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Annulus Fibrosis

Protective outer, fibrous tissue and fibrocartilage forming the circumference of the intervertebral discs

Nucleus Pulposus

Gel-like interior portion of the disc - distributes/absorbs pressure


Condition that includes degenerative disc disease (DDD) with bulging and occasionally herniation; consequence of age-related degenerative changes


Fractures of pars interarticularis


One vertebral body shifts (slips) sagittally in relation to its adjacent vertebra

Spinal Stenosis

Narrowing of the spinal canal results in compression of neural structures in the cervical and lumbar regions where the diameter of the spinal cord is the largest

Cauda Equina Syndrome

Compression, trauma or other damage to the lower lumbar and sacral spinal cord levels as they traverse to exit their respective vertebral bodies; a radiculopathy sx referable to the nerve dermatomes or myotomes


Disorders of nerve root, lead to sx referable to a dermatome or myotome


Often connotes low back pain with radiation into the ipsilateral leg, thereby implying pain radiating along the sciatic nerve which anatomically contains fibers originating in the L4-S2 roots

Normal Spinal Curvature and Anatomy

• Normal Curvature: Cervical & lumbar lordosis; thoracic (& sacral) kyphosis
• Anatomy: 30 vertebra - 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccyx
31 cord segments- same but 8 cervical; C1-C7 exit above vertebrae, C8-coccyx exit below
Conus medularis at L1 level

Red Flags for Spine Pain

1.CA or infection: >50 or <20
-hx of cancer, Immunosuppression
Unexplained wt loss/ fever/chills
-UTI, IV drug use, back persist with rest
2. Spinal fracture: hx trauma, Prolonged use of corticosteroids or osteoporosis
-Age >70 years
3. Cauda equina synd./ neuro.compromise:
-Acute onset of urinary/ fecal retention or incontinence
-Focal neurologic deficit with progressive symptoms
4. Other: hx of prior local surgery
Systemic d/o, bone or arthritic disorder
Duration >6 weeks and Thoracic spine pain

Spinal Stenosis

• Epidemiology: Age >60 y/o; often in cervical and lumbar regions
• Sx: Bilateral leg pain, positive SLR & X-ray
Insidious onset that ↑ with standing, ↓ with bending or sitting

Spinal Stenosis tx

NSAIDs, muscle relaxants, surgery

Herniated Disc

• Epidemiology: Age 30-50 y/o, MC postero-lateral direction
• Sx: Bilateral leg pain, positive SLR but negative X-ray
Insidious onset that ↓ with standing, ↑ with bending or sitting

Herniated Disc tx

NSAIDs, steroids
Avoid invasive tx for 3 months, restrict physical activity
Local heat, massage, spinal manipulation, exercise, yoga, acupuncture
Surgery if no relief, neuro deficit, or severe impairment

Muscle Strain

• Epidemiology: Age 20-40 y/o; MCC of lower back pain (LBP)
• Clinical Manifestations: Unilateral back pain, negative SLR & X-ray
Insidious onset that ↑ with standing, ↓ with bending or sitting

Muscle Strain tx

Same as spinal stenosis and herniated disc - no surgery

common Referred back Pain

• GI: PUD, pancreas, gallbladder
• Vascular: AAA, other aneurysms/occlusions
• Renal: Kidney stone/infection, prostatitis
• OB/GYN: Pregnancy, pelvic tumor, PID
• Ortho: Hip, knee, SI disorders; coccygodinia; mechanical

Low Back Pain Special Tests

1. Straight Leg Raise (SLR)
2. Reverse SLR:
3. Spurling's Test:

Straight Leg Raise

(+) is radicular pain that extends below knee on extension
Knee is extended and hip is flexed
Specificity 85-91% but only 26-52% for dx sciatica caused by herniated disc

Reverse SLR

While face down, extend femur (hip)
(+) if pain in L3-L4 radiculopathy (leg)

Spurling's Test:

Dx acute cervical radiculopathy
Compress foramina and reproduce sx
Extend neck and rotate head, then apply downward pressure on head
(+) pain radiates to limb ipsilateral (same side) to side head is rotated to

