Lumbar Spine: Orthopedic Physical Assessment; Magee Ch. 9

Question 1

Name the (5) pain-sensitive structures around the intervertebral disc:

Answer 1

(1) the anterior longitudinal ligament
(2) posterior longitudinal ligament
(3) vertebral body
(4) nerve root
(5) cartilage of the facet joint.

Question 2

Herniations of the nucleus pulposus into the vertebral body.

Answer 2

Schmorl nodules

Question 3

Identify the (4) problems that can result from the injury to a intervertebral disc:

Answer 3

(1) Protrusion of the disc, in which the disc bulges posteriorly without rupture of the annulus fibrosus.
(2) Disc prolapse, only the outermost fibers of the annulus fibrosus contain the nucleus.
(3) Disc extrusion, the annulus fibrosus is perforated, and discal mate- rial (part of the nucleus pulposus) moves into the epidural space.
(4) Sequestrated disc, or a formation of discal fragments from the annulus fibrosus and nucleus pulposus outside the disc proper

Question 4

Potential complications (4) from disc injuries (or inflammation secondary to disc injuries are):

Answer 4

(1) Pressure on the spinal cord itself (upper lumbar spine) leading to a myelopathy
(2) Pressure on the cauda equina leading to cauda equina syndrome
(3) Bowel/ bladder dysfunction),
(4) Pressure on the nerve roots (most common).

Question 5

How does the nerve root take its identifier:

Answer 5

The exiting root takes the name of the vertebral body under which it travels into the neural foramen. Because of the way the nerve roots exit, L4–L5 disc pathology usually affects the L5 root rather than the L4 root.

Question 6

Which segment is the most common site of problems in the vertebral column?

Answer 6

L5-S1, because this level bears more weight than any other vertebral level.

• The center of gravity passes directly through this vertebra, which is of benefit because it may decrease the shearing stresses to this segment.
• There is a transition from the mobile segment, L5, to the stable or fixed segment of the sacrum (S1), which can increase the stress on this area.
• Because the angle between L5 and S1 is greater than those between the other vertebrae, this joint has a greater chance of having stress applied to it.
• Relatively greater amount of movement that occurs at this level compared with other levels of the lumbar spine.

Question 7

Which sex has a incidence of low back pain?

Answer 7

Women

Question 8

What are the durations of acute, subacute, and chronic back pain?

Answer 8

Acute: lasts 3-4 weeks
Subacute: lasts up to 12 weeks
Chronic: greater than 3 months (greater than 12 weeks)

Question 9

[Mechanisms of Musculoskeletal Pain -> Behavior]:

• Inflammatory process
• venous hypertension

Answer 9

[Behavior]

- Constant ache

Question 10

[Mechanisms of Musculoskeletal Pain -> Behavior]:

• Repeated mechanical stress
• Inflammatory process
• Degenerative disc—hysteresis decreased, less protection from repetitive loading

Answer 10

[Behavior]

- Pain accumulates with activity

Question 11

[Mechanisms of Musculoskeletal Pain -> Behavior]:

• Fatigue of supporting muscles
• Gradual creep of tissues may stress affected part of motor unit

Answer 11

[Behavior]

- Pain increases with sustained postures

Question 12

[Mechanisms of Musculoskeletal Pain -> Behavior]:

- Movement has produced an acute and temporary neurapraxia

Answer 12

[Behavior]

- Latent nerve root pain

Question 13

Unilateral pain with no referral below the knee may be Caused by injury to muscles (strain) or ligaments (sprain), the facet joint, or, in some cases, the sacroiliac joints.

Answer 13

Mechanical Low Back Pain (Lumbago)

Question 14

Pain on the anterolateral aspect of the leg is highly suggestive of:

Answer 14

L4 disc problems

Question 15

Pain radiating to the posterior aspect of the foot suggests:

Answer 15

L5 disc problems

Question 16

All of these actions increase the intrathecal pressure (the pressure inside the covering of the spinal cord) and would indicate the problem is in the lumbar spine and affecting the neurological tissue.

