Chapter 25 - The Spine Flashcards
facet joint dysfunction
localized pain over the joint, can be acute or insidious onset. pain in all movements other than flexion.
suspect facet joint dysfunction, what tests should be performed. what other injuries need to be ruled out?
disc lesions, spondy, stenosing etc
perform tests for disc lesions such as quadrant, valsalva, tension signs, SLR test, etc.
Pain patterns and symptoms of facet joint dysfunction
pain in all movements except flexion
spasming muscles
may be degenerative in nature causing nerve entrapment and associated problems
Lumbar Disc Pathology
rupture - acute onset
can also be degenerative
lumbar disc pathology pain patterns
pain at disc area - also pain along spinal nerve root.
paint down low back and through butt and thigh, possibly into the food
may be limited in all motions
when suspecting lumbar disc problem, what tests?
valsalva, SLR test, well cross SLR, milligram’s, tension signs, femoral nerve tension sign,
-tests that cause stretching nerve, or look for ‘space occupying lesion’
disc lesion - what imaging
MRI
DDx for disc lesion
spondy, stenosis, prirformis syndrome, facet joint dysfunction
Lordosis
increase curvature of lumbar
Kyphosis
increase curvature of thoracic
briefly describe the anatomy of the spine
cervical, thoracic, lumbar, sacrum, cocyx 7 C 12 T 5 L 33 vertebrae
lordotic curve
kyphotic curve
lordotic curve
articulation between the vertebral bodies is what type of joint? what movements occur here
cartilaginous
forward gliding, lateral gliding, compression and distraction
facet joints in the vertebrae are what type of joint?
synovial joint.
name the major ligaments of the spine. what movements do they restrict?
anterior longitudinal - restrict extension
posterior longitudinal - restrict flexion
supraspinous - attaches at every spinous process - limits flexion and rotation of the spine
muscles that extend the spine
erector spinae
- iliocostalis
- longissimus
- spinalis
spinal cord anatomy
extends from foramen magnum to L1-L2 where it forms the caudal equina
how many pairs of spinal nerves
31
roots of nerves
anterior (motor)
posterior (sensory)
injuries occurring above L3 - what must one worry about?
spinal cord damage
name the plexuses and the nerves they involve
Cervical ( C1-C4 ) Brachial (C5-T1) Lumbar (L1-L4) Sacral (L4-S4) Coccygeal (S4-S5)
name the nerves of brachial plexus
axillary radial msuculocutaneous ulnar median
axillary - perform nerve test
abudcts arm , laterally rotates arm
radial - perform nerve test
extends/flexes elbow
extends writs and fingers
thumb muscles
musculotaneous perform nerve test
flexes arm, and forearm
ulnar - perform nerve test
flexes wrist and fingers, abducts/adducts fingers
thumb muscle - palmar muscles
median perform nerve test
pronates,
flexes wrist and fingers
-thumb musclse and thenar/palmar muscles
movements of the vertebral column
flexion, extension, lateral flexion, rotation
trunk rotation
external/internal obliques
lateral flexion
quadratus lumborum, obliques, lats, iliopsoas, rectus abdominus on involved side
flexion
75% occurs at lumbosacral joint
lengthening of deep and superficial back muscles
contraction of abs, obliques and hip flexors
football helmets do not protect against what?
neck injuries
what is spearing?
athlete uses the helmet as a weapon by striking the opponent with its top
most serious football cervical injuries result from what MOI?
axial loading while spearing
neck flexion at the time of contact can cause what type of injuries
fracture or dislocation
most catastrophic diving accidents happen in how deep of water
less than 5 feet with arms not extended in front of face
read NATA positions statement on head down tackiling and spearing
now
managing low back pain
avoiding stress, correcting biomechanics, correct lifting techniques, core stabilization
when taking the history of the spine, what is most critical to know? give examples of questions
if the spinal cord was damaged
- what happened?
- did you hit someone with or land directly on top of your head?
- were you knocked out or unconscious?
- pain in your neck? tingling or numbness anywhere?
- equal muscle strength in hands?
