4. Lumbar Spine

clinical prediction rule for classifying patient with LBP who will benefit from manipulations

(done in a military population; these findings are correlations) -no pain distal to knee (radiculopathy unlikely) -low FABQ-W score (low fear avoidance beliefs about work) -lumbar hypOmobility to segmental exam -time of onset <16 days -hip inernal rotation >35deg

percutaneous diskectomy

(got this from wikipedia) -a surgical procedure in which the central portion of an intervertebral disc is accessed and removed through a cannula. -indications: Prolapsed and sequestrated discs

why are LESI used

(lumbar epidural steroid injections) -inflammation creates pressure --> compression of nerve roots = symptoms -injections can also be done in facet joints if pain is coming from there

analogy between HNP and the foot

- HNP is like a heel spur - they often correlate with pain, but they do not always cause problems

spondylolysis

- defect in pars interarticularis WITHOUT slippage of the vertebrae -commonly occurs from repetitive *extension* (gymnasts, linemen, cheerleaders) -spondylolytic stress rxn

presentation of lumbar stenosis

->50 yo -hx of LBP -c/o pain and/or numbness in 1 or both legs (radiculopathy) -*neurogenic claudication* - relieved with sitting -chronic symptoms may lead to motor loss, reflex changes, sensory deficit (NO dermatomal pattern) -*reproduction of pain with extension* -"shopping cart sign" (relieved with flexion)

how to rule out lumbar radiculopathy, peripheral neuropathy, entrapment

-EMG/NCV -physiatrists are proficient in EMG/NCV, neurologists aren't always ]

LBP pain generators

-HNP -facet joints -SIJ -muscle spasm ("never" the cause of the problem in the lower back in his opinion) -stenosis -ligaments (car accidents, degenerative)

orthopedic special tests for lumbar spine pathology

-SLR (lesagues sign) -braggards test (SLR+DF foot) -ely's test (prone, knee bend) -slump test (bend neck, extend knee) if any of these are pos, send them to an orthopedic dr

braggards test

-SLR for lumbar spine *with DF foot* -inicative of nerve tension

back pain surgeries re-operations

-almost 20% of decompression sx needed another operation in 4 yrs -almost 30% of spinal fusion needed another procedure in 4 yrs

how is LBP managed

-always keep them moving -NSAIDs, muscle relaxer (not rec.), pain meds -PT -epidural steroid -sx

vascularity of intervertebral discs

-avascular in center -periphery vascular -the center gets blood by diffusion

treatment of spondylolisthesis

-bracing -lumbar stabilization TEs -surgery - reserved for 50% slip or neuro compromise (central spinal canal narrows)

spondylolisthesis

-can think of this as a progression of spondylolysis -*anterior displacement* of one vertebral body on the body below (most commonly L4,5,S1) -*extension* causes pain -radiograph gold standard is the "scotty dog sign" on pure lateral xray

supine to sit test

-confirms hypermobile SIJ -excludes LLD

highly correlative predictors of lower back pain (Know this!)

-depression -occupational related injury (workers comp!) -fear avoidance beliefs

types of lumbar disc herniations

-disc bulge (annulus intact); *not a true herniation*; often retracts -prolapse (nucleus is contained by outer annulus only); this is a true herniation -extrusion (nucleus leaks beyond the disc, may strike other sructures); this is a stenosing problem -sequestration (nuclear material separates from disc and becomes a free floating fragment)

jensen et al : on MRI exam of the lumbar spine, many people WITHOUT back pain have - ... conclusion?

-disc bulges or protrusions -but NOT extrusions -given these findings and the high prevalence of LBP, the discovery by MRI of bulges/protrusions may be *coincidental*

lumbar DDD/DJD

-disc dessication occurs with aging -loss of disc height and stability leads to inc load on facets and resultant degenerative changes -will see mechanical back pain, loss of ROM, possible radicular symptoms

what reproduces pain of spondylolysis

-extension and loading one side -remember: commonly occurs from repetitive extension; gymnasts landing

posterior longitudinal ligament significance

-gets thinner as it goes more inferiorly -significance: discs more likely to herniate bc lig is thin -normally it acts as an anatomic barrier

"scotty dog" sign

-gold standard dx of spondylolisthesis on xray (??) -on oblique view -isthmus = dog's face -superior anrticular process = ear -spinous process and lamina of inferior vertebra = dog's body i think he messed up when he explained this. scotty dog is NORMAL. -lysis shows scotty dog with collar, -thesis shows scotty dog with it's head dislocated. dx of -thesis can be confirmed with lateral view x-ray to show slipped vertebra.

