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MSK T3 > Spine > Flashcards

Spine Flashcards

1
Q

What anatomical qualities enhance the lumbar spine’s ability to bear weight?

A

• Large vertebral bodies
• Intervertebral discs
• Lordotic curvature
• Many strong ligaments
• Muscular support from segmental and global muscles
• Dense thoracolumbar fascia

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2
Q

How is weight distributed through the lumbar spine?

A

• 75–80% through vertebral bodies and discs

• 20–25% through facet joints

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3
Q

What is the orientation of lumbar facet joints, and how does it influence movement?

A

• Oriented in the sagittal plane
• Predominantly allows flexion and extension
• Primarily minimizes rotation

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4
Q

What are the primary ranges of motion (ROM) for the lumbar spine?

A

• Flexion: 60°
• Extension: 25°
• Lateral flexion: 25°
• Rotation: 12°

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5
Q

What are the key functions of intervertebral discs (IVDs)?

A

• Absorb and distribute forces
• Maintain proper spacing between vertebral bodies
• Preserve spacing in intervertebral foramina and facet joints

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6
Q

What happens with hypermobility or degeneration of intervertebral discs?

A

• Approximation of facet joints
• Narrowing of intervertebral foramina

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7
Q

Which part of the intervertebral discs (IVDs) is innervated?

A

Only the outer 1/3rd of the disc is innervated.

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8
Q

Are intervertebral discs vascularized?

A

No, IVDs are avascular.

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9
Q

Which ligaments support intervertebral discs anteriorly and posteriorly?

A

• Anterior Longitudinal Ligament (ALL) supports anteriorly
• Posterior Longitudinal Ligament (PLL) supports posteriorly

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10
Q

What is the annulus fibrosis?

A

The outer portion of the intervertebral disc, made up of rings of collagen fibers and fibrocartilage.

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11
Q

What is the function of the annulus fibrosis?

A

Acts as a complex ligament to prevent excessive movement at an individual vertebral segment.

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12
Q

How is the annulus fibrosis attached to surrounding structures?

A

• Firmly anchored to adjacent vertebrae
• Innermost fibers blend with the nucleus pulposus
• Stabilized by the anterior and posterior longitudinal ligaments

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13
Q

What is the nucleus pulposus?

A

A gelatinous mass contained within and bound to the innermost fibers of the annulus fibrosis.

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14
Q

What is the water affinity of the nucleus pulposus, and how does it function?

A

• High affinity for water
• Takes in water during offloading (decreased pressure)
• Squeezes out water during loading (e.g., weight-bearing)

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15
Q

Why are the fluid dynamics of the nucleus pulposus important?

A

They help transport nutrients and maintain disc tissue health.

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16
Q

How does the nucleus pulposus receive nutrients?

A

Through diffusion from the marrow of vertebral bodies via cartilaginous endplates.

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17
Q

Where do nerve roots exit the spinal canal?

A

Through the intervertebral foramina.

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18
Q

What can cause nerve root impingement in the intervertebral foramina?

A

• Degenerative disc disease
• Degenerative joint disease
• Disc lesions
• Spondylolisthesis

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19
Q

What is stenosis, and how does it affect nerve roots?

A

Stenosis is the narrowing of the foraminal space or central canal, which can impinge nerve roots.

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20
Q

Which movements can worsen symptoms in cases of stenosis?

A

• Extension
• Side bending
• Rotation to the affected side

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21
Q

How do movements like extension, side bending, or rotation worsen stenosis symptoms?

A

They further decrease space in the foraminal area, exacerbating nerve root compression.

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22
Q

What is a Motion Segment?

A

connection between 2 adjoining vertebras

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23
Q

What are the symptoms of nerve root compression?

A

• Sensory changes in dermatomal pattern
• Motor weakness in myotomal pattern
• Radicular pain (radiating pain into the lower extremity)
• Low back pain
• Dural tension
• Decreased deep tendon reflexes
• Reproduction of symptoms with increased intraabdominal pressure (e.g., Valsalva, laughing, bowel movements, sneezing)

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24
Q

What sensory pattern is affected in nerve root compression?

A

Sensory changes occur in a dermatomal pattern.

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25
Q

What motor pattern is affected in nerve root compression?

A

Motor weakness occurs in a myotomal pattern.

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26
Q

What is radicular pain?

A

Radiating pain into the lower extremity caused by nerve root compression.

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27
Q

What activities can reproduce symptoms of nerve root compression by increasing intraabdominal pressure?

A

• Valsalva maneuver
• Laughing
• Bowel movements
• Sneezing

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28
Q

Which reflex is associated with the L4 nerve root?

