leg rules!

A

If there are no leg symptoms, not nerve damage generally

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8
Q

Neuropathic Assessment: 5 key clues

A

Leg pain: territory, quality, more intense than LBP
Paresthesia: territory
Lumbar tension tests
Neurological deficits or abnormalities
Lumbar joint loading procedures that cause immediate leg sx

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9
Q

Neuropathic tool: Radicular syndrome - Leg Pain

A

Location - must be past the knee. may be dermatomal. feels superficial
Quality - Often sharp, stabbing, electrical, sharp, painful cold, lancinating
Severity - Worse than back pain
Affected by spinal position

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10
Q

Nerve root pain

A

in most cases nerve root pain should not be expected to follow a specific dermatome but it does have use in diagnosis of radicular pain.
Exception is the S1 root that often follows the dermatome

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11
Q

NT Radicular Syndrome: leg paresthesia

A

Often present and more likely to follow a dermatomal distribution

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12
Q

NT radicular syndrome: Sensory, motor, reflex

A

May be one or more deficits usually corresponding to the same nerve root

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13
Q

Three components of Neurological components

A

Sensory
Motor
Reflex

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14
Q

Dermatomal Sensory Distribution explanation

A

Most often due to nerve root compression from a herniated nerve root disc

Sensory disturbance may set in before muscle weakness or atrophy

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15
Q

L4 pure patch

A

Medial thigh

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16
Q

L5 Pure Patch

A

Medial side of big toe

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17
Q

S1 pure patch

A

5th toe and interdigital web

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18
Q

Sciatic nerve DTR

A

S1, S2

Achilles tendon

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19
Q

Femoral nerve DTR

A

L3, L4

Patellar tendon

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20
Q

Sciatic nerve DTR

A

L5, S1

Hamstring tendon

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21
Q

S1 muscle tests

A

Toe flexors - Tibial n.
Ankle evertors - Peroneal/Fibularis
Plantar flexion - Tibial n.

