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Clin Med > Lumbosacral pathophysiology > Flashcards

Lumbosacral pathophysiology Flashcards

1
Q

Epidemiology and natural history of LBP

A
  • 10,000,000 people off work daily in the US
  • 15,000,000 working days are lost annually in Great Britain
  • missed days cost U.S. industries $14,000,000 each year
  • 25% of cases with LBP account for 90% of cost to industry
  • moderate correlation between x-ray and symptomology
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2
Q

LBP: heavy labor vs sedentary workers

A
  • incidence rate of LBP in sedentary workers is the same as in those doing heavy labor
  • Truck drivers are more effected by LBP than any other group in the US
  • see in people that are sedentary more often than active
  • *could be because of of posture, but even with best medical exam often impossible to establish precise cause
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3
Q

LBP epidemiology and natural history: age

A
  • attacks of acute LBP start about age 25
  • become significant by age 35
  • and peak between ages of 40-45
  • about 80% of adults at least once in their lives will suffer one or more episodes of LBP severe enough to stop them from working temporarily
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4
Q

Low back pain is self limiting

A
  • 44% of people with LBP are better in one week
  • 86% of people with LBP are better in one month
  • 92% of people with LBP are better in two months
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5
Q

Self limiting but…

A
  • 90% LBP is recurrent

- 40% with recurrent LBP develop sciatica

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6
Q

Differential diagnosis

A
  • Subjective exam
  • review of systems: neurological> may see changes when we find directional preference
  • structural exam: note asymmetry; base on pts response to movement
  • systems review: movement exam, neurological exam
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7
Q

Visceral disease

A
  • originates in internal organs and stems from a variety of causes
  • Deep, dull, achy and often diffuse
  • less likely to be influenced by movement exam
  • referred pain
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8
Q

Kidney pain referral

A
  • lumbar spine

- lower and upper abdomen

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9
Q

ureter pain referral

A
  • groin
  • upper abdomen
  • suprapubic
  • medial proximal thigh
  • and TL spine
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10
Q

bladder pain referral

A
  • TL spine
  • sacral apex
  • suprapubic area
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11
Q

prostate pain referral

A
  • sacral spine
  • suprapubic area
  • testes
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12
Q

Uterus pain referral

A
  • sacral and TL spine

- primarily L5/S1

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13
Q

Ovaries/ Testes pain referral

A
  • Lower abdomen

- sacral spine

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14
Q

Pancreas pain referral

A
  • TL spine

- upper abdomen

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15
Q

Duodenum pain referral

A
  • Mid and lower T-spine
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16
Q

Gall bladder pain referral

A
  • TL spine

- right inferior angle of scapula

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17
Q

Colon pain referral

A
  • upper sacral spine
  • suprapubic area
  • left lower abdominal quadrant
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18
Q

Herniation of the IVD

A
  • NOT synonymous with but may be related to DDD
    • 60 years+ individuals more likely to be DDD, slow onset
  • herniation predominate in younger males at levels
    • L4/L5 > L5/S1 > L2/L3 > L1/L2
  • MOI often present but could be insidious
  • Most often posterolateral
  • leg pain/ neuro symptoms
  • more often unilateral
  • bend forward to right= probably herniation to left
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19
Q

Classifications of disc herniations/ insults : Disc Protrusion (avulsion) (annular fibers intact)

A

A) localized annular bulge- usually laterally
B) Diffuse annular bulge- usually posterior (kyphosis)
- displaced nucleus pulposus remains within the annulus fibrosis, but may create a pressure bulge on spinal cord

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20
Q

Classifications of disc herniations/ insults : Disc Prolapse (annular fibers disrupted)

A
  • nucleus has migrated through the inner laminar layers, but still contained within annulus fibrosus
  • reaches posterior edge of disc
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21
Q

Classifications of disc herniations/ insults : disc extrusion (annular fibers disrupted)

A
  • nucleus has broken through annulus fibrosus allowing nucleus pulposus to completely escape from the disc into epidural space
  • more likely to have neuro signs
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22
Q

Classifications of disc herniations/ insults : disc sequenstration ( annulus fibrosis disrupted)

