Spine Three - starts with disc strain/bulge Flashcards
what structures are involved with a disc strain or bulge
nucleus pulposus
annulus fibrosis
what does the nucleus pulposus and annulus fibrosis do?
adapts to pressure secondary to movement (hydrostasis)
aging process ________ solubility
decreases
what happens to the pressure around the nucleus as you age?
- more fibrous
- becomes uneven as you age (30-50 highest risk)
why are you less likely to have a disc strain or bulge in you 50-60s?
b/c about that time the annulus and NP become homogenous
herniated nucleus pulposus (HNP)
stretching and/or tearing of annulus fibrosis
what age is HNP most common in? what level do 90% of them happen at?
20-45
L4/5 and L5/S1
McKenzie theory
- prolonged or repeated flexion cause posterior and possible lateral movement of NP
- NP migrates towards innervated outer AF
- pain peripheralizes as nerve is compromised
what part of the AF is innervated?
outer 1/3
what does repeated stress/strain cause in the annulus
fissures in posterior and posterior lateral annulus
herniation stage 1
- slight posterior lateral protrusion
- small fissure in annulus
- asymptomatic
- easily managed with proper mechanics (but we probs won’t see patients at this level because they don’t have symptoms)
Herniation stage 2
- protrusion to outer annulus
- increase in fissuring
- no nerve root involvement
- may present with lateral shift (usually away from the pain)
Herniation stage 3
- prolapse
- outer annulus is intact but putting pressure on spinal nerve/cord
- referred pain into extremities
*** this is where it can become radicular, monitor patient for neuro changes
Herniation stage 4
- extrusion or requestration
- no annulus containment
- neurologic and motor changes
extrusion
disc is all the way out but not broken free
sequestration
disc has completely broken free
can a herniated disc go back in?
it depends on the stage
early = maybe
later - no
subjective findings with HNP
- increased pain with prolonged sitting, bending and twisting
- increased pain with coughing, sneezing, laughing
- increased pain with flexion activites and standing after prolonged periods of sitting
- decreased pain with standing, walking, and movement
objective findings for HNP
- slumped posture and decreased lordosis
- possible lateral shift
- neuro signs
- tender to palpate
special tests for HNP
- slump, straight leg raise, femoral
If HNP is acute, what kind of posture will you see
very erect (guarding
spondylolithesis
forward displacement of vertebra caused by defect in pars interarticularis
what can cause a defect in the pars interarticularis?
- fracture or elongation of vertebral arch
- facet shape or orientation
Tor F: spondylolysis can lead to spondylolisthesis
T
how do you grade spondylolisthesis
line is drawn on the anterior aspect to measure how far forward superior vertebra is on inferior vertebra
what are the grades of spondylolisthesis
1-4
1-2 are usually responsive to treatment
3-4 usually need surgery
2 types of spondylolisthesis
isthmic and degenerative
is antero or retro spondylolisthesis more common
antero
isthmic spondylolisthesis
- fatigue fracture
- stretching of pars interarticularis
- due to repeated extension with rotation
- common in volleyball, baseball, and gymnasts
t or f: in isthmic spondylolisthesis you may palpate a step higher than the actual problem
T b/c it will drop when it moves anterior
degenerative spondylolisthesis
- wearing out of asymmetry of facet planes
- caused by obesity or arthritis
- entire cephalad vertebra slips forward
- step is at level of slipw
where is degenerative spondylolisthesis most common
L4/5 > L5/S1
subjective findings with spondylolisthesis
- general LBP
- subsides with rest
- difficulty/pain with forward bending
- increased pain with excessive movement or physical activity
- increased muscle tone with standing
objective findings with spondylolisthesis
- hypermobile with passive accessory testing
- excessive lordosis
t or f: there is a direct relationship of displacement with amount of pain
false
x-ray views for spondylolisthesis
oblique and lateral
oblique = scotty dog with collar sign
what other imaging can you get with spondylolisthesis
bone scan - used in young people with acute onset
MRI - movement between bone and endplates, may be indicated if there are bowel/bladder symptoms
what kind of image shows lumbarization or sacralization
AP plain film
lumbarization
6 lumbar vertebra
sacralization
4 lumbar vertebra
common causes of SIJ injuries
- combo of flexion with rotation
- fall or trauma
- pregnancy
- leg length difference
- weak glute med
subjective findings with SIJ pathology
- morning stiffness that gets better with weight baring
- sharp/dull/achy, throbbing
- unilateral pain localized to sij
- pain with walking and climbing stairs
- pain with prolonged posture or standing on affected side
t or f: if it is a true SIJ problem you should be able to clear the lumbar spine
true
t or f: people with SIJ problems usually have neurological signs
F: but they may have referred pain down the leg
possible non mechanical causes of SIJ pathology
psoriatic arthritis
infection
tumors
objective findings with SIJ pathology
- posture (stance shift to one side)
- able to clear lumbar
- spine and hip
- pelvic mobility
- leg length difference
- provocation clusters
if someone has a hypermobile SIJ what muscle is most likely weak
glutes
* also check hamstrings, quads, and hip rotators
anterior pelvic rotation palpation findings
ASIS is low
PSIS high
long medial malleolus
posterior pelvic rotation palpation findings
ASIS high
PSIS low
short medial malleolus
possible causes of superior innominate upslip
landing hard with knee extended
stepping off curb
landing on ischial tuberosity
tight QL
palpation findings with superior innominate upslip
ASIS and PSIS superior
short medial malleolus
what xray view is best for SIJ
anterior posterior
what is the gold standard imaging for SIJ
injection under fluoroscopy
