MIDTERM #1--WEEK 7 Flashcards by ROGER ALONSO

______________:

The presence of specific sign(s) or symptom(s) suggesting with almost certainty that the target condition is present

Pathognomonic

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Test __________ is the ability of a test to correctly identify those with the disease (true positive rate)

sensitivity

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Test ______ is the ability of the test to correctly identify those
without the disease (true negative rate)

specificity

Example: If 100 without a disease are tested, 90 have a negative result; the test has 90% specificity

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Differential Diagnoses =

“ALL THE CONDITIONS THAT APPEAR ______”

Example:
A patient with back &amp; leg pain differential diagnoses may include:
 Disc herniation
Facet syndrome 
Muscular strain
SI Joint injury
 Piriformis syndrome

SIMILAR

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______ ________: “A working
hypothesis formulated from significant items in history and physical findings, a tentative diagnosis; or a working diagnosis.”

Clinical Impression

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Selected Disorders of the Lumbar Spine

____% of all adults will suffer from an episode of LBP at some time in their life

 2nd only to the common cold as a cause of lost days at work

 One of the most common reasons for visits to a doctor’s office or emergency department

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Selected Disorders of the Lumbar Spine

Good news: most LBP is uncomplicated with recovery in about ____ weeks

Estimated 90% will self-resolve within ___-_____months
— Not so good news: 10% of patients do NOT return to normal function even after 2 months
Pose the greatest challenge to practitioners Enormous economic burden on society
NOTE: cLBP is the MOST common cause of disability in Americans younger than ____ years

1–2

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Selected Disorders of the Lumbar Spine

Encouraging News:
~____% of Americans with LBP seek chiropractic care
• Evidence on clinical effectiveness supports the use of manipulation for acute LBP and helps resolve symptoms and restore function of chronic LBP

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Selected Disorders of the Lumbar Spine

In total,_______% of workers who initially visited a surgeon underwent surgery, in contrast to only 1.5% of those who first consulted a chiropractor

42.7

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Selected Disorders of the Lumbar Spine

Disc disruption: _____%
Facet involvement:___-______%
Compression fracture: 4%
Spondylolisthesis: 3%
Malignant Neoplasm: 1%
Ankylosing Spondylitis: 0.3% • Spinal Infection: 0.01%

15-40

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Selected Disorders of the Lumbar Spine

LBP Etiology continued…….
• Spinal Stenosis - common in older population
coupled or enhanced by ___________ processes
• Sacroiliac (SI) Joint
• Other (Prostate, Aneurysm, kidney, female reproductive organs )

degenerative

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Selected Disorders of the Lumbar Spine

Mechanical LBP (97%)

• Muscle/Ligament
– ______/_________, MFPS, fibromyalgia
• Bone/Joint
–_________ syndrome, arthritis, fracture, osteoporosis spondylolisthesis
• Nerve
– Compression/irritation (lateral, central canal), disc, inflammation

Strain/sprain,

Facet

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Selected Disorders of the Lumbar Spine

Spinal pain is multifaceted, involving structural, biomechanical, biochemical, medical, and psychosocial influences that result in dilemmas of such complexity that treatment is often _______ or __________”

difficult

ineffective

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Selected Disorders of the Lumbar Spine

Non-Spinal/Visceral Disease (___%)

• Aortic aneurysm
• Pelvic organs
– Prostatitis, pelvic inflammatory disease, endometriosis
• Renal organs
– Nephrolithiasis (kidney stones),pyelonephritis
(infection of the kidney and the ureters)
• Gastrointestinal system
– Pancreatitis, cholecystitis

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Selected Disorders of the Lumbar Spine
Anatomy of the IVD

Centralportion:
The _____ _______which is composed of cells from the primitive notochord
• Outerportion:
The _____ ______composed of concentric layers of intertwined annular bands - resist forces placed on the lumbar spine
• Subdivided into:
Inner fibers, connected to the cartilaginous endplate
Outer Sharpy fibers, attached to the VB

nucleus pulposus

annulus fibrosis

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Selected Disorders of the Lumbar Spine

ALL and PLL further strengthen the disc space
• ____ resists forces applied in extension
stronger ligament than the PLL
• The _____ resist flexion forces
Strongly attaches to the annulus fibrosis
Frequently is torn in cases of free fragment disc herniation

ALL

PLL

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Selected Disorders of the Lumbar Spine

There is a distinction between an ______ disc and a degenerated disc

Although unfortunately, often considered synonymously
Difficult to differentiate changes that occur solely due to aging from those that might be considered pathological

Degeneration = _________

aging

Disease

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Selected Disorders of the Lumbar Spine

The Aging Disc

ALL discs undergo age related changes

Age related changes occur in ALL collagenous tissue starting at ______
• Can be accelerated by ______

birth

trauma

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Selected Disorders of the Lumbar Spine

Normal Disc Aging

• 1st changes occurs in the nucleus
Changes from soft gel into an mix of fibrous lumps with softer materials adjacent to endplates
Produce fewer proteoglycans therefore,
Water content _________
Accelerated by oxidative stress from ________ compromise
Tissue more brittle, prone to injury
• ________=physically stiffer

decreases

nutritional

Dehydrated

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Selected Disorders of the Lumbar Spine

