Lumbar Lecture Flashcards
How much of the population will eventually experience low back pain?
80%
What are café-au-lait spots?
Pigmented birth marks
What are Lipomata?
Begnine tumor composed mostly of fat
What is the cause of Neurofibromatosis?
Heradiatiry dominate disorder.
What does neurofibromatosis look like?
large (more than .5cm in size at first and can be as big as 1.5cm) bumbs and nodules along nerve sheaths
(pigmented spots, and pedunculated soft-tissue nodules clustered along nerve sheaths)
When do neurofibromatosis begin to appear?
during childhood
Your patient has neurofibromatosis. What else do you expect to see?
- café-au-lait spots over the trunk, pelvis, and flexor patches of the elbows.
- skeletale deformities that may lead to scoliossis
- Vertebral body scalloping,
- Fibrous dysplasia
- Tibial Pseudoarthrosis,
- Sphenoid bone deformity,
- Mental impairment,
- seizures
- hearing loss,
- exopht halmosis,
- decreased visual acuity
- GI bleeding
Your patient has low back pain, and standing with their weight shifted to one side. What do you want to look for?
Herniated disc (which may be causing scatic scoliosis)
True or False: scatic soliosis is a non-structural deformatity
True: it is caused by by lumbar disk herniation and uni- lateral spasm of the back muscle. The convexity is usually toward the symtomatic side.
What is gibbus deformity?
Hyperkyphosis of the lower throacic area. Will effect the lumbar kyphosis.
What interspinous space is associated with the top of the iliac crest?
L4 L5 interspace
What palpable findings does a spondyloslisthesis produce?
One SP clearly more visible or palpable than its neighbors
A palpable or visible step-off from one process to another
spondyloslisthesis vs spondylolysis vs Spondylolytic Spondyloslisthesis
spondyloslisthesis: anterior or posterior displacement of a vertebrae on the adjacent lower vertebrae
spondylolysis: Defect of the PARS (Need an xray to ID)
Spondylolytic Spondyloslisthesis: The combination of the 2 = A unilateral or bilateral defect in the pars interarticularis with anterior or posterior displacement of a vertebrae on the adjacent lower vertebra.
What scale is used to measure Spondylolisthesis?
Meyerding’s Scale
Ranges from 1-4 and measures how far L5 has moved passed the sacral base in 25% increments.
How many joints exist between the vertebrae of the lumbar spine?
3
1 between the bodies + the IVD
2 between the arcticular processes (one on each side) these are the z joints or apopheseal joints
What verteral level does the umbilicus lie at?
L3 L4 Disc space
What anatomically important thing happens at the L3 L4 disc space?
The aorta divides into the common illiacs
What vertebrae can be palpated anteriorly?
L4, L5, S1 (now that the abdominal aorta is out of the way)
What is the primary function of the Zygapophyseal joints in the lumbar spine?
To protect the segment that is moving from
- sheering forces (anteriomedial part does this)
- excessive rotation (the C or J shape makes almost all rotation impossible)
- excessive flexion
What 2 ligaments are here, and super important, and also everywhere else in the body?
ALL - narrows as it assends
PLL - connects to posterior bodies and discs
What ligament connects 2 consecutive lamina?
Ligamentum flava
What ligament connects 2 consecutive spinouses?
interspinous ligament
what does the supraspinous ligament connect?
tip of SP to tip of SP
What does the iliolumbar ligament connect?
L5 to S1
What is the function of the iliolumbar ligament?
to restrict motion at the iliolumbar juntion.
Specifically restricts flexion, extension, lateral flexion, and axial rotation (so everything)
What do the psudoligaments do?
Nothing mechanical!
seperate paravertebral compartements
What are the psudoligaments in the lumbar spine?
intertransverse
transforaminal
mamillo-accessory
Quadratus Lumborum: OINAB
O: lateral lip of iliac crest and iliolumbar ligament
I: post/inf 12th rib and L1-L4 TP
N: Ventral Rami of L1-L4
A: stabilizes/depresses 12th rib. stabilizes with contralateral flexion
B: lumbar artery, subcostal artery
Lumbar multifidus: OINAB
O: mamilary processes I: SPs of segements 2-4 spaces above N: dorsal rami of spinal nerves A: contralateral rotation and lateral flexion (truns you to opposite side) B: muscular branch of abdominal aorta
What makes the QL important clinically in the lumbar region?
funtion as a lumbar spine stabilizer
What makes the multifidus important clinically in the lumbar region?
its ability to control lumbar segmental stability through its ability to provide segmental stiffness and control motion
What muscles make up the erector group?
iliocostalis lumborum
longissimus
spinalis (not seen in the lumbars)
Iliocostalis: OINAB
O: common tendon of the sacrum, iliac crest, and lumbar SPs
I: lower borders of the 6-12th ribs
N: dorsal rami of spinal nerves
A: ipsilateral bending and rotation (move to the side being contracted)
B: muscular branches of the aorta
Thoracic Longissimus: OINAB
O: common errector spine tendon
I: TPs of upper lumbar and Thoraic vertbre. Ribs
N: dorsal rami of spinal nerves
A: ipsilateral bending and rotation (move to the side being contracted)
B: muscular branches of the aorta
What is the function of the thracoclunmar fascia?
