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MSK > Lumbar Spine > Flashcards

Lumbar Spine Flashcards

1
Q

What are the 4 regions of curvature in a normal adult spine?

A
  1. Cervical lordosis
  2. Thoracic kyphosis
  3. Lumbar lordosis
  4. Sacrococcygral kyphosis
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2
Q

What is responsible for the permanent thoracic kyphosis?

A

The thoracic vertebral bodies are greater in height posteriorly than anteriorly.

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3
Q

How do vertebral bodies compensate for scoliosis?

A

They undergo rotation so that the spinous processes face the concavity of the curvature.

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4
Q

In erect posture the sacrum tilts forward which can cause L5 anterior displacement (slipping) on the sacrum, what factors help to prevent/limit this slipping?

A
  • The L5 inferior facet faces anteriorly and the S1 superior facet faces posteriorly.
  • Ligamentous support from supraspinous and interspinous ligaments.
  • The iliolumbar ligament attaches the transverse processes of L5 to the ilium, anchoring L5 in place.
  • The anterior longitudinal ligament also prevents anterior displacement
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5
Q

What is an idiopathic scoliosis?

A

This is a lateral curvature of the spine which develops spontaneously with no clear cause.

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6
Q

What are potential causes of postural/functional scolioses?

A
  • Leg length discrepancies
  • Muscle spasms
  • Degenerative changes in intervertebral discs or apophyseal joints
  • Osteoarthritic changes in the knee and hip
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7
Q

What classifies as anterior pelvic tilt?

A

This is when the vertical place of the ASIS is anterior to the vertical place of the pubic symphysis.

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8
Q

What classifies as posterior pelvic tilt?

A

This is where the vertical plane of the ASIS is posterior to the vertical plane of the pubic symphysis.

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9
Q

What classifies as lateral pelvic tilt?

A

This is where the iliac crest is higher on one side than another.

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10
Q

How many bony segments are there in the vertebral column?

A

33

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11
Q

How are the 33 bony segments of the vertebral column divided?

A

24 bones are mobile segments (7 cervical, 12 thoracic, 5 lumbar), 9 are fused (5 sacral, 4 coccygeal).

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12
Q

How long is the average vertebral column?

A

72-75cm

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13
Q

What percentage of the length of the vertebral column is intervertebral discs?

A

25%

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14
Q

What can diurnal differences in height be due to compression of intervertebral discs throughout the day?

A

Up to 2cm

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15
Q

How does vertebra size change going down the vertebral column?

A

The vertebrae become larger as you move down the spine which helps facilitate load bearing and shock absorbance. This is also associated with thicker intervertebral discs in the lumbar spine.

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16
Q

What spinal structural feature allows for balanced bipedal movement?

A

The lumbar lordosis helps transfer upper body mass over the pelvis for balance.

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17
Q

What protection function does the vertebral column serve?

A

The vertebral column forms a canal through which the spinal cord and conus medullaris runs, providing protection to it.

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18
Q

How much rotation is possible at the lumbar vertebrae and why?

A

2-3 degrees as the vertical orientation of the facet joints prevents further rotation.

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19
Q

Which factors facilitate extension in the lumbar spine?

A
  • Short spinous processes enable extension without collision of the processes.
  • Larger intervertebral discs in the lumbar region.
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20
Q

What structure limits the extension of the lumbar spine?

A

Anterior longitudinal ligament

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21
Q

Which structures limit the flexion of the lumbar spine?

A
  • Posterior longitudinal ligament
  • Supraspinous ligament
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22
Q

When assessing posture, what are the key features to look out for?

A
  • Clavicle and shoulder alignment
  • Sternum and umbilicus alignment
  • ASIS height on both sides
  • Knee alignment
  • Foot positioning

These should all be checked from the front, side and back views

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23
Q

What are the postural elements of sway back?

A
  • Posterior tilt of the pelvis
  • Thoracic kyphosis
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24
Q

Which muscles have increased activity in sway back posture?

A

Rectus abdominis

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25
Q

Which muscles have decreased activity in sway back posture?

A
  • Internal abdominal obliques
  • Iliopsoas
  • Gluteus maximus
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26
Q

Which muscles are lengthened by sway back posture?

A
  • Erector spinae
  • Scapular stabilisers (serratus anterior, rhomboids and lower/mid trapezius)
  • Lower abdominal muscles
  • Hip flexors (iliopsoas, rectus femoris and tensor fascia latae)
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27
Q

Which muscles are shortened by sway back posture?

A
  • Suboccipital muscle
  • Sternocleidomastoid
  • Scalenes
  • Pectoralis muscles
  • Lower part of erector spinae
  • Upper abdominal muscles
  • Gluteus maximus
  • Hamstrings
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28
Q

What is kypholordotic posture?

A

This is where there is excessive cervical lordosis, thoracic kyphosis, lumbar lordosis and anterior pelvic tilt. It is effectively an exaggeration of normal curves of the spine.

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29
Q

Which muscles are lengthened with kypholordotic posture?

A
  • Upper back muscles
  • Front of the neck
  • Abdominal muscles
  • External abdominal obliques
  • Hamstrings
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30
Q

Which muscles are shortened by kypholordotic posture?

A
  • Quadriceps
  • Iliopsoas
  • Lower back
  • Back of the neck
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31
Q

How does kypholordotic posure reduce lumar apophyseal joint space?

A

This posture causes a slackening of the posterior longitudinal ligament resulting in apophyseal facets not being maintained apart under as much tension.

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32
Q

What is flatback posture?

A

This is where the natural curves of the spine are lost, reducing the shock absorbing capacity of the spine, putting the spine at greater risk of damage.

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33
Q

Which muscles are lengthened in flatback posture?

A
  • Quadriceps
  • Lumbar erector spinae
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34
Q

Which muscles are shortened in flatback posture?

A
  • Abdominal
  • Hamstrings
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35
Q

What are the common elements of all vertebrae below C2?

A
  • Large weight-bearing vertebral body anteriorly
  • Vertebral arch made from two laminae and two pedicles
  • A transverse process originating laterally from the point where laminae and pedicles meet
  • A superior and an inferior facet originating from the point where the laminae and pedicles meet
  • A spinous process originating posteriorly from where two laminae meet
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36
Q

Where are pedicles positioned in relation to vertebral bodies?

A

Pedicles pass from the superoposterolateral parts of the vertebral body and pass posteriorly to meet the anterolateral extremity of corresponding lamina.

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37
Q

What space is created between adjacent pedicles?

A

Intervertebral foramina through which spinal nerves and blood vessels can pass.

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38
Q

Where are the start and end points of the anterior longitudinal ligament?

A

Starts at the occipital bone.
Ends at the sacrum.

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39
Q

What doese the anterior longitudinal ligament attach to throughout its length?

A
  • Upper and lower edge of each vertebral body by binding loosely to periosteum and strongly to the fibrocartilage of disc end plates
  • Intervertebral discs by binding to hyaline cartilage
  • Margins of the vertebrae
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40
Q

What are the functions of the anterior longitudinal ligament?

A
  • Protect the anterior aspects of the intervertebral joints
  • Limits excessive extension
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41
Q

What is the structure of the anterior longitudinal ligament?

