Anderson4e Ch11 WithLectureNotes

Lumbar Spinal Conditions
Chapter 11
Copyright © 2009Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy
• lumbar spine
– forms convex curve anteriorly
– 5 lumbar, 5 fused sacral,& 4 small, fused coccygeal
vertebrae
• sacrum articulates with ilium - sacroiliac joint.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (Cont’d)
• F11.1

Anatomy (Cont’d)
• ligaments responsible for • F11.2
articulation with sacrum
– iliolumbar ligaments
– posterior sacroiliac
ligaments,
– sacrospinous ligamen7
– sacrotuberous ligament

Anatomy (Cont’d)
• muscles of trunk
– paired
– unilaterally: produce lateral flexion and/or rotation of the trunk
– bilaterally: trunk flexion or extension
• primary movers back extension - erector spinae muscles

Anatomy (Cont’d)
• F11.3

Anatomy (Cont’d)
• nerve plexus
– lumbar (T12 – L5)
• F11.4

Anatomy (Cont’d)
• nerve plexus
– sacral (portion of lumbar (L4-L5)
• F11.5

Kinematics
• movements involve a number of motion segments
– flexion/extension/ hyperextension
– lateral flexion
– rotation
• spinal flexion vs. hip flexion vs. forward pelvic tilt
• hyperextension

Kinematics
• movements involve a number of motion segments
– flexion/extension/ hyperextension
– lateral flexion
– rotation
• spinal flexion vs. hip flexion vs. forward pelvic tilt
• hyperextension

Kinetics
• effects of body position
– line of gravity passes anterior to spinal column
– trunk flexion
  moment arm for body weight;
 bending moment
• counteract moment via tension in back muscles
  tension in back →  compression lumbar spine

Kinetics (Cont’d)
– load upright •F11.6

standing compared
to
• sitting 
• spinal flexion 
• slouched sitting 
– lifting and carrying

Anatomic Variations: Injury Potential
• lordosis • F11.7
– abnormal exaggeration of
lumbar curve
– causes include
• congenital deformities
• weak abdominal
musculature
• poor posture
• activities with excessive
hyperextension

Anatomic Variations: Injury Potential
• sway back
– increased lordotic curve and kyphosis
– causes include
• muscle weakness; compensatory muscle tightness
– entire pelvis shifts anteriorly, causing the hips to move into
extension
– impact on COG

Anatomic Variations: Injury Potential (Cont’d)
• flat back
– decrease in lumbar lordosis (20deg)
– potential causes
– clinical sign - tendency to lean forward when walking
or standing
– impact on COG

• pars interarticularis
– area between superior and inferior facets
• weakest part of the vertebrae
– spondylolysis—fracture
• congenital or mechanical stress
• repeated weight-loading in flexion,
hyperextension, & rotation
• occur early age (age 8);
asymptomatic until ages 10–15

– spondylolisthesis—bilateral separation
• anterior displacement of a vertbra
• common site—lumbosacral joint
• ages 10–15

• Spondylolysis
– stress fracture of the pars interarticularis.
• Spondylolisthesis
– a bilateral fracture of pars interarticularis
accompanied by anterior slippage of involved
vertebra.
• F11.8

• Spondylolisthesis
– MRI demonstrates anterior shift of L5
• F11.9

– spondylitic conditions—mechanical stress

• do not typically heal with time
• S&S
• low back pain
• associated neurologic symptoms

• particularly susceptible
• female gymnasts, interior football linemen,
weight lifters, volleyball players, pole vaulters,
wrestlers, and rowers
• slippage severity

Prevention of Spinal Injuries
• protective equipment
– rib protectors
– weight-training belts/abdominal binders
• physical conditioning
– strength & flexibility
• proper technique
– proper lifting
– posture

Lumbar Spine Injuries
• contusions, strains, and sprains
– est. 80% of population has LBP at some time
– nearly 97% stems from mechanical inj. to
muscles, ligaments, or connective tissue
– chronic LBP: associated w/LBP, reduced
spinal flexibility, repeated stress, and
activities that require maximal extension of
the lumbar spine

