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123 Cards in this Set

  • Front
  • Back
what are the congenital abnormalities of the LB
1) lumbarized sacral vertebrae
2) sacralized lumbar vertebrae
3) asymmetry of facet joints
describe a lumbarized sacral vertebrae
6 lumbar vertebrae present but S1 has the characteristics of a lumbar vertebra ... leaving only 4 sacral vertebrae
describe a sacralized lumbar vetebrae
4 lumbar vertebrae with L5 being fused to the sacrum
what is a consequence of the sacralized lumbar vertebrae
decreased mobility that we cannot regain
how is a congenital abnormality dx
radiographs - often found as part of a standard exam for back pain
what is important to remember about a congenital abnormality
they are nto always responsible for the problem at hand
what is the treatment for a congenital abnormality
- full detailed evaluation needs to be performed
- address problems based on findings keeping in consideration any relevant tx approac specific for the congenital abnormalities
what tx approach is used for congeintal abnormalities
problem oriented approach... so if decreased mobility, find a way to increase it somewhere else (i.e. hamstring stretch)
what is the general tx for individuals with 6 lumbar vertebrae
- use lumbar stability exercises due to excessive motion created by the additional moving segment
- use strengthening exercises, corset, postural correction
when is a traumatic fracture especially important to r/o
when we have direct access!
what are the S and S for a traumatic fx
- hx of trauma
what is the most important component of a possible traumatic fx
radiological exam is absolutely necessary to determine if there is a fx

