LUMBAR SYNDROMES
What is a Syndrome?
→A clinical entity characterised by a history, signs, and symptoms which fit a typical pattern.
→There are various management regimes have been outlined based on:
–Structure involved
–Stage of disorder
–Available research on management helps to improve management regimes
→Syndromes present with a combination of Mechanical and Inflammatory components
→During assessment you need to determine how much of each
→Works on a Continuum and can range from Mechanical ------------------ Inflammatory.
MECHANICAL:
→Pain worse with specific movements. GELLING PHENOMENON:
→Stiffness follows sustained positions –“Gelling” phenomenon. The perception of stiffness, usually lasting
→Movement aggravates –little movement eases and rest alleviates symptoms. less than 20 minutes in the affected joint,
which occurs because the fluid inside the
→Morning stiffness < 1 hour.
joint becomes thickened like a “gel” and
→No ‘spontaneous’ flares (more injury related). makes movement difficult.
→Night pain unusual.
→Onset may be acute.
→Recovery from acute within a month.
→Anatomical pain distribution.
INFLAMMATORY:
→Insidious onset.
→Morning stiffness > 1 hour.
→Pain diffuse distribution –more difficult to localise.
→Rest may increase pain.
→Night pain –why?
→Spontaneous flares.
INTERVERTEBRAL DISCS:
The intervertebral disc (IVD) is the principal joint between two vertebrae in the vertebral column.
Each IVD is composed of three structures:
1. The nucleus pulposus (NP), a gelatinous inner part;
2. The annulus fibrosus (AF), an outer ring of fibrous tissue that encloses the nucleus pulposus;
3. Two endplates of hyaline cartilage.
**The cells in the outer region of the annulus fibrosus are fibroblast-like cells which are disposed parallel to
the collagen fibers, while those in the inner annulus fibrosus are chondrocyte-like cells.
The nucleus pulposus is made from randomly arranged collagen fibers and radially organized elastin fibers
surrounded in a highly hydrated aggrecan-containing gel. There are a few chondrocyte-like cells in the nucleus
pulposus.
, DISCOGENIC SYNDROMES (A form of low back pain)
→Pain syndrome that originates from a lumbar disc, (pain generator). A degenerated intervertebral disk can
release nociceptive molecules and growth factors which result in nerve ingrowth into the disc.
→Tear in Annulus Fibrosis.
→Discogenic pain is pain arising from stimulation of pain sensitive afferents within the annulus fibrosus and
is a separate condition from disc herniation with associated radiculopathy.
→Aggravated by sitting, lifting, flexion activities –anything that increases intra-discal pressure.
→A weakened disc may herniate – ++ irritates pain sensitive structures in central canal.
→Bilateral ‘band of pain’ in Lx, with/without pain in leg(s.)
→Discogenic pain is attributed to degenerative changes in the intervertebral disc due to aging or a trauma.
→Morning pain.
Here is an example of what a normal disc and its Here is an example of discogenic pain syndrome. Note
surrounding vertebra should look like. Note the amount that the disc has collapsed and ripped open toward the
of nerve fibers that surround the disc but do not greatly back. This tearing (called an annular tear) has allowed
penetrate it. These nerve fibers (sinuvertebral and pain-carrying nerve fibers to grow into the center of the
basivertebral nerves), are known to have the potential disc, effectively wiring the disc for pain. Also note the
to carry pain signals to the brain when inflamed and increased nerve fibers in the vertebral endplates
irritated, which can occur following a special type of disc surrounding the disc, which wires the endplates for pain.
degeneration and disc tearing. Because of biomechanical and biochemical mechanisms,
these nerves are now constantly inflamed/irritated and
sending pain signals to the brain in patients who suffer
DPS.
What is a Syndrome?
→A clinical entity characterised by a history, signs, and symptoms which fit a typical pattern.
→There are various management regimes have been outlined based on:
–Structure involved
–Stage of disorder
–Available research on management helps to improve management regimes
→Syndromes present with a combination of Mechanical and Inflammatory components
→During assessment you need to determine how much of each
→Works on a Continuum and can range from Mechanical ------------------ Inflammatory.
MECHANICAL:
→Pain worse with specific movements. GELLING PHENOMENON:
→Stiffness follows sustained positions –“Gelling” phenomenon. The perception of stiffness, usually lasting
→Movement aggravates –little movement eases and rest alleviates symptoms. less than 20 minutes in the affected joint,
which occurs because the fluid inside the
→Morning stiffness < 1 hour.
joint becomes thickened like a “gel” and
→No ‘spontaneous’ flares (more injury related). makes movement difficult.
→Night pain unusual.
→Onset may be acute.
→Recovery from acute within a month.
→Anatomical pain distribution.
INFLAMMATORY:
→Insidious onset.
→Morning stiffness > 1 hour.
→Pain diffuse distribution –more difficult to localise.
→Rest may increase pain.
→Night pain –why?
→Spontaneous flares.
INTERVERTEBRAL DISCS:
The intervertebral disc (IVD) is the principal joint between two vertebrae in the vertebral column.
Each IVD is composed of three structures:
1. The nucleus pulposus (NP), a gelatinous inner part;
2. The annulus fibrosus (AF), an outer ring of fibrous tissue that encloses the nucleus pulposus;
3. Two endplates of hyaline cartilage.
**The cells in the outer region of the annulus fibrosus are fibroblast-like cells which are disposed parallel to
the collagen fibers, while those in the inner annulus fibrosus are chondrocyte-like cells.
The nucleus pulposus is made from randomly arranged collagen fibers and radially organized elastin fibers
surrounded in a highly hydrated aggrecan-containing gel. There are a few chondrocyte-like cells in the nucleus
pulposus.
, DISCOGENIC SYNDROMES (A form of low back pain)
→Pain syndrome that originates from a lumbar disc, (pain generator). A degenerated intervertebral disk can
release nociceptive molecules and growth factors which result in nerve ingrowth into the disc.
→Tear in Annulus Fibrosis.
→Discogenic pain is pain arising from stimulation of pain sensitive afferents within the annulus fibrosus and
is a separate condition from disc herniation with associated radiculopathy.
→Aggravated by sitting, lifting, flexion activities –anything that increases intra-discal pressure.
→A weakened disc may herniate – ++ irritates pain sensitive structures in central canal.
→Bilateral ‘band of pain’ in Lx, with/without pain in leg(s.)
→Discogenic pain is attributed to degenerative changes in the intervertebral disc due to aging or a trauma.
→Morning pain.
Here is an example of what a normal disc and its Here is an example of discogenic pain syndrome. Note
surrounding vertebra should look like. Note the amount that the disc has collapsed and ripped open toward the
of nerve fibers that surround the disc but do not greatly back. This tearing (called an annular tear) has allowed
penetrate it. These nerve fibers (sinuvertebral and pain-carrying nerve fibers to grow into the center of the
basivertebral nerves), are known to have the potential disc, effectively wiring the disc for pain. Also note the
to carry pain signals to the brain when inflamed and increased nerve fibers in the vertebral endplates
irritated, which can occur following a special type of disc surrounding the disc, which wires the endplates for pain.
degeneration and disc tearing. Because of biomechanical and biochemical mechanisms,
these nerves are now constantly inflamed/irritated and
sending pain signals to the brain in patients who suffer
DPS.
