8- Lumbar Spine Flashcards
_____% of persons in industrialized countries with have LBP at some point in their lives.
70%
One-year prevalence of LBP is _____% and peak prevalence occurs between ______ and _____ years old.
15-45%
35-55 years
____% of patients with acute LBP will self-resolve within 6 weeks.
____% of people develop chronic pain
90%
2-7%
Recurrent and chronic pain accounts for _____ % of total worker’s absenteeism
75-85%
What is the estimated annual US worker’s compensation costs for LBD?
$8.8 billion
What is the strongest predictor of further incidence of LBP?
history of previous episodes
About ___% of people seen with LBP in primary care have compression fractures and about ____% have neoplasm.
4% compression fractures
1% neoplasm
What is the prevalence of prolapsed IVD?
1-3%
When are bulging discs common (age-wise)?
20-39 yo and 60-80 y.o
When are disc herniations more common (age-wise)?
as the patient ages
When is degenerative disc disease most common?
strongly related to aging
What is the approximate ROM for lumbar flexion?
40-50 degrees
What is the approximate ROM for lumbar extension?
55-70 degrees
What is the approximate ROM for lumbar axial rotation?
5-7 degrees
What is the approximate ROM for lumbar lateral flexion?
20 degrees
What are the proportions of 85 degrees of T-L flexion?
35 degrees thoracic, 50 degrees lumbar flexion
What are the proportions of 35-40 degrees of T-L extension?
20-25 degrees of thoracic extension, 15 degrees lumbar extension
What are the proportions of about 40 degrees of T-L axial rotation?
35 degrees thoracic, 5 degrees lumbar rotation
What are the proportions of about 45 degrees of T-L lateral flexion?
25 degrees thoracic, 20 degrees lumbar sidebending
What can large end plate fractures cause?
permit liquid NP to squirt through the end plate into the vertebral body
How do Schmorl’s Nodes form?
sometimes end plate fractures cause a local area of bone to collapse under the end plate, creating a pit or crater that gradually forms a Schmorl’s Node. (associated with spinal compression when the spine is in neutral)
What happens to the annulus fibrosis during end plate fractures?
it remains intact
What is the one-time loading shear tolerance of FSU reported to be?
about 2000-2800 N ranges
What does repeated, cyclic full spin flexion and extension lead to?
fatigue within the posterior arch, leading to a pars fracture (spondylolisthesis)
What is an appropriate rehab objective for patients with pars fractures?
stability (generally don’t tolerate ROM)
How are the collagen fibers of the annulus fibrosis arranged?
multiple concentric layers, with fibers in every other layer running in identical directions (orientation is about 65 from vertical)
What are the 3 major components of the IVD?
nucleus pulposus, annulus fibrosis, end plates
Why are the collagen fibers of the annulus fibrosis oriented the way they are?
they can also resist twisting force (but only 50% can function at a time during this)
What happens to the annulus fibrosis during compression when little hydrostatic pressure is present (like during an end plate fracture or herniation)?
The outer layers bulge outward and the inner layers bulge inward, causing laminae of AF to separate or delaminate (this can be the pathway for nuclear material to leak through lamellae layers and finally extrude)
How must the disc be oriented in order to herniate?
must be bent to full ROM in order to herniate
What is disc herniation associate with (mechanism)?
associated with repeated loading in range of thousands of times (implicating role of fatigue as injury mechanism)
What is disc herniation linked with?
sedentary occupations and sitting posture
What age are disc herniations associated with?
tend to occur in younger spines, those with higher water content, and more hydraulic behavior
What is it called when there is expansion of disc material beyond its normal border (eg., a normal disc during compression, or a degenerated disc with decreased disc height)?
Disc Bulge
What is is called when there is discrete localized bulge in the AF, the disc material is displaced (ie., the NP has protruded through the inner layers of the AF/a true herniation)?
Protrusion
What is it called when the NP has protruded through all layers of the AF, but remains attached to the disc of origin?
Extrusion
What is it called when a free disc fragment is located in the epidural space can migrate superiorly, inferiorly, medially, or laterally?
Sequestration
What ROM is damage to the annulus fibrosis of a disc (herniation) associated with?
fully flexing the spine for repeated or prolonged periods of time
What to the rotatores and intertransversarii do??
Small rotator muscles of the spine (intertransversarii laterally flex)
Where do rotatores and intertransversarii attach?
attach to adjacent vertebrae and are delineated as creating axial twisting torque
Rotatores and intertransversarii are highly rich in _______.
muscle spindles (4-7 times more rich than multifudus)
What do the muscle spindles in rotatores and intertransversarii function as?
length transducers or vertebral position sensors at every thoracic and lumbar joint
What are the major extensors of the thoracolumbar spine?
longissimus, iliocostalis, and multifudus groups
What have fiber typing studies shown about the lumbar and thoracic regions of extensors (iliocostalis and longissimus)?
Thoracic sections contain about 75% slow-twitch fibers, while lumbar sections are more evenly mixed
How are pars thoracis muscles (iliocostalis and longissimus) oriented and attached?
attach to ribs and vertebral components and have relatively short contractile fibers with long tendons that run parallel to the spine to their origins on the posterior surface of the sacrum and medial border of the iliac crests
What sort of force to the pars thoracic muscles (iliocostalis and longissimus) have? why?
they have the greatest possible moment arm and thus produce the greatest amount of extensor moment with a minimum compressive penalty to the spine
What do the lumbar components of the iliocostalis and longissimus do? why?
generate posterior shear force on the superior vertebrae with extensor moment.
