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84 Cards in this Set

  • Front
  • Back
Functions of Spinal Motion Segment
-weight bearing
-SC protection
Disc Function
-permits motion
-transmits shock
Annulus Fibrosis
-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
Nucleus Pulposus
-75% H2O, transmits shock
-receive nutrition through imbibition=>compression relieved as in lying
-fluid gradually dispersed throughout day
Nachemson's Greatest Disc Pressures
-FB w/ weight = 220%
-sitting w/ FB = 185%
-sitting w/ weight lift = 275%
-sit ups = 210%
least in supine => 20%
Lumbar Spine "Equation"
nerve root stenosis
---------- = ---------
nerve root disc

ex: L3 stenosis
--- = --------
L4 disc
LE Dermatomes
L2 = lateral thigh
L3 = medial knee
L4 = medial calf
L5 = lateral calf
S1 = lateral foot
LE Myotomes
L1-2 = hip FL
L3-4 = quads
L4 = tib anterior
L5 = EHL
S1 = FHL/peroneals
S2 = hamstrings
patellar = L3/L4
achilles = S1
can be: absent, diminished, normal or hyperreactive
Disc Bulge and Trunk Shift
-bulge lateral to root causes pt to opposite SB
-bulge medial to root causes pt to SB to side of involvement
Disc Dysfunction History
-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
Disc Dysfunction Impairments
-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
Facet Joint Function
-all plane motion
-guide and restrict motion w/ ligament assistance
Structures Preventing Facet Capsule Pinching
-ligamentum flavum
-caudal and cephalic menisci
Facet Joint Orientation in Lumbar Spine
90 deg from transverse plane, 45 from frontal plane
Lateral Foraminal Stenosis/Nerve Root Entrapment Causes
-degenerative disc disease
-degenerative joint disease
-foraminal stenosis
Degenerative Disc Disease Contribution to Lateral Foraminal Stenosis
-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
Degenerative Joint Disease Contribution to Lateral Foraminal Stenosis
-osteophyte formation within the intervertebral foramen reduces its size, increasing potential for nerve root irritation
Lateral Foraminal Stenosis/Nerve Root Entrapment Pt Subjective
-typically elderly
-gradual pain onset in L-spine, buttock or LE
-LE parasthesias
-symptoms inc with BB or SB to involved side
Lateral Foraminal Stenosis/Nerve Root Entrapment Impairments
-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
Central Spine Stenosis Causes
-posterior vertebral compression to SC or cauda equina
Central Spine Stenosis Symptoms
-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
Central Spine Stenosis Problems
-fwd trunk lean or lordotic posture
-dec fxn/endurance
-LE weakness
-L-spine weakness
Ligamentous Stabilization of the Spine
-ant longitudinal
-post longitudinal
-supraspinous (to L3/L4) then erector spinae tendons
-interspinous (SUP-POST)
-ligamentum flavum
Spine Ligament Function
-mechanoreceptors maintain jt integrity
-allow motion while preventing excessive movement
Superficial Back Muscles
-lats, traps, rhomboids, levator, glut max
Intermediate Back Muscles
-iliocostalis, longissimus, spinalis
*run up and out
*same SB and same ROT
Deep Back Muscles
-transversospinalis, multifidus, rotatores
*same SB and opposite ROT
*multifidi primary intersegmental stabilizers
Symptoms of Ligamentous Weakness and Postural Back Pain
-ache from poor posture
-position change for sx relief
-"cracking back" for sx relief
-lumbar ROM with EROM stretch px
-tight hip musculature
Lumbar Sprain/Strain/Synovitis Subjective
-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
Lumbar Sprain/Strain/Synovitis Impairments
-guarded posture
-limited AROM all planes
-QL, post-lat muscles tight and tender on involved side
-dec strength/endurance
-NO neuro signs
Medical DX: Compression Fracture
-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
Medical DX: Spina Bifida
-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
Spina Bifida Occulta
-least serious
-rare neuro deficit; may see at birth or may develop
-hair patch or pigmentation change only external signs
Spina Bifida Meningocele
-meninges poke through bony defect forming meningocele w/CSF and nerve roots covered by skin
-present at birth or develops with child growth
Spina Bifida Myelocele
-spine and dura fail to close over neural tube
-SC and nerve roots completely exposed
-infection may result in death
-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
Cobb Method for Measuring Scoliosis
-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
Scoliosis Structural Examination
-rib hump on convex side with FB
-unlevel shldrs
-prominent scapula on convex side
-pelvic obliquity may appear as leg length discrepancy
Scoliosis AROM
-SB limited to convex side
-Tspine rib hump remains in FB if structural
-erector spinae prominent on convex side
Scoliosis Muscular Involvement
MLT- hip FL and lumbar myofascia
MMT- weak on convex side (stretched)
Scoliosis Prognosis
-worse curve = more likely to progress
-onset at younger age has worse prognosis because there is more time for the child to grow
Scoliosis Non-Operative Rx
-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
Scoliosis Braces
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
Scoliosis Operative Rx
Harrington Rods - for curves 40+ deg or predicted 40+, operation after growth spurt, up to 50% corrective