Answer 16

• Coughing
• Sneezing
• Deep breathing
• Laughing

Question 17

Pain from _______ ________ down tends to increase with activity and decrease with rest.

Answer 17

Mechanical breakdown

Question 18

__________ of the ______ ________ leads to morning stiffness, which in turn is relieved by activity.

Answer 18

Osteoarthritis of the facet joints

Question 19

…respond to pathology with tightness in the form of spasm or adaptive shortening;

Answer 19

Postural, or static, muscles (e.g., iliopsoas)

Question 20

…tend to respond to pathology with atrophy.

Answer 20

dynamic, or phasic, muscles (e.g., abdominals)

Question 21

These symptoms may indicate a myelopathy and are considered by many to be an emergency surgical situation because of potential long-term bowel and bladder problems if the pressure on the spinal cord is not relieved as soon as possible.

Answer 21

Abnormal sensations in the perineal area often have associated micturition (urination) problems.

Question 22

The best sleeping position is…

Answer 22

in side lying with the legs bent in a semifetal position.

Question 23

In the prone sleeping position…

Answer 23

the lumbar spine often falls into extension increasing the stress on the posterior elements of the vertebrae

Question 24

In supine lying…

Answer 24

…the spine tends to flatten out, decreasing the stress on the posterior elements.

Question 25

Some red flags:

Answer 25

- history of cancer - sudden weight loss for no apparent reason - immunosuppressive disorder - infection - fever - bilateral leg weakness?

Question 26

* Belief that pain and activity are harmful * “Sickness behaviors” (such as extended rest) * Low or negative moods, social withdrawal * Treatment that does not fit best practice * Problems with claim and compensation * History of back pain, time-off, other claims * Problems at work, poor job satisfaction * Heavy work, unsociable hours * Overprotective family or lack of support

Answer 26

Psychosocial Yellow Flag Barriers to Recovery

Question 27

With this SYNDROME, they hypothesized that there was a combination of weak, long muscles and short, strong muscles, which resulted in an imbalance pattern leading to low back pain. They felt that only by treating the different groups appropriately could the back pain be relieved. The weak, long inhibited muscles were the abdominals and gluteus maximus, whereas the strong tight (shortened) muscles were the hip flexors (primarily iliopsoas) and the back extensors. The imbalance pattern promotes increased lumbar lordosis because of the forward pelvic tilt and hip flexion contracture and overactivity of the hip flexors compensating for the weak abdominals. The weak gluteals result in increased activity in the hamstrings and erector spinae as compensation to assist hip extension. Interestingly, although the long spinal extensors show increased activity, the short lumbar muscles (e.g., multifidus, rotatores) show weakness. Also, the hamstrings show tightness as they attempt to pull the pelvis backward to compensate for the anterior rotation caused by the tight hip flexors. Weakness of gluteus medius results in increased activity of the quadratus lum- borum and tensor fasciae latae on the same side.

Answer 27

Pelvic Crossed Syndrome - (often seen with "upper crossed syndrome") - ("Layer syndrome" when both syndromes are seen together)

Question 28

Café au lait spots may indicate...

Answer 28

neurofibromatosis or collagen disease

Question 29

Describe the symptoms and pathology of the "painful arc" pattern in active lumbar flexion or extension:

Answer 29

- The pain seen in a lumbar painful arc tends to be neurologically based (i.e., it is lancinating or lightening- like), but it may also be caused by instability. - If it does occur on movement in the lumbar spine, it is likely that a space-occupying lesion (most likely a small herniation of the disc) is pinching the nerve root in part of the range as the nerve root moves with the motion.

Question 30

What is the Sphinx position?

Answer 30

Bourdillon and Day have advocated doing this movement in the prone lying position to hyperextend the spine. The patient hyperextends the spine by resting on the elbows with the hands holding the chin and allows the abdominal wall to relax. The position is held for 10 to 20 seconds to see if symptoms occur or, if present, become worse.