A

It is split into 3 layers:
* Deep fibres span one segment between vertebrae.
* Intermediate fibres span 2-3 segments between vertebrae.
* Superficial fibres span 3-4 segments between vertebrae.

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42
Q

Which condition is thought to be associated with excessive stretch followed by rapid recoil of the anterior longitudinal ligament?

A

Whiplash

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43
Q

Which is stronger: Anterior or Posterior Longitudinal Ligament?

A

Anterior Longitudinal Ligament

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44
Q

What are the start and end points of the posterior longitudinal ligament?

A

Starts at the body of C2.
Ends at the posterior surface of the sacrum (S2).

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45
Q

What is the posterior longitudinal ligament a continuation of?

A

The cruciform ligament between C1 and C2.

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46
Q

How does posterior longitudinal ligament width change as it descends down the spine?

A

The width of the posterior longitudinal ligament is consistent throughout the cervical and thoracic spine but widens in the lumbar region.

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47
Q

What does the posterior longitudinal ligament bind to in the spine?

A
  • Annulus fibrosis
  • Cartilage of vertebral endplates
  • Margins of the vertebral bodies
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48
Q

What are the functions of the posterior longitudinal ligament?

A
  • To provide support to the weaker posterior of intervertebral discs
  • To prevent excessive spinal flexion
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49
Q

What is the structure of the posterior longitudinal ligament?

A

It has two layers of fibres: superficial and deep. Deep span one vertebral segment whilst superficial span 3-4 vertebral segments.

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50
Q

How does the connective tissue content of ligamentum flavum vary compared to other spinal ligaments?

A

It is more elasticated due to a higher concentration of elastin.

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51
Q

What is the function of ligamentum flavum?

A

It provides a “brake” to laminar separation and its elasticity supports return to upright posture without buckling into the spinal canal.

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52
Q

Where is the ligamentum flavum?

A

Its medial fibres pass posteroinferiorly from one lamina to the next from C2 to S1. Its lateral fibres attach to the anterior part of the superior and inferior apophyseal facets, forming the anterior part of the joint capsule.

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53
Q

What causes the tension in ligamentum flavum in a neutral position?

A

Muscles in the lumbar spine apply tension on the thoracolumbar fascia which holds ligamentum flavum under tension.

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54
Q

Where does the supraspinous ligament run?

A

It connects the apices of spinous processes from C7 to L3/4

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55
Q

What is the structure of the supraspinous ligament?

A

It is consistently thick through the thoracic spine but widens in the lumbar region. It has deep fibres which span adjacent spinous processes, intermediate fibres which span 2-3 spinous processes and deep fibres which span 3-4 spinous processes.

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56
Q

Which muscle reinforces the deeper layers of the supraspinous ligament?

A

Multifidus

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57
Q

What is the function of the supraspinous ligament?

A
  • Prevents excessive spinal flexion
  • Helps to maintain upright posture
  • Prevents excessive separation of spinous processes during flexion
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58
Q

What are interspinous ligaments?

A

These are thin, sheet-like ligaments which connect spinous processes from C1 to S1.

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59
Q

Which other ligaments do the interspinous ligaments interact with?

A

Anteriorly they merge with ligamentum flavum and posteriorly they merge with supraspinous ligaments.

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60
Q

What is the function of interspinous ligaments?

A

Prevents excessive flexion by restricting separation of spinous processes.

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61
Q

What are intertransverse ligaments?

A

Intertransverse ligaments are thin, sheet-like ligaments which connect adjacent transverse processes and prevent excessive lateral flexion.

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62
Q

What are the 3 vertebropelvic ligaments?

A
  1. Iliolumbar
  2. Sacrotuberous
  3. Sacrospinous
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63
Q

What is the structure of the iliolumbar ligament?

A

It is a double band of connective tissue. The anterior band is broad and flat, originating from the inferolateral aspect of the L5 transverse process, fanning out and inserting into the anterior portion of the iliac tuberosity.
The posterior band originates from the apex of the L5 transverse process and inserts onto the anterior margin and apex of the iliac crest.

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64
Q

What is the function of the iliolumbar ligament?

A

It stabilises the lumbosacral spine on the pelvis by restricting lumbosacral and sacroiliac joint movements.

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65
Q

What is the pubic symphysis?

A

This is a fibrocartilaginous disc which forms the joint between the articulating surfaces of the pubic bones.

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66
Q

What is the function of the pubic symphysis?

A

It resists shearing and compressive forces and allows small amounts of movement, producing greater shock absorption.

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67
Q

What is the structure of the articular surfaces of the pubic bones?

A

The articulating surfaces of each pubic bone is ovular and slightly convex, coated in 1-3mm of hyaline cartilage.

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68
Q

Which ligaments reinforce the pubic symphysis?

A
  1. Superior pubic ligament
  2. Inferior pubic ligament
  3. Anterior pubic ligament
  4. Posterior pubic ligament
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69
Q

Where is the superior pubic ligament located?

A

It sits over the superior aspect of the pubic symphysis and attaches to the pubic crests as far laterally as the pubic tubercles.

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70
Q

What is the location of the inferior public ligament?

A

It forms an arch, spanning the inferior aspect of the pubic symphysis and providse fibres which blend with the disc itself.

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71
Q

What are the attachments of the anterior pubic ligament?

A

It attaches the two pubic rami anteriorly and binds the periosteum laterally.

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72
Q

What is the structure of the posterior pubic ligament?

A

It is made of a few thin fibres.

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73
Q

What are the origins of multifidus?

A
  • Dorsal surface of the iliac spine
  • Dorsal surface of the sacrum
  • Mammilary processes of lumbar vertebrae
  • Transverse processes of thoracic vertebrae
  • Articulating processes of C4-C7
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74
Q

What are the insertions of multifidus?

A

Spinous processes of lumbar, thoracic and cervical vertebrae, 2-5 vertebrae above the origin.

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75
Q

Which actions are facilitated by multifidus?

A
  • Trunk and neck extension
  • Lumbar spine support
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76
Q

Which nerves supply mulitifidus?

A

Medial branches of posterior rami of cervical, thoracic and lumbar nerves.

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77
Q

Which blood vessels supply mulitifidus?

A
  • Occipital artery
  • Deep cervical artery
  • Vertebral artery
  • Posterior intercostal artery
  • Lumbar artery
  • Lateral sacral arteries
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78
Q

Which structures are deep to multifidus?

A

Rotatores muscles

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79
Q

Which structure are superficial to multifidus?

A

Erector spinae

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80
Q

Which structures are located laterally to multifidus?

A

Levatorus costarum muscles

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81
Q

Which structures are located medially to multifidus?

A

Interspinalis muscles

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82
Q

Which exercises can strengthen multifidus?

A
  • Bird dog
  • Superman
  • Side plank
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83
Q

Which exercises can be used to stretch multifidus?

A
  • Cat cow
  • Bird dog
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84
Q

How do you palpate multifidus?

A
  1. Place your patient in prone lying
  2. Palpate the laminar groove (space between spinous and transverse processes) and you will mainly feel erector spinae
  3. Move slightly laterally, palpate deeply and then push inwards to feel multifidus.

Alternatively you can palpate the posterior surface of the sacrum and ask the patient to extend their trunk and neck and you can feel the origins of multifidus.

