Lumbar Spine Flashcards
What structure does the spinal cord pass through?
vertebral foramen
Where do ligaments attach to on the spine?
spinous processes
How are spinal nerves named?
after the superior vertebrae
Where does spinal cord terminated? What does it become?
L1/L2; forms a point called conus medullairs, below this point is the caudal equina
Lumbar puncture
lumbar puncture is a needle that allows to get a sample of CSF from subarachnoid space
Epidural
an injection of medication (steroids, anesthetics, anti-inflammatories) into epidural space
Where are lumbar punctures/epidurals done? What level?
below conus medullar is (around L3/4) to avoid the spinal cord
Function of Intervertebral Discs
- allow movement between the vertebral bodies (squishy pad allowing for movement)
- transmit load between vertebral bodies (shock absorbers)
Components of IVD
- vertebral end-plate
- nucleus pulposus
- annulus fibrosis
Vertebral end-plate
- a layer of cartilage covering superior and inferior surfaces of disc
- firmly attached by sharpy’s fibres
- diffusion of nutrients from vertebral body to disc (it is a form of connection between disc and vertebral body)
Nucleus Pulposus
- semi-fluid gel
- 70-90% water
- proteoglycans make up 65% of dry weight- resist compressive forces
- deformable under pressure
- transmits applied pressure in all directions
- tolerant of compression, transmits pressure in all different directions
Annulus fibrosis
- made of collagen arranged in a highly ordered fashion (50-60% of dry weight)- resists tension
- collagen are arranged in 15-25 concentric, circumferential lamellae
- oriented 65% to the vertical
- retains nucleus pulposus
- absorbs compression and can tolerate tensile forces
Distraction
- superior-anterior glide of inferior articular process
- anthrokinematics; superior joint moving on inferior joint
- inferior articular process is on superior vertebrae, superior articular process is on inferior vertebrae.
- results in widening of IVF
- pulling bone off bone
- distraction can be used to treat
Compression
- Inferior-posterior glide of superior vertebrae
- inferior articular process of superior vertebra
- results in narrowing of IVF
- pinches nerve
- compression is used to diagnose
Disc Distraction
- separation of vertebral bodies increases the height of the IVD and all the collagen in annulus fibrosis are lengthened and tense, regardless of orientation
- tension through all collagen fibres
- distraction injuries are rare
Disc Compression
- raises the pressure in the nucleus pulposus which becomes exerted radially onto the annulus fibrosis increasing the tension in the annulus
- the tension in annulus is exerted on nucleus preventing it from expanding radially. nuclear pressure is then exerted on vertebral end-plates.
- vertebral end-plates transmit the load from one vertebrae to the next
Flexion(Anthrokinematics)
- superior-anterior glide of the inferior articular process of the superior vertebrae alone the superior articular process of the inferior vertebrae
Extension (Anthrokinematics)
- inferior-posterior glide of the inferior articular process of the superior vertebrae along the superior articular process of inferior vertebrae
- If you have radiculopathy; extension should decrease symptoms
Disc Flexion
- causes compression of annulus fibrosis in the direction of the movement and along annulus on the opposite side
- this pinches disc in the front which causes it to stretch out back
- forward bending: anterior end of vertebral body lowers will the posterior end rises
- nucleus pulposus will be compressed anteriorly and will migrate posteriorly
- when nucleus pulposus gets driven to the back it causes a disc herniation or bulge
Torsion
- collagen fibres of annulus oriented in the same direction as twist will be stretched and resist torsional force, remainder are relaxed.
- only half of the annulus can share stress of twisting
- this may be why torsion is one of the primary MOIs
Shear
- forward sliding, fibres angled forward on lateral aspect of disc will predominately resist movement as they lie parallel to movement
- anterior and posterior fibres make some contribution but not nearly as much as lateral fibres
- fibres angled posteriorly will be relaxed
Lumbar Lordosis Angle
L1-L5 (A angle)
Sacral tilt
- angle from vertical when we align with spinous processes of sacrum
Sacral Horizontal Angle
- angle derived off of horizontal where we’re looking at superior aspect of sacrum compared to horizontal and getting an angle
Lumbosacral angle
- (wedge angle) angle between inferior aspect of lumbar vertebral body L5 and the superior aspect of sacrum. Acute angle can see L5 wanting to migrate forward. Increase in this wedge angle, more likely it will want to shear
- between bottom of last vertebrae and top of sacrum
Lumbar Disc Herniation
- Pattern One
- displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral space
- herniation process begins from failure of innermost annular rings (lamellae) and progresses outwards to periphery or radially
- most often due to recurrent torsional strains (repetitive rotation)
- nucleus loses hydrostatic pressure and annulus bulges outward during disc compression
- when a tear occurs within fibres, material of nucleus pulposus can track out of the tear and into vertebral or iVF to impinge nerve structures
Bulge
extension of disc beyond margins of adjacent vertebral end-plate.
