PHYSICAL EXAMINATION OF THE LUMBAR SPINE AND SACRUM

Anatomy

There are 10 (five pairs) facet joints (also called apophyseal joints or
zygoapophyseal joints) in the lumbar spine.

These joints consist of superior and inferior facets and a capsule.

Injury, degeneration, or trauma to the motion segment (the facet joints and
disc) may lead to:

• spondylosis
o degeneration ion of the intervertebral disc
• spondylolysis
o a defect in the pars interarticularis or the arch of the vertebrae
• spondylolisthesis
o a forward displacement of one vertebrae over another
• retrolisthesis
o backward displacement of one vertebra on another

mobile Lumbar, fixed sacrum -> L5 prone to injury

The superior facets, or articular processes, face medially and backward and in general, are concave; the inferior facets face
laterally and forward and are convex.

The main ligaments of the lumbar spine are the same as those in
the lower cervical and thoracic (excluding the ribs).

These ligaments include:

• the posterior longitudinal ligaments,

• the ligamentum flavum
• the supraspinous and interspinous ligaments
• intertransverse ligaments
• Iliolumbal ligament

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 Disc herniation ~5% of all back pains = rare
HISTORY

-sudden onset LBP + potential leg pain past knee

-sharp, shooting, dermatomal pattern
-pain excerbated by inc intradiscal pressure

1. What is the patient’s age?

• Different conditions affect patients at different ages.

• Disc problems usually occur between the ages of 15 and 40 years
• ankylosing spondylitis is evident between 18 and 45 years.
• Osteoarthritis and spondylosis are more evident in people older than 45 years of age
• malignancy of the spine is most common in people older than 50 years of age.

2. What is the patients usual activity or past time?

• Back pain tends to be more prevalent in people with strenuous occupations, although it has been reported that
familial influences have an effect as well as occupation.
• truck drivers (vibration) and warehouse workers have a high incidence of back injury.
• How active is the patient at work (are they doing their usual job?, light duties?, full time?, frequent days off
because of back pain?, unemployed because of back?, retired)?
• Patients who have chronic low back pain develop a deconditioning syndrome, which compounds the problem as it
leads to decreased muscle strength, impaired motor control, and decreased coordination and postural control.

3. What is the patients gender?

• Lower back pain has a higher incidence in women.

• Female patients should be asked about any changes that occur with menstruation,
such as altered pain patterns, irregular menses, and swelling of the abdomen or
breasts.
• Knowledge of the date of the most recent pelvic examination is also may be useful.
• Ankylosing spondylitis is more common in men

4. Is there parasthesia or anesthesia in the limbs, perineal (saddle area) or pelvic area?

• A patient may experience a sensation or a lack of sensation if there is pressure on a nerve root.
• Does the patient experience any paresthesia or tingling and numbness in the extremities, perineal (saddle) area, or
pelvic area? Abnormal sensations in the perineal area often have associated micturition (urination) problems.
• Remember that the adult spinal cord ends at the bottom of the LI vertebra and becomes the cauda equina within
the spinal column.

5. Is there bowel or/and bladder dysfunction?

 These symptoms may indicate a myelopathy and are considered to be an situation because of potential long-term
bowel and bladder problems if the pressure on the spinal cord is not relieved.

6. Are the symptoms improving, worsening, or staying the same?

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 • The answers to these questions will indicate whether the condition is improving,
• may indicate that the condition is in the inflammatory (acute) or in the healing phase.
• Does the patient complain of more pain than the injury would suggest should occur?
If so, psychosocial testing may be indicated.

7. Are there any problems sleeping? What kind of mattress does the patient use?

• If the patient lies prone, the lumbar spine often falls into extension increasing the stress on the posterior elements
of the vertebrae.
• In supine lying, the spine tends to flatten out, decreasing the stress on the posterior elements
• In side lying the legs should be bent in a semi-fetal position with pillowing to support the position of the hips and
spine / shoulders.

8. Is there any increase in pain with coughing, sneezing, deep breathing or laughing?

• All of these actions increase the intrathecal pressure (the pressure inside the covering of the spinal cord) and
would indicate the problem is in the lumbar spine and affecting neurological tissue

9. Is the patient receiving any medication?

• Long-term use of steroid therapy can lead to osteoporosis.

• If the patient has taken pain medication just before the assessment, the examiner may not get a true reading of
the pain.

