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 conditions commonly affect the thoracolumbar region

- Both result in LBP

B. What are the features of each

Maigne’s syndrome (Manipulable lesion affecting the thoracolumbar junction with

secondary reflex (not radicular) involvement of the cluneal nerves giving rise to referred
pain)

- Neuropathic in three regions = Low back (iliac crest, hips and groin)
- Neuropathic skin changes may be present (thickening of nodularity of skin, hair loss and
swollen puffy appearance)
- Hypersensitivity of skin over iliac crest
- Pain when facet joints are palpated
- Usually unilateral or bilateral pain over iliac crest area and possibly groin
pain/thoracolumbar pain
- Patients will not have pain radiating below the knee, which is more typical of anterior
ramus involvement.
Osteoporotic compression fracture (A progressive metabolic bone disease that
decreases bone density (bone mass per unit volume), with deterioration of bone
structure)

- Asymptomatic unless a fracture has occurred

- Begins with acute onset of pain, Non-radiating, Wrap around the chest or abdomen,
Referred to top of sacrum
- Aggravated by weight bearing
- +/- point spinal tenderness
- Typically begins to subside in 1 wk. However, residual pain may last for months or be
constant.
 C. How would you differentiate them?

- Onset
- Area of pain
- Light palpation of effected area
- Neuropathic changes
- History

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
episodes chronic progressive or without saddle
LBP; more recent anaesthesia, bowl/bladder
onset of LE symptoms function changes, acute or
chronic LBP
Pain pattern Pain and/ or numbness LE symptoms increase Usually radiculopathy
radiating to unilateral with lumber extension bilateral – pain, tingling,
LE below the knee, and relieved by flexion numbness, increased with
usually increased with flexion
flexion
Neuro Exam Sensory and/ or motor Sensory and motor Bilateral sensory and/or
changes, changes motor changes,
diminished/absent diminished/ absent
DTR unilateral reflex’s, sensory and
motor changes S3-4
ROM Guarded/limited Pain and limited Guarded/limited
extension
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.

Extra info from Q and A

What time of the day is the pain worse? Does it get worse during the end of the day and is it worse
with flexion? (Scheuermann’s Disease)

- Pain is constant and aching throughout the day and night, not time when it
seems to get bettter and has woken in the night from the pan

Is there any restriction or pain in extension? And is there a positive Kemps test? (facet syndrome)

- All ROM are normal however pain is increased with right and left full rotation

Has there been any changes in bowl or urine output? Or any changes or presence of blood in bowl or
urine output? And is the pain centralized or peripheral? (Tight QL or musculoskeletal issues, Facet
syndrome of infection/cancer)

- No changes in bowl or bladder output

- More centralized pain

Is there a positive Valsalva or pain reproduced by axial compression (disc herniation)

- No

Where there any issues before/after he plays sports of is active (compression fracture in
thoracolumbar region due to overactivity)

- No constant pain that has stopped him from playing sport

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

Possible diagnosis:

Age of patient and level of pain suggest muscular involvement – Possibly quadratus lumborum

- Multifidus muscles are also possible cause of pain

o These may be put under press due to scoliosis

L – Thoracolumbar area
O – Unknown (idiopathic)
D – 5 weeks
C – Constant (unchanging, occasionally worse at night)
T – Subacute (5 out of 10)
R – Does not radiate
R – Constant pain (doesn’t seem to be relieved by anything)
A – Sometimes worse at night
P – None
P - None
A – None

T – No notable event
U – None
N - None
A - None
F - None
I - None
S - None
H - None

G – Unknown
O – Pain in thoracolumbar region
R – Pain when rotating to the left
P - 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

V - NA
I – Inflammatory or infectious
N – Could be neoplastic involvement (unlikely)
D – Scoliosis
I - NA
C - NA
A – Possible autoimmune involvement
T - NA
E – Unknown

Exercise 4

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

- Peripheralization refers to the spreading of pain away or distally from where it

originates. For instance when the is a disc issue in the lumbar spine this may cause
the peripheralization down the led in into the foot
- The goal of the chiro is to try and bring that pain back to a central area to which it
originated from

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?

– Low back pain

– Acute or chronic radiating pain

– Unilateral or bilateral lower extremity motor and/or sensory abnormality;

– Bowel and/or bladder dysfunction

As well as

- Numbness of tingling in saddle or perianal region

- Does it feel different when wiping with toilet paper
- Can you stop mid flow of urine (other questions related to flow and ability to control
urine – amount, retention etc)
- Ask about bowl changes
- Issues with sexual function