PT4 - Lumbar Spine Flashcards
What are red flags?
- signs of serious pathology e.g. CES, fracture, tumour, unremitting night pain, sudden weight gain/loss, bladder/bowel incontinence, saddle anaesthesia
What are yellow flags?
- beliefs + appraisals + judgements
- e.g. unhelpful beliefs about pain => indication of injury as uncontrollable or likely to worsen, expectations of poor TTT outcome, delayed return to work
- e.g. emotional responses => worry, fears, anxiety
- e.g. avoidance of activity due to expectations of pain + over reliance on passive TTT
What are Orange flags?
- psychiatric symptoms e.g. clinical depression, personality disorder
What are blue flags?
- relationship between work and health
- belief that work is too onerous and likely to cause further injury
- workspace supervisor + workmates are unsupportive
What are black flags?
- system/contextual obstacles
- legislation restricting options for return to work
Conflict with insurance staff over injury claim - overly solicitous family/health care providers
What is included in the clinical temporal profile?
- speed of onset e.g. acute, subacute, chronic
- duration e.g. acute, subacute, chronic
- symptom picture e.g. focal, multi focal, diffuse
- progression e.g. stable, recovering, fluctuation, unmasking
What is the structure + function of the LSP?
- support/protection for neural + visceral structures
- allows forward movement of centre of gravity
- transmission of body weight forces
- transmission redirection + absorption of forces
In the LSP what works together to control movement and force transmission?
- disc + facet joints
What is the classics presentation of NSLBP?
- unilateral
- no red flags
- may or may not have radiations
- may be relieved by meds
What % of PTs will present with LBP?
- 90% will present with LBP
- 5% will have leg pain (probably not objective symptoms => neuro reveals no loss of reflexes or power)
- 1% will be more interesting
What LBP diagnosis are we likely to see in clinic?
- spondylolysis => pars fracture
- spondylolythesis => slipped pars fracture (lytic => fracture / non-lytic => no fracture, but slippage more likely in older generation due to degenerative spondylolythesis)
- kidney infection => any changes to smell of urine, blood, temperature change, malaise, overweight/unfit women can result in incontinence
- neoplasm (space occupying lesion) => less frequent => see every 3/4 years => has LBP => pain gradually getting worse => imaging required as change management of the TTT
- ankylosing spondylitis/Reiters disease (reactive arthritis => can clear up)
- PMR => affects either shoulder or hip girdle, never fully symmetrical
What LSP diagnosis are we less likely to see?
- CES => a symptom => disc involvement => unlikely to get central compression => osteoporotic collapse is first sign => starting to go to the toilet more often, not always sure when they need to go (if diagnosed early outcomes are very good) => ask do you know when you need to release bowels/urine?
Why does LBP occur?
- lots of forces go through LSP
- has the most anomalous (different) vertebrae
What directions do the lumbar facet joints face?
- top => middle = parafacet (face more vertically upwards to integrate with TSP) for flexion/extension
- lower => facets face frontal direction => allows for more rotation
What’s special about the iliolumbar ligament?
- in a child it’s a MM
- ## special ligament that runs from L5, sometimes L4 (in PT with attachments at L4+L5 => reduced risk of LBP)
What does the iliofemoral ligament control?
- hip extension => don’t want MM to stabilise legs while walking as not efficient => iliofemoral ligament creates tension on iliolumbar ligament => drives counter rotation of spine
What drives movement?
- fascia + ligamentous material
Which 2 ligaments in the LSP/Legs are a pair?
- iliofemoral + iliolumbar ligaments => work together to be efficient in locomotion
What happens when iliofemoral ligament + iliolumbar ligament are less efficient?
- can happen in arthritis
- standing becomes less efficient
What’s special about the shape of the LSP vertebrae?
- wedge shaped for weight bearing
What happens to multifidus in a healthy back?
- MM development of multifidus can result in a healthy back
- multifidus blends with the capsule
- has a proprioceptive capacity especially for rotation
What is spinabifida occulta?
- don’t get full union of an SP @ L5
What can happen in spinabifida occulta if there isn’t an L5 SP?
- not enough attachment site for multifidus
- 25% more likely to get LBP
- the nerve at L5/S1 doesn’t form as well => travels down leg to support perineals
- perineals control eversion of foot => deep perineal nerve not as well formed can lead to inversion => pres cavus foot
- as the PT ages, this can result in the arch becoming more pronounced as L5 nerve decays => loss of perineal MM function => painful feet
What gives our limbs our shape?
- neuronal tissue out growing
- determined by healthy maturation of neurological tissue
What happens when a PT loses hip ROM?
- normal hip range = 110 flexion + 15-20 degrees extension
- if lose 20 degrees flexion => lose extension => results in fixed flexed deformity => transfer of forces to LSP => L5 very vulnerable
- hip joint may not be very painful => fewer nociceptors in hips (less easy to injure) => won’t get early signs of pain in hip OA => will see loss of movement
What are common signs of hip OA?
- knee and LBP
What might older people present with first before having a diagnosis of hip OA?
- knee OA
- LBP
What should you look for in a PT with LBP?
