The Spine

Question 1

What is the scope of LBP?

Answer 1

At least 80% of people with have back pain at some point in their lives.

Question 2

Do patients with low back pain have weaker spinal musculature.

Answer 2

There is little deficit in people with acute back pain, but patients with chronic pain typically demonstrate weak abs and extensor muscles. Normally trunk extensors are 30% stronger than trunk flexors.

Question 3

Discuss Williams’ Flexion exercises.

Answer 3

Williams believed that the basic cause of back pain was caused by poor posture and that lordosis led to inc dysfunction in the posterior aspect of disks. The goals of the exercises are to open the intravertebral foramina and to stretch the back extensors, hip flexors, and facets while strenghtening abs and glutes.
Exercises include pelvic tilts, Knee-to-chest exercises, hip flexor stretching, and crunches.

Question 4

Explain McKenzie’s philosophy and classifications.

Answer 4

Mckenzie believed that the disk was the primary sours of pain but that flexion was the culprit, due to prolonged sitting positions and lack of extension. He believed the accumulation of forces led to early dysfunction in posterior disk. He classified disorders 3 ways:

Postural Syndrome: sedentary occupation, less than 30 years old, midline pain, no referred pain, no pain induced by movement, only prolonged positioning

Dysfunction Syndrome: sedentary occupation, age 30+ years old, often sedentary occupation, back pain at end ROM, restricted ROM c shortened soft tissues

Derangement Syndrome: Typically 20-55 years (working age) sudden onset, possible radiatio nof pain, paresthesias, migrating pain, exacerbated by certain movements

Question 5

Describe the typical treatment for postural syndrome.

Answer 5

Postural correction advice, use of lumbar rolls, active and passive extension exercises

Question 6

Describe the typical treatment for dysfunction syndrome.

Answer 6

Postural education, flexion/ext and/or lateral deviation stretching and coorection, mobilization and manipulation into restricted ROM (basically the same as postural, with side bending and mobilization/manips added)

Question 7

Describe the typical treatment for derangement syndrome.

Answer 7

Reduction of derangement, postural education, repeated ext in prone or standing, use of lumbar supports, address lateral devation, ext manipulation as necessary. When pain is intermittent, add flex exercises in recumbent position, progressing to standing. Always follow flex exercises with ext.

Question 8

Are flexion or extension exercises more effective for LBP?

Answer 8

Research is inconclusive. McKenzie is usually better than back school. Flexion appeared to be more helpful in increasing sagittal mobility but extension exercises are preferred by patients. Flexion and extension coupled c manipulation is helpful.

Question 9

What is the reliability of McKenzie evalation techniques?

Answer 9

Poor inter-tester regardless of post-grad training

Question 10

What are the implications of weak multifidi in relation to LBP?

Answer 10

The multifidus is the larges, most medial, and most used extensor muscle group, contributing to 70% of the stiffness from muscle contraction in the neutral zone of the lumbar spine. Research demostrates multifidus wasting in LBP patients. Selective training significantly increases cross-sectional area and helps prevent and rehab chronic pain.

Question 11

Are intensive exercise programs more effective than gentle programs for LBP?

Answer 11

Yes. Intensive programs with exercises directed at specific muscle groups, movements, and control. Genle programs where patient gradually increases ADLs as tolerated and walks is not as effective.

Question 12

Describe Fryette’s laws of spinal biomechanics.

Answer 12

1. Spine neutral: coupling is contralateral

2. Spine non-neutral: coupling ipsilateral

Question 13

Describe spinal coupling (updated, not Fryette).

Answer 13

C1-C2 has contralateral coupling.
Cervical and upper thoracic: ipsilateral
Mid and Lower thoracic: inconsistent
Lumbar: contralateral if rotation first

However, movement is variable among different people and even in different regions in the same person

Question 14

Describe general trends in spinal ROM.

Answer 14

In general, flex/ext and lateral flex increase from cranial to caudal. Rotation decreases cranial to caudal.

Question 15

Describe normal cervical ROM.

Answer 15

Cervical flex: 50*
Cervical ext: 60*
Cervical SB: 45*
Cervical rotation: 80*

Question 16

Describe normal lumbar ROM.

Answer 16

flex: 90*

SB L, SB R, ext: 25*

Question 17

Define scoliosis.

Answer 17

Any abnormal curvature in the coronal plane >10*. Anything less is spinal asymmetry.

Question 18

Describe spinal ligaments from anterior to posterior.