The strength of the lumbar disc is related to the fluid and proteoglycan content of the disc (Proteoglycan is a ___________)

hydrophilic

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Selected Disorders of the Lumbar Spine

Disc Properties

_______ = Gradual deformation of the disc when under a constant load. Loading expresses ___% of water from disc during the day – most of water loss is from ________
• Non-degenerated disc:creep is very SLOW
• Injured disc:Creep/deformation can be RAPID–more vulnerable to prolapse – less able to recover

Creep

nucleus

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Selected Disorders of the Lumbar Spine

Disc Degeneration

Very common in humans but, NOT an inevitable consequence of ______

Aging, apoptosis, abnormalities in collagen, vascular changes, loads placed on the disc, and abnormal proteoglycans, loss of disc nutrition
• May lead to loss of height of motion segment with concomitant changes in biomechanics of segment.

Disc space __________ is NOT normal = Degeneration

aging

narrowing

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Selected Disorders of the Lumbar Spine

—Etiology: Disc Degeneration—

One of the primary causes of disc degeneration is thought to be failure of the _______ supply to the disc cells
• Can be affected by several factors that affect the blood supply to the vertebral body such as:
_____________appear to lead to a significant increase in disc degeneration
Long-term _______or lack of it appears to have an effect on movement of nutrients into the disc, and thus on their concentration in the tissue

nutrient

Atherosclerosis

exercise

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Selected Disorders of the Lumbar Spine

Disc Degeneration

3 phases of progressive degenerative
changes in the annulus nuclear complex:

___________:= Circumferential and radial tears
__________:= Internal disruption and disc resorption
_________:= Osteophytes and traction spurs. Can lead to stenosis

Dysfunction

Instability

Restabilization

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Selected DISORDERS of the Lumbar Spine Pathomechanical Disc Degeneration 1--• _________ tears = From shear stresses from loading in bending and torsion 2--• ___ _____ = Circumferential avulsions of the peripheral annulus with sclerosis and osteophytosis of the adjacent bone 3--• Internal disc disruption =Inward buckling 4--• Radial fissures = Starting from the inner annulus sometimes progressing to the outer margins of disc so, 5--• NP material can then _________ resulting in disc prolapse = Protrusion, extrusion or sequestration

Circumferential Rim lesions escape

Selected Disorders of the Lumbar Spine Disc degeneration alters disc height and the mechanics of the rest of the spinal column. Possibly adversely affecting behavior of other spinal structures such as _____ and ligaments • Associated with _______ and disc herniation or prolapse Long term: • Can lead to _____ _______, a major cause of pain and disability in the elderly • Apophyseal joints adjacent to discs subject to abnormal loads and eventually develop osteoarthritic changes

muscles sciatica spinal stenosis

Selected Disorders of the Lumbar Spine 2 phases of IVD prolapse/herniation: 1. ________ __________= Displaced nuclear material causing the outer annulus to bulge 2. ________ _________= Nuclear material escapes from the disc. ***________ most often occurs on the posterior or posterolateral aspect of the disc partially due to arrangement of the annular fiber bundles appear. Directs the herniation toward the exiting and traversing nerve roots.

Annular Protrusion Nuclear Extrusion Herniation

Selected Disorders of the Lumbar Spine Disc Herniation 1---__________ Disc– Nucleus protrudes through inner but NOT the outer layer of the annulus (outer annular fibers intact) ``` 2---_______________ Disc – Nuclear material penetrates completely through annulus (annular fiber ruptured) • Beneath the PLL • Penetrate the PLL or • Sequestered ```

Contained Non-Contained

Selected Disorders of the Lumbar Spine ---Lumbar Disc Herniation / Prolapse--- 1---Bulge: - Mild displacement of the annular fibers probably due to a slight nuclear displacement - Involves at least ___% of the circumference of the disc, but may involve up to 100%- The ____ is intact. Bulge may be caused by disc degeneration, response to loading or angular motion, or even a normal variant.

50 PLL

Selected Disorders of the Lumbar Spine ---Lumbar Disc Herniation / Prolapse--- 2--Protrusion: – A focal outcropping of the annulus – The fibers of the annulus are thinned with some tearing – The _______ moves through the ‘tears’ usually in a posterior direction – PLL is intact

nucleus

Selected Disorders of the Lumbar Spine ---Lumbar Disc Herniation / Prolapse--- 3---___________:– Rupture of the annular fibers so that the nuclear material emerges through the annulus – NP remains confined by the PLL

Extrusion

Selected Disorders of the Lumbar Spine Clinical Consideration Patients with severe back pain and sciatica are almost 3 times as likely to have a disc _______ On MRI examination of the lumbar spine, many people without back pain have ____ _____ or _________ but NOT extrusions

extrusion disk bulges protrusions

Selected Disorders of the Lumbar Spine ---Lumbar Disc Herniation / Prolapse--- 4---______________: – PLL is disrupted and the nucleus protrudes into the epidural space – Displaced disc tissue is expelled from disc and is no longer attached to it. ***The _____ and ______ of disc herniation DOES NOT correlate with the degree of patient pain, disability, or suffering

Sequestration size severity

Selected Disorders of the Lumbar Spine Disc Lesion – Immune Response? RECALL: NP has no blood supply – segregated from immune system Herniated disc material causes an _______ reaction due to the release of irritating substances and/or an autoimmune inflammatory reaction

inflammatory ***Immune inflammatory response causes further degradation • Result:herniation & irritation or compression of nerve root. *****It had been suggested by recent studies that the herniation does NOT regress back into the annulus, but actually shrinks from resorption, desiccation, and phagocytosis!!

