Lumbar Spine (Class 1) Flashcards
1
Q
What is a very common complaint from patients regarding the lumbar spine?
A
Low back pain.
2
Q
What is the primary function of the lumbar spine?
A
It helps to transmit the weight of the upper body to the pelvis and lower body.
3
Q
When conducting assessments, what areas should include an evaluation of the lumbar spine?
A
Any spine, hip, or SI joint assessments.
4
Q
Where does the lumbar spine begin in relation to the scapula?
A
It begins about 6 inches from the inferior angle of the scapula.
5
Q
Describe the curvature of the lumbar spine.
A
The lumbar spine creates a lordotic curve before attaching to the sacral spine.
6
Q
How many vertebrae make up the lumbar spine?
A
The lumbar spine is made up of 5 vertebrae.
7
Q
What is located between the vertebrae of the lumbar spine?
A
Intervertebral discs (IVD).
8
Q
How can the vertebrae and intervertebral discs (IVDs) be commonly described in a simplified analogy?
A
The vertebrae are commonly compared to hockey pucks, and the IVDs are compared to jelly donuts.
9
Q
What is the role of the vertebrae in the lumbar spine?
A
The vertebrae allow for the attachment of muscles and ligaments that provide stability and mobility.
10
Q
What is the function of the intervertebral discs (IVDs) in the lumbar spine?
A
The IVDs absorb and transmit axial loads and tensile stresses from one vertebra to another.
11
Q
Which lumbar vertebra is the largest, and what is its significance?
A
The 5th lumbar vertebra is the largest and transmits forces from the upper extremities to the sacrum and pelvis.
12
Q
Describe the shape and orientation of the 5th lumbar vertebra.
A
It has a wedge shape and forward orientation, allowing it to sit slightly backward/posteriorly and facilitate the normal lordotic curve.
13
Q
At which lumbar levels does most movement occur?
A
Most movement occurs at the L4/5 and L5/S1 levels.
14
Q
Why is the L4/5 and L5/S1 region a common area for problems in the lumbar spine?
A
Little obvious movement occurs due to the shape of the facet joints, tightness of the ligaments, pressure of the intervertebral discs, and size of the vertebral bodies.
15
Q
Which segment of the vertebral column is the most common site for problems?
A
The L5-S1 segment is the most common segment for problems.
16
Q
In which plane do the lumbar facet joints (apophyseal or zygapophyseal joints) sit?
A
The lumbar facet joints sit in the sagittal plane.
17
Q
What movements are primarily allowed by the lumbar facet joints?
A
The available movements are flexion and extension, while rotation and side bending are very limited.
18
Q
What are the roles of the lumbar facet joints?
A
They stabilize the spine, allow limited movement, and protect the intervertebral discs (IVDs) from shear forces.
19
Q
How many pairs of lumbar facet joints are there, and what are their orientations?
A
There are 5 pairs (10 total) of lumbar facet joints, consisting of superior facets (facing medial and backward) and inferior facets (facing lateral and forward).
20
Q
What is spondylosis?
A
Spondylosis is the degeneration of the intervertebral disc (IVD).
21
Q
Define spondylolysis.
A
Spondylolysis is a defect in the pars interarticularis, characterized by a fracture between the lamina and pedicle, often visualized with the “Scottie dog” X-ray, typically resulting from overextension that presses the spinous processes together.
22
Q
What is spondylolisthesis?
A
Spondylolisthesis is the forward displacement of one vertebra over another.
23
Q
What is retrolisthesis?
A
Retrolisthesis is the backward displacement of one vertebra over another.
24
Q
What percentage of the total length of the vertebral column is made up by the intervertebral discs?
A
Intervertebral discs make up approximately 25% of the total length of the vertebral column.
25
How do intervertebral discs change with age?
The total length of intervertebral discs decreases with age due to overall degeneration.
26
What are the two main parts of an intervertebral disc?
The annulus fibrosus (approximately 20 rings of crisscross collagenous fibers) surrounds the nucleus pulposus (an incompressible fluid).
27
What is herniation in relation to intervertebral discs?
Herniation is a general term used to describe any change in the annulus shape that causes it to protrude beyond its normal perimeter.
28
Define protrusion as it relates to intervertebral discs.
Protrusion occurs when the nucleus pulposus is only contained by the outer fibers of the annulus and supporting ligamentous structures.
29
What is prolapse in the context of disc injuries?
Prolapse refers to the rupture of nuclear material into the vertebral canal.
30
Describe extrusion concerning disc injuries.
Extrusion is the extension of nuclear material beyond the confines of the posterior longitudinal ligament or above and below the disc space, but still in contact with the disc.