Answer 18

(upper cervical name change)
Anterior longitudinal ligament: ant VB. (alantoaxial and ant alanto-occipital membrane)

Post Long. Lig.: post VB (tectoral ligament)

Ligamentum flavum: ant lamina to sup lamina (posterior alanto-occipital membrane)

interspinous ligament: SP to SP (none)

Supraspinous ligament: tips of SP (ligamentum nuchae)

Transverse ligament: body of C1 to body C1
Alar ligament: dens to occipital condyles
Apical ligament: tip of dens, foramen magnum

Question 19

Describe the anatomy of the intervertebral disk.

Answer 19

Each motion segment has one disk (except C1-C2). Disk is avascular with an outer annulus fibrosis and inner nucleus pulposus and a cartilagenous end plate. NP acts as a shock transmitter (not absorber because it is water) and transmits loads from NP to surrounding tissue (changes vertical forces to horizontal forces so that the surrouding tissues act as shock absorbers). Fibers are arranged in perpendicular lamellar fibers aranged at 45* angles. Disks are taller anteriorly in the cervical and lumbar spine, posteriorly in the thoracic spine (causes the curves).

Question 20

How do disks obtain nutrition?

Answer 20

Through local diffusion. Exercise can help pump the disk which aids in solute transport and possibly by increasing external local vascularity.

Sidelying or hooklying facilitates nutritional pressure changes (approx 80% of nutrition absorbed at night is within the first hour of rest, so laying down during the day may double nutrition)

Question 21

Describe facet orientations.

Answer 21

Cervical: facets are 45* to vertical in the sagittal plane
Thoracic: 60* to vertical in sagittal plane, leading to increased rigidity and dec rotation
Lumbar: vertical, with facets oriented in a v shape with the point anterior

Question 22

Describe spinal loading in different postures.

Answer 22

Measured at L3-4 by Nachemson
Lowest load is sidelying (25%)
Standing (100%)
Seated (145%)
Standing with forward bend (150*)
Sitting with forward bend (180*)
loads are lower during supported than unsupported sitting because part of the weight of the upper body is supported on the backrest.  Backward inclination and use of a lumbar support further reduce loads.

Question 23

What are spinal canal dimensions?

Answer 23

1.5 to 2 cm (spinal cord is 1cm in diameter, stenosis occurs when canal is less than 1.5 cm)
Two levels of enlargement correlate with levels of upper (C4-T1) and lower (L2-S3) innervation. The conus medullaris starts at T10-T11 disk level. The L1-L2 disk level marks the end of the conus medularis and start of the cauda equina

Question 24

How are facet joints innervated?

Answer 24

by the dorsal primary ramus
2 branches (superior and inferior) innervate the facet above and below the level of the nerve root 
(ex: The L2-L3 facet is innervated by the descending branch of L1 and the ascending branch of L3)

Question 25

Where is the nerve root in relation to the pedicle and disk?

Answer 25

In the cervical spine, the spinal NR exits directly lateral from the spinal canal adjacent to the corresponding disk (just superior to pedicle for which it is named). The numbering changes at C7-T1 so that the C8 NR passes superior to T1 pedicle. In the lumbar spine, the NR passes just inferior to the pedicle for which it is named (usually superior to disk at that level)

Question 26

How does spinal movement affect the size of intervertebral foramen?

Answer 26

flexion increases size by approx 20%, extension decreases by 20%

Question 27

What happens during the straight leg raise test?

Answer 27

The sciatic nerve is sigmoid in shape (loose). The first 35 degrees, slack is being taken up along the nerve prior to the NR. From 35 to 70 degrees the NR moves. Above 70*, movement stops and tension is placed on structures.

Question 28

What muscles are involved in lumbar flexion and extension?

Answer 28

flexion: abs, vertebral part of psoas, erector spinae/post hip muscles to control. At full range, muscles act as passive restraints. Ext: pelvis tilts backwards and process reverses using above sequence

Question 29

Describe the effect of situps on spinal loading.

Answer 29

A situp increases disk pressure >2x. A reverse curl is <1.5x. Ab crunch: less than situp

Question 30

What are differences in lumbar spine kinematics between patients with chronic LBP and normal subjects?

Answer 30

Chronic LBP results in earlier and longer activation of erector spinae, suggesting a change to motor program from a open to closed loop system.

Question 31

What are the effects of lumbar diskectomy on trunk muscles?

Answer 31

At 2 months, approx 35-45% dec muscle strength, suggesting importance of rehab.

Question 32

What is the effect of leg length discrepancy on spinal motion?

