Spine Three - starts with disc strain/bulge

Question 1

what structures are involved with a disc strain or bulge

Answer 1

nucleus pulposus
annulus fibrosis

Question 2

what does the nucleus pulposus and annulus fibrosis do?

Answer 2

adapts to pressure secondary to movement (hydrostasis)

Question 3

aging process ________ solubility

Answer 3

decreases

Question 4

what happens to the pressure around the nucleus as you age?

Answer 4

• more fibrous
• becomes uneven as you age (30-50 highest risk)

Question 5

why are you less likely to have a disc strain or bulge in you 50-60s?

Answer 5

b/c about that time the annulus and NP become homogenous

Question 6

herniated nucleus pulposus (HNP)

Answer 6

stretching and/or tearing of annulus fibrosis

Question 7

what age is HNP most common in? what level do 90% of them happen at?

Answer 7

20-45
L4/5 and L5/S1

Question 8

McKenzie theory

Answer 8

• prolonged or repeated flexion cause posterior and possible lateral movement of NP
• NP migrates towards innervated outer AF
• pain peripheralizes as nerve is compromised

Question 9

what part of the AF is innervated?

Answer 9

outer 1/3

Question 10

what does repeated stress/strain cause in the annulus

Answer 10

fissures in posterior and posterior lateral annulus

Question 11

herniation stage 1

Answer 11

• slight posterior lateral protrusion
• small fissure in annulus
• asymptomatic
• easily managed with proper mechanics (but we probs won’t see patients at this level because they don’t have symptoms)

Question 12

Herniation stage 2

Answer 12

• protrusion to outer annulus
• increase in fissuring
• no nerve root involvement
• may present with lateral shift (usually away from the pain)

Question 13

Herniation stage 3

Answer 13

• prolapse
• outer annulus is intact but putting pressure on spinal nerve/cord
• referred pain into extremities
  *** this is where it can become radicular, monitor patient for neuro changes

Question 14

Herniation stage 4

Answer 14

• extrusion or requestration
• no annulus containment
• neurologic and motor changes

Question 15

extrusion

Answer 15

disc is all the way out but not broken free

Question 16

sequestration

Answer 16

disc has completely broken free

Question 17

can a herniated disc go back in?

Answer 17

it depends on the stage
early = maybe
later - no

Question 18

subjective findings with HNP

Answer 18

• increased pain with prolonged sitting, bending and twisting
• increased pain with coughing, sneezing, laughing
• increased pain with flexion activites and standing after prolonged periods of sitting
• decreased pain with standing, walking, and movement

Question 19

objective findings for HNP

Answer 19

• slumped posture and decreased lordosis
• possible lateral shift
• neuro signs
• tender to palpate

Question 20

special tests for HNP

Answer 20

• slump, straight leg raise, femoral

Question 21

If HNP is acute, what kind of posture will you see

Answer 21

very erect (guarding

Question 22

spondylolithesis

Answer 22

forward displacement of vertebra caused by defect in pars interarticularis

Question 23

what can cause a defect in the pars interarticularis?

Answer 23

• fracture or elongation of vertebral arch
• facet shape or orientation

Question 24

Tor F: spondylolysis can lead to spondylolisthesis

Answer 24

T

Question 25

how do you grade spondylolisthesis

Answer 25

line is drawn on the anterior aspect to measure how far forward superior vertebra is on inferior vertebra

Question 26

what are the grades of spondylolisthesis

Answer 26

1-4 1-2 are usually responsive to treatment 3-4 usually need surgery

Question 27

2 types of spondylolisthesis

Answer 27

isthmic and degenerative

Question 28

is antero or retro spondylolisthesis more common

Answer 28

antero

Question 29

isthmic spondylolisthesis

Answer 29

- fatigue fracture - stretching of pars interarticularis - due to repeated extension with rotation - common in volleyball, baseball, and gymnasts

Question 30

t or f: in isthmic spondylolisthesis you may palpate a step higher than the actual problem

Answer 30

T b/c it will drop when it moves anterior

Question 31

degenerative spondylolisthesis

Answer 31

- wearing out of asymmetry of facet planes - caused by obesity or arthritis - entire cephalad vertebra slips forward - step is at level of slipw

Question 32

where is degenerative spondylolisthesis most common

Answer 32

L4/5 > L5/S1

Question 33

subjective findings with spondylolisthesis

Answer 33

- general LBP - subsides with rest - difficulty/pain with forward bending - increased pain with excessive movement or physical activity - increased muscle tone with standing

Question 34

objective findings with spondylolisthesis

Answer 34

- hypermobile with passive accessory testing - excessive lordosis

Question 35

t or f: there is a direct relationship of displacement with amount of pain

Answer 35

false

Question 36

x-ray views for spondylolisthesis

Answer 36

oblique and lateral oblique = scotty dog with collar sign

Question 37

what other imaging can you get with spondylolisthesis

Answer 37

bone scan - used in young people with acute onset MRI - movement between bone and endplates, may be indicated if there are bowel/bladder symptoms

Question 38

what kind of image shows lumbarization or sacralization

Answer 38

AP plain film

Question 39

lumbarization

Answer 39

6 lumbar vertebra

Question 40

sacralization

Answer 40

4 lumbar vertebra

Question 41

common causes of SIJ injuries

Answer 41

- combo of flexion with rotation - fall or trauma - pregnancy - leg length difference - weak glute med

Question 42

subjective findings with SIJ pathology

Answer 42

- morning stiffness that gets better with weight baring - sharp/dull/achy, throbbing - unilateral pain localized to sij - pain with walking and climbing stairs - pain with prolonged posture or standing on affected side

Question 43

t or f: if it is a true SIJ problem you should be able to clear the lumbar spine

Answer 43

true

Question 44

t or f: people with SIJ problems usually have neurological signs

Answer 44

F: but they may have referred pain down the leg

Question 45

possible non mechanical causes of SIJ pathology

Answer 45

psoriatic arthritis infection tumors

Question 46

objective findings with SIJ pathology

Answer 46

- posture (stance shift to one side) - able to clear lumbar - spine and hip - pelvic mobility - leg length difference - provocation clusters

Question 47

if someone has a hypermobile SIJ what muscle is most likely weak

Answer 47

glutes * also check hamstrings, quads, and hip rotators

Question 48

anterior pelvic rotation palpation findings

Answer 48

ASIS is low PSIS high long medial malleolus

Question 49

posterior pelvic rotation palpation findings

Answer 49

ASIS high PSIS low short medial malleolus

Question 50

possible causes of superior innominate upslip

Answer 50

landing hard with knee extended stepping off curb landing on ischial tuberosity tight QL

Question 51

palpation findings with superior innominate upslip

Answer 51

ASIS and PSIS superior short medial malleolus

Question 52

what xray view is best for SIJ

Answer 52

anterior posterior

Question 53

what is the gold standard imaging for SIJ

Answer 53

injection under fluoroscopy