10. LO DR FICARA

o Location (show me)

• Have the patient point to the location or locations.
• Note whether the patient indicates a specific joint or whether the pain is more general.
• The more specific the pain, the easier it is to localize the area of pathology.
• Unilateral pain with no referral below the knee may be caused by injury to muscles (strain)
or ligaments (sprain), the facet joint, or, in some cases, the sacroiliac joints.
• This is called mechanical low back pain (in older books it is called "lumbago").
• With these injuries, there is seldom if ever peripheralization of the symptoms. The
symptoms tend to stay centralized in the back.
o Onset
o Duration
o Radiation (Is the pain centralizing or peripheralizing)

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 • Centralization implies the pain is moving toward the lumbar spine.
• Peripheralization implies the pain is being referred into the limb.
• If there is referral correlate this information with dermatome findings when
evaluating sensation.
 Frequency
 Intensity
 Characteristic
 Aggravating factors (movements, ice, heat, position)
• If sitting increases the pain and other symptoms examiner may suspect that sustained flexion is causing
mechanical deformation of the spine or increasing the intradiscal pressure.
• Classically, disc pathology causes increased pain on sitting, lifting, twisting and bending.
• If standing increases the pain and other symptoms, the examiner may suspect that extension, especially
relaxed standing, is the cause.
• If walking increases the pain and other symptoms, extension is probably causing the mechanical
deformation because walking accentuates extension.
• If lying (especially prone lying) increases the pain and other symptoms, extension may be the cause.
• Persistent pain or progressive increases in pain while the patient is in the supine position may lead the
examiner to suspect neurogenic or space-occupying lesions, such as an infection, swelling, or tumor.
• Remember that pain may radiate to the lumbar spine from pathological conditions in other areas as well
as from direct mechanical problems.
• For example, tumors of the pancreas refer pain to the low back.
▪ Relieving factors
• If there are positions that relieve the pain, the examiner should use an understanding of anatomy to
determine which tissues would have stress taken off them in the pain-relieving postures, and these
postures may later be used as resting postures during the treatment
o Associated symptoms

INSPECTION

For the pelvis to "sit" properly on the femur, the abdominal, hip flexor, hip extensor, and back extensor muscles must be strong,
supple, and balanced.

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 • Look for splinting of movement when the patient disrobes
• Awkward, unnatural movements of the spine
• Assess back for unusual skin markings, redness, heat
• Do a full postural assessment and look for lordosis
• Look for listing to one side while patient is standing or sitting

Lower Cross Syndrome:

-Abd mm WEAK
-hamstrings WEAK
-glut max/med - WEAK

-spinal extensors TIGHT

-hip flexors - TIGHT

PALPATION

-possible local tenderness

- hypertonic low back mm
= don’t find a lot from palpation

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Bony Palpation

1. Iliac crest
2. Spinous process
3. Coccyx
4. PSIS

Soft Tissue Palpation

Paraspinal Muscles
• palpable muscles include: spinalis,
longissimus, and iliocostalis)
• To palpate these muscles have the patient
lying prone with head slightly back to slacken
the overlying fascia
• Differentiate between the 3 muscles
• Knead them between your fingers and feel for
tenderness, spasm,
asymmetry, and atrophy

Gluteal Muscles
• Gluteal muscles originate from various areas just
below the iliac crest
• May find fibro-fatty nodules under the lip of the
iliac crest’s posterior portion

Piriformis
• Runs from sacrum to femur
• Tightness may compress the sciatic nerve

Hip flexors
• May be palpated with patient supine

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 Sciatic Nerve
• Sciatic n. runs vertically down the midline of the posterior thigh
• Gives off branched to the hamstring muscles
• Divides into tibial and peroneal divisions
• Located as it exits through the greater sciatic foramen under
cover of the piriformis and passes midway b/t the greater
trochanter and the ischial tuberosity
• To palpate have the patient flex the hip, locate the midpoint
between the ischial tuberosity and the greater trochanter
• Press firmly at the midpoint as it is usually barely palpable
• Sciatic n. is more tender if a herniated disc or space occupying
lesion is pressing on it

Sacroiliac Ligaments

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RANGE OF MOTION

Little obvious movement occurs in the lumbar spine especially in the individual segments because of the shape of the facet joints,
tightness of the ligaments, presence of the intervertebral discs, and size of the vertebral bodies