Answer 32

asymmetrical lateral side bending toward lengthened side (may lead to scoliosis with the apex on short side)

Question 33

What are the common conditions that can lead to pain and disability (regarding facet joint)?

Answer 33

1) acute synovitis/hemarthrosis 2) stiffness resulting from collagen cross binding following injury 3) mechanical block possibly due to torn or separated meniscoid (in lumbar facet joints) 4) painful capsular entrapment 5) degenerative arthrosis

Question 34

Discuss potential sources of pain associated with dysfunction of the disk.

Answer 34

Nerve endings are found in the outer 2-3 layers of the disk. As a disk degenerates, it may become engorged with blood vessels in an effort to repair the disk. Sympathetic nerves may accompany these blood vessels and inc pain.

Question 35

Why does disk herniation occur?

Answer 35

The first changes are NP leaking laterally. The inner annulus has few fibers while the outer annulus has many fibers. The inner annulus degenerates but tears begin at the outer annulus and spread inward allowing the NP to deform. Healing is possible but is very slow.

Question 36

What structure is most commonly involved in low back pain?

Answer 36

Regardless of the primary source- disk, facet, SIJ - the muscles will always be involved either voluntarily in a protective manner or involuntarily to guard against LBP. Most common cause of initial LBP is facet joint injury, followed by ligamentous weakness, SI strain, and outer annulus pain.

Question 37

At what levels do lumbar disk prolapse occur?

Answer 37

L4/5. Lower lumbar first and then upper lumbar

Question 38

Describe classification of disk herniations.

Answer 38

Disk protrusion (annular fibers intact): -disk bulge -diffuse disk bulge (lateral and post) Disk Herniations (annular disruption) -Prolapsed (NP through inner layers but still contained -Extruded (NP through outer most layers -Sequestered (fragments of NP into spinal canal)

Question 39

What is the incidence of disk herniations?

Answer 39

can't be answered because most don't hurt

Question 40

What are characteristics of lumbar and cervical radiculopathy?

Answer 40

lumbar: most common in middle age, in men, resulting from herniations cervical: most common in late life, in women, from lateral stenosis caused by osteophytes and OA of facets

Question 41

What muscles increase abdominal tone and pressure for stabilization of the lumbar spine?

Answer 41

oblique and TrA inc tone while the multifidus provides stabilization

Question 42

What are the effects of LBP, disk herniation, and surgery on lumbar multifidus?

Answer 42

herniation is associated with selective atrophy of slow twitch fibers. Changes are present in 88% of patients before surgery. Patients who have a positive outcome have had positive changes in structure of multifidi.

Question 43

What is lumbar spinal stenosis?

Answer 43

narrowing of the lumbar spinal canal (central) nerve root canals or intervertebral foramina (lateral) that impinge on nerves. Classified anatomically as central or lateral; may also be classified etiologically as primary (conginetal or dysplastic) or secondary (due to degeneration)

Question 44

Is lumbar stenosis a common problem?

Answer 44

Most common cause of spinal surgery in people older than 65. Typical patient is older (degenerative changes are predominant cause) with a long history of LBP. ROM is limited, esp in ext and is posture dependent (better in sitting than standing or walking). Walking distance is decreased.

Question 45

Differentiate between disk pain and stenotic pain.

Answer 45

Stenosis hurts more in extension (20% less foramina room) and better in sitting. Disks hurt more in sitting usually because of increased pressure. A good test to differentiate is the bicycle test or incline treadmill test (15* incline, walking improves with incline if stenotic)

Question 46

Are plain x-rays helpful for diagnosing lumbar stenosis?

Answer 46

Lateral yes, central-limited.

Question 47

Describe surgical management of spinal stenosis.

Answer 47

Most common procedure is decompression laminectomy where part of the vertebral arch is removed. Fusion may be performed if there is evidence of concurrent spondylolisthesis.

Question 48

What is the best PT Tx for stenosis?

Answer 48

Flexion oriented exercises, general conditioning, mobilization or stretching of the hips, possibly pelvic traction. Deweighted treadmill ambulation may also be good. Oswestry or Roland Morris disability scales may be helpful.

Question 49

What is the typical clinical presentation for patients with cervical stenosis?

Answer 49

radiculopathy: neck and UE pain and paresthesia in dermatomal pattern, possibly weakness in one arm. myelopathy: more subtle, neck pain may not be present. Unsteady gait, usually wasting of intrinsic hand muscles and feelings of weakness Spurling's compression test is expected to be positive in radiculopathy and negative in myelopathy

Question 50

How is spondylolisthesis measured and graded?

