lumbar Flashcards
number of lumbar vertebra
5
anterior portion of lumbar vertebra
body, pedicles, transverse processes, superior articular processes
posterior portion of lumbar vertebra
neural arch composed of laminae, inferior articular processes and spinous process
it’s the part of the lamina between the superior and inferior articular process; site of stress fracture because it is subjected to large bending forces
pars interarticularis
innervated structures (pain generators)
- bone: laminae
- joints: zygoapophyseal
- disk: only external annulus and potentially diseased disk
- ligaments: ant longitudinal ligament, post longitudinal ligament, interspinous
- muscles and fascia
- nerve root
posterior muscles
- lattisimus dorsi
- paraspinals: erector spinae (iliocostalis, longissimus and spinalis)
deep layer
- rotatores
- multifudus
non innervated structures (pain generators
- ligamentum flavum
- disk internal annulus
- nucleus pulposus
chief extensors of spine
erector spinae (iliocostalis, longissimus and spinalis)
tiny segmental stabilizers that act to control lumbar flexion; cannot produce enough force to extend the spine; provides proprioception to spine
multifidus
anterior muscles
psoas, quadratus lumborum
tightening of this muscle accentuates the normal lordosis in the lumber; can cause zygapophyseal joint pain due to increase force acting on spine
psoas muscle
acts in side bending and assists in lumbar flexion
quadratus lumborum
abdominal musculature
superficial: rectus abdominis, external oblique
deep layer: internal oblique, transverse abdominis
this muscle is important to train in treating lbp bc of it’s connection to the thoracolumbar fascia
transverse abdominis
acts as an abdominal and lumbar “brace” particularly when lifting
thoracolumbar fascia
pelvic stabilizers; considered as “core muscle” bc of their indirect effect on lumbar spine even though they don’t have attachment to it
gluteus medius, piriformis, pelvic floor muscles
stabilizes pelvis during gait
weakness of this muscle can cause pelvic instability which induces lumbar side bending and rotation creating sheer and torsional forces on lumbar discs
gluteus medius
hips and sacral rotator; cause excessive external rotation of the hip and sacrum when it is tight and results in shear forces at lumbosacral region
piriformis
main proper positioning of the spine
pelvic floor muscles
consists of an internal nucleus pulposus and outer annulus fibrosus
intervertebral disc
gelatinous inner section of disc; water, proteoglycan, collagen; 90% water at birth but dessicates as we age and lose of their heigt
nucleus pulposus
concentric layers of fibers at oblique angle to eo; help withstand strains in any direction
outer layer has more collagen and less proteoglycans and water than inner fiber thus outer layer can resist flexion, extension, rotation, and distraction forces
annulus fibrosus
lumbar root syndrome of L2
dermatome: back, front of thigh to bone
muscle weakness: psoas, hip adductor
reflex/special test affected: none
paresthesia: occasionally front of thigh
lumbar root syndrome of L1
dermatome: groin, back of trochanter
muscle weakness: none
reflex/special test affected: none
paresthesia: groin
lumbar root syndrome of L3
dermatome: back, upper buttock, front of thigh and knee, medial lower leg
muscle weakness: psoas, quadriceps - thigh wasting
relfex/special test affected: knee jerk sluggish, pain on full SLR
paresthesia: inner knee, ant lower leg
lumbar root syndrome of L4
dermatome: inner buttock, outer thigh, inside of leg, dorsum of foot, big toe
weak muscle: tibialis anterior, EHL
reflex/special test affected: SLR limited, neck flexion pain, weak knee jerk , side flexion limited
paresthesia: medial aspect of calf and ankle
lumbar root syndrome of L5
dermatome: buttock, back and side of thigh, lat aspect of leg, dorsum of foot, inner half of sole and 1st - 3rd toes
muscle weakness: extensor hallucis, peroneals, g medius, ankle dorsiflexors, hamstrings, calf wasting
reflexes/special test affected: SLR limited to one side, neck flexion pain, hamstring reflex decreased, crossed leg raising pain
sacral root syndrome of s1
dermatome: buttock, back of thigh and lower leg, sole of foot
