MIDTERM Flashcards
progression of the stages of acute disc herniation
protrusion
prolapse
extrusion
sequestration
in the lumbar spine, facets carry _____ of the axial load
20-25%
can increase to 70% with degeneration
IVD = 20-25% of length of vertebral column
degeneration of the intervertebral disc, vertebral bodies & facet joints
spondylosis
a defect in the pars interarticularis arch of the vertebra (crack/ stress fracture)
spondylolysis
a forward displacement of one vertebra over another
spondylolisthesis (may indicate a step deformity)
retrolisthesis = backward displacement of one vertebra on another
if the S1 segment is mobile, it results in a sixth “lumbar” vertebra - 1st sacral segment is mobile and not fused to the sacrum
lumbarization
5th lumbar segment is fused to the sacrum and ilium, resulting in four mobile lumbar vertebrae
sacralization
ligament that connects the TVP of L5 to the posterior ilium & prevents anterior displacement of L5
iliolumbar ligament
herniations of the nucleus pulposus into the vertebral body - if pressure is great enough, defects may occur in the cartilaginous end plate
Schmorl’s nodes
disc bulges posteriorly without rupture of the annulus fibrosus
protrusion
only the outermost fibers of the annulus fibrosus contain the nucleus
prolapse
nucleus pulposus emerges through the annulus fibrosus
extrusion
nucleus pulposus protrudes into the epidural space
sequestration
in the lumbar spine, each nerve root is named for the vertebra _____ it
above
L4 nerve root exits between L4 & L5 vertebrae
segment in the lumbar spine that is the most common site of problems because it bears more weight than any other vertebral level
L5-S1
center of gravity passes through here
resting, closed packed, capsular pattern
resting: midway between flex & extend
closed: full extension
capsular pattern: side flex & rot equally limited, extension
thin body build, relative prominence of structures developed from the embryonic ectoderm
ectomorphic
mesomorphic: mm or sturdy build
endomorphic: heavy build
lumbar spine AROM
flex: 40-60º
ext: 20-35º
side flex: 15-20º
rotation: 3-18º
end feel: tissue stretch
pelvic crossed syndrome: weak, long, inhibited muscles
abdominals, gluteals
strong, tight, short mm: hip flexors (iliopsoas), back extensors
hyperlordosis: mm that are short & tight bilaterally
iliopsoas, rec fem, TFL, QL, lumbar erector spinae
mm that are weak & taut: rectus abdominis, external & internal abdominal obliques, glute max
herniation at _____ accounts for 98% of all low back disc injuries
L4-L5 or L5-S1
flexion & rotation = suggested mechanisms of injury
3 stages of degeneration in DDD
- dysfunction
- instability
- stabilization
most common protrusion of an acute disc herniation
posterolateral
with posterior or posterolateral herniations:
flexion is limited & symptoms _____ with movement
extension is limited & symptoms _____ with movement
peripheralize
centralize
when does AS usually begin and end?
insidious onset
beginning early adulthood
inflammatory stage ends by age 40
starts SI joints then gradually moves up spine
in AS, the vertical bone growths replacing the intervertebral discs are called…
syndesmophytes
with severe long-standing AS, the vertebrae take on a fused appearance called _____ spine
bamboo
the articular surface of the ilium is covered with ______
the articular surface of the sacrum is covered with ______
fibrocartilage
hyaline cartilage
what ligament limits anterior pelvic rotation or sacral counternutation?
long posterior SI ligaments
short posterior SI ligament: limits all pelvic & sacral movement
what ligament limits nutation & posterior innominate rotation and provide vertical stability?
sacrotuberous & sacrospinous ligaments
iliolumbar ligament: stabilizes L5 on ilium
major connection between sacrum & ilium, one of the strongest ligaments in the body
interosseous SI ligament
when Pt goes from supine to sitting, what do the innominate bones & pelvic girdle do?
rotate anteriorly as a unit on the femoral head bilaterally
with pelvic degeneration, what structure is usually affected first?
