lumbar Flashcards
Mercer, Bogduk: lumbar lordosis
- Angle of Sacrum (45deg)
- L5/S1 disc = wedge
- L5 vert = wedge
- Inclination of l/s
Lordosis results in
- Inc compression posterior on discs and z-joints
- Stretch annulus and ALL anterior
- Verts tend to move forward in WBing (stopped by z-joints and discs, then ligs)
Pars Interarticularis
- Resist bending forces
- Prone to stress fracture.
Motion segment
Lower half of the top vert, disc, and upper half of bottom vert.
Most stabilizing structure in motion segment
z-joint:
- 40% = 2 z-joints
- 29% = disc
- 31% = lymphatic, vascular, ligs
Mercer/Dogduk: stabilization
Mulrifidi (posterior capsule) and ligamentum flavum (anterior capsule) support z-joints.
Z-Joint orientation
Oriented posterior/medial.
- Resist flexion and rotation
- concave/convex - NOT planar
Z-joint capsule
Fibrous capsule around joint: 2 intra-articular structures (fat pad and meniscoid).
-transmit loads, protect joint during flexion
Disc make up
- Nucleous pulposus (70-90% water)
- annulus fibrosis: concentric rings, thicker ant and lat
- vertebral end plant: cartilage layer 1mm thick
Disc function
Allow movement and transmit force
Panjabi/Wilkes: stability
Stability of spine related to muscular rather than ligamentous factors.
-Breakdown of intrinsic muscles leads to LBP
Panjabi/Wilkes: 3 subsystems of stability
- Passive (ligs, bones, discs)
- Active (muscles and tendons)
- Nervous system
Ligamentum flavum
medial and lateral portions connect to lamina. elastic and allows return from flexion to extension.
connected to ant capsule of z-joints.
Associated with causing stenosis.
ALL
- runs from c/s to sacrum
- covers disc ant and part of annulus
- crura of diaphragm attached to ALL (tendon)
- Resists extension
PLL
-Resists separation of vert in flexion
Supraspinous lig
often absent at L5-S1
Iliolumbar ligament
from TP L5 to inner edge of ilium in 5 bands.
- Age 30 = more fibrous vs muscular
- Prevents ant trans of L5
- Attached to QL
- Resists all motions at L5-S1
Meninges and nerve roots
Anterior root = motor
Posterior root = sensory
Psoas Major
Fascial attachments up to T5 (longus colli fascial attachments down to T5)
-T12-L5: attaches to TP, discs, bodies
Bogduk: Psoas
- Upper fibers tend to extend spine
- Lower fibers flex spine
Basmajian/Janda: Psoas
deep fibers of psoas stabilize the spine
QL
- covers lateral 2/3 of ant surface of L1-4 TPs.
- Extends latterally - may have iliolumbar lig connection
Multifidi
- controls flexion
- compressor of spine
- increases lordosis
Jull, Hodges, Hides: Multifidi
multifidi are stabilizers
Bogduk: Multifidi
Innervation = medial branch of dorsal ramus
Hides: multifidi
Trauma/back pain will inhibit multifidi from stabilizing
Vleeming/Lee: Thoracolumbar fascia
supports breathing and force closure
Force closure
Done by erector spinae, glute max, lats, biceps femoris
Arthrokinematics with flexion: l/s
Facets slide anterior/superior
-opening
Arthrokinematics with extension: l/s
facets slide posterior/inferior
-closing
Arthrokinematics with SB right: l/s
R post/inf, L ant/sup
Anomaly of L5-S1
35% rate of anomaly of articular processes
Fryette’s Law 1
In neutral, SB and rotation are contralateral in lumbar spine
Fryette’s Law 2
In flexion/extension, SB and rotation are ipsilateral in lumbar spine
Fryette’s Law 3
Movement in lumber spine in any direction will decrease amount of movement available in other directions
Type 2 non-neutral dysfunctions
- Closing: loss of post/inf glide (worse in ext)
- Opening: loss of ant/sup glide (worse in flex)
- Single segment = primary dysfunction (worse in 1 direction, corrects in other direction)
Hypermobility
Angular/osteokinematic
- Consistent loss of motion
- can be “normal”
Instability
Linear/arthrokinematics
- Inconsistent loss of motion
- Not stopped by ligs/capsule
Panjabi/Dogudk: Neutral Zone
Movement in neutral posture
Minimal resistance to movement is offered by passive vertebral column
Panjabi: clinical instability
significant decreased in capacity of stabilizing systems of the spine to maintain intervetebral neutral zones within physiological limits
-results in pain and disability
Bergmark: local stabilization
Local muscular stabilizing system: TA, multifidus, diaphragm, pelvic floor
- controls neutral zone
- controls intersegmental motion
- “stiffness” of spine
Bermark: global stabilization
- superficial muscles
- primary movers of spine
- transfers load between t/s, ribs, l/s, pelvis
- transmits load to local stabilizers
Form Closure: Vlemming/Snijders
Congruencey of joints - osseous.
“Puzzle”
Force Closure: Vleeming/Snijders
Muscular synergistic stability
“lock and key”
Compression-Vibration test
screen for:
-potential fx (compression/vib sensitive)
-discogenic (comp sens)
T12 most common fx at TP
Perform: pt supine, hit IT with heel of hand
Kidney/Flank pain test
dull or sharp pain, could be several areas.
-11/10 pain
-Blood in urine, weight loss, hard to move
Perform: percussion over kidney
Aorta Test
Feel for pulse width and length:
-lack of normal “lub-dub”
-larger than 3 finger width
Hx: 50+ y.o male, heart disease, HBP, family hx, LBP with movement sometimes into leg, pain in solar plexus, boring pain in back.
Slump test
lumbrosacral neutral - screen for nerve
Position/motion testing
sitting flexion/extension feel for segment positions
-Can be done in prone, sitting back on knees, prone extension.
PIVMT
Looking at hyper or hypo mobility: ROM
NOT instability
PAIVMT
Combined motion looking at motion segment, not cardinal plane
gliding motion tested at end range, opening/closing, 3D lockup
PEMT
PAIVMT blocking at same vert
CBT
PAIVMT opposite side level below
Spring testing
use heel of hand or thumbs, go slowly
some instabilities are velocity dependent.
Done in prone.
Anterior stress test
P->A test
sidelying - hips at 70deg, 90deg
block segment you want to test, push knees back
Posterior stress test
A->P test
sitting, block inf vert - gives and A>P of sup vert
Rotational stress test
prone (general) or sidelying (specific)
