MSK- Lumbar Spine

Question 1

Nerve root differences Lx vs Cx

Answer 1

Lx, nerve roots leave below
Cx nerve root leave above

Question 2

Why bulges posterolateral?

Answer 2

Weakness in annulus fibrosis anterior laterally
Posterior longitudinal ligament

Question 3

Dermatome- relevant areas

Answer 3

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

Question 4

Myotomes

Answer 4

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

Question 5

Reflexes

Answer 5

L3-4: patellar
L4-5: tib post
L5-S1: medial hammy
S1-2: lateral hammy
S1-2: achilles

Question 6

Special test for lumbar radiopathy

Answer 6

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)

Question 7

Stress individual verve’s

Answer 7

SID (sural nerve= inversion and DF)
TED (tibia nerve= eversion and DF)
PIP (Peroneal nerve= inversion and PF)

Question 8

Crossover sign

Answer 8

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

Question 9

Sign of the buttock

Answer 9

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

Question 10

Bow-string test

Answer 10

Give slack, 20 deg flex knee, poke popliteal area and see if symptoms are found

Question 11

Spinal stenosis of Lx

Answer 11

Common age > 60
Better with flexion (opens the intervertebral foramen)
Worse in extension (closing intervertebral foramen)

Question 12

Intermittent claudication vs Lx neurogenic claudication

Answer 12

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

Question 13

Spinal stenosis- intervention

Answer 13

• flexion based exercises and positioning. Z lying
  Avoidance of aggravating memes and positions

Surgical- laminectomy

Question 14

Disc herniation

Answer 14

30-50 years of age
Acute onset- all of a sudden
80-90% posterolateral

Question 15

Disc herniation types

Answer 15

Protrusion
Prolapse
Extrusion
Sequestration

Question 16

Details on disc herniation

Answer 16

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)

Question 17

Disc herniation- intervention

Answer 17

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)

Question 18

Schmorl Node

Answer 18

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

Question 19

Pelvic (lower) crossed syndrome

Answer 19

Increase lordosis
Weak- abs, glutes
Tight- hip flexor, erector spinae and hammys

Anterior tilt

Question 20

Spondylosis

Answer 20

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

Question 21

Lx Facet syndrome

Answer 21

Pain never crosses the knees

Question 22

Quadrant test

Answer 22

Closes facet joint

Question 23

Interventions for Lx Fcet

Answer 23

Flexion based exercises and position
Avoidance of aggravating mvmts

Question 24

Lx instability- inner unit muscles

Answer 24

Diaphragm, trans abs, multifidus, pelvic floor

Question 25

H and I stability test

Answer 25

H: side flexion extension or flexion
I: start flexion then side flex

Question 26

Prone segmental instability test

Answer 26

Whether or not they need core xercises

Question 27

Lx instability intervention

Answer 27

Core exercises:
- tri A
- lumbar multifiduc isolation
- pelvic floor activation
- diaphragm activation

Question 28

Progression of core stability exercises

Answer 28

1) isolate inner unit
2) train the inner unit
3) maintain inner unit while training outer unit
4) integrate into functional

Question 29

Spondylolysis vs spondyolisthesis vs restrolistheses

Answer 29

A defect in the pars interarticularis (no slippage)

Forward displacement of one vertebra over another

Backward displacement of a vertebra on another

Question 30

Different types of spondylolisthesis

Answer 30

Traumatic (sudden)
Isthmic (overuse)
Degenerative
Dysplastic (congenital)
Pathological

Question 31

Grades of spondylosthesis

Answer 31

1: >25%
2: 25-50%
3: 50-75%
4: >75%
5: 100 % (spondyoptosis)

1-3: core stabilization

4-5: surgical fixation

Question 32

S&S of spondylothesis

Answer 32

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

Question 33

Post op management of a fusion of laminectomy- Protection phase

Answer 33

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

Question 34

Post op management of a fusion of laminectomy- Mod to Min phase

Answer 34

Scar mob
Progressive stretching and joint mob
Exercise (implement strengthening)
Contraindications- joint manip, extension exercises

Question 35

Two red flags of the Lx

Answer 35

Caudal Equina and malignancy

Question 36

Lx malignancy

Answer 36

> 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)