Anderson4e_Ch11_WithLectureNotes

8/7/2019 Anderson4e_Ch11_WithLectureNotes

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Copyright 2009Wolters Kluwer Health | Lippincott Williams & Wilkins

Lumbar Spinal Conditions

Chapter 11


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Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

AnatomyAnatomy

lumbar spine

forms convex curve anteriorly

5 lumbar, 5 fused sacral,& 4 small, fusedcoccygeal vertebrae

sacrum articulates with ilium - sacroiliac joint.


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Anatomy (Contd)Anatomy (Contd)

F11.1


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ligaments responsible forarticulation with sacrum

iliolumbar ligaments

posterior sacroiliacligaments,

sacrospinous ligamen7

sacrotuberous ligament

F11.2


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muscles of trunk

paired unilaterally: produce lateral flexion and/or rotation of the

trunk

bilaterally: trunk flexion or extension

primarymovers back extension - erector spinae muscles


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F11.3


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F11.4

nerve plexus

lumbar (T12 L5)


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F11.5

nerve plexus

sacral (portion oflumbar (L4-L5)


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KinematicsKinematics

movements involve a number ofmotion segments

flexion/extension/ hyperextension

lateral flexion

rotation

spinal flexion vs. hip flexion vs. forward pelvic tilt

hyperextension


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KinematicsKinematics

movements involve a number ofmotion segments

flexion/extension/ hyperextension

lateral flexion

rotation

spinal flexion vs. hip flexion vs. forward pelvic tilt

hyperextension


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KineticsKinetics

effects ofbody position

line ofgravity passes anterior to spinal column

trunk flexion

o moment arm for body weight;o bendingmoment

counteract moment via tension in back muscles

o tension in back o compression lumbar spine


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Anatomic Variations: Injury PotentialAnatomic Variations: Injury Potential

lordosis

abnormal exaggeration oflumbar curve

causes include

congenital deformities

weak abdominalmusculature

poor posture

activities with excessivehyperextension

F11.7


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Anatomic Variations: Injury PotentialAnatomic Variations: Injury Potential

swayback

increased lordotic curve and kyphosis

causes include

muscle weakness; compensatorymuscle tightness

entire pelvis shifts anteriorly, causing the hips to move intoextension

impact on COG


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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)

flat back

decrease in lumbar lordosis (20deg) potential causes

clinical sign - tendency to lean forward when walkingor standing

impact on COG


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pars interarticularis

area between superior and inferior facets

weakest part of the vertebrae

spondylolysisfracture

congenital or mechanical stress

repeated weight-loading in flexion,hyperextension, & rotation

occur early age (age 8);asymptomatic until ages 1015


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spondylolisthesisbilateral separation

anterior displacement of a vertbra common sitelumbosacral joint

ages 1015


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Spondylolysis

stress fracture of the pars interarticularis.

Spondylolisthesis

a bilateral fracture of pars interarticularisaccompanied by anterior slippage of involvedvertebra.

F11.8


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Spondylolisthesis

MRI demonstrates anterior shift of L5

F11.9


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spondylitic conditionsmechanical stress

do not typically heal with time

S&S

low back pain

associated neurologic symptoms


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particularly susceptible

female gymnasts, interior footballlinemen,weight lifters, volleyball players, pole vaulters,wrestlers, and rowers

slippage severity


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Prevention of Spinal InjuriesPrevention of Spinal Injuries

protective equipment

rib protectors

weight-trainingbelts/abdominalbinders

physical conditioning

strength & flexibility

proper technique

proper lifting

posture


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Lumbar Spine InjuriesLumbar Spine Injuries

contusions, strains, and sprains

est. 80% of population has LBP at sometime

nearly 97% stems frommechanical inj. tomuscles, ligaments, or connective tissue

chronic LBP: associated w/LBP, reducedspinal flexibility, repeated stress, andactivities that require maximal extension ofthe lumbar spine


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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)

LBP

pain & discomfort can range (local or diffuse)

no radiating pain

no signs of neural involvement

management: standard acute; stretching


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LBP in runners

associated w/ tightness in hip flexors &

hamstrings S&S

localized pain, w/ active & resisted backextension

no radiating pain

no signs of neural involvement

possible anterior pelvic tilt & hyperlordosis


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management

ice, NSAIDs, muscle relaxants, TENS, and EMS avoiding excessive flexion activities & a

sedentary posture

decrease incidenceuse progressive trainingtechniques


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myofascial pain

referred pain that emanates from a myofascial

trigger point

common trigger point sites: piriformis muscleand quadratus lumborum

S&S- piriformis

referred pain in sacroiliac area, posterior hip,and upper 2/3s of posterior thigh

Aching and deep pain increases with activityor with prolonged sitting with the hipadducted, flexed, and internally rotated


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myofascial pain (contd)

