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Lumbar Spine

Orthopedics

QuestionAnswer
Low Back Pain: lifetime prevalence: 60-80%
Leading cause of work related disability = Low Back Pain
Low Back Pain Risk factors obesity, sedentary, improper biomechanics
Low Back Pain: Prognosis 70% improved in <1 week & asymptomatic in <1 month; 90% asymptomatic in 6-12 wks
Vertebral Disk contains: central nucleus pulposus; peripheral annulus fibrosis
Disc degeneration MOA: degeneration overloads facet joints in verts
Disc herniation MOA: herniation impinges nerve roots
Anterior Mxs: Abdominal & Psoas
Posterior Mxs: Superficial: Erector Spinae, Iliocostal, longissimus & spinalis
Posterior Mxs: Middle: Multifida
Posterior Mxs: Deep: Intersegmental
Anterior & posterior muscles alternate to: control trunk movement
Sensory Dermatomes: Lumbar & sacral n. innervate: lower extremities
Pain: Simple sprains & strains = Nonspecific pain in lower back or one or both buttocks
Nerve root pain: Brief, sharp, shooting, increased by cough, standing, & sitting.
Pain: Neoplasm, Infection: Severe, constant pain persisting at night
Pain: Red Flags > 50 y.o.; kids; Night Pain; Fever, malaise, wt loss; Bladder/ bowel dysfunction; Progressive deficit; Prior ca; Pain > 1 month
LBP Hx: C/C, meds, allergies
LBP HPI: Initiating event, MOA; Site of pain; OLDCARTS; priors, tx, studies
LBP: PE: Inspection: Gait; Posture; Deformity
LBP: PE: Palpation: Bony; Soft Tissue; Pulses
LBP: PE: ROM: Flex, ext, lateral flex, rotation
LBP: PE: Other Tests: SLR; FABER test; Neuro Exam (Sensory, Motor, DTRs)
SLR test: Pain on straight leg flexion reproduces radicular pain
Bragards test: Foot dorsiflexion increases pain
Cross SLR test: Raising contralateral leg causes radicular pain on ipsilateral leg
FABER test: Pain in SI joint
LS Spine Exam: inspection: Symmetry/ Deformity/ Scars
LS Spine Exam: motor: L1: Hip flexion
LS Spine Exam: motor: L2: Hip adductors
LS Spine Exam: motor: L3: Knee extension
LS Spine Exam: motor: L4: Ankle dorsiflexion
LS Spine Exam: motor: L5: Hallicus Longus extension
LS Spine Exam: motor: S1: Hallicus Longus flexion
LS Spine Exam: sensory: L1: Upper outer thigh
LS Spine Exam: sensory: L2: Mid anterior thigh
LS Spine Exam: sensory: L3: Below patella
LS Spine Exam: sensory: L4: Medial ankle
LS Spine Exam: sensory: L5: First web space
LS Spine Exam: sensory: S1: Lateral ankle
LS Spine Exam: DTRs: Knee: L2,3,4
LS Spine Exam: DTRs: Ankle: S1
Waddell Signs: Tenderness: Superficial skin tenderness over wide area; Non-localized deep tenderness
Waddell Signs: Simulations Tests: Axial load should not cause LBP
Waddell Signs: Distraction Tests: Flip test
Waddell Signs: Regional Disturbances: Widespread muscle pain in various groups
Waddell Signs: Over-reaction: Pain out of proportion
Lumbar Strain: Hx: MOI; site of pain
70% of LBP = Lumbar Strain
Lumbar Strain: PE: Tender paravertebral or erector spinae mx; min radiation
