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?

 Both affect the thoracolumbar region

 Both have pain felt into the top of the sacrum and SIJs.
B. What are the features of each

Maigne’s features:
 Thoracolumbar manipulable lesion affecting thoracolumbar junction with secondary
reflex involvement of the cluneal nerves giving rise to referred pain to the SI joint, groin
and lateral hips
 Neuropathic skin changes may be present as the posterior ramus ends cutaneously causing
trophic changes
 A thickening or nodularity of the skin
 Hair loss
 Swollen puffy appearance
 Hypersensitivity of skin overlying iliac crest

Compression Fracture features

 Local spasm and selling
 Pain usually localised or may radiate to the side
 Pain on percussion/vibration
 Pain pattern
C. How would you differentiate them?

 Age
 Maigne’s is manipulable lesion and a fracture isn’t
 Presence of osteoporosis
 History of trauma could lead to a compression fracture
 Is it tender on percussion (fracture may have increased pain on percussion but a typical
manipulable lesion won’t)
 Pain distribution is different. There is no radicular pain in Maigne’s syndrome and pain is
felt is specific regions whereas in a compression fracture the pain is usually local or may
radiate to the side.
 Maigne’s comes more into the buttocks and groin
Exercise 2

Differential Diagnosis of LBP with Radiculopathy

Disc Herniation Spinal Stenosis Cauda Equina

Age 30-55 >60 40-60

History Acute or recurrent episodes Insidious onset of chronic, Insidious onset LBP with or
progressive LBP; more without saddle anaesthesia,
recent onset of LE bowel/bladder function changes,
symptoms acute or chronic LBP

Pain pattern Pain and/or numbness LE symptoms increase with Usually radiculopathy bilateral
radiating to unilateral LE extension and relieved by – pain, tingling, numbness,
below the knee, usually flexion increased with flexion
increased with flexion

Neuro Exam Sensory and/or motor Sensory and motor changes Bilateral sensory and/or motor
changes, diminished/ absent changes, diminished absent
DTR unilateral reflexes, sensory and motor
changes S3/S4

ROM Guarded/limited Pain and limited extension Guarded/limited

Other Tests SLR Treadmill test SLR

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.
Pain is constant aching pain throughout the day and night. There doesn’t
seem to be a time when it is better or worse but he is complaining of it
more in the past few weeks. All ranges of motion are achieved and are not
restricted however, there is increased intensity of the pain on both right
and left full rotation.

QS. To ask:
 Can you touch your toes?
 Is the pain worse on standing/sitting?
 Is the pain only in the lumbar spine or does it refer/radiation to the SI joint, buttock,
upper/lower leg?
 Have you had any troubles at school, with your friends or at home?
 Common mechanical disorder of the IV joints can cause back pain in children.
It can be related to psychological factors.

V – nothing in history presents that is could be vascular

I
N – unlikely but possible neoplastic cause
D – he is only 12 and the pain is constant, so not likely to be a
degenerative condition which is typically found in an older population with
intermittent pain
I
C - no known congenital condition presented in history
A -no known autoimmune condition presented in history
Trauma – neither mark or his mum could remember a specific trauma
date
E – no known endocrine condition presented in history

Exercise 4
Explain Peripheralisation and Centralisation as they apply to the clinical
presentation and treatment of LBP with radiculopathy

 Centralisation means pain moves up the extremity and toward the center of the spine. 
 Peripheralisation means pain moves laterally away from the center of the spine and/or down
the extremity (classic LBP with radiculopathy)
 The further the pain radiates away from the patient centre (centralisation), the more severe
the neuropathic pain process. In treatment, we aim to centralise the pain.

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 any difficulty with retaining urination?

 Have you experienced any difficulty in controlling your bowel movement? (loss of
anal sphincter tone of faecal incontinence?)
 Have you experienced any change in sensation around your genital area or inner
thighs? (saddle anaesthesia)
 Have you noticed any chances or difficulty walking? (Gait disturbance)
 Have you experienced a loss of sexual function?