Intro Flashcards
(111 cards)
1
Q
Why should RMTs know spinal orthopaedics?
A
- To acquire knowledge to understand the guest complaint
- To be able to assess and treat the complaint
- To recommend the appropriate rehabilitation and home/self care
- To communication with other health care practitioners
2
Q
Axial skeleton =
A
skull, vertebrae, sacrum, ribs, sternum
3
Q
Appendicular skeleton =
A
bones of upper and lower limbs; includes clavicles, scapulae,
and innominates
4
Q
there are _____ presacral vertebrae:
A
24 (7 cervical, 12 thoracic, 5 lumbar)
5
Q
- in total the spine has _____ segments:
A
33 (24 presacral, and 5 sacral, 4 coccygeal)
6
Q
thoracic spine is in _____ , while the cervical and lumbar
regions are in ______
A
kyphosis (kyphotic curve)
lordosis (lordotic curve)
7
Q
normal spinal curves offer _______ , as well as _______ to the intervertebral joints
A
flexibility,shock-absorption
stiffness and
stability
8
Q
- the thoracic curve is secondary to _______ of the _______; the same applies of the ________.
A
-the decreased vertical height
-anterior
thoracic vertebral border
-sacral curve
9
Q
thoracic kyphosis is due to the
A
shape of the vertebral bodies
10
Q
biomechanical functions of the spine
A
- housing and protection – of spinal cord
- support – transfers weight and flexion movements to pelvis; framework
for attachments of internal organs - mobility
- control
11
Q
basic functional unit of the spine is spinal motion segment
A
- adjacent halves of two vertebrae, interposed disk and articular facet joints, supporting structures (ligaments, blood vessels, nerves, muscles)
12
Q
posterior articulations (facet joints) control
A
amplitude and direction of movement
13
Q
Facet Orientations;
Cervical
A
superior:
inferior:
14
Q
Facet Orientations;
Thoracic
A
- T1 (transitional):
- T2 - T11:
- T11 - T12 (transitional):
15
Q
Facet Orientations;
Lumbar
A
superior:
inferior:
16
Q
the pelvis is made up of two innominates
- an innominate is the combination of three bones:
A
the ilium, ischium and
pubis
17
Q
the pelvis is an enclosed osteoarticular ring made up of three bony parts ______, and three joints ______
A
(two iliac
bones and the sacrum)
(two sacroiliac joints and the pubic
symphysis)
18
Q
FISH
A
the iliac articular surface is covered in fibrocartilage; the sacral articular surface is
covered in hyaline cartilage
19
Q
early degenerative changes are found to occur on the
A
iliac surface rather than both
surfaces simultaneously
20
Q
nutation
A
(flexion) sacral promontory moves anteriorly and inferiorly
- apex of the sacrum moves posteriorly
- iliac bones approximate
- ischial tuberosities move apart
21
Q
counternutation
A
(extension)
- sacral promontory moves superiorly and posteriorly
- apex of the sacrum moves anteriorly
- iliac bones move apart
- ischial tuberosities approximate
22
Q
movements of the sacrum correspond to movements of the spine
- in forward bending,
A
there is initially a counternutation of the sacrum, then
with complete spinal flexion a nutation of the sacrum
23
Q
position of the sacrum is determined by
A
a force that reaches it from above
24
Q
position of ilium is controlled by
A
movement of the femur
25
Spinal Kinematics
- disk-vertebral height ratio largely determines the degree of movement at spinal
segments
- types of movement that may occur at spinal segments depend on the orientation of
the articular facets of each level
- added factors: rib cage limits thoracic motion, pelvis (and its tilt) increases trunk
motion
26
Freyette’s Laws
- describes coupling of the various spinal motions with one another
- not strict laws, but evolving concepts
27
Freyette’s First Law
When any part of the thoracic or lumbar vertebral segments is in neutral position
without locking of the articular facets, rotation and sidebending are in the opposite
directions. This does not include the cervical spine. Neutral sidebending produces
rotation to the other side: the vertebral body will turn toward the convexity that is being
formed, with maximum rotation occurring near the apex of the curve.
28
Freyette’s Second Law
If the vertebral segments are in full flexion or extension with the articular facets
locked or engaged, rotation and sidebending are to the same side.