Question 31

In the spine, the movement of side flexion is a _____ _____ with rotation. Because of the position of the facet joints, both side flexion and rota- tion occur together although the amount of movement and direction of movement may not be the same

Answer 31

coupled movement

Question 32

The _____ test is a test of the lower peripheral joints. Provided the examiner feels the patient has the ability to do the test, the patient squats down as far as possible, bounces two or three times, and returns to the standing position. This action quickly tests the ankles, knees, and hips as well as the sacrum for any pathological condition. If the patient can fully squat and bounce without any signs and symptoms, these joints are probably free of pathology related to the complaint. However, this test should be used only with caution and should not be done with patients suspected of having arthritis or pathology in the lower limb joints, pregnant patients, or older patients who exhibit weakness and hypomobility. If this test is negative, there is no need to test the peripheral joints (peripheral joint scan) with the patient in the lying position.

Answer 32

quick

Question 33

Which (3) special tests should always be done when assessing the lumbar spine, especially if there are neurological symptoms?

Answer 33

(1) The straight leg raising test (2) The prone knee bending test (PKB) (3) The slump test

Question 34

What is the function of neurodynamic tests?

Answer 34

Neurodynamic tests check the mechanical movement of the neurological tissues as well as their sensitivity to mechanical stress or compression.

Question 35

What are tension points and where are they located?

Answer 35

- Tension points are areas where there is minimal movement of the neurological tissue. - According to Butler these areas are C6, the elbow, the shoulder, T6, L4, and the knee. - It is important to realize, however, that the amount of tension placed on these points depends on the position of the extremity.

Question 36

! The examiner runs a pointed object along the plantar aspect of the patient’s foot. A positive reflex suggests an upper motor neuron lesion if present on both sides and may be evident in lower motor neuron lesions if seen only on one side. The reflex is demonstrated by extension of the big toe and abduction (splaying) of the other toes. In an infant up to a few weeks old, a positive test is normal.

Answer 36

Babinski (Reflex) Test

Question 37

This nonspecific test stresses the facet joints, joint capsule, supraspinous and interspinous ligaments, neural arch, the longitudinal ligaments, and the disc. The patient lies prone. The examiner stabilizes the ribs and spine (at about T12) with one hand and places the other hand under the anterior aspect of the ilium. The examiner then pulls the ilium backward causing the spine to be rotated on the opposite side producing torque on the opposite side. The test is said to be positive if it reproduces all or some of the patient’s symptoms. The other side is tested for compression.

Answer 37

Farfan Torsion Test | [Test for Lumbar Instability]

Question 38

_/The patient lies prone and relaxed. The examiner passively lifts and extends both extremities at the same time to about 1 foot (30 cm) from the bed. While maintaining the extension, the examiner gently pulls the legs (Figure 9-74). The test is considered positive if, in the extended position, the patient complains of strong pain in the lumbar region, very heavy feeling in the low back, or it feels like the low back is “coming off” and the pain disappears when the legs are lowered to the start position. Numbness or prickling sensation are not positive signs.

Answer 38

Passive Lumbar Extension Test | [Test for Lumbar Instability]

Question 39

What does intermittent claudication imply

Answer 39

Intermittent claudication implies arterial insufficiency to the tissues. It is most commonly evident when activity occurs because of the increased vascular demand of the tissues. There are two types of intermittent claudication— vascular and neurogenic. The vascular type is most commonly the result of arteriosclerosis, arterial embolism, or thrombo-angiitis obliterans and commonly manifests itself with symptoms in the legs. The neurogenic type is sometimes called pseudoclaudication or cauda equina syndrome and is commonly associated with spinal stenosis and its effect on circulation to the spinal cord and cauda equina. The symptoms in this case may be manifested in the back or sciatic nerve distribution.

Question 40

This syndrome involves compression of the L5 nerve root as it passes under the iliolumbar ligament in the iliolumbar canal. The usual cause of compression is trauma (inflammation), osteophytes, or a tumor. Symptoms are primarily sensory (L5 dermatome) and pain. There is minimal or no effect on the L5 myotome.

Answer 40

Lumbosacral Tunnel Syndrome.