5002 Case 11 Cheat Sheet by bee.f

- 59 y.o., car mechanic
- Lower Lx spine (L>R) into the lateral aspect of L thigh to the anterior shin & into the toes
- Insidi­ously 2 months ago

-Getting worse
-AF: standing, working overhead
- RF: Sitting down (slouched) diminished leg pain, sleeping on side (firm bed helps)
- AA: Work; is careful with ADL

- High BP
- Postur­e/s­tance: hypolo­rdotic Lx spine; kyphotic Tx spine
- Gait: reduced arm swing bilate­rally; reduced Tx movement (very rigid)

- SLR: 90° bilate­rally, muscle stretch @ end point
- Active SLR: same as SLR
- Percussion & vibration Lx: negative (-ve)
- Trigger points: in ES, glut. max. & glut. med. bilaterally
- Spinal palpat­ions: L T11-L2 restri­cted; L L4-S1 restricted & tender; L SI restricted

Kemps
- Purpose: assess Lx spine facet joint pain
- Findings: L +ve w/ L leg pain into shin; R -ve

Slump's
- Purpose: detect altered neurod­ynamics or neural tissue sensitivity
- Findings: pulling in LB (L>R)

SI distra­ction
- Purpose: provoc­ation of the SIJ
- Findings: -ve

Gaenslen's
- Purpose: diagnose SIJ lesion, pubic symph. instab­ility, L4 nerve root lesion
- Findings: -ve bilate­rally

Pheasant
- Purpose: indicates an unstable spine segment
- Findings: increased pain in Lx

Working diagnosis
- L5 radiculopathy
- Most likely 2° to progre­ssive degene­rative change occurring in the lower Lx & mechanical dysfun­ction, resulting in DNE (dynamic nerve entrap­ment)

- Increased pain on Pheasant's test likely due to extension intole­rance &/or facet pain associated with degene­rative change

→ Radicular pain that is 2° to IVF encroa­chment; leg pain may
- Relieved: sitting & bringing the knees to the chest (anything that flexes Lx & increases the IVF space)
- Aggrav­ated: standing & walking

2 categories of "­mec­han­ica­l" (ortho neurol­ogical) nerve root syndromes (can coexist)
1. Spondy­losis & related degene­rative change: must be more specific & identify whether there's lateral entrapment or central stenosis (LSS)
2. Disc hernia­tion: (lateral entrap­ment) should identify whether it's likely to be a fixed nerve entrapment (FNE) or dynamic nerve entrapment (DNE)

Differ­entials for LBP w/ leg pain
- Cauda equina syndrome (CES)
- Lx central stenosis syndrome (LSS)
- Disc herniation
- Spinal stenosis
- Sciatica
- Lx radiculopathy
- Spondylolisthesis
- SIJ dysfunction
- Piriformis Syndrome

How to screen for cauda equina syndrome (CES)?
⏺ Symptoms:
- LBP
- Bilateral leg radicu­lopathy (sharp shooting pain or dull ache that radiates down the legs)
- Saddle anaesthesia
- Bladde­r/bowel incontinence
- Lower extremity motor & sensory loss
⏺ Imaging:
- MRI & CT screening for compre­ssion / damage of cauda equina
- Cauda Equina Screening Tool (CEST): set questions to assess risk of CES
- Electr­omy­ography (EMG): measures electrical activity of muscles & nerves, detecting nerve damage

Understand the pathop­hys­iology of the mechanical & chemical pathop­hys­iology processes that occur in lateral nerve entrapment
⏺ Lateral nerve entrap­ment:
- Peripheral nerve becomes compressed or entrapped by surrou­nding structures
- Can occur due to anatomical abnorm­ali­ties, trauma, inflam­mation, or repetitive motion
- Sx & SSx: pain, numbness, tingling, muscle weakness, & loss of function in area supplied by affected nerve
⏺ Mechanical pathop­hys­iology:
- Compre­ssion: can disrupt the normal function of the nerve, causing pain &/or abnormal sensations
- Tension: tensio­n/s­tre­tching of nerve, resulting in irritation & dysfun­ction; can arise from muscle imbalances repetitive movements that place strain on the nerve
- Ischaemia: prolonged compre­ssion or tension on the nerve can compromise its blood supply, leading to reduced O2 & nutrient delivery; Ischaemia (lack of blood flow) can cause nerve damage & contribute to develo­pment of symptoms
⏺ Chemical pathop­hys­iology:
- Inflam­mation: compre­ssion irritation can trigger inflam­matory response (cytokines & prosta­gla­ndins) in surrou­nding tissue; chemicals further irritate nerve & contribute to amplifying pain / other symptoms
- Chemical irrita­tion: chemicals (hista­mine, substance P, bradyk­inin) released from damaged tissues, directly stimulate pain receptors in the nerve; resulting in pain & sensitivity
- Neurot­oxi­city: metabolic distur­bances lead to accumu­lation of toxic substances within the nerve tissue; can further damage the nerve cells & exacerbate symptoms