Lumbar Spine Injuries (Cont’d)
– LBP
• pain & discomfort can range (local or diffuse)
• no radiating pain
• no signs of neural involvement
– management: standard acute; stretching

• LBP in runners
– associated w/ tightness in hip flexors &
hamstrings
– S&S
• localized pain, ↑ w/ active & resisted back
extension
• no radiating pain
• no signs of neural involvement
• possible anterior pelvic tilt & hyperlordosis

– management
• ice, NSAIDs, muscle relaxants, TENS, and EMS
• avoiding excessive flexion activities & a
sedentary posture
– decrease incidence—use progressive training
techniques

• myofascial pain
– referred pain that emanates from a myofascial
trigger point
– common trigger point sites: piriformis muscle
and quadratus lumborum
– S&S- piriformis
• referred pain in sacroiliac area, posterior hip,
and upper 2/3’s of posterior thigh
• Aching and deep pain increases with activity
or with prolonged sitting with the hip
adducted, flexed, and internally rotated
• myofascial pain (cont’d)
– S&S – quadratus lumborum
– false sign of disk syndrome
• superficial fibers- sharp, aching pain inlow back,
iliac crest, greater trochanter – can extend to
abdominal region
• deep fibers- sacroiliac joint or lower buttock
region; pain increases during lateral bending
toward the involved side, while standing for long
periods of time, and during coughing or sneezing
– management: involves stretching the involved
muscle back
• facet joint pathology

– may involve:
• subluxation or dislocation of the facet
• facet joint syndrome
• degeneration of the facet itself
– exact pathophysiology is unclear
– toward involved side, & w/ torsional load

– S&S
• nonspecific low back, hip, & buttock pain—deep & achy
• pain may radiate to post. thigh, but not below knee
• pain aggravated by rest & hyperextension; relieved by
repeated motion
• flattening of lumbar lordosis
• point tenderness—unilateral or bilateral paravertebral
area
 pain w/ trunk rotation, stretching into full extension,
lateral bending

• facet joint pathology (cont’d)
– possible clinical findings
• abnormal pelvic tilt & hip rotation secondary to
tight hamstrings, hip rotators, & quadratus
• MMT normal; but subtle weakness in erector
spinae & hamstrings may contribute to pelvic tilt
abnormalities
• + straight leg raising test
– definitive diagnosis
– management: standard acute; education
• sciatica
– classification levels
• sciatica only
• no sensory or muscle weakness
• modify activity appropriately, and develop
rehabilitation and prevention program
• any increased pain requires immediate
reevaluation

• sciatica with soft signs

• some sensory changes
• mild or no reflex change
• normal muscle strength
• normal bowel and bladder function
• remove from sport participation for 6–12 wks.

• sciatica with hard signs

• sensory and reflex changes
• muscle weakness due to repeated, chronic, or acute
condition
• normal bowel and bladder function
• remove from participation 12 to 24 weeks.

• sciatica with severe signs
• sensory and reflex changes
• muscle weakness
• altered bladder function
• consider immediate surgical decompression.

– potential causes:
• herniated disc
• radiating leg pain > back pain
• pain ↑ sitting & leaning forward, coughing,
sneezing, & straining
• neurologic deficits are usually present
• + ipsilateral straight leg raising test
• annular tears
• back pain > leg pain
• pain ↑ sitting & leaning forward, coughing,
sneezing, & straining
• may have muscle spasm and loss of lordosis
• + ipsilateral straight leg raising test

• myogenic or muscle-related disease

• morning pain & muscle stiffness
• pain is unilateral or bilateral, not midline
• pain extends into the buttock and thigh region
only
• pain is reproduced with resisted, prolonged
muscle contraction and passive stretching of the
muscle
• contralateral pain with side bending

• spinal stenosis
• back and leg pain develop after walking a limited
distance, and increase as distance increases
• leg weakness or numbness is present, with or
without sciatica
• negative straight leg raising test
• positive pain on prolonged spine extension,
relieved with spine flexion

• facet joint arthropathy
• pain over joint on spinal extension, exacerbated
with ipsilateral trunk lateral flexion
• compression from piriformis
• symptoms mimic lumbar disc conditions, except
for the absence of true neurologic findings
• pain increases with medial rotation of the thigh
– management: physician referral

• lumbar disc conditions

– protruded disc (A)
• eccentric accumulation of nucleus w/ slight deformity of
annulus
– prolapsed disc (B)
• eccentric nucleus produces a definite deformity as it
works its way through fibers of annulus fibrosus.