- observation: hip externally rotated + abducted + flexed (combo of all)
- passive: no internal rotation => no articular cartilage => no hip pain
What is the function of the lumbar spine?
- lordotic spine bears 16% axial load
- L1-L3 => 11% each
- L3-S1 => 19th each
- allows large amount of movement to aid locomotion
- engages with PLS + TL (thoraco lumbar fascia) to allow force transference
- anterior component + fluid component + posterior component
What happens in Spina Bifida Occulta?
- L5 doesn’t have an SP (benign space lesion)
What happens in spinal bifada?
- L5 creation has completely failed
- nerves haven’t separated and adhere to spine
- bone + nerves are still attached => as PT grows nerves break away from bone => paralysis e.g. Tanny Grey-Thomson
- as PT grows nerves stay attached => lose function of lower body
- most PTs are born without any issues in movement, but lose function
- during pregnancy take folic acid
- now PTs are operated on in utero (26-28 weeks)
What happens during lumbarisation or sacralisation?
- extra vertebrae
- increased risk of LBP
In the lumbar spine which part of the vertebrae should not be weight bearing?
- facets
- should smoothly guide
- articulation with fluid
What happens during lordosis in LSP?
- more pressure on facets
- bone remodels (tries to get away from pressure)
- more contact
- no bony restriction
- more movement in spine forwards
- results in degenerative spondylylothesis
What might you give an older patient with suspected degenerative spondylolythesis?
- more reinforced flexion + core movement
- look at hip + knee + ankle movements
- look at thorax for kyphosis
What is degenerative spondylylothesis more common in women?
- looser tissues
- less resistance against pressures
- child bearing can result in less control around the trunk/pelvis
What structure + function of the support systems are in the lumbar spine?
- myofascial support systems => control + propropeption
- thoraco-lumbar fascia (TLF)
- anterior longitudinal ligaments
- posterior longitudinal ligaments
- posterior ligamentous system
- facet joint capsule ligaments
- posterior ligaments - inter spinous, supraspinous, ligamentum flavum
- posterior layers of TLF
- lost of proprioceptors around facet joints + pre-stressing tissues => loss of integrity of tissues => potentially maladaption
What are the specialisations of the lumbar spine?
- facet shape
- upper lumbar area => Transitional area + all movements possible (rotation, too) + mainly T12/L1
- middle lumbar area => centre of gravity + facilitating locomotion (SB)
- lower lumbar area => force dissipation + transmission + LS (rotation)
Which area in the LSP is most vulnerable?
- L3-L4
What happens to ligaments in the spine?
- too much stretch
- not same movement through disc
- capsule becomes over mobile
- disc narrowing
Describe the life history of the lumbar spine
- happy childhood => normal L5 up to 20 yo
- goes to work place, less exx + more sitting => more stress + stretch into ligaments in facet area => reduced proprioceptive feedback after 20 mins sitting => go to bar for drink => too much stretch on standing
- then, one day => reach around for seatbelt => capsule over stretched => disc height loss -> fires into multifidus @ L4/L5/S1 area
- next day pretty sore => goes to osteopath
- inflamed + very sensitive => stretched ligaments => MM damage
- potentially not using lungs + ribs properly => reduced somatic function (dysfunction)
- mobilise TSP => LSP HVT => alpha motor neuron inhibition => PT feels better => change work station + get back into sport
- 6 months later PT back @ osteopaths…then 5 months after that (continues) => doesn’t implement the required changes regularly
- because PT is not changing anything => outer lamellia are not healthy + nucleus pushing posteriorly through lamina fiscia
- next day no LBP, now pain down leg => nerve root compromise in 30s => lying on back reflexes are really poor
- lying on side PT does have reflexes => now lying on side can conduct, if can find position of ease => we can probably help with this => Txx + ST to reduce tension out of the nerve roots
- profound loss of sensation => refer for MRI => after 12 weeks less recovery from nerve root compression
- PT now plays golf
- as time goes on less blood flow to disc + LSP disc reduce in height + more TSP kyphosis
- 50s important for investing in life => invest + encourage better choices
- ends with spondylitis => results in flexion through LSP
- Hip OA then affects LSP => if already had spondylitis => more likely to get LSP pain, can we assit with shoes?
Give a break down of what you would expect in each decade from 20-50 yo in terms of structural changes in LSP
- 20s ligaments + MM
- 30s radicular pain down leg
- 40s disc prolapse
- 50s spondyloarthritis (facets) + spondylitis (disc)
What are the specialisations of the upper lumbar area?
- transitional area
- all movement possible, rotation
- mainly T12/L1
What are the specialisations of the middle lumbar area?
- centre of gravity
- facilitating locomotion, SB
What are the specialisations of the lower lumbar area?
- force dissipation + transmission
- LS - rotation
What are the lumbosacral specialisations?
- transitional area - mobility/stability
- structure/function - disc/facet + iliolumbar ligament
What is the nerve supply to the spinal segment for the lumbar plexus?
- derived from anterior decision of T12-L4
What is the nerve supply to the spinal segment for the lumbosacral plexus?
- derived from anterior decision of L4-S1