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85
Q

What type of muscle is multifidus?

A

Parallel, non-fusiform

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86
Q

What is the most common cause of multifidus injury?

A

Lifting heavy objects far away from the body e.g., a car battery

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87
Q

What did Shahidi et al 2017 discover about multifidus?

A

They found that in individuals with chronic, degenerative lumbar spine pathologies there was an increase in inflammatory markers and reduction in vascularisation in their multifidus muscles.

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88
Q

What are the origins of rectus abdominis?

A
  • Pubic crest
  • Pubic symphysis
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89
Q

What are the insertions of rectus abdominis?

A
  • Xiphoid process
  • Costal cartilages of ribs 5-7
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90
Q

What functions are mediated by rectus abdominis?

A
  • Trunk flexion
  • Compresses and provides support to adjacent abdominal structures
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91
Q

Which nerves supply rectus abdominis?

A

The anterior rami of 6th-12th thoracic nerves

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92
Q

Which blood vessels supply rectus abdominis?

A
  • Superior epigastric artery
  • Inferior epigastric artery
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93
Q

Which structures are located anteriorly to rectus abdominis?

A

Pyramidalis

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94
Q

Which structures are located laterally to rectus abdominis?

A
  • External abdominal obliques
  • Internal abdominal obliques
  • Transversus abdominis
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95
Q

Which structure is medial to rectus abdominis?

A

Linea alba

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96
Q

Which exercises can be used to strengthen rectus abdominis?

A
  • Sit-ups
  • Crunches
  • Flutter kicks
  • Leg raises
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97
Q

Which exercises can be used to stretch rectus abdominis?

A
  • Cat cow
  • Updog
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98
Q

How do you palpate rectus abdominis?

A
  1. Place the patient in supine and palpate from the xiphoid process to the pubis with the patient relaxed
  2. Ask the patient to raise their head, neck and shoulders off the plinth and you will be able to feel activation of rectus abdominis
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99
Q

What type of muscle is rectus abdominis?

A

Parallel, fusiform muscle

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100
Q

What are the origins of pyramidalis?

A
  • Body of pubic
  • Anterior pubic ligament
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101
Q

What is the insertion of pyramidalis?

A

Linea alba

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102
Q

What function is mediated by pyramidalis?

A

Tensing of linea alba

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103
Q

Which nerves supply pyramidalis?

A
  • Anterior ramus of 12th thoracic nerve
  • Iliohypogastric nerve
  • Ilioinguinal nerve
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104
Q

Which blood vessel supplies pyramidalis?

A

Inferior epigastric artery

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105
Q

Which structures are deep to pyramidalis?

A

Rectus abdominis

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106
Q

Which structures are superficial to pyramidalis?

A

The anterior layer of the rectus sheath

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107
Q

What type of muscle is pyramidalis?

A

Convergent

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108
Q

What are the origins of the internal abdominal obliques?

A
  • Thoracolumbar fascia
  • Iliac crest
  • Inguinal ligament
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109
Q

What are the insertions of the internal abdominal obliques?

A
  • Inferior margins of 10th-12th ribs and adjacent costal cartilages
  • Linea alba
  • Pecten pubis
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110
Q

Which actions are mediated by internal abdominal obliques?

A
  • Trunk flexion
  • Trunk lateral flexion
  • Trunk rotation
  • Compresses and provides support for adjacent abdominal structures
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111
Q

Which nerves supply the internal abdominal obliques?

A
  • Anterior rami of 7th-12th thoracic nerves
  • Ilioinguinal nerve
  • Iliohypogastric nerve
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112
Q

Which blood vessels supply the internal abdominal obliques?

A
  • Lower posterior intercostal artery
  • Subcostal artery
  • Deep circumflex iliac artery
  • Superior epigastric artery
  • Inferior epigastric artery
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113
Q

Which structures are deep to internal abdominal obliques?

A

Transversus abdominis

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114
Q

Which structures are superficial to internal abdominal obliques?

A

External abdominal obliques

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115
Q

Which structures are medial to internal abdominal obliques?

A

Rectus abdominis

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116
Q

Which exercises can be used to strengthen internal abdominal obliques?

A
  • Side plank
  • Weighted trunk rotation
  • Russian twists
  • Crunches with twist
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117
Q

How can you stretch internal abdominal obliques?

A
  • Standing side bend
  • Updog
  • Both knees to 90 degrees in supine and allow hips to drop outwards
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118
Q

How do you palpate internal abdominal obliques?

A
  1. Place the patient in supine
  2. Palpate just below 10th-12th ribs
  3. Request the patient to lift their opposite shoulder towards the side you are palpating and you will feel clear activation of internal abdominal obliques.
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119
Q

Which structures do internal abdominal obliques contribute towards?

A

Internal abdominal obliques give rise to a broad aponeurosis which forms part of the rectus sheath, inguinal canal and Petit’s triangle.

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120
Q

What type of muscle are the internal abdominal obliques?

A

Parallel, non fusiform

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121
Q

What are the origins of the external abdominal obliques?

A
  • External surface and inferior border of 5th-12th ribs
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122
Q

What are the insertions of the external abdominal obliques?

A
  • ASIS
  • Anterior half of iliac crest
  • Pubic crest
  • Pubic tubercle
  • Linea alba
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123
Q

Which actions are mediated by external abdominal obliques?

A
  • Trunk flexion
  • Trunk lateral flexion
  • Trunk rotation
  • Compresses and supports surrounding abdominal structures
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124
Q

Which nerves innervate external abdominal obliques?

A

Anterior rami of 7th-12th ribs

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125
Q

Which blood vessels supply the external abdominal obliques?

A
  • Lower posterior intercostal artery
  • Subcostal artery
  • Deep circumflex iliac artery
  • Superior epigastric artery
  • Inferior epigastric artery
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126
Q

Which structures are deep to external abdominal obliques?

A
  • External intercostal muscles
  • Internal abdominal obliques
  • Transversus abdominis
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127
Q

Which structures are medial to external abdominal obliques?

A

Rectus abdominis

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128
Q

Which exercises can be used to strengthen external abdominal obliques?

A
  • Side plank
  • Weighted trunk rotation
  • Russian twists
  • Crunches with twist
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129
Q

How can you stretch external abdominal obliques?

A
  • Standing side bend
  • Updog
  • Supine hip fallout
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130
Q

How do you palpate external abdominal obliques?

A
  1. Ask the patient to lie in supine
  2. Palpate along the lower ribs (5-12)
  3. Ask the patient to raise their shoulder on the side you are palpating and to bring it towards the opposite hip

You will clearly feel external abdominal obliques firing in this case

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131
Q

Which structure is formed from a broad aponeurosis of external abdominal obliques?

A

The inguinal ligament

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132
Q

Which muscles do external abdominal obliques interdigitate with near its origins?

A
  • Serratus anterior
  • Latissimus dorsi
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133
Q

What type of muscle are external abdominal obliques?

A

Parallel, non-fusiform

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134
Q
A
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135
Q

What are the origins of psoas minor?

A
  • Vertebral bodies of T12-L1 (anterolateral aspect)
  • T12-L1 intervertebral disc
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136
Q

What are the insertions of psoas minor?

