Nycc Flexion-Distraction Midterm Mollin Sp2012

Front 1

Yong-Hing & Kirkaldy Willis Degeneration 3 stages: 1. 2. 3.

Back 1

1. DYSFUNCTION (tx more likely to succeed; subtle findings) 2. INSTABILITY (abnormal movements; more severe pain) 3. STABILIZATION (instability + stabilization are challenging to treat; severe degeneration of disc + facet may reduce movement;some improv

Front 2

INSTABILITY means

Back 2

too much movement

Front 3

INSTABILITY is caused by

Back 3

*Instability means too much movement Caused by ligament laxity, disc degeneration (floppy!), compression of the disc, shear on Z-joints

Front 4

FLEXION and ROTATION are _____ for the disc.

Back 4

BAD Torsion/bending and compression are tolerable individually but TOGETHER make spine VULNERABLE

Front 5

In a HEALTHY DISC, the ________ _______s and ______ provide significant RESISTANCE to rotation

Back 5

FACET JOINT & DISC

Front 6

X-ray signs of INSTABILITY

Back 6

Vacuum sign, Spondylolisthesis, retrolisthesis, traction spurs, visible excessive rotation, laminectomy, gas

Front 7

High intercrestal line passing through UPPER HALF of L4

Back 7

L4/L5 degeneration Other criteria: long TP on L5, transitional segment

Front 8

Intercrestal line passing through the BODY of L5

Back 8

L5/S1 degeneration Other criteria: short TP of L5 and NO transitional segment

Front 9

Short leg on the right

Back 9

a. vertebrae are CONVEX on right (functional scoliosis) b. Discs are compressed on CONCAVE side (left) w/ tensile load on opposite side (right) c. Disc bulges on compressed side-long leg side into concavity

Front 10

DRG irritation is mainly _________

Back 10

Radiculopathy *also muscle-like sx if not sensitized

Front 11

Hallmark signs of CHEMICAL RADICULITIS/Inflammatory radiculopathy

Back 11

Extremity pain and symptoms Minimal LBP Nerve root tension signs and neuro symptoms often ABSENT

Front 12

REFERRED pain

Back 12

Comes from connective tissue (non-myotogenous) SCLEROTOGENOUS associated with the tissues' embryonic relationship

Front 13

What part of the spine is most vulnerable to Mets?

Back 13

LUMBAR

Front 14

Most common malignancy of the spine?

Back 14

Secondary mets

Front 15

Case study: patient develops leg pain that is relieved with flexion and exacerbated with extension...

Back 15

STENOSIS

Front 16

ACUTE back sprain

*type and description of injured tissues

Back 16

Type I:
Injury to peripheral annular fibers and other posterior ligaments or mm/tendon structures; vertebral endplate fractures.

Front 17

ACUTE back sprain

*type and clinical picture

Back 17

Type I:
Specific incident - hx of sudden additional load, acute pain, MS, referred pain, negative SLR

Front 18

ACUTE back sprain

*type and treatment

Back 18

Type I:
Rest, analgesics, CMT
Distraction, manipulation as tolerated

Front 19

ORGANIC or IDIOPATHIC FLUID ingestion

*type and description of injury

Back 19

Type 2:
Sudden passage of fluid into NUCLEUS PULPOSIS

May account for large portion of BP with no dx or cause

Front 20

ORGANIC or IDIOPATHIC FLUID ingestion

*type and clinical picture

Back 20

Type 2:
Back Pain & Muscle Spasm (BP&MS)
NO referred pain
NO sciatica
NO SLR

Front 21

ORGANIC or IDIOPATHIC FLUID ingestion

*type and treatment

Back 21

Type 2:
Bed rest, analgesics, CMT
Distraction, manipulation as tolerated

Front 22

PL ANNULUS disruption

*type and description of injured tissue

Back 22

Type 3:
Failure or disruption of some of the annular fibers.
Referred pain IS caused by stimulation of annular nociceptors by mechanical or chemical irritants.

Front 23

PL ANNULUS disruption

*Type and clinical picture

*also known as?

Back 23

Type 3:
Back pain, pain in HIP/SI/BUTTOCK
Pain in posterior upper thigh
Negative SLR

"REFERRED SCIATICA"

Front 24

PL ANNULUS disruption

*type and treatment

Back 24

Type 3:
bed rest, analgesics, CMT
Distraction, manipulation as tolerated

Front 25

BULGING DISC

*type and description of tissue injury
*what also may be present regarding conditions?

Back 25

Type 4:
Protrusion of the nucleus pulposis, which REMAINS COVERED BY SOME ANNULAR FIBERS, and possibly the PL
*'TRUE ACUTE SCIATICA" may be present w/ mechanical and/or chemical irritation of nerve roots.

