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Lumbar Pain
Lumbar pain
143
Anatomy
Professional
11/01/2012

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Term
What are 2 primary pathophysiology causes of LBP
Definition
Trauma
DJD of the Z joints
Term
What are secondary pathophysiology causes of LBP
Definition
Disc Herniation
Congenital-Spondylolisthesis
Spinal Stenosis
Spinal Infection
Vertebral Fracture
Malignant Neoplasia
Ankylosing Spondylitis
Referred pain
Term
What are 3 places referred pain can come from with LBP
Definition
GI- pancreatitis
GU- pyelonephritis
Vascular problem- AAA
Term
What is the definition of LBP
Definition
discomfort or stiffness between the costal margin and the gluteal folds with or without sensorimotor deficits in the leg
Term
What is the most common complaint of the primary care setting
Definition
LBP
Term
What percentage of people have backache sometime in their lives
Definition
>80%
Term
How much of the costs of disability is due to LBP
Definition
1/3
Term
What percentage of LBP is due to serious spinal pathology
Definition
<5%
Term
Prolonged steroid use is a red flag for
Definition
osteoperosis
Term
Progressive or severe neurological deficit IV drug use and or fever is a red flag for
Definition
osteomyelitis
Term
Young male, backache worse with rest
Definition
ankylosing spondylitis
Term
Lower back pain worse on extension
Definition
facet syndrome
Term
Older man with pain mainly at night
Definition
multiple myeloma
Term
Older man, backache and headaches
Definition
Pagets disease
Term
Middle-aged woman, fatigue, headaches
Definition
depression
Term
Young football player pain after game
Definition
spondylolisthesis
Term
LBP worse with walking, pulsatile mass
Definition
AAA
Term
60 year-old with pain and urinary retention
Definition
cauda equina syndrome
Term
35 year-old, left backache, fever, chill
Definition
pyelonephritis
Term
Worsening LBP, pain in PM, urinary changes
Definition
prostatic metastases
Term
65 year-old female, pain worse on walking
Definition
spinal stenosis
Term
Local pain at SI joint after prolonged sitting
Definition
SI sprain/strain subluxation
Term
Sciatica with tight piriformis and +Bonnet
Definition
piriformis syndrome
Term
Prolapse of the nucleus pulposus of an affected lumbar intervertebral disc with compression or irritation of lumbar spinal nerve roots. Current data suggests that the nerve root is inflamed, but not always compressed.
Definition
Lumbar disc lesion
Term
Etiology of lumbar disc lesion
Definition
DJD or trauma
Term
Low back pain radiating into the back of the thigh and leg, worse with bending and twisting
Definition
Lumbar disc lesion clinical picture
Term
Orthos for Lumbar disc lesion
Definition
SLR (35-75)
Braggards sign-dorsiflex with slr
Term
Investigation of a lumbar disc lesion is
Definition
Xray-narrowing of joint space and osteophytes
MRI- posterolateral disc bulge
Term
Management of a lumbar disc lesion
Definition
Chiropractic for 4 weeks unless evidence of cauda equina

Avoid rotation-flexion and distraction
Term
L4 reflex
Definition
patella
Term
What muscles are tested with L4
Definition
Tibialis Anterior
(resist dorsiflexion and inversion)
Term
What is the sensory of L4
Definition
medial leg and medial foot
Term
L5 Reflex
Definition
none or medial hamstring
Term
What muscles are tested with L5
Definition
extensor hallicus longus (resis dorsiflexion of big toe)
Term
What is the sensory of the L5 nerve root
Definition
Lateral leg and dorsum of the foot
Term
S1 reflex
Definition
achilles
Term
What muscles are tested with S1 reflex
Definition
Peroneus longus and brevis (resist plantarflexion and eversion)
Term
Pain related to the zygapophaseal joint between adjacent vertebrae
Definition
facet syndrome
Term
Etiology of facet syndrome
Definition
Degenerative joint disease or trapped meniscoid tissue between the articular facets
Term
Unilateral back pain that is better on lying down and worse on extension or rotating the spine.
Definition
Facet syndrome
Term
Where is the pain with facet syndrome
Definition
Pain is usually localized but may radiate above the knee
Neurological tests and nerve root tension tests should be normal
Term
Ortho for facet syndrome
Definition
kemps
Term
Investigations of facet syndrome
Definition
DJD on Xray
Term
What lines are used on xray of facet syndrome
Definition
Mcnab's
Hadleys
S curve
Term
What is the treatment of facet syndrome
Definition
chiropractic
Term
Narrowing of the spinal canal with damage to the spinal cord
Definition
central canal stenosis
Term
What is the etiology of central canal stenosis
Definition
DJD (L4, C6), Intrathecal mass (abscess, hemorrhage or tumor)
Term
Extremity pain worse with activity; if located in the lumbar region, there will be “neurogenic” claudication-lower limb pain with activity, relieved by bending forward or sitting down
Definition
central canal stenosis
Term
What test will be positive for central canal stenosis
Definition
bicycle test
Term
if there is LMN weakness in the upper limb what reflexes will you see
Definition
diminished or absent reflex
Term
What type of reflexia will you see in the lower limbs with an UMN lesion
Definition
hyperreflexia with babinski
Term
What orthos would be positive in central canal stenosis
Definition
Lhermittes
Bicycle
Term
What is the investigations of central canal stenosis
Definition
Lateral spinal X-rays
Term
What lines are drawn on the xray to identify central canal stensosis
Definition
Eisensteins (<15mm)
Term
What confirms central canal stenosis
Definition
MRI
CT
Term
What is the management of central canal stenosis
Definition
Chiropractic if there is no contraindication
Flexion distraction

