Congenital Lumbar Anomalies Flashcards
1
Q
Aplasia
A
- Failure of bone to form
2
Q
Hypoplasia
A
- Failure to grow to normal size
3
Q
Dysplasia
A
- Abnormal growth
4
Q
Supernumerary Part
A
- Extra vertebra/ fingers
5
Q
Arrested Development
A
- Spina bifida
6
Q
Neural Tube Defects
A
- Result from failure of the neural tube to close normally during the 3rd and 4th weeks after conception (5th and 6th weeks of gestation)
- 2nd most prevalent congenital anomaly worldwide, second only to cardiac malformations
7
Q
Neural Tube Defect Risk Factors
A
- Inadequate folate intake
- Use of folic acid antagonists (methotrexate)
- Genetic factors causing abnormal folate metabolism
- Antiepileptic drugs (Valproate; Carbamazepine)
- Diabetes (maternal)
- Amniotic bands; disrupt neural tube development
8
Q
Spinal Dysraphism
A
- Incomplete fusion or malformation of bone and neural structures of the spine region by errors in the closure of the neural tube
9
Q
Spina Bifida Aperta
A
- Open spinal dysraphism
- Meningocele- herniation of the meninges through the defect
- Meningomyelocele- herniation of the meninges and nerve roots through the defect
- Characterized by a cleft in the spinal column, w/ herniation of the meninges (meningocele) or meninges and spinal cord (myelomeningocele) through the defect
10
Q
Spina Bifida Occulta
A
- Closed (Occult) spinal dysraphism
- No herniation of the meninges through the defect
- Characterized by failure of fusion of the vertebral bodies due to abnormal fusion of the posterior vertebral arches, w/ unexposed neural tissue; the skin overlying the defect is intact.
- More common and least severe forms consist of isolated vertebral bony defects
- Often see an area of skin over the segment w/ course hair and perhaps some discoloration
- Can occur w/o any external manifestation
- may see skin change, dimple, hairy patch, hemangioma
- Detectable only by x-ray, CT-scan, etc
- Occurs in ~10% of the pop.
11
Q
Spina Bifida
A
- Most common congenital abnormality of the spine
- May occur at any level, but mot frequently at L5-S1 (last part of vertebral column to close)
- Major defects which are obvious at birth have incidence of 2 per 1,000 births
12
Q
Tethered Cord Syndrome
A
- Stretch-induced dysfunction of the caudal spinal cord and conus
- Symptoms: back pain, bladder dysfunction, leg weakness, calf muscle atrophy, diminished or absent deep tendon reflexes, and dermatomal sensory loss
- Orthopedic signs include progressive scoliosis and various foot deformities
13
Q
Tethered Cord Syndrome Symptoms
A
- Toddlers and children present w/ progressive motor and sensory dysfunction, which may include gait abnormalities and loss of bladder control
- Progression of symptoms such as motor and bladder problems
- Children begin to stumble after they have learned to walk normally, then they start dribbling urine after having achieved successful toilet training
- Older children and adolescents are more likely to complain of back pain exacerbated by exercise
- Later, they develop musculoskeletal signs and symptoms: common findings include foot drop (weakness of ankle dorsiflexion) and scoliosis
- Adults may develop back pain, leg pain and scoliosis which may be difficult to distinguish from other more common causes of chronic back pain
14
Q
Spina Bifida Physical Effects
A
- Will more often be treating pts w/ spina bifida occulta
- Ligamentous asymmetry and mal-loading stress is a common cause of pain
- Some reports of sacral base unleveling
- therefore evaluate for heel-lift, sacral dysfunctions, innominate dysfunctions
15
Q
Spina Bifida Treatment
A
- Most OMT will be myofascially oriented
- soft-tissue
- myofascial release
- counterstrain
- facilitated positional release
- Referral to neurologist (if not done yet) for co-management is recommended
16
Q
Spondylolysis
A
- Represents fracture or anomalous development (defect) of the pars interarticularis, usually of the 5th lumbar vertebra
- Rarely occurs <5
- More common at age 7 or 8
- History of minor trauma is common
- Injury is seldom severe
17
Q
Spondylolisthesis
A
- Usually due to stress or fatigue fractures of the pars interarticularis of the named vertebrae
- Roughly 5% of the pop. has this and half will be symptomatic w/ it
- Usually L5 on S1, or L4 on L5
- X-ray in weight-bearing is more accurate
- LBP is usually an ache in back, butt, leg
18
Q
Spondylolisthesis Classifications
A
6 types
