Lumbar Spine Flashcards
Name the five points to the Childs Lumbar Manipulation Clinical Prediction Rule
- Symptom Duration less than 16 days
- No Symptoms Distal to the Knee
- FABQ work subscale less than 19
- At Least 1 Hypomobile Lumbar Segment
- At Least 1 Hip with greater than 35 degrees of Internal Rotation
Describe Fryettes Law of Spinal Biomechanics
- In Cervical Spine, Side Bending and Rotation occur to the same side
- In Neutral Lumbar and Thoracic, Side Bending and rotation occur to opposite sides.
- In Extreme Flexion, Lumbar and Thoracic, Side Bending and Rotation occur to the same side
Atlas Joint, C0-C1 is known as the ____ Joint for what reason?
The Atlas is known as the “Yes” Joint, because it is responsible for much of the Cervical Spines Flexion and Extension
Axis Joint, C1-C2 is known as the ____ Joint for what reason?
The Axix is known as the “No” joint because it is responsible for much of the cervical spines Rotation
Abnormal Curvature of the Spine in the coronal plane is known as what?
Scoliosis if curvature > 10 degrees, if < 10 degrees is known as spinal assymetry
How are the Fibers of the Annulus Fibrosus arranged?
In alternating perpendicular fibers arranged at 45 degree angle to the vertebral end plate
How does disk height account for the curvature of the spine?
Disks fo Lumbar and Cervical Spine are Larger Anteriorly and in the Thoracic Spine are shorter Anteriorly
How does the disk receive nutrition?
Through diffusion. Uncharged solutes, such as glucose occur at the end plates, and negatively charged solutes through the annulus
What changes occur in the disk with aging
In youth, the nucleus has a lot of type II collagen, water, and proteoglycans. As you age, water and proteoglycans become less abundant and much of the type II collagen becomes type I collagen
What are relative loads placed on a disk in different postural positions
Lying Supine 0%, Lying on Side 25%, Standing 100%, Seated 145%, Standing with forward bend 150%, Seated with forward bend 180%
How are spinal roots named in relation to where they exit the spine?
In Cervical Spine, they are named for the Vertebrae below which they pass, in thoracic down, they are numbered for the vertebrae above them
How does spinal movement affect size of the intervertebral foramen
Flexion increases 24%, Extension Decreases 20%
What are the ratios of disk height to vertebral body height in the spine?
Cervical: 1:4
Thoracic 1:7
Lumbar 1:3
How much AROM in the C Spine do you need to perform ADL’s
65-70 degrees of Rotation and Flexion
What are the functions of the Intervertebral disk?
- Provides space and position for neuroforminal elargement.
- Permits, guides, and restrains motion in all directions
What position facilitates disk nutrition?
Side Lying with back flat or slightly curved, lying on back with knees bent and back flat. The first hour of sleep is when most diffusion occurs.
Describe the innervation of the disk
The recurrent sinu vertebral nerve and gray communicating ramus from the sympatetic chain innervate the first and perhaps the second layer of the Annulus.
What characteristics on MRI are most indicative of Discogenic Low Back Pain
Annular Tearing and Vertebral End Plate Damage
Describe Acute Synovitis/ Hemarthrosis and stiffness of the Facet Joint
Facet Joint strain and effusion causes inflammatory response at the joint, Muscle guarding occurs and as a result of guarding and healing, scar tissue is laid down and capsular tightness occurs
Describe a Mechanical Block at the Facet joint
Joint may become locked after stooping. Cause is torn meniscoid, free fragment of articular cartilage, roughness in joint surface with degeneration. Typically occurs in males at L4/5 and is painless
Describe Painful Capsular Entrapment at the Facet Joint
Occasionally with sudden movement, joint capsule can become painfully entrapped in the nearby facet joint. Treated with isometric contraction of multifidi or gappnig technique
Describe the source of pain with a dysfunctional disk
Typically only the outer 1-2 layers of the annulus are vascularized and innervated, however with the healing process from annular tearing comes more vascularization and with it, accompanying sympathetic nerves that can sensitize the disk and lead to increased pain.
At what levels is Cervical Spondylosis most common?
C5/6>C6/7 > C4/5 > C7/T1
At what levels does lumbar disk prolapse most commonly occur?
