MSK Exam 2 Lumbar.pdf

MSK Exam 2: Lumbar Annulus Fibrosis - 60-70% H2O - 60° angle off vertical line (10-12 layers)...

MSK Exam 2: Lumbar Annulus Fibrosis - 60-70% H2O - 60° angle off vertical line (10-12 layers) - Collagen fibers in each adjacent ring are oriented 120° in opposite directions Pedicle - Neurovascular supply to outer 1/3rd Sustains bending & tension forces - Transmits compression & tension forces - Completely surrounds nucleus pulposus - Attaches to end plates & cortical ring Nucleus Pulposus - 70-90% H2O (varies w/age) - No blood or nerves - Nutrients via diffusion from cartilaginous end-plate - Absorbs compression forces - No deformity w/axial loading o Reduces height & expands radially Discs Lamina - thick in lumbar area Cartilaginous joint Superior & Inferior Facets o 25% of total vertebral column height - Lie in sagittal plane à Superior: concave, faces med. & post. o Absorbs shock, distributes load, & à Inferior: convex, faces lat. & ant. allows mvmt o Facets carry 20-25% axial load § Disc degeneration => facet joints carry 70% load Nutrient supplier o Diffusion via vertebral end plate Pain sensitive structures in vicinity of disc: o PLL o Lumbo-sacral (L-S) nerve roots o Vertebral body o Facet joint 5th Vertebral body - Wedge shaped o L5: slides ant. & inf. d/t L-S angle (40°) - Smaller disc surface than others - Smaller spinous process - Larger transverse process – stability - ALL & iliolumbar ligs – stabilize L5-S1 jxn ant-post  Ligamentum Flavum - Between ant. surface of lamina & post. surface of lamina below - Extends laterally to cover facet joint - Contains high % of elastin - Strongest in lumbar Ant. Longitudinal Lig (ALL) Zygapophyseal Joints (Facet) Greatest tensile strength in lumbar Sagittal plane Flat, C or J shape Post. Longitudinal Lig (PLL) - “Diamond” shape Facet Joint Capsule - Deviates lat. at disc level to Ant. formed by ligamentum flavum Reinforced by multifidus & ligament flavum support AF - Weak in lumbar Neurology Med. branch of dorsal root of same segment & segment below Meniscoid (fat pad) à May buckle during flexion & block extension => cause acute “locking” Supraspinous Ligaments Spinous process à spinous process posteriorly - Sacrum à C7 Iliolumbar Ligament Interspinous Ligament Stabilizes L5 from ant. displacement Between adjacent spinous processes - Ant. Band: ant. TP of L5 à ant. iliac crest - Sup. Band: post. TP of L5 à iliac crest - Inf. Band: inf. TP of L5 à iliac crest - Post. Band: sup. TP à ilium Anterior Musculature Posterior Musculature Abdominals – linea alba Superficial layer: erector spinae - Ext. & Int. obliques - Iliocostalis: most effective SB Tissue Changes Over Lifespan - Transverse abdominis - Bi. Contraction: EXT, ant. tilt, L-S - Structures ∆ progressively over time - Rectus abd lordosis - “degenerative” ∆ is inevitable External oblique - Unilateral: SB, ipsi. Rotation - Discs lose H2O content & stiffen - Bi: trunk flex & post. pelvic tilt Deep layer: transversospinal group o ≠ pain necessarily - Uni: trunk SB & contralateral rotation Multifidi: cross 1-4 IV segments - Osteophytes for at margin of Internal oblique - OG TP of vertebra à insert SP other v. disc/bodies - Bi: trunk flex & post. pelvic tilt - Produces compression force during - Facet-joint cartilage thins à - Uni: trunk SB & unilateral rotation contraction (stabilize facets) osteophytes form Transverse oblique - Fatty replacement & m. atrophy - Ligaments/joint capsules become - Bi: compression of abdominal cavity & w/segmental instability less extensible (≠ pain) increase tension on TL fascia Rotatores: cross 1 IV jxn; orientation as Ø Pain generators - Primary stabilizer multifidi - Muscles, nerve roots, annulus - Provides fine control of spinal motions fibrosis, facet