Cervical Spine Structure
-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
Subcranial Biomechanics
FB - atlas slides fwd
BB - atlas slides back
SB right - atlas slides right
Rot right - A/A rotation only, no O/A rotation
Midcervical Biomechanics
FB - bilateral upslide
BB - bilateral downslide
SBR - upslide L, downslide R
RotR - upslide L, downslide R
Cervical Myofascial vs. Facet Restriction
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
Posture Related Neck Ache Pt History
-pain in neck, upper trap, interscapular, suboccipital, maybe HA
-no neuro signs
-gradual onset
-no hx of trauma
Posture Related Neck Ache Impairments
-fwd head and shldr posture
-limited AROM
-muscle imbalance
-tenderness, inc tone
-poor postural awareness or ergonomics
Cervical/Thoracic Sprain/Strain/Synovitis Pt History
-awkward mvmt
-pain at onset w/ worsening over 2-3 days
-unilateral px
-px centered n upper trap/levator to interscapular and suboccipital region
Cervical/Thoracic Sprain/Strain/Synovitis Impairments
-fwd head posture
-dec AROM, especially SB and Rot in one direction
-guarding on involved side
-inc tone/tenderness
-no neuro signs
Painful Cervical Entrapment History
-sudden painful catch w/ head turning or eccentric mvmt
-initially noticed in morning after incorrect sleeping posture
-unilateral pain
Painful Cervical Entrapment Impairments
-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
Painful Cervical Entrapment Rx
-isometric multifidus contraction pulls pinched capsule from facet, may restore AROM immediately
-must restore AROM prior to completing eval due to px
Cervical Radiculopathy Susceptibility
-osteophyte formation of jt of Von Lushka
-vertebral body ht dec due to osteoporosis anteriorly, posterior does not change, causing cspine hyperEXT
Cervical Radiculopathy History
-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
Cervical Radiculopathy Impairments
-fwd head posture
-limited SB toward, BB with radiating px
-+ neuro signs
-distraction relieves sx
-spurling's inc sx
-tender to involved side
Cervical Radiculopathy Predictive Test Cluster
-AROM less than 60 deg
-distraction relief
-spurling's exacerbates sx
Cervical Dermatomes
C4-upper trap
C5-lat deltoid
C7-mid finger
C8-ulnar border hand
T1-medial forearm
T2-medial arm
Cervical Myotomes
C4-upper trap
C7-triceps, wrist EXT
C8-thumb EXT
T1-hand intrinsics
Cervical DTR's
Subcranial Instability Common Causes
-ankylosing spondylitis
-Down Syndrome
Subcranial Instability History
-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
Subcranial Instability Signs
-dysarthria, dysphagia, lingual deviation
-cardiac/resp distress
-Wallenberg's syndrome
-SC sx (bilateral/quad)
-sympathetic paresis
-prominent C2 spinous process
Wallenberg's Syndrome
-staggering gait
-dec coordination
Horner's Syndrome (Sympathetic Paresis)
-ptosis (drooping eyelid)
-miosis (pupil contraction)
-anhydrosis (no sweat)
-enopthalmos (eyeball recession in socket)
Whiplash History
-trauma, usually MVA or rollercoaster
-minor to severe sx
-typically worse unilaterally
-many possible structures involved
-potential sympathetic involvement
Whiplash Impairments
-guarded posture initially
-marked dec ROM, esp Rotation
-typically no neuro signs, check babinski reflex
-tight muscles, inc tone
-jt laxity
-weak anterior musculature
Cervical Central Spine Stenosis and Myelopathy Causes
-SC compression via post osteophytes, disc protrusion, ligamentum flavum, vertebral mvmt
Cervical Central Spine Stenosis History
-bilateral neck/shldr ache w/ px radiating to arms
-hand/feet parasthesias
-LE weakness or balance issues
Cervical Central Spine Stenosis Impairments/Findings
-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
Headaches History
-px in cervical, suboccipital or tspine, radiates to head
-affected by position
-possible trauma
Headache Impairments
-fwd head
-poor posture/ergonomics
-upper trap tightness
-increased tone/tender
-no neuro signs
Muscular Torticollis
-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
Scheuermann's Disease
-osteochondrosis of upper tspine
-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
Cervical Fx/Fx-Dislocation
-result of trauma
-fx spare SC, rx with traction and immob, halo 8-12 wks
-fx-dislocations typically result in quadraplegia and require surgery
A/A Fusion Surgery
-corrective for A/A instability
-wires C2 spinous process or lamina to post arch of atlas w/ bone grafts
-leads to lower cspine hypermobility
Posterior Approach Midcervical Fusion
-for post instability
-wire and bone graft
-denervation of posterior structures possible
Anterior Approach Midcervical Fusion
-for ant instability, to enlarge disc space/IV foramen and preserve posterior structures
-disc removed, bone graft from iliac crest
Cervical Discectomy
-midline incision thru ligamentum nuchae (LN)
-lamina and LN excised, disc removed
-nerve root retracted, then put back covered by fat
Cervical Laminectomy
-hemi for discectomy or lateral foraminal stenosis, can damage multifidus innervation
-total performed if central spinal stenosis
Lumbar Laminotomy w/ Discectomy
-pt in prone 90/90
-muscle/fascia incised, retracted
-ligamentum flavum removed, laminal partially removed
-nerve root medial, annulus cut, remaining nucleus removed