L4/5 > L5/S1 > L3/4 > L2/3 > L1/2
What are most common levels of dysfunction in Thoracic Spine
T1/2 > T12/L1 > T4/5
Describe Disk Protrusion
Annular Fibers are intact, can be localized or diffuse annular bulge
Describe Disk Herniation
Annular Fibers Disrupted.
- Prolapsed - Nucleus through inner annulus but still contained
- Extruded - Nucleus through outer layer of annulus
- Sequestered - Nucleus broken from disk and is is spinal or intervertebral canals
What is the incidence of disk herniation?
In Asymptomatic patients, incidence range from 24-50%
What are common causes of Lumbar Radiculopathy
Occur in Middle age, more common in men, and typically result of disk herniation
What are common causes of Cervical Radiculopathy
Occur later in life, more prevalent in females and most commonly a result of foraminal stenosis
What is most effective treatment for acute mechanical low back pain?
In Descending order
- Manipulation
- Patient Instruction
- Exercise
Describe innervation of facet joints
Branch of the posterior primary ramus innervates the joint capsule and branches to innervate the joint above and below as well
What are effects of Lumbar Stabilization exercise after diskectomy?
Increase muscle tone, endurance and decrease in pain
What are the most common structural changes of Spinal Stenosis
Facet Joint Arthorosis, Thickening of Ligamentum Flavum, Loss of disk height or bulging disk, and degenerative spodylolisthesis
How will most spinal stenosis patients present
Typically older than 50, long history of pain, postural dependent pain - worse with extension and better with flexion
How can Lumbar Stenosis be differentiated from Vascular Claudication
Postural Dependency - walking upright vs walking bent over or up hill. If pnt can walk further bent over, positive for Lumbar Stenosis.
What is most common functional deficit in individuals with Lumbar Stenosis?
Diminished Walking Tolerance
What is most common surgical intervention for lumbar stenosis
Decompression Laminectomy
Will Steroid injections help a patient with lumbar stenosis
Short term benefit may occur
What are best conservative treatment options for patients with Lumbar Stenosis?
Flexion oriented exercise, Traction, Deweighted treadmill walking
What are some early signs of Cervical Myelopathy?
Unsteadiness of Gait and Clumsiness, may not have neck pain. Wasting of intrinsic muscles of hands. Parasthesia in one or both hands or feet, feeling of weakness.
How is Spondylolisthesis measured or graded?
Slipping one vertebral body on the other, Grades 1-4. 25%, 50%, 75% and 100% slippage respectively. Grade 5 superior body slips entirely forward on subjacent body and is known as Spondyloptosis
When is Isthmic Spondylolisthesis (Pars Stress Fracture) most common?
In young gymnasts and football players
How is Isthmic Spondylolisthesis (pars stress fracture) conservatively treated?
Rigid bracing for 3-6 months and trunk stabilization exercise
What are surgical indications for spondylolisthesis?
Progressive Weakness and nuerologic signs as well as progressive slip beyond grade 2. Intervention is typically Lx Fusion.
When should children with scoliosis be braced?
Curve 30 degrees. Bracing not indicated in Skeletally mature patients
What test is most commonly used to assess for scoliosis?
Adams Test - Forward trunk flexion, observe for curve
When is further evaluation by another provider recommended for Scoliosis
Curves > 15-20 degrees
How can progression of Scoliosis be predicted?
Risser Classification. Measures Iliac Epiphysis in skeletally immature patients. Grade 0-5 Ranging from skeletally immature to skeletally mature.
What types of braces are used in Scoliosis
Milwaukee and Boston. Boston preferred because it is newer and lighter weight, compliance is better
What Scoliotic curves respond best to bracing?
Risser type 0, Risser type 4 and 5 do not respond well to bracing
What are indications for surgical intervention in Scoliosis
Curves > 50 deg, Double Major Curves > 30 deg, Curves > 40 deg in skeletally mature patients, Curves > 30 deg with marked rotation
What are the time frames pain is present when describing Acute vs. Chronic LBP?
Acute LBP < 3 monnths
Chronic LBP > 3 months
Acute LBP typically resolves without treatment how fast and in what percentage of people affected?
In 80% of people resolves in 6-8 weeks
What are some indicators that a patient with LBP will recover quickly?