They generate posterior shear force to counteract anterior force caused by hip rotation in the normal lifting position.
What do the multifudus muscles do?
involved in producing extensor torque but only provide ability for corrections or moment support at specific joints that may be the foci of stresses
What is the NIOSH Action Limit Compression?
3300 Newtons (supermans are bad.)
What is the functional significance of the abdominal fascia?
transmit force to fascia and abdominal muscles on the opposite side of the abdomen
What is the major trunk flexor?
rectus abdominis
Why is the rectus abdominis partitioned into sections?
to limit bulking upon shortening and have a bead effect (transmits forces from oblique muscles)
How is the rectus abdominis activated?
all sections are activated together or at similar levels during flexor torque generation
How are the obliques activated?
regionally activated (and have functional separation between upper and lower sections)
What are the 3 layers of the abdominal wall involved in flexion (out to in)?
external oblique, internal oblique, and transverse abdominis
What are the 3 layers of the abdominal wall attached to? What does it do?
linea semilunaris
flexor potential enhanced (redirects oblique forces down rectus sheath to effectively increase flexor moment arm)
What do the obliques do?
involved in torso twisting and lateral bending… play a role in stabilization during compression
Combination of _________ with _________ enhances stability.
transverse activation
elevated intra-abdominal pressure
What should you ask when taking patient history?
(L)ocation (O)nset (D)uration (R)adiation (F)requency (I)ntensity (C)haracterize (A)ssociated symptoms (R)elieving (A)ggravating
What does deep, aching, boring pain typically mean?
bony tissue origin
What dull, achy, sore, burning, and cramping pain mean?
muscle/fascia origin
What does sharp, knife-like, shooting, lancinating, tingling, burning, numbness, and weakness mean?
nerve origin
What does burning, stabbing, throbbing, tingling, and cold mean?
vascular origin
What doe deep pain, cramping, and stabbing mean?
visceral origin
What is the probable cause when flexion relieves pain?
facet joint involvement, low-back strain, or lateral stenosis
What is the probable cause when extension relieves pain?
disk involvement, nerve root irritation (disk herniation)
What is the probably cause when rest relieves pain?
neurogenic claudication
Initial Hypothesis: Reports of restricted motion of lumbar spine associated with LB or buttock pain exacerbated by pattern of movement that indicates possible opening or closing joint restriction (i.e., decreased extension, right sidebending, and right rotation)
Zygapophyseal Joint pain syndromes
Initial Hypothesis: Reports of centralization or peripheralization of symptoms during repetitive movements or prolonged periods in certain positions
Possible discogenic pain
Initial Hypothesis: Reports of lower extremity pain/paresthesias, which is greater than LBP. May report experiencing episodes of lower extremity weakness
Possible sciatica or lumbar radiculopathy
Initial Hypothesis: Pain in lower extremities exacerbated by extension and quickly relieved by flexion of spine
Possible spinal stenosis
Initial Hypothesis: Patient reports of recurrent locking, catching, or giving way of low back during active motion
Possible lumbar instability
Initial Hypothesis: Reports of LBP exacerbated by stretch of either ligament or muscles. Might also report pain with contraction of muscular tissues
Muscle/ligamentous sprain/strain
What are red flags for LBP?
- Severe trauma
- Fever or recent bacterial infection
- Saddle anesthesia
- Severe or progressive neurological complaints
- Recent onset bladder dysfunction associated with onset of LBP
- Unexplained weight loss
- History of cancer
- IV drug abuse, HIV, immunosupression
- Pain worse with recumbency or worse at night
10 Constant progressive, non-mechanical pain - Age of onset < 20 or >55 years
What are tests with good sensitivity good for?
ruling out disorders if negative
What are tests with good specificity good for?
ruling in disorders if positive
What are yellow flags?
factors that increase risk of developing, or perpetuating chronic pain and long-term disability including work loss associated with LBP
When should patients be referred?
signs of cauda equina or rapidly progressing neurological deficits, suspected fracture, infection, or cancer
What should a clinician consider if a patient has multilevel neurological involvement?
imaging
What should a clinician consider if a ptient is unresponsive to care after 1 month?
imaging or referral
L1 myotome
hip flexion
L2 myotome
hip flexion, hip adduction
L3 myotome
knee extension
L4 myotome
ankle dorsiflexion
L5 myotome
foot/toes dorsiflexion
S1 myotome
plantar flexion foot/toes, ankle eversion, hip extension
S2 myotome
knee flexion
S3 myotome
foot intrinsics
Which nerve roots does the patellar reflex test?
L3/L4
Which nerve roots does the medial hamstring reflex test?
L5/S1
Which nerve roots does the lateral hamstring reflex test?
S1/S2
Which nerve roots does the posterior tibial reflex test?
L4/L5
Which nerve roots does the achilles reflex test?
S1/S2
PIVM has generally poor reliability when assessing _______ and moderate reliability assessing_______.
limited/excessive movement
pain
How are the spinal motions coupled in the lumbar spine in neutral?
ipsilateral SP rotation except L5
How are the spinal motions coupled in the lumbar spine in flexion?
contralateral SP rotation
What are some general outcome measures listed?
- Modified Oswestry Disability Index (MODI)
- Roland-Morris Disability Questionnaire (RMDQ)
- Fear-Avoidance Beliefs Questionnaire (FABQ)
- Numeric Pain Rating Scale (NPRS)