– extruded disc (C)
• nuclear material bulges into spinal canal and runs risk
of impinging adjacent nerve roots
– sequestrated disc (D)
• nuclear material from intervertebral disc is separated
from disc itself and potentially migrates

• F11.10

– S&S
• sharp pain & spasm at site of herniation; pain shoots down
extremity
• walk in slightly crouched position, leaning away from side of lesion
• compression on spinal nerve
• sensory & motor deficits
• alteration in tendon reflex

• F11.11

SIGNS L3–L4 L4–L5 L5–S1
AND SYMPTOMS (L4 root) (L5 root) (S1 root)
pain lumbar region and buttocks lumbar region, groin, and lumbar region, groin, and
sacroiliac area sacroiliac area
dermatome and sensory anterior midthigh over lateral thigh, anterior leg, top posterior lateral thigh &lower
loss patella, medial lower leg to of foot, middle three toes leg to lateral foot and 5th toe
great toe
myotome weakness ankle dorsiflexion toe extension (extensor ankle plantar flexion
hallux) (gastrocnemius)
reduced DTR quadriceps medial hamstrings Achilles tendon
straight leg raising normal reduced reduced

test
– management
• significant signs: immediate physician referral
• standard acute; activity modification
• lumbar fractures and dislocations
– transverse or spinous process fracture
• due to
• extreme tension from attached muscles
• direct blow
• additional injury to surrounding soft tissues
– compression fracture
• hyperflexion crushes anterior aspect of vertebral
body
• primary danger—possibility of bony fragments
moving into spinal canal, damaging cord or spinal
nerves
– dislocations
• occur only when a fracture is present
• rare in sports
– S&S
• localized, palpable pain, may radiate down
the nerve root if a bony fragment compresses
a spinal nerve

– spinal cord ends—L1 or L2 level
• fx below not a serious threat, but handle w/ care to
minimize potential damage to cauda equina
– management
• fracture or dislocation: activate EMS
• conservative treatment: initial bed rest, cryotherapy,
and minimizing mechanical loads

Sacrum and Coccyx Conditions
• sacroiliac joint sprain
– mechanisms
• single traumatic episode involving bending and/or
twisting
• repetitive stress from lifting
• fall on buttocks
• excessive side-to-side or up-and-down motion
during running
• running on uneven terrain
• suddenly slipping or stumbling forward
• wearing new shoes or orthoses
Sacrum And Coccyx Conditions (Cont’d)
– S&S
• unilateral, dull pain that extends into buttock &
posterior thigh
• ASIS or PSIS may appear asymmetric bilaterally.
• leg-length discrepancy
• ↑ pain w/ standing on one leg & stair climbing
• forward bending reveals block to normal movement
w/ the PSIS on injured side moving sooner than
uninjured side
• ↑ pain w/ lateral flexion toward injured side
• ↑ pain w/ straight leg raises beyond 45º
– management: standard acute;
gentle stretching
• coccygeal conditions
– contusions and fractures
• mechanism: direct blows
• pain from fx may last several months
– coccygodynia
• irritation of the coccygeal nerve plexus
• prolonged or chronic pain

– management
• analgesics
• use of padding for protection
• ring seat to alleviate compression during
sitting

Spinal Assessment—Conscious Individual
• history
– important to ask questions about
• pain
• location (i.e., localized or radiating)
• type (i.e., dull, aching, sharp, burning)
• sensory changes (i.e., numbness, tingling, or absence of
sensation)
• muscle weakness or paralysis

Spinal Assessment—Conscious Individual
• observation/ inspection
– postural assessment
– scan exam
– gait analysis
– inspection of injury site
– gross neuromuscular assessment