- Dysplastic (congenital)
- Isthmic (A and B)
- Degenerative
- Traumatic
- Pathologic
19
Q
Dysplastic/Congenital Spondylolisthesis
A
If severe displacement of L5 occurs there may be pressure on:
* cauda equina * nerve roots - Back pain w/ or w/o sciatic may occur - Presents during childhood - May be assoc. w/ spina bifida
20
Q
Isthmic Spondylolisthesis
A
- Most common type 51% of all sponylolisthesis
- 2x greater in males but females 4-6x more symptomatic
- Defect in pars interarticularis
- spondylolytic spondylolisthesis
- B/L or U/L
- Most common type in pts. <50
- Probably due to repeated micro-fractures
21
Q
Degenerative Spondylolisthesis
A
- 25% of all spondylolisthesis
- Secondary to degenerative changes in
- facet joints
- intervertebral discs
- Due to long standing intersegmental instability
- Occurs most commonly at L4
- Seldom before age 40
- Women:men = 4:1
- African American:white = 3:1
- Instability and chronic LBP
22
Q
Traumatic Spondylolisthesis
A
- 1% of all spondylolisthesis
- Fracture in vertebra other than pars
- articular processes
- pedicles
- Slip occurs gradually
23
Q
Pathologic Spondylolisthesis
A
- 2% of all spondylolisthesis
- Very rare
- Generalized or localized bone disease
- osteogenesis imperfecta
- infection
- tumor
- paget’s
24
Q
Spondylolisthesis Pain Presentation
A
Intermittent pain
- Usually follows a stressful injury (strain, sprain)
- Aggravated by activity (running, walking, standing)
- Relieved by rest
25
Q
Spondylolisthesis Physical Presentation
A
- B/L tight hamstrings
- Secondary ‘thoracic’ and ‘lumbosacral’ kyphosis
- loss of waistline
- Spinous process step-off w/ grade II to III
- usually easier to feel w/ non-spondylolytic type
26
Q
Spondylolisthesis Susceptible Populations
A
- Most common cause of LBP and sciatica in children and adolescents
- Gymnasts; have hypermobile spines that are subject to constant trauma
- Dancers; have low body weight, develop amenorrhea, and become osteoporitic
- Paratroopers; unknown if it causes spondylolisthesis or irritates an existing problem
27
Q
Radiographic Eval for Spondylolisthesis
A
- AP and lateral views usually ordered for initial work-up
- Oblique views for spondylolysis
- U/L- collar on “scotty-dog”
- B/L- collar or head/neck decapitated
28
Q
Spondylolisthesis Treatment
A
- Usually conservative w/ pt education, controlled activities, med prn., sometimes a lumbar brace and OMM
29
Q
Spondylolisthesis Surgery
A
Operative for spondylolisthesis
- Anterior fusion
*interbody
- Lateral fusion (in situ posterolateral)
*intertransverse process
- Instrumental
*immediate stability
Depends on case and choice of surgeon
30
Q
Spondylolisthesis OMM Treatment
A
- Will generally be treating 1st or 2nd grade slips
- Must not put undo stress directed ventrally thru unstable level (especially w/ pars defect)
*therefore, prone soft-tissue techniques not indicated - DO NOT PUT IN EXTENSION
- Lateral recumbent position is much safer
- Most OMT will be myofascially oriented
*Soft tissue
+supine hip flexion and frog technique
+lateral recumbent techniques
*myofascial release
+supine lumbar and sacral release and/or traction
31
Q
Facet Tropism
A
- Unequal size and/or angling of the zygo-apophyseal joints of a vertebrae (also called facet asymmetry)
- Can cause Hypo- or Hypermobility
32
Q
Facet Tropism Symptoms
A
- Myofascial imbalance
- Articular symptoms may be on hypo- or hypermobile side
- Hypomobile side (sagittal)
- HVLA w/ gapping techniques
- muscle energy
- Hypermobile side: avoid HVLA techniques
33
Q
Facet Tropism Treatment
A
On side of hypermobility
- Counterstrain, Myofascial release
- Facilitated positional release (FPR)
- Probably not HVLA techniques
34
Q
Bertolotti’s Syndrome
A
- Characterized by anomalous enlargement of the transverse process(es) of the most caudal lumbar vertebra which may articulate or fuse w/ the sacrum or ilium and cause isolated L4/5 disc disease
- A cause of back pain in young ppl
35
Q
Transitional Segments Treatment
A
- Techniques recommended are: soft tissue, myofascial release, muscle energy, FPR
- Intended to assist the body in compensating for the abnormality that is present
36
Q
Management of Lumbar Anomalies
A
Conservative
- Might what to start therapy in water
- Rest or immobilization (bracing)
- Stretching and therapeutic exercise
- aquatics
- CORE stabilization/ strengthening
- Analgesics, NSAIDs, muscle relaxants
- OMT
- Avoidance behavior
