[Type text] The Lumbar Spine

natomy Large vertebral body with well-marked trabeculae to aid transmission of forces and a large surface area attachment of muscles to perform frorce dissipation. Triangular vertebral foramen High of the discs gives integrity of the ALL and PLS (leading to segmental nutrition) Thick spinous process projecting horizontally and posteriorly L2-L4 Parasagittal facet orientation. (L5/S1 facet orientation frontal plane, wedge shaped disc of L5 and iliolumbar ligaent). Upper pair facing inwards and lower pair facing outwards. Encourages side bending but limits rotation. Transverse processes project laterally and slightly posterorly Strong pedicles Accessory process - base of posterior surface of TP Mammillary process posterior surface of superior articular process Spinal cord terminates at L1-L2 level, where the conus medullaries lies. The rest of the spinal canal contains only the cauda equine enclosed in its theca, supported by fatty tissue and denticulate lig. The theca and subarachnoid space continue as far as S2. Development: the angle is normally about 30-50(slightly more in women). At birth angle is 20. As walking starts it increases (at the age of 5). Greater than 50 can lead to instability Measured in X-Ray Bridging the mobile lsp with the more rigid pelvis (transitional area) Dissipates rotation oh the hips and pelvis Prevents the lumbar spine from slipping forward Specialisation: wedge shaped disc, frontal facetal shape, iliolumbar ligament Function of upper lsp (sb, rot) mid lsp (apex of lordosis, degenerative changes)& lower lsp (centre of rotation btw pelvis and LEXX) Ligamentum Flavum lamina to lamina (resist flexion), elastine, cause of stenosis of the vertebral canal Interspinous ligaments- SP to SP (resist flexion) supraspinous ligaments SP to SP (attachment for above lig but minimal resistance) Intertransverse ligaments TP to TP Anterior longitudinal ligaments firmly attached to VBs (resist extension), pain sensitive Posterior longitudinal ligaments blends more firmly with IVDs (resist flexion), pain

Integrity of the Lsp

L/S specialisation

Ligaments

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sensitive Iliolumbar ligaments upper band: TP of L5 to iliac crest and fascia of quadrates lumborum//lower band: TP of L5 to sacroiliac ligament Multifidus dominates proprioception of Lsp most medial mm SP to mammillary process 1-3 levels above Longissimus thoracis (LES) Sacrum and SPs to accessory processes and TPs Iliocostalis lumborum (LES) Sacrum, iliac crest and thorcolumber facia to TPs and Lower ribs Psoas VBs and IVDs of T12 L4 and TPs L1-5 to Lesser trochanter Quadratus lumborum th 12 rib + TPs L1-4 to iliac crest Facet orientation facilitates Flexion/extension/side bending (rotation is limited) 3 Branches from aorta supply the spinal cord Anterior spinal a. (ant part body and disc)+ Posterior spinal a. (post part of the body and disc) + Lateral spinal a.(anastomoses with the post artery) Internal venous plexus= Batson plexus= epidural venous plexus: epidural space, valveless (so stasis and even reverse flow is possible, detrimental in spread of infection). Metastasis to breast, cancer Secondary tumors to the lsp: prostate uterus External venous plexus Both of them empty in the venae azygi (< SupVenaCava) External and internal iliac lymph nodes> common iliac and lumbar lymph nodes Sympathetic or ventral rami: ant part of the vertebral body, ant muscles, part of brachial plexus and lumbosacral plexus. It does not cross the midline Recurrent meningeal or sinu-vertebral: distributed within the spinal canal, especially to the PLL. Crosses the midline and innervates the adjacent 2 or 3 segments. Dorsal rami: This has 3 branches: the medial branch innervates the facet joints; the intermediate branch supplies the ligaments, periostium and muscles adjacent to the neural arch; lat branch which spreads out to innervate the periostium and spinous process, post spinal muscles. Nerve doesnt cross the midline

Muscles

Movements Blood Supply

Venous Supply

Lymphatic drainage

Nerve supply

Vindicater Vascular Inflammatory Neurological Degenerative Infection Congenital Autoimmune Trauma Endocrine Rheumatologic
Abdominal Aortic Aneurism (AAA) Ankylosing spondylitis, Reiters syndrome, Enteropathic arthritis, prostatitis, cholecystitis Cauda equina or Nerve root compression/irritation, O/A, Spondylosis, Spondylarthrosis Osteomyelitis, Kidney infection, Spina bifida occulta, Spondylolysis, Spondylolythesis, Crush #, Disc herniation Osteoporosis, Pagets Ankylosing Spondylitis

Common Problems
Facet Capsular inflammation (Joint surfaces may also become pain sensitive when degenerative.)