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22
Q

L5 muscle tests

A

Big toe extensors - Peroneal nerve

Hip abductors - Superior gluteal nerve +LR 11

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23
Q

L4 muscle tests

A

Ankle dorsiflexion - Deep peroneal nerve

Ankle inversion - Deep peroneal/fibular nerve

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24
Q

Radicular syndrome nerve tension tests should _____

A

Often reproduce leg symptoms

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25
Straight Leg Raise
A passive test Main tension is for the L4, L5, S1 nerve roots (and sciatic nerve) Positive test: Creating or aggravating lower extremity pain. Hard positive reproduces pain past the knee.
26
SLR test validity
Sensitivity is thought to be good for patients with posterolateral disc herniations. Poorer sensitivity (but can be present) for patients with: Spinal stenosis, spondylolisthesis, midline and medial disc herniations
27
Tension tests can be used to confirm a positive SLR
Braggard, Bowstring, Bonnet
28
Maximum SLR
SLR, Flex neck, push led medially, invert foot
29
Femoral stretch test
reverse SLR | stretches femoral nerve and the L2, 3, 4 nerve roots
30
Radicular Syndrome Tool - Spinal loading procedures
Rapid reproduction of leg symptoms possible
31
Leg pain can result from Radicular Syndrome with ____, ____, _____
Forward flexion, extension + rotation, valsava maneuver
32
Radiculitis
``` Inflamed nerve root Neuropathic pain (dermatomal) Paresthesia (dermatomal) Positive tension tests Reproduce the pain by loading the spine Increased sensitivity ```
33
Radiculopathy
Compressed/torn nerve roots Motor deficits (muscle weakness, atrophy) Hyporeflexia Dermatomal sensory loss think deficits
34
Cauda Equina Syndrome: Referral
Very uncommon | But it requires urgent referral (same day)
35
Cauda Equina Syndrome: Causes
Large midline disc herniation (top cause) Severe spinal stenosis (top cause) Tumor Infection hematoma Affected nerve roots: S2-4 Damage can occur in damage
36
Saddle Anesthesia
With CES 80% sensitivity Bilateral (maybe unilateral) test with light touch and sharp Strong indicator with unrinary dysfunction
37
Altered perineal sensation may be most important predictor of ___________
Impending bowel or bladder dysfunction Associated with Saddle Anesthesia
38
CES effect on bladder
Painless urinary retention (LR+ = 18; LR- = 0.1) and overflow incontinence Incomplete: Urinary difficulty, altered sensation, loss of desire to void, poor urinary stream, need to strain to urinate Strong indicator with saddle hypesthesia
39
CES effect on bowel
Inability to control defecation Sense rectal fullness Decreased anal sphincter tone absent anal wink
40
CES sexual dysfunction
Decrease in genitalia sensation Inability to get or maintain an erection Reduced sensation during sexual stimulation
41
Symptoms occur ____ after neurological compromise in __% of the cases. Unfortunately ___, ___, and _______ abnormities may not be recognized in the short time frame
Less than 24 hours, 90% | Urologic, bowel, sexual dysfunction
42
Incomplete CES
better prognosis with immediate intervention | Patient has altered urinary sensation, loss of desire to urinate, weak stream, or may have to push to void
43
Complete CES
Urinary retention, overflow incontinence | Complete saddle anesthesia
44
Pudendal (neuropathy) Nerve Lesion
Unilateral or bilateral perineal pain | May be a burning or a sensation of a foreign body in the rectum or vagina
45
Pudendal Nerve Lesion
Alcock's syndrome Urinary incontinence or sexual dysfunction Often related to a fall on the butt or traction injuries, or biking Aggravated by sitting DDX with CES
46
Peripheral nerve damage DDX for CES
Femoral nerve Lateral cutaneous femoral nerve Sciatic nerve Common peroneal
47
PNS Lesions (entrapments and compression)
Piriformis syndrome Peroneal nerve compression Femoral neuropathy (secondary to pelvic tumor)
48
PNS lesions (diseases)
Polyneuropathy Diabetes Alcoholic neuropathy Vitamin B12 deficiency
49
Femoral compression most often occur in _____ _____
Iliac Fossa
50
Causes of femoral neuropathy
``` Diabetic mononeuropathy Tumor Psoas or ilicus hematoma Injury (surgery) Inflammatory conditions (such as rheumatoid bursitis) ```
51
Femoral nerve damage may result in:
Unilateral lower extremity pain that may involve: The groin, anterior thigh and sometime the lower leg Patient may flex the hip for pain relief
52
Femoral damage sensory changes
Numbness and paresthesia on the anterior or medial thigh
53
Motor symptoms of femoral nerve damage
Hip flexors and knee extensors are affected first Sudden knee buckling may be initial symptom (seen in uneven road or step ups and down) None of the affected muscles are below the knee
54
Femoral nerve physical exam findings
Weakness with iliopsoas Weak quadriceps Decreased or absent patellar reflex
55
Lumbosacral plexus damage
Mimics damage to femoral nerve but with the addition of adductor weakness Affects adductor longus and magnus
56
Femoral stretch test
Stretches femoral nerve Stretches L2, 3, 4 Creates sharp anterior thigh pain
57
Diabetic amyotrophy
Multiple lumbosacral nerve roots are affected but sometimes only the femoral nerve Sudden severe lower extremity, Muscles weakness precedes the onset of pain, muscle testing the femoral nerve is painful Patients usually have well controlled type 2 DM and are middle aged or older. Weight loss is a frequent accompanying symptom
58
Painful femoral nerve involvement should trigger an appropriate ______ _____
Diabetes evaluation
59
Diabetic polyneuropathy
The majority of patients with diabetes have LS plexus involvement rather than just femoral nerve involvement Symptoms are bilateral and more distal
60
Classic diabetic peripheral neuropathy
Symmetric/polyneuropathy Results in sensory loss in extremities - usually in feet and hands in a stocking and glove distribution (sensory changes occur first) Causes burning Exaggeratedly intense or distorted experience of touch Late findings are autonomic and motor deficits. Can lead to gait abnormalities
61
Classic diabetic peripheral neuropathy ancillary studies
CT should always be done to rule out mass | EMG and nerve conduction may be necessary to determine where the lesion is
62
Femoral nerve treatments
Hematoma or tumor is removed Diabetes is treated If secondary to surgery then it recovers spontaneously in weeks or months
63
Meralgia Paresthetica pathophysiology/etiology
Entrapment of nerve as it passes the inguinal ligament near the ASIS Tight pants, obese, pregnancy, diabetes, local trauma, or extended sitting/cycling/walking 40-60 yo
64
Meralgia Paresthetica presentation
Lateral femoral cutaneous (anterolateral thigh) distribution of numbness, tingling or dull pain (bilateral in 20%) No motor involvement
65
Meralgia Paresthetica Treatment
Change to looser pants, losing weight OTC pain meds Conservative care
66
Peroneal Nerve Entrapment
Most are due to external compression or stretching of the nerve near the fibular head Some or all of these: Pain is not common, foot drop may be partial or complete Ankle dorsiflexion, great toe extension or eversion Numbness over the lateral aspect of lower leg Ankle inversion may increase pain Normal achilles reflex
67
Peroneal Nerve Entrapment Causes
``` Postural factors (sitting with legs crossed, etd.) Repetitive motion (sports, running) Weight loss Trauma Iatrogenic ```
68
Tibial nerve affects ____
Flexors
69
Common peroneal nerve controls _____
Extensors
70
Myelopathy
Spinal cord lesions (uncommon) compression? Common at L2 Cord problems are not commonly associated with LBP
71
Causes of cord compression
INJURY TLJ compression fracture Upper lumbar disc lesion Spinal canal stenosis DISEASE Tumor
72
Stenosis
The narrowing of the spinal canal due to degenrative changes: disc thinning, facet enlargment, thickening of ligamentum flavum
73
Cord compression
Presents with common leg symptoms Urinary incontinence Constipation Impotence

Spinal Disorders (2 decks)

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