A
  • nucleus separates from disc/ now in spinal and/or intervertebral canals
  • parts of nucleus pulposus and fragments of annulus fibrosus become lodged within epidural space
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23
Q

Disc herniation PT candidates vs surgical

A
  • PT candidates: disc protrusion, and disc prolapse
  • surgical canidates: disc sequestration
  • **Disc extrusion could go either way
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24
Q

Clinical features and diagnosis: Herniation of IVD

A
  • Dramatic onset of symptoms
    • fragmentation/joint mouse (annular tear)
  • early adult life and middle age prevalence
    • 60+ annulus and nucleus more dried out= LESS disc herniation
  • onset often a day or two after rigorous activity
  • acute sciatica often arises
  • muscle spasm with deviation (lordosis decreased or lateral shift/sciatic scolosis)
  • AROM flexion and extension limited
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25
Q

Clinical features and diagnosis: nerve root irritation and conduction evident clinically

A
  • Dermatome/myotome testing
    • ex L5= sensation dorsum of foot and EHL weakness
    • S2,S3, S4 compression- perineal region; bladder and bowel incontinence; cauda equina syndrome; ask pt to curl toes against resistence
  • Radiographs often not helpful because doesn’t rule out other causes
  • MRI/CT/Myelography useful
    • myelography ( dye) 76% as accurate as CT or MRI
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26
Q

Posterior derangement: D1

A
  • central and symmetrical pain across L4/L5
  • rarely buttock or thigh pain
  • no deformity
  • normal lumbar lordosis
  • pain with lifting, and sitting
  • better walking
  • worse with flexion
  • responds to extension in standing
  • don’t usually even come to PT, usually goes away on its own
  • represents embryonic minor problem which progresses on to D6 which is major involving a nerve root
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27
Q

Posterior derangement: D2

A
  • Central or symmetrical pain across L4/L5
  • with or without buttock pain and/ or thigh pain
  • with deformity of flat or kyphotic spine
  • worse with flexion
  • can’t extend well because of kyphosis
    • start prone on pillows, pull out pillows, up on elbows, full pressup
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28
Q

Posterior derangement: D3

A
  • unilateral or asymmetrical pain across L4/L5
  • with or without buttock and/or thigh pain
  • no deformity
  • worse with flexion
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29
Q

Posterior derangement: D4

A
  • unilateral or asymmetrical pain across L4/L5
  • with or without buttock and/ or thigh pain
  • with deformity of lateral shift (usually away from painful side)
  • worse with flexion
  • won’t respond to flx/ext - need frontal plane movement
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30
Q

Posterior derangement: D5

A
  • unilateral or asymmetrical pain across L4/L5
  • with or without buttock and/or thigh pain
  • and with pain extending below the knee
  • no deformity
  • worse with flexion
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31
Q

Posterior derangement: D6

A
  • unilateral or asymmetrical pain across L4/L5
  • with or without buttock and/or thigh pain
  • with pain extending below the knee
  • deformity of a lateral shift
  • worse with flexion
    • won’t respond to flx/ext - need frontal plane movement
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32
Q

Anterior derangement: D7

A
  • central or symmetrical pain across L4/L5
  • with or without buttock pain and/ or thigh pain
  • with deformity of accentuated lumbar lordosis (caused by hyperextension)
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33
Q

1-6 derangements

A

All worse with flexion

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34
Q

5,6 derangements

A
  • Pain below knee & most likely neuro symptoms
  • DO NOT manipulate b/c they have pain below knee
  • complex and failure becomes common
  • further distribution of symptoms
    • better success if pt has directional preference
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35
Q

1 & 2 derangements

A

central and symmetrical

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36
Q

1, 3, &5 derangements

A

No deformity

37
Q

2,4,6 derangements

A

acute deformity

  • 4,6= lateral shift
  • 2= kyphosis
38
Q

D1-D4, D7 derangements

A

rapidly reversible

39
Q

Recent derangement terminology (MDT)

A
  • Central symmetrical ( 1,2,7)
  • unilateral asymmetrical symptoms to knee ( 3,4,7)
  • unilateral asymmetrical to below knee (5,6)
40
Q