ACTIVE ROM
MOTION ACTIVE RANGE OF MOTION ASSESSMENT

Flexion • Instruct patient to bend as far forward as possible with knees straight, try to touch toes
• If she can’t touch toes, measure distance b/t finger tips and floor
• Maximum ROM in the lumbar spine is normally 40° to 60°.
• The examiner must differentiate the movement occurring in the lumbar spine from that
occurring in the hips or thoracic spine.
• Some patients may touch their toes by flexing the hips, even if no movement occurs in the
spine.
• On forward flexion, the lumbar spine should move from its normal lordotic curvature to at
least a straight or slightly flexed curve.
• If this change in the spine does not occur, there is probably some hypomobility in the lumbar
spine resulting from either tight structures or muscle spasm.
• It may be possible to see an instability jog during one or more movements, especially flexion,
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 returning to neutral from flexion, or side flexion.
• An instability "jog" is a sudden movement shift of the muscles during active movement,
indicating an unstable segment.
• If the patient bends one or both knees on forward flexion, the examiner should watch for
nerve root symptoms or tight hamstrings, especially if spinal flexion is decreased when the
knees are straight.
• When returning to the upright posture from forward flexion, the patient with no back pain
first rotates the hips and pelvis to about 45° of flexion; during the last 45° of extension, the
low back resumes its lordosis.
• In patients with back pain, commonly, most movement occurs in the hips, accompanied by
knee flexion, and sometimes with hand support working up the thighs.
• The examiner may use a tape measure to determine the increase in spacing of the spinous
processes on forward flexion.
Extension • Stand behind patient with one hand on low back (palm on PSIS with fingers extending toward
the midline)
• Patient bends backward as far as she can
• Backward bending is normally limited to 20-35 degrees in the lumbar spine.
• A variation is to lie prone, going into what is called the sphinx position. The patient
hyperextends the spine by resting on the elbows with the hands holding the chin and allows
the abdominal wall to relax. The position is held for 10 to 20 seconds to see if symptoms
occur or, if present, become worse
Lateral • Stabilize the iliac crest and ask the patient to lean to their side by running the hand down the
flexion side of the leg and not to bending forward or backward while performing the movement.
• Note how far the finger tips go down the side of the leg
• Normal is approximately 15° to 20° of side flexion in the lumbar spine.
• The examiner can eyeball the movement and compare it with that of the other side.
• The distance from the fingertips to the floor on both sides may also be measured, noting any
difference.
• As the patient side flexes, the examiner should watch the lumbar curve.
• Normally, the lumbar curve forms a smooth curve on side flexion, and there should be no
obvious sharp angulation at only one level.
• If angulation does occur, it may indicate hypomobility below the level or hypermobility above
the level in the lumbar spine

Rotation • Place one hand on the patients iliac crest and the other on the opposite shoulder
• Patient rotates away from the hand on the iliac crest

• Rotation in the lumbar spine is normally 3° to 18° to the left or right, and it is accomplished
by a shearing movement of the lumbar vertebrae on each other.
• may be performed while sitting to eliminate pelvic and hip movement.

• If the patient stands, the examiner must take care to watch for this accessory movement and
try to eliminate it by stabilizing the pelvis
PASSIVE ROM
Range Passive Range of Motion Assessment
Flexion • Apply some overpressure on the thorax at the end range of lumbar flexion
Extension • Apply over pressure (minimal) manually by pushing gently on the chest
Lateral flexion • Stabilize patients pelvis (opposite side), grip the shoulder (same side), and lean them to the side
Rotation • Assist trunk rotation by rotating the pelvis (opposite side) and the shoulder (same side) posteriorly

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RESISTED ROM

Done with the patient is seated, use the instruction don’t let me move you while applying resistance in the ranges of the lumbar
spine.

