Knowledge… Lumbar Spine
Orthopedics and Neurology DX 611 Knowledge enhances awareness and improves the potential for accurate James J. Lehman DC, MBA, DABCO diagnosis… University of Bridgeport College of Chiropractic
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Lumbar Spine Low Back Pain Back Pain Male Gender Prevalence
1. Spondyloarthropathies 2. Vertebral osteomyelitis Back pain is common from the second 3. Benign and malignant neoplasms decade on. 4. Paget’s disease
1 Low Back Pain Female Gender Prevalence in Male Gender Prevalence Low Back Pain
5. Retroperitoneal 1. Polymyalgia fibrosis rheumatica 6. Peptic ulcer disease 2. Fibromyalgia 7. Work-related 3. Osteoporosis mechanical 4. Parathyroid disease disorders
Characteristics of Lumbar Spine Lumbar Spine Pain Generators Pain
Zygapophyseal joint Spinal pain Capsule Discogenic pain Nerve Nerve root pain Ligament Multiple levels of Muscle lumbar spinal Osseous stenosis
The Dermatomal Rule Characteristics of Low Back Pain “Referred pain” Viscero-somatic Convergence Brain cannot Brain often "refers" distinguish between pain from a viscus to nociceptive activity the related somatic originating in the dermatomal area. viscus and that originating in the somatic structure due to convergence.
2 Differential Diagnosis Characteristics of Low Back Pain Low Back Pain Examples Viscero-somatic Convergence
Dehydration Dehydration Nephrolithiasis Gout Gout Murphy test & kidney Renal Carcinoma punch (Peri-nephritic abcess) Metastasis Dr. John Benjamin Murphy (surgeon)
Mechanical Low Back Pain Mechanical Low Back Pain Spinal Motion Segment Overuse
As many as 90% of Strain patients with back Myospasia pain have a Dehydration mechanical reason for their pain secondary Discopathy to overuse or trauma
Mechanical Low Back Pain Mechanical Low Back Pain Post-Traumatic Pain
A normal anatomic structure Lumbar strain Pain secondary to Lumbar sprain trauma Lumbar fracture Deformity of an Lumbar strain/sprain anatomic structure.
3 Mechanical Low Back Pain Mechanical Low Back Pain Deformities of anatomic structures Congenital Scoliosis
Abnormal spine Would you consider 1. Wedged vertebra this condition as a 2. Hemivertebra structural or non- 3. Congenital bar structural scoliosis? 4. Block vertebra
Mechanical Low Back Pain Differential Diagnosis of Lumbar Congenital Scoliosis Pain 1. Disc injuries Rib hump 2. Mechanical joint dysfunction Deviation of spinous 3. Myofascial conditions process 4. Ligamentous conditions Vertebral distortion Posterior convexity 5. Neural conditions Anterior concavity
Mensuration of Lumbar Flexion Schober’s Test
80 degrees of lumbar Mark lumbosacral flexion is WNL junction, 10 cm Movement must occur superior, and 5 cm at lumbar spine and inferior not the hips or Have patient flex thoracic spine forward and measure the differences
4 Mensuration of Lumbar Flexion Lumbar Range of Motion Schober’s Test Flexion and Extension
Normal findings would indicate 4 cm of Flexion 80 degrees increase with superior Extension 35 degrees pair of marks and zero change with inferior pair of marks.
Lumbar Range of Motion Lumbar Range of Motion Lateral Flexion
Coupling of lumbar spine is the opposite of the cervical and thoracic spine Lateral Flexion 25 Lumbar spinous processes move toward degrees concavity with lateral flexion
Lumbar Range of Motion Clinical Picture Lumbar Rotation
What type of range of motion changes would you expect with mechanical low back pain due to posterior joint dysfunction?
5 Lumbar Spine Radiculopathy Low back pain that extends into thigh Intervertebral Disc Disease and leg
Intervertebral disc disease and disc Radicular pain often herniation are most extends below the prominent in the third knee in the affected and fourth decades of dermatome. life.
Back and posterior thigh pain arises from many areas of the spine Lumbar Radicular Syndrome
Facet joints Longitudinal Aging and trauma are ligaments believed to be the Periosteum of the causes of discopathy vertebrae.
Lumbar Radicular Syndrome Lumbar Radicular Syndrome Disc Anatomy At what ages would you suspect the most Attaches vertebral common exacerbation bodies of severe discogenic Provides flexibility radicular pain? Absorbs and distributes Spinal column loads
6 Evolution of Disc Function Posture and Disc Loading
Equal distribution Explains Unequal distribution exacerbations and remissions of pain Dysfunction and disc herniation with change in posture.
Specialized Imaging & Lumbar Disc Specialized Imaging & Lumbar Disc Disease Disease
Protruding herniated Why utilize MRI nucleus pulposus examinations when Thecal sac we suspect lumbar indentation disc disease? Decreased hydration of disc
Lumbar Radicular Syndromes Clinical Picture Lumbar Disc Herniation
Please describe the Nerve root peripheral nerve involvement findings that might Pain referral patterns present with this Sensory & Motor lumbar disc disease. deficits DTR’s compromised
7 Clinical Picture Clinical Picture
What type of range of Please describe what motion changes type of specialized would you expect with tests might be lumbar herniated nucleus pulposus indicated with this (HNP) pain? lumbar disc disease. Why?