A

Patellar reflex.

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29
Q

Which reflex is associated with the S1 nerve root?

A

Achilles reflex.

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30
Q

What is the myotome for L1-2?

A

Hip flexion.

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31
Q

What is the myotome for L3?

A

Knee extension.

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32
Q

What is the myotome for L4?

A

Ankle dorsiflexion.

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33
Q

What is the myotome for L5?

A

Big toe extension.

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34
Q

What are the myotomes for S1?

A

• Ankle eversion
• Plantar flexion
• Hip extension

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35
Q

What is the myotome for S2?

A

Knee flexion.

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36
Q

What is the purpose of the Valsalva maneuver in nerve root compression testing?

A

It reproduces symptoms by increasing intraabdominal pressure.

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37
Q

What does the Straight Leg Raise (SLR) test assess?

A

It assesses dural tension and other factors but is not primarily a test for disc herniation.

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38
Q

What does the Slump test assess?

A

It assesses dural tension and other factors but is not primarily a test for disc herniation.

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39
Q

What are the three subsystems responsible for spinal stability?

A

• Passive subsystem: Inert structures, bones, ligaments
• Active subsystem: Muscles
• Neural control

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40
Q

What happens if one of the spinal stability subsystems is ineffective or inefficient?

A

It affects the stability of the entire spine.

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41
Q

According to Kisner, Colby, & Borstad (2018), what often causes spinal segment instability?

A

• Tissue damage
• Insufficient muscular strength or endurance
• Poor neuromuscular control

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42
Q

What is the neutral zone in spinal stability?

A

A midrange/neutral position where the joint capsule and ligaments provide minimal passive resistance and offer minimal stability.

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43
Q

What is the elastic zone in spinal stability?

A

The zone where inert structures provide passive restraint to stabilize the spinal segment and prevent excessive movement in a given direction.

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44
Q

What happens when a spinal segment moves beyond the elastic zone?

A

It enters the Plastic zone, where deformation of soft tissues and injury occurs.

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45
Q

Give an example of an inert structure stabilizing the spine.

A

The Posterior longitudinal ligament limits spinal flexion and stabilizes the spine during flexion.

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46
Q

What role do sensory receptors in inert structures play in spinal stability?

A

They sense position and changes in position, relaying this information to the central nervous system to contribute to neuromuscular control.

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47
Q

What is the role of the passive subsystem in spinal stability?

A

Provides structural stability through bones, ligaments, and joint capsules.

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48
Q

How do inert structures stabilize the spine in a specific direction?

A

By limiting movement in that direction, they provide passive restraint and prevent excessive movement.

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49
Q

What is the role of the active subsystem in spinal stability?

A

The muscles of the trunk stabilize the spine, act as prime movers, or serve as antagonists to counteract movement caused by gravity during activity.

50
Q

How do trunk muscles contribute to posture?

A

The contraction of trunk muscles allows us to maintain upright posture.

51
Q

What happens when there is weakness in trunk muscles?

A

• Over-reliance on the passive subsystem
• Increased stress on inert structures
• Impaired sensory feedback to the nervous system
• Disrupted motor input to the muscles

52
Q

What are global muscles in the active subsystem?

A

Multisegmental muscles that respond to external loads on the trunk, shifting the center of mass.

53
Q

Can global muscles stabilize individual spinal segments? Why or why not?

A

No, they cannot effectively stabilize individual spinal segments because they have little or no direct attachment to the vertebrae.

54
Q

How do global muscles stabilize the spine indirectly?

A

Through compressive loading.

55
Q

What are segmental (core) muscles in the active subsystem?

A

Deeper muscles with segmental attachments that respond regardless of the direction of motion.

56
Q

What is the role of segmental (core) muscles?

A

They support individual spinal segments to maintain stability and prevent stress on inert structures at the limits of motion.

57
Q

What can happen if an individual spinal segment is unstable?

A

Compressive loading from global muscles may perpetuate pain by stressing inert tissues at the end range of motion of that segment.

58
Q

How do segmental muscles differ from global muscles in their function?

A

• Global muscles: Respond to external loads and shift the center of mass.
• Segmental muscles: Stabilize individual spinal segments regardless of movement direction.

59
Q

What are the global muscles of the spine?

A

• Rectus abdominis
• External obliques
• Internal obliques
• Quadratus lumborum (lateral portion)
• Erector spinae
• Iliopsoas

60
Q

What are the core muscles of the spine?