Dynamic muscular tests

o Normal resisted isometric tests may not reproduce symptoms because the relatively strong abdominals unload
the pressure on the lumbar spine.
o Dynamic muscular tests may find symptoms not found in static resistance tests
o Dynamic abdominal endurance test
o Patient tucks chin and curls as in a slight sit up position and holds
o Dynamic extensor endurance test
o Patient prone, hips are secured to a table patient then extends spine to raise up the body

NEUROLOGICAL EXAM

Dermatomes

Spinal Level Innervation

L1 Groin and suprapubic area
L2 Anterior thigh
L3 Lower anterior/medial thigh and knee
L4 Lower leg and medial foot (L4)
L5 Lower leg and dorsum of foot (L5)
S1 Lateral foot
S2 Plantar surface of heel
S3,4,5 Bulls eye around anus

Myotomes
Neurological Muscle Resisted Motion

L2 Iliopsoas Hip flexion

L3 Quadriceps Knee extension in prone

L4 Tibialis anterior Dorsiflexion Inversion

L5 Extensor Hallucis Longus (EHL) Dorsiflexion of big toe

S1 Gluteus maximus Hip extension

S2 Hamstrings Knee flexion

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Reflex Testing

Motor Reflex Testing

Reflex Spinal level

Patellar L4

Achilles S1

Superficial Reflexes
Superficial Reflex Description
• Abdominal • Patient is supine, using sharp end of neurological hammer stroke each quadrant of the abdomen
• Note umbilicus moving towards the stroke
• Cremasteric • Stroke inner side of upper thigh with sharp end of reflex hammer

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 • Scrotal sack is pulled upward as cremasteric muscle contracts
• Anal • Touch the perianal skin
• External anal sphincter muscles should contract in response
• Babinski • Run a sharp instrument across the plantar surface of the foot from calcaneous along the lateral
border to the forefoot
• Negative = toes either do not move or bunch up
• Positive = big toe extends and toes plantar flex

Lower Limb Tension Tests

Sciatic Nerve – LLTT

• Perform the Straight Leg Raising Test (in special test section)

Femoral Nerve – LLTT

• Patient lying prone
• Examiner stands on the same side as assessment
• Grasps the patient’s ankle and passively flexes the knee bringing the ankle to the patient’s
buttocks • Positive
• radicular symptoms in the anterior thigh along the femoral nerve distribution

SPECIAL ORTHOPEDIC TESTS

Tests to Stretch the Spinal Cord

Straight Leg Raising Test (SLR Test) good for R/O disc herniation

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 • Patient lying supine, hip is medially rotated and adducted
• Lift involved leg upward by supporting the foot around the calcaneous (keep knee straight)
• Positive
o Pain at 35-70 degrees (no dural mvmt <35’, >70’ pain d/t joint)
o Indicates
• IVD pressure on sciatic nerve (usually a lateral herniation)
o Pain at 70 degrees or more neuro, sharp shooting pain
o Indicates
• SI joint pain
posterior-lateral herniation —> antalgic posture AWAY from herniation side

Well Leg Raising Test (WLR Test)

• Patient in supine while doctor raises the uninvolved leg
• Positive
o back and sciatic pain on the opposite side
• Indicates
o Further presumptive evidence of a space occupying lesion
such as a herniated disc (usually a medial herniation
Medial herniation  antalgic posture TOWARDS herniation side

Left leg Right leg Antalgia Disc Herniation

SLR(L pain) WLR(no pain) Right Left lateral

SLR(no pain) WLR(L pain) Left Left medial

WLR(no pain) SLR(R pain) Left Right lateral

WLR(R pain) SLR(no pain) Right Right medial

most protrusions are posterolateral

but if someone is leaning towards the pain -> suspect medial protrusion

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 Lasegue’s Test
• Patient lying supine or sitting
• Doctor lifts leg off table like in SLR Test to the level of pain
• Examiner then lowers the leg just below the level of pain and adds
dorsiflexion of the ankle stretching the sciatic nerve
• Positive
o pain radiating below knee
o Indicates
 disc herniation, neural impingement

come out of painful state —> non SI state

then we pull nerve by dorsiflexion
—> most likely d/t nerve
Slump Test (Variation of SLR) lumbar, thoracic flexion → cervical flexion → dorsiflexion
At any step, elicit pain = DO NOT GO FURTHER
• Patient begins sitting at end of table with back straight, looking straight ahead
• Patient slumps allowing the T/S and L/S to collapse into flexion while looking
forward
• Examiner provides overpressure to maintain the flexion
• Next step patient flexes the C/S,
• Examiner adds over pressure to c-spine
• With the other hand the examiner takes the foot into dorsiflexion
• patient then extends one knee,
• if the patient can’t extend the knee flexion is released from the c-spine
• Process is then repeated to opposite side
• Positive

o Radicular pain at any stage

o Indicates
• Increased pressure in the neuro-menigeal tract, disc pathology, sciatica, nerve
entrapment