Front 26

BULGING DISC

*type and clinical picture

Back 26

Type 4:
Pain may be in the Low Back, buttock, thigh, lower leg, foot

POSITIVE SLR
POSITIVE pain on coughing/sneezing/straining (DeJerine & Valsava)

Front 27

BULGING DISC

*type and treatment

Back 27

Type 4:
Rest, analgesics
Distraction, manipulation, CMT

Front 28

SEQUESTERED FRAGMENT [unanchored]

*alias, type, and injured tissue

Back 28

Type 5: WANDERING disc material
Nuclear material that is sequestered within the annular fibers and can move about randomly

Can cause combination of no pain, back pain, radicular pain and true radiculopathy.

Front 29

SEQUESTERED FRAGMENT
[unanchored]

*type, alias, and clinical picture

Back 29

Type 5: WANDERING disc material

Exacerbations
Remissions
Good response to CMT, traction/manipulation, surgery

Front 30

SEQUESTERED FRAGMENT
[unanchored]

*type, alias, and treatment

Back 30

Type 5: WANDERING disc material
Rest, analgesics
CMT, traction/manipulation
Surgery

Front 31

DISPLACED sequestered fragment
{anchored}

*type and tissue injured

Back 31

Type 6: ANCHORED

Displacement of a sequestrum of annulus or nucleus into the spinal canal or IVF.
Fragment is to some degree 'fixed' or anchored in position

Front 32

DISPLACED sequestered fragment
{anchored}

*type, alias, and description of nerve root problem

Back 32

Type 6: ANCHORED

Nerve root irritation from mechanical, chemical, an autoimmune response or some combination of the 3

"TRUE SCIATICA" w/ (+) SLR !!!

Front 33

DISPLACED sequestered fragment
{anchored}

*type and clinical picture

Back 33

Type 6:
Back Pain, increased with coughing/sneezing/straining
TRUE sciatica
POSITIVE SLR

Front 34

DISPLACED sequestered fragment
{anchored}

*type and treatment

Back 34

Type 6:
Rest, analgesics, SURGICAL EXCISION
Traction and manipulation may help
***BEST RESULTS = SURGERY

Front 35

DEGENERATIVE DISC

*type and tissue injury description

Back 35

Type 7

disruption of normal annular fibers to such an extent that he disc is no longer able to serve adequate mechanical fcn

Front 36

DEGENERATIVE DISC

*type and clinical picture

Back 36

Type 7:
Pain may be chronic, intermittent or absent

May or may not have sciatica or spinal stenosis

Osteophytes and narrowing

Front 37

DEGENERATIVE DISC

*type and treatment

Back 37

Type 7:

Bed rest, analgesics, arthrodesis
Traction/Manipulation, CMT

Front 38

CASE STUDY: patient has lower extremity pain after surgery

Cause?
Imaging?

Back 38

Cause: DISC or SCAR tissue

Imaging: CT w/ CONTRAST to d/dx

Front 39

Imaging for CAUDA EQUINA syndrome

Back 39

MRI

Front 40

Facet Tropism

Back 40

The plane in which the facets face

(sagittal, coronal, opposing)

Front 41

Facet Tropism L1-L5

Back 41

SAGITTAL orientation

Good for FLEXION/EXTENSION (same plane as sagittal)

Front 42

Facet Tropism L5/S1

Back 42

CORONAL

Good for LATERAL FLEXION (same plane as coronal)

Front 43

When facet tropism involves opposing planes?

Back 43

One coronal, one sagittal...puts excessive stress on the annular fibers of the IVD and the facets themselves

MORE VULNERABLE SIDE: SAGITTAL facet side

Front 44

In an opposing facet tropism situation, which side is more vulnerable?

Back 44

SAGITTAL

Front 45

Which posture decreases stress on the majority of the spinal facets?

Back 45

FLEXED posture decreases FACET strain but increases anterior annulus strain

(elderly people are most comfortable in flexed posture)

Front 46

Flexion gives the lumbar spine a high ___________ strength.

3 main advantages to flexion when lifting heavy load...

Back 46

COMPRESSIVE

*improved metabolite transport
*reduced stress on facet joints and posterior annulus fibrosis
*gives spine high compressive strength

Front 47

Most PAIN SENSITIVE LUMBAR spine structure

Back 47

ANNULUS FIBROSIS

*OUTER IVD is tissue of origin in most cases

Front 48

Internal disc derangement

Back 48

breaking down from the inside out (an American made car)

Front 49

Most patients with LPB see

Back 49

their PCP

Front 50

How long do you hold each flexion [contract-distract] in the TOLERANCE TEST?

Back 50

4 seconds

Front 51

COMPLICATIONS of manipulation

Back 51

1. VBA
2. myelopathy
3. cauda equina syndrome
4. stiffness, sprain/strain, fx

Front 52

Most pain sensitive structure in low back?

Back 52

IVD (specifically the outer annulus fibrosis)

Front 53

How should your lumbar lordosis be when lifting heavy objects?