Selected Disorders of the Lumbar Spine _____% of lesions are to L4-L5 or L5-S1 Classic Presentation and Symptoms – Sudden onset of back pain with sharp pain into the leg past the knee, to the foot – Usually follows twisting or bending injury – Often a past Hx of several bouts of LBP that resolved – Pain is made worse with coughing, bearing down, sneezing • Signs – Pain with palpation, splinting, edema, spasm

98 Know

Selected Disorders of the Lumbar Spine L5-S1 Disc ``` • ____% probable if 3 S1 signs are present: 1. Pain projection into the S1 area • sciatic 2. Pathologic achilles DTR 3. Sensory deficit in S1 dermatome ```

Selected Disorders of the Lumbar Spine ``` L4-L5 Disc • _____% probable if 3 L5 signs are present: 1. Ext. Hallicus weakness 2. Pain projection into the L5 area • posterolateral thigh/calf 3. Sensory deficit of L5 dermatome ```

87%

Selected Disorders of the Lumbar Spine Characteristics of Disc Injuries ``` 1--Bulge – Pain increases with flexion – Flexion is limited – No radicular pain – Neuro exam is negative – X-rays are negative – Probably _________ ```

asymptomatic

Selected Disorders of the Lumbar Spine Characteristics of Disc Injuries ``` 2--Protrusion – Pain _________ with flexion – All ROM limited to some degree – Somatic and/or radicular pain – Antalgia – Neuro exam may be normal or be deficit – X-ray: decreased disc angle or decreased lordosis or decreased lumbosacral angle ```

increased

Selected Disorders of the Lumbar Spine Characteristics of Disc Injuries ``` 3---Extrusion – Pain increases with flexion – Radicular and somatic _________ pain – Antalgia – (+) Dural Tension Signs – Hard Neurological Signs (abnormal) – MRI evident – X-ray same as protrusion ```

referred

Selected Disorders of the Lumbar Spine Characteristics of Disc Injuries 4---Sequestration – Back pain history that suddenly Changes to predominantly leg pain – Early dural tension signs that may have disappeared Unrelenting paresthesia/pain – MRI – Posterior migration of the free fragments: ______ __________ syndrome (rare/immediate referral)

Cauda Equina

Selected Disorders of the Lumbar Spine Lower Vs. Upper Lumbar Nerve Root Pathology ______ ________: : (L4), L5, S1, S2, S3 ______ _________: L2, L3, L4

Sciatic Nerve Femoral Nerve

Selected Disorders of the Lumbar Spine Imaging and Special Testing 1--Do NOT reveal herniation; but do help exclude other conditions (eg. fracture, cancer, infection) 2--NOTE: consider whether disc herniation is ______ OR ________ to nerve root

medial or lateral

Selected Disorders of the Lumbar Spine Epidural STEROID Injections * Used in attempt to relieve back and lower limb pain associated with disc conditions with or without nerve root involvement * Typically used when patient has primary leg pain or pain that is too _______ for less invasive management * Early patient satisfaction reported – diminishes over time * Complications exist * Limited evidence about how well injections actually work and limited agreement on when they should be used

severe ***In the absence of: loss of bowel or bladder control and of progressive neurological deficit most patients are suitable for 2-3 month trail of conservative management before proceeding with surgery

Selected Disorders of the Lumbar Spine Suspicion of cauda equina syndrome or __________ neurological deficits warrant surgical consultation to avoid progressive or irreversible neurological deficits

progressive

Select Disorders of the Lumbar Spine PART 2 Lumbar Stenosis---Common and complex degenerative disorder in the aging population WHAT ARE THE 2 TYPES??

Central Stenosis Foraminal Stenosis

Select Disorders of the Lumbar Spine PART 2 Foraminal Stenosis ``` IVF Stenosis = Reduction in size of the space at the IVF due to: – ______ __________ – _________________ – Tumor – Osteophytes ```

Disc Herniation Spondylolisthesis ***Spondylolisthesis is a condition in which a bone (vertebra) in the spine slips out of the proper position onto the bone below it.

