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106 Cards in this Set
- Front
- Back
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What is Schmorl's node
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small protrusion of the nucleus that occurs into the superior vertebral body through the cartilaginous end plate
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where does schmorl's node most commonly occur
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lower thoracic and upper lumbar region
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what is the cause of schmorl's node
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it occurs during adolescence as a developmental phenomenon
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what are the S and S for a schmorl's node
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they never cause andy symptoms and do not require tx.
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how is schmorl's node diagnosed
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through radiology
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what is the treatment for schmorl's node
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none
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what is an intra-spongy nuclear herniation
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protrusion of the nucleus into the vertebral body through the cartilaginous end plate
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where do intra-spongy nuclear herniations most commonly occur
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in the lower thoracic and upper lumbar region
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when do intra-spongy nuclear herniations occur
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during adolescence
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what causes an intra-spongy nuclear herniation
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moderate to severe flexion trauma
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what are the S and S for an intra-spongy nuclear herniation
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- pos radiographs
- typically asymptomatic and not clinically signifcant - if painful, pain will occur with flexion activities: sitting and FB |
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what is the tx for intra-spongy nuclear herniations
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- typically not treated
- rest and avoid compressive forces on the disc - hyperextension exercises and mild traction may be beneficial |
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what is the goal for treating ain intra-spongy nuclear herniation
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decrease muscle guarding that may participate in increasing the compressive forces
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what is a herniated nucleus pulposus
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a bulge of the disc
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what direction is a herniated nucleus pulposus usually in
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posterolateral direction
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what is the mechanism of injury for a herniated nucleus pulposus
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sitting, lifting, forward bending
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what are the stages of disc herniations
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1) normal disc
2) slight posterolateral PROTRUSION 3) mroe advanced PROTRUSION 4) PROLAPS 5) EXTRUSION and SEQUESTRATION |
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what symptoms are present during slight posterolateral protrusion
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no pain yet but progressive deterioration
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what symptoms are present durting the more advanced protrusion
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protrusion now in the outer rings of the annulus
- production of discogenic pain but most likely no neuro signs |
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what symptoms are present during prolapse
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only the outermost fibers of the annulus fibrosus contain the nucleus, likely neurological signs now
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what symptoms are present during extrusion and sequestration (and what is actually happening)
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the annulus is perforated and part of the disc material moves into the epidural space possibly leading to free fragments of the nucleus and the annulus....significant neuro sings and likely a surgical candidate
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why wouldn't you expect pain in the second stage of disc herniation
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because the nucleus is only slightly protruding and there is no innervation at the middle
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where does damage occur first in a herniated nucleus pulposus
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medially so the inner fibers "crack" first
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what distates a mild to moderated herniated nucleus pulposus
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protrusion without spinal nerve root involvement
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what is actually occuring with mild to moderate herniated nucleus pulposus (protrusion)
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displacement of nuclear material with a discrete bulge in the outer annulus
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where is a herniated nucleus pulposus most common
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98% in L4-L5 and L5- S1
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what are the nerve roots most likely irritated by a herniated nucleus pulposus
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L5 (between L4-L5 junction) and S1 (between L5- S1)
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what causes a herniated nucleus pulposus pathology
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developed over numerous years byu cummulative effects of months/years of FB lifting, or sitting in slumped position
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what are the two suggested sources of pain in a herniated nucleus pulposus
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1) outer rings of the annulus (innervated) generate pain due to the mechanical deformation caused by the bulge
2) chemical irritation of the nerve root, secondary to the inflammatory process around the fibers of the outer annulus resulting from imprper segmental mechanics |
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why is it difficult to diagnose a mild-mod herniated nucleus pulposus and what helps you to diagnose it
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difficult because there is no neurological findings.... you must rely on history and exam
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what is the age group for a herniated nucleus pulposus
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25 (old enough to accumulate the damage) -- 50 (too young for fibrotic disc)
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what are the S and S for a mild-mod herniated nucleus
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1) 25-50
2) hx sitting and FB posture 3) hx of back pain prgogressing into butt thigh 4) sitting hurts most 5) difficulty with initially assuming erect posture eventually finding relief in standing 6) back pain greater on one side 7) LE pain unilateral following a dermatomal pattern 8) lumbar kyphosis and lateral shift |
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if patient presents with leg pain (following back --> butt/thigh progression) what does that indicate
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larger protrusion than just mild-mod
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what is a common complaint for a patient with a mold-mod herniated nucleus pulposus post sitting for a long time
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pain extends from back down to the leg
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moving from a ____ posture to a _______ posture would be difficult for a patient with a mild-mod herniated nucl. pulp.