Lumbar Strain: Rx : Pain relief, modified activity, exercise, education, & encouragement; Injection with trigger point pain; PRICEMMM
4% of LBP = HNP
HNP: DDx: Infection, tumor
HNP: Evaluation: MRI / CT
HNP: MRI/CT: asymptomatic disc herniation found in: 17-36%
HNP: Lumbar nerve root compression: L1-3 nerve roots: 5%, pain & numbness above knee
HNP: Lumbar nerve root compression: L4 nerve root (L3-4 disk space): 5%, numbness to shin, weak ankle dorsiflexion
HNP: Lumbar nerve root compression: L5 root: 67%, weakness of EHL & numbness top of foot and 1st web space
HNP: Lumbar nerve root compression: S1 root: 28%, numb lateral foot, weak plantarflexion
HNP: Lumbar nerve root compression: Rx: Conservative, NSAIDs, mx relaxants, Exercise & Education
HNP: Lumbar nerve root compression: 10% require: surgery d/t progressive neurologic deficit
Pharma Tx of Acute LBP: Pain relief: NSAID; Cox-2, Celebrex; Narcotic; Lidoderm patch; Anti-inflammatory; mx relaxants; Steroids
Pharma: LBP: Pain: NSAID: Ibuprofen 800 q6-8h pc; Naprosyn 500 BID
Pharma: LBP: Pain: Narcotic: Percocet 5/325 q4-6h Vicodin 5/500 q 4-6h
Pharma: LBP: Pain: Anti-inflammatory: NSAID, Cox-2
Pharma: LBP: Pain: Muscle relaxants: Flexeril; Skelaxin; Soma, Robaxin
Pharma: LBP: Pain: Steroids: Hold NSAIDs; Burst of oral steroids; consider trigger point
Sacroiliac Dysfn: Acute or chronic injury to SI joint
Sacroiliac Dysfn: Sx: Pain in SI area, Pos FABER, No discogenic pain
Sacroiliac Dysfn: Lab: consider CBC, ESR, ANA, RF, HLA-B27
Sacroiliac Dysfn: RX: Ice, Stretch, NSAIDs, injection
Cauda Equina Syn: affects: L2-L4 nerve roots
Cauda Equina Syn: Mechm: Compression of nerve roots causes paralysis without spasticity (LMN)
Cauda Equina Syn: Etiology: Central disc herniation, abscess, hematoma
Cauda Equina Syn: Sx: Loss of bladder/ bowel control, bilateral LE weakness & sensory deficits
Cauda Equina Syn: Rx: Emergent Surgical Decompression
Lumbar Spinal Stenosis = Progressive degeneration of disc & facet joints; Narrowing of canal; Compression of n. roots
Lumbar Spinal Stenosis: Signs: Neurogenic claudication, radicular sx; Pain increased w/ sitting or spinal ext; Pain relieved w/ flexion, pt walks stooped-over
Lumbar Spinal Stenosis PE: Sensory changes, dec DTR, mild weakness
Lumbar Spinal Stenosis: Course: Deficits may progress
Lumbar Spinal Stenosis: Xray: may show narrowing of the IVD, old burst fx; MRI demonstrates stenosis
Lumbar Spinal Stenosis: Rx: PT, core strength, NSAIDs, dec impact & bending, surgical decompression for progressive dz
Spondylolysis = Pars interarticularis stress fx
Spondylolysis: Prevalence 5%-8 % of population; Dancers, gymnasts, lifters
Spondylolysis: occur most often at: L5
Spondylolysis: S/S Pain adjacent to midline, inc with extension & rotation
Spondylolysis: xray Scotty dog collar only on oblique xray
Spondylolysis: Rx: modify activity, core exercise, gradual RTP
Spondylolisthesis = Vertebral sliding (Dancers, gymnasts)
Spondylolisthesis: PE: Step-off, may be asx.