Back 53

Slightly flattened

*lumbars withstand compressive loads in slightly flexed postures

Front 54

What 3 things attenuate shearing forces?

Which other thing promotes disc prolapse?

Back 54

Attenuating (slowing/stopping) shear:
1. Disc
2. Tropism
3. Coronal facets

SAGITTAL facets PROMOTE disc PROLAPS

Front 55

Where does FLEXION mainly occur? By what percentage?

Back 55

75% of flexion @ L5-S1

Front 56

The more ANTERIOR ANGULATION (forward tilt/AS ilium) of the pelvis, the more _______ stress of ___ on the ________.

Back 56

SHEARING STRESS of L5 on the sacrum

Front 57

When a patient has an anomalous (oddly) facing facet, they are at higher risk for developing a disc lesion on _________.

Back 57

ROTATION

and anomalous facets = bad news in rotation

* 1 in 5 people/patients has an asymmetric orientation or articular facets at a single level

Front 58

Compression is greater in the ___________-facing facet.

Back 58

OBLIQUELY

Front 59

What kind of facet tropism promotes disc PROLAPSE?

Back 59

SAGITTAL = promotes prolapse

Front 60

arthropathy = ________ facet tropism

disc problems = _________ facet tropism

Back 60

arthropathy (osseous djd) = coronal

disc problems (prolapse) = sagittal

Front 61

_________ facet facings are mainly in upper lumbar spine.

________ facet facings are typical in the lower lumbar spine.

Back 61

upper = sagittal (disc prolapse)

lower = coronal (arthropathy)

Front 62

When facet facings are symmetrical (no anomalous facet tropism), then forces are distributed evenly.
If there is a more coronal side, then the ________ is vulnerable.
If there is a more sagittal side, then the ________ is vulnerable.

Back 62

coronal facing - facet more vulnerable

sagittal facing - disc (prolapse) more vulnerable

Front 63

spondylosis

IMPORTANT CONCEPT CARD

Back 63

degeneration of IVD (body, disc)

*ergo, sagittal predominance of upper lumbar verts leaves them open to disc prolapse/spondylosis

Front 64

spondyloarthrosis

IMPORTANT CONCEPT CARD

Back 64

degeneration of facets themselves

*therefore coronal facets dominate the lower lumbar and put them at risk for facet arthropathy/spondyloarthrosis

Front 65

2 basic causes of low back pain

Back 65

internal derangements of IVD

irritation of z-joints

Front 66

LBP arising from the ______ is more common than pain arising from the ___________.

Back 66

DISC = pain more common (upper lumbar)

than the facet joints

Front 67

chemical radiculopathy

Back 67

when the nucleus pulposis produces inflammatory chemicals

(not for Dr. Bloom's class - more involved explanation)

Front 68

Muscle strain is really...

Back 68

disc disruption

It requires a mechanism.
C5-C6 most common cervical.

Front 69

Describe axial rotation in the cervical spine.

When axial rotation is coupled movement?

Back 69

70% occurs between C0-C2 (horizontally oriented facets at C1-C2)

With rotation, coupled lateral flexion in same direction (the PLS or PRS listing) occurs BELOW C2-C4 level.

Front 70

Describe the axial rotation of the cervical spine above C2-3 level

Back 70

With axial rotation, in the OPPOSITE direction.

(vs axial rotation below C2-4 occurring same direction)

Front 71

Describe movement in lower cervicals

Back 71

Flexion coupled with rotation below C5-6

Extension coupled with rotation C4-5

Front 72

Disadvantages of flexed posture on lumbar spine

Back 72

increase stress on ANTERIOR annulus

increase hydrostatic pressure on the nucleus pulposis at LOW load levels

Front 73

List the cervical motions and their levels (5)

Back 73

70% of total axial rotation occurs between C0-C2 (horizontally oriented facets at C1-2)
With rotation, coupled lateral flexion in SAME direction BELOW C2-4
In the OPPOSITE direction above the C2-3 level
Flexion coupled with rotation BELOW C5-6
Extension coupled with rotation ABOVE C4-5

Front 74

What is the water content of the NUCLEUS between the ages of 30-40

Back 74

80% water content, ages 30-40

Front 75

The nucleus pulposis bears ________ loads.

The annulus fibrosis bears _____ loads.

Back 75

NP = VERTICAL load

AF...tangential load

Front 76

Ratio of anterior to posterior
weight bearing forces of the vertebral body?

Back 76

15:1
anterior to posterior

Front 77

Lifting a 150lb load with the arms extended places a ______lb load on the nucleus pulposis.

Back 77

1500

Front 78

Degeneration of the IVD and subsequent changes in adjacent vertebrae and ligaments is called?