- instead of kidney bean shape, we have a bulge going beyond vertebral end-plate
Protrusion
- nucleus pulposus protrudes outward while annulus fibrosis remains in tact. start to get interruption of inner fibres which over time can lead into all fibres being compromised
Extrusion
- nuclear material emerges through annular fibres but the posterior longitudinal ligament remains intact
- wall of annulus fibrosis has ruptured and disc material is able to exit. PLL holds disc material inside
Sequestration
- nuclear material emerges through the annular fibres and the PLL is disrupted.
- a portion of nuclear material has protruded into epidural space, and material loses all connection with disc.
- body will sense disc material as foreign and cause inflammatory response
Dis Herniation (central-vertebral foramen)
- often associated with back pain only
- may present with cauda equina syndrome which is a medical emergency
- LMN lesion
- above conus medullar is = spinal cord compression - UMN lesion
Dis Herniation (posterolateral- IVF)
- most common (90-95%)
- PLL is weakest here
- can lead to lumbar radiculopathy
- LMN lesion
Region Specific (low back) Red Flag Screening
Cauda Equina (SPINE)
Cauda Equina S:
saddle anesthesia- loss of feeling around the buttocks, anus, and genitals
Cauda Equina- P
pain- severe nerve pain in back and/or down one or both legs
Cauda Equina- I
incontinence: bladder and/or bowel
Cauda Equina: N
numbness: lack of sensation and/or weakness in the leg (gait disturbance)
Cauda Equina: E
emergency: immediate referral to a neurosurgeon
Disc herniation most common at L4/L5 and L5/S1- shear
- dramatic shear or decrease in lumbosacral wedge cause excessive anterior shear of L4 on L5 and L5 on S1. this puts a lot of strain on collagen fibres and overtime it can disrupt annulus fibres allowing disc to migrate outside centre of disc
Disc herniation most common at L4/L5 and L5/S1: compression
- we get an increasing amount of weight-bearing load with the lower vertebral levels
Disc Herniation- Subjective History
- twisting injury; frequently an element of combined flexion and rotation (golfing)
- pain in the back with or without radiating into the leg, sensory loss, paresthesia or muscle weakness
- may hear or feel something give- sudden onset of pain and is normally worse the following morning (night time has allowed for inflammatory response)
Uneven loading
- increase in hydrostatic pressure putting an increased pressure on annulus but the challenge is that annulus is already under tension from being in flexed position
- axial loading with a forward bend will result in uneven loading through disc with significant tensile forces applied through posterior half of disc
- repetitive uneven loading (improper lifting) can lead to micro-failure of posterior annulus fibrosis and can result in herniation
Disc Herniation : subjective history-aggravating factors
- sitting,
- bending forward (lifting)
- coughing
- sneezing
- getting up from a chair
Disc Herniation: subjective history- easing factors
- z lying (supine and prone)
- standing
- walking
Disc Herniation: objective
- neurological exam +/- signs and symptoms of unilateral nerve root involvement
- compression test
- traction may relieve pain (nerve gets stuck)
- straight leg raise test at 30-70 degrees- reproducing symptoms between these degrees
What things do you notice compromised with disc herniation?
