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Old lumbar injury

 
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Old lumbar injury - March 1, 2006 9:28:00 AM   
Alex Brenner PT MPT OCS

 

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23 year old male was injured when he was partially pinned between a fork lift and the wall 2 years ago while working in a warehouse. He was not seriously injured but has had low back pain for two years; never seen for it in the past. His recent pain has been exacerbated with yard work and he complains of pain radiating from his mid lumbar spine out into the flank on his left side only. What are the findings?

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< Message edited by David Adamczyk -- July 13, 2007 1:44:25 AM >
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Re: Old lumbar injury - March 1, 2006 11:00:00 AM   
Shill

 

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All I can see on my monitor is what might be an old sacral fx. Hard to tell with all that bowel gas.

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Re: Old lumbar injury - March 1, 2006 6:32:00 PM   
connie.pt

 

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Wow, this is a tough one.
Is there a fx in the body of T-12?
Looks like a reduced lumbar lordosis.
Do you have an oblique view?

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Re: Old lumbar injury - March 1, 2006 6:54:00 PM   
FLAOrthoPT

 

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yeah a LOT of gas here. What are those "pellets" distal to the sacrum? I think there looks to be some abnormality in the sacrum, but I think it may be gas clouding the view. There almost appears to be a small old fracture at the lip of the acetabulum. Disc space looks preserved int he L spine, no real osteophytes or stenosis to speak of, only mild curvuture in frontal plane ubt this can be from behavioral how he is standing.

Overall I'd say his films clear the L-spine and say that his pain in his flank is gastrointestinal in nature, and send him for a endoscopy. Lot's of gas build up there, tell him not to be near any open flames.
Ben

(in reply to Alex Brenner PT MPT OCS)
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Re: Old lumbar injury - March 1, 2006 6:55:00 PM   
FLAOrthoPT

 

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ps that seems to be pretty high up for his intestines no?

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Re: Old lumbar injury - March 1, 2006 7:10:00 PM   
jma

 

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It looks like the lumbar lordosis has straightened out a bit. Not much of a curve. The L1 spinous process looks a little off. Not quite centered. The side view of the T12 body looks like it has a fracture.

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Re: Old lumbar injury - March 1, 2006 7:12:00 PM   
Synergy

 

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First off, this guy may benefit from 'dropping the kids off at the pool'. I see a fx of the 11th thoracic vertebrae and some sort of opacity in the vertebral body of L4. I see those 'pellets' as well Ben. Perhaps this guy was 'peppered' by a 28-gauge shotgun by Cheney. :)

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Re: Old lumbar injury - March 2, 2006 4:18:00 AM   
Jeep

 

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[QUOTE]What are those "pellets" distal to the sacrum? [/QUOTE]Phleboliths

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Re: Old lumbar injury - March 2, 2006 4:45:00 AM   
Jeep

 

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My eye keeps going to the spinous process of L1(per LLS).

I would guess old L1 SP fracture, based on alignment per LLS, and an apparent increased SP opacity per APLS(to the extent visualized on my very non-diagnostic quality PC monitor).


Nice collimation on these films.

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Re: Old lumbar injury - March 2, 2006 8:31:00 AM   
chiroortho

 

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[QUOTE]What are those "pellets" distal to the sacrum?[/QUOTE]Yeah my first reaction was phleboliths too because they are SO common in the pelvic basin but take a closer look - it appears that the bladder is distended and since the opacities kind of follow the outline of the bladder one wonders if they're not urinary calculi.

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Greg Priest, DC, DABCO

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Re: Old lumbar injury - March 2, 2006 10:43:00 AM   
Jeep

 

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[QUOTE]but take a closer look - it appears that the bladder is distended [/QUOTE]YEAH- It really makes one wonder why preparation for such films dose not include a "pee and poop"!!


Even so,------I will stay with "phleboliths".

BTW Greg- What's your take on the L1 SP?

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Re: Old lumbar injury - March 2, 2006 12:47:00 PM   
chiroortho

 

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Jeep I don't see it. You're probably right about the phleboliths though, they are just so common there. I guess we'll see.