joints, dura, SI joint, as a group Ligs & TL fascia, vertebrae Biomechanics **Coupled movements** Pure motions: Flex & Extend à Flexion: top facet slide anteriorly & superiorly on bottom facet = opens à Extension: top facet slides inferiorly & posteriorly on bottom facet = closes Lateral flexion - LEFT lat. flexion: LEFT slide inferiorly & posteriorly (down & back) - LEFT lat. flexion: RIGHT slide superiorly & anteriorly (up & forward) Fryette’s Laws of Spinal Motion à Law 1: - Lumbar/thoracic segments (in neutral w/o locking the facets) o Rotation is in opposite direction of sidebending - Cervical spine: same direction lower rotation & sidebending à Law 2: If cervical, thoracic, or lumbar segments are in FULL FLEX or EXT w/facets locked: - Same direction rotation & sidebending à Law 3: if motion is introduced in ANY plane, then motion is reduced in other planes of motion - Movement in one plane lessens available range of other planes Axial Compression Slow Loading Disc - Vertebral bodies approximate - Squeeze H2O out of disc (5-11% - NP pressure arises & AF bulges water loss) radially - Rapid creep in first 2-10 min à Disc pressure at L3 - Bulging anteriorly > posteriorly plateau at 90 min - End-plate bows toward vertebrae - End-plate = weakest component à would fxr in center if overload - Intradiscal pressure varies (Schmorl’s node) w/posture & activity (Nachemoson) Disc Injuries Ø End-Plate Fracture (Schmorl’s nodes) o Trauma (incident) o Acute pain/spasm o Resolves ≤10 days à (-) SLR – no neural issues à(+) Compressions test Ø Internal Disc Disruption o Separation of inner layers o LBP - local & dull à (-) SLR à Dx: Discogram (no longer common practice) Ø Herniation – Protrusion (contained) o Some AF & PLL intact o LBP o Possible gluteal pain (radiating or referred) o Pain w/cough/sneeze/Valsalva – bc causing compression on root à (+/-) SLR – TBD by dural or nerve root compression Ø Disc Extrusion & Sequestration o LBP o Sciatic pain – nerve root distribution o Pain w/cough/sneeze/Valsalva à (+) SLR ð Mechanical (compression)/Chemical (irritates n. root) effects Ø Degenerative Disc Changes o Discs lose water w/age o Dx associated w/ idiopathic LBP, radiculopathy, myelopathy, stenosis, DDD, Facet joint arthropathy (stiff) Ø Foraminal Encroachment o Lateral narrowing between superior articulating process (SAP) & posterior vertebral margin o Facet osteophytes, vertebral osteophytes, disc protrusion/HNP, lateral recess stenosis, post-surgical scar, swelling, tumor Ø Central Canal Stenosis o Narrowing of spinal canal => pinched nerve o Persistent pain in buttocks o Limping o Lack of feeling in LE (claudication) o Decreased walking/standing ability – bilaterally DECISION TREE - Know this inside & out!! Chronic Low Back Pain (LBP) Observation/Subjective PT Examination Intervention Other Info Population Key Findings Multimodal approach of professionals Risk Factors - 20-69 yo (13%) - Impaired movement patterns Address biopsychosocial factors - Women > Mean à 20-65% depressed - Signs of central sensitization + - 20-60 yo anxiety, fear, &/or pessimism Education - Lower edu status Objective/Subjective - Hurt ≠ harm - Physically demanding jobs - Hx of LBP &/or related LE pain Special tests - Spine is strong - Genetics (degenerative ∆) (> 3 mo) - ↑ scores: FABQ & Pain - Tissues heal - CV HTN & lifestyle (sciatica) Catastrophizing Scale - Depression screening à smoking, overweight/obese Structural Limitations - Oswestry disability index (ODI) - Possible sensory, strength or reflex à MCI = 10 pts Ther-Ex Prognosis involvement - Roland-Morris Disability - General exercises – graded - Psychosocial factors/depression à MCI = 5 pts exposure, activity à greater prognostic factor than Yellow flags of Chronicity - Numeric