31
What does sequestration mean regarding intervertebral discs?
Sequestration occurs when the extruded nucleus has separated from the disk and moved away from the prolapsed area.
32
What actions increase pressure in the L3 intervertebral disc?
- Walking: 15%
- Small jumps: 40%
- Laughing: 40-50%
- Bending forward: 150%
- Lifting 2kg with back straight: 73%
- Lifting 2kg with back bent: 169%
(Note: It is highly recommended to avoid laughing while taking a small jump with your back bent.)
33
What are some common lumbar injuries?
- Myelopathy (pressure on the spinal cord)
- Cauda equina syndrome
- Disc injury (most common between ages 15-40; only 5% of patients with low back pain have a disc problem; leg pain is more dominant if the disc is affected)
- Ankylosing spondylitis (more common between ages 18-45 and in men)
- Osteoarthritis and spondylopathies (more common in individuals 45+ years old)
- Malignancy (more common in individuals 50+ years old)
34
What is the resting position of the lumbar spine?
The resting position is midway between flexion and extension.
35
What is the close-packed position of the lumbar spine?
The close-packed position is full extension.
36
What is the capsular pattern of the lumbar spine?
The capsular pattern is characterized by side flexion and rotation being equally limited, with extension also limited.
37
What are the key components to include in a case history?
Primary complaint, general health, mechanism of injury (MOI), site or spread of pain, behavior of symptoms, duration, persistent pain indicators, and positions during activities.
38
What are the two types of mechanisms of injury (MOI)?
Traumatic and non-traumatic. Non-traumatic can include simple actions like putting on a sock.
39
What should be assessed regarding prior occurrences of pain?
Prior occurrences should include how they were treated and whether they resulted from mechanisms such as motor vehicle accidents (MVA), direct trauma, twisting, or lifting, and if there is pain with coughing.
40
What is local pain and what does it indicate?
Local pain tends to indicate a mechanical injury with unilateral pain and no referral below the knee, often involving muscles, ligaments, facet joints, or SI joints.
41
Describe radiating pain.
Radiating pain travels down the involved limb due to spinal nerve and/or root irritation, with specific areas affected by different lumbar levels: L4 affects the anterolateral aspect of the leg, L5 affects the posterior aspect of the foot, and disc lesions can cause pain into the leg below the knee.
42
What is referred pain and what are some examples?
Referred pain can arise from trigger points, visceral organs (e.g., prostate cancer), or systemic conditions (e.g., ankylosing spondylitis).
43
What symptoms might be associated with specific injuries?
- Pop or tearing: muscle injury
- Numbness: peripheral nerve or nerve root irritation
- Catching: muscle spasm or facet joint injury
- Tingling/warmth/coldness: nerve root or circulation issues
44
How is pain duration classified?
Acute: 3-4 weeks
Subacute: up to 12 weeks
Chronic: more than 3 months
45
What does persistent pain or progressive increases while supine indicate?
It may indicate a neurogenic issue or a space-occupying lesion (e.g., infection, swelling, or tumor).
46
What position increases pressure on the disc?
Sitting, due to sustained flexion.
47
What does standing represent in terms of spinal position?
Standing represents extension, especially when relaxed.
48
What is the spinal position when walking?
Walking also represents extension.
49
What spinal position is assumed when lying, especially in a prone position?
Lying, especially prone, represents extension, which creates posterior vertebral pressure.
50
What is the best sleep position for spinal health?
Side lying with legs bent in a semi-fetal position is the best for spinal health.
51
How does the supine position affect posterior vertebral pressure?
In the supine position, posterior vertebral pressure is released as the back flattens.
52
What are the key components to observe in a clinical assessment?
Regular landmarks, spinal posture, and upper and lower extremities landmarks.
53
What is the normal spinal posture in the lumbar spine?
The normal spinal posture in the lumbar spine features a lordotic curve.
54
What is meant by "neutral pelvis"?
Neutral pelvis refers to a position where the normal lordotic curve is maintained, with the anterior superior iliac spines (ASISs) being slightly lower than the posterior superior iliac spines (PSISs).
55
Why is it important to assess upper and lower extremities landmarks?
Assessing upper and lower extremities landmarks helps to ensure proper alignment and identify any potential imbalances or abnormalities.
56
What are the key components to assess during palpation?
Inflammation, heat, and deformities.
57
What does palpation help identify regarding inflammation?
Palpation can help detect areas of inflammation by assessing tenderness and swelling.
58
How can heat be evaluated during palpation?
Heat can be evaluated by comparing the temperature of the affected area to adjacent tissues, indicating potential inflammation or infection.