A
  • Iliopectineal eminence
  • Pecten pubis
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137
Q

Which actions are mediated by psoas minor?

A

Trunk flexion

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138
Q

Which nerves innervate psoas minor?

A

Anterior ramus of 1st lumbar nerve

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139
Q

Which blood vessels supply psoas minor?

A

Lumbar arteries

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140
Q

Which structure are deep to psoas minor?

A

Psoas major

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141
Q

Which structures are superficial to psoas minor?

A

Ureter

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142
Q

Which structures are lateral to psoas minor?

A

Kidneys

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143
Q

Which structures are medial to psoas minor?

A

Lumbar vertebrae

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144
Q

Which movement is a good test of psoas strength?

A

Standing on one leg, lifting one knee as high as possible towards your chest and standing for 30 seconds

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145
Q

Which exercises can be used to strengthen psoas minor?

A
  • Lunges
  • Supine leg raises
  • Tabletop opposite elbow to knee crunches
  • Standing hip flexion
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146
Q

Which movements can be used to stretch psoas minor?

A

Anything that creates a posterior pelvic tilt e.g., posterior pelvic tilts, glute bridge with posterior pelvic tilt etc

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147
Q

How do you palpate psoas minor?

A

You don’t. It is beneath external abdominal oblique, internal abdominal oblique, transversus abdominis, the inguinal ligament and the digestive organs and so cannot be reached.

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148
Q

What percentage of people have a psoas minor muscle?

A

40%

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149
Q

What type of muscle is psoas minor?

A

Thin fusiform

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150
Q

What are the origins of psoas major?

A
  • Vertebral bodies from T12-L5
  • Transverse processes L1-L5
  • Adjacent interverterbral discs
151
Q

What are the insertions of psoas major?

A

Lesser trochanter of the femur via a rounded tendon

152
Q

Which functions are mediated by psoas major?

A
  • Trunk flexion
  • Hip flexion
153
Q

Which nerves innervate psoas major?

A

Anterior rami of 1st-3rd lumbar nerves

154
Q

Which blood vessels supply psoas major?

A
  • Lumbar arteries
  • Iliolumbar artery
  • Obturator artery
  • External iliac artery
  • Femoral artery
155
Q

Which structures are deep to psoas major?

A
  • Hip joint capsule
  • Quadratus lumborum
  • Iliopectineal bursa
156
Q

Which structures are superficial to psoas major?

A
  • Ureter
  • Inguinal ligament
157
Q

Which structures are lateral to psoas major?

A
  • Kidney
  • Iliacus
  • Femoral nerve
158
Q

Which structures are medial to psoas major?

A
  • Lumbar vertebrae
  • Psoas minor
  • Pectineus
159
Q

Which exercises can be used to strengthen psoas major?

A
  • Lunges
  • Supine leg raises
  • Tabletop opposite elbow to knee crunches
  • Standing hip flexion
160
Q

What can be done to stretch psoas major?

A

Anything that produces a posterior pelvic tilt

161
Q

How do you palpate psoas major?

A

It is not possible as the external abdominal obliques, internal abdominal obliques, transversus abdominis, inguinal ligament and digestive organs are in the way.

162
Q

What type of muscle is psoas major?

A

Psoas major is a long, thick fusiform muscle

163
Q

Where is the lumbar plexus located?

A

Within the posterior portion of psoas major

164
Q

What are the origins of iliocostalis?

A
  • Iliac crest
  • Thoracolumbar fascia
  • Angles of the 3rd-12th ribs
165
Q

What are the insertions of iliocostalis?

A
  • Transverse processes of C4-C7 and L1-L4
  • Angles of ribs1-12
166
Q

Which nerves innervate iliocostalis?

A

Lateral branches of the posterior rami of cervical, thoracic and lumbar nerves

167
Q

Which blood vessels supply iliocostalis?

A
  • Occipital artery
  • Deep cervical artery
  • Vertebral artery
  • Posterior intercostal artery
  • Subcostal artery
  • Lumbar artery
  • Lateral sacral artery
168
Q

Which structures are deep to iliocostalis?

A
  • Ribs
  • External intercostal muscles
  • Quadratus lumborum
  • Multifidus
169
Q

Which structures are superficial to iliocostalis?

A

At points iliocostalis is deep to:
* Serratus posterior (superior and inferior)
* Rhomboid major
* Trapezius
* Latissimus dorsi
* Thoracolumbar fascia

170
Q

How do you palpate iliocostalis?

A
  1. Ask the patient to lie in prone
  2. Palpate the iliac crest round to the posterior superior iliac spine
  3. Ask them to lift their chin, head and chest off the plinth and you will clearly see thick bands of muscle the whole way up the back
171
Q

Which exercises can be used to strengthen iliocostalis?

A
  • Lying in prone and extending the head and neck, adding weights in the hands for progression
172
Q

How can you stretch iliocostalis?

A
  • Cat cow
  • Curling into a ball and pulling knees to chest
  • In long sitting, bring the knee of the tight side of the other leg outstretched and turn towards your affected side and place your outside of your elbow on the outside of your bent leg
173
Q

What type of muscle is iliocostalis?

A

Parallel non-fusiform

174
Q

What are the origins of quadratus lumborum?

A
  • Posterior half of iliac crest
  • Iliolumbar ligament
175
Q

What are the insertions of quadratus lumborum?

A
  • Inferior border of the 12th rib
  • Transverse processes of L1-L4
176
Q

Which actions are mediated by quadratus lumborum?

A
  • Trunk extension
  • Trunk lateral flexion
  • Stabilisation of the 12th rib during inspiration
177
Q

Which nerves innervate quadratus lumborum?

A

Anterior rami of the 12th thoracic and 1st lumbar nerves

178
Q

Which blood vessels supply quadratus lumborum?

A
  • Subcostal artery
  • Lumbar artery
  • Iliolumbar artery
179
Q

Which structures are posterior to quadratus lumborum?

A
  • Iliocostalis
  • Transversus abdominis
180
Q

Which structures are anterior to quadratus lumborum?

A
  • Kidneys
  • Colon
  • Psoas major
  • Lateral arcuate ligament
  • Ilioinguinal nerve
  • Iliohypogastric nerve
181
Q

Which structures are medial to quadratus lumborum?

A
  • Lumbar vertebrae
  • Intertransversarii muscles
182
Q

What are the origins of intertransversarii lumborum?

A

Inferior aspects of L1-L4 transverse processes

183
Q

What are the insertions of intertransversarii lumborum?

A

Superior aspects of L2-L5 transverse processes

184
Q

Which actions are mediated by intertransversarii lumborum?

A

Trunk lateral flexion

185
Q

Which nerves supply intertransversarii lumborum?

A

Anterior and posterior rami of lumbar nerves

186
Q

Which blood vessels supply intertransversarii lumborum?

A
  • Lumbar arteries
  • Lateral sacral arteries
187
Q

Which structures are posterior to intertransversarii lumborum?

A

Iliocostalis

188
Q

Which structures are anterior to intertransversarii lumborum?

A

Psoas major

189
Q

Which structures are lateral to intertransversarii lumborum?

A

Quadratus lumborum

190
Q

What are the origins of interspinalis lumborum?

