1 Lumbar Spine Flashcards
In which directions do L-spine superior facets face? Inferior facets?
- Sup: medial and posterior
- Inf: lateral and anterior
Degeneration of the IVDs is called:
Spondylosis
What’s Spondylolysis, and how does it occur?
- defect in the pars interarticularis–fracture between the pedicle and lamina (Scottie dog X-Ray)
- occurs with over extension pressing the SPs together
Forward displacement of one vertebra over another (generally due to fracture) is called:
Spondylolisthesis
What percentage of total length of vertebral column do IVDs compose?
~25%
Approx how many rings of criss-crossing collagenous fibres make up the annulus fibrosis?
~20
What is disc protrusion?
Injury where there is no rupture of annulus fibrosus
What is disc prolapse?
Injury where only outer fibres of the annulus fibrosis contain the nucleus pulposus
What is disc extrusion?
Injury where annulus fibrosus is perforated and nucleus pulposus bulges into spinal canal
What’s sequestration?
Injury where fragments of nucleus pulposus have broken through and freely float in the spinal canal
What are L-spine rule outs at the hip?
AF flex and medial rotation with overpressure
What are L-spine rule outs at the pelvis?
rocking, gapping, approximation
What are L-spine rule outs at the cervical spine?
AF flex, ext, side bend, rotation with overpressure (except on extension)
What’s normal L-spine range for AF flexion?
40°-60°
With lumbar flexion, what length change should happen between T12 and S1?
7-8cm
Should a healthy L-spine have a uniform curve?
yes
What’s normal range of curvature for AF extension at the L-spine?
20°-35°
What should therapist stabilize while patient extends at L-spine?
stabilize pelvis
What’s normal range for AF sidebending at the L-spine?
15°-20°
What’s normal range for AF trunk rotation at the L-spine?
3°-18°
What does the straight leg raise (SLR) test for?
tests for:
- nerve tension
- space occupying lesion in the lumbar spine
What are the stages of the SLR test?
- supine, passively flex straight leg at hip until px reports pain or tightness in post leg; now lower leg until symptoms are no longer present (but no further)
- px foot is then passively dorsiflexed; this also places a stretch along the nerve via the tibial nerve
- if stage 2 is negative, ask px to actively flex neck (while maintaining step 2)
What’s the name of stage 2 of the SLR test?
Bragard’s test
What’s the name (and AKAs) of stage 3 of the SLR test?
Brudzinski’s sign/Sotto-Hall test/Hyndman’s test
What does Brudzinski’s sign/Sotto-Hall test/Hyndman’s test result in? i.e. what is tensioned?
The cervical flexion increases tension through the meninges, especially the dura mater, down through the sciatic nerve.
What is a positive sign for the SLR test?
numbness/tingling/pain travelling down the leg being tested
What does a positive SLR test implicate? What are we primarily looking for? What’s another possible implication?
Test usually points to a posterolateral disc herniation due to the dural tension pulling the nerve towards the space-occupying lesion (or herniation) lateral to the nerve(s). The later 2 stages of the test (DF and forward C flexion) may also be positive for meningeal irritation if the patient reports pain or restrictions in the neck or back. Remember to always ask where the patient is having the pain! If px can’t flex neck at all, they may be suffering from meningitis.
What’s the purpose of the Well Leg Raise (WLR)?
points to posteromedial space-occupying lesion pressing on nerve root(s) that govern the affected limb
How is the WLR test conducted?
px is supine, the therapist passively flexes unaffected hip while maintaining knee in full ext; a positive is considered when px reports reproduction of symptoms in the affected leg
What’s a positive sign for the WLR?
reproduction of symptoms down the affected leg usually at 40° hip flex or less (flex of unaffected leg)
What are the implications of positive WLR?
A positive points to a space-occupying lesion pressing on the nerve root(s) the govern the affected limb. A positive for the WLR usually points to a posteromedial disc herniation due to the dural tension pulling the nerve towards the space-occupying lesion (or herniation) medial to the nerve(s).