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from flexed -- extended
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where would the location of back pain be for a patient with mild-mod herniated nucl. pulp.
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usually greater on one side, but may be bilateral
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what is the LE pain pattern for someone with a mild-mod. herniated nucl. pulp.
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unilateral and follows a dermatomal pattern of segment affected
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what causes the LE pain in a mild-mod herniated nucl. pulp. despite the lack of compression of the nerve roots
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chemical irritation associated wtih inflammation and or/CNS misinterpretation of the source of pain
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what area is affected with the lumbar kyphosis and lateral shift
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upper torso and shoulders move AWAY from affected side (if the disc bulge is lateral - 90% of the time) shift may be TOWARD the side of involvement if the buldge is medial to the nerve root involved - only 10% of the time
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what happens in a patient with a mold-mod. herniated nucl. pulp post repeated flexion
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pain is peripheralized and lingers after the test is finished
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what would be an expected presentation of extension of the spine in a patient with mild-mod. herniated nucl. pulp.
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limited and may cause pain but in the lumbar spine only
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differentiate compression/distraction (relative to pain) for facet jt. sprain vs. disc
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disc...compress increases, distract decreases
Facet jt. sprain.. compression decreases distract increases |
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what would correction of the lateral shift and extension exerecises do to the pain pattern of a patient with a mild-mod herniated nucl. pulp.
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centralization of the pain
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what must be done before working on extension in a pt. with mild-mod. herniated nucl. pulp.
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lateral shift must be corrected before working on extension
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what are the (+) effects of a lumbar kyphosis with a herniated nucl. pulp.
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opens the foramen and provides space for the buldge and nerve roots--- more short term
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what are the (-) effects of lumbar kyphosis with a herniated nucl. pulp.
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increase intradiscal pressure and promotes further posterior displacement of the nucleus-- more long term
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what are the effects of the lateral shift with a herniated nucl. pulp.
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opens the foramen and "moves" the nerve root away from the protrusion
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when is a lateral shift harder to correct
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when the protrusion is medial and thus the lateral shift is towards the side of protrusion
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what is the best position to see a lateral shift in a patient
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from the front of the patient
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what is the treatment for a mild-mod herniated nucleus pulposus
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1) rest and control ADLs
2) avoid prolonged sitting and FB 3) patient ed on proper posture, siitting, lifting 4) correct pposture and promoted maintaining lordotic curve 5) lumbar corset possibly 6) McKenzie exercises 7) avoiding rotation 8) adjuncty treatment for pain relief 9) be able to retrun to activities with full strength, flexibility, and endurance |
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how long is strict adherence to the treatment for mild-mod herniated nucl. pulp required and why
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for 6-10 weeks to allow the disc to heal -- the defect becomes fibrotic
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what is the cardinal rule of treatment for patients with peripheral pain
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while treatment may cause an increase of pain in the back it must not increase the leg pain (it should be getting more centralized)
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what does McKenzie advocate for the tx of mild-mod. herniated nucl. pulp.
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correction of the lateral shift and passive lumbar extension --- goal being to push the nucleus back in the center of the annulus
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what is the reasoning for use of a lumbar corset for patient's with a mild-mod herniated nucl. pulp.