Answer 50

It is the anterior slippage of one VB on another. Graded I-IV based on percentage of slippage (up to 25%, up to 50%, up to 75%, up to 100%). Grade V is where the VB slips entirely forward, known as spondyloloptosis

Question 51

What is sacral inclination?

Answer 51

The sacrum is angled anteriorly in upright standing postures, but the angle tends to decrease as listhesis increases.

Question 52

What is the slip angle in refers to the sacrum?

Answer 52

AKA sagittal rotation, considered to be the most sensitive measure of potential segmental instability.

Question 53

What are the types of spondylolisthesis?

Answer 53

isthmic: onset in adolescents, males more than females, usually a caused by stress fracture of pars, common in young gymnasts and football lineman Congenital: females more than males, due to dysplastic pars interarticularis Degenerative: females more than males, usually over 40yo, caused by degenerative changes

Question 54

Does spondylolysis always progress to spondylolisthesis?

Answer 54

No, nearly 50% with isthmic do not progress. Listhesis typically occurs at time of fatigue fracture. If it doesn't occur acutely, it usually doesn't progress at all. If diagnosed early and treated with rigid bracing (Boston brace) for up to 6 months, healing may occur. Early in the mobilization period, aggressive ab strengthening and stabilization exercises are initiated

Question 55

How is spondylolisthesis diagnosed radiologically?

Answer 55

"Scotty Dog" sign shows the presence of the fatigue fracture. Serial radiographs are performed to assess progression

Question 56

How is spondylolisthesis treated conservatively?

Answer 56

Hamstring flexibility (usually tight to produce and maintain post pelvic tilt and reduce lordosis/progression). Avoid ext exercises.

Question 57

What are the major types of scoliosis?

Answer 57

functional: may be caused by muscle spasm or leg length discrepancy. Resolves with Tx the underlying problem. structural: idiopathic congenital: caused by abnormalities. Most rare.

Question 58

Describe the presentation of idiopathic scoliosis.

Answer 58

Curves do not straighten when the trunk is flexed forward (Adam's test). Has rotatory components during forward flexion with a rib hump.

Question 59

What screening process is most effective for scoliosis?

Answer 59

most common is Adam's test combined with scoliosometer. Further evaluation is advisable in curves greater than 15 degrees.

Question 60

Describe the Risser classification.

Answer 60

Uses the ossification of the iliac epiphysis to grade remaining skeletal growth. Moves lateral to medial.Measured 1-4 (25% to 100%). Riser type 5 is fusion and doesn't usually occur in females.

Question 61

When should bracing be considered with scoliosis?

Answer 61

Curves greater than 30 degrees, or curves less than 30 degrees that progress more than 5 degrees per year. Most comon braces are the Boston brace (TLSO) and the milwaukee brace (older). The youonger the patient, the better the effects of bracing. Bracing decreases chance of progression by 50%

Question 62

What other treatments have been shown to be effective for scoliosis other than bracing?

Answer 62

Exercise doesn't work, estim doesn't work, chiropractors don't work

Question 63

What is the incidence of disk disease in the thoracic spine?

Answer 63

High, but symptomatic presentations are rare due to relative limitation of motion

Question 64

How many articulations are present on the typical thoracic vertebra?

Answer 64

12. | 4 ZAJ, 2 CTJ, 4 CVJ, 2 VB-disk

Question 65

Describe the typical pattern of rib cage motion.

Answer 65

Upper rib motion during respiration is pump handle (sagittal plane elevation) whereas lower rib motion is termed bucket handle (frontal plane elevation). Lee's model suggests that during spinal flexion, ribs rotate anteriorly, termed internal torsional movement. During extension, elements move opposite (external torsional movement)

Question 66

Describe the cervical rotation lateral flexion test (CRLF).

Answer 66

determines first rib hypomobility. rotate spine passively maximally and SB. has good agreement with findings.

Question 67

Define thoracic outlet syndrome.

Answer 67

Controversial, surgery results in symptom relief in only 28% of patients undergoing first rib resection. Conservative management is advocated.

Question 68

What are the symptoms of thoracic osteoporosis?

Answer 68

midline back pain localized over spine, the most common location for fractures. Tx includes exercise, especially WB activities.

Question 69

Describe Ankylosing spondylitis.

Answer 69

a chronic inflammatory disease characterized by a variable symptomatic course, with stiffness often occurring in the thoracic spine and CVJ. Chest expansion is measured at the 4th intercostal space in men and below the breast in women.