pain rating scale - Cardio physical factors of CLBP - Report of higher severity of pain at à MCI = 2 pts - Cognitive functional therapy - Fear of pain, mvmt, or reinjury or onset - Fear-Avoidance Beliefs low expectations of recovery - Belief that pain is work related Questionnaire Key Needs - Presence of symptoms below knee - Psychological distress (FABQ/FABQW/FABQPA) - Belief change - Pain of high intensity - Psychosocial aspects of work - Behavior modification - Passive coping style - Compensation DDx - Nurture back to normal health - Time off work - Screen for mechanical vs. - Longer off work, less probability for nonmechanical vs. visceral return - Cauda Equina - Aortic aneurism - Spinal fracture – prediction rule: à Female à >70 yo à Significant trauma à Prolonged use of corticosteroids à ↑ Pain w/WB à Point tenderness FABQ Implications FABQ implications Depression Screening - Prediction of those w/higher likelihood of not - Higher scores observed for… - “During the past month, have you often been RTW o Male > Female bothered by feeling …” o FABQW: >34 o Acuity (higher in acute onset < 1 mo) o “down, depressed, or hopeless?” o FABQPA: >14 o Type of onset (higher w/sudden onset) o “little interest or pleasure in doing - Prediction of those that will likely RTW 15 - Pt response: “YES” to 1 or both = raised suspicion à “Is this something with which you would like help?” Red Flags Special Questions - General health? Symptoms related to presence of o Unexplained weight loss? central sensitization o Fatigue or malaise? o Loss of appetite? o Fever? - Any tingling or numbness of feet, perineal or genital area? o Saddle paresthesia? - Gait disturbances? - Bladder disturbances? o Blood in urine? o Pain during urination? o Urinary frequency? o Renal vs. prostate - Other systems if indicated o GI § Symptoms w/digestion, nausea, black stool or blood in stool o Vascular § Claudication, cold feet? The Problem o Abdominal pain - Common, complex, & expensive o Urogenital system - One of the most common reasons for MD o Gynecologic disorders visit § Menstrual irregularities? - LBP = #1 complaint in OP PT - 80% chance of lifetime occurrence of LBP - Self-limiting – 50% resolve in 4-8 weeks - 32% don’t fully recover in 6mo - Recurrent in 25-62% pts in 1-2 years Lumbar Pain w/ Mobility Deficits Observation/Subjective PT Examination Intervention – ACUTE Other Info Population Key Findings Education Risk Factors - > 50-60 yo - Unilateral LBP &/or buttock pain - Remain active - Overweight (3x increase risk) - Younger pts bc trauma w/end range of spinal motions - Optimize posture to reduce stress - Male > Female - Unilateral post à ant pressures of on sensitive structures MOI/Patho involved segment reproduce pt’s - Favorable Hx of acute LBP - Facet joint as source of LBP Objective/Subjective pain w/hypomobility of involved - Self-management to prevent - 25% of LBP - Gradual onset segment recurring LBP episodes - Recent trauma (fall, bend & twist, - Tenderness over involved segment - Flexibility routine or repetitive extension activity) - Associated hypomobility of - Deep, dull ache – intermittent thoracic spine &/or hips Manual Tx - Unilateral LBP &/or buttock - Manipulations (thrust) or mobs for + stiffness & motion limitation Special tests SI or lumbar region - Pain NOT worse w/Valsalva - (+) quadrant test (local) - STM actions - (-) extension rotation test - MET for pain, mobility, etc., Clinical prediction rule Aggravating activities: Ther-Ex - > 50yo à Worse in AM - Symptoms best when walking - AROM à End range spinal motions - Symptoms best w/supported sitting - Postural correction à Prolonged standing, bending - Onset of pain is in paraspinal region - Improve or maintain thorax/LB/hip - (+) Lumbar extension-rotation