How is the slump test conducted?
Have px flx head, then straighten leg, then dorsiflex foot; at end of test, pressure C-spine if no symptoms
What is the purpose of the Slump test?
to detect herniated disc, altered neurodynamics or neural tissue sensitivity
What’s a positive sign for the Slump test?
positive sign is reproduction of S/S that are then relieved when the head is returned to neutral posture or when knee is returned to flexed position
What are the implications of the Slump test?
test will affect the dural sheath of the spine; this combination of movements will put a tension through the entire spine and, if positive, will reproduce S/S that the patient originally presented with
What’s the purpose of the Bowstring test?
tests for possible lumbar disc herniation and/or sciatic nerve pathology
How is the Bowstring test conducted?
supine: passively flex px’s hip with knee extended until pain or paresthesia is felt down the leg; now passively flex knee (while maintaining flexed hip) and place it on your shoulder to support it; with your thumb, attempt to palpate and strum the tibial nerve just medial to biceps fem tendon in the popliteal fossa
What’s a positive sign for the Bowstring test?
positive is a reproduction of px’s symptoms; if the inflammation is severe and chronic, you may be able to feel the nerve, which will feel like a braided cord
What are the implications of the Bowstring test?
If the SLR is positive or if irritation and inflammation of the sciatic nerve is suspected, the sciatic nerve may be directly palpated in the popliteal fossa of the knee. Pressure (or strumming) on the nerve will cause symptoms to be felt locally and distal to the part of the nerve being palpated.
What’s the aka for the Femoral Nerve Stretch?
Nachlas test
What’s the purpose of the Femoral Nerve Stretch/Nachlas test?
Neural tension test used to stress femoral nerve and mid lumbar (L2-L4) nerve roots
How is the Femoral Nerve Stretch/Nachlas test applied?
Px is prone; therapist passively extends the hip (15°) with the knee extended. If no reproduction of S/S is present the therapist then slowly passively flexes the px’s heel to the buttocks.
What’s a positive sign for the Femoral Nerve Stretch/Nachlas test?
reproduction of pain or paresthesia over the L2 and/or L3 and/or L4 dermatome area (lower back and anterior thigh region) may indicate a lesion or irritation to the femoral nerve
What is the implication of the Femoral Nerve/Nachlas test?
This test puts the femoral nerve on stretch, and unilateral pain may be positive for L2 or L3 or L4 dermatomes (mostly L2 and L3) if there is no lesion or contracture to the quadriceps muscle. The feeling or paresthesia is known as formication.
What’s the purpose of the Valsalva test?
tests for herniated disc, osteophyte, or any other space-occupying lesion
How is the Valsalva test performed?
Ask a high-seated px to take a breath, hold it (at least 6 seconds), and then bear down as if evacuating the bowels. Or have them blow into their thumb.
What’s a positive sign for the Valsalva test?
reproduction of symptoms either locally in the spine or down the leg
What’s the purpose of Milgram’s test?
tests for intrathecal (herniated disc) or extrathecal (soft tissue injury) pathology
How is Milgram’s test performed?
px is supine; have them raise both extended legs about 2 inches off the table and hold for 30 seconds
What’s a positive sign for Milgram’s test?
Positive is pain and/or an inability to raise or hold the legs off the table. This test may be a little overly optimistic as many people have trouble holding their ankles off the table.