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Greg Priest, DC, DABCO

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Re: Old lumbar injury - March 2, 2006 2:40:00 PM   
USAPT

 

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I too keep going back to the L1 vertebra. Looks as if there is a left rotation as well.
Chris, liked the Cheney analogy

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Re: Old lumbar injury - March 2, 2006 2:44:00 PM   
FLAOrthoPT

 

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interesting side note how is most opitae derivitive narcotics like hrdrocodon, percocet, etc, cause severely impacted bowels. Could be a die note for this guy, was he on pain meds for long time and ignored that he only visits the thrown once a month?

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Re: Old lumbar injury - March 2, 2006 8:20:00 PM   
docb

 

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Were these films standing?

Its very hard for me to see on my lap top monitor but from what I can see

1. Hypolordosis
2. Possible osteophyte on the anterior margin of L5
3.Mild Disc degeneration at L5/S1
4. Facet arthrosis at L4,5, S1 levels
5. Pelvic unleveling on right, possible torsion with sacral apex angulation off to the right
6. Something going on at T12 cant make out due to screen. woudlnt r/o old compression fracture
7. Gas
8. Phleboliths or possible intraductal calculi.

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Re: Old lumbar injury - March 2, 2006 8:36:00 PM   
FLAOrthoPT

 

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not instigating, really just trying to ascertain how a lot of chiros try to make postural claims such as hyperlordosis and scaral torsions based on static X-Rays. Can't something like this be the manner in which they were positioned, the manner in which they are standing, behavioral changes to avoid painful positions, from leg length discrepencies, etc. how can you label something like loss of lumbar lordosis without posturally screening them in 3 dimensions and checking movement patters of active and passive ranges of motion. Just curious how this can be "seen on X-ray" just would never see "loss of shoulder flexion" on an X-ray film before...I just know that many peopple stand a certain weay to avoid pain, and it is not representative of an anatomical fault, behavioral patterns really shouldn't be assumed in an x'ray reading. If I am wrong, which happens a lot, please correct me, I walwasy wondered about this.
Ben

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Re: Old lumbar injury - March 3, 2006 7:42:00 AM   
docb

 

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FLAOrthoPT

I agree with you 100%. However its not limited to DCs. While working in the ER, and attending Osteopathic school we were taught the same things.
You document what you see on the film so as if the next Dr in line only had your report (no film to look at) he could see the same thing you are seeing.
That however by no means is meant to base a treatment program on 1 static film. It mearly gives a starting point and a another piece of the puzzle.

In regards to my comments above, I was stating what I was seeing at that moment, on that film as if I were to have to document my findings. This could be the pts antalgic posture, no doubt.

I would compare this with previous films and or films I might take at a later date if I were doing corrective care.

I cant speak for other DCs but I would not base a treatment program off of a 1 dimensional plain film xray. I would try a corrilate the physical findings with the xray.
Ex. If there is degeneration at the L5S1 level and the pt has a radicular symptoms running down the leg, and other ortho tests indicated a disc problem then I would possibly order an MRI, EMG and base treatment off that.

Its also like looking at a Spondy on a lat film. Is it there... yes grade 2... yes...stable ??? we need to get a history, flex, extension, obliques(pars defect) films, to make a more accurate dx. not just base it off of one film. However if all you have to look at is a lat film then I would record what I seen at that moment a grade 2 spondy.

Good call Ben, I hope that clears up my stance at least.

have a great day

Bryan

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Re: Old lumbar injury - March 3, 2006 8:27:00 AM   
Jeep

 

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Excellent post Bryan-----

X-rays must always be clinically correlated. They are only rarely, "stand-alone" diagnostically.


Question for Alex-

From the markings on these films: is it indicated supine or standing?

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Re: Old lumbar injury - March 3, 2006 11:19:00 AM   
Alex Brenner PT MPT OCS

 

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All,
The films were conducted in supine. Great discussion.

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Alex Brenner, PT, MPT, OCS

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Re: Old lumbar injury - March 3, 2006 5:02:00 PM   
Jeep

 

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Alex-

Is it indicated on the films?

(in reply to Alex Brenner PT MPT OCS)
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