Lumbar Spine Flashcards
Reflexes
(5)
L3-L4 - Patellar
L4-L5 - Tibialis Posterior
L5-S1 - Medial Hamstring
S1-S2 - Lateral Hamstring
S1-S2 - Achilles
SLUMP
Lumbar Radiculopathy
Patient in sitting w/ legs unsupported
Procedure:
- PT instructs the patient to place hands behind back, go into slump posture (rounded shoulders) bringing thier chin to their chest
- PT passively extends the uninvolved knee then repeats the test on the involved side
- If symptoms have not been reproduced ankle DF is added
- If symptoms of low back pain/ radiating pain in posterior leg are recreated, ask patient to extend their neck while maintaining a rounded back
(+) =
- relief of symptoms when patient extends neck indicates neural tension/restriction of lumbosacral roots
- It can also be interpreted as a restriction of the dura/neural tissues
- If symptoms are reproduced at any stage futher sequential movements are not attempted
Special Test: Straight Leg Raise (SLR)
Lumbar Radiculopathy
Patient lying in supine
Test unaffected side first
Procedure:
- PT slightly adducts & medially rotates patient’s hip, keeping the knee in full extension
- PT flexes patient’s hip (w/ knee in full extension) until the patient indicates pain or rightness in posterior thigh
- Therapist slowly lowers leg slightly until pain or tightness disapears
- PT dorsiflexes the foot or alternately asks the patient to flex their neck to verify if are symptoms reproduced
ROM explained:
- Before 35 degree nerve slack bring taken up
- At 35 root is under tension
- At 60-70 sciatic roots tense over disc
- > 70 degree pain is likely MSK (hamstring stretch)
LLTT
(Lower Limb Tension Test)
Bias (3) Nerves
Sural nerve = Inversion + DF (SID)
Tibial nerve = Eversion + DF (TED)
Peroneal nerve = Inversion + PF (PIP)
Crossover sign
When performing a SLR, on the unaffected side, the patient experiences pain in the affected leg
Indicates a LARGE disc buldge - pulling nerve root INTO disc buldge - causeing compression > S/S
Also known as Well Leg raising test of Fajersztajn or Lhermitt’s Test (test & sign are different)
Sign of the Buttock
Procedure:
- the PT performs a SLR until the point of restriction
- The PT proceeds to flex the knee to see whether an increase in hip flexion may be achieved
(+) =
- Hip flexion does NOT increase when the knee is flexed
- Indicates pathology behind the hip joint in the buttocks
Ex. bursitis, tumor, or abscess
REFERRAL - could be something sinister
Bow-string Test
Lumbar Radiculopathy
Follows a positive SLR
- While maintaining the SLR position which reproduced symptoms, the PT slighly flxes (20 degrees) the patient’s knee to reduce symptoms
Procedure:
- The PT then puts pressure into the popliteal area using his/her thumbs or giners
(+) = Reproduction of radicular symptoms
Indicates pressure or tension on sciatic nerve
Spinal Stenosis
Narrowing of the central canal (central stenosis) &/or interverterbral foramen (lateral stenosis)
- Common age of onset > 60 years old
- Insidious onset
- May be d/t osteophytes, spondylosis, or ligament thickening (ligamentum flavum)
- Stenosis may or may not be symptomatic
- May compress nerve roots or spinal cord
- May result in neurogenic claudification
Better w/ Flexion (opening IVF)
- Ie. Sitting, leaning forward, “shopping cart sign”, foot on stool (hip flexion = post. pelvic tilt = L/S flexion
Worse w/ Extension (closing IVF)
- Ie. standing, walking
Cook’s Rule
(5)
Spinal Stenosis
- > 48 years old
- Bilateral symptoms
- Leg pain worse than back pain
- Pain w/ walking or standing
- Sitting relieves pain
3 out of 5 positive
Spinal Stenosis: DDx - Intermittent Claudification
(4)
Page 142
- Pain or cramping that occurs in the buttock or legs (especially calves) as a result of poor circulation to the affected area
- INC pain with INC activity d/t increased energy demands on the mm which has poor circulation
Anaerobic > aerobic = INC lactic acid = INC uncomfortable = cramping - DEC pain at rest (even in standing positon) - catch up their metabolism
- Must differentiate between Intermittent Claudification & Neurogenic Claudification
