Lumbar Spine (Part 1) Flashcards
__% of persons in industrialized countries will have LBP at some point in their lives
70
What is the peak prevalence of LBP?
35-55 years old
90% of patients with acute LBP self-resolve within _ weeks
6
What percentage of LBP patients develop chronic pain?
2-7%
About _% of people seen with LBP in primary care have compression fractures
4
About _% of people seen with LBP in primary care have a neoplasm
1
What is the prevalence of a prolapsed IVD?
1-3%
The lumbar spine can flex __-__ degrees
50-70
The lumbar spine can extend __-__ degrees
10-30
The lumbar spine can rotate __-__ degrees
20-40
The lumbar spine can side-bend __ degrees
25-35
During 85 degrees of TL flexion, __ degrees are due to thoracic flexion and __ degrees are due to lumbar flexion
35
50
During 35-40 degrees of TL extension, __-__ degrees are due to thoracic extension and __ degrees are due to lumbar extension
20-25
15
During 40 degrees of TL rotation, __ degrees are due to thoracic rotation and __ degrees are due to lumbar rotation
35
5
During 450 degrees of TL side-bending, __ degrees are due to thoracic side-bending and __ degrees are due to lumbar side-bending
25
20
How do end plate fractures occur?
During extreme compressive loading the end plates bulge into the vertebral bodies causing radial stresses and fracture occur
What occurs in the end plate fractures are large enough?
the liquid nucleus pulposus squirts through the end plate into the vertebral body
When local areas of bone collapses under the end plate creating a pit or crater what is gradually formed?
a Schmorl’s node
Schmorl’s nodes are associated with spinal compression with the spine in what position?
neutral
Does the annulus fibrosis remain intact with end plate fractures?
Yes
Why are end plate fractures often misdiagnosed as true herniations?
Following the loss of the nucleus from the disc into the vertebral body there is an immediate loss of disc height and a compromise of the nerve root results mimicking the symptoms of true herniation
What does failure of the posterior elements of the spine lead to?
spondylolisthesis
True or False
The neural arch (pedicles and laminae) are somewhat flexible during flexion and extension movements
True
In athletes such as gymnasts, the damage to posterior elements may be associated with what type of ROM?
full
In patients with a pars fracture (spondylolisthesis) what is the focus of therapy?
stability
The fibers of the annulus fibrosis are oriented in an alternating fashion __ degrees from the vertical
60
What are the 3 major components of the IVD?
- nucleus pulposus
- annulus fibrosis
- end plates
Even though there is no distinct border between the NP and AF, how can you tell the differences between the 2 structures?
The lamellae of the annulus become more distinct moving radially outward
Describe why only half of the fibers of the AF are able to support twisting motions while the other half are disabled
Due to the orientation of the fibers
What direction does the annulus bulge when there is little hydrostatic pressure (end plate fracture or herniation) during compression?
outer annulus bulges outward
inner annulus bulges inward
What does the double convex bulging associated with end plate fractures cause?
The laminae of the AF to separate or delaminate
What does this delamination lead to?
Leaking of nuclear material through the lamellae layers and finally extrude, creating a frank herniated disc
IVDs must be bent to ___ ROM in order to herniate
full
In what types of occupations is herniation linked to?
Those that are sedentary, require sitting posture, and vibratory
Do herniations occur in older or younger spines? Explain why…
Younger, due to the higher water content and more hydraulic behavior
What can be defined as expansion of disc material beyond its normal border?
disc bulge
What can be defined as a discrete localized bulge in the AF which results in the disc material being displaced?
protrusion
What can be defined as a protrusion of the NP through all layers of AF, but remains attached to disc of origin?
extrusion
What can be defined as a free disc fragment located in epidural space that has migrateed superiorly, inferiorly, medially, or laterally?
Sequestration
In summary, damage to annulus of disc (herniation) appears to be associated with fully ____ the spine for repeated or prolonged period of time
flexing
What muscle is most often given the function of lateral flexion?
Intertransversarii
The rotatores and intertransversarii muscles are approximately - times more rich in muscle spindles than multifidus
4-7
What are the 3 major extensors of the spine?
- longissimus
- iliocostalis
- multifidus
The longissimus and iliocostalis muscle groups are arranged into what 2 groups?
- thoracic portions
- lumbar portions
What is the difference between the thoracic and lumbar portions of the longissimus and iliocostalis muscle groups?
The thoracic sections contain about 75% slow-twitch fibers, while lumbar sections are more evenly mixed
The ___ _____components of the longissimus and iliocostalis muscle groups attach to the ribs and vertebral components and have relatively short contractile fibers with long tendons that run parallel to spine to their origins on posterior surface of sacrum and medial border of the iliac crests
pars thoracis
The pars thoracis produce the _____ amount of extensor moment with a ______ compressive penalty to the spine
greatest
minimum
The lumbar portion of the longissimus and iliocostalis muscle groups lose their oblique line of action and reorient to compressive axis of spine with lumbar _____.
flexion
What is the function of the multifidus muscles?