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decreases intradiscal pressure (by up to 25%) and maintains proper posture
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when is the lumbar corset most effective
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probably after proper posture is reestablished
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how does the lumbar corset actually work/help
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reduces intradiscal pressure by increasing intraabdominal pressure causing the abdominal cavity to become a weight bearing structrue .... it also reminds the patient to avoid FB
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what type of traction would be used for mild-mod herniated nucleus pulp.
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typically intermittent either mechanical or manual
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what are the contraindicated exercises for a mild-mod. herniated nucl. pulp. (why?)
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active SLR, and sit ups.... because they increase the intradiscal pressures during this exercise
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why should rotation be avoided for a mild-mod herniated nucl. pulp.
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rotation reduces size of intervertebral space with an increase in intradiscal pressure.... also the oblique annular fibers in one direction are put in relax state while the other directrion are pulled taut - putting the disc in a vulnerable position
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why is it important to encorporate adjunct treatment for pain relief in a patient with mild-mod herniated nucl. pulp.
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decreases guarding which in tern decreases compressive forces on the spine/disc
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what is the time frame you expect the healing of the annulus to occur in (given strong compliance)
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6-10 weeks varying based on compliance, severity of the injury and success of the tx
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what dictates a "moderate to severe" herniated nucl. pulposus
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protrusion/prolapse with nerve root involvement
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what actually happens in the stage where protrusion and prolapse dictate a moderate to severe herniated nucleus pulposus
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- displacement of the nuclear material and discrete/more significant bulge of the outer annulus
- bulge is still contained within the annulus or PLL - bulge is large enough to encroach into the spinal canal and/or intervertebral foramen |
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what is the mechanism by which the nerve root is irritated in a mod- severe herniated nucleus pulposus
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the bulge is still contained within the annulus or PLL but it is large enough to encroach into the spinal canal and/or intervertrebral foramen.... now impinging and irritating the nerve root causing neurological signs
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what are hte S and S for a mod-severe herniated nucleus pulposus
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- same as for protrusion without nerve root involvement
NEW S and S - complaints of leg pain (sciatica), numbness, weakness, tingling - positive neurological signs present - attempts at correcting lateral shift and extension may not work |
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what are the positive neurological signs
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- decreased strength
- decreased sensation - decreased DTR - positive neural tension tests (i.e. SLR and slump) |
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what is the least reliable neurological sign
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decreased DTR
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what is important to keep in mind with a complaint of pain in the LE
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it could be referred pain
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where is the bulge located when impinging a nerve root in the L spine
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bulge impinges nerve root that exits BELOW the disc .... so L5- S1 disc impinges on S1 nerve root
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what is the treatment for a mod- severe herniated nucl. pulp
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- initial goal = relieve pressure on nerve roots
- implement management techniques (sidelying in flexed positing, mechanical traction) - eventually extension exercises initiated and education on proper posture |
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why would correction of the lateral shift, extension exercises, and maintaining proper posture not be possible right away with a mod-severe herniated nucl. pulp
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becasue the disc protrusion is too prounounced
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how does sidelying in a flexed position provide pain relief for a patient with a mod-severe herniated nucl. pulp
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flexed spine takes pressure away from teh nerve and provides relief, while tension on the outer fibers may also promote forward relocation of the disc
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what treatement can you perform while the patient is supine to help with a mod-severe herniated nucl. pulp
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gentle ant/post tilt of the pelvis to relieve pain and assist disc healing
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what are the 4 steps to the general treatment philosophy for treating a mod-severe herniated nucl. pulp
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1) relieve compressive forces
2) reduce herniation with extension exercises 3) maintain correction 4) rehav of movement and function |
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how do you relieve compressive forces for a mod-severe herniated nucl. pulp
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- frequent change sin position between lying and standing
- avoid sitting - while lying down make use of flexed position, positional distraction and/or pelvic tilt/clock exercises |
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explain the benefits of having a patient lie down in a flexed position
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- for short periods of time relieves pain
- post. annulus is stretched holding nucleus forward - reduction in muscle guarding/spasm decreases pressure on disc - eliminates the negative forces of gravity and thus decreases pressure |
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explain the tradeoff fo having a patient lie down in a flexed position
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the anterior annulus is compressed, pushing the nucleus back and the intradiscal pressure is increased due to the flexed position
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when should you attempt to take the patient out of the flexed position
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as soon as pain is under control
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what does positional distraction help with for a patient with mod-severe herniated nucl. pulp.