Back 78

spondylosis

*must occur in upper lumbar where sagittal facet tropism is the norm and disc prolapse is the risk

Front 79

An injury to the disc affects overall spinal mechanics.
TEST QUESTION...
List the 6 stages of injury at one functional spinal unit [FSU]:

Back 79

1. ASYMMETRIC DISC injury at one FSU
2. Disturbed KINEMATICS of FSU's above AND below injury
3. ASYMMETRIC MOVEMENTS at the FACET joints
4. UNEQUAL sharing of FACET LOADS
5. HIGH LOAD on ONE FACET joint
6. CARTILAGE degeneration, and/or facet ATROPHY and nNARROWING of the IVF

Front 80

Disc PROTRUSION

Back 80

Protrusion:
CONTAINED
INTACT
HIGH INTRADISCAL PRESSURE
STRONG VALSALVA's (and DeJerine) due to high intrad. press.
BACK PAIN > lower extremity pain

Front 81

Disc PROLAPSE

Back 81

UNCONTAINED
EXTRUDED nuclear material
CHEMICAL radiculopathy
LOWER EXTREMITY PAIN > back pain (may be no pain at all!)
BETTER PROGNOSIS due to mounted immune response to nucleus' material. Body resorbs.

Front 82

Which has better prognosis, a disc protrusion or a prolapse? Why?

Back 82

PROLAPSE (a protrusion of nuclear material that is uncontained).

Greater immune response mounted by body to pulposis contents. Body resorbs it. Better prognosis.

Front 83

Two typical tears of the annulus

Back 83

Radial (like spokes)

Circumferential (along round border)

Front 84

A study showed a correlation between the cervical spine joints, discs, and ligaments, making the connection that a HEADACHE can come from ?

Back 84

Cervical spine dysfunction CAN cause HEADACHE

Front 85

Regarding cervical disc nerve supply, the cervical disc is PAIN _________

Back 85

SENSITIVE

This is proved by DISCOGRAPHIC examination.
Injured or diseased discs are MORE pain sensitive.

Front 86

What is the mechanism of cervical disc nerve pain?

Back 86

DAMAGE to innervated portions of annulus

INTACT portions start BEARING MORE WEIGHT than normal

Front 87

What causes the inflammatory changes around an injured disc?

Back 87

Nucleus pulposis material leaking out irritates area and causes chemical radiculitis.

Front 88

There is abundant nerve supply to the cervical disc.

What 2 nerves supply the cervical disc?

Back 88

1. VERTEBRAL (supplies anterior half; autonomic root from sympathetic cervical chain ganglion)

2. SINUVERTEBRAL (supplies posterior half)

Front 89

From where does the SINUVERTEBRAL nerve arise to innervate C3-8?

Back 89

SOMATIC & AUTONOMIC ROOTS

Front 90

Most common disc protrusion site

Back 90

posterolateral

Front 91

Lateral Lean away

M-int

Back 91

Lateral disc lesion (disc protruding on top of and to the outside of a nerve would cause patient to lean away)

Medial disc protrusion is under and to inside of nerve, so patient would lean INTO the side of the lesion to lift nerve off of protrusion underneath it)

Front 92

Posterior of the disc is supplied by the _______ nerve.

Back 92

SINUVERTEBRAL

Front 93

The lateral and anterior half of the disc is supplied by the _________ nerve.

Back 93

VERTEBRAL
(sympathetic ganglion chain)

Front 94

Remembering that the SINUVERTEBRAL nerve innervates the posterior portion of the disc, what other elements does it innervate?

Back 94

PLL, posterior disc
Periosteum of pedicle and vertebral body
Epidural veins and dural matter

Front 95

Each SINUVERTEBRAL nerve sends a large branch to the disc immediately ________ it.

Back 95

below

Front 96

C3 sinuvertebral (posterior half of disc supply) joins C1 & C2 sinuvertebral nerves to supply the ____and ____ dura.

Back 96

C1-2 & C0-1 dura

(not sure if this is a test question - it's from the review sheet someone made)

Front 97

When the LIGAMENTUM FLAVUM is hypertrophied, it leads to ________ and is relieved by ______.

Back 97

stenosis

relieved by flexion

Front 98

Some patients may respond better to _______ than flexion exercises.

Back 98

extension

Front 99

Is disc displacement necessary for pain to occur?

Back 99

NO
There only needs to be damage, even if it's internal

Front 100

Case study:
Patient has muscular injury

Back 100

a. Usually 1-sided pain
b. Often sore in morning and after rest
c. Tender over injury

Front 101

DISCOGRAPHY

Back 101

Radiopaque dye injected then imaged
Used in stubborn cases or high suspicion
Used as a LAST RESORT

Front 102

Mechanics of FLEXED posture on annulus

Back 102

Stretched POSTERIOR ANNULUS

Compresses ANTERIOR ANNULUS

Front 103

L5-S1 disc lesion compresses nerve root (NR) _____

Back 103

S1

Front 104

L4-L5 disc lesion compresses NR ____

Back 104

L5

Front 105

FAR LATERAL disc herniation or fragmentation can compress the NR exiting its foramen.
Thus, a far lateral L5-S1 fragment would compress the ____ nerve root.