muscle weakness: calf & hamstrings, wasting of gluteals, peroneals and plantar flexors
reflexes/special test affected: SLR limited, decrease ankle jerk
paresthesia: lateral two toes, lateral foot, lateral leg to knee, plantar aspect of foot
sacral root syndrome of s2
dermatome: same as s1
muscle weakness: same as s1 except peroneals
relfex/special test affected: SLR limited
paresthesia: lateral leg, knee, heel
sacral root syndrome of s3
dermatome: inner thigh to knee, groin
muscle weakness: none
reflex/special test affected: none
paresthesia: none
sacral root syndrome of s4
dermatome: perineum, genitals, lower sacrum
muscle weakness: bladder, rectum
reflex/special test affected: none
paresthesia: saddle area, genitals, anus, impotence
common cause of back pain in the elderly, degeneration at zygapophyseal joints w degeneration of discs
pain referred to buttock and back of legs
most common L4-5 and L5-S1
lumbar spinodylosis
refers to the forward slippage of one vertebral body w respect to the one beneath it
occurs at the lumbosacral junction with L5 slipping over S1, followed by L4-L5
spondylolisthesis
spondylolisthesis - dysplastic
- congenital anomalies of the lumbosacral junction causing slip to occur
spondylolisthesis - isthmic
- most common
- lack of normal continuity in each part interarticularies or isthmus
spondylolisthesis - degenerative
slipping of a single bone but has come unstable bc of degenerative disease of facet or zg joint
spondylolisthesis - traumatic
fracture through part of the vertebra other than the isthmus caused by violence causing ant displacement
spondylolisthesis - pathologic
caused by deforming or destructive bone disease affecting the facets
grade 1 spondylolithesis
0-25%
grade 2 spondylolithesis
25-50%
grade 3 spondylolithesis
50-75%
grade 4 spondylolithesis
75-100%
over 100%; when he vertebra falls completely off the supporting vertebra
spondyloptosis
characteristics if isthmic spondylolisthesis
most common type is lytic spondylolisthesis caused by absence of continuity at the isthmus d/t unherited fatigue fracture or can be hereditary
more often bilateral, L5-S1
pain maybe slight-severe, localized in lumbosacal joint but may radiate to one or two legs
stiff back worse w exercise of strain
characteristics of degenerative spondylolisthesis
neural arch is intact and the forward displacement accompanies sever degenerative arthritic changes in zg joint and subadjacent vertebrae
most common involved vertebrae is L4-L5
50 yrs old women
long standing pain on lower back, buttocks or thigh relieved by sitting or reclining
forward flexion back mobility is limited and hip flexion is increased
no neurologic findings
term used to describe anatomic defect in pars interarticularies w adjacent bone sclerosis
spondylolysis
epidemiology of spondylolysis
one most common causes of back pain in children and adolescents
defects are not present at birth and develop over time (seen in 4-6% of population)
mechanism of spondylolysis
usually activity related and occurs from repetitive hyper extension
prevalance as high as 47% in certain athletes (gymnasts, weightlifters, football linemen)
scottie dog present in xray
treatment of spondylolysis
non operative
observation w no activity limitations (asymptomatic pts w low grade spondylolisthesis or spondylolysis; may participate in contact sport
PT and activity restriction (symptomatic spondylolysis; symptomatic low grade spondylolisthesis)
bracing for 6-12 weeks
surgery (presence of neurologic deficits, instability of spine, pain unrelieved by conservative management, severe/ progressive slipping
- fusion or laminectomy
frequently involved in inflammatory arthritis; pregnancy esp in latter weeks or after delivery d/t sacroiliac strain secondary to hormonal relaxation of symphysis pubis
osteomyelitis, infectious arthritis
tenderness over one or both sacroiliac joints medial to the posterior
associated tenderness over symphysis pubis
causes of sacroiliac pain/disorder
discuss gaenslen’s sign
sidelying; hip and knee on affected side are placed in extreme flexion, opposite hip is hyperextended, + if elicit pain
pain about the coccyx and lower part of sacrum
coccygodynia
