Lumbar Spine

Question 1

There are 5 lumbar vertebral bodies, which are wider and deeper than any other vertebra. What 2 features do lumbar vertebra lack which are found in either cervical or thoracic vertebrae?

Answer 1

Transverse foramina (found in cervicals)

Costal facets (found in thoracics)

Question 2

What anatomical feature of lumbar vertebrae is located immediately beneath each vertebra, containing spinal nerve roots, recurrent meningeal nerves, and radicular blood vessels?

Answer 2

Intervertebral neural foramina

Question 3

Intervertebral neural foramina are narrowed with extension as pedicles glide toward one another. What pathological conditions might cause narrowing of these foramina?

Answer 3

Arthritis
Spurs
Hypertrophy of posterior longitudinal ligamnet
Herniation of nucleus pulposus
Tissue congestion/edema
Inflammation
Perineural edema

Question 4

How are intervertebral discs named?

Answer 4

Named for vertebra above (e.g. below L2 = 2nd lumbar disc)

Question 5

Intervertebral discs funciton to dissipate heavy loads. They consist in part of a _____ ____which is the soft mucoid central core, which is surrounded by the ____ _____ made up of concentric lamellae of collagenous fibers

Answer 5

Nucleus pulposus

Annulus fibrosis

Question 6

Intervertebral discs are thicker anteriorly and thinner posteriorly. Why is this clinically significant?

Answer 6

Discs are more likely to herniate posteriorly

Question 7

Where do lumbar nerve roots exit in relation to their named vertebrae?

Answer 7

Lumbar nerve roots exit below named vertebra

Question 8

What nerve plexus provides sensory and motor info to lower extremity?

Answer 8

Lumbosacral plexus

Question 9

______ = posterior element of lumbar spine that connects other posterior elements to the vertebral body and protects from significant disc herniations of the same vertebra

Answer 9

Pedicles

Question 10

______ = posterior element of lumbar spine that are lateral projections that lie in the same horizontal plane as the spinous processes

Answer 10

Transverse processes

Question 11

The inferior facets of lumbar vertebrae face _____, while superior facets face _______

The facets join to form _______ joints with the vertebral units above and below

Answer 11

Laterally; medially

Zygopophyseal

Question 12

What is the most common lumbar congenital abnormality, occurring in 30% of patients?

Answer 12

Zygapophyseal joint tropism — articular pillars on one side of vertebral unit are twisted so plane of joint does not match that of other side. Assessed with asymmetric muscle tensions and altered spinal motions

Question 13

What characteristics distinguish spinous processes of lumbar vertebrae from thoracic?

Answer 13

They are thick, quadrangular, and “spade-like” at the ends

Question 14

The height of the iliac crests corresponds to what lumbar anatomical landmark?

Answer 14

The L4 spinous process

Question 15

The spinal canal contains the dural tube, spinal cord, and origins of spinal nerves down to approximately ______ or ______ where the spinal cord ends. Below that point is the ______ and ______ of the spinal cord

Answer 15

L1-L2; L2-L3; cauda equina; filum terminalis

Question 16

The lumbar spine is very mobile and thus predisposed to aches and pain. What are the major motions at the lumbar spine?

Answer 16

Flexion/extension

Sidebending and rotation

Question 17

T/F: In the lumbar spine, sidebending and rotation are coupled motions (one cannot occur without the other)

Answer 17

True

[can be type 1 or type 2 mechanics]

Question 18

What are some observations you can make in terms of patient posture while examining the lumbar spine?

Answer 18

Slumped over
Erect stance
Asymmetry
Lumbar lordosis
Gait changes

Question 19

What are some etiologies for slumped over posture while examining the lumbar spine?

Answer 19

Psychiatric considerations — depression
Muscle spasm (e.g., psoas)
Reactive effort (relief of pressure from condition impinging on lumbar nerves in intervertebral foramen)

Question 20

What are some etiologies for erect stance posture while examining the lumbar spine?

Answer 20

Protecting herniated disc or effects of spinal stenosis. Especially consider with muscular weakness, reflex changes, or muscle atrophy

Question 21

How would you evaluate asymmetries while examining the lumbar spine? What are some etiologies for asymmetry?

Answer 21

Evaluate iliac crest heights, greater trochanter heights, asymmetric sacral sulci, and paravertebral muscle humping

Etiologies: short leg syndrome, sacral base unleveling, muscle spasm, scoliosis

Question 22

What are some gait changes you might note while examining the lumbar spine?

