Clinics Ii Final - Lumbar Spine

Front 1

1st LUMBAR ROOT - Cause

Back 1

- neoplasm
- disc lesion often secondary to lower level fusions

Front 2

1st LUMBAR ROOT - Area of Pain

Back 2

forbidden area, outer buttock, trochanter & groin

Front 3

1st LUMBAR ROOT - Dural Signs

Back 3

- +ve neck flexion + slump

Front 4

1st LUMBAR ROOT - Articular Signs

Back 4

- flexion most often affected depending on size
- extension also may be affected

Front 5

1st LUMBAR ROOT - Conduction Signs

Back 5

- motor - none
- sensory - hypoaesthesia just below the medial half on inguinal ligament

Front 6

1st LUMBAR ROOT - Differential Diagnosis

Back 6

Neoplasm

Front 7

1st LUMBAR ROOT - Treatment

Back 7

- refer back to physician initially
- if OK, traction

Front 8

2nd LUMBAR ROOT - Cause

Back 8

- neoplasm
- disc lesions often secondary to lower level fusions
• z-joint
• DDD
• stenosis from a variety of factors
• posterolateral disc lesion from ‘level above’ may capture L2 as it exits laterally

* stenosis and disc bulges rare in lumbar spine

Front 9

2nd LUMBAR ROOT - Pain

Back 9

upper lumbar, anterior thigh to knee

Front 10

2nd LUMBAR ROOT - Dural Signs

Back 10

neck flexion

Front 11

2nd LUMBAR ROOT - Articular Signs

Back 11

- flexion most affected depending on size
- extension also affected

Front 12

2nd LUMBAR ROOT - Conduction Signs

Back 12

- motor - weak hip flexion
- sensory - anterior thigh

Front 13

2nd LUMBAR ROOT - Nerve Root Contribution

Back 13

• femoral and obturator nerve
• may have positive prone knee bend

Front 14

2nd LUMBAR ROOT - Reflex

Back 14

untestable

Front 15

2nd LUMBAR ROOT - Differential Diagnosis

Back 15

- upper lumbar or femoral neoplasm
- meralgia paraesthetica
- claudication

Front 16

2nd LUMBAR ROOT - Treatment

Back 16

traction

Front 17

3rd LUMBAR ROOT - Cause

Back 17

• large IVD (most likely)
• stenosis

Front 18

3rd LUMBAR ROOT - Pain

Back 18

- mid lumbar, upper buttock, whole anterior thigh & knee, medial knee to just above the ankle

Front 19

3rd LUMBAR ROOT - Dural Signs

Back 19

- prone knee flexion
- occasionally +ve SLR

Front 20

3rd LUMBAR ROOT - Articular Signs

Back 20

extension major motion loss

Front 21

3rd LUMBAR ROOT - Conduction Signs

Back 21

- motor - slight weakness of psoas, grosser loss of quadriceps
- sensory - hypoaesthesia inner knee & lower leg

Front 22

3rd LUMBAR ROOT - Reflex

Back 22

- knee jerk absent or diminished

Front 23

3rd LUMBAR ROOT - Differential Diagnosis

Back 23

- hip or knee arthritis
- loose body
- femur neoplasm
- claudication
- long saphenous neuritis
- L3 metastases

Front 24

3rd LUMBAR ROOT - Treatment

Back 24

- neutral or extension protocol

Front 25

How common is a lesion of L4?

Back 25

40% of all nerve root problems are at L4

Front 26

4th LUMBAR ROOT - Clinical Presentation

Back 26

- pain with spinal movements - directional sense of provocation - worse on flexion better in extension
- referral pattern - dermatomal pattern
- history of flexion/rotation injury - acute/sharp pain which then gets worse
- primarily back pain, maybe the buttock (disc creating pain) - then wake up to pain shooting down leg - disc & neurogenic pain (chemical irritation)
- postural findings? (lacks consideration of posture - slumpy)
- AGE: 20 with increasing prevalence in 30's and 40's (rare in 60's)
- not a gender issue
- symptoms centralize

Front 27

4th LUMBAR ROOT - Pain

Back 27

- mid lumbar or iliac crest, inner buttock, outer thigh & over the leg to the inner foot & great toe

Front 28

4th LUMBAR ROOT - Dural Signs

Back 28

SLR, bilateral & crossed-SLR & neck flexion

Front 29

4th LUMBAR ROOT - Articular Signs

Back 29

marked deviation common as is gross limitation of one side flexion

Front 30

4th LUMBAR ROOT - Conduction Signs

Back 30

- motor - weak dorsiflexion
- sensory - hypoaesthesia anterior & medial lower leg & great toe

Front 31

4th LUMBAR ROOT - Key Muscle

Back 31

tibialis anterior w/ dorsi flexion reflex

Front 32

4th LUMBAR ROOT - Reflex

Back 32

- tibialis anterior & posterior
- absent or diminished

Front 33

4th LUMBAR ROOT - Differential Diagnosis

Back 33

- spondylolisthesis or claudication

Front 34

4th LUMBAR ROOT - Treatment

Back 34

- neutral or extension protocol

Front 35

5th LUMBAR ROOT - Cause

Back 35

- compressed by the 4th as well as the 5th disc

Front 36

5th LUMBAR ROOT - Pain

Back 36

- SI area, lower buttock, lateral thigh & leg, middle 3 toes & medial sole of foot