Spondylolisthesis: Grading Grade I – V (25 to >100%); Isthmic, degenerative
Spondylolisthesis: xray Lateral film shows slip
Spondylolisthesis: Rx: Asx: no restriction, core exercise
Spondylolisthesis: Rx: Symptomatic: no restriction, core exercise, consider brace; Surgery for progressing slips or deficit
Piriformis Syndrome = Irritation of sciatic n. (L4,5, S1,2,3) beneath piriformis mx
Piriformis Syndrome: etiology Trauma, spasm, anatomic
Piriformis Syndrome: PE: FROM of lumbar spine; Sciatic notch tenderness
Piriformis Syndrome: DDx: HNP
Piriformis Syndrome: RX: Rest, ice, meds, stretch, injection
Lateral spine curvature = Scoliosis
Scoliosis: < 10 degree: tx observe
Scoliosis: < 20 defree: tx conservative Rx
Scoliosis: Occurs where: T or L spine
Scoliosis: most common cause: Idiopathic
Scoliosis: prevalence Girls 7x > than males
Scoliosis: Adults: secondary dz & pain
Scoliosis: Surgical Rx: Fusion & Rod
Scoliosis: Exam: Forward flexion; Look for spine, scapula or hemi-thorax asymmetry
Scoliosis: Xray Cobb angle: Measure angle from tilted vertebrae above & below apex of curve
50% of pts with solid tumors have: mets to spine
Tumor: Highest prevalence: BrCa, lung, prostate, colon, thyroid, kidney ca (hematogenous spread)
Tumor: Sx: Night pain, n. root compression
10% of spinal bone tumors are: primary
Spinal bone tumors: in children, 20% are: malignant
Spinal bone tumors: Primary malignant: Osteosarcoma, Ewing Sarcoma, Chondrosarcoma
Degenerative joint dz = loss of articular cartilage & growth of new bone around facet joint
Facet Syndrome = n. root compression by loss of disc height & facet hypertrophy
Osteoarthritis: X-ray: joint narrowing, sclerosis, osteophytes
Osteoarthritis: Rx: Wt reduction, pt education; Pain relief
Ankylosing Spondylitis: involves: SI joint, and spine
Seronegative spondyloarthropathy: HLA-B27 usually positive
Ankylosing Spondylitis: Sx: Chronic low back pain in young adults; morning stiffness, improves with movement; 20% peripheral joint sx (Enthesopathies common; 25% with anterior uveitis)
Ankylosing Spondylitis: PE: Schobers test (normal is 5 - 7 cm movement)
Ankylosing Spondylitis: X-ray: Erosion & sclerosis on plain films
Ankylosing Spondylitis: Rx: PT, NSAIDs, Sulfasalazine, Infliximab
Testing Spinal Mobility: Schobers Test
Schobers Test: 2 midline marks 10 cm apart starting at PSIS (dimple of Venus); remeasure w/ lumbar spine at maximal flexion
Schobers Test: Less than 5 cm difference suggests: pathology
Ankylosing Spondylitis = Calcification btw vertebral bodies at edge of discs; gives appearance of bamboo stalk; sclerosis of SI joint
Osteoporosis = Reduction in bone mass (Low peak mass; inc bone loss; hyperparathyroid, chronic steroids)
Visceral Causes: prevalence in LBP 2% of LBP
LBP: Visceral Causes: Referred pain from: GB; Pancreas; AAA; Endometriosis; Chronic PID; Prostate CA; Renal stones or pyelonephritis
LBP: Need for imaging Rarely needed in nontraumatic, recent onset ALBP
LBP: Imaging: when Plain films approp: trauma/ longstanding sx ; if conservative Rx fails
LBP: Imaging: Order: AP / Lateral; Obliques; Flex & Ext
LBP: MRI study of choice for: discopathy
LBP: Tc 99m bone scan for: primary tumors, metastatic disease, or infection
Reading Spine Films: looking for: Fx; Disc space changes; Arthritic changes; Listhesis; Tumors
Spine Film: Frontal View: each vert resembles: an owls head, straight on; each eye = pedicle; beak = spinous process
Spine Films/ Frontal: Horizontal displacement may = fx or dislocation
Spine Films/ Frontal: Decreased intervertebral space = Fx, DDD, HNP
Spine Films/ Frontal: Vert body (owl head) for: Missing eye (destrn); pedicle
Spine Films/ Frontal: Vert body: Crack in owls eye: in = Chance fx (seat belt fx)
Spine Films/ Frontal: Vert body: Inc space btw owls eyes: in = Burst fx
Spine Films/ Frontal: Vert body: Dec head height: in = Burst fx
Spine Films/ Frontal: Vert body: Open bea, or inc distance btw 2 beaks: in = Chance fx or spinous process fx
Spine Films: Oblique: each vert = Scotty Dog: look for: a collar
Spine Films: Oblique: Scotty Dog: front & hind legs = inf intervertebral articular processes
Spine Films: Oblique: Scotty Dog: Ears & tail = superior intervertebral articular processes
Spine Films: Oblique: Scotty Dog: Dog body = the lamina
Spine Films: Oblique: Scotty Dog: dogs eye = a pedicle
Spine Films: Oblique: Scotty Dog: nose = a transverse process
Spine Films: Oblique: Scotty Dog: Neck = the pars interarticularis
Spine Films: Oblique: Scotty Dog: If the tail is to your right, you are looking at: right lamina (& vice versa for left)
Spine Film: Lateral View: Vert alignment: displacement seen in: fx & listhesis.