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alleviate neurological symptoms
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what are the parameters for using positional distraction for a patient with mod-severe herniated nuclp. pulp.
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- start with using positional distraction for a few min. while monitoring the patient
- progressively increase to 20 min (based on pts. response) - only use the min. amount of SB and flexion needed to reduce neuro. S and S - do not use the rotation component |
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what si the goal for use of positional distraction and when is it indicated
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to be used if it alleviates severe pain and restores better neurological function --- with the goal of opening the foramen to relieve nerve root pressure
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what is the disadvantage to positional distraction
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may promote further distraction
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what position is a patient in for positional distraction
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towel/pillow rolled under ilium (about) on their side
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what is extrusion
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the displaced nuclear material extrudes into the spinal canal through disrupted fibers of the annulus
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what is sequestration
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the nuclear material escapes into the spinal canal as free fragments
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what are the signs and symptoms of a herniated nucleus pulposus once it reaches the extrusion or sequestration state
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- past hx of protrusion
- peripheral neuro findings dominate |
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what diagnostic tests can be done for a herniated nucleus pulposus and when are they useful
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- myelogram: not as popular becasue of invasive nature
- MRI: PREFERRED method of choice Useful at any stage of disc herniation |
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what is the treatment for a herniated nucleus pulposus once it is extruding or sequestrating
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- all prior treatment techniques can be attempted
- likely not a "reduceable" disc, but some patients doe show progressive SLOW regression - most patients will need surgery |
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when is surgery performed
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if significant weakness and numbness are present and not being relieved through traditional treatment methods.... usually done as quickly as possible
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why is it recommended to do a trial treatment for disc herniation treatments
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becasue there is no absolute way to make sure of the extent of the disc damage
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can extension exercises and traction show a favorable outcome once disc extrusion is present
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not commonly, but there are cases that have responded favorably
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what is the function of treatment for a herniated disc
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treat in function of reduction of peripheral symptoms
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what would a posterior (central) herniation cause
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pain in both lower extremities --- note it is possible!
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what would an anterior herniation cause
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anterior hip/groin pain
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what is a laminectomy
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removal of lamina to open up the foraminal opening
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what is a discectomy
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removal of the protruding disc material (NOT THE WHOLE DISC)
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what is the purpose of a discectomy
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to prevent increase in herniation by causing scar tissue closing the opening
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what is a chemonucleolysis
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dissolution of the nuclear material with the injection of a chymopapain enzyme
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why are chemonucleolysis procedures no longer performed
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due to high rate of complications
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what is the treatment post op for a laminectomy/discectomy/chemonucleolysis
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Day 1: ankle pmups, quad sets, glut sets
Day 2-3: bed mobility, sit to stand, walking Boston overlap brace if surg. included a lumbar fusion |
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what is a BOB and when is it used
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boston overlap brace
- used if the surgery included a lumbar fusion |
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when would you suggest a cane or WW post surg.
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if difficulty with walking and/or hip pain from the graft site (if fusion)
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what is the outcome of a lumbar laminectomy
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up to 50% of patients who had the surgery were no better or worse 5 years post-op
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what can the disappointing long-term results for a lumbar laminectomy be associated with
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the pateints were given no attention to restore normal posture, strength, flexibility, function post op
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what is the proper sequence for a rehab program post op
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1) posture
2) flexibility 3) strengthing 4) education |
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why has it been suggested that passive SLR stretching be implemented post op
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to reduce chances of nerve root adhesion (BUT remains to be shown effecitve and without adverse effects)
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