A

Superior aspects of L2-L5 spinous processes

191
Q

What are the insertions of interspinalis lumborum?

A

Inferior aspects of L1-L4 spinous processes.

192
Q

What actions are mediated by interspinalis lumborum?

A

Trunk extension

193
Q

Which nerves supply interspinalis lumborum

A

Posterior rami of lumbar nerves

194
Q

Which blood vessels supply interspinalis lumborum?

A
  • Lumbar arteries
  • Lateral sacral arteries
195
Q

What are the origins of iliacus?

A
  • Iliac crest
  • Superior two-thirds of the iliac fossa
  • Anterior sacroiliac ligaments
196
Q

What are the insertions of iliacus?

A

Lesser trochanter of the femur, merging with the rounded tendon of psoas major

197
Q

Which actions are mediated by iliacus?

A
  • Trunk flexion
  • Hip flexion
198
Q

Which nerves innervate iliacus?

A

Femoral nerve

199
Q

Which blood vessels supply iliacus?

A
  • Iliolumbar artery
  • Deep circumflex iliac artery
  • Obturator artery
  • Femoral artery
200
Q

Which structures are deep to iliacus?

A
  • Hip joint capsule
  • Iliopectineal bursa
201
Q

Which structures are superficial to iliacus?

A

Inguinal ligament

202
Q

Which structures are lateral to iliacus?

A
  • Ilium
  • Sartorius
203
Q

Which structures are medial to iliacus?

A
  • Psoas major
  • Femoral nerve
  • Lateral femoral cutaneous nerve
204
Q

What type of muscle is iliacus?

A

Convergent

205
Q

At what level does the spinal cord terminate?

A

L1-L2

206
Q

What are the elements of a spinal nerve?

A
  • Dorsal root
  • Ventral root
  • Dorsal root ganglion
207
Q

What is a dorsal root ganglion?

A

This is the collection of cell bodies of all sensory neurons related to that segment.

208
Q

Why are spinal nerves vulnerable to mechanical injury?

A

They have less protective tissue around them than the spinal cord.

209
Q

Other than spinal nerves, what else is found in the intervertebral foramina?

A
  • Meningeal nerves
  • Blood vessels
  • Transforaminal ligaments
  • Fat
210
Q

Which nerve roots produce the lumbar plexus?

A

L1-L4

211
Q

How many major peripheral nerves originate from the lumbar plexus?

A

6

212
Q

What are the 6 peripheral nerves originating from the lumbar plexus?

A
  • Iliohypogastric
  • Ilioinguinal
  • Genitofemoral
  • Lateral cutaneous
  • Femoral
  • Obturator
213
Q

Which nerve root does the iliohypogastric nerve originate from?

A

L1

214
Q

What sensory innervation is the iliohypogastric nerve responsible for?

A

Gluteal skin in the pubic region

215
Q

Which muscles are innervated by the iliohypogastric nerve?

A
  • Internal abdominal obliques
  • Transversus abdominis
216
Q

Which nerve root supplies the ilioinguinal nerve?

A

L1

217
Q

What sensory innervation is the ilioinguinal nerve responsible for?

A
  • Skin on the superior anteromedial thigh
  • Skin over the anterior scrotum and root of the penis in males
  • Skin over mons pubis and labia majora in females
218
Q

Which muscles are innervated by the ilioinguinal nerve?

A
  • Internal abdominal obliques
  • Transversus abdominis
219
Q

Which nerve roots supply the genitofemoral nerve?

A

L1 and L2

220
Q

What sensory innervation is the genitofemoral nerve responsible for?

A

Genital branch
* Anterior scrotum skin in males
* Skin over labia majora and mons pubis in females

Femoral branch
* Skin on the upper anterior thigh

221
Q

Which muscles are innervated by the genitofemoral nerve?

A

In males, the genitofemoral nerve innervates the cremasteric muscle.

222
Q

Which nerve roots supply the lateral cutaneous femoral nerve?

A

L2 and L3

223
Q

What sensory innervation is the lateral cutaneous femoral nerve responsible for?

A

The skin over the anterior and lateral thigh down to the knee.

224
Q

Which muscles are innervated by the lateral cutaneous femoral nerve?

A

None

225
Q

Which nerve roots supply the obturator nerve?

A

L2-L4

226
Q

What sensory innervation is provided by the obturator nerve?

A

The skin over the medial thigh

227
Q

Which muscles are innervated by the obturator nerve?

A
  • Obturator externus
  • Adductor longus
  • Adductor brevis
  • Adductor magnus
  • Gracilis
228
Q

Which nerve roots supply the femoral nerve?

A

L2-L4

229
Q

What sensory innervation is provided by the femoral nerve?

A

The skin on the anterior thigh and medial leg.

230
Q

Which muscles are innervated by the femoral nerve?

A
  • Iliacus
  • Pectineus
  • Sartorius
  • Quadriceps femoris
231
Q

What is the largest branch of the femoral nerve?

A

Saphenous nerve

232
Q

Where is the sacral plexus located?

A

On the posterior pelvic wall, anterior to piriformis

233
Q

Which nerve roots contribute to the sacral plexus?

A

S1-S4

234
Q

How many nerves originate from the sacral plexus?

A

5

235
Q

Which nerves originate from the sacral plexus?

A
  • Superior gluteal nerve
  • Inferior gluteal nerve
  • Sciatic nerve
  • Posterior femoral cutaneous nerve
  • Pudendal nerve
236
Q

Which nerve roots does the superior gluteal nerve originate from?

A

L4-S1

237
Q

Which sacral plexus nerves exit the pelvis via the greater sciatic foramen and do not return?

A
  • Superior gluteal nerve
  • Inferior gluteal nerve
  • Sciatic nerve
  • Posterior femoral cutaneous nerve
238
Q

What sensory innervation is provided by the superior gluteal nerve?

A

None

239
Q

Which muscles are innervated by the superior gluteal nerve?

A
  • Gluteus minimus
  • Gluteus medius
  • Tensor fascia lata
240
Q

Which nerve roots does the inferior gluteal nerve originate from?

A

L5-S2

241
Q

What sensory innervation is provided by the inferior gluteal nerve?

A

None

242
Q

Which muscles are innervated by the inferior gluteal nerve?

A

Gluteus maximus

243
Q

Which nerve roots contribute to the sciatic nerve?

A

L4-S3

244
Q

At what point does the sciatic nerve separate into the tibial and common fibular branches?

A

At the apex of the popliteal fossa

245
Q

What sensory innervation is provided by the tibial nerve?

A
  • Posterolateral leg
  • Lateral foot
  • Sole of the foot
246
Q

What sensory innervation is provided by the common fibular nerve?

A
  • Lateral leg
  • Dorsum of the foot
247
Q

Which muscles are innervated by the tibial nerve?

A
  • All the muscles of the posterior compartment of the thigh and leg except the short head of biceps femoris
  • Hamstring component of adductor magnus
  • Muscles of the sole of the foot
248
Q

Which muscles are innervated by the common fibular nerve?

A
  • Short head of biceps femoris
  • All muscles in the anterior and lateral compartments of the leg
  • Extensor digitorum brevis
249
Q

Which nerves does the tibial nerve separate into?

A

Medial and lateral plantar nerves

250
Q

What sensory innervation is provided by the medial plantar nerve?

