Ortho Path - Lecture 10

Front 1

What are the four types of congenital lumbar spine disorders?

Back 1

(1)Spina Bifida, (2)Spondylolysis, (3)Lumbrisation, (4)Sacralization

Front 2

What are the five types of acquired lumbar spine disorders?

Back 2

(1)Degenerative Disc Disease, (2)Disc Herniations, (3)Spinal Stenosis, (4)Spondyloysis, (5)Spondylolisthesis

Front 3

What are the three functions of the intervertebral discs?

Back 3

(1)Maintain continuity of VB’s, (2)Attenuate and transfer vertebral loading (shock absorption), (3)Nutrition of the VB (by diffusion)

Front 4

*What are the four main constituents of intervertebral discs?

Back 4

(1)Water, (2)*Type 1 and 2 Collagen, (3)*Proteoglycans, (4)Non-Collagenous Proteins

Front 5

What are the two parts of the intervertebral disc?

Back 5

(1)Annulus Fibrosus, (2)Nucleus Pulposus

Front 6

Approximately how many concentric sheets of collagen tissue make up the annulus fibrosus?

Back 6

10-20 concentric sheets orientated at 65 degrees from vertical

Front 7

Do the sheets run in the opposite or the same direction of the preceding sheet?

Back 7

Opposite

Front 8

Are the collagen sheets of the annulus fibrosus thicker on the anterior or posterior side?

Back 8

Posterior

Front 9

What percentage of water is the annulus fibrosus composed of?

Back 9

60 - 70%

Front 10

What is the location of the nucleus pulposus?

Back 10

Sits near the center of the disc and is quite distinct from the end-plate. No distinct margins between annulus and nucleus (blend together at margins).

Front 11

What percentage of water is the nucleus pulposus composed of?

Back 11

70 - 90%

Front 12

Does the water content of the nucleus pulposus decrease or increase with age?

Back 12

Decreases. Birth=88%, 75 years=68%

Front 13

What part of the intervertebral disc does the end plate cover?

Back 13

Covers most of the inferior and superior surfaces of the disc

Front 14

How thick is the end plate?

Back 14

About 1mm

Front 15

Is the end plate surrounded by any structures?

Back 15

Enclosed peripherally by ring apophysis.

Front 16

What is the end plate attached to?

Back 16

End-plate firmly attached to disc by “Sharpy’s Fibers” and only weakly to the VB -- Rim lesion with trauma

Front 17

How much of the annulus fibrosus is innervated?

Back 17

The outer 1/3

Front 18

Where do the greatest number of nerve endings lie in the intervertebral disc?

Back 18

Greatest number of nerve endings laterally and then posteriorly

Front 19

How can nerve fibers migrate in the intervertebral discs?

Back 19

With disc injury, may get migration of new nerve fibers with scar tissue=pain.

Front 20

Is the intervertebral disc vascular or avascular?

Back 20

Almost totally avascular. Only outer AF receives blood supply. Nutrition is via diffusion.

Front 21

*What are three causes of intervertebral discs becoming drier and more fibrous?

Back 21

(1)Increase in collagen, (2)*Decrease in elastin (plasticity of the disc), (3)Decreased water content

Front 22

What are two changes that a drier and more fibrous disc results in?

Back 22

(1)Disc becomes stiffer and less deformable, (2)Decreased ability to recover from creep (ability to deform and recover)

Front 23

*As disc becomes more fibrous does the the distinction between AF and NP increase or decrease?

Back 23

Increase

Front 24

How does the distinction between AF and NP increase as the disc becomes more fibrous?

Back 24

The AF then takes on more of the compressive loads. This causes separation of the sheets in the AF and formation of *radial fissures.

Front 25

What will repeated torsional trauma (twist and lift) on the IVD result in?

Back 25

Radial fissuring in the posterior or postero-lateral disc (AF)

Front 26

Does the end plate thicken or thin with age?