- Lower than average initial pain
- Shorter duration of Symptoms
- Fewer Previous episodes of LBP
What are Yellow Flags?
A Patients personal mistaken beliefs about pain and injury
Give some examples of Yellow Flags
High Degree of Anxiety or Depression, Excessive Preoccupation with pain, Overestimation of the negative impact of pain, Elevated Fear Avoidance, Believing you have no control over the pain
What is a Blue Flag?
These flags involve a persons perception of work and work conditions that might impair return to work
What is a Black Flag?
Secondary Gain and incentive to remain disabled. Include a lot of factors such as social and financial issues.
What are red flags that raise concern for Cancer?
- History of Cancer
- Night pain or pain at rest
- Unexplained Weight Loss
- Age >50 or < 17
- Failure to improve with conservative treatment
What are red flags that raise concern for Infection?
- Patient is Immunosuppressed
- Prolonged fever over 100.4
- History of IV drug use
- History of recent UTI, Cellulitis, or Pneumonia
What are red flags that raise concern for Vertebral Fracture?
- Prolonged use of corticosteroids
- Mild Trauma Age > 50 years old
- Age > 70 years old
- A known history of Osteoporosis
- Recent major trauma at any age (MVA or Fall greater than 5 ft)
What are red flags that raise concern for Abdominal Aortic Aneurysm?
- Pulsating mass in the abdomen
- History of Atheroslcerotic Vascular Disease
- Throbbing, Pulsating back pain at rest or with recumbency
- Age > 60 years
What are the Criteria to be included in the Manipulation Category in the Treatment Based Classification System?
- No Symptoms Distal to Knee
- Recent Onset of Symptoms
- Low Score on Work Subscale of FABQ
- Hypomobility of Lx Spine
- Hip Internal Rotation > 35 deg of at least one hip
What are the Criteria to be included in the Stabilization Category in the Treatment Based Classification System?
- Younger Age
- Greater General Flexibility
- Instability “catch”
- Positive Prone Instability Test
What are the Criteria to be included in the Extension Category in the Treatment Based Classification System?
- Symptoms distal to buttock that peripheralize with Lx Flexion and Centralize with Lx Extension
- Directional preference for extension
What are the Criteria to be included in the Flexion Category in the Treatment Based Classification System?
- Older Age
- Directional Preference for Flexion
- Imaging Evidence of Lx Stenosis
What are the Criteria to be included in the Lateral Shift Category in the Treatment Based Classification System?
- Visible Frontal Plane Deviation of shoulders relative to pelvis
- Directional Preference for lateral translation of movements of pelvis
What are the Criteria to be included in the Traction Category in the Treatment Based Classification System?
- Signs and Symptoms of Nerve Root Compression
2. No Movements Centralize Symptoms
What is the strongest predictor of Degenerative Disc Disease?
Genetics, Family history. Environmental factors and Lifestyle has not been fully supported in the evidence
How is the level determined in Spinal Cord Injury?
The cord level is defined by the lowest functional motor level (3/5 or better). Sometimes it will be annotated like “T8 motor, T12 sensory”.
What radiographic findings might mean that an injury to the spine might be unstable?
- Injury to 2 or more of the 3 columns of the spine
- Anterior Spine: Ant 2/3 of the body and disk
- Middle: Posterior 1/3 of the body and PLL
- Posterior: The Posterior elements
How does level of injury affect prognosis?
If an injury occurs in a part of the spine that has a very small vertebral canal (Lower Cervical and Thoracic Spine), the likelihood of recovery is less than if the injury were to occur in an area where the canal is larger (Lumbar Spine) and there is more room for swelling before spinal cord compression occurs
What is the most common type of cervical spine injury?
Distractive Flexion injuries
How are Distractive Flexion injuries of the C Spine Treated?
If only Posterior column is affected, can be treated with Collar Immobilization. In more High Energy cases with Facet Dislocation, Reduction with Skull Tongs and Post Spinal Fusion are necessary
What are common signs and symptoms of an Odontoid Fracture?
- Usually associated with High Energy Trauma
- Patients report pain, sense of instability, and will occasionally hold the head with the hands to relieve these Symptoms
What is a hangmans fracture and how is it treated?