A
  • Skin on the anterior two-thirds of the sole of the foot
  • The first 3.5 toes
251
Q

Which muscles are innervatd by the medial plantar nerve?

A
  • Abductor hallucis
  • Flexor hallucis brevis
  • Flexor digitorum brevis
  • Lumbricals
252
Q

What sensory innervation is provided by the lateral plantar nerve?

A
  • Skin on the lateral aspect of the anterior two-thirds of the foot
  • Last 1.5 toes
253
Q

Which muscles are innervated by the lateral plantar nerve?

A
  • Intrinsic muscles of the sole of the foot (except abductor hallucis, flexor digitorum brevis, flexor hallucis brevis and lumbricals)
254
Q

What does the common fibular nerve split into?

A

Superficial and deep fibular nerves

255
Q

What sensory information is provided by the superficial fibular nerve?

A

It innervates the anterolateral lower leg

256
Q

Which muscles are innervated by the superficial fibular nerve?

A
  • Fibularis longus
  • Fibularis brevis
257
Q

What sensory innervation is provided by the deep fibular nerve?

A

A very minimal area between the great toe and second toe

258
Q

Which muscles are innervated by the deep fibular nerve?

A
  • Tibialis anterior
  • Extensor hallucis longus
  • Extensor digitorum longus
  • Fibularis tertius
259
Q

Which nerve roots supply the posterior femoral cutaneous nerve?

A

S1-S3

260
Q

What sensory innervation is provided by the posterior femoral cutaneous nerve?

A

It innervates skin on the posterior surface of the thigh and the perineum.

261
Q

Which muscles are innervated by the posterior femoral cutaneous nerve?

A

None

262
Q

Which nerve roots supply the pudendal nerve?

A

S2-S4

263
Q

What is the path of the pudendal nerve?

A

It leaves the pelvis via the greater sciatic foramen and then returns via the lesser sciatic foramen.

264
Q

What sensory innervation is provided by the pudendal nerve?

A
  • Penis
  • Clitoris
  • Perineum
265
Q

Which muscles are innervated by the pudendal nerve?

A
  • Perineum muscles
  • External urethral spinchter
  • External anal sphincter
  • Levator ani
266
Q

What are degenerative changes?

A

These are slow destructive changes not counterbalanced by regeneration.

267
Q

What is the definition of arthrosis?

A

Degenerative changes in synovial joints

268
Q

What is spondylosis?

A

Degenerative changes in interbody joints e.g., intervertebral joints. This often involves discontinuity in pars interarticularis due to stress fracture.

269
Q

What is spondylolisthesis?

A

This is the forwards shifting on one vertebral body on top of the vertebral body below. This often occurs as a result of spondylosis.

270
Q

Why do vertebral bodies reduce in height in older age?

A

Trabecular tissue undergoes microfracture and becomes more susceptible to deformity.

271
Q

What is trabecular tissue?

A

It is the spongy, porous tissue at the epiphysis of bone, usually at the ends of bones.

272
Q

How does stress fracture in trabecular bone lead to convexity of intervertebral discs?

A

Microfracture of trabecular bone results in more load being applied to cortical bone which can then undergo deformity and apply more pressure on to intervertebral discs causing convexity.

273
Q

What are osteophytes and how do they form?

A

Osteophytes are small bony outgrowths which aim to provide additional resistance to compressive forces. They form in response to weakening of existing bones but can cause issues if they occur in or close to joint spaces.

274
Q

What changes occur in vertebral endplates with aging?

A
  • There is a progressive thinning of articular cartilage and replacement by bone which dramatically reduces the shock absorbing capacity of endplates. This leads to microfracture and further cortical deposition.
  • Structural changes reduce diffusion across endplates, leading to nutrient deficiency and inability to remove waste products from discs.
275
Q

What is the role of proteoglycans in intervertebral discs and how does this change over time?

A

Proteoglycans draw in large amounts of fluid by osmosis, keeping discs thick and strong. Loss of larger proteoglycans with aging reduces water uptake by discs and causes narrowing of discs.

276
Q

How are proteogylcans broken down with aging and what replaces them?

A

They are broken down by inflammation-induced activity of MMPs and cathespins. They are replaced by collagen which makes the disc more rigid and less shock absorbant.

277
Q

How are collagen and elastin aligned in annulus fibrosis and how does this change with age?

A

They are aligned obliquely where each layer is perpendicular to the previous layer. This orientation becomes more disordered with aging leading to less ability to withstand shearing forces.

278
Q

How does disc leakage accelerate disc degeneration?

A

The proteogylcans in nucleus pulposus are highly immunogenic and so they stimulate an immune response which triggers MMP and cathespin activity, accelerating the enzymatic breakdown of discs.

279
Q

How can posture affect discs?

A

Prolonged postures can apply pressure to specific areas of the annulus fibrosis causing weakening, radial fissures, protrusion and extrusion. Prolonged flexion is a common issue leading to posterolateral protrusions.

280
Q

How does disc degneration impact apophyseal joints?

A

Disc degeneration results in transmission of forces onto apophyseal joints which can cause inflammation and pain.

281
Q

Give examples of risk factors for disc degeneration

A
  • Increased lumbar lordosis
  • Heavy physical labour
  • Smoking
  • Obesity
  • Prolonged flexed posture
282
Q

How does smoking increase risk of disc degeneration?

A

Smoking causes atherosclerosis in the microvasculature of the vertebral endplates, resulting in nutrient deficiency and build up of waste products in discs and also prevents repair if they become damaged.

283
Q

How do gradual onset intervertebral disc injuries tend to occur?

A
  1. Repetitive rotational strains can generate circumferential tears or separation between laminae.
  2. Channels can then form from the nucleus pulposus to the weak point of the annulus fibrosus
  3. The nucleus pulposus begins to bulge through this channel producing a protrusion which can then lead to extrusion and sequestration.
284
Q

How does reduction in the cartilaginous lining of apophyseal joints promote gradual onset disc degeneration?

A

Reduction in the cartilaginous lining of apophyseal joints allows greater rotation, leaving discs more vulnerable to repetitive rotational strains.

285
Q

What is a common cause of sudden onset disc protrusion/extrusion?

A

Picking up heavy objects from a distance e.g., car batteries.

286
Q

Why do disc injuries heal very slowly?

A

They are poorly vascularised other than the most periperal sections.

287
Q

What is facet joint syndrome?

A

This is an arthritis-like condition caused by degradation of facet joints leading to inflammation and pain.

288
Q

In what age group is facet joint syndrome most common?

A

40-70 year olds

289
Q

How can facet joint syndrome be caused?

A
  • Inflammatory conditions e.g., arthritis, RA and ankylosing spondylitis can cause immune-mediated facet joint destruction.
  • Spondylosis can cause abnormal weight transmission through facet joints leading to damage.
290
Q

What are the most common symptoms of facet joint syndrome?

A
  • Diffuse dull ache in the lower back, sometimes spreading to the buttocks
  • Pain during rotation or extension of the spine
291
Q

How are symptoms often eased in facet joint syndrome?

A
  • Sitting
  • Leaning forward
  • Changing position
292
Q

What different grades are used to classify spondylolisthesis?