Disc degeneration- DDD

A
  • NP first to degenerate in spine
  • water and chondrotin sulfate loss
  • height of disc decreases
  • normal 60 years and >
  • AF loses elasticity primarily posterior
  • AF becomes thin, separates, and may tear
  • decreased jt space on x-ray
    • can’t see disc on x-ray though
    • could also be stenosis, spondylosis, or protrusion of disc
  • interrelation of IVD disease and posterior facet joint disease
41
Q

Disc degeneration- DDD: schmorl’s nodes

A
  • cartilage end plate weakness

- common but with minimal clinical significance

42
Q

consequences of decreased joint space

A
  • posterior facet compression
  • decreased foraminal opening (stenosis)
  • ligamentous laxity
43
Q

Degenerative joint disease/ spondylosis

A
  • most common in spine as opposed to periphery
  • DJD is not uncommon- but not normal
  • increased incidence in more mobile segments of the spine
44
Q

DJD etiology

A
  • Mechanical: weak trunk muscles due to inadequate PE, obesity, poor working habits
  • chemical: 3x greater incidence in smokers vs non smokers because of deoxygenation of tissues
  • Trauma: fall, MVA, sports injury, poor lifting mechanics
  • infection and neoplasm
45
Q

Segmental narrowing (stenosis)

A
  • late stage in DDD, segment now stiff and stable= less likely acute pain source
  • loss of ROM and stiffness in back
  • radiographs helpful for narrowing and osteophyte formation
  • IV disc space narrowing leads to post facet changes
  • annulus fibrosus bulging creates large osteophytes at bony margins
  • > 60 y/o 90% present with this
  • may or may not be painful
46
Q

intervertebral stenosis (femoral stenosis) (lateral stenosis)

A
  • more likely to cause radiculopathy
  • nerve roots
  • radicular pain
47
Q

central stenosis

A
  • bilateral symptoms
  • may be relieved by flexion aggravated extension
  • bilateral weakness
  • characteristics like UMN lesion
  • Cauda equina compression ( S2, S3, S4) = bowel incontinence
  • diffuse pain/ can be radicular
48
Q

Spinal stenosis

A
  • bony narrowing of spinal canal either centrally or in its lateral recesses including the intervertebral foramen
  • central= cauda equina compression (S2, S3, S4)
  • lateral= nerve roots
  • Congenital: born with narrow spinal canal
  • acquired: poor posture, trauma, improper landing
  • CT and myelography useful
  • Flaccid bladder (reflex incontinence= S2, 3, 4) vs retention (different tissue)
49
Q

Spinal stenosis etiology

A
  • annular protrusion of the disc
  • osteophyte
  • ligamentum flavum folding or bulging- thickened due to microtrauma over time (central stenosis)
  • subperiostial thickening over the vertebral body and laminar arch due to microtrauma ( may need laminectomy)
  • congenital narrowing
  • DJD : can be related to hypermobility
50
Q

foraminotomy

A

widen foramen

- may need fusion with this as well if spine not stable enough

51
Q

Spinal stenosis vs intermittent claudication

A
  • intermittent claudication person gets leg cramps/ pain with walking cause can’t oxygenate distal tissues
    • older, vascular disease (smoker)
  • stenosis mimics intermittent claudication associated with muscle ischemia
    • stationary bike vs treadmill testing- intermittent claudication = pain with both; stenosis biking doesn’t bother them
52
Q

Stenotic syndrome

A
  • deyo et al 1992: 60% sensitivity to neurogenic claudication
  • Roach et al 1997: sensitivity to leg pain 94% in pts with disc disease and spinal stenosis
  • Fritz et al 1997: extension decreases spinal canal 67% in degenerative spine vs 9% in normal spine
  • biomechanical diagnosis of exclusion for PT
  • advancing neuro signs= indication for surgery
53
Q

hypermobility or instability?

