spine conditions

Question 1

how is lower back pain defined?

Answer 1

• pain and discomfort, localised below the costal margin and above the inferior gluteal folds **with or without **leg pain

Question 2

define acute LBP

Answer 2

• usually defined as the duration of an episode of low back pain** persisting for less than 6 weeks **

Question 3

define sub-acute LBP

Answer 3

• episode of low back pain between 6 - 12 weeks

Question 4

define chronic LBP

Answer 4

lower back pain for longer than 12 weeks

Question 5

what other pain might lower back pain also present with?

Answer 5

• with or without **sciatica/leg pain **

Question 6

describe the** epidemiology **of LBP

Answer 6

• back pain affects up to 85% of the population at some time in their lives
• **leading cause of disability **world wide
• 10-15% proceed to become chronic, high recurrence rates
• most LBP is classified in non-specific LBP

Question 7

what are the 3 groups that LBP can be classfied into?

Answer 7

• specific spinal pathology (less than 1%)
• radicular symptoms (5-10%)
• non specific low back pain (90-95%)

Question 8

what are other situations that may cause LBP that arent the classified groups?

Answer 8

• hip pathology
• referred visceral pain
• viral syndrome
• vascular causes

Question 9

what important mental factor can be associated with lower back pain?

Answer 9

• psychosocial factor - eg fear of movement, catastrophising, stress etc

Question 10

when is it important to refer a patient with LBP for a medical opinion / ie to see a doctor?

Answer 10

• if there is a** suspicion of serious underlying condition**
• if the pain meds that the patient is taking arent working well for him
  * if they dont respond or improve after conservative physio treatment for longer than 4-6 weeks
• if they have** severe or progressive neurological deficit**

Question 11

what are examples of specific causes of LBP?

ie anything that isnt non specific lbp

Answer 11

• fracture
• osteoporosis
• inflammatory rheumatology condition
• tumour - spine is common site for secondary bony metastases
• infection
• cauda equina syndrome
• structural changes radicular pain

Question 12

what are red flags?

Answer 12

• clinical findings that increase the level of suspicion that there is a **serious medical condition **presenting as common, non serious, MSK conditions

Question 13

what are examples of red flags for lower back pain?

Answer 13

• thoracic pain
• fever
• unexplained weight loss
• history of cancer
• ill health or presence of medical illness
• bladder or bowel dysfunction
• progressive neurological deficit, especially bilateral (abnormal neurological function )
• saddle anaesthesia (altered sensation in perineal area)
• history of steroid use
• history of osteoporosis

Question 14

what is cauda equina syndrome?

NB

Answer 14

• compression and paralysis of nerve roots in the lumbar spinal canal

Question 15

what are some examples of symptoms of cauda equina syndrome?

Answer 15

• bladder or bowel dysfunction
• progressive neurological deficit- esp bilateral
• saddle anaesthesia **- altered sensation in perineal area **
• disturbed (ataxic gait)- poor coordination of gait

Question 16

what should you do if you suspect a patient may have cauda equina syndrome?

Answer 16

• you should send them to A&E for further investigation
• if patient does have CES - then they will get an urgent decompression surgery - otherwise permenant damage will occur

Question 17

what is degeneration of the spinal column?

Answer 17

• age related change to the spinal column
• by the age of 50 years, 85-95% of adults show evidence of **degenerative disc disease **at autopsy including disc bulge/ prolapsed disc

Question 18

what** 2 types of joints in the spine **can suffer from osteoarthritis?

Answer 18

• central intervertebral joints
• facet joints

Question 19

what is spondylosis?

Answer 19

• a term used to describe a group of degenerative conditions that affect the intervertebral discs, vertebral bodies and associated joints in the spine
• eg lumbar or cervical spondylosis

Question 20

if there is osteoporosis of the IV discs and also the facet joint, what is this condition called?

Answer 20

• degenerative disc disease (DDD)

Question 21

what are the clinical features of osteoporosis in the spine?

Answer 21

• LBP that may or may not accompany referred pain in the buttock/leg
• bilateral or unilateral LBP
• stiffness - eg in the morning
• there may or may not be symptoms of nerve root compresion eg P&N’s, numbness, weakness

Question 22

after examining a patient with suspected osteoarthritis in the spine, what can be noticed?