A

Grade 1 - 0-25% slippage
Grade 2 - 25-50% slippage
Grade 3 - 50-75% slippage
Grade 4 - 75-100% slippage
Grade 5 - Total slippage

293
Q

How is spondylolisthesis managed below grade 3?

A
  • NSAIDs
  • Exercise
  • Traction
294
Q

How are grade 4 and 5 spondylolistheses managed?

A

Surgical realignment and spinal fusion

295
Q

What is the principal consideration with pelvic fractures?

A

Blood loss as the pelvis is richly supplied by blood vessels and thus fractures resulting in haemorrhage can cause extensive internal bleeding leading to shock and possibly death.

296
Q

What are type A pelvic fractures?

A

Stable fractures not involving the ring (A1) or with minimal displacement of the ring (A2).

297
Q

What are type B pelvic fractures?

A

These are vertically stable fractures but rotationally unstable. They can be open book (B1), ipsilateral compression fractures (B2) or contralateral compression fractures (B3).

298
Q

What is a type C pelvis fracture?

A

A type C pelvic fracture is vertically and rotationally unstable and can be unilateral (C1), bilateral (C2) or associated with acetabular fracture (C3).

299
Q

What are the most common causes of type A1 pelvic fractures?

A
  • Sudden muscle contraction in athletes
  • Violence to the pubic crest
300
Q

What is the main symptom of type A1 pelvic fractures?

A

Local tenderness around the fracture

301
Q

How are type A1 pelvic fractures normally managed?

A

Symptom management only e.g., analgesia, and left to heal naturally

302
Q

What is the most common cause of type A2 pelvic fractures?

A

Elderly people falling onto their side.

303
Q

What are the most common presenting symptoms of type A2 pelvic fractures?

A
  • Local tenderness
  • Difficulty walking
304
Q

How are type A2 pelvic fractures normally managed?

A
  • 2-3 weeks bedrest
  • Symptom management
305
Q

What are common causes of B1 (open book) pelvic fractures?

A
  • Run over incidents where the ASIS is forced backwards and outwards
  • Heavy weights falling on both ASISs and pinning people to the ground
306
Q

Which ligaments are torn in type B1 pelvic fractures?

A

Sacrospinous and sacrotuberous ligaments

307
Q

Which ligaments remain intact in type B1 pelvic fractures to maintain vertical stability?

A

Posterior sacroiliac ligaments

308
Q

How are type B1 pelvic fractures usually managed?

A
  • Bedrest if the symphyseal gap is <2.5cm
  • Manipulation and external fixation if symphyseal gap is >3.5cm
309
Q

What are the most common causes of type B2 pelvic fractures?

A

Violence to one side of the pelvis.

310
Q

How are type B2 pelvic fractures managed?

A

Sometimes only symptom management as tissue elasticity performs spontaneous reduction. But sometimes external fixation is required.

311
Q

What are B3 pelvic fractures also known as?

A

Bucket handle injuries

312
Q

How do type B3 pelvic fractures occur?

A

Violence to one side causes one pubic ramus to compress the other such that it produces a contralateral fracture.

313
Q

How are type B3 pelvic fractures commonly managed?

A

With pelvic fixators to reduce deformity and to prevent leg length discrepancy.

314
Q

Which ligaments are disrupted in type C pelvic fractures?

A
  • Sacrotuberous
  • Sacrospinous
  • Posterior sacroiliac
315
Q

How are type C1 and C2 pelvic fractures commonly managed?

A

External fixators and traction to ensure resolution of the hemipelvises to correctly realign. Pins can also be applied across both ASISs.

316
Q

What is the biggest risk with type C1 and C2 pelvic fractures?

A

Life threatening internal haemorrhage

317
Q

How do type C3 pelvic fractures most commonly occur?

A

Force transmission through the femoral head fractures the pelvic e.g., knees on a car dashboard forcing the femur up into te acetabulum during a car crash.

318
Q

How are type C3 pelvic fractures normally managed?

A

Internal fixation and traction

319
Q

What are the most common symptom presentations of disc herniation?

A
  • Radicular pain
  • Low back pain
  • Sensory abnormalities in lumbosacral dermatomal regions
  • Weakness in lumbosacral myotomal regions
  • Limited trunk flexion
  • Pain exacerbated with straining, coughing, sneezing or prolonged sitting
320
Q

What are the 5 classifications of low back pain according to McKenzie?

A
  1. Centralisation
  2. Peripheralisation
  3. Dysfunction
  4. Adherent nerve root
  5. Postural
321
Q

What is centralisation according to McKenzie?

A

This is progressive abolishment of pain from distal to central in response to therapeutic loading strategies.

322
Q

What is peripheralisation according to McKenzie?

A

This is the process of increased or worsening peripheral symptoms in response to therapeutic loading strategies.

323
Q

What is dysfunction according to McKenzie?

A

This is spinal pain only which is intermittent and mainly limits only one movement.

324
Q

What is adherent nerve root according to McKenzie?

A

This is where there is a history of radiculopathy and the patient improved up to a point but now the improvement has stopped and there is intermittent pain and functional limitation.

325
Q

What is postural back pain according to McKenzie?

A

This is spinal pain only which is produced by static loading and improved by postural correction.

326
Q

Which inflammatory cytokines are most common in ankylosing spondylitis?

A
  • TNFa
  • IL17
  • IL23
327
Q

What percentage of ankylosing spondylitis patients are HLA-B27 positive?

A

75-90%

328
Q

What are syndesmophytes?

A

These are bone spurs that join and fuse adjacent vertebrae.

329
Q

How does axial arthritis in ankylosing spondylitis normally present?

A

Initially it presents with alternating hip pain, followed by chronic back pain followed by progressive stiffness and tenderness.

330
Q

Do symptoms of ankylosing spondylitis improve with rest?

A

No, they improve with exercise.

331
Q

Why can stiffness be disproportionate to axial arthritis in ankylosing spondylitis patients?

A

Pain and muscle spasms can produce greater stiffness than the mechanical stiffness produced by axial arthritis.

332
Q

How do syndesmophytes alter posture in ankylosing spondylitis?

A

They cause:
* Loss of lumbar lordosis
* Gluteal atrophy
* Accentuated thoracic kyphosis

333
Q

What is enthesitis?

A

This is inflammation at the point of insertion of a tendon or ligament. It is a common symptom in ankylosing spondylitis.

334
Q

What percentage of ankylosing spondylitis patients experience uveitis?

A

Up to 50%.

335
Q

What percentage of ankylosing spondylitis patients develop inflammatory bowel disorder?

A

5-10% but 60% of AS patients will have isolated incidences of colon or ileum inflammation.

336
Q

In what percentage of ankylosing spondylitis patients does peripheral hip arthritis occur?

A

25-35%

337
Q

What is a common skin symptom associated with ankylosing spondylitis?

A

Psoriasis

338
Q

What did the New York criteria for Ankylosing Spondylitis include and why are they no longer used?

A

Grade 2 sacroiliitis bilaterally or grade 3 unilaterally alongside early morning stiffness, improved with exercise but not with rest or ROM limitation.

These criteria were scrapped as patients often have very late onset of radiographic findings.

339
Q

What are more modern criteria for ankylosing spondylitis?

