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84 Cards in this Set
- Front
- Back
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Functions of Spinal Motion Segment
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-weight bearing
-SC protection -PROVIDE MOTION |
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Disc Function
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-permits motion
-transmits shock |
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Annulus Fibrosis
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-confines nucleus
-6-10 concentric rings -outer annulus injured 1st but has neurovascular supply so CAN HEAL -oblique fiber arrangement means only 50% of fibers resist each direction of rotation |
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Nucleus Pulposus
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-75% H2O, transmits shock
-hydrophilic -receive nutrition through imbibition=>compression relieved as in lying -fluid gradually dispersed throughout day |
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Nachemson's Greatest Disc Pressures
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-FB w/ weight = 220%
-sitting w/ FB = 185% -sitting w/ weight lift = 275% -sit ups = 210% least in supine => 20% |
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Lumbar Spine "Equation"
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nerve root stenosis
---------- = --------- nerve root disc ex: L3 stenosis --- = -------- L4 disc |
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LE Dermatomes
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L2 = lateral thigh
L3 = medial knee L4 = medial calf L5 = lateral calf S1 = lateral foot |
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LE Myotomes
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L1-2 = hip FL
L3-4 = quads L4 = tib anterior L5 = EHL S1 = FHL/peroneals S2 = hamstrings |
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Reflexes
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patellar = L3/L4
achilles = S1 can be: absent, diminished, normal or hyperreactive |
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Disc Bulge and Trunk Shift
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-bulge lateral to root causes pt to opposite SB
-bulge medial to root causes pt to SB to side of involvement |
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Disc Dysfunction History
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-each episode shows worsening
-injury often result of lift & twist, pt continues activity then can't get out of bed -below knee px radiation -sx worse in sitting, relieved with walking -cough/sneeze makes px worse |
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Disc Dysfunction Impairments
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-protective scoliosis
-marked dec in ROM (hip too) -+ neuro signs -dec neural mobility -tight HS and piriformis -distraction dec symptoms -compression inc symptoms -exhibit same side tenderness -dec fxn/endurance |
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Facet Joint Function
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-all plane motion
-guide and restrict motion w/ ligament assistance |
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Structures Preventing Facet Capsule Pinching
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-ligamentum flavum
-multifidus -caudal and cephalic menisci |
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Facet Joint Orientation in Lumbar Spine
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90 deg from transverse plane, 45 from frontal plane
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Lateral Foraminal Stenosis/Nerve Root Entrapment Causes
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-degenerative disc disease
-degenerative joint disease -foraminal stenosis |
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Degenerative Disc Disease Contribution to Lateral Foraminal Stenosis
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-nucleus progressively fibrous with aging, dec H2O absorption
-disc space narrows and superior vertebrae slides down and back on inf vertebrae, narrowing central canal and intervertebral foramen |
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Degenerative Joint Disease Contribution to Lateral Foraminal Stenosis
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-osteophyte formation within the intervertebral foramen reduces its size, increasing potential for nerve root irritation
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Lateral Foraminal Stenosis/Nerve Root Entrapment Pt Subjective
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-typically elderly
-gradual pain onset in L-spine, buttock or LE -LE parasthesias -symptoms inc with BB or SB to involved side |
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Lateral Foraminal Stenosis/Nerve Root Entrapment Impairments
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-possibly lordotic
-limited same SB or BB with radiating px -+ neuro signs -dec neural mobility -tight HS/piriformis -distraction eases px, compression inc px -ipsilateral tenderness -dec strength/endurance/fxn |
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Central Spine Stenosis Causes
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-DDD, DJD
-posterior vertebral compression to SC or cauda equina |
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Central Spine Stenosis Symptoms
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-BILATERAL
-saddle parasthesia/B&B probs indicated cauda equina compression require MD ASAP -burning parasthesia in calves after walking => diff b/n vascular and neuro w/ bike test & 2 stage TM test |
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Central Spine Stenosis Problems
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-fwd trunk lean or lordotic posture
-dec fxn/endurance -LE weakness -L-spine weakness |
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Ligamentous Stabilization of the Spine
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-ant longitudinal
-post longitudinal -supraspinous (to L3/L4) then erector spinae tendons -interspinous (SUP-POST) -ligamentum flavum |
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Spine Ligament Function
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-mechanoreceptors maintain jt integrity
-allow motion while preventing excessive movement |
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Superficial Back Muscles
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-lats, traps, rhomboids, levator, glut max
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Intermediate Back Muscles
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-iliocostalis, longissimus, spinalis
*run up and out *same SB and same ROT |
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Deep Back Muscles
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-transversospinalis, multifidus, rotatores
*same SB and opposite ROT *multifidi primary intersegmental stabilizers |
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Symptoms of Ligamentous Weakness and Postural Back Pain
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-ache from poor posture
-position change for sx relief -"cracking back" for sx relief -lumbar ROM with EROM stretch px -tight hip musculature |
