Lumbar Spine Applied Anatomy

Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education

1

Objectives

Apply key concepts from the cervical anatomy/kinesiology self-study to aid in differential diagnosis for the following:– Lumbar radiculopathy– Lumbar disc and joint disorders– Lumbar “instability”

2

RADICULOPATHY

3

Pathophysiology of Radiculopathy

Tension event associated with protrusion prolapse extrusionprotrusion, prolapse, extrusion

Compression event associated with degenerative disc changesdisc changes

Sizer et al, Pain Practice, 2001

4

Protrusion Prolapse

Increasing degree of annular damageannular damage

Increasing presence of neurological signsof neurological signs

Increasing potential for rapid and complete eradication– In-growth of vascular

supply into fissuresupply into fissure

Winkel et al 1997 5

Locations of Protrusion and Prolapse

Shoulder lesionL t l t t– Lateral to nerve root

– Typically shift laterally away from painy p

– Pain with ipsilateral sidebendingBest treated with traction– Best treated with traction

6

Locations of Protrusion and Prolapse

Axillary lesionM di l t t– Medial to nerve root

– Lateral shift variable– Pain with contralateralPain with contralateral

sidebending– Traction may worsen

conditioncondition Cyriax 1989

7

Degenerative Disc Disease

L4-5 and L5-S1– Decreased nuclear hydrostatic

pressure and disc height with agingaging

– Opposite effects at L3-4 and above

– Leads to lower lumbar accelerated degeneration Sizer et al 2001 Sizer et al 2001

8

Differential Diagnosis of Differential Diagnosis of Radiculopathy

Herniated discP i ith itt l l– Pain with sagittal plane movements, typically flexion

– Most common at L4/5 and L5/S1 levels Oblique orientation of L5-q

S1 articular surfaces Allows for more transverse

plane motion– L4/5 posterolateral

herniation affects L5 root9

Differential Diagnosis of Differential Diagnosis of Radiculopathy

Degenerative disc diseaseP i ith f i l l i– Pain with foraminal closing

– Most common at L4/5 to L5/S1 levels Site of degenerative changes Long and narrow IVF (L5-S1) Thickest lumbar root (L5)( )

– Sizer et al 2001

– L5/S1 stenosis affects L5 rootroot

10

LOCAL LUMBAR PAIN: DISC VS JOINT

11

Pathophysiology of Local Lumbar Pain

Disc disordersDi h i ti L4/5 d– Disc herniation L4/5 and L5/S1

– Degenerative disc gdisease

Joint disordersZygapophyseal joint– Zygapophyseal joint

Symbiotic relationship evident in biomechanics

12

Screening for Spondylarthopathies

Berlin CriteriaM i tiff >30 i

IBP according to expertsA t t <40– Morning stiffness >30mins

– Decreased LBP with exercise but not rest

– Age at onset <40– Insidious onset– Improved with exercise

– Awakening due to LBP in 2nd half of night

– Alternating buttock pain

– Not improved with rest– Night pain, decreased with

getting up

– Postive test: ≥ 2/4– SP: .81, SN: 70

g g p

– Positive test: ≥ 4/5SP: 72 SN: 8SP: .81, SN: 70

– Haskins et al, 2015

– SP: .72, SN: .8

13

Differential Diagnosis of Disc Disorders

Disc herniation L4/5 and L5/S1Acute lateral shift positional fault– Acute lateral shift positional fault

– Pain with sagittal plane motions– Change with repeated movements

Dural tension testing– Dural tension testing Degenerative disc disease

– Biggest predictor is age, greater than 45– No consistent distinguishing pattern of ROM

loss or provocation Zygapophyseal joint

– Pain with 3-D motion testing – Pain relieved with flexion

14

Repeated Movements

Centralization occurs in 80-100% of persons with a100% of persons with a positive discogram

35-40% of those failing to gcentralize still had positive discogramCompetent annulus found in Competent annulus found in 91% centralizers and 54% peripheralizers

– Laslett et al, 2005– Donelson et al, Spine 199715

Repeated Movements

Non-centralizers more likely at one year post-treatment to

– Not return to work– Continue to report pain– Report increased disability– Use healthcare resourcesUse healthcare resources

Werneke and Hart, Spine 2001

Centralizers have good prognosis for recovery withprognosis for recovery with conservative care

– Aina et al, Man Ther 2004

16

INSTABILITY

17

Pathophysiology of Instability

Multisegmented spinal motionmotion

– Greatest degree of motion occurs at most flexible

tsegment– Dysfunction occurs more

readily at flexible t th i fl iblsegments than inflexible

segments

18

Pathophysiology of Instability

Deep muscles control intersegmental motion andintersegmental motion and stability

– TRA/Deep multifidus fires in advance of arm movement, independent of direction

Delayed firing in deep system with arm movements in patients with a history of LBP

– Hodges and Richardson, Spine 1996; Moseley et al, S i 2002Spine 2002

19

Pathophysiology of Instability

Multifidus fat infiltration and atrophy strongly associated p y g ywith LBP

– Kjaer et al, BMC Med 2007 Recovery not automatic after

fi t ti i d f LBPfirst time episode of LBP– Significantly higher

recurrence rates of LBP in a control group versus g pstabilization group at 2-3 year followup Hides et al, Spine 2001

20

Differential Diagnosis Instability

Directional Susceptibility to Movement (DSM)Movement (DSM)– Uni-planar motion

Extension Flexion Rotation

Combined motion– Combined motion Extension-Rotation

– >50% of patients (Van Dillen et al PT 2002)al, PT 2002)

Flexion-Rotation

Sahrmann 200221

Forward Bending Rhythm and Range

FlexionPosterior sway with hip flexion– Posterior sway with hip flexion

– Lumbar flexion– Hip flexion

Ret rn Return– Hip extension– Hip and spine extension

Ranges– Lumbar flexion mean 56deg – 75-80deg hip flexiong p

22

Extension Syndrome

Patient > 55 Relief with lumbar flexion Hypertrophied/tight back extensors

and hip flexors Lumbopelvic rhythm impaired

Return from flexion initiated with– Return from flexion initiated with back extension

– Symptoms decrease when cued to lead with hip extension

A ti t i ht l i ( d Active straight leg raise (prone and supine)

– Anterior pelvic tilt and LBP Passive knee flexion (prone) or hip (p ) p

extension increases anterior pelvic tilt and LBP

Weak abdominals and gluteals23

Flexion Syndrome

Patient 18-45 Impaired LP rhythm and range Impaired LP rhythm and range

– Leads motion with lumbar flexion– Limited hip flexion and increased

lumbar flexion– Symptoms decrease when cued

to only allow hip flexion Passive hip flexion leads to spine

flexion/pain before 120degflexion/pain before 120deg Tight hip extensors Dominant lower abs Weak back extensors and hip Weak back extensors and hip

flexors

24

Rotation Syndrome

Paraspinal fullness of greater than ½ inch on one side

Asymmetrical sidebending/rotation

Early pelvic rotation on bent knee fall outknee fall out

Sidelying painful, decreased with towel under waist

Active SLR painful with lateral l i tilt f t l lpelvic tilt frontal plane

Passive hip rotation painful before end range

Tight hip abductors, rectusTight hip abductors, rectus abdominus, and back extensors

Weak obliques and hip adductors 25