Refer to neurologist if not helpful
Refer to the hospital if there is cauda equina syndrome
Term
Movement of a vertebral body in relation to the vertebral body below
Definition
Spondylolisthesis
Term
What is the etiology of spondylolisthesis
Definition
unknown; if isthmic it is related to repetitive hyperextension
Term
Congenital spondylo
Definition
Type 1
Term
Isthmic spondylo pars fracture
Definition
Type2
Term
What does type 2 spondylo fracture specifically
Definition
pars at L5
Term
Type 2 spondylo is more common in
Definition
youths
Term
Degenerative spondylo
Definition
Type 3
Term
Most common form or type 3 spondylo
Definition
L4 DJD
Term
Who has type 3 spondylo more?
Definition
females
Term
Traumatic spondylo of the pedicles
Definition
Type 4
Term
Pathological spondylo
Definition
Type 5
Term
Iatrogenic spondylo from physician/surgery
Definition
Type 6
Term
Often asymptomatic; may present with low backache worse with extension and a step sign if it is severe; there is no change in the muscle power, sensation
Definition
spondylolisthesis
Term
Investigations of spondylolisthesis
Definition
lateral xray-ant slippage of L5 on S1 (MC) or L4/L5
Term
What method is used to quantify the degree of slippage by dividing the A/P width of the base of the sacrum into fourths
Definition
Meyerding Grading
Term
If there is severe spondylolisthesis what will be present on xray
Definition
inverted napoleon hat sign
Term
What is the management of spondylolisthesis
Definition
Chiropractic management on the segment below (avoid on the unstable)
Avoid extension exercises
Anti lordotic brace
Grade 3 or 4 refer to ortho surgeon
Term
What test will show the early stress reactions in the bone
Definition
SPECT test
Term
Piriformis muscle compression of the sciatic nerve
Definition
Piriformis syndrome
Term
What is the etiology of piriformis syndrome
Definition
Trauma, prolonged sitting or anatomical; 15% of the population has sciatic nerve running through two muscle bellies of the piriformis muscle;
Term
What is the ratio of female to male of piriformis syndrome
Definition
F:M 6:1
Term
Buttock and posterior leg pain
Definition
clinical picture of piriformis syndrome
Term
What are the orthos for piriformis syndrome
Definition
Bonnet test (SLR with internal rotation of foot and adduction of leg)
MRS normal
Trigger points on piriformis
Term
What are the investigations of piriformis syndrome
Definition
no neurological findings; xray normal
Term
What is the managment of piriformis syndrome
Definition
Adjustments, myofacial release techniques and stretching
If neurological signs appear order MRI for possible disc herniation
Term
Stretch, rupture or separation of the muscles and ligaments of the SI joint; strain refers to muscular injury and sprain refers to ligamentous injury
Definition
Sacroiliac sprain/strain
Term
What is the etiology of sacroiliac sprain/strain
Definition
Trauma; overuse; pregnancy
Term
Pain over the SI region that may radiate down the back of the leg; usually made worse when getting up from a bent or stooped position; made better by sitting or lying down
Definition
clinical picture of sacroiliac sprain/strain
Term
What ortho tests are positive for si sprain/strain
Definition
Gaenslen test
Yeoman's test
MRS will be normal
(pain may increase or decrease with compression or distraction)
Term
What are the associated neurological findings of SI sprain/strain
Definition
none
Term
What are the xray findings of SI sprain/strain
Definition
normal
Term
What is the treatment management of SI sprain/strain
Definition
chiropractic adjustments are superior to medical treatment

Acute- light adjusting with possible support brace
Term
Progressive neoplastic plasma cell disease characterized by excessive immunoglobulin production
Definition
Multiple Myeloma
Term
What is the etiology of multiple myeloma
Definition
unknown
Term
What is the peak incidence of multiple myeloma
Definition
50-70 years
Term
Multiple myeloma is the most common primary bone tumor primarily in
Definition
blacks
Term
Fatigue, nocturnal backache, recurrent infections, constipation, blurred vision, constipation, nerve root compression and mental changes
Definition
clinical picture of multiple myeloma
Term
What ortho tests will be positive for multiple myeloma
Definition
tenderness on percussion of spinous
Term
What will a CBC show with multiple myeloma?
Definition
normocytic normochromatic anemia
Term
What will a CMP show in multiple myeloma
Definition
hypercalcemia, elevated serum proteins, reversed albumin/globulin ratio (1:2)
Term
In multiple myeloma what will be found in the urine
Definition
Bence Jones proteins (IgG)
Term
What will a serum electrophoresis show in a multiple myeloma patient
Definition
M spike due to high IgG
Term
What will xrays show with multiple myeloma patients
Definition
70% show multiple lytic bone lesions in skull, long bones, and vertebrae

