Friday 13 June 2014

Case Taking for Lumbar Disc Disease in detail.

LUMBAR DISC DISEASE
By Dr.Prasanth
Kerala Ayurveda Hospital

-Pain

-Radiculopathy

-Severity

-Chronicity

-Numbness/burning/tingling and other neurological symptoms

-Pain upon coughing/sneezing

-Pain upon sitting/standing/walking

-Wether pain present upon rest

-Wether morning stiffness present or not

-Any history of RTA/TRAUMA

-Any history of LAMINECTOMY/DISCECTOMY

-Any history of chronic physical strain

-Any history of continuous travelling esp in two wheeler

-Any history of sitting before computer

-Other relevant occupational history

-XRAY/MRI/NEURO REPORT/DOPPLER/CT SCAN ???

SLR

The straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).
With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient's leg while the knee is straight.
A variation is to lift the leg while the patient is sitting.[1] However, this reduces the sensitivity of the test.
If the patient experiences sciatic pain when the straight leg is at an angle of between 30 and 70 degrees, then the test is positive and a herniated disc is likely to be the cause of the pain.
A meta-analysis reported the accuracy as:
·         sensitivity 91%
·         specificity 26%
If raising the opposite leg causes pain (cross or contralateral straight leg raising):
·         sensitivity 29%
·         specificity 88%
Lasègue's sign was named after Charles Lasègue (1816-1883). In 1864 Lasègue described the signs of developing low back pain while straightening the knee when the leg has already been lifted. In 1880 Serbian doctor Laza Lazarević described the straight leg raise test as it is used today, so the sign is often named Lazarević's sign in Serbia and some other countries.


Gait
The pattern of how a person walks is called the gait. Different types of walking problems occur without a person's control. Most, but not all, are due to a physical condition.
Some walking abnormalities have been given names:
  • Propulsive gait -- a stooped, stiff posture with the head and neck bent forward
  • Scissors gait -- legs flexed slightly at the hips and knees like crouching, with the knees and thighs hitting or crossing in a scissors-like movement
  • Spastic gait -- a stiff, foot-dragging walk caused by a long muscle contraction on one side
  • Steppage gait -- foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking
  • Waddling gait -- a duck-like walk that may appear in childhood or later in life
Abnormal gait may be caused by diseases in many different areas of the body.
General causes of abnormal gait may include:
  • Arthritis of the leg or foot joints
  • Conversion disorder (a psychological disorder)
  • Foot problems (such as a callus, corn, ingrown toenail, wart, pain, skin sore, swelling, or spasms)
  • Fracture
  • Injections into muscles that causes soreness in the leg or buttocks
  • Infection
  • Injury
  • Legs that are different lengths
  • Myositis
  • Shin splints
  • Shoe problems
  • Tendonitis
  • Torsion of the testis
This list does not include all causes of abnormal gait.
CAUSES OF SPECIFIC GAITS
Treating the cause often improves the gait. For example, gait abnormalities from trauma to part of the leg will improve as the leg heals.
Physical therapy almost always helps with short-term or long-term gait disorders. Therapy will reduce the risk of falls and other injuries.
For an abnormal gait that occurs with conversion disorder, counseling and support from family members are strongly recommended.
For a propulsive gait:
  • Encourage the person to be as independent as possible.
  • Allow plenty of time for daily activities, especially walking. People with this problem are likely to fall because they have poor balance and are always trying to catch up.
  • Provide walking assistance for safety reasons, especially on uneven ground.
  • See a physical therapist for exercise therapy and walking retraining.
For a scissors gait:
  • People with a scissors gait often lose skin sensation. Skin care should be used to avoid skin sores.
  • Leg braces and in-shoe splints can help keep the foot in the right position for standing and walking. A physical therapist can supply these and provide exercise therapy, if needed.
  • Medications (muscle relaxers, anti-spasticity medications) can reduce the muscle overactivity.
For a spastic gait:
  • Exercises are encouraged.
  • Leg braces and in-shoe splints can help keep the foot in the right position for standing and walking. A physical therapist can supply these and provide exercise therapy, if needed.
  • A cane or a walker is recommended for those with poor balance.
  • Medications (muscle relaxers, anti-spasticity medications) can reduce the muscle overactivity.
For a steppage gait:
  • Get enough rest. Fatigue can often cause a person to stub a toe and fall.
  • Leg braces and in-shoe splints can help keep the foot in the right position for standing and walking. A physical therapist can supply these and provide exercise therapy, if needed.
For a waddling gait, follow the treatment your health care provider prescribed.


