Pathokinesiology of the Spine

effects of aging on the spine

1. decreased fluid in disc

2. decreased height of disc

3. changes in facet relationship

4. increased compressive forces on joints

5. PLL slack

6. increased neutral zone causing decreased stability

7. osteophytes

scoliosis

abnormal lateral curvature of the spine in the frontal plane with vertebral rotation

TYPES:

1. non-structural

2. structural

non-structural scoliosis

a reversible lateral curvature of spine without a rotational component

*straightening as individual flexes the spine

NOT a boney abnormality

ex. leg length difference

structural scoliosis

BONEY ABNORMALITY

*fixed lateral deformity that does not correct with bending

1. congenital

2. neuromuscular

3. idiopathic

infantile--> under 3

juvenile--> 3-10 yrs

adolescent--> 10-skeletal maturity

forward bending test

test for scoliosis

*positive if rib cage elevated on one side (rib hump)

rib hump

positive finding in forward bending test for scoliosis

convexity

Scoliosis is named based on the side of _________________.

ex. R scoliosis in image

left, right

A patient with RIGHT scoliosis with present with lateral flexion to the __________ and rotation to the ___________.

dislocations/subluxations

traumatic

- may cause cord compression

- requires surgical stabilization

- unilateral versus bilateral (superior subluxation or dislocation due to forced flexion)

bilateral

A patient with cord compression caused by a dislocation/subluxation will present with what type of symptoms?

cervical degeneration

cervical spine appears very straight with a variance in disc space & body size

*calcifications (degenerative) also common

whiplash injuries

stress and strain on soft tissues of the cervical spine

1. hyperextension injury

2. hyperflexion injury

hyperextension injuries

MVA hit from behind OR rebound flexion injury

*results in ligament strains/muscle sprains

MUSCLES INVOLVED:

1. SCM

2. longus colli

3. scalenes

**facets are forced closed and cause compression

anterior longitudinal ligament (ALL)

Which ligament is typically affected in a hyperextension injury?

hyperflexion injuries

MVA hit from the front

*results in ligament strains/muscle sprains

MUSCLES INVOLVED:

1. trap

2. levator scap

interspinous, supraspinous, ligamentum flavum, PLL

Which 4 ligaments are commonly sprained during a hyperflexion injury?

facet joint dysfunction

postural or traumatic

*limited in capsular pattern

**may have nerve root irritation

***review FRS and ERS lesions

cervical disc dysfunction

disc impinges on nerve root

determined based upon neurologic exam:

1. myotomes

2. dermatomes

3. reflex testing

myotomes, dermatomes, reflex testing

What are the 3 components of a neurologic exam?

cervical myotomes

C1, C2: neck flexors

C3: lateral neck flexors

C4: shoulder shrugs

C5: shoulder abduction

C6: elbow flexion, wrist extension

C7: elbow extension, wrist flexion

C8: thumb extension

T1: finger abduction

neck flexors

What is the C1-C2 myotome?

lateral neck flexors

What is the C3 myotome?

shoulder shrugs

What is the C4 myotome?

shoulder abductors

What is the C5 myotome?

elbow flexors, wrist extensors

What is the C6 myotome?

elbow extensors, wrist flexors

What is the C7 myotome?

thumb extensor

What is the C8 myotome?

finger abductors

What is the T1 myotome?

8, 7

There are ___ cervical nerve roots and ___ vertebrae.

above

In the cervical spine, do the nerve roots come out above or below the vertebrae?

lower

In the cervical spine, the disc always impinges on the _____________ vertebrae's nerve root.

ex. C2-C3 disc impinges on the C3 vertebrae

C6

The C5-C6 disc will impinge what nerve?

posterior, posterior-lateral, anterior

What are the 3 types of disc displacement?

fissure/bulge/protrusion/contained

disc bulge, but NO rupture of annulus fibrosis

prolapse/sub-ligamentous extrusion

outermost fibers contain nuclear material, but none has escaped

herniation/extrusion/trans-ligamentous extrusion

nuclear material has perforated the annulus fibrosis

*leaked into epidural space

ruptured/fragmented/sequestered

discal fragment broken off

cervical spinal stenosis

narrowing of the cervical spinal canal

*usually age-related changes (most common in people older than age 50)

COMPLAINTS:

- stiffness, pain, numbness, or weakness in the neck, shoulders, arms, hands, or legs

- balance coordination problems

- loss of bowel or bladder control (incontinence)

thoracic outlet syndrome

compression of the neurovascular bundle

*brachial plexus

CAUSES:

- pec minor tightness

- cervical rib

- compression over shoulder (ex. heavy bags, tight bra)

- overhead activities

- sitting with poor posture

Scheuermann's disease

osteochondritis of the thoracic spine that results in wedge-shaped vertebrae

*growth disturbance of the epiphyseal plates

**accentuated thoracic kyphosis

***Schmorl's nodes

Schmorl's nodes

herniation of the nucleus pulposus through the vertebral endplate into the vertebral body