iliac surface
form closure
-close packed position
-no outside forces necessary to hold joint stable
-nutation (sacral locking)
force closure
compression generated by mm & through them, tensing of ligaments when they act to accommodate specific load citations
forward motion of the base of the sacrum into the pelvis OR the backward rotation of the ilium on the sacrum
nutation (sacral locking)
anterior rotation of the ilium on the sacrum OR backward motion of the base of the sacrum out of the pelvis
iliac bones move farther apart and ischial tuberosities approximate
counternutation (sacral unlocking)
if the ASIS & PSIS on one side are higher than the ASIS and PSIS on the other, it indicates an _____ of the ilim on the sacrum on the high side, a short leg on the opposite side or mm spasm caused by lumbar pathology
upslip
pressure or entrapment of the lateral femoral cutaneous nerve near the ASIS
Meralgia Paresthetica
sensory only nerve: lateral aspect of thigh
this nerve, which lies within the transverse abdominus mm, may be compressed by spasm of the mm
ilioinguinal nerve
sensory only: alteration/ pain occur in superior aspect of anterior thigh (L1 dermatome area) also in scrotum of labia
non-inflammatory bone formation on the iliac side of SIJ, appears in younger adults; usually bilateral, common in pregnancy & may disappear in menopause
Osteitis Condensans Ilii
may involve the pubic symphysis, innominate bones, acetabulum, sacroiliac joint or sacrum
pelvic fractures
dangers: hemorrhage, genitourinary, intestinal, & neurologic injuries
minor stable fractures: require only symptomatic Tx
unstable fractures: require external or internal fixation
contributing factors to SI joint sprains
congenital hypermobility
history of SI joint sprains
altered biomechanics (leg length discrepancy)
CT pathologies (RA)
rotational stress
pregnancy
conditions that affect the sciatic nerve refer pain down the _____ thigh
posterior
the sciatic nerve is composed of nerve roots ______ and is comprised of two peripheral nerves: common peroneal & tibial nerve
L4-S2/ S3
functions of the piriformis muscle
-restrain rapid/ vigorous int.R of hip
-ext.R femur when hip is extended or in neutral
-horizontally ABD thigh when hip is flexed to 90º
-int.R femur when hip is fully flexed
symptom picture of piriformis syndrome
-nerve entrapment & active TPs: pain increased by sitting/ any position with prolonged hip flex, ADD & med.R, arising from seated position or by standing
-P often decreases with ext.R of hip
-weakness in performing ABD, flexion & int.R
when applying a posterior lateral glide on the ilium (at the ASIS) on the sacrum, it will help to correct…
an inflare
causes for pathological SI joint hypomobility
-associated with lumbar or pelvic rotational stress
-may develop after pregnancy/ trauma
-can be insidious & associated with structural faults
-usually occurs in younger people
where can radiation of pain with regard to SI joint lesions spread to?
abdominal area and sometimes the groin
when does the pain occur with problems in the SI joint?
-when turning in bed/ getting out of bed
-stepping UP with affected leg
-often P is constant & unrelated to position
what will you likely see when observing a patient with Piriformis Syndrome?
-torsion of hips & hyperlordosis of L-spine
-hypertrophy of gluteals
-ataxic-like gait due to P
-guarding of limb on affected side
which special test would best test for a pathology in the anterior SI ligament?
Yeoman’s
which special tests would best test for an SI joint dysfunction or hip pathology?
Gaenslan’s
facet lock syndrome responds well to what type of manipulation?
joint
purpose of the facet joints in the lumbar spine is to…
control the direction of spinal movement
what can occur with longstanding Ankylosing Spondylitis?
inflammation of the iris
aortic valve incompetence
fused appearance of vertebrae
T/F - once fusion of the spine is complete for a patient with Ankylosing Spondylitis, pain may diminish
TRUE
in the extended position, patient complains of strong pain, heavy feeling in lumbar area or low back is ‘coming off’
passive lumbar extension test
what variation of the straight leg raise increases the dural stretch through cervical flexion?
Brudinski’s Sign
dorsiflex foot = Bregard’s test
what is the best special test to assess for stress fracture of the pars interarticularis?
one-leg standing lumbar extension test
between _____ degrees of hip flexion is where the sciatic nerve is stretched during the straight leg raise test
35 and 70
how is a positive Babinski test demonstrated?
by extension of the big toe and abduction of the other toes
which ligament is broader and thicker in the lumbar region?
anterior longitudinal ligament
which ligament lies deeply between two consecutive spinal processes?
interspinous (prevent excessive flexion)
supraspinous: joins tips of two adjacent SPs
ligamentum flavum: connects two consecutive laminae & is very elastic
when the lumbar spine is laterally flexed to the left, the vertebrae translate and rotate to the _____
right
Tx of sacralization is equal to treatment for ____ while Tx of lumbarization is equal to treatment for ____
hypomobility, hypermobility
what position puts the least amount of pressure on the intervertebral discs?
lying flat on your back
most amount of pressure: sitting while leaning forward & lifting weight
T/F - intervertebral discs are pain sensitive because the anterior & posterior aspects of the annulus fibrosus are innervate
FALSE
only the posterior aspect is innervated
what test is used to confirm that a person is faking an injury?
Hoover test
T/F - symptoms of a disc protrusion vary depending on the vertebral level, direction of protrusion & amount of protrusion
TRUE
contributing factors to Degenerative Disc
Disease
-mm imbalances leading to asymmetric loading of spine
-poor blood supply to disc
-postural dysfunction (head-forward posture)
T/F - a herniation of the L4 disc will compress the nerve roots of L4 and L5
TRUE
T/F - with a complete annular rupture and sequestered nucleus, movement cannot relieve the symptoms
TRUE
T/F - primary goal in the early stages of a disc herniation is to reduce compressive forces in the lumbar region
TRUE
when suggesting home-care for a patient with an acute disc herniation, you should…
suggest they find postures to help maintain a more natural lumbar lordosis
T/F - Spondylolisthesis, ITB syndrome & Hyperkyphosis are likely to be found with Hyperlordosis
TRUE
Tx goals for a patient with an Acute Disc Herniation
-reduce SOME fascial restrictions & TPs
-decrease SNS firing
-reduce spasm, pain & edema
-reduce compressive forces
which muscle supports the lumbar spine during forward flexion?
rectus abdominis
what type of pain is most commonly associated with a herniated disc at L4-L5?
radiating pain along lateral aspect of thigh
standing position: radiating P in calf & foot
the straight leg raise primarily assesses which nerve root?
