MSK- Lumbar Spine Flashcards
Nerve root differences Lx vs Cx
Lx, nerve roots leave below
Cx nerve root leave above
Why bulges posterolateral?
Weakness in annulus fibrosis anterior laterally
Posterior longitudinal ligament
Dermatome- relevant areas
L4- crosses over the patella and great toe
L5- most toes on dorsum and plantar surface and lateral side of the heel
S1- pinky toe
Myotomes
L1,2- hip flexion
3- knee extension
4- ankl dorsiflexion
5- big te extension
S1- ankle plantarflexion, ankle eversion, hip extension
S2- knee flexion, hip extension, ankle plantarflexion
Reflexes
L3-4: patellar
L4-5: tib post
L5-S1: medial hammy
S1-2: lateral hammy
S1-2: achilles
Special test for lumbar radiopathy
SLUMP
Straight leg raise
- before 35 deg (nerve slack being taken)
- at 35 deg (roots under tension)
- at 60-70 deg sciatic roots over disc
- > 70 deg pain is likely MSK (hamstring stretch)
Stress individual verve’s
SID (sural nerve= inversion and DF)
TED (tibia nerve= eversion and DF)
PIP (Peroneal nerve= inversion and PF)
Crossover sign
SLR on the unaffected side, the patient expereiences pain on the affected leg
- indicates a large disc bulge
- also known as Well leg raise of Fajerztajn or Lhermitt’s test
Sign of the buttock
After SLR, bend knee and flex further- if no further flexion then something with the buttock (could be a bursitis, tumour, or abscess) - refer to doc
Bow-string test
Give slack, 20 deg flex knee, poke popliteal area and see if symptoms are found
Spinal stenosis of Lx
Common age > 60
Better with flexion (opens the intervertebral foramen)
Worse in extension (closing intervertebral foramen)
Intermittent claudication vs Lx neurogenic claudication
IC due to increased demand on a poorly circulated area. Slowly creeps up (distal to proximal and unilateral). Relief at rest. Feels cramp like
NC due to nerve root compression. Immediate (proximal to distal peripheralization bilaterally), relief in spinal flexion. Feels burning or tingling
Spinal stenosis- intervention
- flexion based exercises and positioning. Z lying
Avoidance of aggravating memes and positions
Surgical- laminectomy
Disc herniation
30-50 years of age
Acute onset- all of a sudden
80-90% posterolateral
Disc herniation types
Protrusion
Prolapse
Extrusion
Sequestration
Details on disc herniation
Flexion mechanism
Worse in flexion, better in extension
Worse in the morning (disc gets thick over night and then BOOMs out in the morning)
Worse with coughing, sneezing, or valsalva maneuver
May also lateral shift (away from the side of bulge)
Disc herniation- intervention
Posterolateral
- extension exercises (progress; prone lying, prone with 1 fist and then 2, prone on elbows, extension in lying, extensions in lying with OP, extensions in standing)
- lumbar roll
Lateral bulge
- mvmts in lateral towards the bulge
Anterior bugle
- flexion exercise (knees in chest supine lying)
Exercises may be painful during but should be better after and we are looking for centralization (bring from legs, to back and smaller than gone)
Centralization (raking leaves, easier to get rid of it when in a neat pile)
Green/ amber/ red light method (centralization is the goal, peripheralization is not the goal)
Schmorl Node
Herniation goes up or down through the cartilaginous end plate and vertebral body
MOI is direct compression axial loading
Typically occurs at higher Lx levels
Pelvic (lower) crossed syndrome
Increase lordosis
Weak- abs, glutes
Tight- hip flexor, erector spinae and hammys
Anterior tilt
Spondylosis
OA in the spine- see loss of lordosis (flat Lx)
Typically over 50
Dehydration of discs, approximation of vertebral bodies
Worse with prolonged flexion, extension, sitting and standing
Lx Facet syndrome
Pain never crosses the knees
Quadrant test
Closes facet joint
Interventions for Lx Fcet
Flexion based exercises and position
Avoidance of aggravating mvmts
Lx instability- inner unit muscles
Diaphragm, trans abs, multifidus, pelvic floor
H and I stability test
H: side flexion extension or flexion
I: start flexion then side flex
Prone segmental instability test
Whether or not they need core xercises
Lx instability intervention
Core exercises:
- tri A
- lumbar multifiduc isolation
- pelvic floor activation
- diaphragm activation
Progression of core stability exercises
1) isolate inner unit
2) train the inner unit
3) maintain inner unit while training outer unit
4) integrate into functional
Spondylolysis vs spondyolisthesis vs restrolistheses
A defect in the pars interarticularis (no slippage)
Forward displacement of one vertebra over another
Backward displacement of a vertebra on another
Different types of spondylolisthesis
Traumatic (sudden)
Isthmic (overuse)
Degenerative
Dysplastic (congenital)
Pathological
Grades of spondylosthesis
1: >25%
2: 25-50%
3: 50-75%
4: >75%
5: 100 % (spondyoptosis)
1-3: core stabilization
4-5: surgical fixation
S&S of spondylothesis
Pain in hyper extension
Hyper lordotic posture
Tight hammys
Scotty dog collar sign on X-ray
May or may no step deformity on palpating
May or may not have signs and symptoms of central or lateral stenosis
Post op management of a fusion of laminectomy- Protection phase
Maximum protection phase
- education
- no heavy lifting more than 10 lbs for 3 months
- look out for infectio/ inflammation
- avoid wetness
Bed mobility
Exercise
- walking and gentle exercises (heel slides, quad sets, glute sets, ankle pumps)
Contraindications
- extension exercises et (prone press ups) in patients who have undergone a laminectomy
Post op management of a fusion of laminectomy- Mod to Min phase
Scar mob
Progressive stretching and joint mob
Exercise (implement strengthening)
Contraindications- joint manip, extension exercises
Two red flags of the Lx
Caudal Equina and malignancy
Lx malignancy
> 50 yrs old
Previous Hx of cancer
Unexplained weight loss
Constant unrelenting pain
Pain unrelieved by rest
Pain worsens at night
Failure to improve with conservative therapy (w/in 1 month)