S&S quadratus lumborum

false sign of disk syndrome

superficial fibers- sharp, aching pain inlow back,iliac crest, greater trochanter can extend toabdominal region

deep fibers- sacroiliac joint or lower buttockregion; pain increases duringlateralbendingtoward the involved side, while standing for longperiods of time, and during coughing or sneezing

management: involves stretching the involvedmuscle back


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facet joint pathology

may involve:

subluxation or dislocation of the facet

facet joint syndrome

degeneration of the facet itself

exact pathophysiology is unclear toward involved side, & w/ torsionalload


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S&S

nonspecific low back, hip, &buttock paindeep & achy

pain may radiate to post. thigh, but not below knee

pain aggravated by rest & hyperextension; relieved byrepeated motion

flattening oflumbar lordosis

point tendernessunilateral or bilateral paravertebralarea

opain w/ trunk rotation, stretching into full extension,lateralbending


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facet joint pathology (contd)

possible clinical findings

abnormal pelvic tilt & hip rotation secondary totight hamstrings, hip rotators, & quadratus

MMT normal; but subtle weakness in erectorspinae & hamstrings may contribute to pelvic tilt

abnormalities

+ straight leg raising test

definitive diagnosis

management: standard acute; education


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sciatica

classification levels sciatica only

no sensory or muscle weakness

modify activity appropriately, and develop

rehabilitation and prevention program

any increased pain requires immediatereevaluation


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sciatica with soft signs

some sensory changes mild or no reflex change

normalmuscle strength

normalbowel and bladder function

remove from sport participation for 612 wks.


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sciatica with hard signs

sensory and reflex changes

muscle weakness due to repeated, chronic, or acutecondition

normalbowel and bladder function

remove from participation 12 to 24 weeks.


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sciatica with severe signs

sensory and reflex changes

muscle weakness

altered bladder function

consider immediate surgical decompression.


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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd) potential causes:

herniated disc radiatingleg pain > back pain

pain sitting &leaning forward, coughing,sneezing, & straining

neurologic deficits are usually present + ipsilateral straight leg raising test

annular tears back pain > leg pain pain sitting &leaning forward, coughing,

sneezing, & straining may have muscle spasm and loss oflordosis + ipsilateral straight leg raising test


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spinal stenosis

back and leg pain develop after walking alimited distance, and increase as distanceincreases

leg weakness or numbness is present, with orwithout sciatica

negative straight leg raising test

positive pain on prolonged spine extension,relieved with spine flexion


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facet joint arthropathy

pain over joint on spinal extension, exacerbated

with ipsilateral trunk lateral flexion

compression from piriformis

symptoms mimic lumbar disc conditions, exceptfor the absence of true neurologic findings

pain increases with medial rotation of the thigh

management: physician referral


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lumbar disc conditions

protruded disc (A)

eccentric accumulation of nucleus w/ slight deformity ofannulus

prolapsed disc (B)

eccentric nucleus produces a definite deformity as it

works its way through fibers of annulus fibrosus.


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extruded disc (C)

nuclear materialbulges into spinal canal and runs riskof impinging adjacent nerve roots

sequestrated disc (D)

nuclear material from intervertebral disc is separatedfrom disc itself and potentiallymigrates


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F11.10


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S&S

sharp pain & spasm at site of herniation; painshoots down extremity

walk in slightly crouched position, leaning awayfrom side oflesion

compression on spinal nerve

sensory &motor deficits alteration in tendon reflex


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F11.11


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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)SIGNSAND SYMPTOMS

L3L4(L4 root)

L4L5(L5 root)

L5S1(S1 root)

pain lumbar region and buttocks lumbar region, groin, andsacroiliac area

lumbar region, groin, andsacroiliac area

dermatome and sensory

loss

anterior midthigh over

patella, medial lower leg togreat toe

lateral thigh, anterior leg, top

of foot, middle three toes

posterior lateral thigh &lower

leg to lateral foot and 5th toe

myotome weakness ankle dorsiflexion toe extension (extensor hallux)

ankle plantar flexion(gastrocnemius)

reduced DTR quadriceps medial hamstrings Achilles tendon

straight leg raisingtest normal reduced reduced

management

significant signs: immediate physician referral

standard acute; activitymodification


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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd) lumbar fractures and dislocations

transverse or spinous process fracture

due to extreme tension from attached muscles

direct blow

additional injury to surrounding soft tissues

compression fracture hyperflexion crushes anterior aspect of vertebral

body

primary dangerpossibility ofbony fragmentsmoving into spinal canal, damaging cord or spinalnerves


