Lumbar II

Question 1

Questions to ask when forming differential diagnosis

Answer 1

. How severe symptoms are
. Is there traumatic anatomic damage
. Is there serious underlying medical condition
. DO symptoms have progressing neurologic involvement
. Is patient child, elderly, or high risk

Question 2

Non mechanical differential diagnoses for back pain

Answer 2

. 1%
. Neoplasia
. Infection
. Inflammatory arthritis
. Metabolic bone disease

Question 3

Referred pain differentials of low back pain

Answer 3

. GI
. GU/reproductive
. cardiovascular

Question 4

Mechanical differentials for LBP

Answer 4

. Sprains
. Somatic dysfunction
. Fracture 
. Spondylolsis
. Facet syndrome 
. Spinal stenosis
. Disc issues 
. Congenital 
. Instability 
. 97% of cases

Question 5

Characteristics of mechanic LBP

Answer 5

. Assoc. w/ bending/twisting
. Better w/ rest
. Pain varies w/ motion, position
. Assoc. w/ dec. range of motion, muscle spasm, trigger points in muscle, tendinitis or joint inflammation
. Strongest predictor of future mechanical LBP is history of previous mechanical LBP

Question 6

Strain

Answer 6

Tendon inflammation

Question 7

Sprain

Answer 7

Ligament back pain

Question 8

Only consider xrays for mechanical LBP if ____

Answer 8

. Patient over 50

. There is additional medical info that raises suspicion for organic disease

Question 9

T/F don’t treat X-ray, adults will have radiographic findings but are asymptomatic

Answer 9

T

Question 10

Consider non-mechanical/systemic disease as underlying cause of LBP if _____

Answer 10

. Abnormal vitals 
. History of cancer
. Spinal infection
. Prolonged steroid use 
. history of IV drug use 
. UTI
. Unexplained weight loss 
. Old
. Night pain or sweats
.  No pain relief w/ rest
. Failure to respond to standard therapies 
. Osteoporosis
. immunocompromised
. Rheumatologist disorders

Question 11

WHen to consider diagnostic imaging and laboratory tests

Answer 11

. Young patients under 18
. Patients over 50
. Trauma 
. Neurological deficit
. Fever
. Unexplained weight loss
. Cancer history
. Drug use history

Question 12

Bat wing deformity

Answer 12

. Enlargement of 1 or both transverse processes of L5

Question 13

Sacralization of L5

Answer 13

. Partial or complete fusion of 5th lumbar vertebra w/ sacrum
. Causes fewer moving lumbar segments that inc. mechanical stress at remaining lumbar levels

Question 14

Lumbarization of S1

Answer 14

. Partial or complete separation of S1 from sacrum
. Patient functionality has 6 lumbar vertebrae
. Causes lumbo-sacral instability

Question 15

Spina bifida

Answer 15

. Most common birth defects w/ incidence os 1-2 cases/1000 births
. Incomplete closing of embryonic neural tube
. Vertebra overlying spinal cord not formed and remained infused and open
.most common areas: lumbar and sacral
. Detected during pregnancy by testing mother’s blood (AFP screening) or detailed fetal ultrasound

Question 16

Spina bifida occulta

Answer 16

. Mildest form 
. Hairy patch on skin
. Dark spots or birth marks 
. Red/purple spot on back composed to blood vessels 
. Dimpling in back 
. Less skin color than other areas

Question 17

T/F disc repair is less efficient than other tissues

Answer 17

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Question 18

Lumbar disc disease

Answer 18

. Compromised disc causes LBP
. Causes: multifactorial from wear and tear, trauma, or genetic causes
. Due to low energy injury of disc that progresses w/ time
. At least 30% people from 30-50 have some degree of disc degeneration
. Routine finding after 50 y/o

Question 19

Disc bulge mechanics

Answer 19

. Flexing forward motions inc. lumbar intradiscal pressure
. Repetitive/excessive force causes bulging/herniation in thinner post. Or posterolateral wall
. Invades space by nerve root
. Neurological signs may be present

Question 20

Radicular pain

Answer 20

. Annular tearing, compression of nerves or root sleeve from arthritic spurs or degenerating joints
. Most common it L4-5, L5-S1

Question 21

Radiculopathy considerations

Answer 21

. Consider MRI/surgical consult if they have significant neurologic deficits
. Surgery if large disk protrusion, spinal cord compression, worsening neuro deficits
. Contraindication for OMM (soft tissue finer, no HVLA or rotational maneuvers)

Question 22

Neurologic signs assoc. w/ LBP

Answer 22

. Motor loss
. Sensory loss
. Loss of deep tendon reflex

Question 23

Heeel walking checks which nerve root?

Answer 23

L4, ankle dorsi flexion

Question 24

Tow walking checks which nerve root?

Answer 24

. Ankle plantarflexion

. S1

Question 25

What nerve root is checked by great toe extension

Answer 25

L5

Question 26

Bragard test

Answer 26

. Modification of SLR involving dorsi flexion of ankle | . Has reticular symptoms when leg is raised or when ankle is doriflexed

Question 27

Contralateral straight leg test (contralateral laseque)

Answer 27

. Lift leg on uninvolved side . Reproduces symptoms in involved side legs . More specific than SLR but less sensitive for radiculopathy

Question 28

Nachlas test

Answer 28

. Differentiates btw femoral nerve, disc disease, radicular symptoms, lumbar ligamentous strains. And SI pathology . Patient prone w. Knee bent until heel approaches ipsilateral butt . Affects L2-3 and L3-4 discs and stretches lumbar nerve roots irritating femoral nerve . If no symptoms, lift thigh off table w/ knee flexed and hold 1 min to stress lumbar dura (pos. If symptoms seen in but and post. Thigh) . If pain in ant. Thigh it is pos. For tight quads and stretching for femoral nerve (Ely’s test)

Question 29

Screening tests done first for lumbar somatic dysfunction

Answer 29

``` . Standing structural exam . AROM . Standing flexion test . Pelvic side shift . Seated flexion . Modified Thomas test and prone psoas tests ```

Question 30

Lumbar segmental motion

Answer 30

. Sagittal plane . Extension more than flexion bc of lumbar lordosis . Considerably less rotation and sidebending . Limited at L1-4 sue to z-joint shapes . L5 permits more rotations due to it’s facet joints

Question 31

Lumbar segmental motion testing

Answer 31

. Prone or seated (prone easier, seated can assess flexion/extension) . Use same naming as thoracic

Question 32

Prone lumbar segmental motion testing

Answer 32

. Rotate segments L and R . Sidebending: apply lat. translation R and L . Flexion and extension: downward pressure over spinous process . Resistance to pressure is flexed, excess freedom is extension . Patient also can prop themselves up using elbows to test extension, laying flat is flexed

Question 33

Seated lumbar segmental motion testing

Answer 33

. Similar to thoracic | . Important bc many LBP patients cannot lie prone

Question 34

Disc L3-4 root, reflex, muscles, and sensation

Answer 34

. L4 root . Patellar reflex . Ant. Tibialis muscles . Medial leg and foot

Question 35

L4-5 disc root, reflex, muscles, and sensation

Answer 35

. L5 . No reflex . Extensor hallucis longus . Lat. leg and dorsum of foot

Question 36

L5-S1 disc root, reflex, muscles, and sensation

Answer 36

. S1 . Achilles reflex . Proneus longus and brevis muscles . Lat. foot sensation