*occurs Scheuermann's disease

osteoporosis

decreased mass of normally mineralized bone

TYPES:

1. post-menopausal

2. age-related

*increased change of compression fracture in thoracic and lumbar vertebrae

lumbar disc dysfunction

nerves exit below the vertebrae

ex. L3-L4 disc impinges on L4 nerve root

traversing root

In the lumbar spine, is the exiting root or the traversing root more likely to be impacted?

lumbar myotomes

L1, L2: hip flexors

L3: knee extensors

L4: ankle dorsiflexors

L5: great toe extension

S1: plantarflexors, ankle evertors

S2: knee flexors

hip flexors

What is the L1-L2 myotome?

knee extensors

What is the L3 myotome?

ankle dorsiflexors

What is the L4 myotome?

great toe extensors

What is the L5 myotome?

plantar flexors, evertors

What is the S1 myotome?

knee flexors

What is the S2 myotome?

L4 (ankle dorsiflexors)

Having a patient walk on their heels tests what myotome?

S1

Having a patient walk on their toes tests what myotome?

lateral shift

shifting of the trunk either toward or away from the painful side

*depends where bulging lumbar disc is

away

If the lumbar disc is bulging laterally, the patient will lean __________ from the painful side.

toward

If the lumbar disc is bulging medially, the patient will lean _____________ the painful side.

spondylolysis

fracture of pars interarticularis

spondylolisthesis

the forward slipping movement of the body of one of the lower lumbar vertebrae on the vertebra or sacrum below it

TYPES:

1. congenital

2. isthmic

3. degenerative

__________________

less common:

4. traumatic

5. pathological

6. post-surgical

degenerative

What is the most common type of spondylolisthesis?

HINT: aging

scottie dog sign

normal appearance of the lumbar spine in an oblique radiograph

*fracture occurs at the "collar"

lumbar spinal stenosis

narrowing of the lumbar spinal canal

*common in elderly (degenerative)

STRUCTURES INVOLVED:

- bone hypertrophy

- ligamentum flavum buckles

- enlargement of inferior facets

- osteophytes

*BILATERAL SYMPTOMS*

ankylosing spondylitis

form of spinal arthritis

*ages 25-45 years of age

CHARACTERISTICS:

1. bamboo spine

- starts to fuse

2. decreases lordosis, decreases flexibility

3. restricted chest expansion

4. increased thoracic kyphosis

muscle strains (ligament sprains)

MOI or repetitive activity

- resisted testing (isometric contraction) of muscle is painful

- active movement is painful due to muscle contraction

- passive stretch in the opposite direction is painful

- palpation of muscle reproduces pain

*tends to be accompanied by ligament sprains

piriformis syndrome

compression of the sciatic nerve by the piriformis muscle

*sciatica

**lumbosacral dysfunction

pubic subluxation, upslide/downslip, inflare/outflare, anterior/posterior tilt

What are the 4 iliosacral/innominate dysfunctions?

HINT: ilium on sacral

pubic subluxation

ILIOSACRAL DYSFUNCTION

subluxation where the pubic bones connect

*usually superior/inferior, but can also be anterior/posterior

**common postpartum

upslip/downslip

ILIOSACRAL DYSFUNCTION

one ilium higher relative to other

*may occur with fall onto one side

PALPATIONS:

1. ASIS

2. PSIS

3. iliac crests

4. ischial tuberosities

inflare/outflare

ILIOSACRAL DYSFUNCTION

look at the distance from umbilicus to ASIS

out = greater

in = less

anterior/posterior tilt

ILIOSACRAL DYSFUNCTION

one side of pelvis is more tilted than the other

**palpate ASIS/PSIS to assess

superior, inferior

A patient with an anterior tilt of the left innominate will present with the PSIS more _____________ and ASIS more ______________.

sacroiliac dysfunction

sacral rotation

1. forward

2. backward

piriformis, multifidus

Forward sacral rotation may indicate a ________________ muscle problem, while backward sacral rotation may indicate _______________ muscle problem.

normal, decreased

Forward sacral rotation indicates ______________ lumbar mobility, while backward sacral rotation indicates _______________ lumbar mobility.

same

For a forward sacral rotation, the rotation and axis direction are the ___________.

opposite

For a backward sacral rotation, the rotation and axis direction are the ________________.

sacral sulcus, inferior-lateral angle

Which 2 structures are palpated to assess sacral rotation?

left

Forward sacral rotation to the RIGHT makes the __________ sacral sulcus and ILA deeper.

right

Forward sacral rotation to the LEFT makes the __________ sacral sulcus and ILA deeper.

left

Backward sacral rotation to the RIGHT makes the __________ sacral sulcus and ILA deeper.

right

Backward sacral rotation to the LEFT makes the __________ sacral sulcus and ILA deeper.