Select Disorders of the Lumbar Spine PART 2 Central Stenosis Cause:= Bony or soft tissue encroachment often at ______ ________.

multiple levels

Select Disorders of the Lumbar Spine PART 2 Central Stenosis CAUSES X 2 1---____________--- Trefoil shape of canal or short pedicles 2----_________ (most common)----- IVD prominence posteriorly, bony outgrowths, degenerative spondylosisthesis or hypertrophied &/or calcified lig. flavum, HYPERtrophied articular facets, tumor, postoperative (consequence of decompression surgeries eg. laminectomies) *** Neurologic deficits may cross dermatomal and other nerve root boundaries

Congenital Acquired

Select Disorders of the Lumbar Spine PART 2 Central Stenosis: Classic Presentation and Symptoms * Over ___ YOA with LBP and unilateral or bilateral (MC) leg pain * Leg complaints usually come on after _______ and relieved by stooping over or by resting for 15-20 min * Going up stairs and bicycling are NOT as provocative * Flexion theoretically opens up the canal and IVF taking pressure off neural structures

50 walking

Select Disorders of the Lumbar Spine PART 2 ___________________= A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.

CLAUDICATION

Select Disorders of the Lumbar Spine PART 2 ____________________ = is a collection of symptoms resulting from LUMBAR spinal stenosis, or the lower back. 1--Positional – relief with forward bending 2--Walking: pain pattern not fixed 3--Pain: Proximal to distal (thigh vs. calf) 4--Cycling is better vs. walking 5--Peripheral pulses: normal 6-- narrowing of the spinal canal in the lower back. 7--Dermatomal/Myotomal 8--Radiographs for stenosis may reveal canal widths of less than 15mm (10 -12 mm =relative stenosis,

Neurogenic Intermittent Claudication

Select Disorders of the Lumbar Spine PART 2 ___________________ = stops quickly when you rest, even in the standing position. By comparison, pain due to spinal stenosis is related to body position and may continue for as long as you remain standing. Bending forward or sitting down usually relieves the pain, but even then the pain of spinal stenosis does not stop as quickly as pain resulting from insufficient blood flow. Caused by atherosclerosis of the iliofemoral vessels – Peripheral vascular disease (PVD)

Vascular Claudication

Select Disorders of the Lumbar Spine PART 2 Vascular Claudication = commonly associated with: • Impotence in men • Dystrophic skin changes (nail atrophy, alopecia) • Foot pallor or cyanosis • Decreased or ________ peripheral pulses • Relief with rest • NOT effected by changes in ___________ • Pain in the gastrocnemius

absent posture

Select Disorders of the Lumbar Spine PART 2 Management of L/S Stenosis 1---Surgical consult indicated if patient has intolerable symptoms (leg and back pain) and shows ______ neurological deficits 2--- Surgery is rarely performed otherwise – unless, pt is NOT responding to an aggressive and comprehensive trial of conservative management first

severe

Select Disorders of the Lumbar Spine PART 2 Facet syndrome--- is a syndrome in which the zygapophysial joints (synovial diarthroses, from C2 to S1) cause back pain. 55% of facet syndrome cases occur in ________ vertebrae, and 31% in _______. Facet syndrome can progress to spinal osteoarthritis, which is known as spondylosis.

cervical lumbar.

Select Disorders of the Lumbar Spine PART 2 Lumbar Facet Syndrome * A ______ AND ________ injury of the richly innervated articulating facets of the lumbar spine * Characterized by LOCAL and/or ______ pain arising from the zygapophseal joints

rotational and compression referred

Select Disorders of the Lumbar Spine PART 2 Lumbar Facet Syndrome = _______ is the most common location. – Transitional – Joints more coronal – Site of most weight bearing – Center of gravity passes through the vertebrae ***Pain decreases with flexion and increases with extension!!

L5/S1

Select Disorders of the Lumbar Spine PART 2 Lumbar Facet Syndrome...............Possible Causes: – Richly innervated facet and it’s capsule may be source of pain – Entrapped meniscoid (synovial folds) may become entrapped or pinched and cause pain – Inflamed joint surface – Degeneration in older adults – Faulty posture may be contributing factor – Trauma, microtrauma

KNOW

Select Disorders of the Lumbar Spine PART 2 Tropism = Joint tropism = Joint asymmetry: a turn in the orientation of the facet. Congenital anomaly • Occurs in ___% to ___% of the population • L4/L5 and L5/S1 facets are the M/C location – Although this must alter the biomechanics at that segmental level, it has NOT been demonstrated to cause an increase in LBP – May cause you to alter your CMT

21 - 37%

Select Disorders of the Lumbar Spine PART 2 Facet Syndrome Management-- Particularly responsive to ____! It is proposed that manipulation may free the entrapped meniscoid OR causes reflex mediated changes that diminish spasm and pain.

CMT

Select Disorders of the Lumbar Spine PART 2 Facet Syndrome: * Lacks neurologic findings and nerve root tension signs * Lacks pain below the ____ * Facet syndrome has dull achy pain that stops before the knee with Kemp’s and SLR * Radiographs of facet syndrome may reveal signs of facet imbrication

knee

Select Disorders of the Lumbar Spine PART 2 Lumbar Sprain/Strain ``` • ________: an injury to a ligament; stretch or tear • _________: an injury to a muscle – Muscle belly – Tendon – Musculotendinous junction (M/C site) ```

Sprain Strain

Select Disorders of the Lumbar Spine PART 2 Lumbar Sprain/Strain----------Grade I (mild) ___ _______ of the muscle or ligament with little or no outright tearing of the fibers. • There is NO hemorrhage, minimal swelling or edema and palpable tenderness. • Slight laxity is possible with a sprain, but unlikely to be palpable by the doctor