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Disc If there is an injury to the disc, four problems can result, all of which can cause symptoms: Protusion/Bulge : A bulging disc with intact annular and PLL. Prolaps: Disruption of the inner annular fibres with intact outer annular fibres. Herniation: Tear in the outer annulus fibrosus of an intervertebral disc allows the soft, nucleus pulposus to bulge out beyond the damaged outer rings. Tears are almost always postero-lateral. Extrusion: Nucleous pulposus breaks through the annulus fibrosus but remains within the disc Sequestration: Nucleous pulposus breaks through the annulus fibrosus& lies outside the disc in the spinal canal.

Spondylolysis Spondylolythesis

Spondylosis

Disc herniations are normally a further development of a previously existing disc protrusion/prolaps. Fracture of the pars interarticularis. This may occur asymptomatically and cause an increase in segmental mobility. It occurs almost without exception at the L5 vertebra. Anterior movement of one vertebral body relative to the one below Spondylolytic type due to pars defect (often L5). It is usually associated with congenital weakness (bony weakness, presence of only fibrous union) of the pars interarticularis so usually occurs at the level of L5 as this is the most variable vertebra in the lumbar spine and involves a fracture of the pars due to the high load at this level from weight bearing forces (impact sport, increased lsp lordosis). A step is felt above the site of fracture as the L5 SP will stay in place but the L4 SP will move forward with the L4 vertebra. Non-sponylolytic due to instability of facet joints often secondary to spondylarthrosis. Usually not associated to congenital weakness (agenesis or congenital anomaly). Usually associated with degenerative changes and occur at the mid lumbar area where facets may be approximated due to compensation or spondylosis leading to remodeling of the facets allowing a forward slip of the vertebra without fracture. Thus the step will be felt at the level of the spondylolisthesis. Degenerative process of the spine involving essentially the annulus fibrosus and characterized by:

-Narrowing of the disc space, -Decrease of the intervertebral disc height -Fibrosis of the annulus fibrosus -Diffuse bulging of the annulus beyond the disc space -Extensive fissuring (ie, numerous annular tears) -Sclerosis of the endplates - Osteophytes at the vertebral apophyse (mainly antero-laterally) Pathophysiology: -Reduced proteoglycan content within the disc (and consequent decreased hydration and function) -Decreased endplate permeability (and consequent decreased metabolic exchange). -The type II collagen molecules are replaced by the denser type I collagen molecules in the nucleus (further inhibits exchange of nutrients and metabolic waste) Aging disc: Changes in the nucleous (30-40 yo) high water content/asymptomatic protusion, annulus (>60) decreased water content/atrophy/rarely protrudes. P.F: Body weight, lifting strength, occupational risks such as exposure to

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vibrations, heavy manual labor (and concomitant forces in the lumbar spine) leading to endplate damage, and smoking and atherosclerosis causing decrease in nutrient supply.
Spondylarthrosis Degenerative process of the spine including the facet joints often leading to marginal osteophytes and hypertrophy of the articular processes. Degenerative changes usually occur at the mid lumbar area where facets may be approximated due to compensation or spondylosis leading to remodeling of the facets, leading to changes in horientation. Pathophysiology: Changes in the articular surface: decrease number of GAGs, loss of arrangement of the collagen fibres, softening, splitting, fragmentation and erosion. Synovial fluid:Irritation, inflammation and hypertrophic Synovial capsule: hyperplasia and fibrosis Subchondral bone: sclerotic, osteophytic formation (decreased IV foramen space), eburnation and cyst formation. Decreased joint space, decreased propioception, increased hypertonicity Def: Narrowing of the spinal canal that can be congenital from spinal malformation or due to a secondary narrowing effect. Incidence: Usually affects elderly. Male>female P.F: spondylosis, disc herniation, articular facet joint invasion, spondylolisthesis, proliferation ligamentum flavum (non-elastic ligamentum flavum bulging into the vertebral canal) SOL: tumors, arachnoiditis, sequelae of disc material (young adult), venous congestion Congenital: congenital narrowing, achondroplasia, spina bfida Others: Pagets disease A diameter of the spinal canal of 14 or less is suggestive of stenosis Signs and symptoms: Lsp stenosis can cause extra segmental dural referral pain or nerve root pain as the cord stops at L1 compared with csp and tsp where UMN symptoms may occur. Neurogenic claudication: inconsistent pattern of back and leg pain that increases with activity, agg: uphill/ rel:flexion, sitting, possible neurologic deficit, loss of lumbar lordosis and post tilt of the pelvis, diffuse pain that can be unilateral or bilateral.

