CHIR12007

Clinical Assessment and Diagnosis Portfolio Exercises Week 5

Exercise 1
Compare Maigne’s syndrome and osteoporotic compression fracture of at the
thoracolumbar junction

A. What do these two conditions have in common?

- Maigne’s syndrome (thoracolumbar junction syndrome) can due to the compression fractures
- both commonly happen in the thoracolumbar junction

B. What are the features of each

Maigne's syndrome
- is a low back disorder that affects the area of the spine which connects the lumbar and thoracic
regions (the thoracolumbar junction).
- The Maigne’s Syndrome also known as the thoracolumbar junction syndrome (TLS) caused by
thoracolumbar lateral nerve branch
- Involvement with Cluneal nerve give rise to the referral pain

Osteoporotic compression fracture

- Forward flexion
- Mid and anterior vertebral body loss of height greater than 20% of the posterior height
- If posterior height loss – significant for underlying pathology
- compression fracture of vertebra most commonly related to osteoporosis but can also be due
to high-energy trauma, infection, or cancer

o anterior column - contains the anterior longitudinal ligament, anterior half of the vertebral
body, and the related portion of the intervertebral disk and its annulus fibrosus
o middle column - contains the posterior longitudinal ligament, the posterior half of the
vertebral body, and the intervertebral disk and its annulus
o posterior column
▪ contains the bony elements of the posterior neural arch and the ligamental
elements, including the ligamentum flavum and interspinous and supraspinous
ligaments
▪ also includes the joint capsule of the intervertebral articulations
 - 3 major Types

o wedge fracture (most common)

▪ > 50% of all VCFs reported to be wedge fractures
▪ usually characterized by compression of the anterior segment of the vertebral body
(less commonly posterior)
▪ usually occur at the midthoracic region of the spine

o biconcave or concave fracture

▪ about 20% of all VCFs reported to be biconcave or concave fractures
▪ characterized by the collapse of the middle portion of vertebral body, while the
anterior and posterior walls remain intact

o burst fracture (also known as crush fracture)

▪ 13% of VCFs reported to be crush fractures
▪ characterized by collapse of entire vertebral column, including anterior, posterior,
and central elements
▪ often associated with high-energy trauma, such as a car accident, fall from great
height, or sports-related trauma
▪ usually occur at the thoracolumbar junction and between levels T5 and T8
(midthoracic region)

C. How would you differentiate them?

Exercise 2

Differential Diagnosis of LBP with Radiculopathy

Disc Herniation Spinal Stenosis Cauda Equina

 Age 30-55 >60 40-60
History Acute or recurrent Insidious onset of Insidious onset LBP with or
episodes chronic without saddle anaesthesia
bowel/ bladder function
Progressive LBP changes, acute or chronic
LBP
More recent onset of
LE (lower
extremities)
symptoms
Pain pattern Pain and/or LE symptoms Usually radiculopathy
numbness radiating increase with lumber bilateral – pain, tingling,
to unilateral LE extension and numbness, increased with
below the kneed, relieve by flexion flexion
usually increased
with flexion
Neuro Exam Sensory and/or Sensory and motor Bilateral sensory and/or
motor changes, changes motor changes,

Diminished/absent Diminished/absent reflexes,

DTR (deep tendon sensory and motor changes
reflexes) unilateral S3-S4
ROM Guarded/ limited Pain and limited Guarded/limited
extension

Other Tests SLR (hip joint: 0-40º; Treadmill test SLR (hip joint: 0-40º;
nerve/disc: 40º-80º; (Cardiac stress test) nerve/disc: 40º-80º;
SI/Lumbar: above SI/Lumbar: above 80º )
80º )

Exercise 3

This exercise will require some investigation on your part

You are required to ask for any additional information in the Q&A moodle chat. However, when
you ask for more information you must identify specifically what information you want and why (ie.
What differential diagnoses are you considering and what will the information provide to help
you)

Case History

Mark, 12yom, presented to your office with his Mum. Mark’s mother explained that he has been
complaining of back pain for the past few weeks, maybe longer. She is unaware of any particular
injury that started this and Mark doesn’t recall any specific injury either. She explains he is a typical
boy, plays soccer and rides at the mountain bike park a few times a week. She would consider
him relatively active but he does like his ‘devices’ when he’s allowed. Mark says the pain is ‘pretty
sore’ sometimes, he guesses it is about 5/10 and when asked to indicate where it is he runs his
hand across the region of the thoracolumbar spine. (No bowel, bladder or changes to urine output or
other notable changes, More in the middle)

History:

Home is fine. Goo relationship with parent and siblings

School reports are good; teachers have noted nothing unusual
Marks general attitudes have not changed
Generally a cheerful, outgoing boy no weight loss, no night sweats
Maximum of 2 hours game time after homework is complete; no specific position, mobile device or computer No.
Not unwell, no urinary symptoms

DDX:

Facet problem due to pain on the bilateral rotation

Maybe Scheuermann’s disease

Mark has a negative Adam's test and no leg length inequalities? Assessing for a functional,
compensatory scoliosis.