SIJ dysfunction exam

-high false positive, so do multiple tests -supine to sit teset, ant and post SI gapping, Piedallus sign, Gaenslens test, caudal and cephalic shear -pain provocation -pelvic landmark symmetry, LLD -AP radiograph, CT scan -diagnostic injection via fluoroscopy -ddx: ankylosing spondylitis often begins as inflam of SIJ

Ely's test

-if you suspect upper lumbar problem -lay pt prone, bend their knee, stretches quad -stretches femoral n.

his opinion for surgery reccommendation

-in absence of intractable LEG pain, reflex loss, focal motor deficit dure to nerve root compression, bowel/bladder change, myopathy - he does NOT recommend surgery

reasons why the SIJ doesnt move

-incongruent joints -self locking mechanism (gravity+GRF compression) -strong ligaments

positive straight leg raise for lumbar spine

-induce numbness, tingling, disesthesias in buttock/thigh -aka Lesagues sign

presentation of spondylolysis

-insidious onset -pain with *extension*, relief with flexion -U/L pain referred to *PSIS* -can be misinterpreted as SIJ pain -no accomponying strength deficit, no radiculopathy, no reflex pain

IDET

-intradiscal electrothermal therapy -surgical placement of a catheter that heats up around the annulus -indications: chronic internal disc disruptions (pts with some type of annular ring teraing within the substnace of the annulus) -typically used for pts with axial pain, NOT pts with LE radicular pain -not used much anymore

things to look for in posterior view of gross postural assessment

-lateral shift (lean to one side) - usually indicative of disc lesion -described based on *shoulder position* (left lateral shift = shoulders shifted to left)

anatomical classification of lumbar stenosis

-lateral: narrowing of the IV foramen and/or nerve root canal encroaching spinal nerve -central: narrowing of spinal canal causing encroachment on cauda equina

positions that increase pressure on IV discs

-laying supine = lowest pressure -laying on side -standing upright -sitting -standing hunched over -sitting and bending to pick something up puts the most pressure on discs

signs and symptoms of HNP

-leg pain (dysesthesia) - buttocks, post thigh, lateral calf, lateral foot -sensation changes -weakness -reflex loss -muscle spasm -ROM limitation -lateral shift

micro disckectomy

-minimally invasive procedure -uses a probe to aspirate material from IV discs -indications: pts *with radicular pain* and a *contained* herniated disc (NO extrusions or sequestrations) -only done in a single level problem with no stenosis and minimal to no degenerative ps -indicated for *younger patients* -you do not need to stabilize the disc

indications for lumbar fusion

-most common reasons: neuro compromise, compromise of bony elements of spine, instability btwn segments -*not indicated for pain* -often accompanied with decompression

lumbar stenosis =

-narrowing of lumbar spinal canal, nerve root canal, or IV foramina

neurogenic claudication vs vascular claudication

-neurogenic claudication - relieved with sitting, spinal flexion (walking up stairs, pushing a shopping cart) -vascular claudication - ischemia in LE; diminished pulses

things to look for in lateral view of gross postural assessment

-normal lordosis (excessive or absaent?) -abdominal tone -flexed posture/kyphosis - muscular implications

clinical presentation of spondylolisthesis

-often affects kids and adolescents -c/o pain after running, jumping, wtisting -adults: complaints with extension postures -may have *palpable step-off* deformity -may get neuro symptoms (central spinal canal is narrowed)

layers of the intervertebral disc

-outer annulus fibrosis (type 1 collagen) -inner annulus fibrosis (type 2 collagen) -central nucleus pulposus (viscoelastic proteoglycan, water) the 2 outer parts: collagen fibers change orientation to make the annulus stronger and inc tensile strength

types of lumbar fusion

-pedicle fusion -ALIF = anterior lumbar interbody fusion -PLIF = posterior (*discs are removed*) -arthroplasty can be used but not common

discogram/discography

-pre-op injection technique -patient lies in prone position -purpose is to confirm/refute that pain is coming from disc pathology -looks to see if pain is reproduced when they inject in the area of concern -most beneficial for pts with multi level disc pathology to see which one is worse

laminectomy

-primary intent: decompression of the central spinal canal, lateral recess, or both; *involves facetectomy* -commonly used for stenosis from a herniated disc or from degenerative changes -if you do more than a couple levels, need to *fuse*

etiologic classification of lumbar stenosis

-primary stenosis: congenital defect -secondary stenosis: narrowing due to DJD, spondylolisthesis, fx

ex: patient has lower back pain, no pain in buttocks or leg, negative straight leg raise. Positive MRI for lumbar HNP. What is causing their LBP?