test backward, carrying or return from mobility & aerobic conditioning ≥ 3 variables (SpIN 91%) full flexion Manipulation CPR: Easing activities: repeated activity, - No symptoms distal to knee - Recent onset of symptoms sitting, lying w/knee flexed - Low levels of fear avoidance beliefs - Hypomobility of lumbar spine Structural Limitations - Hip IR >35° - Spondylosis OR DDx - Degenerative Disc - Imaging: facet degeneration Facet Injections – correlated w/pain relief from injection Lower Crossed Syndrome - Older age - Hx of LBP - Normal gait - Maximal pain w/extension from fully flexed - Absence of leg pain - Absence of muscle spasm - No pain w/Valsalva maneuver Cauda Equina Syndrome - EMERGENCY Observation/Subjective PT Examination Intervention Objective/Subjective Key Findings Education - B/B retention or incontinence - ↓ ankle reflex - EMERGENCY (911) - Bilateral symptoms - Saddle paresthesia or anesthesia - Global or progressive weakness in LE’s Aortic Aneurism Lumbar Soft Tissue Strains Observation/Subjective Observation/Subjective PT Examination Intervention Population Objective/Subjective Key Findings Manual Tx - Males - Lumbar muscle strain related to - Pain w/activities that require - STM to paraspinals, multifidus, - ≥ 65 yo trauma or lifting activities contraction of lumbar &/or psoas of affected - Broad area of LBP musculature myofascial Objective/Subjective - Possible buttock pain - Pain w/activities that stretch - Joint mobs/manips/MET for pain - Midline/lower thoracic/lumbar - Abdominal strains common involved lumbar musculature & muscle guarding pain w/rotation injury à Passive motion less painful - Throbbing, pulsating pain - Pain w/contraction (return from - Palpation of involved mm. Ther-Ex - No position of comfort bending) & w/stretch of injured reproduces pain – possible - Pain free stretching - Hx of smoking (5x risk) tissue spasm - Strength (progress as tolerated) - Hx of vascular, atherosclerotic - NOT radiating to legs - Guarding & increased tone of à Concentric à eccentric disorders paraspinals/QL - Trunk strengthening - Family Hx of aneurysm disorders - Functional mvmt - General conditioning Modalities - E-stim - Ice/heat Lumbar Instability Observation/Subjective PT Examination Intervention – ACUTE/CHRONIC Other Info Objective/Subjective Key Findings Education Risk Factors - LBP &/or LB-related LE pain in - Aberrant movement impairments - Favorable natural Hx & fear - Hx of MVA recent years during flex/ext avoidance - Lifting injury - “Catches”, giving way, w/sharp à Painful arc or catch - Avoid aggravating motions pain during active motions à Gower’s sign - Stay active MOI/Patho - ↑ Pain w/sustained postures - Symptom provocation & - Acute exacerbation of recurring (standing) or end range mvmts hypermobility w/segmental exam Manual Tx LBP – commonly associated - Severe pain w/minor perturbations (PA’s) - Thrust & non-thrust mobs w/referred LE pain - Possible general hypERmobility - Mobility deficits above/below - STM for pain & mobility spine => compensatory movement at L-spine Ther-Ex - Diminished trunk - Specific trunk activation exercises strength/endurance of L- - Trunk strengthening & endurance spine/pelvic muscles (strength/coordination) - Flexibility above/below L-spine Special tests (stretch) - Passive lumbar ext à (+) = strong LBP or heavy feeling à Strong SpIN & SnOUT - Prone instability test à (+) = pain remission in 2nd step à med. SpIN & SnOUT DDx - Rule out neural involvement (SLR, neuro exam) Spondylosis Degenerative changes & Fractures Observation/Subjective PT Examination Other Info Population Key Findings Risk Factors - Adolescent athletes (50%) - Hx & pt features > clinical exam - Repetitive rotation/ext activities - Female > Male - Severe pain w/rotation in