Tenderness graded as from    +ve to ++++ve

tenderness is pain or discomfort when an affected area is touched. it should not be confused with pain. Pain is patient's perception; while tenderness is a sign thatclinician elicits.
 +ve  for  Slight or mild tolerable discomfort on palpation
++ve  for  More severe pain on ordinary palpation, which the patient prefers not to tolerate
+++ve   for  More intolerable pain even with light palpation or pressure
++++ve  for  Pain which may be caused by even a mild stimulus such as a sheet touching the joint often characteristic of acute gout

Swelling   graded as from  +ve to ++++ve

swelling, turgescence or tumefaction is a transient abnormal enlargement of a body part or area not caused by proliferation of cells.It is caused by accumulation of fluid in tissues. It can occur throughout the body (generalized), or a specific part or organ can be affected (localized).
+Ve for   Join swelling which may not be apparent on casual inspection, but should be recognizable to an experienced examiner
++ve   for  Joint swelling obvious even on casual observation
+++ve  for   Markedly abnormal swelling
++++ve  for  Joint swelling to a maximally abnormal degree

Limitation of motion  ranging  from   0 to 100%

About 25% loss of motion
About 50% loss of motion
About 75% loss of motion
100% loss of motion or complete ankyloses of the joint


DTR :

Patient should be relaxed and positioned symmetrically, preferably lying supine.
Biceps reflex: (C5-C6) With the arm gently flexed at the elbow, tap the biceps tendon with a reflex hammer. It may help to locate this tendon with your thumb, and strike your own thumb with the hammer. There should be a reflex contraction of the biceps brachii muscle (elbow flexion).
Triceps reflex: (C7-C8) With the elbow in flexion, tap the triceps tendon, just proximal to the elbow, with a reflex hammer. The arm could also be abducted at the shoulder for this maneuver. There should be a reflex contraction of the triceps muscle (elbow extension).
Brachiradialis reflex: (C5-C6)
Knee reflex: (L2-L4) Slightly lift up the leg under the knee, and tap the patellar tendon with a reflex hammer. There should be a reflex contraction of the quadriceps muscle (knee extension). (If performed in a sitting position, have the legs dangle over the edge of the chair or table).
Ankle reflex: (S1) Slightly externally rotate at the hip, and gently dorsiflex the foot, tapping the Achilles tendon with a reflex hammer. There should be a reflex contraction of the gastrocnemius muscle (plantar flexion).
When the reflexes are absent try eliciting it after re-enforcing (Jendrassik maneuver0, by asking the patient to interlock and pull flexed fingers.
Deep tendon reflexes should be graded on a scale of 0-4 as follows:
0 = absent despite reinforcement 
1 = present only with reinforcement
2 = normal
3 = increased but normal
4 = markedly hyperactive, with clonus

Heel to toe walking-

Compression of S1 S2 nerve roots make toe walking painful while that of L5 make heel walking painful.


Power of upper and lower limbs

·         Grade 0: No contraction or muscle movement
·         Grade 1: Trace of contraction, but no movement at the joint
·         Grade 2: Movement at the joint with gravity eliminated
·         Grade 3: Movement against gravity, but not against added resistance
·         Grade 4: Movement against external resistance, but less than normal
·         Grade 5: Normal strength


Modified Medical Research Council Scale for measuring hand muscles

Grade 5: full active range of motion & Normal muscle resistance
Grade 4: full active range of motion & Reduced muscle resistance
Grade 3: full active range of motion & No muscle resistance
Grade 2: Reduced active range of motion & No muscle resistance
Grade 1: No active range of motion & Palpable muscle contraction only
Grade 0: No active range of motion & No palpable muscle contraction



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