a series needs to be taken of every patient who complains of spinal pain (post trauma)
what is the tx for a traumatic fracture
- restore strength, mobility, endurance, and function after healing occured
- possible immobilization in a rigid brace such as the BOB
- possibly surgery
how does osteoporosis cause a fracture (compression)
Osteoporosis is a metabolic process related to endocrine disorders, nutrition, and activity..... it leads to compression fractures of the vertebral body secondary to weakening of the bone
where are compression fractures due to osteoporosis most common
in the thoracic spine, but can be in the lumbar spine
what part of the vertebra does the fracture usually involve in osteoporosis
the anterior portion of the vertebral body (hopefully not affecting the nerve roots)
what are the S and S for a compression fracture due to osteoporosis
- (+) findings on a radiograph
- sharp, localized pain
- increased pain with flexion
- spinal abnormalities (prominent spinous process, marked kyphosis)
- possible nerve root compression signs
what would a single thoracic fracture reslt in
a FB fault of that vertebra causing a a prominante spinous process and increased interspinous space below that prominent spinous process
what is another name for a compression fracture of a single v. body
a wedge fracture, becasue it collapses in the front
what would multiple thoracic fractures result in
marked kyphosis of the t-spine
why is it unlikely to have nerve root compression signs
it is compressed anteriorly and the nerve root travels through the foramen located posteriorly
what is the treatment for a compression fracture
- education on harmful positions (i.e. teach to log roll out of bed)
- active and passive extension exercises
- good lumbar support in sitting to promote better sitting posture
- heat and electrical stim can help relieve discomfort
when should extension exercises begin for a patient with a compression fracture
as soon as the patients pain has decreased to the point that he/she can tolerate them
what should be avoided for a patient with a compression fracture
- all activities and positions involving spinal flexion
- sleeping in flexed positions
- using large pillows under head
what is the role of a spinal corset
maintain extension and prevent flexion
where does the corset get placed
depends on the fracture.... anywhere between sternal notch and pubis
when is the corset worn
worn when up in a chair or walking, not worn at night or when lying down
what is a spondylolysis
defect of the pars interarticularis of the nural arch of the vertebra
what is a spondylolisthesis
bilateral defect of the pars interarticularis with slippage of the anterior portion of the vertebra causing separation of the anterior and posterior elements
lysis = ________ whereas listhesis = _________
lysis = defect.... listhesis = slippage
what would you expect to see on a radiograph for a spondylolysis
collar on scotty dog
what would you expect to see on a radiograph for a spondylolisthesis
"decapitated dog"
where do BOTH of the spondys occur
at the pars interarticularis
what is the pars interarticularis
its the boney bridge between the super facets and inferior facets on the same vertebra
what is the etiology of a spondylolysis and/or spondylolisthesis
- congenital weakness of pars interarticularis occuring as a stress fracture ..... often related to athletics or vigorous activities during adolescence
what sports are more likely to cause a spondy
sports requiring hyperlordosis (gymnastics) and contact sports (football)
when is an evaluation for a possible spondlolysis indicated
in any teenager with a hx of back pain for >2-3 weeks
what is the imaging that should be used for dx a spondylolysis
bone scan because since its a stress fx, it may not appear on a radiograph until 3-4 weeks post injury
what would the "hot" spot on a bone scan reveal.... and how should this patient be treated
possibility of healing..... treat with bracing
what would a "cold" spot on a bone scan reveal..... and how should this patient be treated
a non-uniont has resulted..... bracing may be useful to reduce pain and provide stability to the segment but healing is unlikely to occur
where is a spondy most common and why
at L5 on S1 where the facets are in the frontal plane
what direction would the vertebral bodies move in a L5 on S1 spondylolisthesis
L5 moves anterior on S1
what is a grade 1 spondy
0-25% slippage of L5 on S1 (asymptomatic)
what is a grade 2 spondy
25-50% slippage, possible cord signs
what is a grade 3 spondy
50-75% slippage, most likely cord signs, should be fused
what is a grad 4 spondy
75-100% slippage, most likely cord signs should be fused
what does the grade denote for spondys
how far the top vertebra (L5) is displaced on the inferior vertebra (S1)
what grade is the lowest that should be palpable
grade 3 (grades 1 and 2 are not palpable, grades 3 -4 should be)
If there was a spondylisthesis of L5 S1 what would a palpation exam reveal
L4 would feel more anteriorly displaced over L5.... this is because the spinous process and inferior facets of L5 (fall below pars) stay put, while the sup facets and body (sup. to pars) move anterior causing everything in above to follow in chain-like fashion
what is the direction of a radiograph for a spondy dx
posterior oblique
what are the S and S for a spondy
- (+) radiographs
- step deformity in severe cases (L4 feels anterior to L5)
- hyperlordosis
- standing aggravates pain
- sitting relieves pain (especially slumped)
- neurological signs (if anterolisthesis)
what position can the step deformity caused by a spondy be felt in
standing and sidelying, step disappears when prone with pillow under stomach
when will a spondylolisthesis be the cause of the problem
only if the segment is unstable, if the segment is stable it may not be the primary cause of the problem for a patient to come in
what are the cord signs
- bladder/sexual dysfunction
- numbness in saddle area
- weakness >1 myotome
- numbness >1 dermatome
how could you differentiate between facet jt pain vs. spondy pain
facet joint is more localized vs. spondy pain which is not very easy to sort out
what is the treatment for a spondy
1) avoid stressful physical labor and vigorous sctivities
2) address posture (decrease lordosis)
3) abdominal strengthening
4) stretch hipflexors if tight
5) gentle flexion exercises
6) brace to possibly help reduce vertical forces
what can you recommend to a patient while standing to decrease the lordosis
use a step stool so 1 leg up causes a posterior roll in the pelvis
what must be considered when stretching the hip flexors for a patient with a spondy
stabilize the back to avoid the forward translation of the lumbar segment
what is lumbar central spinal stenosis
narrowing of the spinal canal which causes compression of the cauda equina
where does the spinal cord end
L4.... below L4 cauda equina!
what causes the symptoms in lumbar central spinal stenosis
vascular insufficiency of the cauda equina nerve roots
what is the difference between lateral spinal stenosis and central spinal stenosis
lateral refers to narrowing of intervertebral foramen compressing spinal nerve roots whereas central refers to narrowing of spinal canal compressing cauda equina nerve roots
what population is most likely to have lumbar central spinal stenosis
elerly >50s
what is the etiology for lumbar central spinal stenosis
- contenital deformity
- spondylosis/DDD/DJD (due to foloding or bulging of lig. flavum, thickening of lamina and vertebral body, ostephytes that diminish size of sc)
- disc protrusion (posterocentral)
- cancerous growth
what are the S and S for central spinal stenosis
- pain in low back and one or both legs
- numbess and tingling in feet and legs (not dermatome specific)
- motor weakness
- decreased DTR
- syptoms appear upon walking, relieved by rest and FB
- imaging showing reduction in size of sc
what is the hallmark of central spinal stenosis
exercising causes leg pain ... probably related to blood supply to nerve root- especially when more than one nerver root is involved and/or both sides
why does BB aggravate symptoms of central spinal stenosis
reduces volume of spinal canal and increases nerve root bulk ... also bulges lig. flavum
how can you differentiate central spinal stenosis from vascular intermittent claudication
VIC will not cause back pain and flexion does not relieve the pain
what tests could be used to differentiate between VIC and central spinal stenosis
Stoop test and bycycle test of vangelderen
what is the stoop test
1) walk until symptoms
2) rest in FB (measure time for relief of sympt)
3) repeat walking until symptoms
4) rest in extension (measure time for relief of sympt)
what are the results of a stoop test indicative of
if no difference in recovery time = vascular problem