59
What should be observed regarding deformities during palpation?
Deformities should be noted for any irregularities in shape, alignment, or contour of bones and soft tissues.
60
What is the active range of motion test for the hip during rule outs?
Active free flexion and internal rotation.
61
Describe the Gillet’s test for the sacroiliac joints.
In the Gillet’s test, the patient stands while the examiner palpates the posterior superior iliac spine (PSIS) and the sacral spine. The patient then fully flexes the same side. The PSIS should drop; if it elevates, this indicates fixation of the SI joint on that side.
62
What movements are assessed for the cervical spine during rule outs?
Flexion, extension, side bending, and rotation with overpressure (except for extension).
63
What is the purpose of Active Free (AF) functional tests?
To assess willingness to move and differences in range of motion with all movements performed in standing.
64
What is the normal range of motion for lumbar spine flexion?
40 to 60°.
65
How is lumbar flexion initiated and controlled during the Active Free test?
Initiated by a concentric contraction of the psoas muscle and abdominal group; controlled eccentrically by the sacrospinal muscles (lumbar erectors) and multifidi muscles.
66
What should be noted during the lumbar flexion test regarding qualitative observation?
The lumbar lordosis should flatten but not produce kyphosis. If it does not fully flatten, assess for hyperlordosis in postural assessment.
67
What is the expected increase in length measured from T12 to S1 during lumbar flexion?
The tape should increase in length by about 7-8 cm.
68
What conditions may cause pain with movement during lumbar flexion?
Spasm or tightness of back muscles, local facet capsular restriction, advanced ankylosing spondylitis, sacrospinalis muscle spasm.
69
What does pain at the end range of lumbar flexion indicate?
Potential issues such as dura mater stretch, lumbar nerve root irritation, thoracolumbar fascial injury, or sprains of the posterior capsular ligament.
70
What could radiating pain in the lower limb during lumbar flexion indicate?
Disc herniation with nerve root irritation.
71
What is the normal range of motion for lumbar spine extension?
20 to 35°.
72
What is the safest position for lumbar extension testing?
The sphinx position: prone, with the patient lifting the head, neck, and shoulders off the table, propped on elbows.
73
What conditions may cause pain during lumbar extension?
SI dysfunction, gluteal or hamstring strain, ankylosing spondylitis, articular derangement in a joint, abdominal muscle spasm.
74
What is the normal range of motion for lumbar side (lateral) flexion?
15 to 20°.
75
How should side bending be performed during functional tests?
Ideally in a high seated position or standing, without flexion or extension of the spine.
76
What does pain on the side being bent during lateral flexion indicate?
Potential issues with ipsilateral muscles initiating the movement, such as external/internal obliques or quadratus lumborum.
77
What is the normal range of motion for lumbar rotation?
3 to 18°.
78
How is lumbar rotation best tested?
With the patient seated to reduce movement of the pelvis and lower limbs, focusing on the spine.
79
What may ipsilateral pain during rotation indicate?
Injured or inflamed facet joint surfaces, iliolumbar/sacral ligament compression, or shortened musculature that is irritated.
80
What may contralateral pain during rotation indicate?
Stretching of injured tissues, irritated facet joint capsules, or eccentric contraction of guarding muscles.
81
What is the challenge of performing Passive Relaxed (PR) assessments?
It is difficult due to the weight of the body.
82
When can overpressure be applied during Passive Relaxed assessments?
Overpressure can be applied to Active Free (AF) movements if they are full and pain-free.
83
How can passive movements of the lumbar spine be safely assessed?
Passive movements can be assessed more specifically with motion palpation during joint play assessment.
84
What should all end feels be during Passive Relaxed assessments?
All end feels should be tissue stretch.
85
What is the purpose of resisted testing in Active Resisted (AR) assessments?
To differentiate pain generated by muscle contraction from pain generated by inert tissue.
86
What position should the patient be in for resisted testing?
A high seated position, ensuring they can hold a neutral pelvis.
87
How many contractions are needed to differentiate muscle pain from inert tissue pain?
Only one contraction is needed to differentiate pain, but repeated contractions are necessary to establish strength grading or observe a positive myotome test.
88
What occurs when pain is present during a resisted contraction?
Pain reflexively inhibits muscle contraction, revealing the muscle as weaker.
89
Describe the process for testing lumbar flexion in AR assessments.
Instruct the patient in a neutral high seated position, saying “don’t let me move you,” while the therapist attempts to push the shoulders backward to engage the lumbar flexors.
90
Describe the process for testing lumbar extension in AR assessments.
Instruct the patient in a neutral high seated position, saying “don’t let me move you,” while the therapist attempts to push the shoulders forward to engage the lumbar extensors.
