Lumbar Spine Flashcards
What percentage of the general population will experience low back pain (LBP) at some time in their lives?
80 percent.
Neurofibromatosis
heredity disorder (autosomal dominant trait) that produces pigmented spots and pedunculate soft-tissue nodules clustered along nerve sheaths.
Neurofibromatosis nodules develop:
during childhood, growing to more than .5 cm in size. throughout life they can reach 1.5 cm or more in size
Café-Au-Lait patches
seen over the trunk, pelvis, and flexor creases of the elbows and knees
Neurofibromatosis bone changes may result in:
skeletal deformities: scoliosis, vertebral body scalloping, fibrous dysplasia, tibial pseudoarthosis, sphenoid bone deformity, mental impairment, seizures, hearing loss, exophthalamos, decreased visual acuity and GI bleeding
Gibbus deformity:
sharp kyphosis in the lower thoracics, affecting the normal lordosis of the lumbar spine
Top of the iliac crest is followed towards the midline of the spine at what level?
L4-L5 interspinous space (usually, may vary by individual)
A palpable or visible step off from one process to another may indicate what?
spondyloslsthesis
a pars interarticularis defect indicates what?
spondylolysis (seen on oblique x-ray)
Spondylolytic spondyloslisthesis:
a unilateral or bilateral defect in the pars interarticularis with anterior or posterior displacement of a vertebrae on the adjacent lower vertebrae.
What scale is used to measure spondylolistehesis?
Meyerding’s Scale. Ranges from grade 1-grade 4. The grades represent 25 percent of the measurement of the sacrum to L5
The articulations between 2 consecutive lumbar vertebrae form three joints:
1) the two vertebral bodies and the IVD
2 & 3) formed by the articulation of the superior articular process of one vertebra and the inferior articular process of the vertebra above
The umbilicus lies at what disc level?
L3-L4
Anterior portions of the vertebral bodies are covered by what?
ALL (anterior longitudinal ligament)
Primary function of the zygapophyseal joint?
to protect the motion segment from anterior shear forces, excessive rotation, and flexion
Anterior Longitudinal Ligament (ALL):
from sacrum along the anterior aspect of the entire spinal column, becoming thinner as it ascends.
Posterior Longitudinal Ligament (PLL):
Found throughout the spinal column where it covers the posterior aspect and the IVD
Ligamentum Flavum:
Connects 2 consecutive laminae
Interspinous Ligament:
connects 2 consecutive spinal processes
Supraspinous ligament
connects the tips of two adjacent spinous processes
Iliolumbar ligament:
functions to restrain flexion, extension, axial rotation and side bending of L5-S1
Pseudoligaments:
interetransverse, transforaminal, and mamillo-accessory, resemble the membranous part of the fascial system separating paravertebral compartments and do not have any mechanical function.
Quadratus lumborum:
lumbar spine stabilizer
Lumbar multifidus:
lumbar segmental stability. provides segmental stiffness and controls motion
erector spinae:
composed of iliocostalis lumborum and throacic longissimus
thoracolumbar fascia:
assists the transmission of extension forces during lifting activities, stabilizes the spine against anterior shear and flexion moments
psoas muscles:
takes origin from anterior portion of T12-L5 vertebral bodies and discs. (main hip flexor) pain from psoas access increases when hip is actively flexed
Sciatic Nerve
largest nerve in the body, gives off braces to the hamstrings and then divides into 2 terminal braces : tibial and peroneal divisions
Sciatic nerve palpation:
midpoint between ischial tuberosity and the greater trochanter. Disc pathology or space-occupying lesion can cause the nerve to be tender.
A disc is named after the vertebrae ____:
above.
A disc pathology affects the nerve root ____:
below. i.e.: an L4 disc pathology affects the L5 nerve root.
Disc pathologies: Protrusion:
little pieces of the nucleus pulposus protrude into the annular fibers and weaken them.
Disc pathologies: Prolapse (Bulge):
nucleus pops out of the annular fibers. fibers not torn, just stretched.
Disc pathologies: extrusion (herniation):
fibers torn, nucleus bursts into PLL, PLL is torn, patient describes shredding noise
disc pathologies: sequestration:
multiple pieces of the nucleus are in the spinal canal.
L4 muscle testing and reflex:
Muscle test: foot dorsiflexion and inversion: tibias anterior (deep peroneal nerve) L4 reflex= patellar reflex
L4 dermatome:
medial leg, behind the medial malleolus and along the medial side of the foot and great toe
L5 muscle testing and reflex:
foot dorsiflexion
big toe dorsiflexion: extensor helices longus (deep peroneal nerve), toes 2, 3, 4 dorsiflexion: extensor digitorum longs and brevis (deep peroneal nerve), hip and pelvis abduction: gluteus medium and minimum (superior gluteal nerve)
L5 Reflex= there is no reflex for this nerve root level.
L5 dermatome:
lateral aspect of the leg, anterior to the lateral malleolus, dorsum of the foot and the middle three toes (2,3,4)
S1 muscle testing:
foot plantar flexion: gastrocnemius and soleus (tibial nerve), foot plantar flexion and eversion: peroneus longus and braves (superficial peroneal nerve), hip extension: gluteus maximus (inferior gluteal nerve)
S1 reflex:
achilles reflex
S1 sensation:
posterior aspect of the leg, lateral aspect of the foot, and lateral aspect of the little toe
Nerve supply to the lumbar spine:
outer half of the IVD innervated by sinuvertebral nerve and the gray rami communicants. posterior lateral aspect innervated by both sinuvertebral and gray rami. Lateral aspect receives only sympathetic innervation.
zygapophyseal joints are innervated by what:
medial branches of dorsal rami
Motion at lumbar spine joints:
sagittal (flexion/extension), coronal (side bending), and transverse (rotation).. 6 degrees of freedom are available at the lumbar spine.
most flexion and extension occurs:
in the lower segmental levels
most side bending occurs:
mid-lumbar area
rotation occurs:
rotation occurs with side bending as a coupled motion. it’s minimal, and occurs most at the lumbosacral junction
Flexion:
produces a combination of an anterior roll and an anterior glide of the vertebral body, and a straightening of the lordosis. (at l4-l5, reversal of the lordosis may occur but at the l5-s1 level the joint will straighten, not reverse unless there is a pathology)
Extension:
involves a posterior roll and glide of the vertebra, a posterior inferior motion of the zyg. joints but not a change in the degree of lordosis.
axial rotation:
about 13 degrees to both sides. about 5 degrees occurs at the L5-S1 segment
physical examination of the lumbar spine:
must include thorough assessment of neuromuscular, vascular and orthopedic systems of the hip, lower extremities, low back and pelvic region
Active ROM:
involves fully functional contractile and inert tissues and optimal neurological function. QUALITY of motion and symptoms provokes is more important than the quantity of motion.
Acute Phase intervention goals:
decrease pain, inflammation and muscle spasm, promote healing of tissues, increase pain-free ROM, regain soft tissue extensibility, regain neuromuscular control, allow progression to the functional stage
Functional phase intervention goals:
correction of imbalances of strength and flexibility, incorporate neuromuscular re-education, strengthening of entire kinetic chain, postural correction and retraining, initiate and execute functional activities without pain and while dynamically stabilizing the spine in an automatic manner.