29
joint play =
small ROM, beyond regular AROM, that is obtained passively
30
joint play movements are
accessory movements of the joint and required for full
| painless function and AROM
31
loss of joint play =
joint dysfunction
32
normal joint play is usually
less than 4mm in any direction
33
Tonic Muscles
* muscles responsible for maintaining upright posture
* tendency to become tight and hypertonic with pathology or develop contractures
* less likely to atrophy
34
Phasic Muscles
```
all other (non postural) muscles
• tendency to become weak and inhibited with pathology
```
35
Greatest mvmnt L spine
L5 S1
36
Pelvic tilt measurements
7-10 deg men
| 10-15 degree women
37
```
Muscles "balancing"
the pelvis (A) The posterior oblique muscle system includes
```
the
| latissimus dorsi, gluteus maximus, and thoracolumbar fascia
38
```
Muscles "balancing"
the pelvis(B) The anterior oblique muscle system includes
```
the external
and internal obliques, contralateral adductors of the thigh,
and intervening anterior abdominal fascia
39
Muscles "balancing" The inner muscle unit including
multifidus, transverse
| abdominus, and the pelvic floor muscles
40
Sacroiliac joints:
* Resting position – neutral
* Capsular pattern – pain when joints stressed
* Close pack position – nutation
* Loose pack position – counternutation
41
Sacroiliac Joints are both a
synovial (“C “shaped – convex
iliac surface/fibrocartilage) & syndesmosis jt.
(Sacral surface – slightly concave / hyaline cartilage) with
an interosseous membrane
42
in adulthood the articulating surfaces become
• irregular and fit into one another /restricts movement & adds joint
strength for weight-bearing
43
Fibrocartilage
| contains
```
bundles of
collagen fibers in its
matrix. It does not
have a perichondrium.
Combining strength
and rigidity, it is the
strongest of the three
types of cartilage.
```
44
Fibrocartilage Found at
```
the pubic symphsis,
intertebral disc,
menisci at the knees
and portions of
tendons that insert
into the cartilage
```
45
Hyaline cartilage is the most .
abundant but weakest type of cartilage and has fine collagen fibers embedded in a gel-type matrix. affords flexibility and support, and at joints, reduces friction and absorbs shock
46
Hyaline cartilage is Found at
```
the
end of long bones,
anterior ends of ribs,
nose, parts of the
larynx, trachea,
bronchi, bronchial
tubes, embryonic and
fetal skeleton
```
47
Elastic cartilage
| contains
```
a
threadlike network
of elastic fibers
within the matrix. A
perichondrium is
present. It provides
strength and
elasticity and
maintains the
shape of certain
organs
```
48
Elastic cartilage found at
top of
larynx, part of the
external ear and
auditory tubes.
49
Long Posterior Ligaments
| Action / movement it limits
Anterior pelvic rotation/ sacral counter nutation
50
Short Posterior
Ligaments
Action / movement it limits
All pelvic and sacral movement,
| esp. prevention of inflare
51
Posterior
Interosseous
Ligaments
Action / movement it limits
Shearing forces on the joint
52
Anterior SI
Ligaments
Action / movement it limits
Prevents outflaring of the ilium
53
Sacrotuberous
Ligaments
Action / movement it limits
Nutation and posterior rotation of the
innominate
* Biceps femoris attaches to
Sacrotuberous ligament *
54
Iliolumbar
Ligaments
Action / movement it limits
Stabilizes L5 on the ilium
55
Sacrospinous
Ligaments
Action / movement it limits
Nutation and posterior rotation of the
| innominate
56
PELVIS characteristics:
* Gynecoid, shorter + wider (predominantly female)
| * Android (primarily male)
57
Structural Pathologies of the Pelvis
| UPSLIP;
```
- ASIS+PSIS will both be higher
on effected side
- Ilium moves up on sacrum
Other causes:
short leg on other side
Muscle spasm
```
58
Structural Pathologies of the Pelvis
| DOWNSLIP;
- ASIS+PSIS will both be lower on
effected side
- Ilium moves down on sacrum
59
Structural Pathologies of the Pelvis
| INFLARE;
- PSIS is more lateral, ASIS moves
medially
- Can also indicate anterior
rotated ilium
60
Structural Pathologies of the Pelvis
| OUTFLARE:
-PSIS is more medial, ASIS moves
laterally
- Can also indicate posterior
rotated ilium
61
```
Structural Pathologies of the Pelvis
ANTERIOR ROTATION (ilium):
```
-Ilium rotates anterior & slightly
superior on the sacrum
-Commonly accompanies inflare
62
```
Structural Pathologies of the Pelvis
POSTERIOR ROTATION (ilium):
```
- Ilium rotates posterior &
slightly inferior on the sacrum
- Commonly accompanies
outflare
63
LUMBARIZATON:
-S1 segment of
sacrum is mobile
-Behaves like a
lumbar vertebrae
64
SACRALIZATION:
- L5 immobile on S1
(sacral fusion)
- L5 behaves like S1
65
Pelvic Pathologies
* Degenerative / inflammatory arthritis
* Pelvis fractures
* Pubic Symphysis disruption
* SI joint disruption /altered mechanics
* Coccydynia
66
Level of iliac crests
| *normal =
level with L4
67
Level of PSIS,
| *normal =
dimples at S2
68
PELVIS PALPATION
| • Anterior observational view.