Low Back Pain Imaging

• Lecturer: Suspected benign condition in which sx severe, >4 weeks, surgery considered
Sx of nerve root compression
History of neurogenic claudication or other serious condition
Other serious condition examples - cauda equine syndrome, fx, infection, tumor

Low Back Pain Non-Surgical tx

Avoid invasive tx for 3 months, restrict physical activity
Local heat, massage, spinal manipulation, exercise, yoga, acupuncture
Surgery if no relief, neuro deficit, or severe impairment

Central Cord Syndrome Etiologies

Syringomyelia (spinal cord expanded by CSF); intermedullary tumor
Post-traumatic cervical injury in pt with pre-existing cervical spondylosis or herniation

Central Cord Syndrome sx

LMN s/sx at level of lesion; UMN s/sx below lesion
LMN - hypotonic weakness, ↓ reflexes
UMN - hypertonic weakness, spastic paralysis, ↑ reflexes, (+) Babinski
Band of loss of temperature & pain sensation at level of lesion
Urinary retention

Central Cord Syndrome tx

IV steroids, ensure vitals, treat complications - if unstable may need surgery

L4 radiculopathy Pain

Across the thigh and medial aspect of the leg to the medial malleolus

L4 radiculopathy muscle weakness

Quadriceps- extends knee,
tibialis anterior- dorsiflexes foot
Patellar reflex L2-L4

L4 radiculopathy sensory loss

Medial part of the leg and reflex loss of knee
-dorsum of foot

L5 radiculopathy Pain

Posterior aspect of the thigh and lateral aspect of the calf, dorsum of foot

L5 radiculopathy muscle weakness

Extensor digitorum longus- extends toes

L5 radiculopathy sensory loss

Plantar of foot

S1 radiculopathy Pain

Buttock and posterior aspect of the thigh, calf, and lateral border of the foot

S1 radiculopathy muscle weakness

Hamstrings- flex kne
Flexox hallicus longus- flex great toe
loss of achilles reflex

S1 radiculopathy sensory loss

Sole or lateral border of the foot
-loss of reflex at the Ankle

S2-S4 radiculopathy Pain

Posterior aspect of the thigh, buttocks, genitalia

S2-S4 radiculopathy muscle weakness

Gastrocnemius, Soleus, Abductor hallucis, Abductor digiti quinti pedis, and Sphincter muscles

S2-S4 radiculopathy sensory loss

Buttocks, anal region, genitalia
Loss of reflex Anal wink & Bulbocavernosus

C5 radiculopathy Pain

Neck, shoulder, and interscapular region; lateral aspect of arm

C5 radiculopathy Muscles Weakness

Deltoid, Infraspinatus, Rhomboids
-Abd.arms and extr. rotaion

C5 radiculopathy Sensory Loss

Lateral border of the shoulder and upper part of the arm Reflex loss: Biceps &Brachioradialis

C6 radiculopathy Pain

Shoulder; lateral aspect of the forearm, and the 1st two digits

C6 radiculopathy Muscles Weakness

Biceps, and brachioradialis
-Flex elbow

C6 radiculopathy Sensory Loss

Lateral aspect of the forearm, and the 1st two digits
Reflex loss: Brachioradialis & biceps

C7 radiculopathy Pain

Interscapular region, posterior of the arm, midforearm

C7 radiculopathy Muscles Weakness

Triceps, extensor carpi and digitorum
-Extend elbow and fingers

C7 radiculopathy Sensory Loss

Midforearm and middle digit
-Reflex loss:Triceps

C8 radiculopathyn pain

Medial aspect of the forearm and hand

C8 radiculopathy muscle weakness

flexor digitorum and flexor Pollic longus
-flex finger and thumb

C8 radiculopathy sensory loss

Medial aspect of forearm and hand and 4th and 5th digits
Reflex loss: Finger flexors (triceps)

T1 radiculopathy pain

Medial aspect of the arm to the elbow

T1 radiculopathy muscle weakness

Intrinsic hand muscles
-Spread fingers

T1radiculopathy sensory lost

Medial aspect of arm to the elbow

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