SEE CHART ON 142
Spinal Stenosis: Intervention
(2)
PT Management:
- Flexion based exercises & positioning (knees towards chest)
- Avoidance of aggravating movements & positions
Prone: aggravating so maybe more supine/ crook-lying / z-lying (legs up on the chair)
Surgical Management
- Laminectomy (spinal decompression)
MAXIMUM protection - limit rotation - “log-rolling”
Disc Herniaton
Description & Types (4)
Migration of nucleus polposus away from its typical positon (central - slightly posterior
- Common age of onset is 30-50 years of age
>60 yo - less likely they have a disc bulge b/c as we age out discs dry out - dehydrates & annulus fibrosis becomes more fibrotic = less mvmt & less likely to herniate - ACUTE onset
- Disc herniations may or may not be symptomatic (PCE = symptomatic)
- 80-90% of disc bulges/herniations are postero-lateral
- May compress nerve root in the direction of herniation potentialy causing radicular signs & symptoms
Types:
1. Protusion (Pro-T)
2. Prolapse (Pro-L) - Little bit more migration BUT still contained
3. Extrusion - has gotten out of fibers - free nuclear materal
4. Sequestration (symptoms resolve faster)
Postero-Lateral Disc Herniation:
Symptoms
(6)
- Flexion mechanism of injury
- Worse w/ flexion
Ie: lifting from floor, sitting - Better w/ extension
Ie: standing, walking, lying prone < may still be a load toleramce - Worse in morning - sleeping = unloaded position - no gravity influencing HYDROSTATIC pressure > refills disc > “more bulgy = more pressure on nerve root
- Worse w/ coughing, sneezing, or Valsalva manuever
- May present with lateral shift (listing) AWAY from the side of buldge
- LABEL top segment - Bulge is LT but shifting to the RT
- More w/ LATERAL than posterior
Dynamic Disc Theory - High > Low
FLEXION = Anterior > posterior
Disc Bulge: Interventions
2 Types - 4 + 1
PT Management:
- Directional perference exercises & positioning (MDT - Mackenzie approach)
Postero-lateral bulge (posterior derangement)
- Typically perfer extension-based exercises & mvmt such as reapted extension in (prone) ling (REIL)
- May use lumbar roll to promote extension in sitting - cobra
Not causing extension BUT less flexion
- Typical progressions:
Prone lying > Prone w/ 1-2 fists under chin > prone on elbows > extensions in lying > extensions w/ OP > extensions in standing
Lateral bulge (lateral derangement)
- Typically perfer movements in lateral direction (side glides) TOWARDS the direction of the bulge
- Hips to wall w/ pt who have poor kinesio-awareness
Anterior bulge (anterior derangement)
- Typically prefer flexion-based exercises & movements such as repeated knee to chest in (supine) lying (RFIL)
- No nerves to impede BUT annulus fibrosis have nocicptors that can be damaged / refer pain (Never down the leg)
- Exercises may be painful initially but must complete entire set in order to evaluate its effect on the patient’s symptoms - looking for CENTRALIZATION - priority
- Green / yellow / red light systems
- Green: keep going w/ the exercises - got centralization
- Yellow: intensity is more BUT still achieved centralization
- Red: peripheralization - STOP May have showed preferential direction in clinic BUT may not be ready for the load, etc - Avoidance of aggravating mvmt & positions
Surgical Management:
- Surgery (laminectomy, discectomy) if necessary - avoid spinal mvmt early in post-op
- Anything surgeon recommends - log-rolling, etc
Posture Dysfunction: Pelvic (Lowered) Cross Syndrome
Imbalance pattern which promotes increased lumbar lordosis
- Overactivity of hip flexors compensate for weak abdominals leading to anterior pelvic tilt
- Overactivity of hamstring & erector spinae mm compensate for weak glutes to assis in hip extension\
- Hamstrings also become tight in an attempt to posteriorly rotate the anteriorly rotated pelvic
- Short spinal mm (ie. multifidus, rotators) show weakness < inner unit mm
Abominals (lengthened & weak)
ASIS low
Iliopsoas (tight)
Erector spinae (tight)
PSIS higher
Gluteals (lengthened & weak)
Hamstring tension (tight)