Mild stretching

Select Disorders of the Lumbar Spine PART 2 Lumbar Sprain/Strain-----Grade II (moderate) * There is tearing of the fibers of the muscle or ligaments. This tearing is less than 100% of the fibers. * Clinically, there is an appreciable inflammatory response (swelling, tenderness, heat), hemorrhage, and usually protective muscle spasm or splinting. * Produces a _____ of the joint

laxity

Select Disorders of the Lumbar Spine PART 2 Lumbar Sprain/Strain---Grade III (severe) 1-----100% of the ligament or muscle fibers are torn 2----Clinically: severe pain, diffuse hemorrhage gross swelling, complete loss of muscle function and severe spasm of the surrounding musculature in the acute phase. • Grade III sprains create laxity and possible functional instability – _____ ______ must be present for this less likely sprain

Major trauma

Select Disorders of the Lumbar Spine PART 2 Lumbar Sprain/Strain------Healing Time * Minor: Resolves in ~1-2 week * Moderate: ~___-____ weeks * Severe: ~5-10 weeks = Severe Sp/St may require surgery and postoperative rehabilitation

3-4

Select Disorders of the Lumbar Spine PART 2 Spondylolisthesis--Slippage of one vertebra on another Classifications X 5 – Type I: ________ = Congenital abnormality in sacrum or neural arch – Type II:______ = Lytic or fatigue fracture of the pars interarticularis • Elongated but intact pars • Acute fracture of the pars

Dysplastic Isthmic *** Spondylolysis only refers to the separation of the pars interarticularis (a small bony arch in the back of the spine between the facet joints), whereas spondylolisthesis refers to anterior slippage of one vertebra over another (in the front of the spine). **Can have a spondylolysis without spondylolisthesis

Select Disorders of the Lumbar Spine PART 2 Spondylolisthesis Classifications X 5 – Type III:___________ = Secondary to long standing arthrosis – Type IV: ________ = Fractures other than the neural arch – Type V: Iatrogenic = Above or below a spinal fusion

Degenerative Traumatic

Select Disorders of the Lumbar Spine PART 2 Spondylolisthesis • 2 most common types: 1--– Isthmic: Patient with stress fracture of the pars interarticularis (spondylolysis) or an elongated pars 90% at ____ 2--– Degenerative: Older patient with degenerative slippage, usually at _____

L5 L4

Select Disorders of the Lumbar Spine PART 2 Spondylolisthesis-----Isthmic Spondylolisthesis * Most Common type * ____ is weakest part of neural arch * Repetitive flexion and extension motion creating fracture * Increased incidence in athletes (eg. gymnastics, weight lifting, and football) * ____% at L5 * Majority of slippage occurs in children under age of ___ * Lysthesis---- most likely to occur in patients with weakness in iliolumbar ligament and TPs not well developed

Pars 90 10

Select Disorders of the Lumbar Spine PART 2 Degenerative Spondylolisthesis---• A degenerative disc leads to instability and the_______ facet subluxates. • The axis of rotation shifts from the vertebral body/disc to the ______ **• 3 F’s: Female, Forty, Fourth Lumbar (L4)

inferior facets

Select Disorders of the Lumbar Spine PART 2 Spondylolisthesis ---- Grading Divide the sacrum or vertebra below into 1/4ths • Each slip of the 1/4 is considered a grade: – Grade 1 & 2: stable – Grade 3 & 4: require surgical consultation

Meyerding Grading System ``` Grade I: 1-24% Grade II: 25-49% Grade III: 50-74% Grade IV: 75%-99% slip. Grade V: Complete slip (100%), known as spondyloptosis ```

Disorders of the SI Joint and Pelvis Sacroiliac Joint Syndromes * A pain syndrome presenting with pain over 1 sacroiliac joint, which may be accompanied by _____ _______ to the buttock, groin, and leg * Caused by dysfunction or lesion to the joint

referred pain

Disorders of the SI Joint and Pelvis Causes x 3 1---___% of SIJ syndrome cases from a one time traumatic event 2--- ___% due to repetitive injury 3--- 35% had idiopathic/spontaneous onset

44 20

Disorders of the SI Joint and Pelvis SI Joint Syndrome • SI joints can cause LBP • No standard pain referral pattern (Schwarzer) • Local aching, burning or dull pain (pain can be sharp at times) • Point tenderness or pain on motion palpation • NO radiation of pain above L__ • Can refer pain to buttocks, posterior or lateral thigh, groin or anterior pelvis

Disorders of the SI Joint and Pelvis Examples of SIJ Orthopedic Tests X 7 ``` Gaenslen’s Test Lewin-Gaenlen’s Test Yeoman’s Test Nachlas Test Pelvic Rock Test Hibb’s Test Sign of the Buttocks ```

KNOW

Disorders of the SI Joint and Pelvis SI Joint Sprain Management-------Acute = • SIJ belt • Cautious CMT (avoid increased stretch to ligaments) • Ice • Core stabilization