A
  • hypermobile= move too much actively and passively
  • instability = more severe
  • if disc material extruded= there will be too much movement
  • *intratesting= good
  • *intertesting= poor
54
Q

Segmental hyperextension

A
  • Chronic intermittent LBP (lumbago)
  • local or referred to buttocks
  • exacerbated by extension with eternal load and relieved by flexion
  • tight hip flexors
    • radiographic flexion/extension films helpful
55
Q

segmental hyperflexion

A
  • often associated with herniated or DDD
  • may be relieved by extension
  • pain comes on when they flex to end range- stability increase
  • radiographic flexion/extension films helpful
56
Q

Segmental instability

A
  • Chronic, intermittent back ache
  • increases with activity and decreases with rest
  • local or referred to buttocks
  • muscle splinting, guarding, and loss of function may present
  • often associated with positive neuro findings
  • radiographic exam helpful
  • better with movement= better prognosis than people that are better stationary
57
Q

Hypermobility vs instability

A
  • Mechanism of injury: instability= traumatic
  • level of function: worse with instability
  • AROM weightbearing: decrease most with instability
  • PIVM WBing vs non WBing: in non wbing both have too much motion and in wbing instability pt will be apprehensive and not move as much
  • neurological tests: neuro findings= instability
  • palpation: more pain with instability
58
Q

segmental hyperextension can cause…

A
  • check reins to extension compromised: abdominals and ligaments
  • may lead to sprain or posterior sublux (trauma)
  • malalignment= OA, loss of AC, osteophytes and pain
59
Q

Disc degeneration leads..

A
  • uneven, and excessive motion
  • traction spur formation
  • *form of osteophyte
    • susceptible now to injury which may create sprain of facet joints
  • adapt flexed posture to relieve
60
Q

Spondylolysis

A
  • defect in pars interarticularis (isthmus)
  • 85% incidence at L5
    15% incidence at L4
  • etiology remains obscure but thought to be a stress fx
  • found in 10% of adults
61
Q

Spondylolysis demographics

A
  • seldom found less than 5 years old
  • 8 y/o 4-5% incidence
  • Caucasian males 18 y/o 6-8% incidence
  • Caucasian females18 y/o 2-3% incidence
  • Eskimos incidence as high as 50%
  • African americans less than 3% incidence
62
Q

Spondylolysthesis

A
  • forward slippage of one vertebra and the remainder of the spinal column above it
  • “step deformity”
  • increased lumbar lordosis
  • grade 1-4 ( %vertical body slippage)
  • L5/S1 followed by L4/L5= most common
  • if doesn’t change standing and prone over pillows= stable spondylolysthesis
  • if disappears when prone over pillows= unstable
63
Q

Spondylolysthesis grades/treatment: grade I

A
  • 25% slipped
  • restrict aggravating activities
  • co-contraction trunk strengthening
  • Rest/NSAIDS/TLSO
  • no brace if move well
64
Q

Spondylolysthesis grades/treatment: grade II

A
  • 50% slipped
  • asymptomatic, x rays every 4-6 months until end of growth
  • symptomatic- as noted in grade I, posterior fusion
65
Q

Spondylolysthesis grades/treatment: grade III & IV

A
  • 75% slipped
  • likely to have neurological signs
  • posterior fusion
66
Q

Myelography

A
  • injection of dye; not used often because invasive and people have rxn to it
  • indications:
    • give surgeon guidance to what level to do surgery
  • value: specificity
67
Q

CAT scan

A
  • indications: trauma

- value: to look at disc

68
Q

MRI

A
  • indications and value:
    • GO TO because both sensitive and specific
  • more costly ($1200-$2000)
  • neuro deficits and whats causing it; disc fx
69
Q

Bone scan

A
  • suttle fx

- picks up info but not specific to whats causing it

70
Q

Discectomy (micro)

A

indications:
- neurologic deficit
- failure to respond to conservative measures of > 6 weeks
- unrelenting pain, recurrent sciatica
Procedure
- remove disc
- should have severe pain not relieved by anything, can’t bear weight, no centralization

71
Q

Microdiscetomy

A
  • uses microscope
  • ambulatory procedure
  • removes part of the disc
  • minimal complications
  • needs to be easily visible and captureable with scope
72
Q

Epidural steroid injection

A
  • invasive but non surgical
  • decrease inflammatory response to allow for testing such as repeated movements to see if they have a directional preference
73
Q