Spinal Stenosis

Intermittent neurogenic claudication characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with paresthesis (bilaterally),[7] weakness heaviness in buttocks radiating into lower extremities with walking or prolonged standing.[5] Symptoms occur with extension of spine and are relieved with spine flexion. Minimal to zero symptoms when seated or supine.
AAA: Abdominal aortic aneurysm Vascular problems Pathophysiology: Due to a weakening of the wall of a blood vessel, most commonly as a result of atheroma, The blood vessel bulges, either as a sac on one side of the vessel or as a fusiform swelling. The latter is more common in the aorta. Cause: -Primary: Atheroma -Secondary: syphilis, arteritis, and connective tissue diseases such as Marfans syndrome and Ehlers Danlos syndrome. Signs: the aorta may be enlarged on palpation, with an increased sense of pulsation compared to a normal aorta. There may be thrombosis in the vessel at the site of swelling, which leads to reduced blood supply distal to this point. Thus vascular

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claudication may occur with pain into the legs P.F: Obesity, H BP, H cholesterol, smoking, family history Incidence: Men>Women around 60

There is often no local symptoms with an AAA. Occasionally the patient will have local backache, sometimes associated with upper abdominal aching.
Symptoms:

Ttt: If an aneurysm is suspected on examination of the abdomen, referral to the GP is

appropriate. Generally if the swelling is less than 4cm the GP will merely monitor the patient. Above 5cm surgery is likely to be advised. The outcome of elective surgery is usually much better than with emergency surgery. Complications: developing a large dissection and rupture the blood pressure drops rapidly and the patient may die in minutes. Thus unless they are already in a hospital the survival rate is very low. Symptoms of dissection: If a dissecting aneurysm develops, acute pain is experienced usually in the back at the level of the tear. The pain is often described as tearing. This constitutes a medical emergency Inflammatory Prostatitis: Def: Inflammation of the prostate gland, sometimes caused by an infection. Incidence: Can develop in male of all ages Types: acute(bacterial infection), chronic (non-bacterial infection), asymptomatic inflammatory prostatitis, and chronic pelvic pain syndrome. Signs and symptoms: pain when urinating, pain when ejaculating semen,

Prostate

problems urinating, discomfort in the pelvis/genitals/lower back and buttocks

Complications: acute prostatitis is a medical emergency Tests: check for the presence of bacteria in urine, rectal examination, blood test (PSA) Ttt: antibiotics, alpha blockers Beningn prostatic hyperplasia: Def: is an increase in size of the prostate. Pathophysiology: hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra, which interferes with the normal flow of urine. Lateral glandular lobes and post lobe are affected. Incidence: Associated with aging (50, 60% at the age of 60). Men with prostate enlargement do not have a higher risk of prostate cancer compared to men without an enlarged prostate. Cause: Androgen-oestrogen hormonal imbalance (low levels of DHT, testosterone and high levels of oestrogen) Signs and symptoms: "stopping and starting", strain to pass urine, frequently need to urinate, wake up frequently during the night to urinate, sudden urge to urinate, which can result in incontinence if you cannot find a toilet quickly enough, not be able to empty your bladder, cause blood in the urine (haematuria). P.F: Diabetes and High BP Tests: urine test, rectal examination, blood test: PSA (high may indicative of BPH and significant raised level could indicate cancer), ultrasound Ttt: alpha blockers, surgery (transurethral incision, transurethral excision, prostatectomy, laser)