Brudzinski-Kernig Test – Meningitis

Active movement of patient
Combine bruzinski-kernig
• Ask the patient to lie supine, have him/her place both hands behind the
head to forcibly flex his head onto his chest
• Raise the extended leg until pain is felt
• The patient then flexes the knee to see if the pain disappears
• Positive
o Pain in C/S, low back, or down the legs, usually sharp, shooting
pain / patient reluctant to do it, or other hip flexes(?)
o Indicates
• Meningeal irritation, nerve root involvement, or
irritation to the dural coverings of nerve root

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 Hoover Test
• Cup one hand under the calcaneous of the opposite foot as the patient try’s to raise his leg
• When a patient is genuinely trying to lift his leg he will put pressure on the calcaneous of his
opposite leg for leverage, you can feel this downward pressure in your hand
• Positive
o An absence of downward pressure on the foot opposite to the one the patient has
been instructed to lift
o Indicates
• Patient is malingering and not really trying to lift their leg
differentiate someone trying to pretend to be sick
Tests to Increase Intrathecal Pressure (ITP)

Milgram Test
• Patient lying supine
• Have keep both legs straight and raise them to a position about 2” above the
table
• Hold the position for 30 seconds
• Positive
▪ Affected limb(s) cannot be held for 30 seconds or
symptoms are reproduced in the affected limb(s)
• Indicates
▪ Intrathecal pathology such as a herniated disc
• Do not do if suspect disc rupture

Naffziger Test – NOT ON OUR TEST; FOR NPLEX

• Patient lies supine, doctor gently compresses the jugular veins for 10 seconds (both at
same time) until face flushes, then ask them to cough
• Positive
• pain increases with coughing
• Indicates
▪ An increases in intrathecal pressure (space occupying
lesion)
Valsalva Test
• Patient is seated, takes a deep breath and blows out with closed mouth (like straining at
stool)
• Positive
• Pain in back or down the legs
• Indicates
 A space occupying lesion causing an increase in intrathecal pressure
• WARNING: patient may become dizzy or lose consciousness by restricted blood
flow

Tests to Rock the SI Joint

Pelvic Rock Test

• Patient lies supine, while doctor places his hands on the the iliac crests with
thumbs on ASIS and palms on the iliac tubercles
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 • Forcibly compresses the pelvis toward the midline of the body
• Positive
▪ Pain around the SI joint
o Indicates
 SI joint pathology

Gaenslen’s Test
• Patient lies supine, ask him to bring both legs onto his chest
• Shift him to the side of the table so that one buttock is over the edge of the
table while the other remains on the table
• All his unsupported leg to drop over the the edge while his opposite leg remains
flexed
• Doctor can apply over pressure to help stretch the leg
• Positive
▪ Pain in SI joint or pain in hip
o Indicates
• SI joint pathology or hip pathology

Patrick Faber Test

• Patient lies supine, and doctor places the foot of his involved side on his opposite knee
• Hip joint is now flexed, abducted, and externally rotated
• Doctor applies over pressure downwards on the flexed knee and the opposite side ASIS
• Positive
▪ increased pain in SI joint or hip joint
o Indicates
 Pathology of SI joint or Hip joint

Other Tests

Single Leg Hyperextension Test

 Patient stands in the straddle position with one lower limb extended behind the
other
 Patient then leans back as far as possible while examiner prevents patient from
falling over
 Test is repeated with lower limb position reversed
 Positive
• Exacerbation of the patient’s pain and the pain tends to be more severe when
the lower limb of the affected side is extended posteriorly
 Indicates
• Spondylolysis and spondylolisthesis
• If pain comes on when rotation is added may indicate facet pathology on the
side to which the body is rotated

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REHABILITATION OF LUMBAR SPINE AND SACRUM

Rehabilitation Goals
• Acute
o Control symptoms; allow musculature to rest without becoming stiff; progress to sub-acute phase ASAP
• Sub-Acute
o Restore Flexibility; controlled motion, manual therapy; limited work & ADL’s
• Chronic
o Restore full ROM by mobilization; strengthen musculature for hypermobile segments; Return to
function, RTW, recreation & sports

CONDITIONS OF THE LOW BACK AND SACRUM

DEGENERATIVE DISC DISEASE

The intervertebral discs make up approximately 20% to 25% of the total length of the vertebral column. The function of the
intervertebral disc is to:

• act as a shock distributing and absorbing some of the load applied to the spine,
• to hold the vertebrae together and allow movement between the bones,
• to separate the vertebrae as part of a functional segmental unit acting in concert with the facet joints,

Separating the vertebrae, to allow the free passage of the nerve roots out from the spinal cord through the intervertebral foramina.

