Lumbar Spine Flashcards
(83 cards)
1
Q
What is the medial border of the nerve root canal?
A
Rural Sac
2
Q
What is the posterior border of the nerve root canal?
A
Ligamentum flavum, superior articular process, and lamina
3
Q
What is the anterior border of the nerve root canal?
A
Vertebral body and IVD
4
Q
What happens to the nucleus pulposus with aging?
A
Water amount decreases, increased type 1 collagen fibers, decrease of proteoglycans, decreased capacity for osmosis.
5
Q
What happens to the Anulus Fibrosis with aging?
A
Decrease in water, increase in type III collagen, decrease in proteoglycans.
6
Q
How are lamellae arranged?
A
Arranged in concentric rings that surround the NP. The Labelle are thicker towards the center of the disc, thick in the ant/late portions of the annuls, but posteriorly they are finer and more tightly packed.
7
Q
What happens with the lamellae with deterioration/dehydration?
A
The disc cannot maintain the 65 degree angle with respect to the vertical.
8
Q
What is the advantage of the arrangement of the fibers of the lamellae?
A
Each fiber can offer a component of resistance both vertically and horizontally which allows it to resist movements in all directions.
9
Q
What is the sensory innervation of the intervertebral disc?
A
The recurrent sinuvertebral nerve and it supplies the disc at its level and the level above.
10
Q
What is the function of the IVD?
A
It allows movement between the vertebral bodies by transmitting loads from one vertebral body to the next. Also could have a proprioception function.
11
Q
What part of the disc is most resistant to tension?
A
The ant/post portion
12
Q
When do tensile forces occur with the IVD?
A
Rotation and compression
13
Q
What resists the compressive forces in the IVD?
A
When the weight is applied to the nucleus, the nucleus may be deformed but the volume cannot be compressed. The NP reduces height and tries to expand radially towards the AF. The tensile properties of the AF resist the stretch.
14
Q
What happens with a “shear” force of IVD?
A
One vertebra “sliding forward” on another - only the angular fibers oriented in the direction of the line of force will resist the motion (1/2 are stretched and 1/2 are relaxed)
15
Q
How does the IVD receive nutrition?
A
Since there is no blood supply directly to the IVD, the disc relies on diffusion of water and nutrients from vessels surrounding the outer annuls and capillaries just beneath the vertebral endplates.
16
Q
What is the optimal stimulus for regeneration?
A
Annuls: rotation. Nucleus: intermittent compression/decompression. Facets: compression/decompression with glide
17
Q
What is the vertebral end plate?
A
The layer of cartilage that covers the area between the body and the disc. Covers the NP entirely, but peripherally does not cover the entire AF.
18
Q
What are Shaper’s fibers?
A
Where the end plate is deficient, the superficial collagen fibers of the AF insert directly into the bone of the vertebral body
19
Q
Where do L1 and L2 nerves exit?
A
Exit the intervertebral foremen above the disc
20
Q
Where does L3 nerve exit?
A
Travels behind the inferior aspect of the vertebral body and the L3 disc
21
Q
Where does L4 nerve exit?
A
Crosses the whole vertebral body to leave the spinal canal at the upper aspect of the L4 disc
22
Q
Where does the L5 nerve exit?
A
Emerges at the inferior aspect of the fourth lumbar disc and crosses the fifth vertebral body to exit at the upper aspect of the L5 disc
23
Q
Where does the S1 nerve exit?
A
Crosses the L5 disc
24
Q
What is the never supply to the zygophyseal joints?
A
Medial branch of the dorsal primary ramus
25
What are the biomechanics of flexion?
A combination of anterior sagittal rotation and small anterior translation (minimal reversal of lordosis)
26
What are the biomechanics of extension?
A combination of posterior sagittal rotation and small posterior translation
27
What limits anterior rotation?
PLL (Posterior longitudinal ligament), LF (ligamentum flavum), ISL (interspinous ligament), SSL (supraspinous ligament), facet joint
28
What limits extension?
spinous process, Anterior longitudinal ligament, capsule
29
How are the facets of L1-L4 oriented and how does it effect the biomechanics
Vertically oriented to the sagittal plane facilitating flexion/extension and limiting rotation and lateral flexion
30
How are the facets of L5-S1 oriented and how does it effect the biomechanics
Oriented obliquely in frontal plane this resists flexion/extension
31
Describe coupled movements of the neutral spine
SB and rotation occur to the opposite side
32
Describe coupled movements of the extended spine
SB and rotation occur to the opposite side
33
Describe coupled movements of the flexed spine
SB and rotation occur to the same side
34
How do we test combined movements
Quadrant test
35
What is Stage I of Intervention
Relieve primary impairment
36
What is Stage II of intervention
Relieve movement issues at adjacent body segments
37
What is Stage III of intervention
Address global issues - activity limitations/participation
38
What is centralization?