Helps with transmission of extension forces during lifting
stabilizes against anterior shear and lifting forces
Iliopsoas: OINAB
O: Anterior lumbar spine (T12- L5 vertebral bodies and discs)
I: Lesser trochanter
N: Ventral Rami of L2-L4 - psoas part
and Femoral Nerve (L2-L4) - illiacus part
A: Main hip flexor. External Rotation
B: iliolumbar artery
What will exacerbate pain if there is an abscess of the iliopsoas?
active hip flexion
What is the largest nerve in the body?
Sciatic Nerve
What are the terminal branches of the sciatic nerve?
Tibial Nerve Peroneal Nerve (aka Fibular)
What structures should you located if you want to palpate the sciatic nerve?
ischial tuberosity and the greater trochanter - nerve is 1/2 way between the 2
In the lumbar spine, does a disc pathology effect the nerve root above or below?
Below
In the lumbar spine, is the disc named for the segment above or the segment below?
Segment above
What are the different types of disc pathologies?
- Protrusion
- Prolapse aka Bulge
- Extrusion aka Herniation
- Sequestration
The nucleus has popped out of the annular fibers, but no fibers are torn. Name the disc pathology.
Prolapse aka Bulge
The Anular fibers are weakened, and there are a few bits of the nuclus present in the fibers. Name the disc pathology.
Protrusion
There are peices of the the nucleus in the spinal canal. Name the disc pathology
Sequestration
The anular fibers have torn and the nucleus is pushing into the PLL. Name the disc pathology
Extrusion AKA herniation
What type of disc pathology can be accompanies by a shredding sound?
Extrusion AKA Herniation
L4 muscle test: action, muscle , nerve
Dorsiflextion and Inversion: Tibialius anterior - deep peronieal nerver
L4 Reflex
Petellar reflex
L5 muscle test: action, muscle, nerve
Foot Dorsiflex: Peronius tirtious, extensor halloucus longs, extensor digitorm longus and brevis - deep peroneal nerve
Big Toe Dorsiflex: extensor hallucis longus -deep
peroneal nerve
Toes 2,3,4 dorsiflex: extensor digitorum longus &
brevis - deep peroneal nerve
Hip and Pelvis abduction: gluteus medius & minimus - superior gluteal nerve
L5 Refelx
There is no reflex for this nerve root
S1 muscle test: action muscle nerve
Foot Plantar flexion and eversion: peronous longus and brevis - superficial peroneal nerve
Foot plantar flextion: Gastrocnemius and soleus (tibial nerve)
Hip extention: Gluteus Mazimus (inferior gluteal nerve)
S1 reflex
Achilles
What innervates the outter 1/2 of the IVD?
sinuvertebral nerve and the grey rami communicants
(this nerve is the SIgN that says U are entering the VERTEBRAL disc space) and their are gray pay phones (RAMI COMMUNICANTS) next to the sign
Does the lateral IVD get ParaNS or SNS inervation
SNS
What innervates the z joints?
Doral Rami
How many degrees of freedom are available in the lumbar spine?
6
What motion is coupled with side bending in the lumbars?
Rotation.
Where dose most of the flexion/extenion occur in the lumbar spine?
lower segmental levels
Where does most of the rotation occur in the lumbar spine?
lumbosacral junction
Where does most of the lateral flexion occur in the lumbar spine?
mid-lumbar area
What happens at the segmental level during lumbar flextion
Anterior roll and anterior glide of the vertebral body
Does the lordois revers during flexion of the lumbar spine?
It depends on the segment level. At L4-L5 you might have minimal reversal. at L5-S1 it should straighten but not reverse
What occurs at a segmental level during extension of the lumbar spine?
posterior roll and posterior glide of the vertebral body
posterior and inferior motion of the z-joints
no real change in the level of lordosis
How much rotation is there in the lumbar spine as a whole?
about 13 degrees.
What segment level has the most axial rotation? how much?
L5-S1 has about 5 degrees of rotation
According to this class, what is the relationship between spinal alignment in the lumbars and pain?
none
When palpating the lumbar spine, what other area should you palpate?
hip and pelvic
What am I really assessing with active ROM
quality of movement
How long should isometric contraction be held during muscle tests?
at least 5 seconds
if we suspect weakness repeat 2-3 times to test how easy it is to fatigue
L1 L2 L3: Muscle Test
Hip flexion - Iliopsoas - L1-L3
L1 L2 L3 disc level
T12-L2
L1 L2 L3 refelx
there is no refelx
L2 L3 L4 Muscle test:
Knee extension: rectus femoris, vastus medialis, vastus intermedius (L2-L4 and Femoral nerve)
L2 L3 L4 disc level
L1-L3
L2 L3 L4 reflex
Petellar
T2-T12 disc level
T2-T12
T2-T12 muscle test
Rib elevation - interconstals - segmentally inervated (lots of overlap)
rectus abdominus
T2-T12 refelx
None
Superfical abdominal refelx
Where is the T4 sensation distribution?
nipple line
Where is the T7 sensation distribution?
xyphoid process
Where is the T10 sensory distribution?
level of umbilicus
where is the T12 sensory distribution?
Groin