adolescents MOI/Patho Objective/Subjective - Defect in pars interarticularis - Repetitive microtrauma Special tests (vertebral arch) à Ext &/or rotational motions - Provocation (no good tests for w/loading adolescents) SCOTTIE DOG - Lower lumbar area - Head: sup. articular facet DDx - Nose: transverse process - Rule out fracture (radiologically) - Eye: pedicle à bone scan or oblique radiograph - Neck: pars interarticularis - Body: lamina & SP - Foreleg: inf. articular process Spondylolisthesis Degenerative changes & Fractures Observation/Subjective PT Examination Intervention Other Info Population Key Findings Education MOI/Patho - Females (8x) > Male - Pain worse w/lumbar EXT - Treatment = Non-operative - Displacement/”slipping”/subluxation - > 40yo (degenerative) à relieved w/FLEX management w/NSAIDs & PT of one vertebra over another - Adolescents (5-7%) à Grocery cart lean - Surgery: indicated for… - Retrolisthesis: backward à Pars stress defect à progressive disabling pain displacement of one vertebra on - Football lineman, gymnast, DDx (failed nonoperative mgmt.) another weightlifters - Lateral radiographs à &/or progressive neuro deficits - Anterolisthesis: forward à Flexion/extension views displacement of one vertebra on Objective/Subjective - Rule out vascular claudication another - Mechanical back pain à butt/leg pain NOT relieved by à relieved w/rest & sitting standing in one place (as is - Neurogenic claudication & leg vascular claudication) pain à Buttock & leg pain/discomfy caused by walking - Neuro symptoms cause by central &/or foraminal stenosis Discogenic Pain Observation/Subjective Other Info Population MOI/Patho - 25-50 yo - Central LBP w/progression to LE - Foraminal encroachment maybe Objective/Subjective d/t: - LBP from disc: Band-form w/dull, à facet pathology vague pain à osteophytes/DJD - LBP from nerve root: sharp, à disc protrusion/HNP agonizing pain (chemical irritation) à post-surgical scar à Common, narrower band of leg à swelling symptoms à tumor Structural Limitations - PLL & outer annulus both innervated LBP – referred/related LE pain - Sciatica Observation/Subjective PT Examination Centralization Objective/Subjective Key Findings Directional preference & centralization - LBP - Lat. trunk shift - Shorter duration of symptoms - Referred buttock, thigh, or leg pain - Reduced lumbar lordosis - Younger pts - Worsens w/flexion activities & - Limited lumbar ext mobility sitting - Neuro exam Failure to centralize - Numerous LB-related LE pain - Mvmt coordination impairments - Predictor of poor outcome episodes - Associated w/psychosocial issues - Pain can be centralized & diminished w/positioning, manual Treatment procedures, &/or repeated mvmts - Mechanical Dx & therapy interventions (directional preference) - Progress to Acute LBP w/Movement Coordination Impairments intervention strategies LBP w/Radiating Pain - LEG Observation/Subjective PT Examination Intervention Objective/Subjective Key Findings Education - LE paresthesia, numbness, & - Reduced lumbar lordosis - Favorable Hx for LBP resolution (B) weakness - Limited lumbar ext mobility - Avoid excessive flexion, sitting, - Numerous LB-related LE pain - Provoked w/prolonged, static prolonged postures activities - Disc can heal MOI/Patho - Symptoms reproduced w/mid- - Establish movements that best Nerve root à inflammation aggravated range spinal mobility relieve pt’s symptoms w/flexion or flex/rotate mvmt w/narrow à Worsens w/end-range spinal band of pain mobility Manual Tx – as tolerated - Symptoms reproduced w/LE - Thrust or non-thrust joint mobs neural tension (SLR, slump test) - STM - Nerve root involvement (sensory, à diminish pain, reduce disability, strength) - Mobilize articulations close to - Radiating pain exacerbated