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Questions and Answers
What characteristic symptom can indicate the onset of a herniated disc?
What characteristic symptom can indicate the onset of a herniated disc?
Which position tends to exacerbate symptoms of a herniated disc?
Which position tends to exacerbate symptoms of a herniated disc?
What finding in a medical history would most likely indicate a risk of fracture in a patient with low back pain?
What finding in a medical history would most likely indicate a risk of fracture in a patient with low back pain?
What red flag symptom is associated with potential cauda equina syndrome?
What red flag symptom is associated with potential cauda equina syndrome?
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What type of herniation may provoke low back pain and saddle pain in the S1 and S2 distributions?
What type of herniation may provoke low back pain and saddle pain in the S1 and S2 distributions?
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Which of the following might be a sign of serious complications from a central herniated disc?
Which of the following might be a sign of serious complications from a central herniated disc?
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Which of the following is NOT a red flag that warrants immediate investigation in patients with low back pain?
Which of the following is NOT a red flag that warrants immediate investigation in patients with low back pain?
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What is typically assessed first in the physical examination for suspected disc herniation?
What is typically assessed first in the physical examination for suspected disc herniation?
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What is the primary difference between pain associated with disc herniation and degenerative diseases?
What is the primary difference between pain associated with disc herniation and degenerative diseases?
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Which condition is characterized by pain and stiffness that worsen in the morning and improve throughout the day?
Which condition is characterized by pain and stiffness that worsen in the morning and improve throughout the day?
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What leg symptom is often associated with a herniated disc?
What leg symptom is often associated with a herniated disc?
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How is pain caused by a low back strain different from that caused by a herniated disc?
How is pain caused by a low back strain different from that caused by a herniated disc?
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Which of the following findings most strongly suggests a possible tumor or infection in low back pain evaluation?
Which of the following findings most strongly suggests a possible tumor or infection in low back pain evaluation?
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What important aspect might provide insight into the patient's condition when taking the medical history?
What important aspect might provide insight into the patient's condition when taking the medical history?
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What is the most common location for a herniated disc in low back pain patients?
What is the most common location for a herniated disc in low back pain patients?
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Which factor would NOT be considered a 'red flag' during assessment of acute low back pain?
Which factor would NOT be considered a 'red flag' during assessment of acute low back pain?
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What type of pain is indicated by lumbar flexion?
What type of pain is indicated by lumbar flexion?
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Which lumbar movement is associated with facet disease?
Which lumbar movement is associated with facet disease?
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Weakness in the quadriceps muscle may suggest involvement of which lumbar nerve roots?
Weakness in the quadriceps muscle may suggest involvement of which lumbar nerve roots?
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What test evaluates the function of the iliopsoas muscles?
What test evaluates the function of the iliopsoas muscles?
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Which of the following symptoms is associated with L4-5 nerve root involvement?
Which of the following symptoms is associated with L4-5 nerve root involvement?
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Diminished or absent Achilles reflex can indicate issues with which spinal segment?
Diminished or absent Achilles reflex can indicate issues with which spinal segment?
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What should be done during the examination to determine the source of pain?
What should be done during the examination to determine the source of pain?
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What reflex might be diminished if the L2-L3 nerve roots are involved?
What reflex might be diminished if the L2-L3 nerve roots are involved?
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What does the L5 nerve root control?
What does the L5 nerve root control?
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What does a positive Trendelenburg test indicate?
What does a positive Trendelenburg test indicate?
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What symptom may suggest cauda equina syndrome?
What symptom may suggest cauda equina syndrome?
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What does the straight-leg raising test help identify?
What does the straight-leg raising test help identify?
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In a crossed straight-leg raising test, what does it suggest when pain is reproduced on the affected side?
In a crossed straight-leg raising test, what does it suggest when pain is reproduced on the affected side?
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What do Waddell signs help to identify?
What do Waddell signs help to identify?
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What is evaluated by extending the thigh at the hip and flexing the knee in the femoral stretch test?
What is evaluated by extending the thigh at the hip and flexing the knee in the femoral stretch test?
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What might severe pain during the straight-leg raising test indicate?
What might severe pain during the straight-leg raising test indicate?
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What condition is specifically mentioned as a surgical indication for herniated disc?
What condition is specifically mentioned as a surgical indication for herniated disc?
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What is the reported effectiveness of epidural steroid injection therapy for lumbar disc herniation with radiculopathy?
What is the reported effectiveness of epidural steroid injection therapy for lumbar disc herniation with radiculopathy?
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Which of these is NOT an indication for referral to a specialist for herniated disc treatment?
Which of these is NOT an indication for referral to a specialist for herniated disc treatment?
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What should surgical decisions regarding herniated discs be based on?
What should surgical decisions regarding herniated discs be based on?
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What are some reported limitations of steroid injections in treating radiculopathy?
What are some reported limitations of steroid injections in treating radiculopathy?
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What is one reason patients with a herniated disc might be referred to a specialist?