Back 105

L5

Front 106

L3-L4 disc lesion usually compresses the ____ nerve root

Back 106

L4

Front 107

TIBIAL portion of sciatic n. innervates the?

Back 107

PLANTAR surface of foot
POSTERIOR CALF

Front 108

COMMON PERONEAL portion of sciatic n. innervates the?

Back 108

L5 innervates DORSUM (extensor hallucis brevis mm. test in MRS)

ANTEROLATERAL leg (think peroneus for peroneal n.)

Front 109

S1 nerve root would be compressed by what disc level?
Describe this presentation:

Back 109

L5-S1disc herniation compressing S1 nerve root:
S1 dermatome pain
Absent or diminished Achilles reflex
Calf muscle weakness
SLR (+)

Front 110

L5 nerve root would be compressed by a disc herniation at what level?
Describe this presentation:

Back 110

L4-L5 disc herniation would compress the L5 nerve root:
L5 dermatome pain
Hamstring reflex diminished
Extensor hallucis, Tibialis anterior mm weakened
SLR (+)

Front 111

The Achilles reflex is often diminished when there is a disc herniation at L4-L5 (37%) or one at L5-S1 (67%). At what level can the herniation cause the Achilles reflex to be altogether ABSENT?

Back 111

L5-S1

Front 112

L4 nerve root compression would be caused by disc herniation at what level?
Describe presentation:

Back 112

L3-L4 disc herniation would compress L4 nerve root:
Anterior FEMORAL pain
Weak QUADS
Diminished PATELLAR REFLEX
SLR usually NOT positive

Front 113

After age 30, the SLR test may be normal in cases of ?

Back 113

true disc herniation

Therefore, do not rule out HNP just because SLR is negative on someone over 30

Front 114

How to diagnose SCIATICA due to a HERNIATED nucleus pulposis (HNP)?

Back 114

UNILATERAL leg pain worse than low back pain
SINGLE nerve ROOT signs
SLR 50% diminished on involved side but 97% positive on a CROSSED SLR
(+) neurologic signs: mm weakness, sensory deficit, reflex changes
Positive imaging (MRI, CT, etc.)

Front 115

What 2 clinical signs give us an 86% positive diagnosis of a disc herniation?

How about getting a 95% accurate diagnosis?

Back 115

Positive SLR + Neurologic signs = 86% accurate for HNP

Add the above with imaging = 96% accuracy for HNP diagnosis

Front 116

Pudendal Plexus Compression: What nerve roots?

Back 116

S2-3-4

Can result in perineal, scrotal, penis or labial pain, anal sphincter innervation

Front 117

Disc compression of nerve roots at S2-3-4 can result in?

Back 117

(Pudendal Plexus compression): infertility, miscarriages, infection of kidney/urinary bladder/fallopian tubes/ovaries/prostate

(don't know if test question)

Front 118

Neurological complication of NRC

Some examples?

Back 118

Urinary incontinence w/ LBP
Bladder dysfunction w/ lumbar stenosis
L5 nerve root compression of DRG caused 50% reduction in nerve impulses

Front 119

Neuro complications of Nerve Root Compression:
1. ____ _____ syndrome
2. ________ numbness
3. _______ difficulty
4. _____ _____ weakness
5. bilateral _____-like dysthesias of pelvis and lower extremties

Back 119

1. CAUDA EQUINA syndrome
2. PERINEAL numbness
3. URINARY difficulty
4. ANAL SPHINCTER weakness
5. bilateral SADDLE-like dysthesisa

Front 120

Nerve root affecting Achilles reflex

Back 120

S1:
calf mm weakness
SLR positive
absent or diminished Achilles' reflex
L5-S1 disc herniation
S1 dermatome

Front 121

Visceral conditions from disc lesion:

Back 121

INCONTINENCE
BLADDER/BOWEL DYSFUNCTION
INTERSTITIAL CYSTITIS
ANYTHING in Lumbar area (REPRO, KIDNEYS, PROSTATE)

Front 122

SUB-RHIZAL antalgia

Back 122

FLEXED posture

Front 123

Intradiscal pressure from greatest to least postures:

Back 123

SITTING
UPRIGHT
SIDELYING
PRONE

Front 124

At which stage of disc degeneration (dysfunction, instability, or stabilization) is STENOSIS probable?

Back 124

STABILIZATION STENOSIS

*stiff, loss of flexibility. Severe degenerative changes of disc and facet reduce motion. Improvement may be experienced.

Front 125

What kind of pain does internal disc derangement cause?

Back 125

REFERRED/SCLERATOGENOUS

Neurologic signs are not present.
Nucleus pulposis protrudes into inner rings of annulus, causing LBP.
Buttock, posterolateral thigh, groin.

Front 126

If the disc protrudes towards the middle and periphery, then causes?

