LUMBAR SPINE Flashcards
Lumbar Spine
L3 dermatome
distal anterior medial thigh
Local muscles of the trunk control what?
Inter-segmental motion
(Multifidus, intertransversari, interspinalis, transversus abdominus, internal
oblique, deep Erector spinae)
50-75% slippage=
Grade 3
name of muscle
quadratus lumburum
in the lumbar spine, passive range of motion examination is done by
two parts:
- Osteokinematic PROM: good reliability
-
Arthrokinematic (segmental) motion tests: poor reliability:
- PAIVM (Passive accessory intervertebral motion: joint glides to determine end-feel (hyper, hypo, normal) and pain/no-pain
- PIVM (Passive intervertebral motion): move the spine osteokinematically and
palpate motion of a single segment
what is the main function of the interspinales and intertransversarii muscles
- Primary function may be as motion indicators
- Small muscles with small moment arms and loaded with proprioceptors
The multifidus attaches to the spinous processes and, therefore, has an excellent moment arm for _________ . It also has a compressive element and contributes to sacral nutation.
spinal extension
Right Rotation of the lumbar spine is associated with posterior rotation of the right ilium. The right ASIS will move ________ as L5 rotates right relative to the sacrum.
In this position the right SI joint is _______ .
- superiorly
- “gapping.”
what it is for?
name of test?
Gaenslens test
- SI pain provocation test
>95% of lumbar disc herniations occur at
L4-5 or L5-S1
Right Rotation of the lumbar spine is associated with posterior rotation of the right ilium. The right ASIS will move superiorly as L5 rotates right relative to the sacrum. In this position the right SI joint is “gapping.” Given the ___________ ligaments this makes sense. As the ilium moves posterior it “drags” the ipsilateral transverse process with it. Or conversely, as L5 rotates right it provides “slack” in the iliolumbar ligament “allowing” posterior rotation of the ilium.
iliolumbar
SPONDYLOLYSIS
Fx of pars inter-articularis
what are the 5 predictors that has been validated to thrust the spine?
- No symptoms distal to the knee
- Recent onset < 16 days
- FABQW < 19
- Hypomobility of at least 1 segment
- At least 35 degrees one hip IR
💡during AROM
Reproduction of symptoms when the pelvis was stabilized implicates a dysfunction originating primarily from the _____ .
spine
The psoas and DES provide opposite tensions to the spine, thereby ________ it, similar to “guy wires” for a tent pole.
stabilizing
zygapophyseal joints.
facet joint
“main goal of the examination of the lumbar spine is….
reproduction of pain.”
(Dr. )
👉🏻what is the cut off time for pt with LBP?
name of test
Sorensen Test (Sn: 92%, -LR 0.08; Sp: 94%, +LR 15.4)
- Patient presentation: younger age < 40 years, hypermobility in SLR, aberrant movements during, lumbar flexion and extension, Positive prone instability test.
- normal 2-3 minutes
- Cut off for patients with LBP is > 28-29 sec (Arab et al, 2009)
“a predictor for who may develop LBP” (Dr. M)
Sorensen test
Slump Test (Sn: 84%, -LR 0.19; Sp: 83%
- lumbar radiculapathy
- Patient slumps as far as possible producing full trunk flexion; examiner adds firm overpressure
- +ve test is reproduction of patient’s symptoms
Nutation (meaning to nod) is defined as the relative _______ of the base (top) of the sacrum relative to the ilium.
anterior tilt
name of manipulation
LUMBOPELVIC THRUST MANIPULATION
______% of patients with LBP will have non-specific mechanical LBP
85%
💡can develop into which pathology?
Clinical significance of the ligamentum flavum
- It is located inside the spinal canal
- With age, the ligament flavum will degenerate and may hypertrophied (becoming fibrotic) → spinal stenosis
when you directly impart forces to a single segment creating joint glides and determine the end-feel and amount of motion of a single segment (hypo, hyper, normal). You will also determine the
presence or absence of pain at each segment you push on.
