Anatomy and Classification of Lower Back Pain

Question 1

Lumbar Vertebral Body:

1. Designed to support ___________ loads
2. Internal Structure: _______ shell with cancellous cavity
3. Trabeculae: strong, but ______ ________ load bearing structure
4. ________ _________: spaces between trabeculae for blood supply and venouse drainage

Answer 1

1. Longitudinal
2. Cortical
3. Light Weight
4. Verteral Spongiosa

Question 2

Lumbar Vertebrae Pedicles:

1. Cylindrical with thick walls, ________ center
2. Enables them to ______ motion in ___ ___________

Answer 2

1. Hollow
2. Resist, All Directions

Question 3

Lumbar Vertebrae Posterior Elements (4)

Answer 3

1. Artiular Processes (inferior and superior)
2. Spinous, Transverse, Accessory, and Mamillary Processes
3. Lamina
4. Pars Interarticularis

Question 4

Definition: Processes that form lumbar synovial joint that locks and prevent forward sliding and twisting of vertebral bodies

Answer 4

Term: Inferior and Superior Articular Processes

Question 5

Definition: Processes for lumbar muscular attachment, processes also acts a levers

Answer 5

Term: Spinous, Transverse, Accessory, and Mamillary Processes

Question 6

Definition: Transmits forces from spinous process or inferior articular process

Answer 6

Term: Lamina

Question 7

Definition: Between superior and inferior articular processes, significant junction between vertical lamina and horizontal pedicle

Answer 7

Term: Pars Interarticularis

Question 8

Q: What two muscles attache to vertebral bodies?

Answer 8

1. Crura of the diaphragm
2. Psoas

Question 9

Q: Where does the multifidi muscle attach?

Answer 9

Mamillary Process

Question 10

Q: Define the three borders of the vertebral canal.

Answer 10

1. Anterior = Vertebral Body
2. Lateral = Pedicle
3. Posterior = Lamina

Question 11

Q: List the advantage and disadvantage of the trabecular structure of vertebral bodies

Answer 11

1. Advantage: light weight and stability to longitudinal forces
2. Disadvantage: provide limited stability to horizontal and rotational forces

Question 12

Q: What structure of the lumbar vertebrae resist horizontal and rotational forces?

Answer 12

The posterior elements (articular processes, processes, lamina, pars interarticularis)

Question 13

Q: What structure forms the neural arch?

Answer 13

Pedicles

Question 14

Q: What structures form the intervertebral foramina?

Answer 14

The vertebral notches above and below the pedicles of each vertebrae

Question 15

Q: List the two types of stress fractures that occur in lumbar pedicles

Answer 15

1. Fatigue
2. Stress: due to repetitive large activity of the spine, contralateral spondyloolysis, prior lumbar sx. Stress can be shear/twisting followed by hyperextension/flexion. Extremely rare cause of LBP

Question 16

Zyapophyseal Joints

1. Typical __________ joint
2. Most cases ___ or ___ shaped to resist both ______ _______ and ________ motions
3. Capsule has loose superior and inferior poles for ____

Answer 16

1. Synovial
2. C, J, Forward, Sliding, Rotary
3. Fat

Question 17

Facet Orientation

1. Orientation is defined by the average plane of the joint relative to the __________ plane
2. The ability to restrict forward displacement depends on the orientation of the ___________ articular facet backward.
3. The ability to restrict rotary motion depends on the ________ orientation of the __________ facet.

Answer 17

1. Sagittal
2. Superior
3. Medial, Superior

Question 18

Facet Orientation During Lumbar Degradation

1. Spodylolithesis is associated with _________ orientation
2. Osteoarthritis is associated with _________ orientation
3. Frontal plane orientation will resist ________ displacement but will be less capable of limiting __________
4. Sagittal plane orientation will resist ________ movements but will be less capable of limiting _________ displacement.

Answer 18

1. Sagittal
2. Sagittal
3. Forward, Rotation
4. Rotational, Forward

Question 19

Q: What 3 joints are formed by the intervertebral joint?

Answer 19

1 interbody joint and 2 zygopophyseal joints

Question 20

Q: What are the 2 functions of the lumbar disc?

Answer 20

1. Allow movement between vertebral bodies
2. Transmit load from one vertebral body another

Question 21

Q: How would the intervertebral joint function without the lumbar disc?

Answer 21

1. 2 flat vertebrae could bear weight but would only allow gliding motion
2. If only the joint only had the curved surfaces of the vertebrae it would allow for rocking/rolling but would result in decreased stability to load (due to decreased surface area and tendency to roll)

Question 22

Lumbar Disc Structure

1. Nucleus Pulposis: ______% water/fluid, _______% protoeglycans, _______% collagen
2. Anulus Fibrosis: ______% water/fluid, _______% protoeglycans, _______% elastic, aligned in _________ ____
3. Vertebral Endplate: ________ to vertebral endplate (weak attachment) and _________ to nucleus (strong attachment)

Answer 22

1. 70-90, 65, 15-20
2. 60-70, 50-60, 10, Concentric Rings
3. Hyaline, Fibrocartilage

Question 23

Q: What are the 3 components of the lumbar disc structure?