Pain and symptoms move proximal - good thing
39
What is peripheralization?
Pain and symptoms move distal - bad thing
40
How do you perform a central PA
Use the ulnar border of the hand and press down on the spinout process
41
How do you perform a unilateral PA
Ask Marcie
42
How do you perform transverse pressures
Haven't gone over yet
43
How do you perform rotations grades 1 and 2
In a position of comfort (or in axial separation Ext position) lightly push on the greater trochanter
44
How do you perform rotation grades 3 and 4
Align the pt for SI Regional manip and push on the greater trochanter with some force
45
How do you perform a local V lumbar rotation in neutral?
Haven't done yet
46
How do you perform a SI regional manipulation?
Haven't done yet
47
How do you perform manual traction in neutral?
Pt laying on good side facing PT. Use middle fingers, pull slightly with cranial hand, then shift weight causally to get the actually traction.
48
How do you perform axial separation in extension? What is the difference between the dehydration and the dehydration?
Rehydration - Patient on side with top leg is bent, PT behind pt. Have one hand on shoulder to create a counter pressure, other hand on greater troch (on skin if possible) and pushing caudally to create a side bending motion.
Add info for dehydration
49
How do you perform axial separation in flexion? What is the difference between the dehydration and the dehydration?
Rehydration - Patient 3/4 prone (one arm behind if possible) and lower leg is bent. Top hand at mid back providing tension, and bottom hand on the greater troch (on skin if possible) pushing caudally to create a side bending motion
Add info for dehydration
50
What is the difference in profile for vascular claudication vs. spinal stenosis/neurogenic claudication?
VC - ages 40-60+
| SS/NC - A disorder of the elderly (65% of pets with spinal stenosis also present with NC)
51
What is the difference in location of symptoms for vascular claudication vs. spinal stenosis/neurogenic claudication?
VC - Pain is usually bilateral, occurs in calf (foot, thigh, hip, or buttocks), no burning or dysethesia
SS/NC - Pain is usually bilateral and occurs in back, buttocks, thighs, calves, and feet. Burning and numbness present in LE
52
What is the difference in behavior of symptoms for vascular claudication vs. spinal stenosis/neurogenic claudication?
VC - Pain insistent in all spinal positions. Pain is brought on by physical exertion, relieved promptly by rest (1-5 min), and increased by walking uphill.
SS/NC - Pain is decreased in spinal flexion and increased in spinal extension and with walking. Pain is decreased by walking uphill. Pain is relieved with prolonged rest (may persist hours after resting in SS)
53
What is the difference in OE findings for vascular claudication vs. spinal stenosis/neurogenic claudication?
VC - Decreased or absent pulses in LE. Color and kin changes in feet; cold, numb, dry, r scaly skin; and poor nail and hair growth.
SS/NC - Normal pulses, good skin nutrition.
54
Describe DDD/DJD
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
Profile - 55-60
Body Chart/Location - DDD>DJD: Disc can present with bilateral low back symptoms (one side can be greater); can refer to buttock
DJD>DDD: facet can be local pain and refer to buttock, posterior thigh, groin
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Activity Limitations (Agg Factors) - Acute disc: Cough/ sneeze, repeated bending, sitting, lifting, stooping
Chronic Disc: sitting in lordosis, carrying in extension, pain with stooping
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Ease Factors - Lying down, unloading
History - episodic, repeated angular tearing
Neurodynamic Testing - No
Neurological Examination - negative
ROM - Flexion, SB
Special Tests - None
Palpation - Central PA > unilateral PA stiff/ pain if in acute episode
Muscle Length/Muscle Strength - Check hip flexors, rectus, hamstring, glut med, max, abdominals
55
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Describe Disc (IDD, EDD)
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
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Profile - young (20-40)
Body Chart/Location - IDD: Local unilateral pain, spreads with progression; referral to buttock
EDD: bilateral Paravertebral
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Activity Limitations (Agg Factors) - Acute disc: Cough/ sneeze, repeated bending, sitting, lifting, stooping
Chronic Disc: sitting in lordosis, carrying in extension, pain with stooping
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Ease Factors - Lying down, unloading
History - None
Neurodynamic Testing - IDD: negative
EDD: positive
Neurological Examination - negative
ROM - IDD and EDD: pain worse with sagittal movements (Flexion)
Special Tests - none
Palpation - Central PA > unilateral PA stiff and pain
Muscle Length/Muscle Strength - Check hip flexors, rectus, hamstring, glut med, max, abdominals
56
Describe Disc with nerve root involvement
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
Profile - 40-45 (central proL/ proT); 30-45 (exT); (18-35) PPL proT/ proL
Body Chart/Location - ProT: bilateral paravertebral with buttock/ leg pain in partial or complete dermatomal line
PPL: little to no lumbar pain, posterior leg pain
ProL: leg pain> back pain; dermatomal pattern
ExT: leg pain>back pain; poly-segmental (radicular and non-radicular pain)
Activity Limitations (Agg Factors) - Flexion, sitting (disc)
Standing, walking (nerve root involvement)
Sneezing
Ease Factors - Lying down, unloading
History - ProT: recurrent history
ProL: typical fast onset
Bending, lifting
Episodic
Neurodynamic Testing - Positive: SLR/ Slump, PKB
Neurological Examination - ProT: negative or mild neurological signs
Central ProL: negative segmental; possible reduced DTRs
PLL ProL: positive
ExT: positive
ROM - ProT: variable non-capsular limits; possible painful arc
ProL and ExT: Large limits of sagittal plane movements (Flexion, Extension, SB)
Shoulder Lesion: lateral shift to opposite side of symptoms and increased pain with ipsilateral sidebending.