Spine Film: Lateral View: decreased intervert disc space in: fx, DDD, & HNP
Spine Film: Lateral View: Cf ant & post vert body cortex for: changes in ht cf to the others (Burst or wedge fx)
Spine Film: Lateral View: fx lines in spinous processes = black (lucent) fx lines
Spine films: stable fxs = Wedge fx; spinous process fx
Spine films: unstable fxs = Burst fx; Chance fx
Chance fx: Unstable: best seen on what film? lateral
Chance fx: MOI MVA: lap belt immobilizes pelvis & thorax is forcefully flexed forward
Chance fx: Seen on AP = crack thru eyes (pedicles), or open beak (crack through spinous process)
Burst fx: Unstable = Collapse of vert body
Burst fx: Unstable: seen on lateral view as: smaller vertebral body
Burst fx: Unstable: on AP = inc distance btw pedicles
Burst fx: MOI: fall from a ht, landing on feet or buttocks
Burst fx: Fragments: may extend into spinal canal causing neuro S/S
Wedge fx: Stable = Collapse of ant vert body w/ an intact posterior wall
Wedge fx: Stable: result of: hyperflexion injury and / or osteoporosis.
Spinous Process fx: Stable: on lateral view = Lucency thru spinous process
Most common Spinous Process fx found in: C-spine (Clay Shovelers fx)
Spinous Process fx: MOI: sudden forceful ligamentous traction on spinous process, or a direct blow to the process
Coccyx fx: MOI Fall on coccyx
Coccyx fx: PE: Do: rectal to R/O hematoma, displaced fx
Coccyx fx: mild trauma: xray = Radiographs not indicated
Lower Back Rehab to: Ctrl pain; Reduce inflame; relative rest; Pain free ROM; correct inflexibilities & strengthen core mx; aerobic conditioning; wt reductn; correction of biomechanics; prevent recurrence
LBP Prevention Regular strength/ flexibility exer; correct lifting & moving tech; posture standing/ sitting; proper body wt
LBP tests xrays if pain >4 wks; MRI/CT sens > xray for infxn, ca, hern disk, stenosis; CBC, ua, Ca, PO4, ESR, alk phos
LBP: anemia, ESR anemia w/MM, high ESR in malig, infxn, CTD
most common hip problems Trochanteric & gluteus medius bursitis, OA, femur fx
Lateral hip pain that is aggravated by direct pressure = trochanteric bursitis
Meralgia paresthetica affects the _____ nerve lateral femoral cutaneous nerve
LBP: most common site of disk herniation L5-S1 (also L4-L5)
Osteoporosis: prevalence in LBP Causes 4% of LBP
Disc degeneration MOA: degeneration overloads facet joints in verts
Sciatic nerve neurapraxia: with L-S spine, pelvic, hip Fx, or HNP
Disc herniation MOA: herniation impinges nerve roots
Coccyx fx: PE: Do: rectal to R/O hematoma, displaced fx
Coccyx fx: mild trauma: xray = Radiographs not indicated
Bragard test: Foot dorsiflexion increases pain
Cross SLR test: Raising contralateral leg causes radicular pain on ipsilateral leg
Waddell Signs = Non-organic Physical Signs in LBP; TTP, axial load, flip test, Pain out of proportion
Lumbar Strain: PE: Tender paravertebral or erector spinae mx; min radiation
HNP = Herniated Nucleus Pulposus
HNP: most common = L4-5, L5-S1
HNP: MOI: Flexion & rotation; Tears in annulus
HNP: Sx: Sciatica (radiating pain, numbness & weakness to LE)
HNP: Signs: Pos SLR, Flip sign, Pain worse on back ext
Pharma Tx of Acute LBP: Pain relief: NSAID; Cox-2, Celebrex; Narcotic; Lidoderm patch; Anti-inflammatory; mx relaxants; Steroids
Female exam, asymmetric posterior chest wall or uneven scapula height with forward bending Scoliosis (> 25 degree Cobb angle = surgery)
Subluxation of vertebral body = Spondylolisthesis
Created by: Abarnard