Answer 23

1. Nucleus Pulposis
2. Anulus Fibrosis
3. Vertebral Endplate

Question 24

Definition: Thick anterior/laterally, thin/tight posteriorly, alternating orientation 65-70 deg

Answer 24

Term: Lamellae

Question 25

Q: List the 3 biomechanical requirements of the lumbar disc.

Answer 25

1. Sustain a longitudinal load 2. Accommodate to movement of the vertebrae 3. Able to sustain stresses withouth injury

Question 26

Ligament: - Sacrum to C2 (then Ant Atlanto-Occipital Membrane) - 4 bands (deepest spans 1 segment) - NOT attached to disc - Resists anterior separation of vertebrae (extension) - Resists anterior bowing of spine

Answer 26

Anterior Longitudinal Ligament

Question 27

Ligament: - Resists separation of posterior vertebral bodies - Serrated, thin over body, expands over disc - Deepest fibers span 2 discs - Attaches to annulus - Long fibers span 3, 4 and 5 segments

Answer 27

Posterior Longitudinal Ligament

Question 28

Ligament: - Lamina to lamina - Paired ligament - Anterior Z-joint capsule - 80% elastin, 20% collagen - Prevents buckling into the spinal cord - Resist excess separation of lamina

Answer 28

Ligamentum Flavum

Question 29

Ligament: - 3 bands running postero-cranially between SP's - Paired with fat - Resist separation of SP's - Limit forward bending

Answer 29

Interspinous Ligament

Question 30

Ligament: - Midline SP to SP - Most studies show that it extends to L3,4, and sometimes (5%) L5 - Usually lacking L5-S1 - 3 layers- deep layer tendonous and reinforced by multifidus

Answer 30

Supraspinous Ligament

Question 31

Q: List the 5 parts of the Iliolumbar Ligament

Answer 31

1. Anterior: well developed, ant TP L5, vertebral body to ant ilium 2. Superior: ant/post fascia thickenings to surround QL 3. Posterior: tip/post border TP L5 to ilium behind origin of QL 4. Inferior: - lower border L5 TP, vertebral body to cross ant S-I ligament 5. Vertical: ant/inf border L5 TP and descends vertically to iliopectineal line of pelvis

Question 32

Ligament: - TP to TP, more membranous - Divides anterior muscles of lumbar spine from posterior muscles - Laterally divided into 2 layers (ant and middle layers of T-L)

Answer 32

False Ligament: Intertransverse Ligament

Question 33

Q: List the 3 Functional Muscle Groups of the Lumbar Spine

Answer 33

1. Anterior-lateral (Psoas) 2. Transverse Process Lateral and Anterior (Intertransversarii Laterales & QL) 3. Behind the Posterior Elements (Lumbar Back Muscles)

Question 34

Multifidus 1. _________ and most medial fibers 2. ______________ attachments from spinous processes 3. __________ innervation 4. _________ stabilizer 5. Stabilize against _________ and ________ moments 6. Create ___________ forcse on the lumbar segment 7. Also has attachments to the _____ \_\_\_\_\_\_\_\_

Answer 34

1. Largest 2. Multi-segmental 3. Segmental 4. Local 5. Flexion, Extension 6. Compressive 7. Joint Capsule

Question 35

Q: What is the T/L fascia combined with?

Answer 35

Transverse Abdominus

Question 36

Lumbar Nerve: - Off spinal cord - Spinal Nerve which lies in intervertebral foramen

Answer 36

Nerve Roots (Dorsal and Ventral)

Question 37

Q: Where does the spinal cord end?

Answer 37

L1-2

Question 38

Lumbar Nerve: - Extension of dura mater and arachnoid mater - As far as Intervertebral foramen

Answer 38

Dural Sleeve

Question 39

Lumbar Nerve: Within dural sleeve, just above intervertebral foramen

Answer 39

Dorsal Root Ganglion

Question 40

Lumbar Nerves: Cross Sectional Area 1. _________ from L1-2 to L4-5 2. _______ has the smallest forament 3. _____ is the largest spinal nerve, occupies \_\_\_\_\_\_% of the foramen and is more susceptible to ___________ \_\_\_\_\_\_\_\_\_\_\_

Answer 40

1. Increases 2. L5-S1 3. L-5, 25-30, Foraminal Stenosis

Question 41

Lumbar Nerves: Dorsal Rami 1. ____ branches from L1-4 2. ____ branches at L5 3. _________ branch: iliocostalis lumborum, some cutaneous 4. _________ branch: longissimus muscle 5. _________ branch: multifidus, interspinous ligament/muscle, Z-joints above and below

Answer 41

1. 3 2. 2 3. Lateral 4. Intermediate 5. Medial

Question 42

Q: The ventral rami enter the substance of what muscles?

Answer 42

Psoas

Question 43

Lumbar Nerves: Sinuvertebral Nerve 1. Recurrent from _______ ramus 2. Mixed Nerve: ________ (Ventral Ramus) and _________ (Grey Rami Communicantes) 3. To _____ at its level and one above

Answer 43

1. Ventral 2. Somatic, Autonomic 3. Disc