A

• Transversus abdominis
• Multifidus
• Quadratus lumborum (deep portion)
• Deep rotators
• Diaphragm
• Pelvic floor

61
Q

How do the Transversus abdominis (TrA), diaphragm, and pelvic floor work together?

A

They contract in synchrony to:
• Increase abdominal pressure
• Offload compressive forces from the spine

62
Q

What is the role of the core muscles during limb movement?

A

They contract before limb movement to stabilize the spine while the arms and legs are in motion (e.g., during gait).

63
Q

What are some common tests used to assess core muscle function?

A

• Diaphragmatic breathing
• Transversus abdominis (TrA), pelvic floor, and multifidus firing
• Dead bug progression
• Bird dog progression
• Side plank
• Front plank

64
Q

What is one of the major true functions of the core muscles?

A

To stabilize the spine while the arms and legs are in motion.

65
Q

What is a disc herniation?

A

A change in the shape of the annulus fibrosis that causes it to bulge beyond its normal perimeter.

66
Q

What are the common locations for disc herniation in the lumbar spine?

A

• Posterolateral
• Lateral
• Central
• Anterior herniation is possible but far less common.

67
Q

At which spinal levels do 95% of lumbar disc herniations occur?

A

At L4-L5 or L5-S1, due to greater mechanical stress from supporting weight and acting as a fulcrum during extension and flexion.

68
Q

What are the symptoms of disc herniation?

A

• Low back pain
• Radicular pain (radiating to buttock, posterior thigh, leg, and foot)
• Motor weakness
• Dural tension
• Sensory deficits
• Impaired reflexes

69
Q

How does annulus fibrosis damage typically occur?

A

• Repeated stress or traumatic rupture
• Overloading the spine in flexion with asymmetrical forward bending and torsional stresses
• Loaded flexion mechanism (e.g., bending over to pick up a pen)

70
Q

Why do discs take a long time to heal?

A

• Poor vascularization
• Aneural nature
• Self-healing is possible but results in weak fibrous repair prone to reinjury.

71
Q

How do symptoms vary with disc herniation?

A

• Depend on the size and direction of the protrusion
• Depend on the spinal level affected

72
Q

What symptoms may indicate a large posterior disc protrusion?

A

• Spinal cord signs
• Loss of bladder control
• Saddle anesthesia
This is a medical emergency!

73
Q

Do all disc injuries cause symptoms?

A

No, because the disc is aneural, not all disc injuries are symptomatic. Neurological symptoms only occur if the herniation is severe enough to compress the spinal nerve root.

74
Q

What are the types of disc herniation?

A

• Protrusion: Nuclear material is contained by the outer layers of the annulus and supporting ligamentous structures.
• Prolapse: Rupture of nuclear material into the vertebral canal.

75
Q

What are the subtypes of disc prolapse?

A

• Extrusion: Nuclear material extends beyond the posterior longitudinal ligament or above and below the disc space, but is still in contact with the disc.
• Sequestration: The extruded nucleus separates from the disc and moves away from the prolapsed area.

76
Q

What happens when the nucleus pulposus extends into the neural canal?

A

• Causes an inflammatory reaction
• Irritates the dural sac and its nerve root sleeves
• May irritate the nerve roots themselves
• Often coupled with muscle spasm of lumbar extensors and pelvic muscles

77
Q

How might a patient present clinically with a disc herniation?

A

• Antalgic scoliosis (to offload the injured disc)
• Short stride during gait (due to hamstring spasm)

78
Q

Describe the pain patterns associated with acute phase disc herniation.

A

• Constant pain (varies in intensity with position or activity)
• Pain is often more severe in the morning because the disc absorbs water overnight in an offloaded position.

79
Q

How do symptoms change as the disc lesion heals?

A

• Nuclear matter is resorbed
• Symptoms tend to centralize and move proximally

80
Q

How do positions and movements affect symptoms in disc herniation?

A

• Higher disc load positions → Symptoms peripheralize
• Offloaded positions → Symptoms centralize

Centralizing movements and positions help guide treatment and self-care!

81
Q

What are the key goals and treatments in the acute stage (protection phase) of disc herniation?

A

• Inflammation management: Ice, NSAIDs, steroid injection
• Pain management: Massage, acupuncture, hydrotherapy, TENS
• Position of ease: Self positional release
• Traction: If relieving
• Tolerable/pain-free movement
• Core activation
• GST, GTO, muscle approximation: To ease spasm in lumbar and pelvic muscles
• Relaxation and breathing exercises

Duration: Generally > 4 weeks

82
Q

What are the key treatments in the subacute stage (Controlled Motion Phase) and chronic stage (Return to Function Phase)?