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spinal cord endsL1 or L2 level

fx below not a serious threat, but handle w/ care to

minimize potential damage to cauda equina

management

fracture or dislocation: activate EMS

conservative treatment: initialbed rest, cryotherapy,

and minimizing mechanicalloads


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Sacrum and Coccyx ConditionsSacrum and Coccyx Conditions sacroiliac joint sprain

mechanisms

single traumatic episode involvingbending and/or

twisting repetitive stress fromlifting

fall on buttocks

excessive side-to-side or up-and-down motion

during running running on uneven terrain

suddenly slipping or stumbling forward

wearing new shoes or orthoses


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Sacrum And Coccyx Conditions (Contd)Sacrum And Coccyx Conditions (Contd) S&S

unilateral, dull pain that extends into buttock &posterior thigh

ASIS or PSISmay appear asymmetric bilaterally. leg-length discrepancy

pain w/ standing on one leg & stair climbing

forward bending reveals block to normalmovementw/ the PSIS on injured side moving sooner than

uninjured side pain w/ lateral flexion toward injured side

pain w/ straight leg raises beyond 45

management: standard acute;gentle stretching


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Sacrum And Coccyx Conditions (Contd)Sacrum And Coccyx Conditions (Contd)

coccygeal conditions

contusions and fractures

mechanism: direct blows

pain from fx maylast severalmonths

coccygodynia

irritation of the coccygeal nerve plexus

prolonged or chronic pain


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Sacrum And Coccyx Conditions (Contd)Sacrum And Coccyx Conditions (Contd)

management

analgesics use of padding for protection

ring seat to alleviate compression duringsitting


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Spinal AssessmentConscious IndividualSpinal AssessmentConscious Individual

history

important to ask questions about

pain location (i.e., localized or radiating)

type (i.e., dull, aching, sharp, burning)

sensory changes (i.e., numbness, tingling, or absence of

sensation) muscle weakness or paralysis


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Spinal AssessmentConscious IndividualSpinal AssessmentConscious Individual

observation/ inspection

postural assessment

scan exam

gait analysis

inspection of injury site

gross neuromuscular assessment


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Spinal AssessmentConscious Individual (Contd)Spinal AssessmentConscious Individual (Contd)

palpation

patient prone

pillow under the hip region to tilt the pelvis back andrelax the lumbar curvature

physical examination testing

if at anytime, movement leads to increased acute pain orchange in sensation, or the individual resists moving thespine, a significant injury should be assumed and EMSactivated


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Range of MotionRange of Motion

active range ofmotion (AROM)

cervical flexion

forward trunk flexion

trunk extension

lateral trunk flexion(left and right)

trunk rotation


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ROM (Contd)ROM (Contd)

active range ofmotion (AROM)

F11.14


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Normal ranges

forward trunk flexion4060

trunk extension2035

lateral trunk flexion (left & right)1520

trunk rotation3550


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passive ROM

seldom performed

resisted ROM

weight of the trunk will stabilize the hips


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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)

straight leg raising

well straight leg raising bowstring test

F11.18

sync w/ straight leg

F11.19

sync w/ bowstring


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Brudzinskis

Kernigs test

F11.20


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bilateral straight legraising

Valsalvas

Milgram test

piriformis muscle stretch

F11.21

sync w/ Milgram

F11.22

sync w/ piriformis


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prone knee bending

spring test for joint

mobility

F11.23

sync w/ prone knee

F11.24

sync w/ piriformis


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Farfan torsion test

trunk extension test

F11.25

sync w/ Farfan

F11.64

sync w/ trunk


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femoral nerve tractiontest

quadratus lumborumstretch test

F11.27

sync w/ femoral

F11.28

sync w/ quad


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single leg stance

quadrant test

F11.29

sync w/ single leg

F11.30

sync w/ quadrant


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Hoover test

Burns test

F11.31

sync w/ Hoover

F11.32

sync w/ Burns


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Sacroiliac compression &distraction test

approximation test

F11.33

sync w/ sacoiliac

F11.34

sync w/ approximation


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squish test

Faber (Patrick) Test

F11.35

sync w/ Faber


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Gaenslens test

long sitting test

F11.36

sync w/ Gaenslens


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Neurologic TestsNeurologic Tests

Babinski

Oppenheim

F10.27

this is not a mistake


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Neurologic Tests (Contd)Neurologic Tests (Contd)

myotomes

Nerve Root Segment Action Tested

L1L2 hip flexion

L3 knee extension

L4 ankle dorsiflexion

L5 toe extension

S1 plantar flexion of the ankle, foot eversion, hip extension

S2 knee flexion


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cutaneous patterns

F5.8



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referred pain

F5.1



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RehabilitationRehabilitation

relief of pain and muscle tension

AROM exercises vs. prolonged position

conscious relaxation training

Grade I and II mobilization exercises

restoration ofmotion

Grade III and IV mobilization exercises

flexibility and range-of-motion exercises

pelvic and abdominal stabilizing exercises


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Rehabilitation (Contd)Rehabilitation (Contd)

restoration of proprioception and balance

Closed-chain exercises

muscular strength, endurance, & power

neck strength

abdominal strength

erector spinae strength

cardiovascular fitness

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Anderson4e_Ch11_WithLectureNotes