Question 70

Describe pain from cholecystitis.

Answer 70

Inflamed gallbladder. pain typically occurs 1-2 hours after ingestion of a heavy meals, with pain peaking at 2-3 hours.

Question 71

What is Scheuermann's disease?

Answer 71

anterior wedging and vertebral end-plate irregularity in the thoracic spine associated with kyphosis. Also known as juvenile kyphosis. Disk material herniated into the VB is a common associated finding (Schmorl's nodes).

Question 72

Define T4 syndrome.

Answer 72

a group of symptoms including dysfunction within T2-T7 segments. Presentations include various combos of pain in the upper quadrant, but the T4 segment is usually involved. limited mobility is present, PA pressure reproduces symptoms.

Question 73

Discuss cancer and the spine.

Answer 73

Metastatic lesions are much more common than primary tumors (25 to 1). Metastases occur more commonly in the axial skeleton than in the appendicular skeleton.The thoracic spine is the most common region affected, with breast cancer being the most common site of origination.

Question 74

Define costochondritis.

Answer 74

Inflammation or irritation of the costochondral junction. Tx includes segmental mobilization and manipulation.

Question 75

Describe thoracic spine and CRPS 1.

Answer 75

manipulation has been used to help reduce pain and dystrophic symptoms in this syndrome.

Question 76

Can treatment of the thoracic spine and rib cage aid in management of shoulder disfunction?

Answer 76

Deyle demonstrated that procedures targeting the cervical and thoracic spine result in decreased pain and improved function in patients with shoulder impingement syndrome.

Question 77

How common is trauma to the spinal column?

Answer 77

Over 50k/yr (males more than females). Injury is most common at cervicothoracic junction and thoracolumbar junctions.

Question 78

What is the long-term prognosis of a SCI pt?

Answer 78

10 yr survival rate is 86%. If over age 29, only a 50% chance, primariloy due to pneumonia and suicide

Question 79

Describe incomplete cord syndromes.

Answer 79

Some function below the level of injury is preserved. Central: Age>50, extension. UE>LE, M&S loss Anterior: flexion-comp, incomplete motor, some sensory Brown-Sequard: penetrating trauma: ipsilateral motor, contralateral pain/temp Root: foraminal cmopression

Question 80

How is the level determined in SCI?

Answer 80

The cord ends at the L1-L2 disk space so the level of injury to the spinal column may not match the level of cord injury. The cord level is defined as the lowest functional motor level (3/5 strength)

Question 81

What is a hangman's fracture?

Answer 81

A traumatic spondylolisthesis of the Axis. Represents a bilat fracture of the C2 pars interarticularis. This actuall enlarges the canal so injuries are rare. Tx is usually stabilization with collar

Question 82

What is a jeferson fracture?

Answer 82

A bursting fracture of the atlas

Question 83

What are the typical symptoms of whiplash?

Answer 83

Most patients report neck pain and/or occipital headaches that are usually worse with movement. On examination, dec ROM and spasms are noted.

Question 84

How are injuries to the thoracolumbar spine classified?

Answer 84

A minor injury includes isolated fractures of spinous and transverse processes, pars, and facets. Major fractures includ compression fractures.

Question 85

What are compression fractures and how are they treated?

Answer 85

Represent almost half of all major thoracolumbar injuries. Result from a compression failure of the anterior column with the middle and post columns intact. Often treated with injection of bone cement either with (kyphoplasty) or without (vertebroplasty) baloon reduction.Good outcomes are reported almost immediately in 80-100% of patients.

Question 86

What is a seat belt injury?

Answer 86

Seen in belted passengers in a MVA without a shoulder harness. Often results from tension failure of the posterior and middle columns. This injury may occur through bone or soft tissue. If it occurs through bone injury, it is called a Chance fracture.

Question 87

What are common postop medical problems to which spinal trauma patients are prone.

Answer 87

DVT, PE, and pressure sores. Pneumonia and pneumothorax as well. Autonomic dysreflexia is seen in patients with cervical and upper thoracic spinal cord injuries. Usually bladder overdistension or fecal impaction causes an ANS reaction leading to severe hypertension. Symptoms often include pounding HA, anxiety, profuse sweating, and blurred vision.

Question 88

What is the role of PT in osteoporotic patients following vertebral compression fracture?

Answer 88

A rehab program including gait, balance training, and extensor muscle training is being recommended in conjunction with an educational program about appropriate lifting techniques and back protection.