w/flex involved nerve root(s) or flex/rotation mvmts - Mobilize hips & thoracic as needed n Leg pain > LBP - Central PA’s reproduce symptoms Ther-Ex & pain at affected segment - General trunk strength & fxnl movement training DDx - Sliders – neural mobs - CANNOT be centralized - Hip/thoracic mobility w/positioning, manual procedures, - Aerobic exercise &/or repeated movements - Rule out if: LE tension test (SLR) or slump testing do not reproduce reported pain Type of Pain LBP w/Radiating Pain – Central Spinal Stenosis Observation/Subjective PT Examination Intervention Other Info Population Key Findings Education Risk Factors - > 60 yo - Stooped posture – loss of lordosis - Avoid extension for prolonged - - Limited EXT ROMw/increase in periods Objective/Subjective symptoms - Establish posture & body MOI/Patho - Insidious onset (d/t advancing mechanics - Central-midline sagittal spinal degenerative change) Special tests - Establish mvmts or positions that canal diameter narrows & may à DDD, HNP, PLL calcification, - Neuro exam: sensory & myotomal best relieve symptoms elicit neurogenic claudication or spondylolisthesis weakness pain in buttock, thigh, or leg - LBP w/persistent pain (+) SLR Manual Tx - Slow, progressive disorder - Paresthesia, numbness, weakness - Severe cases: hyperreflexia (LE - STM to erector spinae, hips - Possible genetic tendency in LE’s (bilateral – neurogenic DTR) à (+) Babinski &/or clonus - Mobs: lumbar for pain, - Leading cause of spine surgery in claudication) thoracic/hips for mobility geriatric pop - Pain w/prolonged sitting DDx - Neuro mobs as tolerated – for pain - Decreased walking distance - Confirmed via MRI - Better w/flexion, sitting, pushing Ther-Ex cart/walker, & bike - Stretch (hips flexors, lumbar flexion mobility – paraspinals) - Trunk strength - Functional mvmt exercise w/flexion bias - Balance Modalities - Traction as tolerated Lumbosacral Radiculopathy Intermittent Neurogenic Claudication (caused by stenosis) Peak incidence 30-65 yo >60 yo Course Acute/Subacute onset Insidious onset Spontaneous recovery back pain legs Localization Unilateral (mostly) Bilateral Provocation Increasing pressure (cough), Standing, walking w/straight back standing, sitting, walking Relief Lying down Biking, sitting, bending over, squatting Physical examination Diminished strength/sensation, Often no abnormal findings reflexes, +ve provocation tests (SLR)  “Greatest predictor of surgery is number of surgeons in local population” “when it comes to spinal surgery… geography is best predictor” Surgical Interventions Spinal fusions rose significantly, but CLBP disability has dramatically risen as well Ø Indications Ø Leg pain w/neuro signs Ø Medical Approach Ø Epidural injections - Specific trauma - Radiculopathy - Meds: NSAIDS, oral - Disc herniation - Specific neurological signs - Lumbar disc herniations steroids, neuropathic meds - DDD o Progressive loss of myotomal strength - Stenosis (lateral or central) - Activity modification - Spinal stenosis o DTR changes - Synovial cysts - PT! - Synovial cyst o Loss of sensation - Tumors - Epidural injections - Annular tears - Red flags: Cauda equina syndrome - Bed rest - Diagnostic Types of surgical interventions Laminectomy/ Decompression Discectomy Spinal Fusion Disc Replacement Procedure Indication: herniated disc Various procedures to achieve arthrodesis A. Maverick - Lamina & ligamentum flavum - Minimally invasive Indications: B. Flexicore removed à Percutaneous discectomy - DDD? C. Charite - Used for disc herniation & spinal à Endoscopic discectomy - Severe pain stenosis à Microdiscectomy - Post-traumatic instability - Successful (90%) & satisfactory - Removal of disc material - Degenerative spondylolisthesis (75%) - Reoperation rate 18%