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Complications:Urinary tract infection, acute urinary retention Prostatic cancer: nd Incidence: >50. 2 most common cause of cancer death. Slow progression Cause: Hormonal imbalance (reduced androgens) Type: adenocarcinoma, or glandular cancer Arises in the peripheral zone of the prostate and it is, therefore, often well stablished before the development of urinary symptoms. Signs and symptoms: frequent urination, nocturia (increased urination at night), difficulty starting and maintaining a steady stream of urine, hematuria, and dysuria (painful urination), difficulty achieving erection or painful ejaculation, bone pain. Metastasis: commonly metastasizes to the bones, lymph nodes (pelvic and para-aortic nodes) metastasis to bone is thought to be venous as the prostatic venous plexus draining the prostate connects with the vertebral veins(Batsons plexus) . Also to the liver and lungs. Bone sclerosis: bone production rather than lysis (bone destruction) Local invasion: may invade rectum, bladder and lower ureters after local progression Test: PSA, digital rectal ultrasound, biopsy Def: inflammation of the gallbladder. It is usually caused by a gallstone that becomes trapped in the cyst duct. Pathophysiology: Blockage of the cystic duct with gallstones causes accumulation of bile in the gallbladder and increased pressure within the gallbladder. Concentrated bile, pressure, and sometimes bacterial infection irritate and damage the gallbladder wall, causing inflammation and swelling of the gallbladder. Inflammation and swelling of the gallbladder can reduce normal blood flow to areas of the gallbladder, which can lead to cell death due to insufficient oxygen (necrosis). Not everyone who has gallstones will go on to develop acute cholecystitis. P.F: increasing age, female sex, pregnancy, certain medications, obesity, rapid weight loss Signs and symptoms: -Pain in the right upper quadrant or epigastric region. -Gallbladder may be tender and distended. -An inflammatory component: fever, increased white cell count. -Pain is initially intermittent, but later usually presents as constant and severe. -The pain may be referred pain that is felt in the right scapula rather than the right upper quadrant or epigastric region (Boas' sign). - It may also correlate with eating greasy, fatty, or fried foods. Diarrhea, vomiting, loss of appetite and nausea are common. - The Murphy sign is specific, but not sensitive for cholecystitis. -Yellowing of the skin and the whites of the eyes (jaundice). Tests: Murphys test, blood test (increased bilirrubin and WBC), ultrasound scan Ttt: antibiotics, cholecystectomy Complications: gangrene, perforation Neurologycal Def:Reduction of the capacity of the spinal canal at any level below the T10 vertebra. Cauda equine is an acute neurocompression of the terminal spinal cord, nerve roots from T12 to S5 and the filum terminate.

Cholecystitis

Cauda equine syndrome

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Causes: central disc herniation, trauma, spina bifida occulta, tumour, spinal stenosis, spondilolysthesis, abcess, epidural haematoma Signs and symptoms: LBP Motor symptoms: (depending on the affected root) weakness and wasting of the hamstrings, glutei and muscles below the knee (tibialis ant is spared) Reflexes: Absent DTR Sensory: saddle-area, over the foot and outer aspect of the leg Bladder and bowel dysfunction: impotence in male, urinary retention and faecal incontinence. Trophich changes: LEXX cold and cyanotic, oedematous Test: MRI Nerve root compression/irritation Pain sensitive structures: Apophyseal joint: ALL & PLL: Dura: Myotendinous structures: Nerve root sheaths: Disc: Nucleous pulposus is avascular and thus hidden from the systemic circulation. Presentation of the nucleous pulposus could result in an autoimmune reaction. Nerve root: Somatic pain vs neupathic pain: Pathophysiology: Mechanical compression of the nerve root/ Biochemical irritation: - impairment of the blood flow of the vaso nervorum and venular stasis >Intraneural edema formation -Impairment/reduction of the nerve conduction activity -Reduction of the nutritional transport of the nerve tissue -Long term intraneural oedema can lead to intraneural fibrosis -Pain due to axonal changes/demyelination . Neoplasm

Discitis/Osteomyelitis

Kidney infection Spina Bifida Occulta

Infection Def:Discitis is infection of the disc space, and vertebral osteomyelitis infection of a vertebral body Incidence: rare Cause: IVD use and immunocompromised pt Signs and symptoms: Unwell, pyrexia and complaing of severe unrelated LBP. Swelling, TTP, reduced ROM Test: ESR, CRP, narrowed disc space (discitis) and bony destruction (osteomyelitis) Ttt: Intravenous antibiotics T10- L1 dermatomes Congenital Def: Failure of the ossification process for the posterior arch of the vertebra that fails to develop and unite normally, it leaves a greater exposure of the spinal canal and reduces the attachment sites for local ligaments, muscle and fascial attachment, giving poor propioceptive information. Signs: Dimple, hairy patch, pigmented area, haemangioma, loss of lordosis Symptoms:rarely causes neurological symptoms. Insiduous development of peculiar gait, stiffness in the LB, cavo varus, clawed toes and adducted foot. Minor symptoms

