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Lumbar Spine 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 You are the chiropractic Key to Success physician of the future… Mastering the diagnosis and treatment of these “Diagnosis is the key neuromusculoskeletal to successful conditions will determine treatment!” your success in school, clinic, and throughout your career... 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
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