LODCTRRAPPA

- L: location
➢ Where do you feel the pain, can you point it out? – thoracolumbar spine area
➢ Pain localised around the thoracolumbar spine but not specifically pinpointed
➢ Minor discomfort on the left when rotate to left
➢ On palpation, mild tenderness on the left around T11, T12, L1 and tightness of the erector
spinae bilateral but more on the left around the T/L junction
➢ Can he touch his toes? He can touch his toes
➢ Does he have a round-shouldered posture? On observation there is a notable mild
thoracolumbar spinal curve, convex to the right, No increased kyphosis
➢ Does Mark have an increased thoracic kyphosis/ is he able to flatten it during hyper
extension?
➢ Considering possibly Scheuermann’s disease:

- O: onset
➢ How did this problem start?- cannot recalled
 ➢ Symptoms often follow overuse and an assessment should be made of the total load
applied by the patient to a joint

- D: duration
➢ How long have you experienced this pain? – past few weeks, maybe longer: (between
acute and subacute)
➢ Acute (3 weeks), subacute (3-6 weeks) , chronic (over 6 weeks)

- C: course
➢ Is the pain getting better, worse or staying the same since you first experienced it?
➢ Is the pain constant or does it come and go?

- T: type
➢ Is the pain sharp, dull, throbbing etc.? (let patient describe their pain first)
➢ Can you describe the pain for me (scale the pain from 0-10)
➢ Musculoskeletal pain is usually described as being deep, dull and aching. Other
descriptors may be sharp, throbbing or stabbing.

- R: radiation (travel)
➢ Does the pain travel if so where? thoracolumbar spine area

- R: relieving
➢ What makes the pain go away? Mum has mentioned that when he wakes her in the night
with the pain, paracetamol and a heated wheat bag help and he is able to go back to sleep.
She has sent him to school with paracetamol as well because it helps ease the ache
➢ Is the pain worse in the morning, afternoon or night time?
➢ Any specific activities/ posture can reduce the pain?

- A: aggravating
➢ What makes your pain worse? NO

- P: previous episodes
➢ Have you ever had anything like this before? No previous episodes. She is unaware of
any particular injury that started this and Mark doesn’t recall any specific injury either

- P: previous treatment
 ➢ Have you ever been to a chiropractor, physio, or massage therapist before? No prior
treatment
➢ Have you ever attended your GP for back pain before?

- A: associated symptoms
➢ Is there any other health related problem that you think or have noticed that may be
associated or have started at the same time as this problem?
- Include stiffness, swelling, crepitus, locking, instability, weakness and neurological
symptoms

Exercise 4

Explain Peripheralisation and Centralisation as they apply to the clinical presentation and
treatment of LBP with radiculopathy

Clinical presentation Treatment

Centralisation On the one pot, Manipulation or mobilization
targeted to sacroiliac or lumbar
Centralization describes a phenomenon where pain region
originating from the spine and referred distally, moves Active ROM exercise
or retreats back towards the midline of the spine in
response to repeated movements or guided
positioning.

Centralization can be achieved most commonly with

disc-related pain. In a bulging or herniated disc, the
nucleus is force out of place and can irritate the
annulus or the adjacent nerve root

When pain centralizes, the problem-causing nucleus

inside the disc has been reduced, which relieves
pressure on the pain- sensitive structures responsible
for back or leg symptoms
Centralization usually implied that the annulus fibrosus
would be intact in MRI examination.

In these cases the MRI revealed herniations.

 Centralization also occurred in cases of extrusions
where the spinal canal was wide, and the liquid reserve
was preserved.

Reduction of a disk derangement is accompanied by

centralization

It The prevalence of centralization appears to be

dependent on several factors: the more acute the pain,
the more proximal the pain, the younger the patient,
the higher the prevalence. The definition of
centralization also affects the prevalence
Peripheralisation Down to the leg, feature of lumbar radiculopathy Base the finding of orthopaedic test
Peripheralization occurred in cases of sequestration to make sure there is nothing
and extrusions when there was stenosis of the spinal seriously first, try to reduce the
canal.liquid reserve was preserved. radiculopathy.

Peripheralisation occurred in the cases of Manipulation or mobilization

sequestration and extrusions when spinal canal was targeted to sacroiliac or lumbar
narrow. region
Active ROM exercise
worsening of a disk derangement is accompanied by
peripheralization.

pain moves laterally away from the center of the spine

and/or down the extremity.

Exercise 5

Besides those examples provided in the lecture, what questions might you ask to determine if a
patient has signs and symptoms associated with Cauda Equina Syndrome?

Do you have:
• Low back pain.
• Unilateral or bilateral sciatica.
• Saddle and perineal hypoesthesia or anesthesia.
• Bowel and bladder disturbances.
• Lower extremity motor weakness and sensory deficits.
• Reduced or absent lower extremity reflexes.