L-Spine Pathology Flashcards
What 3 ligaments are continuous systems that wrap the lumbar spine in a “stocking”?
- Supraspinous ligament
- Interspinous ligament
- Ligamentum Flavum
What is the function of the ligamentum flavum in the lumbar spine?
- Forms a roof for the vertebral canal that doesn’t buckle with flexion or extension
What are the 4 key muscles/ muscle groups that stabilize the lumbar spine?
- Multifidi
- Transverse abdominus
- Pelvic floor muscles
- Diaphragm
What force do the multifidi resist?
- Shear
What is a protrusion of a disc?
- Posterior disc buldge without rupture of the outer annulus
What is a prolapse of a disc?
- Nucleus contained only by the outermost fibers of the disc’s annulus fibers
What is an extrusion of a disc?
- Disc material enters the epidural space due to a ruptured annulus
What is a sequestration of a disc?
- Disc material within the epidural space fragments
What are the 3 types of spinal stenosis?
- Central
- Lateral recess
- Foraminal
Where does lateral recess stenosis occur?
- On the lateral aspect of the spinal canal
What is the major symptom of lumbar spinal stenosis? What makes it better? What makes it worse?
- Neurogenic claudication (pain in the legs when walking
- Static standing, walking, and coughing make it worse
- Spinal flexion makes it better
What are 2 ways that arterial ischemic claudication can be differentiated from neurogenic claudication?
- Assess pulse (a neurogenic claudication will have normal pulses)
- Have the patient ride a stationary bike (will provoke arterial; neurogenic will be mostly unchanged)
What muscles should be trained to manage lumbar spinal stenosis?
- Transverse abdominis
- Pelvic floor
- Multifidi
- Diaphragm (?)
What muscles should be stretched when managing lumbar spinal stenosis? Why?
- Stretch hip flexors to reduce lumbar lordosis
How can posture be corrected to help manage lumbar stenosis?
- Encourage flexion when possible, and avoid extension postures/ movements
How can the patient be educated to manage lumbar stenosis?
- Avoid extension of the lumbar spine, as well as quadrant like positions
What type of orthotic can be used to help manage lumbar stenosis?
- If the symptoms are unilateral, put a heel lift in the contralateral shoe
What is a spondylolisthesis?
- Forward subluxation of one vertebra on the vertebra below it
What are 4 subjective reports that are common with spondylolisthesis?
- Generalized back ache
- Gluteal pain
- Lower back weakness
- Lower quarter weakness
What specific movement can be used a clinical sign for spondylolisthesis?
- A pain with return to an extended position from flexion that is made better by contracting the glutes and core before performing the motion
What muscles are strengthened, and which are stretched when managing spondylolisthesis?
- 4 key core muscles trained
- Careful stretching of the iliopsoas to avoid an anterior shear force on the spine
How is the patient educated in managing a lumbar spondylolisthesis?
- Avoid extension movements/ positions and movements that cause shear
What is one of the most common diagnoses in an outpatient setting?
- A sprain-strain of the iliolumbar ligament
How a sprain of the iliolumbar ligament treated during the acute stage? (4 main components)
- Pt education to avoid reinjury/ aggravation
- Modalities and manual therapy for pain control
- Gentle stretching
- Aerobic activities as tolerated
What is the treatment for a ligament sprain of the lumbar region past the acute stage?
- Core training and conditioning
What are 5 red flags that may seem present as lumbar pain?
- Aortic aneurism (Pulsate pain in abdominal region)
- Pyelonephritis (kidney infection)
- Nephrolithiasis (kidney stones)
- Malignant tumors of the spinal column (cords or meninges)
- Metastatic tumors (from: thyroid, prostate, breast, colon, lung…)
How can a metastatic tumor easily be differentiated from a metastatic tumor?
- It is outside of the dura
Where are the 2 locations a tumor may appear as a primary cancer?
- Within dura, but outside of cord
- Within the spinal cord
What are examples of what a job task inventory may entail during an intake/ physical exam of a patient with lumbar spine impairments?
- Lift-carry
- Bend-stoop
- Squat
- Walk
- Sit
- Stand
- Climb
- Environmental exposures
What are 3 scales used to measure a patient’s perception of their disability/ pain?
- Oswestry disability questionnaire
- PACT-Sort
- FABQ
What is assessed during a postural screen of the lumbar spine?
- Start from the head and shoulders
- Observe scoliosis
- Observe rib symmetry
- Check position of: Iliac crests, ASISs, PSISs
- LE symmetry/ length
- Lumbar lordsis
- Pelvic rotation
How can centralization or peripheralization be assessed during the exam?