- changes in sensation of L5 dermatome
- fatiguable weakness of L5 myotome
- hypo-reflex of L5 nerve root
- pain with compression
Disc herniation treatment: education
- avoid rotation, flexion (sitting, side-lying)
- encourage extension (standing, walking, prone lying, cobra) to drive disc forward
Disc herniation treatment: exercise
- Mckenzie extension protocol
- isometric core strengthening initially
- nerve flossing if radiculopathy
Disc herniation treatment: manual therapy
- segmental (open up foramen), global traction
Disc herniation treatment: other
- NSAIDs (family physician)
Disc Herniation- Surgery
spinal fusion vs lumbar disectomy
- surgery is not common
- disectomy will take out things so nerve has more room
Disc Herniation: pattern two pain
- pain is intermittent and comes with extension only
Disc Herniation: pattern two- facet joint background
- facet joint syndrome is an articular disorder related to lumbar facet joints and their innervations–produces radiating pain
- strain of lumbar facet joint is highest at end-range extension
- with a reduction of disc height, mechanical load will increase which can also lead to degeneration
- felt as unilateral back pain
- combined extension and back bend
- lose disc height, joint is closed more often - now bearing more load than it is designed to
Facet Joint pain
- joint can refer pain
- L3/L4 will have back pain but can also have pain going from back down posterior leg and lateral calf
- L4/L5 has pain down hamstring passed knee and more posterior distribution of this pattern
- felt as unilateral pain +/- referral
Pattern Two Aggravating Factors
- extension
- ipsilateral side-bending
Pattern Two Easing Factors
- flexion (sitting) or slouching to allow superior anterior glide to open joint
- posterior pelvic tilt (reduces lordosis)
Pattern Three:
- lumbar radiculopathy
- range of symptoms due to pinching a nerve root within IVF
- most commonly due to herniated disc
- Symptoms include: tingling, burning, numbness, weakness, pain and altered reflexes (similar to neuropathic pain)
- pinching of L5 nerve root
L4 nerve injury flow chart
L4 pain is along L4 dermatome, L4 to the floor..
- down across the knee and towards floor to medial malleolus and big toe. Tingling and burning through these.
- weakness is through L4 which is knee extension, we resit knee extension or quads and repeat and would notice fatiguable weakness.
- impaired weakness of L4 nerve root
- diminished knee reflex
L5 nerve injury flow chart:
- follow pain and tingling along L5 dermatome
- fatiguable weakness of dorsiflexion
- reflex can be considered medial hamstring
S1 nerve injury flow chart
- pain goes down posterior leg to heel
- S1 myotome is calf raises
- reflex is achilles tendon (hypo-reflexive)
Sciatica
- sciatica pain radiates unilaterally from lower back to lower leg, foot and toes (peripheral nerve pattern)
- leg pain is more than back pain
- numbness and paresthesia may occur in same distribution
example of peripheral neuropathy NOT radiculopathy - common cause is piriformis
What is sciatica?
- impingement of sciatic nerve
- can have leg pain because issue is distal to the hip
- piriformis; abnormal deformity or hypertrophy
- issue of peripheral nerve
- sciatic nerve is L5-S3 combined
- versus a radiculopathy would only affect one single nerve root
Radiculopathy/Neuropathy Treatment: education
- z lying
Radiculopathy/Neuropathy Treatment: exercise
- exercise will aggravate pain so start with pain reducing positions
- change positions frequently from sit to stand to lie or walking (any posture that stays too long will cause pain)
- gentle nerve flossing
Radiculopathy/Neuropathy Treatment: manual therapy
- traction: opening up the IVF to try to decompress or go into a flexed position to open up IVF
Radiculopathy/Neuropathy Treatment: other
- acupuncture
Pattern Four
central stenosis (neurogenic claudication)
- degenerative condition in which there is diminished space available for neural and vascular elements
- degenerative changes of vertebral foramen (osteophytes, calcification)
- compression can cause radiation pain to thigh/glutes
- symptoms are usually bilateral but asymmetric
- narrowing can cause impingement of cauda equina or spinal cord
Central Stenosis
- people with this tend to lean forward or hunch over to allow for flexion which would be an easing factor
- if they like flexion you can identify stenosis
Central Stenosis: aggravating factors
- standing, walking, downstairs
Central Stenosis: easing factors
- flexion
- sitting
- stooped position
- upstairs
Central Stenosis Causes:
- disc herniation
- ligamentum flavum hypertrophy- most common
- ligamentum flavus tends to buckle anteriorly with extension which causes vertebral canal to narrow
- flexion we can stretch out
- facet joint antipathy; age related changes, degenerative discs, osteophytes
- spondylolisthesis - dislocation of spine
Central Stenosis Surgery: laminectomy
- surgical removal of part of or all of the lamina (neural arch) to reduce compression in central canal
Disc Herniation vs Central Stenosis: Disc Herniation
- better with extension, pinching the back driving it forward
- worse with flexion
- flexion pinches front of the disc and drives the nuclear material to the back and puts pressure on structures
Disc Herniation vs Central Stenosis: Central stenosis
- worse with extension, will impinge central canal
- better with flexion; we reduce stenosis and create space in vertebral canal
Spondylosis
- unilateral or bilateral bony defect (stress fracture) in the pars interarticularis
- micro-trauma usually due to repetitive extension
- worsened with repetitive activity (flexion or exntension )
- typically affects adolescents, particularly athletes (male ?female)
- gymnasts, dance, rowing, football
- radicular symptoms are rare
Spondylosis mostly occurs at L5- why?