91
Describe the process for testing side flexion in AR assessments.
Instruct the patient in a neutral high seated position, saying “don’t let me move you,” while the therapist attempts to push the shoulders sideways to engage the opposite side bending muscles, done in both directions.
92
Describe the process for testing rotation in AR assessments.
The patient is high seated. The therapist stabilizes the knee with their thigh on the side the patient will be rotating toward, manually resisting both shoulders as the patient rotates, testing ipsilateral deep rotators, internal oblique, and contralateral external oblique.
93
Which additional muscles should be tested in relation to lumbar orientation during AR assessments?
The length and strength of the rectus femoris and iliopsoas (which increase anterior pelvic tilt and lumbar lordosis) as well as the hamstrings and gluteals.
94
What is crucial to remember about special tests in clinical assessment?
It is important to note the difference between what a positive test is and what a test is positive for.
95
When should the Straight Leg Raising test (SLR) and Slump test be performed?
They should always be done if there are neurological signs and symptoms as a subjective finding.
96
Describe Stage One of the Straight Leg Raising test (SLR).
The patient is supine with hip internal rotation (into neutral position) and adduction, with the knee extended. The therapist passively flexes the hip until pain or tightness is felt in the back or back of the leg.
97
What indicates a positive result in Stage One of the SLR?
Positive: pain and/or neurological symptoms.
98
Describe Stage Two of the SLR (Bragard’s Test).
The patient’s foot is passively dorsiflexed (stretching the tibial nerve) while maintaining the position from Stage One, or the patient can actively flex the neck or do both simultaneously.
99
What indicates a positive result in Stage Two of the SLR (Bragard’s Test)?
Positive: pain and/or neurological symptoms, as dorsiflexion increases tension through the nerve.
100
Describe Stage Three of the SLR (Hyndman’s sign/Brudzinski’s sign/Lindner’s sign/Soto-Hall Test).
The patient actively flexes the neck while the therapist maintains passive dorsiflexion from Stage Two.
101
What indicates a positive result in Stage Three of the SLR?
Positive: pain and/or neurological symptoms, as forward flexion increases tension through the meninges, especially the dura mater, down through the sciatic nerve.
102
What is the range of hip flexion at which signs can arise during the Straight Leg Raising (SLR) test?
Signs can arise from as little as 15° to up to 70° of hip flexion.
103
What happens after 70° of hip flexion during the SLR test?
After 70° of flexion, the sciatic nerve is no longer placed on any more stretch, and most pain felt will be due to sacroiliac (SI) or hip joint dysfunction.
104
What is essential to avoid confusing during assessment of the SLR test?
Do not confuse your findings with hamstring tightness.
105
What is the nerve supply of the sciatic nerve?
The sciatic nerve (L4-S3) supplies nearly all the skin of the leg, the muscles of the back of the thigh, and those of the leg and foot.
106
What does the posterior femoral cutaneous nerve of the thigh (S1-S3) innervate?
It provides innervation to the skin of the posterior surface of the thigh and leg, as well as the perineum.
107
What does a positive result for the SLR usually indicate?
A positive result usually points to a posterolateral disc herniation due to dural tension pulling the nerve towards a space-occupying lesion.
108
What can the later stages of the SLR test (dorsiflexion and forward flexion) indicate?
They may be positive for meningeal irritation if the patient reports pain or restrictions in the neck or back.
109
Why is it important to always ask the patient where they are feeling pain during the SLR test?
To better assess the source of pain and its relevance to potential conditions.
110
What could it indicate if a patient cannot flex their neck at all?
They may be suffering from meningitis.
111
What is the difference between Kernig’s sign and the SLR test?
Kernig’s sign tests for meningitis by attempting to extend a partially flexed knee, while the SLR test is used to assess for disc herniation.
112
What is a potential issue with Kernig’s sign in cases of viral meningitis?
Kernig’s may incorrectly give a negative result in the case of viral meningitis.
113
How can the SLR test be modified for patients who cannot lie supine?
The SLR can also be performed in side-lying or seated positions (as in the Slump Test).
114
What is a long sitting position considered in relation to the SLR test?
A long sitting position is also a form of a straight leg raise.
115
What is the purpose of the Well Leg Raise test?
The test is performed on the leg that does not have any symptoms traveling down the back of the leg (the unaffected or “well” leg) to assess for issues in the affected leg.
116
When is a positive sign observed during the Well Leg Raise test?
A positive sign is observed when there is reproduction of signs and symptoms in the patient’s affected leg.
117
What does a positive Well Leg Raise indicate?