Back 126

Low Back Pain

Front 127

Why can there be no neurologic signs (at least not lower motor neuron) unless there is an external herniation of disc?

Back 127

Because something has to compress/impact the DRG to create LMN signs.

Front 128

FARFAN's 3 stages of disc disease:

Back 128

1. ANNULAR BULGE
2. FACET ARTHROSIS as disc thins and extrudes
3. STENOSIS if stages 1&2 are severe, w/ TAUTENING of nerve root

Front 129

The ____ & ____ are BOTH capable of producing LBP.

Back 129

DISC & FACET

Scleratogenous (referred) pain can be traced to various facet levels: L5-S1, L4-L5, L3-L4

Front 130

L5-S1 scleratogenous (referred) pain pattern:

Back 130

DOWNWARD: coccyx, hip, post thigh, groin, perineum, into extremities

Front 131

L4-L5 scleratogenous (referred) pain pattern:

Back 131

coccyx, post Hip & thigh

(less intense than L5-S1, less into extremities)

Front 132

L3-L4 scleratogenous (referred) pain pattern:

Back 132

UPWARD:
thoracic area, flank, anterior thigh

Front 133

Higher level discs can cause __________ thigh pain.

Back 133

anterior

L2,3,4
Elderly patients
Femoral radiculopathy

Front 134

When the nucleus creeps into a space into which it doesn't belong and takes up space,

Back 134

Herniation

Front 135

Stage I of disc lesion (Arns_

Back 135

Nucleus pulposis protrudes into INNER rings of annulus fibrosis
Results in LBP

NO neurologic signs
Valsalva's and DeJerine's POSITIVE
Referred scleratogenous pain (not radicular)

Front 136

Stage II of disc lesion (Arns)

Back 136

Penetration of n.p. into OUTER rings
of annulus
Pressure on spinal nerve ROOTS
RADICULAR [radiating] pain
Neurologic signs PRESENT

Front 137

The disc is one of the most _________ structures in the back.

Back 137

SENSITIVE disc

Front 138

___% weight borne on DISC

Back 138

90% on disc

10% on facets

Front 139

disc structure

Back 139

nucleus pulposis + annulus fibrisos

Front 140

chemical structure of disc

Back 140

GLYCOSAMINOGLYCANs

*DAMAGED BY NSAIDS and decreased in DJD

Front 141

Pain is produced by the

Back 141

disc

Front 142

DJD is always preceded by a loss of

Back 142

glycosaminoglycans (hydrostatic structure of disc)

Front 143

Nerve supply of disc

Back 143

Dual:
anterior 1/2 by SYMPATHETIC
posterior 1/2 by SINUVERTEBRAL

Front 144

Regarding the 1/2 posterior innervation of disc by sinuvertebral n., what mediates pain?

Back 144

GANGLION CHAIN

Front 145

2 types of disc tear

Back 145

CIRCUMFERENTIAL
RADIAL

Front 146

Are zygapophyseal joints good for weight bearing?

Back 146

NO

They only bear 10%. (disc=90%)
Z-joints are made to GUIDE & GLIDE spinal unit.

When Z-joints are pained, it is SCERATOGENOUS/referred (because no nerve root involved so cannot be radiuclar)

Front 147

Anything that increases lordosis increases the load bearing on the

Back 147

facets, which don't bear loads well. Instead, they are for the GUIDE & GLIDE of bones.

Front 148

Examples that increase weight bearing load on facets (detrimental):

Back 148

High heels
Pregnancy
Obesity
Degeneration

Front 149

Resist most of the SHEAR forces

Back 149

FACETS

*not designed to resist compression (load bearing)

Front 150

resist most of the COMPRESSIVE forces

Back 150

IVD

Front 151

When the lumbar spine is slightly _______, all the compressive loads are resisted (transferred) to the disc entirely.

Back 151

flattened (into flexion)

Front 152

When lordotic postures are held for long periods of time, such as standing, the subadjacent vertebra bears ___ of the compressive load

Back 152

1/6

Front 153

The compressive force transmitted across the facet increases with ___________

Back 153

EXTENSION

Front 154

_________ _________ provide 39% of the intervertebral joint resistance to flexion.

Back 154

CAPSULAR LIGAMENTS

(disc provides 29%)

Front 155

Is there any reliable evidence suggesting what constitutes good posture is 'sit up straight' don't slouch?

Back 155

No
Actually, flattening the lordosis is LESS pressure on the facets and transfers the weight completely to the discs.

Front 156

Which posture(s) is the most beneficial?

Back 156

COMBINATION of alternating, varying postures

*clicker question

Front 157

How do discs absorb compressive loads?

Back 157

by squeezing fluid out of the nucleus and allowing fibers of the outer shell to stretch

Front 158

Disc ____ can take as much as 10x compression as the vertebral bones.