- Traumatic Spodylolisthesis of the Axis
- A Bilateral fracture of the C2 pars interarticularis
- If minimally displaced can be treated with a Philadelphia collar, if less stable and more displaced, surgical stabilization is required
What is a Jefferson Fracture?
- Burst fracture of the Atlas C1
Describe the Difference between a Burst Fracture and a Compression fracture
- Burst Fractures include failure of the Anterior, Middle, and Post Columns and are more rare
- Compression fractures are more common and include failure of the Anterior Column only
What is Autonomic Dysreflexia
- Seen in patients with cercial and upper thoracic Spinal Cord Injuries
- Bladder Overdistention or Fecal Impaction causes and Autonomic Nervous System reaction and leads to severe hypertension
What are common signs and symptoms of Autonomic Dysreflexia and how is it treated?
- Patient presents with pounding headache, anxiety, perfuse head and neck sweating, nasal obstruction, and blurred vision
- Immediately treat with placement of Foley Catheter and Bowel Disimpaction, if this does not work, medication may be necessary
What are the key Myotome, Dermatome, and Reflex to test for L2?
- Hip Flexors
- Groin, Anterior, and Medial Thigh Sensation
- No Reflex
What are the key Myotome, Dermatome, and Reflex to test for L3?
- Hip Flexors, Knee Extensors
- Groin, Anterior, and Medial Thigh Sensation
- No Reflex
What are the key Myotome, Dermatome, and Reflex to test for L4?
- Knee Extensors, Ankle Dorsiflexors
- Medial Lower Leg Sensation
- Patellar Tendon Reflex
What are the key Myotome, Dermatome, and Reflex to test for L5?
- Great Toe Extensors
- Lateral Lower Leg and Dorsum of Foot Sensation
- No Reflex
What are the key Myotome, Dermatome, and Reflex to test for S1?
- Plantar Flexors
- Lateral Foot, Posterior Lateral Thigh and Lower Leg
- Achilles Reflex
What are the key Myotome, Dermatome, and Reflex to test for S2?
- Foot Instrinsic Muscles
- Plantar Surface of Foot Sensation
- No Reflex
What are Yellow Flags?
- Patients personal mistaken beliefs about pain and injury
- Examples include Emotional Distress, Hypervigilance, Low Self Efficacy, Elevated Fear Avoidance Beliefs
What are Blue Flags?
- Relate primarily to injured workers
- Describe a patients perception of work and conditions that might impair their desire to return to work
What are Black Flags?
- Wider Context of factors such as social and financial issues
- Secondary Gain
What is Self Efficacy?
- The belief that one can achieve future goals
What are some examples of Red Flags for Cancer?
- History of Cancer
- Night Pain
- Unexplained Weight Loss
- Age >50 or < 17
What are some examples of Red Flags for Osteomyelitis or Infection of the disk?
- Patient is Immunosuppressed
- Prolonged fever > 100.4
- History of IV Drug Use
- History of recent UTI, Cellulitis, or pneumonia
What are some examples of Red Flags for Undiagnosed Vertebral Fracture?
- Prolonged use of corticosteroids
- Mild Trauma age > 50
- Age > 70
- Known history of osteoporosis
- Major Trauma at any age
What are some Red Flags for AAA?
- Pulsating mass in the Abdomen
- History of Atherosclerotic Vascular Disease
- Throbbing, Pulsing back pain at rest or with recumbency
- Age > 60
What are Inclusion Criteria for Lumbar Stabilization group?
- Younger Age
- Greater General Flexibility
- Instability Catch
- Positive PIT Test
What are Inclusion Criteria for Lumbar Extension Group?
- Symptoms distal to buttock that peripheralize with Flexion and Centralize with extension
- Directional Preference for Extension
What are Inclusion Criteria for Lumbar Flexion Group?
- Older Age
- Directional Preference for Flexion
- Imaging Evidence of Lumbar Stenosis
What are Inclusion Criteria for Lumbar Lateral Shift Group?
- Visible frontal plane deviation of shoulders relative to pelvis
- Directional preference for lateral translation of movements of the pelvis
What are Inclusion Criteria for Lumbar Traction Group?
- Signs and Symptoms of nerve root compression
- No Movements Centralize Sx
What is the strongest known predictor for the development of Degenerative Disk Disease?
- Genetics/ Family History