A

• GST/MFR: Address postural dysfunction
• Traction: If relieving
• Centralizing movements: E.g., McKenzie exercises if extension centralizes pain
• Progressing core exercises
• Stretching and mobility: Increase tissue extensibility and address postural imbalances
• Retraining functional movement patterns: Squats, lifts, etc.
• Education: Postural awareness, good ergonomics, reducing prolonged postures
• Relaxation exercises

Subacute Stage Duration: 4-12 weeks
Chronic Stage Duration: 12+ weeks

83
Q

What are the medical intervention options for disc herniation?

A

• Surgery: Indicated for patients who have failed conservative treatments (e.g., Physio, Massage, medication, steroid injection)
• Common surgical interventions: Laminectomy and fusion

84
Q

What are the Red Flags for Cauda Equina Syndrome?

A

• Loss of bladder or bowel function
• Saddle anaesthesia: Loss of sensation in buttocks and perineum
• Significant lower extremity weakness: May progress to paraplegia

Important:
• Cannot be treated conservatively
• Medical emergency: May result in permanent loss of bladder/bowel function and paralysis if not treated quickly

85
Q

What are additional Red Flag signs to consider in disc pathology?

A

• Symptoms cannot be reproduced with testing
• Symptoms don’t improve after a month of treatment
• Unexplained weight loss

86
Q

What is Degenerative Disc Disease (DDD) and its causes?

A

• Natural occurrence of aging or secondary to disease, infection, disc herniation, or a bony defect in the spine
• Excessive/accelerated degeneration typically linked to prolonged dysfunctional posture or repetitive loading of the spine
• Degeneration leads to progressive fibrous changes in the nucleus pulposus, disorganization of annular rings, and loss of cartilaginous endplates

87
Q

What are the effects of degeneration on the intervertebral discs?

A

• Nucleus pulposus becomes fibrotic and loses the ability to draw in water
• Flatter disc shape leads to segmental instability and abnormal forces on the facets, ligaments, and muscles

• Secondary conditions can include:
-Lumbar sprain/strain
-Facet irritation
-Stenosis (narrowing of central or foraminal space)

88
Q

Why is disc herniation rare in elderly individuals?

A

Due to degenerative disc disease, the disc flattens, reducing its ability to bulge, and increasing the risk of other issues such as lumbar sprains or facet irritation.

89
Q

What are the symptoms of mild degeneration in Degenerative Disc Disease?

A

• Stiffness
• Increased muscle tension
• Relatively asymptomatic

90
Q

What are the symptoms of moderate/severe degeneration in Degenerative Disc Disease?

A

• Increased muscle resting tension and spasm
• Restricted ROM
• Weakness
• Bony changes to stabilize the segment
• Neurological symptoms due to stenosis and spinal nerve compression

91
Q

What is the treatment for Degenerative Disc Disease?

A

• Reduce muscle resting tension and spasm
• Mobilize restricted segments
• Traction: To increase joint and foraminal space
• Normalize lumbar and pelvic posture
• Increase or maintain ROM
• Strengthen core and pelvic muscles
• Encourage movement
• Relaxation exercises

92
Q

What is the cause and treatment for Lumbar Sprain/Strain?

A

• Cause: Often related to prolonged dysfunctional posture and disruption of the 3 subsystems of spinal stability.
• Can be traumatic or insidious onset
• For insidious low back pain, do not assume it’s muscular. Perform postural assessment, functional testing, and lumbar instability tests!

93
Q

What is the treatment approach for acute lumbar sprain/strain?

A

• Gentle MFR and GST to reduce tissue impairments (spasm, MFR, TRPS)
• Positional release, GTO, muscle approximation
• Pain-free movement
• Muscle setting
• Relaxation exercises

94
Q

What is the treatment approach for subacute to chronic lumbar sprain/strain?

A

• Dynamic techniques
• MFR and GST to reduce tissue impairments
• Stretching and strengthening to improve posture and movement
• Relaxation exercises

95
Q

What are facet joints and how are they supported?

A

• Facet joints are synovial joints
• They are enclosed in a joint capsule and supported by ligaments

96
Q

What movements aggravate facet joints?

A

• Extension approximates facet joints
• Ipsilateral rotation and lateral flexion also aggravate facet joints

97
Q

How is facet pain typically described?

A

• Point-specific pain (especially during provocative movements)
• Deep, achey, and diffuse pain (if referring pain)

98
Q

What is Kemp’s test used for?

A

Kemp’s test is used to provoke facet joint pain

99
Q

How are the disc and facet joints related biomechanically?