recovery faster with FB position = spinal stenosis
what is the bicycle test of van gelderen
1) pedal with back extended until apparition of symptoms
2) continue pedaling with back in flexion
3) if pain alleviated with flexion, return to pedaling with back in extension
what are the results of the bicycle test of van gelderen indicative of
when pedaling with back in flexion...
pain will increase if vascular claudication
pain will decrease if spinal stenosis (then confirmed if returning to pedaling with back in extension returns symptoms)
what is the treatment for central spinal stenosis
conservative...
- educate patient to avoid activities aggravating the disorder
- lumbar support
- treat dysfunction, mobility
- avoid BB and teach relief of symptoms with FB
- severe cases- surgery
why do flexion exercises help with spinal stenosis if we cannot increase the canal size
because flexion increases the volume of the spinal canal, not the diameter
what is ankylosing spondylitis
inflammatory arthritic disorder characterized by progressive joint sclerosis and ligamentous ossification
where does ankylosing spondylitis first appear
first in SIJ later spreads into lumbar and t-spine and rib cage can eventually progress to complete ankylosis of the joints
ankylosing spondylitis may ease the pain but at what cost
leading to disability dependent on the fixed position of the joint
what affects the prognosis of ankylosing spondylitis
age.... younger patient is at onset = worse prognosis

gender.... men do worse than women
what is the incidence of ankylosing spondyliits in men vs. women
men 3x more likely to get it then women
what do 90% of people with anklyosing spondylitis have compared to only 10% of the general population
antigen HLA-B27
what are the S and S for ankylosing spondylitis
1) onset between 20-35
2) first appears as vague LBP with general stiffness especially in the AM
3) movement relieves stiffness
4) symptoms typically recurring with episodes lasting weeks or months
5) flattening of Lspine and increased rounding of Tspine
6) (+) signs of SIJ and L-spine calcification on radiographs
what is the tx for ankylosing spondylitis
- avoiding work that requires heavy work (as to not flare up the inflammatory process)
- education on posture and exercises to avoid fixed flexion deformity
what are the components to avoid a fixed flexion deformity
- sit and stand with lordosis
- avoid prolonged sitting and FB postures
- sleep on firm matress
- avoid using more than 1 pillow
- avoid lying curled up on your side
- ROM exercises for shoulders and hips
- gentle exercises and lumbar support to maintain proper mobility and posture
- medication and modalities during acute episodes
what is a coccyx injury
injury to sacrococcygeal joint includeing sprain, subluxation, and fractures
why is a coccyx injury very painful
because the area is highly innervated
why is the coccyx joint likely to become hypomobilie while healing
due to the sclerosing process
what is the etiology for a coccyx injury
direct trauma or childbirth
what are the S and S for a coccyx injury
- hx of direct trauma or child birth
- painful to palpation and hypomobilie
- unable to sit on both buttox at the same time
- increased pain in slouched posture
what are the treatments for a coccyx injury
- surgical removal likely if hypermobile or dislocated in flexed position
- if joint hypomobile or in extension use of US, mobilization techniques, and coccyx pillow can give good results
what is a true leg length inequality
actual asymmetry due to a fx, growth abnormalities, coxa vara/valga with a difference >0.5 inche (1cm)
what is a functional leg length inequality
asymmetry due to improper alignment of structures (unilateral foot pronation, genu valgus, tightness of adductor muscles, SIJ lesions)
what are the S and S of a true leg length inequality
- iliac crests and g. trochanters will be differnt height in standing and tests implicating SIJ will be negative
what is the consequence of a leg length difference
lumbar scoliosis with convexity TOWARD SHORT LEG
what consequences would you expect on the side of the concavity (longer leg)
adaptive muscle shortening, ligamentous and capsular hypomobility, DJD of facet joints
what consequences would you expect on the side of the convexity (short leg)
osteoarthritic spurring of the facet joints and disc protrusion is promoted
what is the first step to treating a leg length difference
must determine the cause true or functional