A
  • Age <45
  • Back pain >3 months
  • Limited coronal and sagittal plane lumbar spine movement
  • Limited chest expansion
  • Sacroiliitis on x-ray (grade 3-4 unilateral or 2-4 bilateral) OR subchondral bone marrow oedema by MRI
340
Q

How does sacroiliitis present on radiographs?

A

It presents initially as blurring of cortical margins of subchondral bone before undergoing erosions and sclerosis.

341
Q

What is a modified Schober’s test?

A

This is a test for ankylosing spondylitis:
1. Patient stands erect with feet hip width apart
2. The PSIS or L5 are palpated and a horiztonal line is drawn across the middle of the back in line with them
3. Another line is drawn 5cm below this and another 10cm above
4. The patient is asked to flex and attempt to touch their toes and the distance between the top and bottom lines is measured
5. This distance should increase to at least 20cm (from 15cm) in healthy individuals

342
Q

How is chest expansion measured in ankylosing spondylitis?

A

A tape measure is used around the patient’s chest while they have their hands behind their head. The difference between maximal inspiration and maximal forced expiration is measured. In healthy individuals this should be >2.5cm

343
Q

What is the threshold for normal in lateral side flexion testing?

A

10cm fingertip reach

344
Q

Give examples of scales used to measure disease activity in Ankylosing Spondylitis

A
  • Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
  • Ankylosing Spondylitis Disease Activity Score (ASDAS)
345
Q

Give an example of a scale used to measure functional limitation in ankylosing spondylitis

A

Bath Ankylosing Spondylitis Functional Index (BASFI)

346
Q

What is the stepwise progression of medical management of ankylosing spondylitis?

A
  1. NSAIDs for symptom relief and anti-inflammation
  2. Sulfasalazine or methotrexate for immune suppression
  3. Biologics e.g., TNF or IL17 inhibitors
347
Q

What percentage of ankylosing spondylitis experience symptom relief and limitation of disease progression in response to NSAIDs?

A

70%

348
Q

What is the proposed mechanism of sulfasalazine in ankylosing spondylitis?

A

Inhibition of prostaglandin and leukotriene production

349
Q

What is the proposed mechanism of methotrexate in ankylosing spondylitis?

A

T and B cell suppression

350
Q

In what type of ankylosing spondylitis patients are sulfasalazine and methotrexate seemingly most effective?

A

Those with peripheral arthritis

351
Q

What is a potential negative to TNF inhibitors in ankylosing spondylitis?

A

The immune suppression can leave users vulnerable to infections such as tuberculosis.

352
Q

When should surgery be considered in ankylosing spondylitis?

A

Where medical treatment and physiotherapy are ineffective.

353
Q

According to Karaca et al 2024, what significantly correlates with kinesiophobia in ankylosing spondylitis patients?

A
  • Worse body awareness
  • Higher rates of depression
  • Catastrophising
354
Q

Which 5 exercise interventions were found to significantly improve function in ankylosing spondylitis patients in a systematic review by Luo et al in 2024?

A
  • Running
  • Pilates
  • Stretch
  • Yoga
  • Tai Chi
355
Q

What are red flag conditions in the lumbar spine?

A

Red flag conditions are conditions which are pathologically serious. These include:
* Cauda equina
* Spinal infection
* Spinal malignancy
* Spinal fractures

356
Q

What are the 3 phases of cauda equina syndrome?

A
  1. Suspected cauda equina syndrome
    This is where there is back pain, bilateral radiculopathy and/or subjective sphincteric changes or perianal sensory changes.
  2. Incomplete cauda equina syndrome
    This is where there is objective evidence of cauda equina syndrome with validated saddle anaesthesia and altered bladder/bowel sensation and/or function.
  3. Retention
    This is where there is complete loss of sphincteric control and neurogenic urine retention.
357
Q

Give examples of cauda equina syndrome red flags

A
  • Paraesthesias in the inner thighs, genitals or perianal region
  • Altered bladder and bowel sensation
  • Altered bladder and bowel function
  • Loss of genital sensation during sex
  • Altered ability to achieve an erection or ejaculate
358
Q

What are the GIRFT CES guidelines if there are any urinary, perianal, genital or rectal symptoms?

A

Emergency MRI

359
Q

If patients have bilateral radicular leg pain or radiculopathy but no other symptoms of cauda equina syndrome, what do the GIRFT CES guidelines recommend?

A

They recommend that the patient is provided with a safety netting card informing them to attend A&E straight away if they develop other signs of cauda equina. They also recommend and MSK triage appointment within 2 weeks.

360
Q

How does metastatic spinal cord compression occur?

A

Tumours in the extradural space apply pressure to the dural sac and its contents.

361
Q

What are common symptoms of metastatic spinal cord compression?

A
  • Back or neck pain
  • Radicular pain with a “tight band” feeling around the chest and abdomen
  • Pain aggravated by straining e.g., coughing, sneezing
  • Pain aggravated by lying flat
  • Muscle weakness
  • Loss of coordination or paralysis
  • Sensory loss
  • Loss of bladder and bowel control
  • Unintentional weight loss
362
Q

What percentage of women 50-70 years old have an osteoporotic spinal fracture?

A

12%

363
Q

What percentage of women over 70 have an osteoporotic spinal fracture?

A

20%

364
Q

What are risk factors for spinal fracture?

A
  • Osteoporosis (those with previous osteoporotic fractures are 5.4-fold more likely to have a second compared to the incidence in the general population)
  • Corticosteroid use >7.5mg for over 3 months
  • Previous history of cancer
  • Severe trauma, especially from a height
365
Q

What are common symptoms of spinal fracture?

A
  • Sudden onset of pain in the thoracolumbar region after low impact trauma e.g., fall
  • Severe localised pain
  • Pain on performing weight bearing activities
  • Restricted ROM
  • There is sometimes increased prominence of spinous processes at the affected level
  • Tenderness to palpation
366
Q

Why are spinal infections thought to have increased in high and middle income countries in recent years?

A

An aging population and increased intravenous drug use

367
Q

Why are spinal infections thought to have increased in low income countries in recent years?

A

HIV/AIDS and TB epidemics leading to increased vulnerability to infection

368
Q

What are risk factors for spinal infection?

A
  • Immunosuppression e.g., HIV/AIDS, RA medication, alcohol abuse, long term steroid use
  • Invasive surgery
  • Intravenous drug use
  • Occupational exposure to pathogens
  • Homelessness
  • Contact with infected animals
  • History of TB
369
Q

What are common symptoms of spinal infection?

A
  • Spinal pain
  • Neurological symptoms
  • Fatigue
  • Fever
  • Unexplained weight loss
370
Q

What is STarT?

A

This is a 9-item tool to assess biopsychosocial risk factors for back pain prognosis. It separates patients into low, medium and high risk of poor outcomes and stratifies patients into which treatment will likely work best for them.

371
Q

From fingerstips to which anatomical landmark is often used to measure spinal flexion?

A

Tibial tubercle

372
Q

From fingerstips to which anatomical landmark is often used to measure spinal extension?

A

Popliteal crease

373
Q

From fingerstips to which anatomical landmark is often used to measure spinal lateral flexion?

A

Head of fibula

MSK (2 decks)

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