Back 158

FIBERS

Front 159

_________ is much less tolerated than compression of a disc.

Back 159

TORSION is baaaaad.

Front 160

The greatest possibility of disc injury?

Back 160

COMPRESSION + TORSION (twisting and bending) together

Front 161

The ANNULUS acts like a _________ to help RESIST rotation/torsion.

Back 161

TENDON

Front 162

Which restricts torsion more: annulus or facets?

Back 162

an INTACT ANNULUS resists axial rotation/torsion more than bone itself (facets)

Front 163

considered the first sign of disc degeneration

Back 163

circumferential tears and peripheral rim lesions of the ANNULUS FIBERS

Front 164

horizontal tears in the very outer fibers of the annulus (Sharpey's fibers) near their insertion point into the bony ring apophysis are called?

Back 164

RIM LESIONS

Front 165

Why would back pain be experienced when a radial annular ring tear crosses the outer annulus?

Back 165

The pain-carrying nerves are in the outer annulus.

Front 166

A rim lesion is a _________ tear.

Back 166

horizontal

(think: right at border where annulus meets Sharpeys' fibers on endplate)

Front 167

A concentric tear is a tear in the _________ plane.

Back 167

vertical plane

*from endplate to endplate

Front 168

Radial annular tears run in the horizontal plane and go from ____ to _____

Back 168

nucleus pulposis to outer annulus (hence, pain!)

Front 169

In side posture, compression is gone but rotation does compromise what little rotation the lumbar has so for patients w/ disc lesions, perform?

Back 169

FLEXION DISTRACTION

Front 170

If the axis of rotation is on the facets, what resists the rotation?

Back 170

the disc

Front 171

If the axis of rotation is forward of the facets and onto the disc, what resists rotation?

Back 171

the facets

Front 172

When is the spine more vulnerable to ROTATION INJURY?

Back 172

FLEXIOn because the spine can rotate more in flexion

*like an open-packed spine

Front 173

What plays a more significant role in limiting rotation: facets or disc?

Back 173

DISC limits rotation

(facets resist shear)

Front 174

The spine has a greater ability to rotate when in some degree of _______

Back 174

flexion

predisposing it to injury, esp in side posture
Just put their foot in the popliteal fossa and leave it there. Heavy flexion and bringing knee up makes it harder to adjust!

Front 175

Which forces are the most harmful to the lumbar discs?

Back 175

compression and torsion/rotation

Front 176

Criteria for probable L4-5 degeneration

Back 176

High intercrestal line through upper half of L4, meaning L5 is way 'down in the bowl' between iliac crests (patient has high hips)

Long TP on L5

Transitional vertebra

Front 177

Criteria for probable degeneration of L5-S1

Back 177

(low hips) Intercrestal line passing low through body of L5, meaning distance between sacral base and iliac crests is shallow

Short TP of L5

NO transitional segment

Front 178

Shallow iliac crests + high sacral base leaves ____ most vulnerable

Back 178

L5

Front 179

Problems usually occur ____ transitional segments

Back 179

above

Front 180

The L5-S1 disc is less vulnerable to degeneration if?

Back 180

the TP's are LONG and INTERCRESTAL line passes through BODY of L5

Front 181

When physiologic loads produce abnormal motion, major deformity, and incapacitating pain

Back 181

INSTABLITY definition

*key is normal physiologic loads

Front 182

Denotes impending catastrophe, as in cases of severe trauma, or tumors, that will destroy most of the spinal structural support

Back 182

ACUTE instability

as in rheumatoid arthritis

Front 183

What kind of instability will we as chiropractors see most often?

Back 183

CHRONIC

Front 184

the result of a prolonged degenerative process in which pathomechanics are less clear, and the radiographic and clinical correlations are more difficult to establish...

Back 184

CHRONIC INSTABILITY

the one chiros see most often - prolonged degenerative process

Front 185

RADIOGRAPHIC findings of INSTABILITY are most common at what level?

Back 185

L4-L5

*rare at L5-S1

Front 186

findings assoc. w/ instability on radiograph []

Back 186

retrolisthesis (excess movement)
traction spur
spondylolisthesis
previous total laminectomy or fusion BELOW the motion segment
gas/vacuum sign in disc
facet degeneration
**MALALIGNMENT of spinous PROCESS at affected level
**ROTATIONAL deformity of PEDICLES

Front 187

2 most apparent signs of instability on xray

Back 187

MALALIGNMENT of spinous processes at affected level

ROTATIONAL deformity of pedicles

Front 188

Most common diagnostic x-ray views for instability

Back 188

FLEXION/EXTENSION

Lateral flexion less so
79% instability cases revealed on F/E views while only 49% by lateral flexion views.

Front 189

Gold standard radiograph for excessive movement

Back 189

F/E

Front 190

Greater than ___ between neutral flexion and neutral extension is considered a RED FLAG for INSTABILITY.

Back 190

3mm

Front 191

What are the clinical implications of recognizing instability?