Back 26

Thin

Front 27

What causes/allows foreign chemicals (blood) to migrate into the nucleus pulposus?

Back 27

The combination of radial fissuring and end plate thinning causes foreign chemicals to migrate into the NP

Front 28

What circumstances create a disc that is susceptible to herniation?

Back 28

These chemicals (usually blood) cause the NP to become less viscous (breakdown). This will lead to thinning of the disc and possible herniation.

Front 29

What are the two processes of degeneration?

Back 29

(1)Dehydration of disc, (2)Radial fissuring

Front 30

*What are the four types of disc lesions?

Back 30

(1)Protrusion, (2)Prolapse, (3)Extrusion, (4)Sequestration

Front 31

*Describe a protrusion.

Back 31

Nuclear material may bulge into the AF but remains contained within the AF (also called Disc Degeneration)

Front 32

*Describe a prolapse.

Back 32

Nuclear material may migrate through a radial fissure in the AF to strain but not escape from the outer AF

Front 33

*Describe an extrusion.

Back 33

Nuclear material may escape the AF to bulge externally into the intervertebral canal but remains attached to the disc

Front 34

*Describe a sequestration.

Back 34

The migrating nuclear material may escape contact with the disc entirely and fragment into the intervertebral canal (free fragment)

Front 35

What does nutrition of the IVD depend on?

Back 35

Diffusion

Front 36

How does diffusion occur in the IVD?

Back 36

This diffusion is facilitated by movements of the spine and alternate loading and unloading of the disc. Fluids and metabolites are pushed out when pressure on the disc increases and the reverse process takes place when the load on the disc is reduced.

Front 37

*Where does maximum mechanical stress of the spine occur?

Back 37

Maximum mechanical stress occurs at the lumbosacral junction (L5-S1) and the disc between L4-5

Front 38

When is intradiscal pressure least?

Back 38

Intradiscal pressure is least when an individual is supine lying.

Front 39

Do patients with pain due to a prolapsed IVD prefer to stand or sit?

Back 39

Patients with pain due to a prolapsed intervertebral disc prefer to stand rather than sit because it is less painful.

Front 40

What is the onset of a disc lesion?

Back 40

There may or may not be any history of trauma. The duration of symptoms is variable. The pain is usually located in the low back or gluteal region on one or both sides +/- leg pain.

Front 41

*Will pain radiate or refer with a disc lesion?

Back 41

Pain may radiate down the thigh and leg to the foot depending on severity of the nerve root involvement

Front 42

What five positions/actions may aggravate the pain?

Back 42

(1)Forward bending, (2)coughing, (3)sneezing, (4)prolonged sitting, (5)lifting

Front 43

T/F: Paresthesia, weakness(paresis) and other neurological problems may occur with disc lesions

Back 43

True

Front 44

*What test action is used for L4 myotomes?

Back 44

Ankle dorsiflexion

Front 45

*What six muscles are affected by L4 myotomes?

Back 45

(1)Tibialis Anterior, (2)Quadriceps, (3)Tensor Fasciae Latae, (4)Adductor Magnus, (5)Obturator Externus, (6)Tibialis posterior

Front 46

*What test action is used for L5 myotomes?

Back 46

Toe extension

Front 47

*What nine muscles are affected by L5 myotomes?

Back 47

(1)Extensor Hallicuis Longus, (2)Extensor Digitorum Longus, (3)Gluteus Medius, (4)Gluteus Minimus, (5)Obturator Internus, (6)Semimembranosus, (7)Semitendinosus, (8)Peroneus Tertius, (9)Popliteus

Front 48

*What four test actions are used for S1 myotomes?

Back 48

(1)Ankle Plantar-flexion, (2)Ankle Eversion, (3)Hip Extension, (4)Knee Flexion

Front 49

*What eleven muscles are affected by S1 myotomes?