Axillary Lesion: lateral shift to same side same side of symptoms and increased pain with contralateral sidebending.
Special Tests - None
Palpation - Central PA and unilateral PA stiff and painful
Muscle Length/Muscle Strength - Check hip flexors, rectus, hamstrings, glut med, max, abdominals
57
Describe Lateral Stenosis
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
Profile - 40 - 60
Body Chart/Location - Leg pain (with patchy, dermatomal, multi-segmental)
Acute: distal worse than proximal
Chronic: proximal worse than distal
DRG: paraesthesia and radicular lancinatng pain
Activity Limitations (Agg Factors) - Extension postures, prolonged standing and walking, lying flat, walking downhill.
Ease Factors - Flexing spine (sitting or squatting, walking uphill)
History - none
Neurodynamic Testing - Positive: SLR/Slump, PKB
Neurological Examination - Dorsal and Ventral: Hypo or a-reflexia
Dorsal: sensation
Ventral: Motor loss (segmental pareisis
ROM - Extension limited and painful/ SB/ Quadrant
Special Tests - None
Palpation - Unilateral PA may be stiff/ painful
Muscle Length/Muscle Strength - Short hip flexors (iliopsoas/ rectus femoris; Lengthened hip extensor muscles (glut max, hamstrings)
58
Describe Central Stenosis
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
Profile - 60-70
Body Chart/Location - Back and leg pain, bilateral, extrasegmental
Activity Limitations (Agg Factors) - Extension postures, prolonged standing and walking, lying flat, walking downhill.
Ease Factors - Flexing spine (sitting or squatting, walking uphill)
History - gradual
Neurodynamic Testing - positive
Neurological Examination - Dorsal and Ventral: diminished reflexes
Dorsal: sensation
Ventral: Motor loss
ROM - Extension limited and painful/ SB
Special Tests - None
Palpation - Central PA, unilateral PA stiff/ painful
Muscle Length/Muscle Strength - None
59
Describe Facet
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
Profile - Chronic > 55-60
Body Chart/Location - Local unilateral pain
Facet: can refer to buttock, posterior thigh, groin
Activity Limitations (Agg Factors) - More pain with standing vs. sitting; 3-D motion extension (cartilage) vs. flexion (capsule)
Ease Factors - Variable
History - Gradual or sudden unguarded movement
Neurodynamic Testing - negative
Neurological Examination - Negative
ROM - Quadrant, Flexion
Special Tests - None
Palpation - Unilateral PA stiff/ painful
Muscle Length/Muscle Strength - None
60
Describe Instability
Profile, Body Chart/Location, Activity Limitations (Agg Factors), Ease Factors, History, Neurodynamic Testing, Neurological Examination, ROM, Special Tests, Palpation, Muscle Length/Muscle Strength.
Profile - Young: older if degenerative
Body Chart/Location - Highly variable
Catching, unilateral pain, deep dull ache
Back feels weak or feels as if it will “give way” with certain movements
Sharp pain with sudden or unexpected movement of the trunk
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Activity Limitations (Agg Factors) - Prolonged postures (sitting, standing, bending, semi-flexed postures).
Forward bending, sudden unexpected movements, return to erect posture after FB, lifting, loading in extension
Night: possible clunking with position change
AM: ache usually worsens as the day progresses
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Ease Factors - NA
History - Gradual or episodic. History of recurrent dysfunction that becomes more pronounced with each successive episode.
Minor provocations produce disabling pain.