- Sustained or repeated endrange movements: assess effect on symptoms
What is Gower’s sign?
- Pressing through the hands to move the lumbar spine into extension
When should the painful spinal movements be assessed during the movement assessment?
- Last
How should lumbar extension be assessed for movement?
- Symmetry
- Quality
- Segmental recruitment
How should lumbar flexion be assessed for movement?
- Segmental motion
- Rib humps
- When the pelvis is recruited (lumbo-pelvic rhythm)
- A flattening of the lumbar lordosis
How should lumbar lateral flexion/ rotation be assessed for movement?
- Segmental movement/ symmetry
What is a rib hump indicative of?
Scoliosis
How can passive movements of the lumbar spine be assessed?
- Pt sidelying with hooked legs
- Place the patient’s knees against your hip
- Guide motion of the L-spine through while holding onto the patient’s ankles
What is a quick test to clear the joints of the lower quarter? For whom is this test inappropriate?
- Full squat with a bounce at end range Avoid with: - Patients who are pregnant - Elderly patients - Patients with know LE pathology such as arthritis
What is the March Test?
- A quick SIJ screen
- Pt stands; PT positioned behind patient
- Place one thumb on patient’s PSIS, and place the other on the patient’s spinous process
- Patient lifts ipsilateral knee towards chest
- PSIS should drop medioinferiorly
What are the break tests for lumbar myotomes L2 - S2?
L2: Hip flexion L3 - L4: Knee extension L4: Ankle dorsiflexion/ heel walk L5: Great toe extension S1: Ankle plantar flexion, eversion/ Walking on tip toes S2: Knee flexion
How are dermatomes measured in the lumbar spine?
- Pinwheel/ light touch along the distribution of the lumbar myotomes
What are the 2 DTRs for the L-spine, and what spinal segment do they measure?
- Knee jerk (L3/4)
- Ankle jerk (S1/2)
What is the iliac crest used to located in the L-spine?
- L4-5 interspace
What is the PSIS used to locate in the spine?
S2
What 3 accessory joint motions are assessed in the L-spine?
- CPA
- UPA
- Transverse pressure
What spinal segments are tested by a straight leg raise?
- L5
- S1
On which side is the SLR performed first?
The uninvolved side.
How can the SLR be sharpened?
- With dorsiflexion of the ankle.
What is a positive test of the SLR?
- Radicular complaints distal to knee
What is a cross-over sign during SLR? What is indicated?
- A lightning bolt type pain down the contralateral leg
- Neurological or central disc problem is indicated
What structure is tested by Ely’s test? What spinal segments?
- Femoral nerve
- L2
- L3
- L4
How is Ely’s test performed when assessing Femoral nerve lesions?
- Pt prone, flex knee and monitor for symptoms for 30 - 45 seconds
What are 4 positive tests for Ely’s test
- Unilateral buttock pain
- LB pain
- Posterior thigh pain
- Unilateral quad tightness
How must the Femoral nerve stretch test be modified in individuals over 40?
- Move into and out of flexion slowly to avoid hamstring cramping
Describe a Slump Sign test.
- Pt sitting
- Pt flexes at the thoraco-lumbar spine
- Overpressure the shoulder girdle with combine C-spine flexion
- Sharpen with ankle dorsiflexion
- Sharpen with passive or active knee extension
- Assess presence of radicular symptoms
- See if neck extension reduces symptoms
What is tested by the Slump Sign test?
- Spinal cord
- Nerve roots
What does the Thomas Test assess?
- Hip flexor tightness
Describe the quadrant position of the lumbar spine.
- Extension
- Lateral flexion and rotation to the same side
What are positive signs of a quadrant test?
- Radicular signs
- Localized pain
What is indicated by radicular signs in a quadrant test?
- Disc pathology
What is indicated by localized pain in a quadrant test?
- Facet joints
- Degenerative joint disease
What is an easy way to guide the patient through a quadrant test?
- Patient stands
- Pt places hand on contralateral posterior thigh/ buttock
- Pt slides hand down leg rotating, sidebending, and extending
Describe a prone instability test.
- Pt prone on exam table with feet on floor
- Examiner applies CPA
- Assess symptoms
- Pt lifts feet slightly off floor contracting erectors, glutes, and abdominals
- Apply CPA
- Assess if symptoms are better
What may not be a successful treatment following a positive prone instability test is not positive?
- Core stability training