What’s the purpose of Hoover’s test?
test is designed to see if the client is malingering or exaggerating their complaint of low back pain
How is Hoover’s test conducted?
supine: take each of px’s heels in palm of my hand; ask px to raise each leg individually; when px raises one leg, I should feel downward pressure from other leg
What’s a positive sign for Hoover’s test?
no downward pressure from contralateral leg when px lifts ips leg (means px is not actually trying to lift ips leg)
What’s the aka for Kemp’s test?
quadrant test
What’s the purpose of Kemp’s/Quadrant test?
tests for possible facet joint irritation, or foramenal stenosis
How is Kemp’s/Quadrant test performed?
px is standing; have them rotate and extend their trunk while running their hand down the back of their thigh
What’s a positive for Kemp’s/Quadrant test?
localized pain on ipsilateral side
What are the implications of Kemp’s/Quadrant test?
The movement provides greater provocation by decreasing the Intravertebral foramen of the lumbar spine on the side to which the client bends. This test puts ultimate pressure on the facet joints by placing them in their close-packed position. Facet joint pain may be site-specific to the facet that is provoked, or may radiate several centimetres around the joint. Localized pain on the same side may also come from: an injured muscle being placed in a short position and then spasming, pressure placed on inflamed iliolumbar ligaments or from compression of the joint surfaces of the sacroiliac joint. The latter can mimic neurological pain in the gluteal-hip region. Pain from the side not being tested usually comes from tissue being stretched.
What is the purpose of the Pheasant test?
tests for spinal instability (L-spine)
How is the Pheasant test applied?
Px is prone; place one hand on the patient’s lumbar spine and gently compress. With other hand, pick up px’s ankles and passively flex knee until ankle is at buttocks.
What is the positive sign for Pheasant test?
Hyper-lordotic presentation in the L-spine and/or pain in lower limb. (some versions of this test suggest an Achilles Tendon Reflex test at beginning and end of this test)
What’s the purpose of the Segmental Instability test?
tests for spinal instability (L-spine)
How is the Segmental Instability test applied?
Patient is prone on the table with their legs hanging off (hip passively flexed at 90°); the therapist will apply P-A glides segmentally over individual SPs of the lumbar spine while the px remains relaxed. Once pain is identified over a particular segment, the therapist maintains pressure then instructs the px to lift their legs up off the floor by contracting the hip and spinal extensors.
What’s a positive sign for the Segmental Instability test?
Positive sign will result in LBP with pressure when the px is relaxed, and no pain when pressure is applied with active muscle contraction (i.e. when legs are extended). This lack of pain is attributed to the area of instability being protected (and masked) by the muscular contraction.
How is the QL muscle test applied?
(Impossible to test in isolation, the following can give an indication as to strength or weakness)
Px is prone with one thigh/leg slightly extended and abducted. The degree of abduction is intended to mimic the line of pull of the muscle’s fibres. Px attempts to elevate pelvis (hip hike). Therapist opposes with a longitudinal traction of thigh/leg along line of pull of the muscles’s fibres.
How is the Latissiumus Dorsi muscle test applied?
(More of a shoulder muscle, but does have some influence on tilting the pelvis anteriorly and laterally. Weakness may result in diminished lateral trunk flexion.)
Prone: px attempts to adduct the arm in a position of extension and medial rotation. Therapist applies pressure against the forearm in the direction of abduction and slight G/H flexion.
How is the Lower Abdominals muscle test applied?
(Refers to the lower fibres of all 4 abdominal muscles. Note: it is impossible to separately test the individual abs, but it is clinically important to isolate the lower and upper fibres of the ab group.)
Supine: hips flexed to 90° and knees fully extended. The px should tilt their pelvis posteriorly to flatten the lumbar spine against the table. Therapist can place their hand under px’s lumbar spine to gauge when they lose the ability to maintain a posterior pelvic tilt. Px slowly lowers their legs to the table. Instruct them to continue pressing low back into your hand.
The strength of the lower abs is graded on their ability to maintain a posterior pelvic tilt during the leg lowering.
With dermatome tests, what part of my hand do I use to brush px? How many times do I brush? Bi or unilateral?