Lindner’s Sign Valsalva’s Maneuver Assessment for Lumbar Nerve Root Neuro-orthopedic application Irritation
Assessment for space-occupying Passive flexion of lesion, tumor, neck with chin to intervertebral disc chest herniation, or Supine, seated, or osteophytes standing position
Lindner’s Sign Kemp’s Test
May be performed in either a standing or sitting position Sign is present if procedure produces A positive test pain in lumbar spine involves radicular & sciatic distribution pain
8 Kemp’s Test Kemp’s Test Assessment Oblique bending Intervertebral nerve toward symptomatic root encroachment side increases pain with a lateral Muscular strain protrusion Ligamentous sprain Pericapsular inflammation
Straight-Leg-Raising Test Kemp’s Test Dynamics
Oblique bending 1. 0-35 degrees = no dural movement away from symptomatic side 2. 35-70 degrees = tension of sciatic nerve increases pain with a over intervertebral disc medial protrusion 3. Above 70 degrees presents very little additional deformation of nerve root
Straight Leg Raise Test SLR Nerve Root Tension Pain Reaction
0-35 = extradural Dull pain in posterior 35-70 = disc lesion thigh may be due to tight hamstrings 70-90 = lumbosacral lesion Bowstring test differentiates
9 Straight-Leg-Raising Test Straight-Leg-Raising Test
Assessment for space-occupying mass in the path of a Bilateral SLR testing nerve root, sacroiliac Simultaneously inflammation and perform Well-Leg- lumbosacral Raising test involvement
Well-Leg-Raising Well-Leg-Raising Test SLR of unaffected limb presents
SLR of unaffected LE Increased pain with a Contralateral LE medial protrusion due radicular pain is to the compression of positive test for nerve the nerve root root lesion
Well-Leg-Raising Bragard’s Sign SLR of unaffected limb presents
Decreased pain with 1. Perform SLR lateral protrusion 2. Lower affected LE 5 due to pulling away degrees of the nerve root 3. Dorsiflex the from the protrusion ipsilateral foot
10 Bragard’s Sign Fajersztajn’s Test
Assessment for Assessment for lumbar nerve root sciatic neuropraxia, lesion caused by IVD intervertebral disc syndrome or dural lesions, and spinal sleeve adhesion nerve irritation Contralateral LE SLR Perform Bragard’s
Sicard’s Test Turyn’s Test Assessment for Sciatic Radiculopathy Assessment for Sciatic Radiculopathy
SLR Supine position Lower affected LE 5 Dorsiflexion of large degrees toe without SLR Dorsiflex large toe Positive test with Positive test with radicular pain radicular pain
Minor’s Sign Minor’s Sign
Painful or antalgic List will vary with behavior due to medial vs. lateral protective myospasia discopathy Crawling up thigh with listing
11 Clinical Picture Vanzetti's Sign
If a patient presented In sciatica the pelvis is with leg pain below always horizontal in the knee, a level spite of scoliosis, but in pelvis, and scoliosis, other lesions with would you suspect scoliosis the pelvis is discopathy? inclined. (pelvic Why? obliquity)
Antalgic Lean Sign Antalgia Sign “Antalgia Sign”
Medial protrusion presents with antalgic Painful discopathy list to the painful side of lesion causes listing in order Lateral protrusion presents with antalgic to reduce mechanical nerve root pain. list opposite the side of painful lesion Central disc lesion presents with flexed antalgic list
Differentiate Lateral Disc from Antalgic Lean Sign Medial Disc Protrusion
Lateral disc protrusion Antalgic lean produces a Well Leg Test contralateral list Kemp’s test Most common
12 Evolution of Discopathy Evolution of Discopathy
Disc Injuries Disc Extrusion
A focal herniation Disc Protrusion is contained by the present when nuclear posterior longitudinal material does not ligament that extends extend beyond the into the spinal canal annulus in a contained HNP.
Sequestered or Fragmented Lumbar Disc Degeneration Disc
A free fragment that has broken off or through the annular Disc degeneration peripheral fibers in may occur and the vertebral canal remain (prolapsed) asymptomatic
13 Lumbar Discopathy MRI
At what age would you expect the most Disc degeneration serious disc lesions may be associated that usually require with changes within surgical intervention? the disc itself, which Why? may produce pain
Degenerative Disc Degeneration Mechanical Instability Lumbar Discopathy
May give rise to Once you make the mechanical diagnosis of lumbar instability that discopathy, what is renders the spine your next clinical vulnerable to trauma step?