- unable to move ankle or toes?
what are you looking for in the observation portion of a spinal evaluation
posture abnormalities look from all angles kyphosis forward head swayback - anterior shifting of the pelvis lordosis scoliosis flatback level shoulders, symmetry -ask the patient to perform all movements - note painful ones -level pelvis -unusual curve in lumbar area -sitting, standing, and lying
common cause of thoracic pain
dysfunction of joints - usually facet joint
-associated with increased pain when placing chin on chest
Trendelenburg Test
tests for glute med weakness
-lift uninvolved leg
positive test: pelvis lowers on non-weight bearing side
nerve root impingement, damage to nerve, muscle weakeness
Thomas Test
Hip flexor tightness - supine
if leg cannot be brought all the way back - tightness of that hip flexor
if opposite knee bends - tightness of that iliopsoas group (leg examiner is holding)
if opposite leg lifts up off the table - tightness of opposite hip flexors
Ely’s Test
hip flexor tightness - prone (specifically rectus femoris)
passive flexion of the knee results in hip flexion,
causes hip to rise up off the table
Beevor’s Sign
hook lying position
pt performs abdominal curl
look for movement of the umbilicus
- segmental involvement of the nerves innervating the rectus abdominis (T5-T12)
- umbilicus will move toward stronger muscle group
Valsalva test
pt is sitting,
bear down, or blow air through fist
-increases intrathecal pressure - paint secondary to space-occupying lesion (herniated disk, tumor, osteophyte)
Milgram Test
supine
patient holds bilateral leg raise for 30 sec
-increases pressure on lumbar nerve roots.
-if there is a disk lesion - both legs will drop
pt cannot hold legs, cannot lift leg, or experiences pain is a positive test sign
Kernig’s Test
supine - pt performs SLR until pain occurs, when pain occurs, pt flexes the knee. pn should be relieved when knee flexes
nerve root imingement secondary to a bulging disk or bony entrapment or irritation of the dural sheath or irritation of the meninges
Brudzinski’s test
if not pn is is present during Kerngi’s Test, elongate the spine by flexing the cervical spine
hyporflexia
flaccidity of ht muscles, denervation atrophy
due to lower motor neuron trauma
SLR Test
test of lasegue
passive raise leg, until pn is felt or full ROM achieved,
postive test: pn at end of ROM
- radiating pn
- highly significant is pn is at 30 degrees or less of hip flexion
implies: Sciatica
pn felt before end of ROM (70) may involve disk
lower leg to point of no pain and dorsiflex the ankle, if no pain is felt - the prior pain was do to tight hamstrings
Well (Cross) SLR Test
elevate unaffected leg
positive test: pain experienced on the side opposite being raised
-large space occupying lesion
Slump Test
pt is sitting over edge of table slump shoulders - apply overpressure flex neck extend knee dorsiflex the ankle repeat steps on opposite side
-if pn is felt anywhere - relax the current position to relieve pain and then redo the position to see if symptoms reappear
sciatic pain or reproduction of other neurologic symptoms
impingement of dural lining, spinal cord, or nerve roots
Quadrant Test
pt is standing - moves into extension followed by side bending and rotation to the affected side
-examiner provides overpressure through the shoulders
positive test: reproduces pain
radiating pn: compression of the intervertebral foramina impinging the lumbar nerve roots
local pain - facet joint pathology
Run through a neurologic screen of the Lower Extremity
L1/L2 - hip flexion L3 - knee extension L4 - dorsiflexion L5 - great toe extension S1 - eversion S2 - knee flexion
L2-L4 - patellar reflex
L5-S1 - achilles tendon reflex
S2 - hamstring tendon reflex
Femoral Nerve Stretch Test
prone - pillow under abdomen
leg is bent - passively extend hip
postive test: pn at anterior and lateral thigh
nerve root impingement at L2-L4
associated with false positives
Tension Sign
Supine - hip flexed, knee flexed 90/90
palpate tibial portion of the sciatic nerve
extend knee
tenderness and pain
sciatic nerve irritation
Bowstring
variation of tension sign
extend knee until pain, flex knee to relieve pain, press the nerve to reestablish symptoms
Single Leg Stance Test
pt is standing, lifts on leg, extends back, repeat on opposite leg
pain is noted in the lumbar spin or SI area
shear forces on pars inarticularis by the iliopsoas pulling the vertebrae anteriorly, causing pain
FABERE (Patrick’s), Gaenslen, Compression/Distraction
SI dysfunction
review upper motor neuron screens
C4 - shoulder - shoulder raise
C5 - deltoid - abduction - biceps reflex
C6 - lateral aspect of forearm, elbow flexion - brachial reflex
C7 - middle finger/palm - elbow ext - triceps reflex
C8 - median lower forearm - opposition
T1 - median upper arm - armpit - finger abduction
Upper Motor Neuron Lesions Tests
Babinski - bottom of foot
-great toe extends and other toes splay
Oppenheim - down the lower medial leg
-great toe extends and other toes splay or patient reports hypersensitivity