DDD could —> herniation

Functional Segment Unit = facet + disc, 25% of spinal height

decrease with age, day progression (less water)
1-2 cm change with day progression

• Degeneration of the disc is a normal process.

• As a person ages, the vertebral discs undergo slow wear and tear.
• This typically consists of fibrous changes in the nucleus and in the organization of
the annulus fibrosus rings, and disappearance of the cartilaginous end-plates.
• The discs of the lumbar and cervical spine are most affected
• The nucleus gradually changes from a gel to a fibrous structure; its water-binding
capacity decreases while its collagen content increases.
• The overall height of the disc decreases and the disc space narrows.
• If there is an injury to the disc, four problems can result, all of which can cause symptoms.
• Protrusion
• Prolapse
• Extrusion
• Sequestration / sequestrated disc,

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Annulus fibrosus - sharpey’s fibers (3 layers, denser inside)
cervical + lumbar areas most developed
with age —> fibrocartilage holds less water, less likely to herniate
• The posterolateral portion of the disc fibres weaken first.
• One contributing factor is the functional movements of the spine.
o These are often diagonal combinations of flexion and rotation, placing more stress on the posterolateral portion of
the annular fibres by the nucleus.
o Another factor that leads to weakness is that the posterior longitudinal ligament is thicker and stronger than the
thinner, more lateral portions of the annulus.
• As early as 20 years of age, changes in the lumbar discs can be noticed as the vascular supply to the disc becomes occluded,
affecting its nutrition.
• By the third decade of a person's life, the facet joints become involved in the degenerative process.
• They experience abnormal stress due to the altered disc mechanics; synovitis and joint effusion may occur
• Over time, as the posterolateral annular fibres compress and bulge, clefts appear between the layers of the annulus.
• The clefts may meet and form gaps.
• Eventually these clefts and gaps become radial and horizontal tears; the nucleus is allowed to protrude into the annular
space
• The annular fibres, over time, become weaker and less elastic, creating tension on the outer fibres.
• This, combined with altered disc mechanics and weight bearing in the spine, encourages bone reinforcement at the outer
edges of the vertebrae.
• Osteophytes form anteriorly and posteriorly
• Between the ages of 40 and 50, discs in the lumbar spine are still capable of imbibing water, it is during this decade that the
nucleus gradually changes to a fibrous material
almost indistinguishable from the annular fibres.
• Narrowing occurs in 70 per cent of men and 55 per
cent of women between ages 55 and 64 years
• The intervertebral foramen space is also reduced
leaving less room for nerve roots.
• In the cervical spine this process occurs sooner, by
age 40 the nucleus pulposus in the cervical spine is
virtually nonexistent having changed to fibrous
material

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In the lumbar spine, the nerve roots exit through relatively large intervertebral foramina, and as in the thoracic spine, each one is
named for the vertebra above it (in the cervical spine, the nerve roots are named for the vertebra below). For example, the L4
nerve root exits between the L4 and L5 vertebrae.

Because of the course of the nerve root as it exits, the L4 disc (between L4 and L5) only rarely compresses the L4 nerve root; it is
more likely to compress the L5 nerve root.

Herniation often affects N of the segment below = Rostral patterning of nerve exiting
*EXAM*
- Level of Disc Herniation —> symptom in L4 N = Herniation at L3 level

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Left: If herniation is bigger, would hit L5 + L4

Right: Central protrusion - hitting all N = cauda equina syndrome

DDD:
1 .Dysfunction: joint effusion, mm spasming, facet joint irritation = reversible
2. Instability: Laxity - can’t be repaired. Vert seg extra motion make it worse. Pain on stress ligaments,
stress on joint capsule —> spondylolisthesis, osteophytes form= irreverisble
3. Stabilization - losing disc height, intv foramen changing, stenosis, DD start to other segments dec
ROM