Answer 22

“Listing” of trunk to one side
Antalgic or limping
Foot drop, hiking up hip, rotation of lower extremity
Shuffling or fenestrated gait

Question 23

Etiologies of gait change: “listing” of trunk to one side

Answer 23

Disc herniation, muscle weakness — especially glut medius

Question 24

Etiology of gait changes: foot drop, hiking up hip, rotating of lower extremity

Answer 24

Neuromuscular etiologies

Question 25

Etiology of shuffling or fenestrated gait

Answer 25

Parkinson’s disease

Question 26

What are some etiologies for tenderness to the spinous processes of lumbar vertebrae?

Answer 26

Fracture, dislocation, underlying infection, arthritis

Question 27

What are some etiologies of “step-offs” palpated on lumbar spinous processes?

Answer 27

Spondylolisthesis (forward slippage of vertebra which may compress spinal cord)

Question 28

What are all aspects of your palpation exam of lumbar spine?

Answer 28

Spinous processes for tenderness and/or step-off SI joint tenderness Paravertebral muscles for tenderness and/or spasm Sciatic n. tenderness

Question 29

Etiologies of SI joint tenderness

Answer 29

Sacroiliitis | Ankylosing spondylitis

Question 30

Etiologies of paravertebral muscle tenderness and/or spasm in lumbar region

Answer 30

``` Degenerative/inflammatory MSK abnormalities Overuse injury Poor posture Anxiety Somatic dysfunction ```

Question 31

Herniated intervertebral discs, which occur most commonly at ____-____ or _____-_____ may produce tenderness of spinous processes, intervertebral joints, muscles, and/or nerves. Low back pain may also be referred from the pelvis or abdomen.

Answer 31

L5-S1; L4-L5

Question 32

Palpation for sciatic nerve tenderness is done in the ____ position with the hip _____

Answer 32

Lateral recumbent; flexed

Question 33

The sciatic n. is the largest nerve in the body consisting of _____ nerve roots. It lies midway between the _____ and _______ (=sciatic notch)

Answer 33

L4-S3; greater trochanter; ischial tuberosity

Question 34

Etiologies of sciatic n. tenderness

Answer 34

Herniated disc or mass lesion impinging on contributing nerve roots

Question 35

It is important to inspect and evaluate overlying skin in lumbar region, as dermatologic conditions/rashes may occur with various conditions including infection, reactive processes, and spondyloarthropathies. What are some examples of skin changes you could see?

Answer 35

Birth marks, port-wine stains, lipomas Patches of hair (spina bifida) Cafe-au-lait spots, skin tags, or fibrous tumors (neurofibromatosis)

Question 36

Normal ROM for lumbar flexion

Answer 36

40-90

Question 37

Muscles involved in lumbar extension

Answer 37

Deep intrinsic back muscles

Question 38

Normal ROM of lumbar spine extension

Answer 38

20-45

Question 39

Muscles involved in lumbar rotation

Answer 39

Abdominal mm. | Intrinsic mm. of back

Question 40

Normal ROM for lumbar rotation

Answer 40

3-18

Question 41

Muscles involved in lumbar sidebending

Answer 41

Abdominal mm. | Intrinsic back mm.

Question 42

Normal ROM for lumbar sidebending

Answer 42

15-30

Question 43

Describe test, what is positive, what this indicates: Straight Leg Raise (Lasegue) Test

Answer 43

Patient supine, passively flex pt’s ipsilateral hip with knee extended. Add dorsiflexion to increase dural tension in low lumbar and high sacral levels + test = presence or worsening of radicular pain radiating into ipsilateral leg, especially between 30-60 degrees and worse with dorsiflexion Indicates: lumbosacral radiculopathy (usually from herniated disc) and/or sciatic neuropathy

Question 44

SLR is considered positive for lumbosacral radiculopathy between 30-60 degrees. What would a positive test mean at greater than 70 degrees vs. pain at around 15 degrees?

Answer 44

Positive signs at >70 is more likely mechanical LBP d/t muscle strain or joint disease Pain laterally at >15 degrees could indicate IT band contracture

Question 45

Greater than 95% of disc herniations occur at what region of the spine? Why?

Answer 45

L5-S1 — spine angles sharply posterior

Question 46

What 2 signs/symptoms make diagnosis of sciatic 5x more likely?

Answer 46

Ipsilateral calf wasting | Weak dorsiflexion

Question 47

The diagnostic accuracy of the SLR test is limited by its low specificity (but high sensitivity) for dx of radiculopathy due to disc herniation. What additional test can be done to increase specificity?

Answer 47

Contralateral (crossed) SLR test

Question 48

Describe test, what is positive, what this indicates: Contralateral (crossed) SLR test

Answer 48

Patient supine, passively flex patient’s contralateral hip with knee extended + test = presence or worsening of radicular pain radiating into the contralateral leg, especially between 30-60 degrees Indicates: lumbosacral radiculopathy (usually from herniated disc) and/or sciatic neruopathy