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of LB agg by neck flexion and SLRT Complications: congenital neoplasm, mid-line spur splitting the spinal canal, tight shortening of the filum terminae. Development: Spinal cord occupies the entire length of the spinal canal at birth and ascends during the first few years of life. Scoliosis Def: Lat curvature of the spine, either structural with permanent changes in the bone and soft tissues; or a functional, caused by reflex or postural activity of spinal muscles. Types: STRUCTURAL SCOLIOSIS: Progressive, and the curve does not disappear on forward flexion, bony deformity, muscular weakness, lacks normal flexibility, side bending becomes asymmetrical, most common seen in thoraci or thoracolumbar spine 1. Idiopathic scoliosis of unknown (uncertain) cause accounts for 75-85% of all structural scoliosis, 9:1 girls. It arises in children and many of this type are now thought to have an neurogenic / failure of segmental reflex maturation cause. age of onset:- 0-3 infantile, 4-13 juvenile, 13-20 adolescent, 20+ adult. 2. Secondary structural scoliosis where the curvature is secondary to a known disorder. a. Congenital/Osteogenic eg. from a hemi-vertebra, Marfan's, wedged vertebra (failure of segmentation) b. Myogenic eg. from muscular dystrophy, polio c. Neurogenic eg. as in cerebral palsy d. FUNCTIONAL SCOLIOSIS: No bony deformity, not progressive, curvature disappears in forward flexion, spine shows segmental limitation and s/b is symmetrical, cervical/lumbar/thorcolumbar. 1. Compensatory postural scoliosis eg. from a short lower extremity. 2. Sciatic scoliosis, a temporary deformity eg. from acute spasm. Idiopathic scoliosis: -vertebral bodies rotate towards the convexity -sp towards the concavity -distorsion of the vertebral body, compression of the thoracic organs and vital capacity is lowered if the lat curvature exceeds 60. -ribs shift backwards in the convexity - disc space narrowed in the concave side and widen in the convex side Cause: axial motor control problems Incidence: 9:1 girls Onset: 4 to 14 years Major deformities previous cessation of skeletal growth, affects the thorax or the thoracolumbar spine, primary curve with secondary compensatory curves Ttt: surgery, brace use in maximum growth period (Milwaukee brace) Tests: Cobb angle, rib angulation, tissue flexibility Questions: onset of menarche, growth spur, voice change, difficulties breathing, st dominant hand, surgeries or ttt, is it progressive, pregnancy (1 trimester, period of congenital anomalies develop), drug intake during pregnancy, connective tissue illnesses. Functional: Sciatica, glove puppet, string puppet

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Lumbarised sacral segment (TRANSITIONAL VERTEBRA) Def: congenital spinal anomalie defined as sacralization of the lowest lumbar vertebral body

Bertolotti's syndrome:
-Low back pain associated with an LSTV may arise from the level above the transition, the contralateral facet when unilateral, and/or the anomalous articulation when present -instability and early degeneration of the level cephalad to the transitional vertebrae - nerve root compression from hypertrophy of the transverse process - The degree of morphologic variation of these segments ranges from L5 vertebrae with broadened elongated transverse processes to complete fusion to the sacrum -wedging vertebral body

Sacralised lumbar segment (TRANSITIONAL VERTEBRA)