if functional correct the cause or use a lift under short side.

if true use a lift under short side
before correcting the leg length difference what must have already been treated/restored
mobility, strength and normal posture
what does the correction of the leg lenght's effect on the scoliosis tell us
if correcting leg lenght does not correct the scoliosis then it will likely create new difficulties because structureal changes may have taken place in the back
if the leg length difference is > 0.5 inche, what should the initial correction be
half of the measured difference
when can a correction for leg length be made inside the shoe
if the lift is 3/8 inch or less
when can a correction for the leg length be made outside the shoe
if lift is >3/8 inch
what are some examples of systemic diseases that can cause back pain
venereal disease, gout, lupus erythematosus, RA and urological infections, also metastatic lesions and visceral structures
what are the red flags indicative of systemic disease or referred pain
- pain increasses with rest
- not associated with specific movements or positions
- insidious onset
- covers large areas
- migrates and/or is not well defined
- no hx of trauma
- lack of objective findings on investigation
- do not respond to physical therapy in a timely manner
how do you proceed if you suspect a patient has a visceral or systemic disorder
still treat with "safe" procedures such as correction of posture, education on lifting, gentle ther ex, and make contact with physician for proper screening
- AVOID modalities and mobs
what are the benign tumors that can result in severe back pain
1) osteoid-osteoma
2) hemangloma
3) meningloma
4) neurinoma
what is an osteoid-osteoma
found in bone, may cause severe back pain, especially at night
- relieved by aspirin and excision of the tumor
what is a hemangloma
extradural tumor, may enlarge and press on the spinal cord leading to pain and dysfunction
- excise tumor
what is a meningloma
benign extramedullary intradural tumor (within dura but not SC)
- enlarges to produce severe symptoms needs surgery
what is a neurinoma
benign intramedullary intradural tumor that can impair spinal cord function
when can a correction for leg length be made inside the shoe
if the lift is 3/8 inch or less
when can a correction for the leg length be made outside the shoe
if lift is >3/8 inch
what are some examples of systemic diseases that can cause back pain
venereal disease, gout, lupus erythematosus, RA and urological infections, also metastatic lesions and visceral structures
what are the red flags indicative of systemic disease or referred pain
- pain increasses with rest
- not associated with specific movements or positions
- insidious onset
- covers large areas
- migrates and/or is not well defined
- no hx of trauma
- lack of objective findings on investigation
- do not respond to physical therapy in a timely manner
how do you proceed if you suspect a patient has a visceral or systemic disorder
still treat with "safe" procedures such as correction of posture, education on lifting, gentle ther ex, and make contact with physician for proper screening
- AVOID modalities and mobs
what are the benign tumors that can result in severe back pain
1) osteoid-osteoma
2) hemangloma
3) meningloma
4) neurinoma
what is an osteoid-osteoma
found in bone, may cause severe back pain, especially at night
- relieved by aspirin and excision of the tumor
what is a hemangloma
extradural tumor, may enlarge and press on the spinal cord leading to pain and dysfunction
- excise tumor
what is a meningloma
benign extramedullary intradural tumor (within dura but not SC)
- enlarges to produce severe symptoms needs surgery
what is a neurinoma
benign intramedullary intradural tumor that can impair spinal cord function
what is the difference between a primay and secondary malignant tumor
primary: arises locally in a specific bone or neural tissue

secondary: metastatic spread, extremely common due to rich blood supply
what is the most common malignant tumor in the back
multiple myeloma which invades and replaces cancellous bone, causeing low back pain
what structures may be involved in a benign tumor
bone, soft tissue, neural structures