Answer 22

• reduced spinal ROM
• stiffness on accessory glides of spinal vertebrae
• may or may not be signs of nerve root compression

Question 23

what can be seen on x ray with osteoarthritis of the spine?

Answer 23

• narrowing intervertebral disc space
• osteophyte formation - ‘spurs’
• narrowing of inter vertebral foramen

Question 24

how does** spinal stenosis** occur?

Answer 24

• spinal stenosis happens when the space inside the spinal canal is too small
• this puts pressure on the spinal cord and or the nerves

Question 25

at what age can spinal stenosis occur?

Answer 25

over the age of 50 years old

Question 26

what are the** signs/symptoms** of **spinal stenosis**?

Answer 26

* flexed spinal posture * limited spinal extension * pain & symptoms worsen with extension and are better/relieved with flexion * treadmill test may reproduce leg symptoms

Question 27

what are the 3 options for surgery for spinal stenosis?

Answer 27

* spinal decompression * laminectomy * urgent decompression surgery if cauda equina syndrome

Question 28

what is **spondylolisthesis**?

Answer 28

* the **slippage one 1 vertebral body with respect to the adjacent vertebral body** causing mechanical or radicular symptoms of pain

Question 29

what are the causes of spondyloisthesis?

Answer 29

* traumatic spondylolisthesis - L5/S1 - most common * degenerative changes - L4/L5 - more common * graded I-IV in severity, with IV being the worst

Question 30

what is spondylolysis?

Answer 30

* a condition involing a bony defect or stress fracture in the pars interarticularis * can be unilateral or bilateral * may predispose to slip - spondylothesis * can be congenital or acquired

Question 31

what kind of activities is spondylolysis associated with?

Answer 31

* associated with **hyperextension activities** eg gymnastics, high jump and throwing sports

Question 32

what are clinical features of spondylolysis?

Answer 32

* may be asymptomatic if grade I * may present with unilateral LBP and +/- buttock pain * pain worsens with extension movements like walking * rest usually relieves the symptoms * localised tenderness * localised protective muscle spasm

Question 33

what are clinical features of spondyloisthesis? | hint: similiar to spondylolysis symptoms

Answer 33

* patients have low back pain * pain is made worse by extension movements * pain decreases as the patient goes into a flexed posture * localised tenderness

Question 34

what does the treatment for grade I-II spondylolisthesis involve?

Answer 34

* relative rest from aggregating movements & activities * exercise * no manual therapy at level of slip * anti-lordotic brace

Question 35

what does the treatment for a **grade III-IV** for spondylolisthesis involve?

Answer 35

* no contact sport * same as grade I&II * may require spinal fusion (fusion of 2 or more unstable vertebrae into 1 to relieve pain)

Question 36

what is lumbrosacral radiculopathy?

Answer 36

* disorder that causes pain in the lower back and radiates down the back of the thigh into the leg (sciatica) * very common cause of back pain * patient will present with symptoms related to nerve root compression or irritation to a nerve

Question 37

what is sciatica?

Answer 37

* pain going down the leg from the lower back

Question 38

where do the lumbar nerve roots exit the spinal column?

Answer 38

* **below **the corresponding vertebra

Question 39

what are examples of pathologies can cause radicular back pain?

Answer 39

* disc prolapse or herniation * OA * stenosis in older patient

Question 40

what is a prolapsed intervertebral disc? | example of cause for radicular back pain

Answer 40

* protrusion of nucleus pulposus through the outer layer - annulus fibrosis * varying degrees of severity

Question 41

what discs are most common for prolapsed intervertebral discs?

Answer 41

* l5/S1 * L4/L5

Question 42

in which direction does the nucleus protrude?

Answer 42

posterolaterally or posteriorly

Question 43

what are the symptoms of radiculopathy related to disc pathology?

Answer 43

* age 20-50 years * **males > females** * **trivial event involing flexion and possibly +/- rotation** * **acute severe pain**, unable to move * pain - central or unilateral LBP, may have buttock pain, may have leg pain * aggravated by **coughing, sneezing, flexion movements** and positions eg sitting, driving etc * eased by **lying and short periods of walking **

Question 44

what is the ASIA scale?

Answer 44

* the american spinal injury association impairment scale * describes a patients functional impairment as a result of a spinal cord injury

Question 45

describe** non specific lower back pain**

Answer 45

* lower back pain that is not due to a recogniziable, known specific pathology * several structures in the back including joints, discs and connective tissues may contribute to symptoms