Passive accessory intervertebral motion
PAIVM
Contraction of the erector spinae muscles will cause sacral _______
nutation
L2-L4 reflex
patellar
Patients with acute symptoms should be informed that…
recovery is likely in a short-period of time, but recurrence is likely and this does not mean a failure of treatment
contraindicated exercises in a patients with spondylosis
extension ex in the early phase
- age > 50
- with Degenerative narrowing of the spinal canal or intervertebral foramen
- with Neurogenic claudication (bilateral leg pain) with walking
Spinal Stenosis
S2 dermatome
heel
Anterior displacement of spine above pars inter-articularis fracture
SPONDYLOLISTHESIS
- Urinary retention (Sn: 0.90, Sp: 0.95)
- Motor deficits at multiple levels
- Fecal incontinence
- Saddle anesthesia
- Sensory deficits in the buttocks, posterior superior thigh, and perianal region
CAUDA EQUINA
medical emergency
History question: Do you feel numbness between your legs when you wipe after using the toilet?
name each disc pathology in the picture
L2/L3 myotome
hip flexion
Specificity and Sensitivity
lumbar radiculopathy special tests
- Crossed Straight Leg Raise (Sn: 25%, -LR 0.79; Sp: 95%): rule in
- Straight Leg Raise (Sn: 97%, -LR 0.05; Sp: 57%): rule out
- Slump Test (Sn: 84%, -LR 0.19; Sp: 83%)
- Femoral Nerve Tension Test (Sn 84%)
what it is for?
name of test?
Thigh Thrust Test
- SI pain provocation test
Provocations in ____ or more tests plus tenderness in Fortin’s area is fairly conclusive of SI joint origin to the pain.
three
Neurogenic claudication, also known as pseudoclaudication, is
- bilateral leg pain
- claudication, from the Latin for limp, because the patient feels a painful cramping or weakness in the legs.
- NC should therefore be distinguished from vascular claudication, which is when the claudication stems from a circulatory problem, not a neural problem.
TBC: mobilization group treatment
- Mobilization and manipulation of the lumbopelvic region
- Active ROM exercises
L2 dermatome
anterior mid thigh
THORACOLUMBAR FASCIA is located directly under the skin, and is very important for
lumbar stability
- DF weakness
- Great toe extension weakness
- Ankle reflex S1 (Sn 0.83)
- Sensory deficit
- Clinical tests:
- SLR (Sn0.91)
- X-SLR (Sp 0.88)
Sciatica
grade?
<25% slippage =
Grade 1
primary stabilizers ligaments of the SI joint
- Anterior SI ligaments
- Posterior SI ligaments
L4 dermatome
medial melleolus
📖 Donald Neuman textbook
The downward force of gravity resulting from body weight passes through the lumbar vertebrae, usually just anterior to an imaginary line connecting the midpoints of the two sacroiliac joints. At the same time, the femoral heads produce an upward directed compression force (GRFV) through the acetabula. Each of these two forces acts with a separate moment arm to create a _______ torque about the sacroiliac joints
nutation
💡During AROM examination
Reproduction of symptoms when the lumbo-pelvic region rotates as a unit implicates a ______ dysfunction.
hip
intermittent low back pain with increasing frequency, excessive ROM, catching, weakness, increased joint mobility, “fidgeter”, returns from FB by holding onto thighs:
all suggest hypermobility and necessity of Stabilization exercises
TBC
- Symptoms distal to the buttock
- Symptoms peripheralize with lumbar flexion
- Symptoms centralize with extension
Specific Exercise Extension group
TBC: stabilization group treatment
- Strengthening of the large global muscles
- Motor control training of the deep local muscles
Movement Analysis II
Clinically ______ exercises temporarily reduce pressure on a lumbar nerve root impinged by obstructed foramen
flexion
But flexion also increases compresses forces anterior disc which push nucleus posterior
what is the main difference between facet joint syndrome and spinal stenosis?