-probably not the herniated disc -in absence of clinical dx, don't dx as a herniated disc

slump test

-pt sits on edge of table -slowly passively extend knee and bend their neck and head down -positive: pain in back/shooting pain down leg= means pain is coming from back

why is LBP so difficult to evaluate/treat

-specific pathology/primary lesion very rare -pain is usually nonspecific -surgery unsuccessful -difficult to esablish subgroups

spondylolysis vs spondylosis vs spondylolisthesis

-spondylOSIS = spinal arthritis, DJD/DDD -spondylOLYSis = defect in pars interarticularis WITHOUT slippage of vertebrae -spondylolisTHESIS = a progression of spondyloLYSis; *anterior displacement* of one vertebral body on the body below

presentation of SIJ dysfunction

-unilateral -female>male, 15-40 age -localized pain over SIJ and PSIS, can radiate to buttock and lateral thigh -pain with *sitting and unilateral shear*, pain with certain sex position -pain intermittent and position dependent -NO NEUROLOGICAL symptoms -common during pregnancy -hypERmobility often cause problems

symptoms of spondylolysis

-unilateral symptoms -localized pain -NO radiculopathy

range of motion for lumbar spine: flexion/extension

-usually taken when *standing* -flexion: 40-60deg -extension: 25-30deg -should ask if this reproduces pain/symptoms

movement at the SIJ

1-4deg rotation 2-3 deg translation

range of motion: side bending

15-20 deg total movement

L2 dermatome

2-3 inches below ASIS

herniated nucleus pulposus can be found in _% of normal patients

20-30

range of motion: rotation

3-18deg due to facet orientation

weight of upper body is carried through what parts of the lumbar spine

80-85% through IV disc joints 15-20% through facets

T/F the most common reason for lumbar fusion is pain

F - pain is not an indication for lumbar fusion

most common location of disc herniation

L4-5 and L5-S1

fibular head and dorsum of foot = what dermatime

L5

in which fusion procedure are discs removed

PLIF - posterior lumbar interbody fusion

LBP often gets referred pain to

PSIS

burning sensation at lateral and plantar foot = what dermatome

S1

S1 reflex

achilles

L4-5 myotome test

ankle DF test: heel walk

S1 myotome test

ankle PF test: toe walk

L3 dermatome

ant mid thigh

diagnosis of herniated disc most often based on -

clinical exam and imaging

what causes pain from a herniated IV disc

compression of pain sensitive structures around the disc (ligaments, facet joints), NOT the disc itself disc herniations without pain are very common

laminectomy is used for -

decompression need to stabilize if you do multiple levels

in a patient with suspected stenosis,m what position would make it worse

extension

what standing position relieves the pain of a herniated disc

extension

what position reproduces pain in spondylolisthesis

extension (top vertebral body slips anteriorly on the body below it)

L5 dermatome

fibular head, dorsum of foot

which standing position makes the pain of a herniated disc worse

flexed spine/hunched over because if you bend forward, the nuclear material goes backwards

tx of spinal stenosis

flexion exercises epidural laminectomy fusion

L5 myotome test

hallux extension

L1-2 myotome test

hip flexion

L3-4 myotome test

knee extension

SI dermatome

lateral/plantar foot

what is the most common reason to undergo spinal surgery over age 65?

lumbar stenosis

what type of exercises can be used to help relieve pain from a lumbar HNP

mackenzie exercises - uses extension exercises

if pt has loss of reflex, focal motor deficit that follow myotomal pattern, who do you send them to?

ortho or neuro spine dr signs of nerve root compression

L4 reflex

patella

L4 dermatome

patella and medial mal

L5 reflex

post tib

which direction do IV disc herniations occur

posteriorly

IDET is used for -

problems within the annulus (internal disc pathology)

what is an extremely sensitive finding for a herniated disc

radiculopathy

with lumbar stenosis, pts get rproduction of pain with what position

spinal extension relieved by flexion

lumbar stenosis pain is relieved with what standing position

spinal flexion ("shopping cart sign" - can walk around in stores with a shopping cart with no symptoms)

most common cause of LBP in children

spondyloLYSIS remember: commonly occurs from repetitive extension - think gymnasts landing (KNOW THIS)

= spinal arthritis

spondylosis = DDD/DJD

L1 dermatome

ventral pelvis