They produce extensor torque but only provide ability for corrections, or moment support, at specific joints that may be foci of stresses
What is the major function of the rectus abdominis?
trunk flexion
Why is the rectus abdominis partitioned into sections?
It limits bulking upon shortening
What does the “beaded” rectus allow for?
lateral transmission of forces from the oblique muscles which forms a continuous hoop around the abdomen
What prevents the rectus fibers from being ripped apart laterally from these hoop stresses?
Intermuscular tendons and fascia
True or False
Training of the rectus can be accomplished with a single exercise
true
What are the 3 layers of the abdominal wall?
- external oblique
- internal oblique
- transverse abdominis
What enhances the flexor potential of the abdominal wall?
The attachment to linea semilunaris which redirects oblique forces down the rectus sheath to effectively increase the flexor moment arm
What forms the “hoop” around the entire abdomen?
The obliques with the transverse abdominis
What do these “hoop stresses” assist with?
spine stability
A pain that is reported as a deep ache and boring in nature has its origins where?
bony tissues
A pain that is reported as dull, achy, sore, burning, or cramping has its origins where?
muscle/fascia
A pain that is reported as sharp, knife like, shooting, lancing, burning, numbness, or weakness has its origins where?
nerve
A pain that is reported as burning, stabbing, throbbing, tingling, or cold has its origins where?
vascular
A pain that is reported as deep, cramping, and stabbing has its origins where?
visceral
What is the probable cause of pain relieved by flexion?
- facet joint involvement
- low back strain
- lateral stenosis
What is the probable cause of pain relieved by extension?
- disc involvement
- nerve root irritation
What is the probable cause of pain relieved by rest?
neurogenic claudication
What can you initially hypothesize if a patient reports of restricted motion of lumbar spine associated with LB or buttock pain exacerbated by pattern of movement that indicates possible opening or closing joint restriction?
Zygapophyseal joint pain syndromes
What can you initially hypothesize if a patient reports of centralization or peripheralization of symptoms during repetitive movements or prolonged periods in certain positions?
discogenic pain
What can you initially hypothesize if a patient reports of lower extremity pain/paresthesias, which is greater than LBP and also reports experiencing episodes of lower extremity weakness?
sciatica or lumbar radiculopathy
What can you initially hypothesize if a patient reports of pain in the lower extremities exacerbated by extension and quickly relieved by flexion of spine?
spinal stenosis
What can you initially hypothesize if a patient reports of recurrent locking, catching, or giving way of low back during active motion?
lumbar instability
What can you initially hypothesize if a patient reports of LBP exacerbated by stretch of either ligament or muscles and also reports of pain with contraction of muscular tissues?
Muscle/ligamentous sprain/strain
What are the 11 red flags for the lumbar spine?
- Severe trauma
- Fever or recent bacterial infection
- Saddle anesthesia
- Severe or progressive neurological complaints
- Recent onset bladder dysfunction associated with onset LBP
- Unexplained weight loss
- History of cancer
IV drug abuse, HIV or immunosupression - Pain worse with recumbency or worse at night
- Constant progressive, non-mechanical pain (no relief with bed rest)
- Age of onset 55 years
When side-bending to the left causes pain on the left side you can conclude that the nerve is compressed by a _____ disc protrusion
lateral
When side-bending to the right causes pain on the left side you can conclude that the nerve is compressed by a _____ disc protrusion
medial
Describe the myotomal distribution of the spinal nerve roots in the LEs
- L1: Hip flexion
- L2: Hip flexion, hip adduction
- L3: Knee extension
- L4: Ankle dorsiflexion
- L5: Foot/toes dorsiflexion
- S1: Plantar flexion foot/toes, ankle eversion, hip extension
- S2: Knee flexion
- S3: Foot intrinsics
What nerve level is implicated if there is a diminished patellar reflex?
L3/L4
What nerve level is implicated if there is a diminished Achilles reflex?
S1/S2
What does PPIVM stand for?
Passive Physiologic Intervertebral Motion Testing
What does PAIVM stand for?
Passive Accessory Intervertebral Motion Testing
What is PPIVM testing reliable at assessing?
pain
When side-bending and rotation are combined with the spine in neutral the what way do the lumbar SPs rotate?
ipsilaterally (except for L5 - it can go either way)
When side-bending and rotation are combined with the spine in flexion the what way do the lumbar SPs rotate?
contralaterally
When analyzing lateral flexion and rotation of the neutral lumbar spine the SPs should rotate what direction?
upward, in the same direction as the rotation (into the cave)
When analyzing lateral flexion and rotation of the flexed lumbar spine the SPs should rotate what direction?
downward, in the opposite direction as the rotation (out of the cave)