• DDD is thought to go through 3 stages of degeneration

• Dysfunction Stage
 Biomechanical changes over many years result in weakness, bulging and minor tears in the annulus which
heal slowly
• Instability stage
 Posterior annular fibres and joint capsule become lax causing the vertebral segment to become
hypermobile
• Stabilization stage
 Loss of disc material and decreased disc height, the intervertebral foramen narrows, the joint capsules
and posterior ligaments fibrose

Acute Disc Injury

• Most commonly occurs between 30 and 45 years of age as the annular fibres have weakened and can withstand less
stress
• It is possible to have rupture in the 20’s with no signs of degeneration.
• Rupture is unlikely in the 50’s because of fibrosing of the nucleus pulposus

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 • Men are affected more than women in a ratio of 3:2
• Herniation at L4 to L5 or L5 to S1 accounts for 98% of all low back disc injuries
• Symptoms of a protrusion vary depending on the vertebral level, direction of protrusion, as well as the amount of
protrusion.
• Healing is slow due to the hypovascular nature of the disc.
• As the condition resolves through the subacute to chronic stages, the spinal deformity reduces, range of motion increases
and orthopedic tests such as the straight leg raise, slump and upper limb tension tests become negative.
• Worsening signs in the lumbar spine are a lack of back pain but an escalation of neurological symptoms.

Signs & Symptoms

30-45 yo
90% L4-5, L5-S1
< activity

• Posterolateral and Posterior disc injuries

o Worse with activities that increase the interdiscal pressure, such as flexion, sitting, coughing and standing from
a sitting position
o Symptoms usually decrease with walking
• Anterior protrusion
o Causes back pain and likely no neurological signs.
o The bulge compresses the anterior longitudinal ligament.
o Symptoms may shift if the annulus is intact.
o On the other hand, if the annulus ruptures, this allows material to leak and the
hydrostatic mechanism is no longer intact; in this case, the symptoms cannot be
relieved by movements of the spine
• Acute Posterior Neck Lesions
o May refer pain and paresthesia across the shoulder and down the affected arm in a specific
dermatomal pattern.
o Pain may be sharp or deep and aching; it is worse with weight bearing such as carrying a bag or
purse.
o Acute anterior disc bulges may produce difficulty in swallowing
• Acute Lumbar Lesions
o Start as sudden back pain that progresses to mainly leg pain.
o The pain may be sharp, deep or aching.
o Herniation is always painful, with the onset often before noon when the disc is most
hydrated and the nucleus is able to move the most
o Calf cramping may be present with herniation.
o Standing and walking are less painful than sitting with a posterior or posterolateral
lesion
o Pain on standing or walking suggests an anterior lesion
smaller disc as day goes on, pain worse in the morning, better as I walk around
most likely posterior —> feel better walking around

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Contraindications to treatment

• Treatment is contraindicated with saddle anesthesia and bladder weakness;

o this indicates herniation and compression of the fourth sacral nerve root.
o The patient is referred for immediate medical attention
• If no position can be found that relieves the pain, treatment is contraindicated until the client is referred to a
physician for assessment
• Positions that aggravate symptoms are avoided.
• Do not mobilize hypermobile joints
• Do not remove all protective spasming with acute disc lesions; spasm stabilizes the hypermobile segments
• Pressure and direction of techniques are modified and deep or longitudinal techniques are not used on areas
of muscle atrophy

Exercise Prescription

Positional traction

• For the cervical spine,

o a passive positional traction of the cervical spine is used to relieve pain
o This is also termed unloading the spine.
o The supine patient rests the head on a small towel roll, positioning the neck in flexion
and sidebending away from the painful side
• For the lumbar spine
o positional traction is achieved by lying prone on a kitchen or dining room table so the
pelvis and legs hang over the end of the table.
o The hips and knees are in flexion, the feet do not touch the ground.

o Unloading of the spine is also achieved with swimming

Tx:
-sooner pt is up + moving better prognosis
-pain control
-mobilization * manipulation
-patient education
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LUMBAR SPINAL STENOSIS

