Lumbar Spine Quiz

Anatomy of Lumbar Spine

• Nerve roots exit at the level below the named vertebrae
• Important to ask about previous cancers in regards to lower back pain

Lumbar Pain Presentation

• Simple sprains and strains: often described as lower back pain in the paravertebral or super gluteal region
• Nerve root pain: presents as sharp, shooting pain, but may not be present in the back due to referred pain
• Neoplastic or infectious pain: severe, constant pain persisting at night

Red Flag Symptoms of Lumbar Pain

• Age greater than 50 years
• Children
• Night pain
• Fever, malaise, weight loss, bladder or bowel dysfunction
• Progressive deficits
• Previous history of cancer

Special Tests of the Lumbar Spine

• Straight leg test: performed by gradually raising the patient's straight leg while supine to illicit radicular pain
• Cross straight leg test: performed by raising the contralateral leg, positive sign for a herniated nucleus pulposus would be radicular pain on the ipsilateral side
• FABER test (Patrick's Test): flexion, abduction, and external rotation of the hips to illicit pain, positive sign is pain in the SI joint only

Lumbar Spinal Stenosis

• Progressive degeneration of the vertebral discs and facet joints
• Leads to narrowing of the spinal canal and compression of nerve roots
• Patients report neurogenic claudication with radicular symptoms that worsen with standing or spinal extension
• Patients report pain relief with spinal flexion or walking with a more flexed spine
• Physical exam findings: changes to sensory nerve patterns and decreased deep tendon reflexes that progress with the disease process
• MRI is the test of choice to demonstrate lumbar spinal stenosis
• Managed with physical therapy, core strengthening, NSAIDs

Piriformis Syndrome

• Occurs when the piriformis muscle in the buttocks spasms
• Patients report buttocks pain that comes with tingling along the back of the leg into the foot due to the sciatic nerve spasms
• Diagnosis made with the piriformis test
• Treatment: NSAIDs, rest, and stretching

Nerve Roots in the Lumbar Spine

• L4: causes ankle dorsiflexion and is the sensory nerve for the medial ankle/foot
• L3: extends the knee and is the sensory nerve for the mid-thigh region above the knee
• L2, L3, L4: control the patellar deep tendon reflex
• S1: controls the achilles deep tendon reflex
• The Babinski reflex: looks for great toe extension with fanning of the lesser toes, which is a sign of spinal cord injury
• Ankle clonus: after sudden ankle dorsiflexion, indicative of stroke or multiple sclerosis

Acute Low Back Pain (ALBP)

• Most common cause of lost work time and disability in patients less than 45 years of age
• Tends to resolve on its own in 4-6 weeks
• First line pharmaceutical therapy: NSAIDs
• If radicular symptoms present, a short burst of oral steroids should be used instead of NSAIDs

Chronic Low Back Pain

• Defined as greater than 3 months
• Important to rule out causes such as cancer, stenosis, deformities, infections, and osteoporosis by referring to orthopedics
• Patients often complain of pain that is aggravated by activity but relieved with rest
• Most predominant symptom: pain into one or both buttocks

Herniated Nucleus Pulposus

• Presents as "radiating pain, numbness, and weakness to the unilateral lower extremity"
• A patient with a herniated nucleus pulposus will have a positive straight leg test
• Key finding: worsened pain with spinal flexion
• Best diagnostic tool: MRI
• Can be treated conservatively with NSAIDs, muscle relaxers, and physical therapy

Cauda Equina Syndrome

• Medical emergency that must be ruled out if suspected
• Signs: loss of bladder and bowel function with saddle paresthesia
• Patient with suspected cauda equina syndrome must go to the emergency department for emergent MRI
• If MRI confirms, treatment is emergent surgical decompression

Sacroiliitis

• More common in females and obese patients
• Patient will likely report pain over one or both SI joints with posterior hip pain that may radiate down the leg
• Pain over the SI joints is referred to as "fortin point" pain
• Special tests: FABER and Fortin finger test
• Can be treated with conservative measures

Degenerative Disc Disease

• Due to the loss of articular cartilage and growth of new bone around the facet joints
• Patient often reports stiffness in the morning that is brief as the main complaint
• X-ray findings: joint narrowing, sclerosis, osteophytes

Spondylolysis

• Most common in younger athletes such as dancers, gymnasts, and lifters
• Pars interarticular stress fracture most commonly due to repetitive extension of the lower back
• Most cases occur at the L5 vertebrae
• Key clinical finding: "scotty dog collar" on an oblique x-ray
• Can be treated with modified activity, physical therapy, and gradual return to practice

Spondylolisthesis

• Due to vertebral sliding from repetitive extension
• Most common to occur in the L5-S1 region
• Two types: isthmic (more common in younger athletes and children from pars defect) and degenerative (more common in females above the age of 40 years)
• Lateral film x-ray will show the slipped vertebrae