(A) Level of anterior superior iliac
spines. Are they equidistance to center line? (B) Level of iliac
crests.
69
PELVIS PALPATION
| Posterior observational view
```
(A) Level of iliac crests
*normal = level with L4
(B) Level of PSIS,
*normal = dimples at S2
(C) Level of ischial
tuberosities
(D) Level of gluteal folds
```
70
PELVIS – Motion Palpation
```
• (A) Starting position for sacral
spine and posterior superior iliac
spine.
• (B) Hip flexion; the ilium (PSIS)
should drop inferiorly
• (C) Starting position for sacral
spine and ischial tuberosity.
• (D) Hip flexion; Ischial tuberosity
should move inferior + lateral
```
71
Treatment techniques for ant / posterior rotation of the ilium& SI joint fixation include:
Positioning of the client – Prone
Specific pillowing for Ant / Post rotations of the iliums – using wedges
On Anteriorly rotation ilium– place wedge under ASIS – this will encourage posterior rotation of that ilium.
Mobilize sacrum into nutation and ilium posterior
Contract hamstrings
On Posterior rotated ilium – place wedge under Greater trochanter
mobilize PSIS anterior and sacrum into conter-nutation.
Contract quadriceps
72
On Anteriorly rotation ilium– place wedge under
ASIS – this will encourage posterior rotation of that ilium.
Mobilize sacrum into nutation and ilium posterior
Contract hamstrings
73
On Posterior rotated ilium – place wedge under
Greater trochanter
mobilize PSIS anterior and sacrum into conter-nutation.
Contract quadriceps
74
Treatment techniques for ant / posterior rotation of the ilium& SI joint fixation include:
Positioning of the client – sidlying
To increasing anterior rotation – bring top leg into extension, as you mobilize the PSIS anterior. Also contract quadriceps
To increase posterior rotation – bring top leg into flexion; engage the ASIS and ischialtuberosity and mobilize in posterior direction. Contract hamstrings.
75
To increasing anterior rotation –
bring top leg into extension, as you mobilize the PSIS anterior. Also contract quadriceps
76
To increase posterior rotation –
bring top leg into flexion; engage the ASIS and ischialtuberosity and mobilize in posterior direction. Contract hamstrings.
77
Musculature of the Lumbar spine:
Transverse Abdominalis
– commonly weak in people with low back pain
Multifidus
QL,Iliopsoas, erectorspinae, latisimusdorsi
78
Ligaments and fascia of the Lumbar spine:
```
Interspinous
Intraspinous
Iliolumbar
Anterior longitudinal
Thoracolumbar fascia
```
79
Abdominal Regions
- R Hypochondrium (1/2 Liver, Gall Bladder)
- Epigastric region (1/2 liver, esophagus, upper stomach, pancreas)
- L Hypochondrium (Spleen, L cholic flexure)
- R Flank (Lower portion liver and gall badder,ascending colon, R colic flexure)
- Umbilical (bottom stomach,Transverse colon, duodenum)
- L Flank (jejunum, descending colon)
- R Groin (Ceacum, R ilium, inguinal lig)
- Pubic Region (sigmoid colon, rectum, anal canal, anus)
- L Groin (descending colon, ilium, inguinal lig)
80
Lumbar Spinal Vertibrea
- Body
- Pedicle
- Transverse Process
- Lamina
- Spinous Process
- Vertebral Foramen
- Superior Articular Facet (Med/Post)
- Inferior Articular Facet (Lat/Ant)
81
Transitional vertebrae
(L1 & L5)
82
Normal Lordodic Curve =
50° (5 discs)
| Any change to the lordosis can cause a nerve root irritation
83
A contributing factor to low back pain is the
loss of the lumbar curve
84
Superior facet =
| Inferior facet =
faces medial and slightly posterior
faces lateral and slightly anterior
85
Lumbar facet orientation
Allows for movements of flexion/extension /lateral flexion/rotation
86
Concave / convex rule in the lumbar vertebrae
| With flexion
(anterior roll / posterior glide) = SP’s move further apart and posteriorly
87
Concave / convex rule in the lumbar vertebrae
| With extension
(posterior roll / anterior glide) = SP’s move closer together and anteriorly
88
Epidemiology Lumbar
5% related to disk … 95% related to disk (books differ)
Bone:Osteoperosis, compression fracture, degenerative changes
Joint:DDD, DJD, facet lock, osteophytes (leads to bony fusion that then places pressure on nerves)
Referral:Ovaries, prostate, kidney, aortic aneryism
Muscles, fascia, ligaments-strains and sprains
Nerves:L4-L5 most commonBlood vessels:Aneurism
Other: space occupying lesion, genetics…
89
Congential Pathologies:
| Spina bifida
Latin for "split spine” is a developmental birth defect caused by the incomplete closure of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to stick out through the opening in the bones.