- back of hand
- 7-10 times
- bilateral (simultaneously)
Describe all relevant dermatomes (areas), myotomes (action), and DTR of L1
- Derm: oblique band on the upper anteriort thigh immediately below the inguinal lig. from the iliac crest down to the groin
- No myotome
Describe all relevant dermatomes (areas), myotomes (action), and DTR of L2
- Derm: middle anterior thigh
- Myo: hip flexion
Describe all relevant dermatomes (areas), myotomes (action), and DTR of L3
- Derm: ant thigh immediately prox to the patella
- Myo: knee extension
Describe all relevant dermatomes (areas), myotomes (action), and DTR of L4
- Derm: patella, medial leg and medial aspect of the foot
- Myo: ankle dorsiflexion
- DTR: Patellar reflex
Describe all relevant dermatomes (areas), myotomes (action), and DTR of L5
- Derm: lateral leg and dorsum of foot, web space between first two toes
- Myo: first toe extension
Describe all relevant dermatomes (areas), myotomes (action), and DTR of S1
- Derm: lateral malleolus and lateral and plantar aspect of foot
- Myo: foot eversion
- DTR: achilles
Describe all relevant dermatomes (areas) and myotomes (action) of S2
- Derm: back of leg and thigh
- Myo: knee flexion or hip extension
What’s the disc, reflex, muscle(s), and sensation of root L4?
- Disc: L3-L4
- Reflex: Patellar
- MM: Tibilalis Anterior
- Sensation: Medial leg and foot
What’s the disc, reflex, muscle(s), and sensation of root L5?
- Disc: L4-L5
- Reflex: none
- MM: EHL
- Sensation: lateral leg, dorsum of foot
What’s the disc, reflex, muscle(s), and sensation of root S1?
- Disc: L5-S1
- Reflex: achilles
- MM: peroneals
- Sensation: lateral foot
What tests should be conducted for a possible disc herniation/lesion?
- SLR
- WLR
- Slump
- Valsalva
- Milgram’s
- possibly Bowstring
What tests should be conducted for possible Spondys/Instability/Muscle weakness?
- Pheasants
- Segmental Instability
- Muscles Tests
What tests should be conducted for possible facet irritation?
- Kemps
- Myotome/Dermatome/DTR
What tests should be conducted for possible Nerve Compression?
- SLR
- Femoral Nerve Stretch
- Bowstring
- possibly Myotome/Dermatome/DTR
What tests should be conducted for possible Disc Degeneration (DDD)?
- SLR
- WLR
- Slump
- Valsalva
- possibly Segmental Instability
What tests should be conducted for possible Muscle Tightness?
- Muscle tests
- Myotome/Dermatome/DTR
What tests should be conducted for possible Nerve Root Compression?
- Myotome/Dermatome/DTR
- Kemps
- possibly Motion Palpation (e.g. mobilizing vertebral segments)
- possibly SLR, WLR
What’s the difference between nerve root and other types of compression?
Nerve Root patterns vs just general S/S
What might local pain in the L-spine indicate?
facet joint irritation, paravertebral irritation, paravertebral muscle spasm, ligament sprain
What might radiating pain in the L-spine indicate?
travels down the involved limb due to spinal nerve and/or root irritation
What might referred pain in the L-spine indicate?
TrPs, visceral organs (prostate cancer), systemic conditions (ankylosing spondylitis)
What’s the aka for the Straight Leg Raise?
aka Laseque’s test
Which vertebral segment most commonly has problems in the spinal column?
L5-S1 segment
In which plane do lumbar facet joints face?
sagittal
With pelvic rocking, if there’s immediate translation, which side is stuck?
immediate translation of the pressure on one ASIS into the other implies the ASIS being pressured is locked
What are L-spine ruleouts?
- hip: AF flex and medial rotation with overpressure
- pelvis: rocking, gapping, approximation
- c-spine: AF flex, ext, side bend, rotation with overpressure (except on extension)
With a positive femoral nerve stretch/nachlas test, the feeling of paresthesia is known as:
formication
