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?

A: Both cause pain in the thoracolumbar junction region and effect this region,
therefore symptoms/signs may overlap with the two conditions. Such as referred
pain through the nerves into top of buttocks and SIJ’s.

B. What are the features of each

A:
Compression fracture: Progressive, metabolic bone disease that decreases bone
density with deterioration of bone structure. Skeletal weakness leads to fractures in
lumbar, thoracic/rib, hip and wrist regions especially.
• Type A: local pain at site of fracture.
• Type B1/2: local with radiating band of pain.
• Type C: local pain with referred L5/SIJ pain and down to bilateral, lateral aspect of
legs.
•
Maigne’s syndrome: Manipulable lesion affecting thoracolumbar junction with
secondary reflex (not radicular) involvement of the clonal nerves. Unexplained
activation of the primary division of a posterior ramps of a spinal nerve (dorsal ramus
of spinal nerve).
• Referred pain in lower back, hips and groin (but not radicular).
• Radicular patterns following L1-2, L2-3 patterns.

C. How would you differentiate them?

A:
Age (>50), ability to manipulate, presence of osteoporosis, presence of trauma,
tenderness upon percussion, would all differentiate a compression fracture from
Maigne’s syndrome.Otherwise, a bone scan (DEXA) to confirm compression fracture
and differentiate from Maigne’s syndrome.
Addiitonally, compression fracture usually has radiating band of pain more local to
the LT junction, where as Maigne’s has radicular patterns to L1-3.
Exercise 2

Differen'al Diagnosis of LBP with Radiculopathy

Disc Hernia/on Spinal Stenosis Cauda Equina

Age

History

Pain pa<ern

Neuro Exam

ROM

Other Tests

A:
Disc herniation
Age: 30-55
Hx: Acute or recurrent episodes.
Pain pattern: Pain and/or numbest radiating unilateral LE below the
knee. Agg: spinal flexion.
Neuro exam: sensory and/or motor changes, diminished/absent DTR
(unilateral).
ROM: guarded/limited.
Other test: SLR

Spinal stenosis
Age: >60
Hx: insidious onset of chronic, progressive LBP, more recent onset of LE
symptoms.
Pain pattern: LE symptoms. Agg: lumbar extension. Rel: lumbar flexion.
Neuro exam: Sensory and motor changes.
ROM: Pain and limited extension.
Other test: Treadmill test
Cauda equina
Age: 40-60
Hx: insidious onset LBP with or w/o saddle anaesthesia, bowel bladder
function changes, acute or chronic LBP.
Pain pattern: Bilateral (usually) radiculopathy. Pain, tingling, numbness.
Agg: spinal flexion.
Neuro exam: Bilateral sensory and/or motor changes, diminished/
absent reflexes, sensory and motor changes around S3-4.
ROM: guarded/limited.
Other 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.

LODCTRRAPPA:

Location: back - thoracolumbar region

Onset: insidious

Duration: past few weeks/2-3 weeks.

Course: Pain constant, at all times of day.

Type: Pain is local, no radiating. Band-like across T-L junction. VAS 5/10.

Radiating: No.

Relief:

Aggravation:

Previous episode:

Previous treatment:

Associated symptoms:

Red flag rulings:

Has the mother noticed any weight changes or has he had any night sweats? NO

Has he experienced any trauma previously? NO

Any bowel/bladder or urine changes? NO

Orthopaedic tests:

Vasalva or compression: NO.

DDx: As he is over 10 yo, it isn’t as imperative that organic causes such as tumours
are ruled out. However, history/note taking red flag questions such as “Does your
child experience pains at night?”, or “Have you noticed any weight loss?” Or “Are
you aware of any traumas that may have happened while he was playing soccer or
on the mountain bike recently?” Should be ruled out. The most common cause, and
most likely cause of is pain would be some sort of mechanical disorder, as he is quite
active.

Exercise 4

Explain Peripheralisation and Centralisation as they apply to the clinical presentation

and treatment of LBP with radiculopathy.

A:
Peripheralisation: Pain that presents laterally and/or down the extremity, away from
the centre of the spine (or away from the source of pain).

Centralisation: characterised by spinal pain with referred symptoms that are

progressively abolished in a distal to proximal direction when responding to
therapeutic/treatment strategies.

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?

A:
• Is there any radiation or sensory changes following the neurological caudal equina
patterns? E.g. dermatome/myotome patterns from L2-S5, whether it be altered
reflexes or decreased strength.
• Is there any sensory changes when wiping the anal region after going to the toilet?
• Was there any noted history of trauma in the caudal equina region (L2-S5)? Both
recent and distant past.
• Is there any history of degenerative or inflammatory conditions in the lumbar
spine? E.g. known disc bulge or spinal stenosis.