Crush/compression fracture

Osteoporosis

Def:congenital spinal anomalie defined as lumbarization of the uppermost sacral segment -Low back pain associated with an LSTV may arise from the level above the transition, the contralateral facet when unilateral, and/or the anomalous articulation when present -instability and early degeneration of the level cephalad to the transitional vertebrae - nerve root compression from hypertrophy of the transverse process - S1 vertebral segment can show varying degrees of lumbarization, such as the formation of an anomalous articulation rather than fusion to the remainder of the sacrum, well-formed lumbar-type facet joints, a more squared appearance in the sagittal plane, as well as a well-formed fully-sized disk, rather than the smaller-sized disk typically seen between S1 and S2. -squaring vertebral body -presence of facet joints between S1 and S2 Trauma Def: collapse of a vertebra Types: Traumatic (check also for calcaneal #), secondary to osteoporosis or osteogenesis imperfect, lytic lesions from metastasis or tumours and infection. Cause: Extreme vertical forces Signs: wedge deformities, with greater loss of height anteriorly than posteriorly Tests: X-Ray Complications: spinal cord compression Endocrine Def: is a progressive bone disease that is characterized by a decrease in bone mass and density and that leads to an increased risk of fracture. BMD is expressed as a Tscore. This is the number of standar deviations by which the BMD varies in relation to the mean value for young normal adults. The WHO defines osteoporosis as a T-score of less than -2.5. Osteopenia as a T-score of btwn -1 and -2.5 Cause: Primary: age related Secondary: Hyperthyroid, hyperparathyroid, hypogonadism, cushings, RA, malabsorption (IBD, coelic disease), medication (corticosteroids), excess alcohol, high dietary protein, vit D deficiency, tobacco, underweight, inactivity, drugs used in breast cancer and prostate cancer. Clinical features: No signs and symptoms until a minor fracture occurs # vertebral, wrist and hip # vertebral: compression #, wedge shaped, loss of height and kyphotic deformity, stopped posture. Wrist #: Colles # (fall onto the outstretched arm, dinner fork deformity) Hip #: femoral neck #. Test: DEXA scan to measure the BMD Tttt:Modify risk factors, drugs, prevention of falls Drugs: biphosponate, Ca, vit D, oestrogen replacement therapy with menopause

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Pagets disease women, strontium, calcitonin and parathyroid hormone Def: is a disorder of bone remodeling Indicende: 3% of the population in UK (<40), men 3: women 2. Causes:Viral, genetic Pathophysiology: -increased bone reabsorption mediated by osteoclasts. -osteoblasts then respond by producing weak, disorganized bone. -abnormal cycles of this activity lead to areas of bone becoming large and deformed with increased vascularity Signs and symptoms: 1/3 asymptomatic Bone pain, deformity and # Affects pelvis, lsp, femur, skull and tibia Affected area tender and warm due to increased vascularity Deafness, tinnitus Complications: Osteosarcomas (check for sudden worsen of pain) Test: X-Ray, elevated alkaline phosphate in blood,

Tests: SLUMP test: increased tension in the neuromeningeal tract. Purpose of Test: To assess whether a herniated disc, neural-meningeal tension, or altered neurodynamics are contributing to the patients symptoms. Test Position: Sitting. Performing the Test: Patient is seated upright with hands held together behind his/her back. The examiner instructs to the patient to flex his/her spine (slump), followed by neck flexion. The examiner then places his/her hand on top of head and has the patient perform knee extension, and dorsiflexion of foot. Finally, the patient is told to return the neck to neutral. The test is considered positive if symptoms are increased in the slumped position and decreased as the patient moves out of neck flexion. Diagnostic Accuracy for Lumbar Disc Herniation: Sensitivity: .84. Specificity: .83. (The sensitivity and specificity of the SLUMP and straight leg raised tests in patients with lumbar disc herniation). Importance of Test: This test's results can be interpreted in multiple ways. Like other neural tension tests, the test may indicate if a patient is experiencing symptoms related to nerves adhering to various tissues while travelling throughout the body. The patient may experience stretching, pain, or other neurological sensation in the area of adhesions. Another use for the test is detecting lumbar disc herniations. With the flexed lumbar spine and hip completed simultaneously with the extended LE, the sciatic nerve and its respective nerve roots are put on tension to detect the potential of a disc herniation. The results of the test should be interpreted based on the patient's pain/symptoms for which they are seeking treatment. SLRT: Clinically, the passive straight leg raise (PSLR) is used extensively to assess neuropathic involvement. Nerve root from disc prolaps (lateral disc prolaps): leg pain>back pain when performing the test +ve test: if pain extends from the back down into the the leg in the sciatic nerve distribution.