osteoperosis
blastic lesions
Term
What test confirms multiple myeloma
Definition
bone marrow biopsy shows malignant plasma cells
Term
Who manages a multiple myeloma patient
Definition
hematologist
Term
Secondary malignant deposits far away from the primary site
Definition
Metastatic cancer
Term
What are the common sites from metastatic cancers
Definition
breast, lung, thyroid, kidney, prostate
Term
What is the most common site of metastasis in males
Definition
prostate
Term
what is the most common site of metastasis in females
Definition
breast
Term
What bone tumors are most common
Definition
secondary
Term
What is the main clinical picture of primary metastasis
Definition
nocturnal bone pain with or without unintentional weight loss
Term
What ortho test will be positive in metastatic cancers
Definition
tenderness on boney or spinal percussion will be positive if there are fractures
Term
What will xrays show in metastatic cancers
Definition
osteolytic or osteosclerotic lesions in affected bones
60% will show owl winking sign (missing pedicles)
40% of the bone must be destroyed before changes on X-rays
Term
What blood levels will be elevated
Definition
alkaline phosphatase

AST and ALT will be normal
Term
What will show hot spots in osteoblastic tumors
Definition
bone scans with technetium 99
Term
Who manages metastatic cancers
Definition
oncologist and chiropractic co management

do not adjust locally
Term
Infection of the bone and bone marrow
Definition
osteomyelitis
Term
History of recent infection such as respiratory, urinary tract infection, IV drug use or diabetes
Definition
osteomyelitis
Term
What is the organism of osteomyelitis
Definition
staphlococcus aureus
Term
What is the organism of osteomyelitis in sickle cell disease
Definition
salmonella 4% in the spine
(60% lumbar, 30% thoracic, 10% cervical)
Term
What increases a patients incidence of having osteomyelitis
Definition
IV drug use with pseudomonas organisms
Term
What is the clinical picture of osteomyelitis
Definition
fever, chills, generalized malaise, nocturnal pain, swelling in the region
Term
If osteomyelitis affects an extremity what will be the clinical picture
Definition
joint pain, swelling and tenderness
Term
What orthos will be positive in osteomyelitis
Definition
percussion
Term
What does xray of osteomyelitis show initially
Definition
normal
Term
What will the first initial changes seen on xray associated with osteomyelitis show?
Definition
subperiosteal elevation and soft tissue swelling
Term
After the initial changes there are lytic changes seen and what will appear 3-4 weeks later
Definition
brodies abcess
Term
In osteomyelitis in later stages may have an
Definition
involucrum
Term
What is an involucrum
Definition
sequestrum of dead bone appears within a rim of new bone
Term
If there is osteomyelitis in the vertebrae what will be seen on X-ray
Definition
loss of disc space and destruction of vertebral end plates
Term
What will a CBC show in osteomyelitis
Definition
elevated WBC and raised neutrophils
Term
What is the management of osteomyelitis
Definition
refer to hospital for admission and antibiotics
Term
Focal area of weakening of the abdominal aorta causing dilatation [>3.0 cm]
Definition
Abdominal Aortic Aneurysm
Term
What is the genetic predisposition for AAA
Definition
atherosclerosis in males (5:1)
Term
What is the common age and lifestyle of AAA
Definition
over 55; smoker
Term
Where is the most common location of AAA
Definition
infra renal
Term
Often asymptomatic; however may present with backache or abdominal pain, perhaps with intermittent claudication in the lower limb or impotence
Definition
AAA
Term
What will abdominal palpation reveal with AAA
Definition
expansile pulsatile mass in the midline above the umbilicus with bruit in 50% of patients
Term
If an AAA ruptures what may the patient present with
Definition
sudden onset of severe bachache and hypotension (low BP and rapid pulse rate)
Term
What will a lateral lumbar xray reveal with AAA
Definition
curvilinear radio opaque densities located anterior to the anterior border of the lumbar vertebrae
Term
What size will the radioopaque densities be in AAA
Definition
>3.8cm
Term
What may be shown in the vertebral column with AAA on xray
Definition
erosion of vertebral bodies
Term
What is the preferred imaging modality for AAA?
Definition
ultrasoundography
Term
Who manages an AAA
Definition
vascular surgeon for opinion on surgery
Term
The risk of an AAA rupture increases expoentially after the diameter reaches
Definition
>5 cm
Term
Can you adjust a patient with AAA
Definition
yes; but rotational adjusting is contraindicated
consider non force
Term
If a patient with AAA has pain, a pulsatile abdominal mass, and hypotension what is the management
Definition
call 911
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