Front 37

5th LUMBAR ROOT - Dural Signs

Back 37

- unilateral SLR & neck flexion

Front 38

5th LUMBAR ROOT - Articular Signs

Back 38

- may deviate during flexion otherwise as expected for size

Front 39

5th LUMBAR ROOT - Conduction Signs

Back 39

- motor - weakness of peroneal, EHL & hip abductors
- sensory - hypoaesthesia outer leg & middle 3 toes & medial sole

Front 40

5th LUMBAR ROOT - Key Muscles

Back 40

- extensor hallucis longus and peronei
- hamstrings/adductors
- test great toe extension

Front 41

5th LUMBAR ROOT - Reflex

Back 41

- peroneus longus, EHL & EDB absent or diminished

Front 42

5th LUMBAR ROOT - Differential Diagnosis

Back 42

- peroneal neuritis
- claudication
- loose body or meniscal derangement at knee with pressure on tibial nerve
- spondylolisthesis
- trochanteric syndromes

Front 43

5th LUMBAR ROOT - Treatment

Back 43

- neutral or extension protocol

Front 44

1st SACRAL ROOT - Cause

Back 44

- compressed usually by 5th disc

Front 45

1st SACRAL ROOT - Pain

Back 45

- SI area, inner buttock, posterior thigh & occasionally heel & lateral foot & 2 toes

Front 46

1st SACRAL ROOT - Dural Signs

Back 46

- SLR & neck flexion

Front 47

1st SACRAL ROOT - Articular Signs

Back 47

- as expected for size

Front 48

1st SACRAL ROOT - Conduction Signs

Back 48

- motor - weakness of plantarflexion, hamstrings & peroneii
- sensory - hypoaesthesia outer leg & foot & lateral 1-2 toes

Front 49

1st SACRAL ROOT - Key Muscles

Back 49

- ankle plantar flexion
- ankle eversion
- hip extension

Front 50

1st SACRAL ROOT - Reflex

Back 50

- peroneus longus, EHL, EDB absent or diminished

Front 51

1st SACRAL ROOT - Differential Diagnosis

Back 51

- sacroilitis, claudication, spondylolisthesis

Front 52

1st SACRAL ROOT - Treatment

Back 52

- neutral or extension protocol

Front 53

2nd SACRAL ROOT - Pain

Back 53

- buttock, posterior thigh to heel

Front 54

2nd SACRAL ROOT - Dural Signs

Back 54

- SLR & neck flexion

Front 55

2nd SACRAL ROOT - Articular Signs

Back 55

- as expected for size

Front 56

2nd SACRAL ROOT - Conduction Signs

Back 56

- motor - weakness of plantarflexion, hamstrings & hip extensors
- sensory - hypoaesthesia posterior thigh & medial calf to heel

Front 57

2nd SACRAL ROOT - Key Muscles

Back 57

- test knee flexion
- achilles
- hamstrings

Front 58

2nd SACRAL ROOT - Reflex

Back 58

- triceps surae, hamstring, gluteus maximus absent of diminished

Front 59

2nd SACRAL ROOT - Differential Diagnosis

Back 59

- sacroilitis, claudication, spondylolisthesis

Front 60

2nd SACRAL ROOT - Treatment

Back 60

- neutral or extension protocol

Front 61

3rd SACRAL ROOT - Pain

Back 61

- inner groin, medial thigh to knee

Front 62

3rd SACRAL ROOT - Dural Signs

Back 62

- none or neck flexion

Front 63

3rd SACRAL ROOT - Articular Signs

Back 63

- as expected for size

Front 64

3rd SACRAL ROOT - Conduction Signs

Back 64

- motor - none
- sensory - hypoaesthesia medial thigh

Front 65

3rd SACRAL ROOT - Differential Diagnosis

Back 65

- adductor strain or osteitis pubis

Front 66

3rd SACRAL ROOT - Treatment

Back 66

- neutral or extension protocol

Front 67

4th SACRAL ROOT - Pain

Back 67

- lower sacral, peroneal & genital areas
- saddle area paraesthesia

Front 68

4th SACRAL ROOT - Dural Signs

Back 68

- none or neck flexion

Front 69

4th SACRAL ROOT - Articular Signs

Back 69

- may or may not have gross limitation of all movements

Front 70

4th SACRAL ROOT - Conduction Signs

Back 70

- motor - bladder, bowel and/or genital dysfunction
- sensory - lower sacral, peroneal & genital areas - saddle area

Front 71

4th SACRAL ROOT - Reflex

Back 71

- anal wink reduced

Front 72

4th SACRAL ROOT - Differential Diagnosis

Back 72

- genital & bladder dysfunctions but always assume a root palsy

Front 73

4th SACRAL ROOT - Treatment

Back 73

- refer to physician - careful traction

Front 74

Most significant hindrance to nerve conduction

Back 74

A lack of O2 to a nerve root is more significant in decreasing conduction than is mechanical pressure.