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Lumbar Sprain/Strain/Synovitis Subjective
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-pt describes awkward mvmt, overstretch, fall or MVA
-onset px, worsens over 2-3 days -usually unilateral px -usually l-spine px -may also have butt/post thigh px |
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Lumbar Sprain/Strain/Synovitis Impairments
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-guarded posture
-limited AROM all planes -QL, post-lat muscles tight and tender on involved side -dec strength/endurance -NO neuro signs |
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Medical DX: Compression Fracture
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-vert body fx from compressive force
-T or L-spine fx w/ fall on butt in FL position -minor slip may fx w/ osteoporosis -usually stable fx, unstable requires brace/surgery |
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Medical DX: Spina Bifida
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-incomplete bony closure of post neural arch
-usually lumbosacral -most common birth deformity of spine -neuro deficit most important; may range from mild weakness/sensory to paraplegia & B&B incontinence |
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Spina Bifida Occulta
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-least serious
-rare neuro deficit; may see at birth or may develop -hair patch or pigmentation change only external signs |
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Spina Bifida Meningocele
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-meninges poke through bony defect forming meningocele w/CSF and nerve roots covered by skin
-present at birth or develops with child growth |
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Spina Bifida Myelocele
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-spine and dura fail to close over neural tube
-SC and nerve roots completely exposed -infection may result in death |
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Scoliosis
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-lat curvature w/ rotational deformity
-non-structural is reversible -structural irreversible w/ fixed rotation toward convex side -adolescent females, not noticed until 30 deg curve |
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Cobb Method for Measuring Scoliosis
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-greatest angle toward concave
-10 deg WNL -10-20 deg mild -20-40 moderate -40-50 severe px and DJD in adults -60-70 cardiopulm changes, dec life expectancy |
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Scoliosis Structural Examination
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-rib hump on convex side with FB
-unlevel shldrs -prominent scapula on convex side -pelvic obliquity may appear as leg length discrepancy |
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Scoliosis AROM
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-SB limited to convex side
-Tspine rib hump remains in FB if structural -erector spinae prominent on convex side |
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Scoliosis Muscular Involvement
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MLT- hip FL and lumbar myofascia
MMT- weak on convex side (stretched) |
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Scoliosis Prognosis
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-worse curve = more likely to progress
-onset at younger age has worse prognosis because there is more time for the child to grow |
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Scoliosis Non-Operative Rx
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-exercise alone will not halt/correct 20-40 deg curve
-20-40 deg curve + 2 yrs anticipated growth = spine brace and exercise can reduce curve and prevent progression |
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Scoliosis Braces
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Milwaukee - 23-24 hrs/day, deformity can be halted in 70% of mild/moderate cases
Boston - molded plastic jacket, no metal suprastucture, hidden by clothes |
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Scoliosis Operative Rx
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Harrington Rods - for curves 40+ deg or predicted 40+, operation after growth spurt, up to 50% corrective
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Cervical Spine Structure
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-nerve roots exit ABOVE
-disc prob and stenosis affect same nerve root -facet angle = 45 deg -uncovertebral jts -vertebral artery -discs differ in structure and hydration |
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Subcranial Biomechanics
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FB - atlas slides fwd
BB - atlas slides back SB right - atlas slides right Rot right - A/A rotation only, no O/A rotation |
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Midcervical Biomechanics
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FB - bilateral upslide
BB - bilateral downslide SBR - upslide L, downslide R RotR - upslide L, downslide R |
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Cervical Myofascial vs. Facet Restriction
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1)SB with pts arm at side
2)support arm, then pt SB SB improves w/ support, then myofascial restriction, if NO improvement, then facet restriction |
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Posture Related Neck Ache Pt History
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-pain in neck, upper trap, interscapular, suboccipital, maybe HA
-no neuro signs -gradual onset -no hx of trauma |
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Posture Related Neck Ache Impairments
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-fwd head and shldr posture
-limited AROM -muscle imbalance -tenderness, inc tone -poor postural awareness or ergonomics |
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Cervical/Thoracic Sprain/Strain/Synovitis Pt History
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-awkward mvmt
-pain at onset w/ worsening over 2-3 days -unilateral px -px centered n upper trap/levator to interscapular and suboccipital region |
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Cervical/Thoracic Sprain/Strain/Synovitis Impairments
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-fwd head posture
-dec AROM, especially SB and Rot in one direction -guarding on involved side -inc tone/tenderness -no neuro signs |
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Painful Cervical Entrapment History
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-sudden painful catch w/ head turning or eccentric mvmt
-initially noticed in morning after incorrect sleeping posture -unilateral pain |
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Painful Cervical Entrapment Impairments
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-postural shift away from involved side
-marked dec AROM and px with Rot and SB to involved side and BB -swollen facet capsule -paraspinal and levator pain/guarding -no neuro signs |
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Painful Cervical Entrapment Rx
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-isometric multifidus contraction pulls pinched capsule from facet, may restore AROM immediately