Back 49

(1)Gastrocnemius, (2)Soleus, (3)Gluteus Maximus, (4)Obturator Internus, (5)Piriformis, (6)Biceps femoris, (7)Semitendinosus, (8)Popliteus, (9)Peroneus Longus, (10)Peroneus Brevis, (11)Extensor Digitorum Brevis

Front 50

*Describe the dermatome of L4.

Back 50

Starts at lateral hip runs inferomedially down the leg, crossing the the medial side of the lower leg just below the knee. Covers the medial side of the big toe and the foot above the 1st metatarsal.

Front 51

*Describe the dermatome of L5.

Back 51

Starts at lateral hip and continues down the lateral side of the thigh and leg. Covers the lateral side of big toe and the web between the 1st and 2nd digit, digits 2 and 3, as well as plantar surface of distal 2/3 of foot.

Front 52

*Describe the dermatome of S1.

Back 52

Beginning at low back/sacrum area, continuing down the lateral posterior thigh covering the lateral heel and 5th digit.

Front 53

What are the facet joints of the spine?

Back 53

The facet joints (apophyseal joints) are synovial joints between the superior and inferior articular processes of the vertebrae

Front 54

Where does spondylosis occur most commonly?

Back 54

Spondylosis occurs most commonly atL4/5 and L5/S1 segments

Front 55

What is the onset of degenerative disease of the facet joints?

Back 55

Onset of the disease may be early if there are any predisposing factors. Otherwise, degenerative disease of the facet joint may become symptomatic after the fifth decade.

Front 56

*What do patients with degenerative disease of the facet joints usually complain of?

Back 56

The patient complains of low back pain which is usually worse in the morning after getting up from sleep or any period of inactivity. This may be accompanied by stiffness. These symptoms are relieved by activity but may return after a full day’s work (due to muscle fatigue)

Front 57

What usually aggravates the pain and stiffness of degenerative disease of the facet joints?

Back 57

Pain and stiffness are usually aggravated during cold and damp weather and are relieved by local heat and analgesics

Front 58

*Can low back pain of degenerative disease of the facet joints refer into the lower extremities?

Back 58

The low back pain may or may not refer into the lower extremities

Front 59

What can degenerative disease of the facet joints sometimes be confused with?

Back 59

A prolapsed intervertebral disc with radiculopathy (pathology of nerve roots)

Front 60

*What is spondylolysis?

Back 60

A defect at the lamina pedicle junction. *A mysterious defect that develops in one or both side of the neural arch. Most often bilateral.

Front 61

What percentage of spondylolysis occurs at L5?

Back 61

85%

Front 62

What percentage of spondylolysis occurs at L4?

Back 62

15%

Front 63

*What does the defect consist of?

Back 63

The defect consists of fibrous tissue which develops in the weakest part of the neural arch— *pars interarticularis

Front 64

Where is the pars interarticularis located?

Back 64

This is located between the superior and inferior articular processes.

Front 65

*What is spondylolisthesis?

Back 65

Spondylolithesis is a forward slippage of a lumbar vertebra on the vertebra below it

Front 66

Where does spondylolisthesis normally occur?

Back 66

It normally occurs at L5/S1 or between L4/5

Front 67

What normally prevents the vertebral body from slipping forward?

Back 67

An intact neural arch, the posterior facet joints, the intervertebral disc and the surrounding ligaments

Front 68

What part of the vertebrae is most prominent with a spondylolytic spondy?

Back 68

The spinous process.

Front 69

What is most prominent with a degenerative spondy?

Back 69

A step deformity

Front 70

What can cause a spondylolisthesis?

Back 70

A defect in the pars interarticularis oran abnormality of the posterior facet joints can lead to spondylolisthesis

Front 71

What percentage of the population does spondylolisthesis occur in?

Back 71

2%

Front 72

What are three other causes of spondylolisthesis?

Back 72

(1)stress fractures(caused by repetitive hyper-extension of the back, commonly seen in gymnasts), (2)traumatic fractures, (3)may occasionally be associated with bone diseases (DJD, osteo)

Front 73

What are two ways to monitor the progression of spondylolisthesis?