The most common location of the malformations is the lumbar and sacral areas.
The incidence of spina bifida can be decreased by up to 75% when daily folic acid supplements are taken prior to conception.
90
Spondylolysis
CAUSES:
DIAGNOSIS:
Spondylolysis
Is a defect in the pars interarticularis of a vertebra.
The great majority of cases occur in the lowest of the lumbar vertebrae (L5), but spondylolysis may also occur in the other lumbar vertebrae, as well as in the thoracic vertebrae.
CAUSES:
Congenital
Typically caused by stress fracture of the bone, and is especially common in adolescents who overtrain in activities such as tennis, diving, martial arts & gymnastics
DIAGNOSIS:
- The defect is seen in the oblique lumbar radiograph. An oblique x-ray of the lumbar spine shows a “Scotty Dog" appearance
91
Spondylolysis
A defect in the pars interarticularis or the arch of the vertebra
92
Spondylolisthesis
A forward displacement of one vertebra over another
93
Retrolisthesis
A backward displacement of one vertebra over another
94
Meyerding Grading System
is used to classify the degree of vertebral slippage. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below.
95
Meyerding Grading System used for?
is used to classify the degree of vertebral slippage. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below.
96
Meyerding Grading System
```
Grade I: 1-24%
Grade II: 25-49%
Grade III: 50-74%
Grade IV: 75%-99% slip.
Grade V: Complete slip (100%),
known as spondyloptosis
```
97
Other Lumbar Pathologies
```
DDD/ arthritis
Disc protrusion-herniation
Spinal stenosis
Nerve root compression & facet lock
Fracture & Soft tissue injury
Hypo / Hyper lordosis
Medical lower back pain – muscles, ligaments and fascia involvement
```
98
DEGENERATIVE DISK DISEASE (DDD):
Phase I:Dysfunctional
In the first phase of the degeneration process we see a tearing around the outer surfaces of the disc cartilage material. The normal height of the disc has now been compromised as it begins to shrink. The disc has lost some of its effectiveness in providing flexibility and cushioning to the spine.
Phase II: Unstable
In the second phase of degeneration, the joint experiences a progressive loss of strength. Further tearing and loss of disc height and cartilage degeneration occurs.
Phase III: Stabilization
Even further loss of disc height occurs, the surfaces of the vertebrae above and below the disc now start to show moderate to severe damage, the disc has become thin and fibrotic, and we now see the formation of arthritic osteophytes (spurs).
Over time pain and symptoms worsen in the absence of proper treatment.
99
% H2O discs?
(70% water)
100
Four stages of disc
| protrusion-herniation:
1. Protrusion – the disc bulges posteriorly without any rupture in the annulus firbosis
2. Prolapse – only the outermost fibers of the annulus fibrosus contains the nucleus
3. Extrusion – the annulus firbosus is perforated and discal material moves into the epidural space
4. Sequestration – a formation of discal fragments outside of the disc
101
Protrusion –
the disc bulges posteriorly without any rupture in the annulus firbosis
102
Prolapse –
only the outermost fibers of the annulus fibrosus contains the nucleus
103
Extrusion –
the annulus firbosus is perforated and discal material moves into the epidural space
104
Sequestration –
a formation of discal fragments outside of the disc
105
peripheralization and centralrization
Periph pain moves away from center
Central pain moves toward core (retreats to source = healing)
106
Herniation
Immediate pain – posterior thigh leg and foot
Pain gluteals, hamstrings and down to heel
* If pain complaint is anterior thigh or groin, then consider hip joint involvement
107
Facet Lock
Pain doesn’t go distal to knee
| Back gets locked in position (ie. Reach forward into flexion and can’t return to neutral)
108
PSOAS INVOLVEMENT
Hypo-lordosis –
Hyper-lordosis –
is accompanied with hip flexion (femur moves around the ilium)
is accompanied with anterior rotation of the ilium (ilium moves around the femur) and lumbar extension
109
Lumbar lordosis
```
Abdom- long/weak
Erect sp- tight
ASIS-low
PSIS- high
Glutes-Long/weak
Iliopsoas- tight
Hamstring tension- tight
```
110
Effect of different leg lengths and posture.
Note presence of scoliosis on the side with the "short" limb. (A) Normal. (B) Short left femur. (C) Short left tibia. (D) Pronation of left foot.
111
MYOTOMES
```
C3-5 -Diaphragm
C5- Shld and flex elbow
C6 – Bending Wrist back
C7 -Extend Elbow
C8-Bends fingers
T1-Spreads fingers
T1-12-Chest wall Abdominal Cavity
```
L1 – L2-Bends hip - Iliopsoas
L3-Extends knee - quadriceps
L4-Dorsiflex – tibalias anterior
L5-Wiggles Toes – extends bid toe
S1-Plantar flex - soleus
S3-5-Pelvic Region
