Chapter 4 - Lumbar Flashcards
Why are disc herniations common in the lumbar area?
Posterior longitudinal ligament begins to narrow at L1
Thoracic and lumbar - nerve root is (above/below)
BELOW
Lumbar nerve roots - exit through the ___ aspect of the intervertebral foramina
SUPERIOR (because they are extending down from the conus medullaris)
Erector spinae group - muscles
Spinalis, Iliocostalis, Longissimus
Psoas - origin and insertion
O = T12-L5 vertebral bodies I = lesser trochanter
Psoas syndrome - other findings (3)
Precipitated by ____
Pelvic side shift
Positive Thomas test
Upper lumbar vertebral SD
Prolonged shortening
Iliac crest - level?
L4-L5 disc
Umbilicus - level?
L3-L4 disc
Facet trophism - define
Cause?
Importance?
Asymmetry of the facet joint angles - one may point more medially or laterally than normal
Congenital anomaly (MC in lumbar spine)
VERY difficult for the vertebrae to move against each other – THUS EARLY DEGENERATIVE CHANGES
Sacralization - define
Cause?
Importance?
One or both TPs of L5 get fused with the sacrum
Congenital anomaly
Altered L-S junction –> early disc degeneration
Lumbarization - define
Failed fusion of L5 to S1
Spina bifida - what is the structural defect?
Failed closure of LAMINA (connects TP to SP)
Main motion of lumbar spine
Flexion, Extension
L5 SB –> sacral ____
OBLIQUE axis engaged on SAME side
L5 Rot –> sacral ____
Rotation to OPPOSITE side
Ferguson’s angle
Normal?
Angle between HORIZONTAL axis and axis of SACRAL BASE
25-35 degrees
Acute back pain - options?
Fracture Strain Herniation Infection (osteomyelitis, meningitis) Referred pain
Pain in low back, buttock, posterior lateral thigh
Increased with activity or prolonged standing or sitting
Increased muscle tension
Diagnosis?
Treatments?
Lumbosacral SD (back strain/sprain)
Counterstrain, ME, HVLA
L4-L5 disc herniation - which nerve root affected?
L5-S1 disc herniation - which nerve root affected?
L5
S1
Numbness/tingling w/ sharp, burning, shooting pain down leg, worse with flexion of lumbar spine
Decreased reflexes and strength and sensory
Diagnosis?
Test that will be positive?
Radiology?
Treatment (for most)?
Herniated disc
Straight leg raise
MRI (gold standard)
Bed rest, indirect OMT, gentle direct OMT
Organic causes of psoas syndrome (6)
Importance?
Appendicitis Sigmoid colon dysfunction Ureteral calculi Ureter dysfunction Metastatic prostate carcinoma Salpingitis
Must be ruled out before treatment for mechanical cause
Low back pain radiating to groin, achy
Increased when standing or walking
Positive test? **Tenderpoint? ***Lumbar SD? Pelvic finding? Sacral finding? Other muscular finding?
Psoas syndrome
Positive Thomas test **Tenderpoint medial to ASIS ****L1-L2 Flexed, R and SB to SAME side Pelvic shift test to CONTRALATERAL side Sacral dysfunction on OBLIQUE axis CONTRALATERAL piriformis spasm
Psoas syndrome - treatment
Ice (NOT heat)
**Counterstrain to tenderpoint
**ME or HVLA to high lumbar dysfunction
Stretching (ONLY if CHRONIC)
Pain in low back, achy, shooting to leg w/ paresthesias
Worsened by extension (standing, walking, supine)
3 causes?
Radiology findings?
Treatments?
Spinal stenosis
- Hypertrophy of facet joints
- Calcium deposits w/in ligamentum flavum and PLL
- Loss of intervertebral disc height
Osteophytes, decreased disc space, foraminal narrowing
- OMT to decrease restrictions and improve ROM
- PT, NSAIDs, Low dose tapering steroids
- Surgery
Low back, buttock, and/or posterior thigh pain, achy Increased w/ extension Tight hamstrings bilaterally Stiff leg, short stride, waddling gait NO neurologic deficits
Positive exam finding?
Radiology finding?
Treatments?
Spondylolisthesis
Step-off sign (forward displacement of a SP)
Forward displacement of one vertebrae on another
OMT - reduce lumbar lordosis and SD (NO HVLA)
Weight loss, no high heels, avoid flexion
Heel lifts, lumbo-sacral orthotics
Define…
- Spondylolisthesis
- Spondylolysis
- Spondylosis
Listhesis = forward displacement of vertebrae
Lysis = defect in pars interarticularis w/o displacement
Losis = degenerative changes w/in intervertebral disc + ankylosing of adjacent vertebral bodies
Scotty dog
What view?
SpondyloLYSIS - the black “collar” on the dog is the fracture
OBLIQUE view
**Diagnosing spondylolisthesis vs. spondylolysis on X-ray
Listhesis = LATERAL view Lysis = OBLIQUE view
Sharp low back pain Saddle anesthesia Decreased DTRs Decreased rectal sphincter tone Loss of bowel and bladder control
Cause?
Treatment?
Danger?
Cauda equina syndrome
Massive CENTRAL (directly posterior) disc herniation
Emergent surgical decompression
Irreversible paralysis
Grading spondylolisthesis…
Grade 1
Grade 2
Grade 3
Grade 4
1 = 0-25% 2 = 25-50% 3 = 50-75% 4 = 75+%