Back 73

(1)Slip angle, (2)Meyerodings Grading System

Front 74

Where is the slip angle measured?

Back 74

Between the sacral base and the end plate of L5

Front 75

What is the reference point in the Meyerodings Grading System?

Back 75

The posterior-inferior hornu of L5

Front 76

How does the Meyerodings Grading System work?

Back 76

Divide the base of the sacrum into 4 equal parts/boxes, draw a plumb line from the posterior-inferior hornu of L5, whichever box of the sacrum the line lands in is the grade.

Front 77

What are the stable grades of the Meyerodings Grading System?

Back 77

Grades 1 and 2

Front 78

What percentage of spondylolisthesis are grades 1 and 2?

Back 78

More than 50%

Front 79

What percentage of spondylolisthesis are grades 3 and 4?

Back 79

Less than 50%

Front 80

Is spondylolisthesis associated with increased kyphosis or increased lordosis?

Back 80

It is associated with and can produce increased lordosis

Front 81

Can spondylolisthesis produce any defects to the skin?

Back 81

May have a skin crease at the level of the spondylolisthesis (caused by a step defect)

Front 82

*What are the symptoms of spondylolisthesis?

Back 82

(1)Pain in LBK, thighs, and buttocks, (2)Stiffness, muscle tightness, and tenderness in the slipped area (just above the pelvis (L5/S1 level)), (3)Neurologic damage (leg weakness or changes in sensation) may result from pressure on nerve roots and may cause pain radiating down the legs, (4)Marked lordosis +/- step deformity, (5)Tight hamstrings (Bilateral), (6)Pain with extension

Front 83

*What position should the patient be in when having a x-ray for spondylolisthesis?

Back 83

Standing

Front 84

*What are four treatments for spondylolisthesis?

Back 84

(1)Most patients require only strengthening and stretching exercises→Flexion routine(avoid extension exercises) (2)Activity modification (avoid contact sports, heavy lifting, twisting), (3)Some practitioners also use a rigid brace, (4)prolotherapy

Front 85

What is the treatment for a severe case of spondylolisthesis?

Back 85

For cases with severe pain and/or severe neurologic changes which are not responding to therapy, spinal fusion maybe indicated. This surgery has a higher incidence of nerve injury than most other spinal fusion surgeries. A brace or body cast may be used after surgery.

Front 86

What is the prognosis for spondylolisthesis?

Back 86

Conservative therapy for mild spondylolisthesisis successful in about 80% of cases. Surgery produces satisfactory results in 85 to 90%.

Front 87

What are two potential complications of spondylolisthesis?

Back 87

(1)Compression and temporary/permanent damage of spinal nerve roots, which may cause sensation changes, weakness, or paralysis of the legs, (2)Chronic back pain

Front 88

What is lumbarisation?

Back 88

S1 becomes mobile (L6). Makes S1-2 the last mobile segment. Occurs in 2-8% of the population.

Front 89

What is sacralisation?

Back 89

L5 becomes fused to the sacrum or pelvis. L4-5 becomes the last mobile segment. Occurs in 3-6% of population.

Front 90

What is intermittent claudication?

Back 90

Pain with walking

Front 91

What do patients with narrowing of the spinal canal usually present with?

Back 91

Pain or weakness in the lower extremities on walking+/- paresthesia

Front 92

What would cause pain or weakness to be mistaken for intermittent claudication?

Back 92

Vascular disease

Front 93

What is vascular claudication?

Back 93

Vascular claudication is pain that is associated with an inadequate blood supply to muscle

Front 94

What percentage of patients attending a vascular clinic have a spinal stenosis?

Back 94

~ 10%

Front 95

How are the anterior border of the spinal canal formed?

Back 95

The spinal canal is formed anteriorly by the posterior surface of the vertebral body and the posterior longitudinal ligament

Front 96

How are the sides and posterior border of the spinal canal formed?