Back 191

1. contradiction for HVLA
2. requires significant rehab
3. longer treatment and guarded prognosis

*answer: all of the above

Front 192

The clinical importance of leg length inequality depends on the degree of

Back 192

DEGREE of the inequality and its relationship with a number of conditions and problems

Front 193

Possible correlations of leg length inequality

Back 193

1. resultant obliquity and and degenerative changes in the lumbar spine
2. poss. assoc. w/ LBP
3. correlation w/ HIP djd
4. correlation w/ KNEE djd [long leg arthropathy]
5. psychological effects of short leg

Front 194

Clinically important LLI

Back 194

1. Functional LLI are associated w/ DJD
2. It may be a PERPETUATING factor
3. It correlates w/ PROGNOSIS

Front 195

Which side does disc protrude in a leg length inequality (LLI)?

Back 195

LONG LEG SIDE

(sciatica, knee, hip, chronic LBP all on long leg side)

Front 196

How patient compensates for pelvic tilt due to LLI?

Back 196

FUNCTIONAL SCOLIOSIS convex to short side

(meaning the open wedge faces the short leg)

Front 197

Which side compresses discs w/ LLI

Back 197

CONCAVE (long side). Disc gets compressed on concave/long side.

Closed side faces long leg so TENSILE LOAD is put on short side

Front 198

In LLI, which side does disc get compressed (squeezed between the two surfaces closest together)?

Back 198

Long side/concave side is compression side

Load is transferred to short side

Front 199

In LLI, what puts additional torsional load on a disc, joints and ligaments?

Back 199

COUPLED ROTATION

Front 200

THE reason discs protrude on the LONG leg side:

Back 200

because discs protrude on CONCAVE side of curves (they get pinched between the two closest surfaces)

Front 201

The most expensive ailment between the ages of 30-60

Back 201

LBP

Front 202

Where do most people seek care for low back pain?

Back 202

family physicians

(out of the 85% of persons w LPB that seek professional care, only 1/3 use chiropractors)

Front 203

The most costly aspect of low back pain is?

Back 203

loss of productivity from workplace

(I think)

Front 204

Sciatic pain can be caused by

Back 204

chemical radiculitis

Front 205

Degenerative disease may produce an __________ mechanism as a prolonged cause of pain.

Back 205

autoimmune (inflammatory response)

Front 206

Approximately 25% of the IVF is filled by the

Back 206

Dorsal Root Ganglion

Front 207

DRG compression causes

Back 207

RADICULOPATHY

Front 208

Where does DRG get nutrients?

What contains the DRG to keep it safe?

Back 208

Nutrients from BLOOD

Safety from DURAL SAC

Front 209

What sx may result w/ DRG compression?

Back 209

TENDINITIS & MYALGIA-like sx

Front 210

The DRG is an _____ processor.

Meaning?

Back 210

ACTIVE processor:

-It makes SUBSTANCE P

-Actively processes AFFERENT impulses and is a source of EFFERENT impulses

Front 211

Compression of the DRG causes:

Back 211

1. SCIATICA
2. CLAUDICATION
3. GROIN PAIN

Front 212

When Posterior Disc Height is ___mm or less, nerve root ________ is found.

Back 212

<4mm posterior disc height=nerve root compression

Front 213

some effects of neural compression (Rydevik)

Back 213

ISCHEMIA
AXONAL CYTOPLASM flow disturbance
CHEMICAL RADICULITIS

Front 214

The DRG synthesizes essential ______ for the neuron

Back 214

proteins

Front 215

Chemical radiculitis by DRG stimulation w/ nuclear material can produce NO...

Back 215

NO root tension signs, JUST LEG PAIN

Front 216

Does chemical radiculitis by DRG stimulation b/c of escaped nuclear material produce root tension signs?

Back 216

NO, it doesn't have to.
Just leg pain.

Front 217

Would a CONTAINED disc cause chemical radiculitis of the DRG?

Back 217

NO, there must be escaped nuclear material that irritates the DRG and sets the inflammation cascade in motion.
Non-contained discs can have high immunoglobulin levels.

Front 218

Describe findings of chemical radiculitis?

Back 218

SLR and DTR may be normal

PAIN in LEG may be worse than LBP

Front 219

Normal nerve roots are/are not sensitive to compression?

Back 219

YES
Sciatica, claudication, groin pain all found when compressed nerve root (posterior disc height < 4mm)

Front 220

RADICULOPATHY is most commonly associated with ______

Back 220

DEGENERATION

("the only thing that will cause radiculopathy is the degeneration of a nerve root" - Dr. Mollin)

Front 221

Much relief from pain of a disc can be gained from?

Back 221

Dissipation of chemical irritants w/ or without reduced compression by disc herniation.

Front 222

What percentage of disc reduction is necessary for symptom resolution?

Back 222

Don't know - will answer after we have that lecture.