Question 49

Describe test, what is positive, what this indicates: Hoover’s sign

Answer 49

Patient supine. Hold hand under heel of the unaffected leg. Ask pt to try and flex affected (weak) leg against slight resistance while maintaining extension at knee (straight leg). If an honest effort is made, the physician should feel unaffected leg’s heel pushing down as they attempt to raise the affected leg by flexing at the hip + test = no downward force of unaffected leg as they are “attempting” to lift affected leg Indicates: functional weakness (“conversion disorder”) or malingering of the pt

Question 50

Describe test, what is positive, what this indicates: Thomas test

Answer 50

Pt supine with buttocks toward end of table. Flex both hips and knees to chest (flattens lumbar lordosis and stabilizes pelvis). Have pt extend affected leg toward table and relax to allow full extension + test = lower extremity on involved side will be unable to fully extend at hip Indicates: iliopsoas tension, shortening, or contracture

Question 51

T/F: iliopsoas hypertonicity is a common finding in acute and chronic LBP

Answer 51

True

Question 52

Describe test, what is positive, what this indicates: Gaenslen test

Answer 52

Patient supine. Flex one hip and knee to chest while simultaneously extending opposite hip (off side of table) **alternative**: lateral recumbent; patient flexes lower hip and holds, physician then extends top hip. Maneuver stresses both SI joints + test = posterior pelvic pain Indicates: SI joint dysfunction or pathology

Question 53

Describe test, what is positive, what this indicates: Valsalva test

Answer 53

Pt holds breath and bears down which increases intrathecal pressure + test = sciatic symptoms (sharp or burning pain radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle) Indicates: sciatica (sciatic n. compression or irritation), often associated with numbness or tingling

Question 54

T/F: pain radiating to just above the knee is more likely to represent true radiculopathy than distal leg pain

Answer 54

False; pain radiating below the knee is more likely to represent true radiculopathy than proximal leg pain

Question 55

Describe test, what is positive, what this indicates: Stork test

Answer 55

Patient standing. Have patient flex hip and knee of one leg. Stabilize patient’s iliac crests, if needed, and have them lean back extending the lower back + test: pain in lower back as it stresses the posterior elements of the spine on the ipsilateral side Indicates: possible pars defect/stress fracture; if bilateral, increased risk of spondylolisthesis

Question 56

Condition of spinal nerve root compression usually by massive disc protrusion, fracture/trauma, or tumor that results in bowel/bladder dysfunction

Answer 56

Cauda equina syndrome

Question 57

There is no single test for cauda equina syndrome, but what are some clinical features that require investivation?

Answer 57

LBP (usually first symptom, present in 83-95% of pts at time of dx; can precede neurologic symptoms by weeks in cases not secondary to immediate trauma) Bowel/bladder dysfunction (overflow incontinence) Sensory loss of perineum (“saddle anesthesia”) and decreased anal sphincter tone Bilateral sciatica and leg weakness

Question 58

T/F: cauda equina syndrome requires emergent management and surgical decompression within 48 hours, or permanent neurologic damage can remain

Answer 58

True

Question 59

Congenital malformation (usually failure of lamina fusion in vertebra) leading to neural tube defects (incomplete closure) in lumbar spine

Answer 59

Spina bifida

Question 60

What type of spina bifida results in a small split in vertebra, with NO spinal cord protrusion, is asymptomatic and usually an incidental finding on radiograph?

Answer 60

Spina bifida occulta [may also see patch of hair, birthmark, or dimple]

Question 61

At what spinal segment is spina bifida occulta most common?

Answer 61

L5-S1

Question 62

What type of spina bifida involves meninges forced out between vertebra and requires surgical repair, usually without any neurological damage

Answer 62

Meningocele

Question 63

What is the most common type of spina bifida?

Answer 63

Myelomeningocele — unfused portion of spinal cord protrudes through opening. Very severe (permanent) neurologic complications

Question 64

What is a normal Ferguson’s angle?

Answer 64

30-40

Question 65

What condition, typically seen on x-ray, appears as a defect or fracture in pars interarticularis of the vertebral arch?

Answer 65

Spondylolysis

Question 66

What condition, typically seen on lumbar x-ray, appears as an anterior displacement of vertebral body?

Answer 66

Spondylolisthesis

Question 67

Age-related wear and tear of the spine

Answer 67

Osteoarthritis (spondylosis)