Neurodynamic Testing - Variable adverse mechanical tension findings
SLR>91 degrees
Neurological Examination - Negative
ROM - LS F: Good ROM with painful arc vs. through range pain, walk hands up knees;
LS E: segmental shifts or hinge at one segment
Minor perturb-ations provoke major pain
Special Tests - Positive stability test
Palpation - Pain/ spasm with central PA pressure
Excessive PPIVM and PAIVM findings
Muscle Length Muscle Strength - Significant reduction in symptoms with activation of deep abdominal muscles during provocational movements
61
What is the weakest area of the disc?
Postero-lateral portion
62
What Is the primary mechanism of injury to a lumbar disc?
Sustained or repetitive lifting
63
Transverse radial fissures
Annuls splits from inside to out; seen in acute disc related disorders.
64
Rim Lesion
Transverse angular tear; partial detachment of annulus to the rim of vertebral body starts mid and goes to post/sup portion of disc.
65
Concentric delamination
circumferential tear; nucleus loses water, annulus buckles and layers separate all around.
66
IDD
Young, variable non-capsular pattern, negative tension signs
67
EDD
Young, variable non-capsular pattern, positive tension signs
68
ProT
Displacement of nuclear material beyond inner annulus causing bulge in outer annulus without escape of nuclear material (outer annulus is intake)
69
ProL
Displacement of nuclear material beyond inner annulus with escape of nuclear material
70
ExT
Annular fibers disrupted such that nuclear material extruders into spinal canal. PLL ruptured, considered to be a sick disc and unstable
71
Shoulder lesion
If the bulge is lateral to the nerve root, the pt shifts to the opposite side (most common). Increased pain with ipsilateral side bending; slump pain > SLR pain
72
Axillary Lesion
If the bulge is medial to the nerve root, the pt shifts to the same side (least common). Increased pain with contralateral side bending; slump pain > SLR pain
73
What can progress to Cauda Equina Disorder? What are some symptoms of CED?
Central Stenosis. Bowel and bladder dysfunction, saddle anesthesia, sexual dysfunction, neurological signs like positive Babinski, increased DTRs
74
Describe Active Anterior Stability Test
Use PIVMS to find neutral. Have pt pull legs into PTs legs. Feel if there is extensive movement in the segment.
75
Describe Prone Stability Test
Have pt stand at end of table and lay over the table (feet still on ground). Do PAs and see I there is any pain. Have pt pull legs up and repeat PAs. Less pain = positive test.
76
Describe Level 1 of Lower Abdominal Assessment
Level 1: the patient’s starting position is supine with both hips and knees flexed with feet on the treatment surface, abdominal muscles contracted. The patient should flex one hip toward chest to at least 90°. The patient lifts the other extremity from the supporting surface and then lowers it, keeping the lumbar spine flat.
Positive Finding: If the pelvis tilts anteriorly, abdominal control is deficient.
77
Describe Level 2 of Lower Abdominal Assessment
Level 2: the patient assumes the same starting position. Again, one hip flexes to 90º while the other leg is completely extended by sliding the heel lightly on the table, keeping the lumbar spine flat.
Positive Finding: If the pelvis tilts anteriorly, abdominal control is deficient.
78
Describe Level 3 of Lower Abdominal Assessment
Level 3: starting position is assumed. The patient performs level 2, but this time extends the leg with the heel off the table (unsupported) and then lowers it to the supporting surface once the leg is fully extended. After relaxing, the foot slides back to the starting position.
Positive Finding: If the pelvis tilts anteriorly, abdominal control is deficient.
79
Describe Level 4 of Lower Abdominal Assessment
Level 4: starting position is assumed. After contracting the abdominals with hips and knees flexed, the patient slides both legs along the table into full extension then returns to the starting position.
Positive Finding: If the pelvis tilts anteriorly, abdominal control is deficient.
80
Describe Level 5 of Lower Abdominal Assessment
Level 5: starting position is assumed. After contracting the abdominals with hips and knees flexed, the patient slides both legs into extension with heels off the table while keeping back flat. The patient can then lower the feet onto the supporting surface
Positive Finding: If the pelvis tilts anteriorly, abdominal control is deficient.
81
Describe spondylolysis
A defect of the pars interarticularis
Unilateral or bilateral
Acquired or developmental
The fracture, by definition is usually non-displaced
82
Describe Spondylolisthesis
Anterior slippage and instability to resist shear forces relative to the vertebra below.
Most common site is L5-S1
Can lead to instability
Congenital, isthmic, degenerative, traumatic, or pathologic
83
Describe the grades of spondylolisthesis
Grade 1 - 25% slippage
Grade 2 - 50% slippage
Grade 3 - 75% slippage
Grade 4 - >75% slippage
