Lordosis Flashcards
Define lordosis.
An abnormal extension deformity of the spine in which the concavity in the curvature of the lumbar and cervical spine as viewed from the side is increased.
As part of your physical exam, you perform a screening osteopathic structural evaluation which includes assessment of what?
Symmetry/asymmetry
Mid-gravity lines
Spinal curve
Normal lumbar or cervical curvature is referred to as what as opposed to what?
lordotic - lordosis
What are some more colloquial names for lordosis?
Hollow/saddle/sway back
What types of somatic dysfunction can cause increased lordosis?
Cervical extended segments Thoracic flexed segments Lumbar extended segments Anterior innominate rotation Sacral flexed dysfunctions - bilaterally flexed sacrum, unilaterally flexed sacrum, anterior sacral torsion
Why would you do an erect, standing radiographic analysis?
For both quantification of the curve and determination of etiology.
What would you measure with a standing radiographic analysis?
Lateral mid-gravity line: extended downward from the mid-body of L3; should fall at the sacral promontory.
What is Fergusen’s Angle?
Angle of sacral promontory and horizontal line. Normal is 30-40 degrees.
What is Mitchell’s Angle?
Outside angle between spine and sacrum. Normal is 125-145 degrees.
What is the lumbosacral lordotic angle?
Cobb Angle from superior endplate of S1 to superior endplate of L2. Normal is 40-60 degrees.
What is the lumbo-lumbar lordotic angle?
Cobb Angle from superior endplate of L2 to the inferior endplate of L5. Normal is 35-55 degrees.
What is Jungmann’s Pelvic Index?
Ratio of measurements representing the position of the sacrum relative to the innominates (line across top of pubic symphysis/line through sacral promontory). Ratio is age dependent: 0.55 at 20 years; 0.65 at 50 years. Chronic low back pain is greater than 0.65-0.75. With age, the pelvis tends to rock back and the sacrum tends to rock forward.
What are some consequences of increased lumbar lordosis?
Increased weight-bearing on the facets and facet joint pain
Narrowing of the intervertebral foramina with neural entrapment
Approximation of the spinous processes (kissing spines - Baastrup Syndrome)
Visceroptosis
Lumbar vertebral wedging (Wolff’s Law)
Fixed flexion of sacrum
Anterior rotation of the pelvis on the hip joints
Increased anterior concavity of the sacrum
What is visceroptosis?
Descent of viscera from their normal position. Can result in viscera ischemia syndrome.
What are the signs and symptoms of visceral ischemia syndrome?
Sign - diarrhea
Symptoms - postprandial (post-eating) pain, anorexia (from fear of eating), weight loss
What are physical findings of visceral ischemia syndrome?
Occasionally, occult fecal blood
Short systolic bruit in the epigastrium or umbilical region
What causes symptoms of visceral ischemia syndrome?
Celiac artery compression
What are the etiologies of visceral ischemia syndrome?
Increased lumbar lordosis Atherosclerosis Fibromuscular hyperplasia Neoplasia Embolism Polyarteritis nodosa Thromgoangiitis obliterans Carcinoid
What is an etiology of increased lumbar lordosis?
Poor posture - weakness of the recuts abdominus & abdominal oblique muscles and/or shortening of the psoas muscles (prolonged sitting).
What congenital anomaly can cause increased lumbar lordosis?
Failure of segmentation - do segmental motion testing to find this.
What do high heels do to the body?
They shorten the achilles tendon. A sudden discontinuation of the wearing of heels actually increases the lordosis even further. May have to do heel lift regression to correct.
What other condition may cause an increased lumbar lordosis?
Spondylolisthesis - one disc slips out of proper position onto the vertebra below it.
Is there never compression with low back pain due to Spondylolisthesis around L5/S1?
No - spinal canal has widened, making more room for cauda equina.
Do girdles/binders help obese patients with increased lumbar lordosis?
Abdominal binders and lumbar supports must be wide enough at the back to provide broad support. If the binder is too narrow, it will actually increase the lordosis.
Does pregnancy cause an increase or decrease in lumbar lordosis?
Increase
Name 3 hip disorders.
Congenital dislocation of the hip
Coxa vara
Flexion contracture due to arthritis
What is coxa vara?
Angle between head and shaft of femur. Normal hip angle is between 120 - 160 degrees. Coxa vara angle is below 120 degrees and is usually bilateral. Average adult is 127 degrees. Children have greater angle.