Spinal Assessment—Conscious Individual (Cont’d)
• palpation
– patient prone
• pillow under the hip region to tilt the pelvis back and
relax the lumbar curvature
• physical examination testing

– if at anytime, movement leads to increased acute pain or
change in sensation, or the individual resists moving the
spine, a significant injury should be assumed and EMS
activated

Range of Motion
• active range of motion (AROM)
– cervical flexion
– forward trunk flexion
– trunk extension
– lateral trunk flexion
(left and right)
– trunk rotation

ROM (Cont’d)
• active range of motion (AROM)
• F11.14

ROM (Cont’d)
Normal ranges
• forward trunk flexion—40°–60°
• trunk extension—20°–35°
• lateral trunk flexion (left & right)—15°–20°
• trunk rotation—35°–50°

ROM (Cont’d)
• passive ROM
– seldom performed
• resisted ROM
– weight of the trunk will stabilize the hips

Stress and Functional Tests (Cont’d)
– slump test
• F11.17

• F11.18
– straight leg raising
• sync w/ straight leg
– well straight leg raising
– bowstring test
• F11.19
• sync w/ bowstring

– Brudzinski’s
– Kernig’s test
• F11.20

– bilateral straight leg • F11.21

raising • sync w/ Milgram
– Valsalva’s
– Milgram test
– piriformis muscle stretch
• F11.22
• sync w/ piriformis

– prone knee bending • F11.23
– spring test for joint • sync w/ prone knee

mobility
• F11.24
• sync w/ piriformis

– Farfan torsion test • F11.25
– trunk extension test • sync w/ Farfan
• F11.64
• sync w/ trunk

– femoral nerve traction • F11.27
test
• sync w/ femoral
– quadratus lumborum
stretch test
• F11.28
• sync w/ quad

– single leg stance • F11.29
– quadrant test • sync w/ single leg
• F11.30
• sync w/ quadrant

– Hoover test • F11.31
– Burns test • sync w/ Hoover
• F11.32
• sync w/ Burns

– Sacroiliac compression & • F11.33

distraction test • sync w/ sacoiliac
– approximation test
• F11.34
• sync w/ approximation

– “squish” test • F11.35
– Faber (Patrick) Test • sync w/ Faber

– Gaenslen’s test • F11.36
– long sitting test • sync w/ Gaenslen’s

Neurologic Tests
• Babinski • F10.27
• Oppenheim • this is not a mistake

– myotomes
Neurologic Tests (Cont’d)
Nerve Root Segment Action Tested

L1–L2 hip flexion
L3 knee extension
L4 ankle dorsiflexion
L5 toe extension
S1 plantar flexion of the ankle, foot eversion, hip extension
S2 knee flexion

– reflexes
Reflex Segmental Levels

Patellar L2 , L 3 , L 4
Posterior tibial L4 , L 5
Medial hamstring L5 , S 1
Lateral hamstring S1, S2
Achilles S1, S2

• cutaneous patterns
• F5.8
• this is not a mistake

• referred pain
• F5.1
• this is not a mistake

Rehabilitation
• relief of pain and muscle tension
– AROM exercises vs. prolonged position
– conscious relaxation training
– Grade I and II mobilization exercises
• restoration of motion
– Grade III and IV mobilization exercises
– flexibility and range-of-motion exercises
– pelvic and abdominal stabilizing exercises

Rehabilitation (Cont’d)
• restoration of proprioception and balance
– Closed-chain exercises
• muscular strength, endurance, & power

– neck strength
– abdominal strength
– erector spinae strength
• cardiovascular fitness

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Lumbar Spinal Conditions

Copyright © 2009Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• spinal flexion vs. hip flexion vs. forward pelvic tilt

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• spinal flexion vs. hip flexion vs. forward pelvic tilt

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

– load upright •F11.6

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

– spondylitic conditions—mechanical stress

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Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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• facet joint pathology

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• sciatica with soft signs

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• sciatica with hard signs

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• myogenic or muscle-related disease

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• lumbar disc conditions

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reduced DTR quadriceps medial hamstrings Achilles tendon

straight leg raising normal reduced reduced

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Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins