1. shock absorption 2. hold vertebrae together while allowing movement 3. separate vertebrae into functional segments 4. separate vertebrae to allow passage of nerve roots through intervertebral foramina

Lumbar Flashcards by Nicole Yuen

How many facet joints in lumbar spinal segments?

Five pairs

Apophyseal or zyoapophyseal (facet)

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What direction do lubar facets face?

Superior: medial and posterior
Inferior: lateral and anterior

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Which movements are limited by facet joints

Side flexion
Flexion
Extension

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Relationship between lumbar TVPs and SPs

Same level

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Lumbar joints: Capsular pattern

Side flexion = rotation, then extension

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Degrees of AROM: lumbar flexion

40-60º

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Degrees of AROM: lumbar extension

20-35º

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Degrees of AROM: lumbar lateral flexion

15-20º

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Degrees of AROM: Rotation

2-18º

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Lumbar: IL side flexion increases pain; no radicular symptoms

Problem probably intra-articular (since muscles and ligaments relaxed)

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Lumbar: IL side flexion increases pain and radicular symptoms

Likely disc protrusion lateral to nerve root

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Lumbar: CL side flexion increases pain and radicular symptoms

Likely disc protrusion medial to nerve root

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Lumbar: coupled movements

side flexion + rotation

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Ligament unique to lumbar spine

Iliolumbar ligament
TVP of L5 to posterior ilium
Stabilizes L5, prevents anterior displacement

Commonly injured with flexion + twisting

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Anterior longitudinal ligament

Occiput –> sacrum
Strongest ligament in body
Prevents hyperextension

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Posterior longitudinal ligament

Occiput to sacrum
Anterior aspect of neural canal
Attaches to IVD but not vertebral bodies
Limits forward bending

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Ligamentum flavum

Ant-inf border of superior lamina –> posterior border of inferior lamina
C2 –> S1
Most elastic tissue in the body
Prevents meninsci and synovial lining from being caught in articular joint surfaces

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Intertransverse Ligaments

Limit lateral flexion and rotation

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Interspinous ligaments

Go up and backwards, not up and forwards

–> allow for flexion but within control

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Supraspinous ligaments

Connect aspices of spines C7-L4

Most superficial, most likely to sprain

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Nuchal Ligament

Supraspinous ligament from C7–> occiput

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Lumbar: Each nerve root is named for …

The vertebra above it.

Thoracic: same; Cervical: named for below

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Two components of Intervertebral Discs

Nucleus pulposes

Annulus pulposes

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Function of IVD

shock absorption
hold vertebrae together while allowing movement
separate vertebrae into functional segments
separate vertebrae to allow passage of nerve roots through intervertebral foramina

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Lumbarization

Unfused S1 --> additional lumbar segment Lower stability, increased mobility

Sacralization

Fused L5 --> additional sacral segment Lower mobility, increased stability

Spondylosis

Degeneration of IVD

Spondylolysis

Defect in pars interarticularis

Spondylolisthesis

Forward displacement of one vertebral segment over another

Retrolisthesis

Backwards displacement of one vertebra on another

Motion segment

Facet joints + IVDs

Four stages of disc herniation:

1. protrusion 2. prolapse 3. extrusion 4. sequestration

Protrusion

Nucleus bulges without rupture of annulus fibrosus

Prolapse

"Only outermost fibres of annulus contain nucleus" (I think it's a big protrusion)

Extrusion

Annulus is perforated and discal material moves into epidural space

Sequestration

Formation of discal fragments from annulus and nucleus outside the disc proper

Most common herniation locations

L4-5 (affects 5th lumbar nerve root) then L5-S1 (affects first sacral root) then L3-4

Common presentation of disc herniation

- - few days after excessive activity or mild injury - - aggravated by coughing, sneezing, reaching or stooping - - lumbar muscle spasm --> decreased lordosis - - lateral truck shift in standing - - restricted active flexion and extension

Most common herniation direction

Posterolateral | PLL prevents it from going directly posterior

Herniation: Pain and position

Worse with sitting, lifting, twisting, bending, sustained posture Morphs to severe pain radiating down one limb Often better with extension

Herniation: pain in anterolateral leg

Herniation: pain radiating to posterior foot

Cauda equina syndrome

Lesion affecting cauda equina | Loss of bladder and bowel function, saddle anaesthesis

Schmorl's Nodules

Herniations of nucleus pulposus into vertebral body | Results from direct vertical pressure

Paresthesia

Pins and needles, burning

Herniation vs Facet Lock

Herniation: -- immediate pain, posterior thigh, leg, foot, glutes, Facet Lock - - pain doesn't go distal to knee - - back may get locked into position

Mechanical LBP

aka lumbago Unilateral pain with no referral below knee Possible strain, sprain, facet joint or SI joint problem

Back/buttock pain. Worse in flexion. Better with extension. Stiff in am

Mechanical LBP | Likely disc involvement (minor herniation, spondylosis, sprain, strain)

Back/buttock pain Worse with extension/rotation Better with flexion

Mechanical LBP | Likely facet joint involvement, strain

Leg pain below knee Myotomes affected, dermatome pain Worse with flexion, better with extension

Nonmechanical LBP | Nerve root irritation -- most likely herniation

Leg pain below knee, maybe bilateral Myotomes affected, dermatome pain Pain with walking, better with rest

Neurogenic intermittent claudication Stenosis

What refers pain to the low back?

Pancreatic tumours

Looks mechanical, but DDx of disc involvement

Pain on standing, flexion Improvement when walking No muscle tenderness

Normal lordotic curve

50º

What happens to lumbar SPs during flexion

(Anterior roll, posterior glide) | Move further apart and posteriorly

What happens to lumbar SPs during extension

(Posterior roll, anterior glide) | Move closer together and anteriorly

Three grades of DDD

1. dysfunctional 2. unstable 3. stabilization

Dysfunctional DDD

Phase 1 Tearing around outer surface of annulus Disc begins to shrink

Unstable DDD

Phase 2 Joint loses strength Continued tearing on horizontal axis of didsc Cartilage degeneration

Stabilization (DDD)

Phase 3 Surface of vertebral bodies above and below of IVD showing damage. Disc thin and fibrotic. Formation of arthritic osteophytes (spurs)

Constant ache

Inflammatory process, venous hypertension

Pain on movement

Noxious mechanical stimulus (stretch, pressure, crush)

Pain accumulates with activity

Repeated mechanical stress Inflammation DDD

Pain increases with sustained posture

Muscle fatigue | Gradual tissue creep

Latent nerve root pain

Movement has produced an acute and temporary neuropraxia

IVD's make up how much of the length of the vertebral column

20-25%

Lumbar resting position

Between flexion and extension

Lumbar close packed position

Full extension

If lumbar lesion is medial to nerve root:

Patient may list to same side as lesion Demonstrate pain during SLR of unaffected leg

Most important signs of disc herniation

History Decreased ROM Neuro dynamic tests