OPP Exam 5 (1st of 2nd Semester)

Posterolaterally

Disc herniations are most likely to occur in which directly?

Thinner

Herniations are more likely to occur posterolaterally, where the annulus fibrosus is _____ and lacks the structural support from the posterior longitudinal ligament. 

Posterior Longitudinal Ligament

Herniations are more likely to occur posterolaterally, where the annulus fibrosus is thinner and lacks the structural support from the _____

sensation and muscle strength

Disc herniations may cause changes in what should the impinge upon a nerve or nerve roots?

Without

Over 85% of patients with symptoms associated with an acute herniated disc will resolve within 8-12 weeks [with/without] specific treatments

Intervertebral foramen

Where do spinal nerves exit the cord?

above

The corresponding spinal nerve exits [above/below] the vertebral pedicle for C1-C7

below

The nerves below C8 exit the spinal cord through the intervertebral foramen [above/below] their designated level

C5

If a patient has difficulty feeling the lateral deltoid region and abducting their arms, that is a ___ nerve dysfunction

Paracentral

Besides simply “lateral” what is the other term for posterolateral?

C5/C6 and C6/C7

What are the most common cervical disc herniations?

hyperreflexia

Cervical disc herniations may present with decreased motor strength, decreased sensation, paresthesia (feeling of tingling, numbness, or “pins and needles”), and what?

Biceps

The C5 nerve root exits between C4 and C5 foramina, innervates deltoids and biceps (with C6), sensory distribution: lateral arm (axillary nerve), and is associated with what reflex?

Brachioradialis

The C6 nerve root exits between C5 and C6 foramina, innervates biceps (with C5) and wrist extensors, sensory distribution: lateral forearm (musculocutaneous nerve), and is assessed with what reflex?

Triceps

The C7 nerve root exits between C6 and C7 foramina, innervates triceps, wrist flexors, and finger extensors, sensory distribution: middle finger, and is assessed with what reflex?

None

The C8 nerve root exits between C7 and T1 foramina, innervates interosseous muscles and finger flexors, sensory distribution: ring and little fingers and distal half of forearm (ulnar side), and is assessed with what reflex?

L4/L5 and L5/S1

95% of disc herniations in the lumbar spine occur between what?

traversing

A paracentral or lateral herniation will cause which nerve root to be affected?

L5

A lateral herniation of the L4/L5 disc would cause a radiculopathy in which nerve root?

L5 radiculopathy

This would cause sensory loss around the great toe and decreased ability to extend the great toe.

Exiting

A far lateral herniation will cause which nerve root to be affected?

L4

A far lateral herniation of the L4/L5 disc would cause a radiculopathy in which nerve?

L4 radiculopathy

What would cause sensory loss around medial aspect of the ankle and foot and muscle weakness with inversion of the ankle?

L1

What nerve root innervates the iliopsoas muscle, with a sensory distribution of the upper third thigh, and is assessed with the cremasteric reflex in males?

L2

What nerve root innervates the iliopsoas muscle, hip adductor, and quadriceps, with a sensory distribution of the middle third thigh, and no associated reflex?

L3

What nerve root innervates the iliopsoas muscle, hip adductor, and quadriceps, with a sensory distribution of the lower third thigh and no associated reflex?

L4

Which nerve root innervates the quadriceps and tibialis anterior, with a sensory distribution of the anterior knee and medial side of the leg, and is assessed with the patellar reflex?

L5

What nerve root innervates the extensor hallucis longus, extensor digitorum longus and brevis, and gluteus maximus, with the sensory distribution of the anterior leg and dorsum of the foot, and no associated reflex?

S1

What nerve root innervates the gastronemius, soleus, and gluteus maximus, with a sensory distribution of posterior thigh, lateral lower extremity, and plantar region, and is assessed with the Achilles reflex?

T12-L3

What myotome covers the Iliopsoas (hip flexion)?

L2-4

What myotome covers the quadriceps (knee extension)?

L4

What myotome covers the tibialis anterior (foot inversion and dorsiflexion)?

L5

What myotome covers great toe extension?

S1

What myotome covers fibularis longus and brevis (foot eversion) and gastronemius (plantar flexion)?

Straight leg test

What test is better at ruling out a disc herniation with a sensitivity upwards of 92%? It has a poor specificity of ruling in a lumbar disc herniation.

Crossed straight leg test

What test is better at ruling in a lumbar disc herniation with a specificity upwards of 90%? It has a poor sensitivity of ruling out a lumbar disc herniation.

Back pain

What are these symptoms associated with that turn them into major red flags?:
Urinary retention/incontinence, fecal incontinence/decreased sphincter tone, saddle anesthesia, lower leg weakness or numbness, progressive neurological deficit, major motor or sensory deficit, cancer (history of, weight loss, night pain), History prolonged corticosteroid use or significant trauma (=Fracture), infection (fever, recent or current bacterial infection, rest pain).