L5
what is the primary cause of “facet syndrome” in the lumbar spine?
overuse or repetitive stress on facet joints
Sx: aching P close to spine
which exercise is the most beneficial for strengthening the multifidus muscles?
birddog
multifidus: contributes most to lumbar spine stabilization in the neutral position
what is the most common mechanism of injury for lumbar disc herniation?
forward flexion & rotation
(same movement would exacerbate symptoms)
which muscle is the most important for stabilizing the lumbar spine during static postures?
QL
which movement would likely cause discomfort with spinal stenosis?
extension
flexion would relieve symptoms
test for lumbar disc herniation/ lesion in the spinal cord
straight leg raise
-well leg raise
-Milgram’s
in lumbar facet syndrome, which movement would most likely worsen symptoms?
lumbar extension
the “sitting flexion test” assesses for possible involvement in which spinal structure?
SI joints
what role does the diaphragm play in stabilization of the lumbar spine?
assists in maintaining intra-abdominal pressure
most common source of pain in Pt with lumbar DDD
inflammation of facet joints
which muscle is most likely to develop TPs in response to poor posture & prolonged sitting, contributing to lumbar pain?
psoas major
the Patrick’s (FABER) test primarily assesses for issues in which area of the spine?
SI joint (sprain)
which spinal movement places the greatest strain on the lumbar discs
flexion
which ligament will become lax in a Pt with excessive lumbar lordosis
ALL
most common clinical manifestation of thoracic disc herniations
thoracic P radiating around the chest
test used to assess SI joint involvement in a Pt with low back pain
Gaenslen’s
a Pt reports deep, constant pain along the thoracolumbar junction, what is most likely involved?
facet joints, IVDs
the “stork standing test” is typically used to assess for which condition in the lumbar spine?
spondylolysis
primary load-bearing surface in the lumbar spine
vertebral bodies
gel-like substance inside an IVD is known as…
nucleus pulposus
biomechanical result of decreased lumbar lordosis
increased compressive load on the IVDs
ex. prolonged sitting in poor posture
a Pt with a moderate strain to the erector spinae mm is likely to have the most pain with which evaluation procedure?
resisted lumbar extension
what is commonly correlated with spondylolisthesis?
hamstring tightness
if your Pt presents with a hypertonic left QL & functional scoliosis, what would you also expect?
increased compression on left lumbar facet joints
in excessive lumbar lordosis, a greater percentage of the bodyweight is transferred though the…
lumbar facet joints
(ant. pelvic tilt leads to lumbar facet joint dysfunction)
a disc herniation that protrudes in a straight posterior direction is likely to produce…
cauda equina syndrone
hypertonicity in one QL is most evident from…
high ilium on same side
in what region of the spine are disc herniations least common?
thoracic
if your Pt has limited & restricted motion in left lateral flexion performed from a standing position, the most likely tissue causing this would be…
right QL
which muscle group is primarily being used during slow lumbar forward flexion?
erector spinae
your Pt has been diagnosed with a herniated lumbar disc pressing on nerve roots, he will most likely complain of…
pins & needles down his leg
which condition has symptoms similar to piriformis syndrome & could be easily confused with it?
lumbar nerve root compression
what muscle would be strongly contracting in a MRT for lateral/ external rotation of the hip?
piriformis
which hip movement would engage the iliopsoas in concentric contraction during AROM?
flexion
a left lateral pelvic tilt is most likely caused by…
hypertonic R QL
compression of the superior gluteal nerve in piriformis syndrome is most likely to produce weakness in which muscle?
gluteus minimus
primary nerve compressed in piriformis syndrome
sciatic
which muscle has fibrous connections with the sacrotuberous ligament & could therefore be implicated in SI joint dysfunction?
hamstrings
what is most likely the cause of a posterior pelvic tilt?
short & tight hamstrings
stretching the iliopsoas muscle would be most effective with which combined motions?
hip & lumbar extension
a structurally longer right leg would most likely produce…
left lateral pelvic tilt
what is NOT a key contributing factor to SI joint pain?
gluteus medius trigger points
if your Pt has an iliopsoas strain, the evaluation procedure that would most likely reproduce pain would be…
resisted hip flexion
differences between the 3 grades of sprains
grade 1: minor stretch/ tear, no instability
grade 2: tearing variable, hypermobile but stable
grade 3: complete rupture, instability