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[Type text] Purpose of Test: To test for the presence of a disc herniation. Test Position: Supine. Performing the Test: The examiner will passively flex the patients hip while maintaining the knee in full extension. A positive test is considered when the patient reports reproduction of pain at 40 degrees of hip flexion or less. The examiner should make note of the degree of hip flexion where the patient reported pain or reproduction of symptoms. Diagnostic Accuracy: Sensitivity: .91, Specificity: .26, +LR: .35, -LR: 1.2 ("The test of Lasegue. Systematic review of the accuracy in diagnosing herniated discs"). Sensitivity: .52, Specificity: .89 (The sensitivity and specificity of the SLUMP and straight leg raised tests in patients with lumbar disc herniation). Importance of Test: Disc herniations are a common problem in patients with low back pain. During this test the examiner is placing a traction force on the involved nerve root, reproducing the pain the patient presented with. Normally, patients can reach 70-90 degrees of hip flexion before a sensation of tightness occurs in the posterior thigh. If pain is felt significantly earlier, the patient could potentially be suffering from a disc herniation. (Interesting fact: The SLR primarily puts a stretch on the L5-S1 nerve root segment). It should be noted that a painful, stretching, or other neurological symptom may be produced by this test as a result of neural tension due to adhesions while travelling throughout the body. Compare the results of the test with the pain for which the patient sought treatment. Also, utilize the angle at which symptoms were produced to help differentiate the source of the patient's pain Modified SLR test: pt side-lying Back>Leg: Central herniation Neck flexion and foot dorsiflexion painful: meningitis, tumor, SLO, disc herniation Raise one leg and symptoms in the opposite leg: SOL PATTERN differential diagnosis: Anterior Thigh Pain: -Pain in the anterior thigh -Wasting of the quadriceps -Absent knee jerk -Disc lesions are an unusual cause of this picture (5% of lsp disc lesion). -Consider METASTATIC CARCINOMA or DIABETC AMYOTROPHY -Consider MERALGIA PARAESTHETICA with anterolateral thigh pain and no wasting of quads Femoral nerve:
Diabetes, femoral hernia, Retroperitoneal haematoma (pelvis or abdomen), femoral art. aneurysm, post. abdomen neoplasm, psoas abscess, catheter places upon the femoral artery, # of the plevis

PRIMARY BONE CANCER:

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Osteosarcoma (also called osteogenic sarcoma)

Osteosarcoma is the commonest type of primary bone cancer. Its most common in teenagers, young adults and adults in their 60s, but people of any age can be affected. It can occur in any bone, but is most likely to develop around the knee, in the thigh bone (femur), in the shin bone (tibia) or in the upper arm (humerus).

Ewings sarcoma
Ewings sarcoma is named after the surgeon who first described it. This type of bone cancer is also more common in teenagers and young adults, but can occur at any age. Its more likely to occur in young children than osteosarcoma is. Any bone can be affected, but the pelvis, thigh bone (femur) and shin bone (tibia) are the most common sites. Its also possible for Ewings sarcoma to start in the soft tissues of the body. This is called extraosseous Ewings sarcoma (extra means outside, osseous means bone), or soft tissue Ewings sarcoma.

Chondrosarcoma
Chondrosarcoma is usually a slow-growing tumour and is most common in middle-aged people. The cancer starts in cartilage cells, although it can also grow within a bone or on its surface. The most common places in the body for it to develop are the upper arm (humerus) or thigh bone (femur), but it can occur in other bones such as the ribs, pelvis or shoulder blade (scapula).

TUMORS AND THE SPINAL CORD: -In adults 20-30 % are metastatic: 68% metastasis of breast, 40% prostate, 25% lungs, 15% thyroid, 10% uterus and cervix and multiple myeloma and Hodgkins disease. -Classification: extradural, intradural/extramedullary and intramedullary. -Types: -Neurofibroma: A neurofibroma is a benign nerve sheath tumor in the peripheral nervous system. Sex incidence equal, 30-50 years age, 60% above L1 causing spastic paraparesia, 30% bellow L1 causing lateral cauda equine syndrome. -Meningioma: Meningiomas are a diverse set of tumors arising from the meninges. 9 female: 1 male. Mid thoracic level (T3-T6). Few in foramen magnum -Ependymoma: 2 male: 1 female. 30 average age. C6-T2 or in filum terminae -Gliomas: From glial cells. -Dermoids -Chordomas: cellular remnants of the notochord. -Vascular tumours: benign or malignant formed from blood vessels MICTURITION AND NEUROLOGICAL DISEASE: 12

[Type text] -Spinal bladder: damge to the spinal cord by trauma, cord tumour, MS -Autonomous bladder (Subsacral lesion): damage to the motor and sensory components in the cauda equine, pelvic surgery, pelvic malignant disease, spina bifida and high lumbar disc lesion. -Sensory bladder: MS, tabes dorsalis, DM, subacute combined degeneration of the cord LUMBAR PUNCTURE: Pressure measurement of CSF Diagnostic of: Guillen Barre, meningitis, Subarachnoid haemorrhage Side effects: back pain, HA, infection and meningitis

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