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

Copyright © 2009Wolters Kluwer Health | Lippincott Williams & Wilkins

Lumbar Spinal Conditions

Chapter 11

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

AnatomyAnatomy

• lumbar spine

– forms convex curve anteriorly

– 5 lumbar, 5 fused sacral,& 4 small, fused coccygeal vertebrae

• sacrum articulates with ilium - sacroiliac joint.


Anatomy (Cont’d)Anatomy (Cont’d)

• F11.1



• ligaments responsible for articulation with sacrum

– iliolumbar ligaments

– posterior sacroiliac ligaments,

– sacrospinous ligamen7

– sacrotuberous ligament

• F11.2



• 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



• F11.3



• F11.4

• nerve plexus

– lumbar (T12 – L5)



• F11.5

• nerve plexus

– sacral (portion of lumbar (L4-L5)


KinematicsKinematics

• movements involve a number of motion segments

– flexion/extension/ hyperextension

– lateral flexion

– rotation

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

• hyperextension


KinematicsKinematics

• movements involve a number of motion segments

– flexion/extension/ hyperextension

– lateral flexion

– rotation

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

• hyperextension


KineticsKinetics

• 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)Kinetics (Cont’d)

– load upright standing compared to

• sitting

• spinal flexion

• slouched sitting

– lifting and carrying

•F11.6


Anatomic Variations: Injury PotentialAnatomic Variations: Injury Potential

• lordosis

– abnormal exaggeration of lumbar curve

– causes include

• congenital deformities

• weak abdominal musculature

• poor posture

• activities with excessive hyperextension

• F11.7


Anatomic Variations: Injury PotentialAnatomic 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)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 InjuriesPrevention of Spinal Injuries

• protective equipment

– rib protectors

– weight-training belts/abdominal binders

• physical conditioning

– strength & flexibility

• proper technique

– proper lifting

– posture


Lumbar Spine InjuriesLumbar 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)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


Lumbar Spine Injuries (Cont’d)Lumbar Spine Injuries (Cont’d)• 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.


Lumbar Spine Injuries (Cont’d)Lumbar Spine Injuries (Cont’d)– 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


Lumbar Spine Injuries (Cont’d)Lumbar Spine Injuries (Cont’d)SIGNSAND SYMPTOMS

L3–L4

(L4 root)L4–L5

(L5 root)L5–S1

(S1 root)

pain lumbar region and buttocks lumbar region, groin, and sacroiliac area

lumbar region, groin, and sacroiliac area

dermatome and sensory loss

anterior midthigh over patella, medial lower leg to great toe

lateral thigh, anterior leg, top of foot, middle three toes

posterior lateral thigh &lower leg to lateral foot and 5th toe

myotome weakness ankle dorsiflexion toe extension (extensor hallux)

ankle plantar flexion (gastrocnemius)

reduced DTR quadriceps medial hamstrings Achilles tendon

straight leg raisingtest

normal reduced reduced

– management

• significant signs: immediate physician referral

• standard acute; activity modification


Lumbar Spine Injuries (Cont’d)Lumbar Spine Injuries (Cont’d)• 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 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) 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


Sacrum And Coccyx Conditions (Cont’d) Sacrum And Coccyx Conditions (Cont’d) • 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


Sacrum And Coccyx Conditions (Cont’d)Sacrum And Coccyx Conditions (Cont’d)

– management

• analgesics

• use of padding for protection

• ring seat to alleviate compression during sitting


Spinal Assessment—Conscious IndividualSpinal 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 IndividualSpinal Assessment—Conscious Individual

• observation/ inspection

– postural assessment

– scan exam

– gait analysis

– inspection of injury site

– gross neuromuscular assessment


Spinal Assessment—Conscious Individual (Cont’d)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 MotionRange 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)ROM (Cont’d)

• active range of motion (AROM)

• F11.14



Normal ranges

• forward trunk flexion—40°–60°

• trunk extension—20°–35°

• lateral trunk flexion (left & right)—15°–20°

• trunk rotation—35°–50°



• passive ROM

– seldom performed

• resisted ROM

– weight of the trunk will stabilize the hips


Stress and Functional Tests (Cont’d)Stress and Functional Tests (Cont’d)

– slump test

• F11.17



– straight leg raising

– well straight leg raising

– bowstring test

• F11.18

• sync w/ straight leg

• F11.19

• sync w/ bowstring



– Brudzinski’s

– Kernig’s test

• F11.20



– bilateral straight leg raising

– Valsalva’s

– Milgram test

– piriformis muscle stretch

• F11.21

• sync w/ Milgram

• F11.22

• sync w/ piriformis



– prone knee bending

– spring test for joint mobility

• F11.23

• sync w/ prone knee

• F11.24

• sync w/ piriformis



– Farfan torsion test

– trunk extension test

• F11.25

• sync w/ Farfan

• F11.64

• sync w/ trunk



– femoral nerve traction test

– quadratus lumborum stretch test

• F11.27

• sync w/ femoral

• F11.28

• sync w/ quad



– single leg stance

– quadrant test

• F11.29

• sync w/ single leg

• F11.30

• sync w/ quadrant



– Hoover test

– Burns test

• F11.31

• sync w/ Hoover

• F11.32

• sync w/ Burns



– Sacroiliac compression & distraction test

– approximation test

• F11.33

• sync w/ sacoiliac

• F11.34

• sync w/ approximation



– “squish” test

– Faber (Patrick) Test

• F11.35

• sync w/ Faber



– Gaenslen’s test

– long sitting test

• F11.36

• sync w/ Gaenslen’s


Neurologic TestsNeurologic Tests

• Babinski

• Oppenheim

• F10.27

• this is not a mistake


Neurologic Tests (Cont’d)Neurologic Tests (Cont’d)

– myotomes

Nerve Root Segment Action Tested

L1–L2hip flexion

L3knee extension

L4ankle dorsiflexion

L5toe extension

S1plantar flexion of the ankle, foot eversion, hip extension

S2knee flexion


Neurologic Tests (Cont’d)Neurologic Tests (Cont’d)

– reflexes

Reflex Segmental Levels

Patellar L2, L3, L4

Posterior tibial L4, L5

Medial hamstring L5, S1

Lateral hamstring S1, S2

Achilles S1, S2


Neurologic Tests (Cont’d)Neurologic Tests (Cont’d)• cutaneous patterns

• F5.8



Neurologic Tests (Cont’d)Neurologic Tests (Cont’d)• referred pain

• F5.1



RehabilitationRehabilitation

• 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)Rehabilitation (Cont’d)

• restoration of proprioception and balance

– Closed-chain exercises

• muscular strength, endurance, & power

– neck strength

– abdominal strength

– erector spinae strength

• cardiovascular fitness

Documents

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