L1/L2

Where does the spinal cord typically terminate? With nerve roots becoming longer in the lower segments of the spine

Intervertebral disc

Nerve roots in the lumbar spine exit intervertebral foramen below corresponding vertebrae, just above what?

Posterior Longitudinal Ligament

This ligament runs vertically along posterior vertebral bodies, beginning to narrow in the lumbar region, at L4-L5 is ~1/2 width as compared to L1 level

Narrowing

What weakens the posterior lateral aspect of intervertebral discs, making lumbar area more susceptible to disc herniations?

5

How many lumbar vertebrae are there?

Lordotic

What kind of curve exists in the lumbar spine normally?

L3

At what point does the posterior longitudinal ligament taper laterally?

Iliopsoas

This is the primary flexor of the hip, has an important role in maintaining lumbosacral angle. COmposed of psoas major and iliacus muscles. Origin T12-L5 vertebral bodies, insertion lesser trochanter of femur. Somatic dysfunction of this is very common, usually secondary to prolonged shortening of the muscle

Erector Spinae

Includes Spinalis, Iliocostalis, and longissimus. Dysfunction here can cause type 1 dysfunction

Quadratus lumborum

This muscle Stabilizes the spine and pelvis, Assists in hip flexion and extension, and Contributes to trunk rotation and side bending. Dysfunction here can cause Type 1 dysfunction

Facet tropism

Asymmetry of facet joint angles, more closely aligned to coronal plane (normal alignment of facets is in sagittal plane backwards and medial). Most common anomaly, pre-disposition to early degenerative changes

Sacralization

Deformity where one or both transverse processes of L5 articulate with the sacrum. ~3.5% of people have this, may lead to early disc degeneration

Lumbarization

S1 failure to fuse with rest of sacrum. Less common than sacralization

Spina bifida

Developmental anomaly, lamina of vertebral segment fails to close

Spina bifida occulta

No herniation through defect, rare neurological deficits, often only physical sign is a coarse hair patch over the defect site

Spina bifida meningocele

Herniation of meninges through defect

Spina bifida menigomyelocele

Herniation of meninges and nerve root through defect. Associated with neurological defects.

Fryette’s 1st law

In neutral position, sidebending and rotation occur to opposite sides. Applicable to a group of vertebrae

Fryette’s 2nd Law

In flexed/extended position, sidebending and rotation occur to the same side. Applicable to a single vertebrae

same; opposite

L5 sidebending causes sacral oblique access to be engaged on [same/opposite] side. L5 rotation causes sacrum to rotate to [same/opposite] side

Lumbosacral angle

Formed in upright position, from a side view, by extending the line of inclination of the sacrum as it meets a line parallel to the ground.

25-35 degrees

What is a normal lumbosacral/Ferguson’s angle?

increased

[Increased/Decreased] lumbosacral angle changes articular relationships, inferior lumbar facets slide caudally on matched superior sacral facets, andresults in back pain. Also increases lumbar lordosis

Factors that increase lumbosacral angle

Obesity, pregnancy, abdominal muscle weakness, wearing high heeled shoes, foot pronation, spondylolisthesis, poor posture, occupation, hereditary predisposition, and many more factors

Back sprain/strain and/or somatic dysfunction

Patient presents with pain to the low back, buttocks, or posterior lateral thigh areas. Pain quality described as ache or spasm. Increased pain with activity or prolonged standing/sitting. Increased muscle tension. 

Psoas Syndrome

Flexion contraction of iliopsoas. Often from prolonged position that shortens muscle. Possible other causes: Appendicitis, Ureter Dysfunction, Sigmoid Colon Dysfunction, Ureteral Calculi, Salpingitis, Metastasis of Prostate CA. Presents with low back pain, some patients may have pain radiating to groin. Increase pain with standing, walking. May have contralateral piriformis spasm. Pain quality described as ache or spasm. Often associated with flexion/extension dysfunction of L1 or L2.

Herniated Nucleus Pulposus

Due to posterior lateral herniation of intervertebral disc near narrowing of posterior longitudinal ligament exerting pressure on nerve root. 98% at L4 and L5. Patient presents with pain to the low back, and lower extremity. Pain quality described as numbness/tingling, possible sharp/burning/shooting pain toward lower extremity. Increased pain with flexion. Weakness & Decreased Reflexes from affected nerve root, sensory deficit to affected dermatome.

Annulus fibrosis

Made of concentric rings that surround the nucleus pulposus. Attaches to the edges of the hyaline cartilage of adjacent vertebral end plates. A sudden, compressive and/or rotation force may then cause a teat in this, through which the nucleus pulposus may bulge or an actual herniation may occur.

Spinal stenosis

Narrowing of the spinal canal or intervertebral foramina, causing pressure on nerve roots. Usually secondary to degenerative changes. Degenerative changes can include: Facet joint hypertrophy, Calcium deposits of ligamentum flavum, Calcium deposits of posterior longitudinal ligament, Intervertebral disc height loss. Patient presents with lower back pain that radiates to lower extremities, worse with exertion.

Spondylolisthesis

Anterior displacement of one vertebra in comparison to the vertebra below, very often occurs at L4 or L5, usually secondary to fatigue fractures of pars interarticularis of vertebra. 5% prevalence in population, ~1/2 asymptomatic. Most that are symptomatic are above the age of 20 years. Patient presents with LBP, positive vertebral step off sign, bilateral tight hamstrings. Graded I - IV based on degree of anterior displacement

Retrolisthesis

A backwards vertebral slippage

Spondylolysis

Defect/fracture of pars interarticularis without anterior displacement of vertebral body. Symptoms and presentation of patient are similar to spondylolisthesis. Lateral view lumbar XRays will not show anterior displacement, however oblique view lumbar XRays will permit for visualization of the pars interarticularis. Fracture of pars interarticularis appears as a “collar on neck of a scotty dog”  

Cauda equina syndrome

Pressure on nerve roots of the cauda equina usually secondary to massive central disc herniation. Patient will present with low back pain, saddle anesthesia (anesthesia to perineum area), decreased rectal sphincter tone, loss of bowel/bladder control, decreased deep tendon reflexes. Condition requires emergent surgical decompression, if surgery is delayed irreversible paralysis may result.

Left lateral

Patient position with the patient’s left side down

Recumbant

Patient position with the patient’s back flat on table

Sim’s position

Patient position with the patient’s chest is down flat on the table (may be called “modified recumbant with chest on table”)

Dorsal recumbant

Patient position with the patient’s back and posterior lower body flat against the table, or “supine”

Ventral recumbant

Patient position with the patient’s chest and anterior lower body flat against table, or “prone”

transverse

The sacroiliac joint moves around 2 degrees in flexion and extension around a ____ axis at S2 in a sagittal plane

vertical

The sacroiliac joint moves around 1.5 degrees in rotation around a ____ axis in a transverse plane

anteroposterior

The sacroiliac joint moves around 0.8 degrees in lateral bending around an _______ axis in a frontal/coronal plane

Nutation

The forward tilting (flexion) of the sacrum relative to a posterior rotation of the ilia

sacral base

This moves both anteriorly and inferiorly in the sagittal plane on the middle transverse axis located at S2 in a nutation

Apex of the sacrum

This will move both superiorly and posteriorly in nutation

ilia

In nutation, both ____ rotate posteriorly in a sagittal plane on an inferior transverse axis located at S2

anterior-posterior

In nutation, each iliac crest, ASIS, PSIS, and superior aspect of pubic symphysis tilt inward in a frontal/coronal plane on an ______ axis towards one another

inferior

In nutation, simultaneously each ____ aspect of the pubic symphysis moves away from each other

pelvic inlet

Nutation causes a decrease in what?

pelvic outlet

Nutation causes an increase in what?

nutation

The pelvis should be in a position of ____ for delivery of the baby through the pelvic outlet

Post-partum lumbo-pelvic pain

If the birthing parent’s pelvis gets stuck in excessive nutation after a delivery, it can result in what??

Counternutation

The posterior tilting of the sacrum relative to an anterior rotation of the ilia

Middle transverse

In counternutation, the sacrum extends moving the sacral base superiorly and posteriorly in the sagittal plane on a ______ axis located at S2

Sacral apex

the sacrum extends moving ____ inferiorly and anteriorly in the sagittal plane on a middle transverse axis located at S2

anteriorly

In counternutation, both ilia rotate ______ in the sagittal plane on a transverse axis located at S2

frontal/coronal

In counternutation, each iliac crest, ASIS, PSIS, and superior aspect of pubic symphysis tilt outward in a ______ plane on an anterior-posterior axis away from one another

pubic symphysis

In counternutation, simultaneously each inferior aspect of the ______ moves toward each other

Pelvic inlet

Counternutation causes an increase in what?

Pelvic outlet

Counternutation causes a decrease in what?

SIJ ligaments

Nutation causes tensioning of _______; therefore, drawing together the posterior iliac bones. The coming together of the posterior iliac bones increases the compression of the sacroiliac joint

pelvic stability

Nutation = ???

This increased compression creates increased friction between the sacrum and the innominate. This combination of compression and increased friction creates a force closure tat allows the SIJ to effectively transfer loads between the trunk, pelvic, and lower extremities

slackening

Counternutation causes _______ of SIJ ligaments (except long dorsal ligament); therefore, allows the posterior iliac bones to be drawn away from each other. This decreases compression in the SIJ and make it less stable; consequently, the patient will be more susceptible for injury and pain

Flexion Down Recumbant

This type 2 somatic dysfunction muscle energy treatment involves having the patient in lateral recumbant position with the affected side down, extend the patient’s top leg up and have them push Down against physician resistance (isometric contraction)