- during extension, L4 inferior articular process and S1 superior articular process cause pinching force on the L5 pars interarticularis
- lumbosacral angle- lower vertebrae is in more lordosis than higher levels
- ## due to increased anterior pelvic tilt
Spondylosis: scotty dog fracture
- outline of scotty dog, fracture happening making it look like dog is wearing collar
- patients will be asymptomatic
- found on x ray when looking for something else
- joining between spinous and transverse process to the neural arch
Sponylolisthesis
- slippage of one vertebral body with respect to the adjacent vertebral body causing mechanical or radicular symptoms
- most often preceded by spondylosis
- due to fracture of par interarticularis, we need fracture to allow for translation
Sponylolisthesis: retrolisthesis
anterior slippage (most common)
Sponylolisthesis: retrolisthesis
posterior slippage (superior vertebrae is transported posterior)
Sponylolisthesis most common at L5/S1, why?
dramatic lumbosacral angle which can cause spondylitis which can break open the dam for anterior translation.
L5-S1 has the most shear happening because vertebral bodies sit on an angle here on a down slope
- can be due to congenital, acquired or idiopathic causes, can be caused by repetitive extension
difference between spondylosis vs spondylolisthesis
spondylosis- scotty dog has collar
spondylolisthesis- head of dog is detached
Grade 1 slippage:
less than 25% slippage, see only a sliver pulled forward
Grade 2 slippage:
25-50% slippage, slippage of superior vertebrae on adjacent vertebral body
Grade 3 slippage:
50-75% slippage,
Grade 4:
> 75% slippage, spine is dislocated
- the more we translate it the worse it is, and cauda equina has to made 90 degree turn prior to going down which causes pressure and traction on nerves
Spondylolisthesis- Clinical Presentation: Subjective
- onset of pain, if present, is typically insidious in nature and initially mild in severity
- pain is diffuse, dull ache
- may radiate to glutes or posterior thigh
- sciatica or other radicular
- positional worsening of pain may not be present
- some people may not feel pain
Spondylolisthesis: Objective
- increased lumbar lordosis (more extension and more tendency for vertebral body to slip forward)
- palpable step deformity
- maintaining posture of trunk extension relieves symptoms
Spondylolisthesis treatment: Education
- avoid recurring trauma resulting from repeated flexion, hyper-extension and twisting (stop whatever compromised bony structure)
- low aerobic impact sports are recommended
- avoid running
- weight loss
Spondylolisthesis treatment: exercise
- core strengthening
- isometric, isotonic (strengthen without moving) repetitive flexion and extension can hurt them.
- movements in closed-chain kinetics, anti-lordotic movement patterns of the spine
Spondylolisthesis treatment: other
surgery:
- spinal fusion
- cauda equina decompression ?
Ankylosis Spondylitis
- chronic inflammatory rheumatic disease primarily involving sacroiliac joints and spine
- subtype of spondyloartropathies
- onset is 20-40 years old, male: female is 2-3:1
- unknown cause- genetic component (HLA-B27 gene)
- disease occurs at enthesis (attachment points between tendon, ligament, capsule)
- inflammation > bone erosion> syndesmophyte formation
Syndesmophyte
- bony growth originating inside a spinal ligament or of the annulus fibrosis
- Bony bridge forming within the anterior longitudinal ligament fusing multiple vertebral segments
- starts with bone growth originating at spinal ligament of annulus fibrosis and progresses dramatically asa fusing bony bridge
Ankylosis Spondylitis Clinical Presentation
- pain is worse in the morning or after prolonged rest
- low back pain > 3 months
- morning stiffness > 30 mins (biggest indicator of inflammatory pain)
- nocturnal back pain
- improves with activities
- responds well to NSAIDs
also associated with - neck pain
- anterior uveitis
- inflammatory bowel disease
-chest pain - various enthesitis
Ankylosis Spondylitis Diagnosis
- limited lumbar spine motion
- decreased chest expansion for age and sex
- x-ray sacroilitis
- elevated inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, +ve HLA B27
Ankylosis Spondylitis Treatment; Conservative- exercise
- extension-based exercise +++
- cardiovascular exercise
Ankylosis Spondylitis Treatment: conservative- manual therapy
- increase spinal mobility (if in remission)
-
Ankylosis Spondylitis Treatment: pharmacological
- NSAIDs- considered first-line drug treatment
- tumor necrosis factor (TNF) inhibitors
- biologic disease-modifying anti-rheumatic drugs (DMARDs)
i. e; methotrexate