• Narrowing of the lumbar spinal canal

• Due to hardened IVD bulging into the spinal canal or enlargement of spinal facet joints and
ligaments due to arthritis
• Spinal stenosis is like the lime build-up on the inside of a garden hose. Over time, it narrows the
diameter of the hose, just as spinal stenosis narrows the spinal canal
• X-ray, MRI or CT-scan are needed to make the diagnosis
• Signs and symptoms
o Pain or numbness in the back and/or legs
o Cramping or weakness in the legs
o Bowel or bladder problems can occur
o Symptoms usually worse with prolonged standing or walking
o Symptoms can come and go and may very in severity
o Bending forward or sitting increases space in the spinal canal and may improve symptoms
-inconsistent pattern of leg+back pain < activity
-forward flexion may relieve pain
-diffuse pain may be uni/bilateral
-possible neruologic deficit
-biomechanical analysis may revela loss of lumbar lordosis and/or posterior tilt of pelvis

management:
-Flexion exercise (williams)
-avoid extension
-lumbar distraction
-osseous manipulation
-massage therapy
-Phys modalities
- TENS, IFC, U/S
-Patient Education
-Rehab - stretch & strength, core strength, water aerobics
-Consider surgery if sx do not improve w/ conservative care

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SPONDYLOLYSIS

• A defect in the “pars interarticularis” (a thin isthmus of bone connecting the superior and inferior facets)
• Can be hereditary where the individual is born with a thin vertebrae making them susceptible to this
condition
• Sports such as weight lifting, gymnastics and football where lots of stress in extension can cause a stress
fracture in this area
• Can be unilateral or bilateral
• Most common vertebrae involved = L5
• Signs and Symptoms
 Can be present with no symptoms
 Pain usually spreads across the low back and feels like a muscle strain
 Can have lumbar tenderness at the area of involvement
 Pain exacerbated by hyperextension of the lumbar spine (passive, active, and single leg extension)

SPONDYLOLISTHESIS

• If a spondylolysis or stress fracture weakens the bone so much that it is unable to maintain proper position, the vertebrae
can start to slip out of place
• If too much slippage occurs it can begin to press on nerves, and surgery may be needed to correct the condition
• Signs and Symptoms
o If slippage is significant, it can compress nerves and narrow the spinal cord, leading to motor and sensory deficit
o Visible or palpable “step off” deformity

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LUMBAR FRACTURE

• A fracture of one or more parts of the lumbar vertebrae usually by a high energy trauma like a
MVA, fall, sports injury or act of violence (gunshot wound)
• Males 4X > Females
• Spinal cord may be injured depending on the severity of the fracture
• Surgery or bracing is often necessary
• People with osteoporosis, tumors, or other underlying conditions that weaken the bone can
get a spinal fracture with minimal trauma or normal daily activities
• Signs and Symptoms
o Moderate to severe back pain made worse with movement
o If spinal cord is involved symptoms include”
o Numbness

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 o Tingling
o Weakness
o Bowel or bladder dysfunction

LUMBAR STRAIN/SPRAIN INJURY - shouldn’t have shooting pain down the leg for this

• A strain is when muscles are abnormally stretched or torn vs.

• A sprain is when ligaments are torn to varying degrees from their attachments
• Both injuries show similar symptoms
• Many doctors refer to these injuries as “musculoligamnetous injuries”
• The treatment for both is very similar
• Risk factors for getting a lumbar muscle strain/sprain include:
o Obesity
o Smoking
o Improper lifting technique
o Poor conditioning
• Sprain/strain injuries cause inflammation which causes pain and spasm
• Can be debilitating and often force the patient to be in bed for a couple of days, and cause intermittent symptoms for
weeks
• 90% completely recover after one month
• Symptoms
• Symptoms are usually isolated to the low back
• Rarely do you get symptoms into the legs like some other spine conditions
• Pain around the low back and upper buttocks
• Low back muscle spasm
• Pain associated with activities and generally relieved by rest

CAUDA EQUINA SYNDROME (CES)

• Compression of the cauda equina (nerve roots at the lower end of the spinal cord)
• These nerve roots get compressed and paralyzed, cutting off sensation and movement
• Nerve roots that control the function of the bowel and bladder are also vulnerable to damage
• This is a surgical emergency
• CES can be caused by a ruptured disc, tumor, infection, narrowing of the spinal canal, MVA
• Signs and Symptoms:
o Bladder and bowel dysfunction
o Severe or progressive problems in the lower extremities including loss of or altered sensation b/t the legs, over
the buttocks, inner thighs and back of legs (saddle area), and feet and heels
o Pain, numbness or weakness spreading to one or both legs that may cause you to stumble or have difficulty getting
up from a chair

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