KNOW

Disorders of the SI Joint and Pelvis Sacroiliitis----• Inflammation to the _____ – Attempt to determine cause • Infection, arthritide, etc… – Treatment directed at cause

SIJ

Disorders of the SI Joint and Pelvis-Piriformis Syndrome • Buttock pain with or without ______ ________ pain secondary to injury or contracture of the Piriformis muscle (spasm or strain) • May mimic ____________ • Possible PAIN patterns – Groin – Posterior thigh into calf and ankle or foot – Exacerbated by activity, bowel mvnt, prolonged sitting, or rise from seated position

sciatic nerve radiculopathy

Disorders of the SI Joint and Pelvis-Piriformis Syndrome Anatomical Considerations: O: Anterior surface of the lateral sacrum S2-S4 and sacrotuberous ligament I: Greater trochanter (superior) – Gluteal nerves, sciatic nerve and gluteal vessels all pass ______ the greater sciatic notch with the piriformis muscle Sciatic Nerve– Passes ______ piriformis or through muscle or divides through and below/above

through below

Disorders of the SI Joint and Pelvis-Piriformis Syndrome ``` Causes: – SIJ dysfunction – Trauma – Prolonged ______ __________ or – Activities requiring internal rotation of leg with flexion ```

sitting postures

Disorders of the SI Joint and Pelvis-Piriformis Syndrome Piriformis Syndrome Management * ____ or myofascial release techniques are often helpful * When acute, ___ modalities may help * CMT for SI joint restriction * Home stretching program

PIR PT

Disorders of the SI Joint and Pelvis Coccydynia / Coccygodynia = Irritation of the coccyx or sacrococcygeal junction with possible displacement of the __________ 1---Etiology: • Trauma: direct contusion or flexion sprain/anterior displacement or the rare extension injury from childbirth

coccyx

Disorders of the SI Joint and Pelvis Coccydynia / Coccygodynia Symptoms:- Local pain and soreness; pain on sitting Signs:- Contusion/inflammation over coccyx, palpable tenderness Treatment: - CMT: internal vs. external - Cryotherapy - Anti-inflammatory therapy - Donut pillow

know

Disorders of the SI Joint and Pelvis--Osteitis Pubis | aka: __________ ___________

Gracilis Syndrome

Disorders of the SI Joint and Pelvis--Osteitis Pubis • Inflammation of the pubic symphysis • Prevalence: athletes • Etiology: acute trauma, genitourinary infection, pelvic surgery, pregnancy, arthritic conditions • S/S: Ache or tenderness on palpation; Pain with passive _______ or resisted ______ Management: – Rest and time – Modalities including _____or ____ may provide symptomatic relief

abduction adduction heat or ice

Arthritides and Red Flags ----Arthritis Classification ***Arthritis = conditions involving damage to the joints EROSIVE x 3 ``` a. ___________ • Gout • Pseudogout • Hydroxyapatite deposit disease b. ___________ Rheumatoid: • RA • JCA/Still’s Disease Seronegative: • Reiter’s Syndrome/Reactive Arthritis • Psoriatic • AS Connective Tissue: • Lupus Erythematosus • Scleroderma c. __________(septic) ```

Metabolic Inflammatory Infectious

Arthritides and Red Flags ----Arthritis Classification ***Arthritis = conditions involving damage to the joints ``` SCLEROTIC x 1 d. ______________ • Primary (idiopathic) • Secondary (known factor/trauma) • Spinal • Erosive • DISH • Neuropathic Arthropathy ```

Osteoarthritis ***Theory: Barometric pressure falls before the arrival of wet, damp weather • Bones, muscles, ligaments and tendons have to adjust by expanding • When expansion occurs, sensitized nerves send out pain signals

Osteoarthritis / Degenerative Joint Disease ``` Pathogenesis: Abnormal biomechanics – cartilaginous erosion – sclerosis of subchondral bone – subchondral cysts – marginal osteophytes – variable synovial inflammation – Also, ____________ distribution ```

asymmetric *** Often will c/o morning stiffness that resolves after ~ 30 min, also stiffness following prolonged rest

Osteoarthritis / Degenerative Joint Disease ________--Degenerative changes to facet, discs and vertebral bodies • Degenerative Disk Disease (DDD): Refers to back PN symptoms attributable to ___ degeneration

Spondylosis IVD

Osteoarthritis / Degenerative Joint Disease Seronegative Arthritides Refers to a diverse group of musculoskeletal syndromes linked by common clinical features and common immunopathologic mechanisms • Characterized by the ________ of Rheumatoid Factor (RF) ex– Reiter’s/Reactive Arthritis ex– Ankylosing Spondylitis ex– Psoriatic Arthritis

absence

Osteoarthritis / Degenerative Joint Disease Seronegative Arthritides • Spontaneous exacerbations and _______ Wide range of non-articular features examples: • inflammatory eye disease • inflammatory bowel disease • urethritis Human Leukocyte Antigen B27--(+) HLA-B27 • Strongly associated with Seronegative Arthritides • Ordered to help strengthen or confirm a suspected diagnosis.