What is one reason patients with a herniated disc might be referred to a specialist?
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Which of the following conditions may indicate a need for surgical intervention due to a herniated disc?
Which of the following conditions may indicate a need for surgical intervention due to a herniated disc?
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What is a common misconception about conservative treatment for herniated discs?
What is a common misconception about conservative treatment for herniated discs?
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Study Notes
Spinal Disorders: Red Flags
- Fracture: Major trauma or strenuous lifting in older or osteoporotic patients.
- Tumor or Infection: Age over 50 years or under 20 years, history of cancer, constitutional symptoms (fever, chills, unexplained weight loss), recent bacterial infection, intravenous drug use, immunosuppression (corticosteroid use, transplant recipient, HIV infection).
Cauda Equina Syndrome
- Symptoms: Pain worse at night or in the supine position, saddle anesthesia, recent onset of bladder dysfunction, severe or progressive neurologic deficit in lower extremity.
- Diagnosis: Medical history and physical examination may disclose bowel or bladder dysfunction.
- Treatment: Immediate referral to a specialist for emergency surgery to prevent permanent loss of function.
Herniated Disc
- Onset: Usually a distinct time of onset with contributing factors, while gradual onset pain suggests other degenerative diseases.
- Common Levels: L4-5 and L5-S1.
- Symptoms: Sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, below the knee, often associated with numbness or tingling. In advanced cases, motor deficit, diminished reflexes or weakness may occur.
- Central Herniation: Relatively uncommon, provokes low back pain and saddle pain in the S1 and S2 distributions, can compress nerve roots of the cauda equina, resulting in difficult urination, incontinence or impotence.
Differentiating Low Back Strain from Herniated Disc
- Low Back Strain: Pain exacerbated during standing and twisting motions.
- Central Disc Herniation: Pain worse in positions like sitting that produce increased pressure on the anular fibers.
- Sitting: Increases pressure on the intervertebral disc, exacerbating herniated disc symptoms.
Physical and Neurologic Examination of the Lumbar Spine
- Assessment: Search for external manifestations of pain, including an abnormal stance, posture, gait, sciatic list, and palpate spinous processes and interspinous ligaments for tenderness.
- Range of Motion: Pain during lumbar flexion suggests discogenic pain, while pain on lumbar extension suggests facet disease. Ligamentous or muscular strain can cause pain when the patient bends contralaterally.
- Neurologic Examination: Assess motor, sensory and reflex function to determine the affected nerve root level.
- Muscle Strength Grading: 0 (no evidence of contractility) to 5 (complete range of motion against gravity, with full resistance).
Nerve Root Level Evaluation
- Upper Lumbar (L1, L2, L3): Controls the iliopsoas muscles, evaluated by testing resistance to hip flexion.
- L2, L3, L4: Control the quadriceps muscle, evaluated by manually trying to flex the actively extended knee.
- L4: Controls the tibialis anterior muscle, tested by heel walking.
- L5: Controls the extensor hallucis longus, tested by seated dorsiflexion of both great toes against resistance, also innervates hip abductors, tested by the Trendelenburg test (positive if pelvis drops on the opposite side when standing on one leg).
- Cauda Equina Syndrome: Unexpected laxity of the anal sphincter, perianal or perineal sensory loss, or major motor loss in the lower extremities.
Nerve Root Tension Signs
- Straight-Leg Raising Test: Raises patient's leg to approximately 90 degrees, severe pain in the back of the affected leg indicates nerve root compression, can reveal L5 or S1 nerve root involvement.
- Crossed Straight-Leg Raising Test: Straight-leg raising of the contralateral limb reproduces more specific but less intense pain on the affected side, suggests nerve root compression.
- Femoral Stretch Test: Patient lies in prone or lateral decubitus position, thigh extended at the hip, and knee flexed, pain reproduction suggests upper nerve root (L2, L3, and L4) disorders.
Non-Organic Physical Signs (Waddell Signs)
- Signs: Superficial tenderness, positive results on simulation tests (maneuvers that appear to be a test but actually are not), distraction tests that attempt to reproduce positive physical findings when the patient is distracted, regional disturbances that do not correspond to a neuroanatomic or dermatomal distribution and overreaction during the examination.
- Patient Types: Patients with work-related injury or those involved in litigation related to their injury are more likely to demonstrate these signs.
Epidural Steroid Injection Therapy
- Efficacy: Some studies report effectiveness in patients with lumbar disc herniation with radiculopathy, while others report limited value.
Surgical Indications for Herniated Disc
- Indications: Cauda equina syndrome, progressive neurologic deficit, profound neurologic deficit, severe and disabling pain refractory to 4-6 weeks of conservative treatment.
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Description
This quiz covers critical aspects of spinal disorders, focusing on red flags associated with vertebral fractures, tumors, infections, and conditions like cauda equina syndrome. Test your knowledge on symptoms, diagnosis, and the importance of prompt treatment for these conditions.