Front 75

Important Notes

Back 75

- assume L1/2 nerve root findings are “sinister” until proven otherwise
- L3 nerve root finding commonly mimic OA hip
- equal incidence of L4 & L5 nerve root involvement
- “S234 keep the poop up off the floor”
- S4 findings a surgical emergency

Front 76

Sign of the Buttock - S/S

Back 76

- SLR is limited & painful
- passive hip flexion with the knee flexed is limited & more painful
- pain felt in the buttock - may radiate into the posterior thigh & lower leg trunk flexion is limited
- all other lumbar movements are full
- non-capsular pattern of restriction of the affected hip
- empty end-feel
- all resisted hip movements painful & weak
- affected buttock may appear larger
- warm, swollen buttock confirmed by palpation

Front 77

Sign of the Buttock - Causes

Back 77

- osteomyelitis of the upper femur
- chronic septic sacroiliac arthritis
- ischiorectal abscess
- fractured sacrum
- gluteal contusion
- neoplasm involving the upper femur iliac neoplasm
- septic bursitis
- rheumatic fever with bursitis


Front 78

LE Myotomes

Back 78

• L2: Hip flexion
• L3 :knee extension
• L4: Ankle dorsiflexion
• L5: Great toe extension
• S1: AnkIe plantar flexion, ankle eversion, hip extension
• S2: Knee flexion

Front 79

Which 2 vertebral discs could cause an L1 nerve root lesion?

Back 79

• T12/L1 & L1/L2
• with a posterolateral disc lesion T12 could affect L1 because L1 nerve moves laterally in preparation to exit at the level below

Front 80

Why could there be evidence of cord involvement OR cauda equina involvement with an L1 nerve root?

Back 80

• at the level of L1 the spinal cord transitions into the cauda equina
• could have either cord signs or cauda equina signs
• could have UMN or LMN

Front 81

What are identifying factors of metastatic lesions (as compared to myofascial or articular?)

Back 81

• unremitting night pain
• weight loss
• will have a problem identifying ‘causes’ of pain
• weightbearing activities painful because trabecular bone is affected

Front 82

How will you till the difference between dural and myofascial involvement during the prone knee bend for femoral nerve mobility?

Back 82

• dura will cause symptoms below 90° (i.e., ~80°)

Front 83

Fatigueable Weakness

Back 83

Can generate one strong contraction, it slowly fades away then 2nd contraction only have 1/2 strength… slowly declining

Front 84

What would a hypotonic patellar tendon reflex tell you about L3 involvement?

Back 84

• LMN
• nerve root could be captured inside spinal canal because cauda equina is LMN or captured in IVF

* if its hyper-reflexive - UMN - pathology would be higher up (somewhere where the cord still is)

Front 85

L3 Nerve Root versus Hip OA

Back 85

• OA = capsular pattern of hip, much more provocative hip examination
• L3 nerve = neurogenic symptoms (parasthesia/anesthesia) - not OA of the hip, would be something else

Front 86

Vascular Claudication versus Spinal Stenosis

Back 86

• Claudication = PVD - aching lower limbs with exercise, better with rest - should get better if they stop and stand still - don't need to unload spine to get better

• Spinal Stenosis - need to stop and sit to get better, spinal stenotic changes in the spine (worse going downhill, better uphill & leaning over)
- i.e., extension is provocative because it closes off the spinal canal and IVF

Front 87

Typical aggravating/relieving factors for disc lesions

Back 87

- can't sit for long periods
- lie on their tummy (prone) makes it better
- happiest to be 'gently on the move'

Front 88

Crossed Straight Leg Raise

Back 88

- rules in disc herniation
- pain in opposite side to SLR test

Front 89

SIJ Pathology - Clinical Presentation

Back 89

- joint naturally fibrosis
- incidence decreases in 50's and 60s
- most common 20's and 30's
- females
- history of micro/macro trauma
- no neurogenic symptoms
- has widespread area of pain (innervation of joint from muscles that cross it - psoas etc…) - non dermatomal - could be lots of areas in the leg but not below the knee
- SI & groin pain - mimics high lumbar pathologies
- glut. med weakness - defacilitated

Front 90

SIJ Pathology - Causes

Back 90

- stand/walk/run - transitioning from one position to another
- repeated microtrauma
- hypermobility
- pregnancy - causes laxity (hormones)
- yoga
- leg length discrepancy
- muscle balance
- acute trauma - MVA (brake injuries)

Front 91

S1 Nerve Root versus Spondylolisthesis

Back 91

- spondylolisthesis....
- translate L5 on S1 anteriorly
- occurs with area of lordosis (aggrevating factor)
- can become discogenic in nature
- functionally unstable:
- don't like flexion - feel apprehensive
- reverse spinal rhythm
- don't like extension really
hinging at a segment

Front 92

What nerve do S 2, 3, 4 innervate?

Back 92

S2-3-4 innervate - pudendal nerve (voluntary muscles of external sphincters - anus & rectum)
- pelvic floor muscles
- bladder sphincter
sensory to perineum (saddle area)