Consultation with Patient Lumbar Spondylosis Discopathy Osseous and Discal Involvement It is essential that you Degenerative first make an accurate changes in discs and diagnosis of joints discopathy and then Bony overgrowths or discuss the diagnosis spur formations, and treatment with which are the patient prior to osteophytes manipulation…
14 Osteophytes Lumbar Spondylosis
Osteophytes located Lumbar predominantly at the Osteophytosis anterior, lateral, and, Osteochondrosis less commonly, Degenerative Joint posterior aspects of Disease the superior and inferior margins of Vertebral vertebral bodies. Osteophytosis
Lumbar Spondylosis Past teleologically misleading names
Spondylarthropathy Osteoarthritis Spondylitis
Causes of Lumbar Mechanical Joint Dysfunction Spondylosis Documentation of the Subluxation: The P.A.R.T. System The P.A.R.T. documentation system for Medicare has been a topic of much concern and discussion among 1. “Sprung back” hyperflexion injury chiropractors. Recall that the subluxation may be documented by one of two methods: x-ray or physical 2. “Kissing spines” hyperextension injury examination, and that if the latter is used, it must be documented according to the P.A.R.T. system. The four 3. Capsular and ligamentous sprain injuries components of P.A.R.T. are described below. CMS “Facet joint degeneration” or requires that at least two of the four components must be “zygapophyseal joint imbrication” documented, and at least one of A or R. http://www.acatoday.com/content_css.cfm?CID=1217#Initial
15 Vertebral Subluxation Complex Textbook of Clinical Chiropractic: A biomechanical approach Positional dyskinesia (sprain/strain) Examples: Retrolisthesis or Anterolisthesis Fixation dysfunction Examples: Meniscoids, myospasia, adhesions, & inflammation Compensatory hypermobility and instability Disc protrusions
Lumbar Facet Syndrome Lumbar Facet Syndrome Low Back Pain Symptoms
Constant dull ache
Intermittent sharp What specialized pain orthopedic tests Catch with certain would you perform to movement evaluate a low back Increased pain with pain patient with this standing and syndrome? extension
Lumbar Facet Syndrome Lumbar Facet Syndrome Innervation
Medial branch of the Palpation may reveal primary dorsal rami PVM hypertonicity and pain
16 Lumbar Facet Syndrome Lumbar Facet Syndrome
Flexion should be Extension and WNL rotation increase pain Extension should be Flexion reduces pain reduced with localized Kemp’s produces pain localized pain
Lumbar Facet Syndrome Lumbar Facet Syndrome
Degenerative joint changes at Degeneration of zygapophyseal joints cartilage Meniscoid entrapment
Farfan
Lumbar Facet Joint Facet Joint Injection and Imbrication Spinal Manipulation
Zygapophyseal joint imbrication with Reduces pain and capsular edema prior to spinal degeneration manipulation
17 Spondylolysis with Meyerding’s Classification of Spondylolisthesis Spondylolisthesis
Separation at pars Grade 1 = 0-25% interarticularis Grade 2 = 26-50% Anterior slippage of Grade 3 = 51- 75% superior vertebral Grade 4 = 76%-100% body on inferior body
Lumbar Central Canal Stenosis Anterolisthesis or Spondylolisthesis Structural Causes
1. Osseous: inferior facet 1. Degenerative (L4-L5 level) arthrosis 2. Spondylolysis or Isthmic 2. Discogenic: central disc spondylolisthesis (L5-S1) herniation 3. Congenital caused by inadequate 3. Ligamentous: ligamentum development of the L5-S1 facet flavum buckling in degenerative spinal complexes disease
Lumbar Central Canal Lateral Spinal Canal Recess Stenosis Stenosis Neurogenic claudication with pain upon walking Degenerative joint Feel like legs are “giving way” disease Temperature changes Encroachment of and weakness in legs nerve root in canal Night pain Sciatic tension signs are Nerve root present entrapment
18 Lateral Spinal Canal Recess Stenosis IVD or Space Occupying Lesion Neurogenic Pain Milgram’s Test
Intermittent episodes of pain in the hips, buttocks, or posterior thigh Positive with either Pain referred to foot intrathecal or or toes extrathecal pathology Sensorial deficits in calf are common
Milgram’s Test Positive Milgram’s Test Assessment for IVD or Space-Occupying Lesion Indicates intrathecal or extrathecal pathology Patient able to hold for 30 seconds The test is positive if the patient Rules out intrathecal pathology experiences low back pain
Intrathecal Pathology Extrathecal Pathology
Extrathecal pathology Intrathecal pathology may involve a may involve a spinal herniated disc or tumor. space occupying lesion
19 Neurofibromatosis Neurofibromatosis von Recklinghausen’s Disease
Tumors grow on and along A complicated genetic various types of nerves. disease that can The disease can also affect non-nervous tissues like bones affect both men and and skin and lead to developmental abnormalities women in all races such as learning disorders. and ethnic groups.
1/4000 births U.S. National Neurofibromatosis Foundation (NNFF).
Neurofibromatosis Neurofibroma
Tumor or growth located along a “Café au lait” skin nerve or nervous markings tissue. Neurofibromas Inherited disorder Skeletal deformities May cause neural (scoliosis) deficits
Neurofibromatosis Neurofibromatosis Lumbar Skin Markings
Faun’s beard “Café au Lait”
20 Neurofibromatosis
Neurofibromas
21