Loco: 4. The Chef's Back

Loco: 4. The Chef's Back

1. Alexei

   • 36 y/o
   • Presentation
     • Low Back & L. Leg pain
       • Back problems for 6yrs ; but gotten worse recently
       • Pain 8/10- at worst; 5/10- at best
       • Pain sharp around lower back & Radiating down back of leg to L. knee
     • Pain in both hips
     • Back goes into spasms; esp. when bends forward
     • As chef: sometimes gets 'stuck' when bending forward
     • Mild numbness & tingling in L. Lower Leg & Big toe
     • Sense of weakness in L. Leg- No giving away of L. leg
     • Pian is worse in Mornings, pain does keep him awake @ night too
   • Pastry chef; requires to bend a lot
   • Feels
     • Frustrated: Cannot afford to take time off work & Restricts ability to play w/ kids
   • Examination
     • L. lateral shift & decreased Lumbar Lordosis when standing
     • Slight swelling over L. lower back & Paraspinals
     • Flexion- limitedby pain to 75 degrees
       • L. side bending decreased by 50% in comparison to R. side
       • Right rotation decreased by 25% from left
     • Pain w/ resisted lumbar extension & L. Hip External Rotation
     • On palpatation there's tenderness of bilateral paraspinals L. quadrates lumborum & L. gluteal muscles
     • Positive L. straight leg raise at 45 degrees of hip flexion & Dorsiflexion of L. foot
       • Positive sitting slump test for reproduction of pain @ L. low back & hip
     • Decreased sensation in L. L5 dermatome
   • Treatment
     • 4 week course- Diclofenac
     • Referred to Physiotherapist for segmental mobilisation of Lumbar spine to correct postural problems & soft tissue mobilisation of musculature around the lower back & hips
       • Physio gives a programme of home exercises to do daily
   • Post- treatment
     • Still sokme pain, rated at 5/10; but he hasn't had a worse attack
     • Told to continue w/ exercise regime

2. Lumar & Sacral Plexi

   • Lumbar: L1-L4
     • Psoas Major muscle: L1-L4
       • Iliohypogastric N: L1
         • Ilioinguinal N.: L1
           • Lateral Femoral Cutaneous N.: L2-L3
             • Branches to Iliacus Muscle N.: L3-L4
               • Genitofemoral N.: L1-L2
                 • Genital & Femoral Branch
                 • Obturator N. =: L2-L4
                   • Femoral N.: L2-L4
     • Branch from Sympathetic Trunk
   • SACRAL: L4-S4
     • Sup. Gluteal N.: L4-L5, S1
       • Inf. Gluteal N.: L5, S1-S2
         • N. to Obturator Intemus: L5, S1-S2
           • Pudenal N.: S2- S4
             • N. to Quadratus Femoris: L4-5, S1
               • Sciatic N.:
                 • Branches
                   • Fibular division: L4-5 & S1-2
                   • Tibial division: L4-5 & S1-3
                 • Post. Femoral Cutaneous N.: S1-S3
                   • Inferior cluneal N.'s
                   • Perineal branch

3. Movement(s) of Spine

   • Flexion; Extension; Lateral flexion; Rotation

4. Paraspinals & Quadrate Lumborum

   • Paraspinal Intermediate muscle layers: Erector Spinae (longissmus iliocostalis, spinalis)
     • Deep layer of Back Muscles: Paraspinals (interspinalis, rotatores, multifidi) & Quadrate Lumborum
   • Paraspinals & Spinal N. Compression
     • Slight swelling notd over L. lower back & paraspinals. Tenderness of bilateral paraspinals left quadrates lumborum

5. Lumbar Vertebrae

   • Problems
     • Degenerated Disc; Bulging disc; Herniated disc; Thinning disc; Disc Degeneration w/ Osteophyte Formation
   • Herniation
     • Herniated Disks
       • Herniation between L4 & L5 compresses L5 N. root
         • Herniation between L5 & S1 compresses s1 N. root
           • Post. herniation L4-5 Cauda Equina- Bladder & Bowel Paralysis
     • He feels numbness/ tingling in L. lateral lower leg & big toe (S1)
       • L4- Lateral knee to medial lower leg
         • L5- Lateral knee to Big toe
           • S1- Lateral leg to Llittle toe
       • Therefore...It's a L5/S1 Disc Herniation & a Far lateral disc herniation
   • Anatomy
     • Muscles- help hold up spine & permit movement by contracting
       • Ligaments- hold vertebrae together
         • SC: main nerve that runs from brain through your spine
           • Vertebrae@ movable bones, give spine its shape & house/ protect SC & Spinal N.'s
             • Discs:(joint) help cushion & connect vertebrae, shock absorbent when you move
               • Joints: in vertebrae (facets) connect bones, allowing movement
                 • Nerves: branch from SC, exit through openings between vertebrae

6. Tests

   • Slump
   • Straight Leg Raising

7. Treatment

   • Conservative
     • Ice & Paracetamol
       • NSAIDs + Corticosteroid injections
         • Relative rest + Exercise rehabilitation
           • Prolotherapy + Topical glyceryl trinitrate
   • Acute
     • Scaffolds for IVD repair/ Regeneration; Scaffold in combo of cells for IVD repair (Injectables); Nucleus Pulpous Repair/ Regeneration; Scaffolds for Annulous Fibrous Repair/ Regeneration

8. Chronic VS Acute

   • Potential sign of an underlying issue; Pain worse @ night- maybe an inflammatory process