A

• The disc and facets make up a three-joint complex (vertebrae, intervertebral disc (IVD), and facet joints)
• They are biomechanically interrelated, with proper disc integrity and size essential for maintaining proper alignment of the facets and preventing asymmetrical movements and abnormal stress

100
Q

What are the causes of facet joint irritation or pathology?

A

• Prolonged dysfunctional posture
• Repetitive trauma
• Acute trauma
• Disc injury

101
Q

What is the difference between acute and chronic facet pathology?

A

• Acute pathology results from short-term irritation/inflammation
• Chronic pathology results from prolonged loading, leading to degeneration and osteoarthritis

102
Q

What is Osteoarthritis also known as?

A

Also referred to as degenerative disc disease (DDD) or spondylosis

103
Q

What are the common causes of Osteoarthritis?

A

• Dysfunctional posture
• Severe trauma
• Prolonged immobilization
• Repetitive trauma
• Degenerative changes in the disc

104
Q

What happens in the early stage of Osteoarthritis?

A

Hypermobility and instability are present, affecting the entire three-joint complex

105
Q

What is the progression of Osteoarthritis over time?

A

• Stress from altered joint mechanics leads to osteophyte formation with spurring and lipping along the joint margins and vertebral bodies
• This causes progressive loss of ROM and bony stenosis

106
Q

How does degeneration at one joint segment in Osteoarthritis affect the spine?

A

Degeneration at one segment will affect neighboring spinal segments

107
Q

What are the symptoms of Osteoarthritis?

A

• Decreased ROM
• Weakness
• Sensory deficits
• Decreased reflexes

108
Q

What are the common conditions associated with Osteoarthritis?

A

• Lumbar sprain/strain
• Nerve impingement

109
Q

What movements increase pain and neurological symptoms in Osteoarthritis?

A

Lumbar extension and ipsilateral side bending

110
Q

What is the treatment for facet irritation and Osteoarthritis?

A

• Cold hydrotherapy if spasm and inflammation are present
• GST, GTO, and muscle approximation to treat muscle resting tension and spasm
• Normalize lumbar and pelvic posture
• Strengthen core and pelvic musculature
• Encourage movement (walking, swimming, resistance training)
• Mobilize affected segments into flexion and contralateral rotation/side bending
• Minimize provocative postures while acute
• Optimize ergonomics and avoid repetitive loading and prolonged postures

111
Q

What is Spondylolysis?

A

A defect or fracture of the pars interarticularis, most commonly at L5

112
Q

What are the types of Spondylolysis?

A

• Dysplastic (congenital)
• Isthmic (sports injury)
• Degenerative
• Traumatic

113
Q

What is the most common type of Spondylolysis?

A

The most common type is isthmic spondylolysis, which occurs in active children and adolescents

114
Q

What happens if a Spondylolysis fracture persists?

A

The superior vertebra may slip anteriorly, which is called spondylolisthesis

115
Q

What are the symptoms of Spondylolysis?

A

• “Beltline” pain across the low back
• Hyperlordotic posture, often coupled with hamstring restriction or spasm
• Initially sharp pain, becoming achey over time
• May radiate into gluteals
• Rest alleviates pain
• Extension and rotation aggravate pain

116
Q

What are some tests for Spondylolysis?

A

• AROM extension will aggravate pain
• Positive lumbar instability test
• ‘Step deformity’ in the lumbar spine
• Prone bilateral hyperextension test
• X-ray or MRI

117
Q

What is a Compression fracture?

A

• Most common at the L1 segment (also lower T spine)
• Caused by osteoporosis or trauma (acute or repetitive)
• Often presents insidiously

118
Q

What are the symptoms of a Compression fracture?

A

• Sharp, focal pain in the spine
• Pain may radiate anteriorly, mimicking heart and lung pathology
• Typically no spinal nerve involvement
• Often causes significant compensatory thoracic hyperkyphosis

119
Q

What are the assessment tests for a Compression fracture?

A

• Heel drop test
• Compression (aggravates pain)
• Traction (alleviates pain)
• X-ray or MRI

120
Q

What is the treatment for Spondylolysis and Compression fractures?

A

• Pain and inflammation management in the acute stage
• Decrease, but do not eliminate muscle spasm in lumbar muscles or glutes/hamstrings
• Normalize posture
• Strengthen core and posterior chain
• Regain length and muscle extensibility in posterior chain and lumbar muscles
• Graded return to function and sport

121
Q

What are other conditions related to spine pathologies?

A

• Ankylosing spondylitis
• Rheumatoid arthritis (review inflammatory arthritides)

MSK T3 (9 decks)

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