It indicates a space-occupying lesion (such as a herniated disc or inflammatory swelling) pressing on the nerve root(s) that supply the affected limb.
118
What is the procedure for performing the Well Leg Raise test?
1. The client is positioned supine.
2. The therapist slowly raises the well/unaffected leg until it reaches the end range or reproduces the chief complaint of neurological symptoms down the leg.
119
What does a positive result for the Well Leg Raise usually point to?
A positive result usually points to a rather large intervertebral disc protrusion, commonly a posteromedial disc herniation, due to dural tension pulling the nerve towards the space-occupying lesion medial to the nerve(s).
120
What is the purpose of the Bowstring test?
The Bowstring test is used to directly palpate the sciatic nerve in the popliteal fossa if the Straight Leg Raise (SLR) is positive or if irritation and inflammation of the sciatic nerve is suspected.
121
What symptoms may occur during the Bowstring test?
Pressure or a strumming motion on the sciatic nerve will cause symptoms to be felt locally and down the leg from the part of the nerve being palpated.
122
What is the procedure for performing the Bowstring test?
1. The client is positioned supine.
2. The therapist performs a Straight Leg Raise (SLR) by passively lifting the leg into flexion.
3. If a positive test occurs (recreation of symptoms), the therapist will slightly lower the leg, flex the knee, and place it on their shoulder for support.
4. The therapist then pushes with their thumb just medial to the biceps femoris tendon in the popliteal fossa on the sciatic nerve, creating pressure on the nerve.
123
What indicates a positive Bowstring test?
A positive test is indicated by pain and recurrence of the symptoms the client originally presented with, suggesting pressure or tension on the sciatic nerve (L4-S3).
124
What might be felt if the inflammation of the sciatic nerve is severe and chronic?
If the inflammation is severe and chronic, the therapist may be able to feel the nerve, which will feel like a braided cord.
125
What is the purpose of the Slump Test?
The Slump Test is designed to assess the dural sheath of the spine and identify conditions such as disc herniation, dural tightness, meningitis, and space-occupying lesions by reproducing signs and symptoms originally presented by the patient.
126
Describe the initial position of the patient during the Slump Test.
The patient is high seated with their upper limbs clasped behind their back.
127
What is the first movement the patient performs in the Slump Test?
The patient is instructed to actively move into a "slump" position, achieving thoracic and lumbar flexion.
128
What should the therapist do if there is no pain after the initial slump position?
If there is no pain, the therapist applies overpressure on the upper back to increase the slump position.
129
After achieving lumbar and thoracic flexion, what is the next step if there is no pain?
The patient actively moves into cervical flexion.
130
What should the therapist do if there is no pain during cervical flexion?
If there is no pain, the therapist applies overpressure on cervical flexion.
131
What are the next steps if there is still no pain after cervical flexion?
The patient can actively move into ankle dorsiflexion, or the therapist can passively move the ankle into dorsiflexion.
132
If there is no pain during the previous movements, what can the patient do next?
The patient can slowly extend the knee as much as possible.
133
What should the therapist do if the patient experiences pain during the test?
The therapist should release the overpressure to the spine and have the patient actively extend the neck to confirm if the pain is caused by increasing the neuromeningeal tract.
134
How is a positive Slump Test determined?
A positive test is indicated by the reproduction of the patient's pathological symptoms, not just any symptoms, which are then relieved when the head is returned to (at least) a neutral posture.
135
What is the purpose of the Prone Knee Bending Test (Nachlas Test)?
This test puts the femoral nerve on stretch and may indicate unilateral pain related to L2, L3, or L4 dermatomes (mostly L2 and L3) if there is no lesion or contracture in the quadriceps muscle.
136
Describe the initial position of the patient during the Prone Knee Bending Test.
The patient lies prone (face down) on the examination table.
137
What is the first action taken by the therapist in the Prone Knee Bending Test?
The therapist passively extends the hip of the patient by approximately 15 degrees with the knee kept extended.
138
What should the therapist do if no signs or symptoms are reproduced after the initial hip extension?
The therapist should slowly passively flex the patient’s heel toward their buttocks.
139
Can the Prone Knee Bending Test be performed in a different position? If so, what is it called?
Yes, the test can also be performed in a sidelying position, similar to Ober's position, and is referred to as the Femoral Nerve Stretch/Femoral Nerve Traction Test.
140
What indicates a positive result in the Prone Knee Bending Test?
A positive test is indicated by the reproduction of pain or paresthesia over the L2, L3, or L4 dermatome areas (anterior thigh), suggesting a lesion or irritation of the femoral nerve.
141
What is the sensation of paresthesia felt during the test known as?
This feeling of paresthesia is known as formication.