- In both the pain is worse with extension and improves with flexion
- However, in facet joint syndrome pain is very localized, whereas in spinal stenosis the pain radiates down the the leg
cut off time for pt with LBP?
name of test
Supine Isometric Chest Raise Test (Sn: 96%, - LR 0.24; Sp: 72%. +LR 4.0)
- Cut off for patients with LBP is > 34 sec for males and > 24 seconds for females (Arab et al, 2009)
Note facet orientation, orientation return back to frontal plane from sagittal plane facets of lumbar spine. This prevents _______ slippage of the lumbar segment
anterior
Seronegative arthritis characterized by inflammation and, eventually, ankylosis
Ankylosing Spondylitis
MA II
The facet surfaces of the L5-S1 apophyseal joints are usually oriented in a more _____ plane than those of other lumbar regions
frontal
cut off time for pt with LBP?
name of test
Prone Isometric Chest Raise Test (Sn: 80%, -LR 0.08; Sp: 80%, +LR 15.3)
- Patient presentation: younger age < 40 years, hypermobility in SLR, aberrant movements during, lumbar flexion and extension, positive prone instability test
- Cut off for patients with LBP is > 31-33 seconds (Arab et al, 2009)
During the neutral gapping thrust manipulation, the therapist’s superior hand is on the ____________ pushing toward the table. The therapist’s inferior hand is on the _____________ pulling upwards to the ceiling.
- superior segment’s spinous process
- inferior segment’s spinous process
Degenerative narrowing of the spinal canal or intervertebral foramen
Spinal Stenosis
is there lateral flexion in the lumbar spine?
yes, especially at the L5-S1 facet joint becasue they oriented in a more frontal plane
💡 muscles
To correct anterior innominate, use activation of
hamstrings/glutes to pull innominate posterior
name of tests
Femoral Nerve Tension Test (Sn 84% Porcher et al, 1994)
Disc problems L2 to L4
lumbar radiculopathy
- One hand on PSIS
- Bend knee until the onset of symptoms
- Back the leg out of the position
- The examiner can use PF, DF, or head symptoms to sensitize the findings
- Further sensitization can be elicited by hip extension
L5 dermatome
lateral leg
What it is for?
name of test
Gillet Test (poor reliability)
SI dysfunction
In those with pelvic pain in which SI joint dysfunction is suspected, the PSIS may move superiorly instead, or not move at all.
Counternutation occurs by _______ sacral-on-iliac rotation,_______ iliac-on-sacral rotation, or both motions performed simultaneously.
- posterior
- anterior
spondylolysis population
- Gymnast
- Dancers
- Weightlifters
which muscle is located closest to the spinous process in the lumbar spine?
multifidus
Spondylolysis can progress to
spondylolisthesis
what makes it positive?
name of tests
Prone Instability Test (Sn: 61%, -LR 0.69; Sp: 57%, +LR 1.41 Fritz et al, 2005)
- A PA spring test is given over the back and symptoms are assessed
- Pt lift their legs
- +ve test is reduction of symptoms
💡two things
the primary function of the deep erector spinae is…
to prevent anterior shear of each segment and to provide vertical compressive force.
very important ligament in prevention of anterior displacement of L5 on Sacrum
Iliolumbar ligament
SIJ Joint
Are either centralisation or peripheralisation phenomena observed?
if yes →
if no →
- If yes → diagnosis of symptomatic disc lesion
- if no → Are three or more SIJ provocation tests positive?
name of ligament
resists nutation or posterior innominate motion
Sacrotuberus and Sacrospinous ligaments
Nutation occurs by ______ sacral-on-iliac rotation, ________ iliac-on-sacral rotation, or both motions performed simultaneously.
- anterior
- posterior
name of test
- One hand palpates left PSIS
- the other hand palpates S2
- Patient flexes the hip to 90 deg
Gillet Test
In those with pelvic pain in which SI joint dysfunction is suspected, the PSIS may move superiorly instead, or not move at all.
(Poor reliability)
Movement Analysis II
Full lumbar extension increases amount of load and area of contact at
facet joints