Decompression and laminectomy

A

indications:
- severe disabling back or leg pain (ie spinal stenosis)
- bowel and bladder involvement/ cauda equina syndrome
- central stenosis
Procedure:
- removal of posterior arch/ ligamentum flavum possibly with fusion
Post op
- PT
** LS brace or corset
** Prognosis > good takes 6 months to a year for bone to fuse
** home program see us much later to check progress

74
Q

Fusion

A 
Indications
- as in discectomy and laminectomy along with instability due to degenerative changes and/or trauma
- neuro signs
procedure
- instrumentation vs non istrumentation
Prognosis
- good 
- in alot of pain after b/c of number of tissues surgeon has to cut through
75
Q

instrumented fusions

A
  • harrington rod
  • pedicle screw
  • anterior (spondylolysthesis) approach vs posterior
76
Q

interbody fusions

A
  • titanium cages: open IV foramen > doesn’t sub for norm disc
  • allograft bone: from persons own body
  • bone morphogenic protein
77
Q

Cauda equina syndrome

A
  • large midline disc herniation that may compress several roots of cauda equina
  • L4/L5 most common
  • micturition difficulty- increased frequency, overflow incontinence, recent impotence
  • LBP: leg pain severe numbness of feet and difficulty walking
  • saddle paraesthgias/ dysesthegias
  • prompt surgical intervention tx of choice
78
Q

Cauda equina syndrome studies

A
  • 95% specificity for urinary incontinence
  • 80% for unilateral or bilateral sciatica and sensory/motor deficits
  • 75% for saddle anesthesia
79
Q

ankylosing spondylitis

A
  • Hereditary - HLA B27 antigen
  • 15-40 y/o male
  • slowly progressive LBP and stiffness
  • up to 4:1 male/female ratio
  • affects the SIJ’s, ZJ’s, and CV joints of axial skeleton
  • ossification of annulus fibrosis into vertebral bodies
  • “bamboo spine”
  • trochanteric to gluteal region pain and thoracic
  • radiculopathy common above knee
  • increased pain with rest and decreased pain with activity
80
Q

Ankylosing spondylitis diagnostics

A

X-ray

  • erosion, sclerosing and fusion of SI joints
  • fusion of facet joints
  • low back pain for > 3 months improved by exercise and not relieved by rest
  • limitations of lumbar spine movement in frontal and sagittal plane ( more than 1 plane)
  • reduced chest expansion ( involves costavertebral joints)
81
Q

Ankylosing spondylitis intervention

A
  • NSAIDS- indomethacin widely used
  • education
  • PT
    • thermal modalities, ROM t/o trunk especially extension, PRE’s erector spinae, swimming, education
82
Q

Sacroilitis

A
  • Inflammation of SI joints

- A-P radiograph before CT (juvenile AS)

83
Q

Sacroiliac osteomyelitis

A
  • hematogenous infection to SIJ
  • predisposing factors: due to inoculation or injection
  • patient presentation= pain over SI
  • microorganisms responsible: staph
84
Q

Metabolic/ endocrine diseases: osteoporosis/ osteomalacia/ Paget’s Dz

A

potential to affect the structural integrity of vertebae and sacral bones

85
Q

Paget’s disease

A
  • Rare before 40 y/o
  • males=females
  • 3-4% after age of 40 and up to 10% by age 90
  • Dz affects lumbar spine 60% and sacrum 45%
  • non musculoskeletal symptoms:
    • increased hat (head) size, hearing loss, tinnitus, vertigo, HA, CHF, basilar invagination
  • exam reveals: flat lumbar spine, slow gait, anterolateral bowing legs (saber shin)
  • may have white matter disease in spine
86
Q

Paget’s disease diagnosis

A
  • bone deformities on xray / bone scan +

- elevated serum alkaline phosphate

87
Q

Paget’s disease treatment

A
  • NSAIDS
  • hormone calcitonin
  • bisphospohates
    • bind to bone materials= inhibition of bone loss
88
Q

spondylolysis most common in what athletes?

A
  • gymnastics, football linemen, butterfly swimmers, weight lifters
  • x-ray and bone scan utilized

Clin Med (3 decks)

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