How does coxa vara affect an increase in lumbar lordosis?
Smaller angle alters the pattern of muscle attachment with subsequent anterior rotation of the pelvis.
What is muscle contracture?
Fibrosis of a muscle producing permanent shortening. Muscle is reduced to a hard cord, smaller in diameter than normal; does not permit full range of motion of a joint.
What are some etiologies of muscle contracture?
Congenital
Muscle disease
Prolonged ischemia
Inflammatory myositis
What does the Thomas Test check for and how do you do it?
Hip flexion contracture
Patient is supine on the table. Physician lifts one knee to create hip flexion; the lumbar spine flattens and the pelvis is stabilized. Further flexion can then only originate in the hip joint. Normal limit for hip flexion is 135 degrees.
What is a fixed flexion contracture characterized by during a Thomas Test?
The inability to extend the leg straight without arching the thoracic spine. (Patient is supine.)
How can the extent of a flexion contracture be determined during a Thomas Test?
By estimating the angle between the table and the patient’s leg.
What muscles are involved with hip flexion contracture?
Psoas, iliacus, and rectus femoris
What can cause AIIS exostoses and what was the patient doing at the time?
Traction on rectus femoris apophysis - heavy weightlifting put traction on the bones, thus elongating them as they grew.
What are some developmental causes of increased lumbar lordosis?
Larger than normal erector spinae musculature
Often associated with massive gluteal & thigh muscles
Lifetime yoga participants (cobra)
What is Rickets characterized by, and what can it cause?
It is characterized by Vitamin D deficiency, and it can cause deformity of the lumbar vertebrae.
What is Stiffman Syndrome?
Rare condition (Mayo Clinic saw only 13 cases in 30 years) characterized by an insidious onset with hypertonicity and rigidity of the paravertebral muscles. Episodic spasms can be caused by sudden movement, jarring, noise, or emotional upset. Motor & sensory exams are normal, intellect is normal, but EMG is abnormal - continuous motor activity at rest (always stiff, tight).
What are treatment options for Stiffman Syndrome?
Diazepam (valium) 20-300mg per day
Lumbar flexion exercises
Range of motion exercises for extremities
OMT: soft tissue, muscle energy, HVLA
What is the normal dose for valium?
5mg
What kinds of somatic dysfunction can cause decreased lordosis?
Cervical flexed segments Thoracic extended segments Lumbar flexed segments Posterior Innominate rotation Sacral extended dysfunctions (bilaterally extended sacrum, unilaterally extended sacrum, posterior sacral torsion)
What are some consequences of decreased lumbar lordosis?
Increased weight-bearing load on discs with increased risk of disc herniation
Other effects are dependent on the cause of loss of lordosis
What are some etiologies of decreased lumbar lordosis?
Lumbar sprain & strain Acute lumbar disc herniation Lumbar spondylosis (osteoarthritis of the spine) Ankylosing spondyliitis Psoas contracture
What is Flat Back Syndrome?
Flattening of all anterior-posterior curves
How can you treat Flat Back Syndrome?
Heel lifts bilaterally and lumbar extension exercises.
What is Flat Back Syndrome commonly associated with?
Symptomatic mitral valve prolapse
Are men or women affected by Flat Back Syndrome in associated with what bacteria? What is the percentage of persons of this gender affected?
Flat Back Syndrome occurs in 27% of women with mycobacterium avium complex.
What are the consequences of increased cervical lordosis?
Increased weight bearing on facet joints
Narrowing of intervertebral foramina
Kissing spinous processes (Michotte Syndrome)
What are the etiologies of increased cervical lordosis?
Increased thoracic kyphosis
Osteoporosis
Poor posture (via slouching shoulders)
Ill-fitting bifocals
What are causes of decreased cervical lordosis?
Cervical strain & sprain
Cervical disc herniation
Cervical spondylosis
Flat Back Syndrome
What is the swan neck deformity?
Kyphosis of upper neck, lordosis of lower neck
How can abnormal lordoses be managed?
Management is determined by etiology. Some curve abnormalities are self limited (sprain/strain) and recover with time. Some will correct when underlying disorder is corrected (somatic dysfunction, psoas contracture). Some are irreversible and care becomes largely symptomatic (ankylosing spondylitis, osteoporosis).