Back 96

The pedicles and laminae form the sides and posterior boundaries of the canal

Front 97

At what junction is the facet joint located?

Back 97

The facet joint is at the junction of the pedicle and lamina

Front 98

What shape is the spinal canal in the lumbar region?

Back 98

Triangular

Front 99

Where does the spinal nerve root come out of?

Back 99

The lateral recess

Front 100

If the nerve root is affected (IVF compression) what is the disorder called?

Back 100

Lateral Stenosis

Front 101

If the spinal cord/cauda equina is compressed, what is the disorder called?

Back 101

Central Stenosis

Front 102

What can be the cause of a small spinal canal?

Back 102

Congenital/developmental factors or degenerative changes

Front 103

*What are three types of degenerative changes that can cause a stenosis?

Back 103

(1)Osteophytes from facet joints and the vertebral body, (2)Thickening of the posterior longitudinal ligament or ligamentum flavum, (3)Retrolisthesis (posterior slippage of one vertebra onto another) of the vertebral body secondary to narrowing of the disc space

Front 104

What could cause the intermittent nature of the stenosis symptoms?

Back 104

The intermittent nature of symptoms maybe due to increased venous congestion within the confined space of the spinal canal

Front 105

*What types of activities/movements bring on the neurogenic stenosis symptoms?

Back 105

The diameter of the canal is narrowed by extension of the spine, and thus, any activity carried out with the spine in extension, e.g. walking, brings on the symptoms. Often patients complain that they can only walk for a certain time or distance before the symptoms occur.

Front 106

*What types of activities/movements relieve the neurogenic stenosis symptoms?

Back 106

The symptoms are relieved by flexion of the spine, which increases the spinal canal dimensions and reduces congestion and pressure on the cauda equina, e.g. riding a bicycle

Front 107

*What is the incidence and onset of neurogenic stenosis symptoms?

Back 107

The symptoms start gradually and usually occur in males over age 45-50 years

Front 108

*What are four complains a patient with neurogenic stenosis might have?

Back 108

(1)weakness, pain, tingling, or numbness of one or both legs after walking, (2)Legs feel “heavy” or “rubbery”, (3)May be some pain in the gluteal region or legs, and he has to sit down or stand with the spine flexed to relieve symptoms, (4)May complain of pain radiating down the sciatic nerve

Front 109

What could be a differential diagnosis for neurogenic stenosis?

Back 109

Peripheral vascular disease (PVD)

Front 110

Why is PVD a differential diagnosis for neurogenic stenosis?

Back 110

Peripheral vascular disease (PVD) is a catch-all term for various problems caused by poor circulation due to clogged arteries. It occurs in the same age group and is more common than spinal stenosis.

Front 111

What causes the pain of PVD?

Back 111

Pain due to intermittent vascular claudication occurs after walking the same distance every time and is relieved by standing in one place for a few minutes

Front 112

*Where is the pain of PVD felt?

Back 112

The pain is felt in calf muscles or buttocks and there are no neurologic symptoms or signs(tingling, numbness, weakness, absent reflexes). Arterial pulses in the lower extremities may be absent.

Front 113

What is arterial plaque?

Back 113

Plaque is a kind of sludge made up of hardened fat, cholesterol, white blood cells, calcium, decaying tissue, and other cellular "garbage“

Front 114

What is a viscerogenic differential diagnosis for low back pain?

Back 114

Genitourinary tract, pelvic organs-not aggravated by activity

Front 115

What is a vasculogenic differential diagnosis for low back pain?

Back 115

Descending aorta, iliac arteries (occlusion or aneurysm)

Front 116

What is a neurogenic differential diagnosis for low back pain?

Back 116

Infections and neoplasms that involve either spinal cord or cauda equina

Front 117

What is a sponylogenic differential diagnosis for low back pain?

Back 117

Most common causes of low back pain, with or without sciatica

Front 118

What is a psychogenic differential diagnosis for low back pain?

Back 118

Emotionally unstable patient can also suffer from lumbar pain