LSP Flashcards by Heather Lassiter

Common LSP Dx

Spinal stenosis
Lumbar strain
Spondylolistesis / lysis
Herniated nucleus pulposus
Cauda equina syndrome
Pott's dz
Compression fx

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Spinal stenosis - in general

Congenital or acquired narrowing of the spinal canal
Usually worsening with age
>50yo
Distinguish by neurogenic vs. vascular claudication

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Spinal stenosis - s/s

LBP & leg pain worse with extension
Leg pain with ambulation - dermatomal pattern
Leg weakness
Relief with lumbar flexion
Ask about night pain and bladder / bowel dysfunction

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Spinal stenosis - exam

Increased leg pain with lumbar extension
Diminished reflexes
Decreased leg strength and sensation
SLR +/-

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Motor - tibialis anterior
Reflex - patellar
Sensation - medial ankle

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Motor - Extensor hallicus longus
Reflex - none
Sensation - top of foot

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Motor - Peroneus
Reflex - Achilles
Sensation - lateral ankle

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Spinal stenosis - dx

Plain AP & lat x-rays
- DDD, Degenerative scoliosis, osteophyte formation or Degenerative spondylolisthesis
CT/Myelogram vs. MRI

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Spinal stenosis - tx

LESI
NSAIDs
Sx decompression
Refer
- bladder / bowel incontinence
- fail conservative tx

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Herniated disc - in general

<50yo
Acute onset of leg pain
Pain usually dermatome specific
L4-5 HNP most common
Pain results from direct mechanical compression of nerve root or chemical irritation

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Herniated disc - s/s

LBP &amp; leg pain
Worse with
- sitting 
- bending
- coughing / sneezing
- twisting
Difficult to remain in one position

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Herniated disc - exam

Difficult to sit
Increased leg pain with lumbar bending
Positive SLR - sitting and supine
Positive "bowstring sign"
L3 femoral N. stretch test
Decreased or absent reflex
Decreased muscle strength
Decrease sensation

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Nerve Root - L4

Motor - Quads
Reflex - knee jerk
Sensation - anterior thigh

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Nerve Root - L5

Motor - EHL (big toe)
Reflex - none
Sensation - Shin, top & medial foot

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Nerve Root - S1

Motor - Ankle plantar flexion
Reflex - Achilles
Sensation - calf; lateral foot

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Herniated disc - dx

X-rays

MRI scan***

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Herniated disc - tx

PT
LESI
Taper dose prednisone
NSAIDs
Muscle relaxers
Analgesics
Nicotine abstinence
Reassurance
Sx

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Herniated disc - when to refer

Cauda equina symptoms
Progressive neuro deficit
Paralysis
Failed conservative tx

Lumbar strain - in general

Repeated twisting or lifting heavy objects
May last a few days to 4 weeks
Annular tear may cause pain
Tendons, ligaments and muscles may be involved

Lumbar strain - s/s

LBP, may radiate to buttock

Difficulty standing straight

Lumbar strain - RF

Lifting
Twisting
Sitting for prolonged periods
Poor fitness
Smoking
Operating Vibrating equipment

Lumbar strain - exam

Low back tenderness & spasm
Limited ROM
Normal reflexes and muscle strength
SLR produces LBP

Lumbar strain - dx

Plain x-rays usually not helpful

Atypical s/s, such as rest or night pain or trauma obtain x-rays

Lumbar strain - tx

Short course of NSAIDs
Muscle relaxers
Early PT
No long term bed rest
Avoid narcotics

Spondylotisthesis

"slip" or "listhesis" Vertebral body slips in relation to one below Defect in junction of lamina with pedicle (pars intra-articularis_ - Spondylolysis Adolescent (L5-S1) vs. Degenerative (no pars defect) Most likely a fatigue fx that fails to heal Participation in gymnastics and football, may increase incidence Degenerative slip secondary to DD found in older adults

Spondylotisthesis - s/s

May be asymptomatic LBP with posterior leg radiation Pain worse with standing and lumbar extension

Spondylotisthesis - exam

Diminished lumbar lordosis Palpation - pain and "step-off" with spinous process of slipped vertebra Lumbar pain with extension Reflexes and MS usually normal

Spondylotisthesis - dx

X-ray - AP, lat, oblique view Pars defect seen on oblique view (scotty dog) absent neck CT scan Bone scan

Spondylotisthesis - tx

``` PT Avoid aggravating activities Lumbar orthrosis Sx - degenerative slips Evaluate every 6 months with x-rays until growth complete ```

Compression Fx - in general

``` Osteoporosis related Occurs with or w/o trauma Acute onset of back pain May become multiple All heal in time (2 months) Feel better with brace (warm-n-foam, camp) ```

Compression Fx - tx

Kyphoplasty | Vertebroplasty

Kyphoplasty / vertebroplasty

1-3% neurologic complication | Reasonable choice for prolonged pain

Pott's Dz

TB of the spine Result in destruction of vertebral bodies X-ray show vertebral ostolysis or compression fx Tx - rest and anti-TB meds

Cauda Equina Syndrome - in general

Compression of causda equina roots May result from large midline disc herniation Occurs in only 2% L4-5 most common

Cauda Equina Syndrome - s/s

Incontinence Severe leg pain Numbness Difficulty walking

Cauda Equina Syndrome - dx

Emergent MRI

Cauda Equina Syndrome - tx

When to order x-rays

>65yo Hx of trauma Pain lasting >4weeks Hx of ca (MRI or bone scan)

When to order MRI

``` Loss of bladder/bowel control Neurological deficit Severe leg pain not responding to ESI Suspected malignancy (ca hx, night pain) Back pain for 4 months despite tx ```

"Hip pain"

Buttock - referred back pain Groin - true hip joint pain Lateral - trochanteric bursitis

Hx keys

What makes pain worse? Better? Ca - constant, may be worse at night Pain - increased by activity, relieved by rest TRUE loss of bladder control

Exam keys

``` Decreased Knee Jerk - L3 or L4 Decreased EHL strentgth - L5 Decreased Ankle Jerk - S1 Beware - "breakaway weakness" or "cogwheeling" SLR- positive if it produces leg pain ```

Don't forget other causes

Aortic aneurysm Ca Fx DVT