Cervical Compression Test
reproduces pain symptoms
axial load
-compression of the facet joints and narrowing of the intervertebral foramen resulting in pain
spurling test
axial load with lateral bending
nerve root impingement by narrowing of neural foramina
Cervical Distraction test
pt is supine
should relieve symptoms
-implies that compression of facet joints and or stenosis is causing pain
Vertebral Artery Test
+ dizziness, confusion, nystagmus, unilateral pupil changes, nausea
implies: occlusion of the cervical vertebral arteries
Shoulder Abduction Test
hand on top of head for 30 sec
+decrease in symptoms due to decreased tension on the nerve root
implies: herniated disk or nerve root compression
Brachial Plexus Traction Test
push head away from shoulder
+ reproduces pain or paresthesia throughout involved extremity
imples: brachial plexus neuroplaxia
- tension for pn on side being stretched
- nerve root compression for pn on side being bent towards
Adson’s Test
tests for Thoracic Outlet Syndrome
pull arm away - take pulse, turn head towards examiner
+ radial pulse disappears or diminishes
implies: subclavian artery is occluded between the anterior and middle scalene muscles and the pec minor
Allen Test
tests for Thoracic Outlet Syndrome
abduct and ext rotate arm, head looks away
take pulse
+ pulse diminishes or disappears
pec minor is compression the neurovascular bundle
Military Brace Position TEst
tests for Thoracic Outlet Syndrome
pull arm back, pt looks up
take pulse
pulse disappears or diminishes
subclavian artery is blocked by the costoclavicular structures of the shoulder
Roos test
for Thoracic Outlet Syndrome
ecto/meso/endo - morph
ecto - tall skinny
meso - body builder
endo - short fat
Spondyalgia
pain arising from the vertebrae
Spondylitis
inflammation of the vertebrae
Spondylizema
downard displacement of a vertebra caused by degeneration of the one below it
spondylolithesis
forward slippage of a vertebra on the one below it
spondylolysis
degeneration of a vertebral structure secondary to repetitive stress
-usually affects the pars inarticularis
-collared scotty dog
spondylopathy
any disorder of the vertebrae
spondylosis
arthritis or osteoarthritis of the vertebrae; results in pressure being placed on the vertebral nerve roots
step deformities often occur at
L4/L5 and S1
Spinal Stenosis
narrowing of the spinal canal or intervertebral foramen
-degeneration associated with aging
-pn with walking, numbness, tingling, muscle weakness, radiating pn, leg pn with standing resolved with sitting,
intervertebral disk lesions
degeneration of disk causes loss of water from the nucleus pulpous
protusion - prolapse - extrusion - sequestration
many remain asymptomatic
s/s - radicular pain insidious onset, repetitive stress, changes in body position are painful -slow, deliberate gait due to pain and pressure -flattened lumbar spine -standing with lateral shift
tests: femoral nerve stretch test, tension sign
Scheurermann’s disease
juvenile kyphosis
vertebral bodies wedge anteriorly , creating an abnormally rounded spine
dysarthria
speech impairment caused by dysfunction of the muscles and joints associated with speech
dysphasia
speech impairment caused by a brain lesion
myelopathy
diseases that affect the spinal cord
primary movement at atlanto-occipital joint
C0-C1 articulation
flexion and extension
atlanto-axial joint primary movement
cervical rotation C1-C2
why is the superior cervical region of the spine prone to acute injuries
lack of bony restraint of substantial facet joints of lower vertebra increasing case of subluxations
coupled motion
the association of one motion about an axis with other motion around a different axis.
cervical spine extension causes a decrease in..
space within the foramen where the nerve root pass
orientation of major spinal ligaments from posterior to anterior
supraspinous ligament interspinous ligament ligamentum flavum posterior longitudinal ligament (vertebral bodies) anterior longitudinal ligament
vertebral disks are not found where?
at C0-C1 and C1-C2
cervical plexus
composed of C1-C4
where is the pars inarticularis, why is it notable?
area between the superior and inferior facets of a vertebra
common site of stress fractures in the lumbar spine
Waddell signs
physical findings such as pain with axial loading, widespread tenderness, and an excessive show of emotion that may be present in patients with greater behavioral influences on their pain
incontinence
loss of bowel or bladder control
Café-Au-Lait spots
normally occurring skin discolorations or may represent collagen disease or neurofibromatosis
neurofibromatosis
increased cell growth of neural tissues; normally a benign condition; pain possible secondary to pressure on the local nerves
faun’s beard
spina bifida occulta
step off deformities indicate
spondylolisthesis
what to palpate on the neck
spinous process, transverse process, traps, hyoid, sternocleidomastoid, scalene, thyroid cartilage, carotid artery, lymph nodes under the mandible