remissions

Arthritides and Red Flags ----Ankylosing Spondylitis-- is an inflammatory disease that can cause some of the vertebrae in your spine to fuse together. This fusing makes the spine less flexible and can result in a hunched-forward posture. If ribs are affected, it may be difficult to breathe deeply.

know ``` Rheumatoid Factor (RF) : • An autoantibody • Identified through blood test • Part of the usual disease criteria of Rheumatoid Arthritis ```

Arthritides and Red Flags -----Ankylosing Spondylitis Classic Presentation: • Young male ( 3 months) • Relief with mild to moderate activity • Fatigue is common

know *** Progressive spinal stiffening and fusion ***Unpredictable course remission/relapse

Arthritides and Red Flags ------Ankylosing Spondylitis ``` With Progression: – Gradual stiffening – Loss of L/S _________ – Increase in T/S ___________ – Cardiac and lung involvement possible – 50% have peripheral joint involvement: » Hips » Shoulders » Knees ```

lordosis kyphosis

Arthritides and Red Flags ------Ankylosing Spondylitis Radiographic Changes: • Early changes seen in SI: _______ – ________, symmetric pseudo-widening, erosions and sclerosis, eventual fusion • Spine: marginal sclerosis, erosion of sup. and inf. margin of ________ _________ – Squaring appearance • Calcified spinal ligaments and annular fibrosis create “_____ _______” sign & eventual fusion: Bamboo spine • Radiographic changes may not be visible for 4-6 years AFTER onset

Saroiliitis Bilateral vertebral bodies trolley track

Reiter’s Syndrome / Reactive Arthritis* Classic Presentation: • Young male • Associated w/ venereal or dysenteric infection • c/o LBP began after onset of urethritis, conjunctivitis, and ____ ________ Evaluation: • Mechanical testing of ___ will usually increase PAIN! ---_______involvement, jt. space narrowing, erosive changes may be seen

skin lesions SI Unilateral

Reactive Arthritis Diagnostic Tetrad: 1. Polyarthritis affecting the knees and ankles __________ but SI is most common symptomatic joint (asymmetric sacroilitis) 2. Urethritis 3. Conjunctivitis (resolves w/n 1-2 d) 4. Lesion (tongue, palate, penis or foot)

asymmetrically

Reactive Arthritis Management: • Primarily symptom relief/ anti-inflammatory •______: used to treat underlying infection but does NOT change course of the disease • Caution with CMT: – Inflammatory; CMT to SI may aggravate

Antibiotics

Psoriatic Arthritis • Psoriasis usually precedes _________ – Occasionally by as many as 5 - 20 y – Can develops in the absence of detectable psoriasis – __-___% of patients, arthritis appears BEFORE the psoriasis • Affects 5-8% of patients with psoriasis • MC in caucasians, 35-55 yoa (but can occur at any age) • Men and women affected EQUALLY • Labs: elevated ESR, (+) or (-) HLA-B27, (-) RF – NOT diagnostic

arthritis 15-20

Psoriatic Arthritis--Spondylitis (with or without sacroiliitis) (Spondylitis)--- is an inflammation of the vertebra. It is a form of spondylopathy. In many cases spondylitis involves one or more vertebral joints as well, which itself is called _______ – Occurs in approx 5% of patients with psoriatic arthritis, male predominance – Sacroiliitis: if present, tends to be _____ – May appear radiologically without classic symptoms of morning stiffness in the lower back – Vertebrae affected _________

spondylarthritis. asymmetric asymmetrically

Psoriatic Arthritis Management: * Treatment is directed at controlling the ________process * _______ is an important part of the total treatment to limit the pain, maintain mobility

inflammatory Exercise

Initial LBP Assessment Classify into 1 of 3 working categories: 1. Potentially serious spinal condition: _____,______ spinal fracture, or a major neurologic compromise, such as cauda equina syndrome, suggested by a red flag 2. ______: back-related lower limb symptoms suggesting lumbosacral nerve root compromise 3. __________ back symptoms: occurring primarily in the back and suggesting neither nerve root compromise nor a serious underlying condition OR: __________ pathology: (abdominal, pelvic, etc.) that can present as low back symptoms

tumor, infection, Sciatica Nonspecific Non-spinal

Abdominal Aortic Aneurysm (AAA) • Relatively common, potentially life-threatening condition • Ruptured AAA is the ___th-leading cause of death in the United States • Incidence of 2-4% in the adult population • MC in ________ males b/w 65 - 75 yoa • 5:1 – 7:1 male predominance • More frequent in men smokers • Often have Hx of HTN • _____________ is the M/C cause • Between L2 - L4 is the M/C location * Most are asymptomatic until they rupture/bleed

13 Caucasian Atherosclerosis

Abdominal Aortic Aneurysm Classic Presentation: • Mild to severe abdominal or low back pain – ______ _____ will have throbbing or aching – Epigastric, flank, or low back pain, weakness • May be associated complaint of leg pain with exertion (Claudication)