-must restore AROM prior to completing eval due to px |
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Cervical Radiculopathy Susceptibility
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-osteophyte formation of jt of Von Lushka
-vertebral body ht dec due to osteoporosis anteriorly, posterior does not change, causing cspine hyperEXT |
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Cervical Radiculopathy History
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-most common in 40s-50s; F>M
-C6/7 most common segment -gradual onset px in neck spreading to arm -night px = difficulty sleeping -UE parasthesias -SB/BB exacerbate sx |
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Cervical Radiculopathy Impairments
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-fwd head posture
-limited SB toward, BB with radiating px -+ neuro signs -distraction relieves sx -spurling's inc sx -tender to involved side |
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Cervical Radiculopathy Predictive Test Cluster
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-ULTT +
-AROM less than 60 deg -distraction relief -spurling's exacerbates sx |
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Cervical Dermatomes
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C4-upper trap
C5-lat deltoid C6-thumb C7-mid finger C8-ulnar border hand T1-medial forearm T2-medial arm |
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Cervical Myotomes
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C4-upper trap
C5/6-biceps C7-triceps, wrist EXT C8-thumb EXT T1-hand intrinsics |
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Cervical DTR's
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C5/6-biceps
C6-brachioradialis C7-triceps |
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Subcranial Instability Common Causes
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-RA
-ankylosing spondylitis -Down Syndrome -corticosteroids -trauma |
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Subcranial Instability History
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-px in upper neck radiating to occipital/temporal/frontal areas
aggravated by jarring mvmt -difficulty turning head to neutral -feel like head is falling fwd -MUST HAVE OPEN MOUTH XRAY |
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Subcranial Instability Signs
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-dysarthria, dysphagia, lingual deviation
-cardiac/resp distress -Wallenberg's syndrome -SC sx (bilateral/quad) -sympathetic paresis -prominent C2 spinous process |
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Wallenberg's Syndrome
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-dysarthria
-dysphagia -staggering gait -vertigo -dec coordination -nystagmus |
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Horner's Syndrome (Sympathetic Paresis)
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-ptosis (drooping eyelid)
-miosis (pupil contraction) -anhydrosis (no sweat) -enopthalmos (eyeball recession in socket) |
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Whiplash History
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-trauma, usually MVA or rollercoaster
-minor to severe sx -typically worse unilaterally -many possible structures involved -potential sympathetic involvement |
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Whiplash Impairments
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-guarded posture initially
-marked dec ROM, esp Rotation -typically no neuro signs, check babinski reflex -tight muscles, inc tone -jt laxity -weak anterior musculature |
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Cervical Central Spine Stenosis and Myelopathy Causes
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-SC compression via post osteophytes, disc protrusion, ligamentum flavum, vertebral mvmt
-DJD, DDD |
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Cervical Central Spine Stenosis History
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-bilateral neck/shldr ache w/ px radiating to arms
-hand/feet parasthesias -LE weakness or balance issues |
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Cervical Central Spine Stenosis Impairments/Findings
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-fwd head/tspine kyphosis
-limited AROM, jt hypomobility -permanent or transient neuro signs, + babinski and clonus -general UE/LE weakness -tender/inc tone in upper trap and cervical region |
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Headaches History
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-px in cervical, suboccipital or tspine, radiates to head
-affected by position -possible trauma |
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Headache Impairments
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-fwd head
-poor posture/ergonomics -upper trap tightness -increased tone/tender -no neuro signs |
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Muscular Torticollis
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-infant head cocked to side
-unknown etio, could be in utero position -SCM tumor develops over few wks -xray to r/o bony torticollis -RX: stretching |
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Scheuermann's Disease
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-osteochondrosis of upper tspine
-M>F -affects ant epiphyseal plate causing disc projection (Schmorle's Nodes)into vert body -wedge shape bodies result in marked kyphosis RX: bracing and posture therex |
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Cervical Fx/Fx-Dislocation
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-result of trauma
-fx spare SC, rx with traction and immob, halo 8-12 wks -fx-dislocations typically result in quadraplegia and require surgery |
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A/A Fusion Surgery
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-corrective for A/A instability
-wires C2 spinous process or lamina to post arch of atlas w/ bone grafts -leads to lower cspine hypermobility |
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Posterior Approach Midcervical Fusion
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-for post instability
-wire and bone graft -denervation of posterior structures possible |
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Anterior Approach Midcervical Fusion
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-for ant instability, to enlarge disc space/IV foramen and preserve posterior structures
-disc removed, bone graft from iliac crest |
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Cervical Discectomy
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-midline incision thru ligamentum nuchae (LN)
-lamina and LN excised, disc removed -nerve root retracted, then put back covered by fat |
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Cervical Laminectomy
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-hemi for discectomy or lateral foraminal stenosis, can damage multifidus innervation
-total performed if central spinal stenosis |
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Lumbar Laminotomy w/ Discectomy
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-pt in prone 90/90
-muscle/fascia incised, retracted -ligamentum flavum removed, laminal partially removed -nerve root medial, annulus cut, remaining nucleus removed |