Mild bleeding

Abdominal Aneurysm • In asymptomatic patient: - MC finding is _______ abdominal mass - Auscultation may reveal a bruit • Dissecting: – Ripping chest, upper back, and __________ pain that is very severe • Ruptures: – Exsanguinations, pulsating masses, pain may be worse with lying down (14%)

pulsatile abdominal

Abdominal Aneurysm Radiographs: • Diameter exceeding 3.8 cm at the most distant calcified borders is diagnostic • __-__ cm requires a consultation and ultrasound • >6 cm usually requires surgery • __-____ % survival rate for ruptures • Smaller AAA’s, when surgery may not yet be indicated, will be monitored over time

4--6 10 - 20

Cauda Equina • Cauda equina is formed by nerve roots caudal to the level of spinal cord termination – Average adult: cord terminates b/w 1st and ____ lumbar vertebrae • Distal to this end of the spinal cord is a collection of nerve roots, (which have horsetail-like appearance) called the cauda equina (Latin for horse's tail) Cauda Equina Syndrome is characterized by: – Low back pain – Unilateral or usually bilateral _________ – Saddle sensory disturbances – _________ and _________ dysfunction – Variable lower extremity motor and sensory loss * Rare but serious: may be irreversible and may be a surgical emergency

2nd sciatica Bladder and bowel

Cauda Equina Syndrome • The most sensitive (90%) and specific (95%) indicator is _____ ________ that eventually leads to overflow incontinence –Therefore, patients without ______ ______ are UNLIKELY to have cauda equina syndrome – Other conditions cause urinary retention • Saddle anesthesia • Motor deficits

urinary retention urinary retention

Metastatic Disease • The spine is the 3rd MC site for cancer cells to metastasize, following the lung and the liver – Approximately ___-____% of patients with systemic cancer will have spinal metastasis • Spinal metastasis may be the initial presentation in ___% of patients with systemic cancer • Skeletal metastases is MC in adults > 50 yoa

60-70 10

``` Spinal Metastatic Disease • Primary sources for spinal metastatic disease include the following: – _______ - 31% – _____ - 24% – GI tract - 9% – Prostate - 8% – Lymphoma - 6% – Melanoma - 4% – Unknown - 2% – Kidney - 1% – Others including multiple myeloma - 13% ```

Lung Breast

Metastatic Carcinoma Classic Presentation: • Pt c/o insidious onset of pain, persistent • Worse at _____ and NOT mechanically affected • Often a Hx of _____ ______ and fatigue NOTE: – Patient may be asymptomatic until late in course of disease – May become symptomatic after trauma due to pathological weakness of the vertebrae

night weight loss

Metastatic Carcinoma Radiographs: • Posterior vertebral collapse is suggestive • May be ______ (one eyed pedicle, increased serum calcium), or _________ (ivory white vertebra, increased alk phos) What to do: • Immediate referral to oncologist (or GP)

osteolytic osteoblastic

Multiple Myeloma • Most common PRIMARY malignant tumor of bone • > 50 yoa • ____% of patients have bone pain at presentation • The lumbar spine is one of the MC sites of pain • C/O persistent back pain unrelieved by rest – PN is worse at night – may have associated rib pain

Multiple Myeloma • Osteopenia (generalized) • Hypercalcemia • Anemia • Renal disease • Infection (often pneumonia) due to decreased immunity • _____ ________ proteins found on 24hr urine test • Monoclonal (M) spiking on electrophoresis, increased IgG

Bence Jones

Multiple Myeloma Radiographs: • Will show ______, then “_____ _______” lytic lesions involving the spine, ribs, and skull – does NOT usually affect the posterior elements Definitive Diagnosis: • Bone marrow aspirate showing more then 20% plasma cells

osteopenia punched out

Infectious Spondylitis Classic Presentation: No typical patient but some red flags include: • Presents with a complaint of deep back pain • History of a recent respiratory tract, urinary tract, or skin ________ (or IV drug use or DM) • Patient is antalgic • Complains of ______ and difficulty sleeping due to pain NOTE: pt is NOT always febrile

infection fever

Infectious Spondylitis * Deep pain made WORSE by percussion of SP * Increased ESR, fever and WBC is variable Bone: __________ Disc: Discitis

Osteomyelitis

Infectious Spondylitis Two Types: 1. ________: staphylococcus (90%), streptococcus, & gram-negative organisms • Involve more than one vertebra, may NOT involve the disc, posterior elements rarely affected 2. ___________: tuberculosis (Pott’s disease), brucella, or fungi • Centers around L1, posterior elements may be involved • 3-4 wk history to see on films What to do? Refer for ortho consult (or to GP) • Infection is spread via hematogenous routes

Pyogenic Nonpyogenic

Mechanical vs. Non-mechanical LBP In general: Mechanical = Relief of symptoms--1 or more PN free--Can usually get some sleep--Able to mechanically reproduce the cc Non-mechanical--No relief of symptoms--No pain free positions---May be worse at night---Unable to mechanically reproduce the cc

KNOW THE DIFFERENCE

Outcome Assessment Questionnaires May prove to be even more reliable and reproducible than clinical exam findings 2 most popular, valid and reliable for LBP: 1. Oswertry Disability Index for LBP---Use for ________disability & comparison for future improvement 2. Roland-Morris LBP Questionnaire _______ ________=>greater disability

baseline Higher score