Axial: Lumbar Pathology

Why are lumbar vertebral bodies so large?

Because they accommodate all the weight

Which plane are the lumbar facets primarily arranged?

Sagittal plane

Which facets in the lumbar vertebrae face medially and are generally concave?

Superior facets

Which lumbar facets face laterally and are generally convex?

Inferior facets

At what level do the facets arrangement change to more anterior/posterior?

L5/S1

What is the primary movement of the lumbar spine?

Flexion/extension

What are the arthrokinematics of the lumbar spine for b/l flexion? Extension?

Upglide; downglide

What is the arthrokinematic movement of the lumbar spine during lateral flexion?

Upglide on the contralateral side, and a downglide on the ipsilateral side

what are the arthrokinematics of lumbar rotation to the R?

Left facet compression, right facet distraction

What motion at the lumbar spine increases central canal ~11%?

Flexion

What motion at the lumbar spine increases neuroforaminal area ~12%?

Flexion

What motion at the lumbar spine causes a posterior annual fibers of disc to become taught while slackening the anterior portion but increases its compression there?

Flexion

What motion at the lumbar spine increases nucleus of disc posteriorly?

Flexion

What motion at the lumbar spine decreases central canal ~11%?

Extension

What motion at the lumbar spine decreases neuroforaminal ~15%?

Extension

What motion at the lumbar spine causes a anterior annual fibers of disc to become taught while slackening the posterior portion but increases its compression there?

Extension

Hypertrophy of what spinal ligament will directly result in the closing of the IVF?

Ligamentum flavum

What does interspinal ligament tenderness indicate?

Segmental hypermobility

What is the 3 step process of the ligamentum flavum hypertrophying?

Excessive mobility or repeated stress → Inflammation → Scar

Which causes the most amount of pressure to the lumbar disc: sitting vertically, sitting while leaning forward, or sitting while leaning backward?

Leaning forward

Which position causes the greatest amount of pressure to the lumbar discs while holding a box: standing with flexed hips, standing with flexed knees and hips, or standing vertically?

Standing with flexed hips

Which position is better for lumbar pressure relief: supine or s/l?

Supine

Which position creates half-tension on the annular fibers?

Rotation

What happens to the annular fibers during forward bending?

All posterior fibers tension

Which combo of movements causes the most strain to the posterior annular IVD fibers?

Flexion and rotation (hunched back snow shovel guy)

At what level does the SC approximately end and turn into the cauda equina?

L1

If a disc protrudes at the L4-L5 junction in the posterolateral direction, what nerve root is impinged?

L5 caudally

If a disc protrudes directly posteriorly or centrally at the L4-L5 junction, what structures are impinged?

All structures BELOW L4-L5 junction

If a disc protrudes laterally at the L4-L5 junction, what nerve root can sometimes be affected?

The L4 nerve root

If a disc protrudes at the L5-S1 junction, what nerve root is affected?

S1 nerve root

What are the 7 main muscles in the lumbar musculature posteriorly?

1. Multifidus

2. Erector Spinae

3. Quadratus Lumborum

4. Psoas Major

5. Latissimus Dorsi

6. Thoacolumbar Fascia

   1. Lumbopelvic Fascia

What are the 4 muscles which make up the Erector Spinae?

1. Longissimus thoracis pars lumborum

2. Iliocostalis lumborum pars lumborum

3. Longissimus thoracis pars thoracis

   1. Iliocostalis lumborum pars thoracis

What are the 4 routine radiological views for the lumbar spine?

AP, Lateral, Oblique, and Lateral L5-L1

What are the ABCDS of spinal radiographs?

A = Alignment

B = Bone Density

C = Cartilage

D = Disc Integrity/Space

S = Soft Tissue

Which view did Dr. Bean refer to as the “elephant in the room?”

AP view

What all can be visualized in the AP view of the lumbar spine?

Vertebral bodies, pedicles, SP, TP, IVD space, and sometimes sacrum/coccyx

What can be seen in the lateral view of the lumbar spine?

Lumbar vertebral bodies, IVD spaces, pedicles, SP, IVF, and lumbosacral articulation

A right oblique view of the lumbar spine shows structures where in the lumbar?

Structures on the pt’s R

What can be seen in the oblique view?

Facet joints, superior/inferior articular process, pars interarticularis, and pedicles

Which view shows the “Scottie dog” images?

Oblique view

On the “Scottie Dog” what does the eye represent?

Pedicle

On the “Scottie Dog” what does the ear represent?

Superior articular process

On the “Scottie Dog” what does the nose represent?

TP

On the “Scottie Dog” what does the neck represent?

Par interarticularis

On the “Scottie Dog” what does the Front Paw represent?

Inferior articular process

On the “Scottie Dog” what does the body represent?

Lamina and SP

On the “Scottie Dog” what does the tail represent?

Superior articular process (opposite side)

On the “Scottie Dog” what does the back paw represent?

Inferior articular process (opposite side)

What does the lateral L5-S1 radiograph of the lumbar spine show?

lumbosacral junction more easily viewable through superimposition of the Ilia

How do CT scans add value to radiographs?

Show detailed depiction of bones

Which plane of imaging is the least commonly utilized view when using an MRI of the lumbar spine?

Coronal or frontal view

What does a T1 weighted MRI show?

Anatomy

What does a T2 MRI show?

Inflammation

What are the 11 Red Flags for Low Back Pain?

1. Abdominal aortic aneurysm

2. Kidney disease

3. Liver disease

4. Duodenal ulcer

5. Pancreatitis

6. Endometroiosis

7. Cancer

8. Cayda Equine Syndrome

9. Spondyloarthropathies

10. Fx

11. Infections

A pt c/o pain radiating in their RIGHT side lower back and wraps around to the front of the RIGHT lowest ribs or just below the ribs. What organ refers pain there?

Liver

A pt c/o pain radiating in their RIGHT side mid back and wraps around to the front RIGHT lower ribs. What organ refers pain there?

Gallbladder

A pt c/o pain radiating in their RIGHT upper shoulder and trap area. What organs can refer pain to this region?

Liver, glaabladder, and duodenum (resulting from irritation of diaphragm)

A pt c/o pain radiating in the center of their back, between their shoulder pain. They also state the pain is under their sternum and travels slightly toward their lower RIGHT chest. What organ can refer pain to these regions?

Stomach

A pt c/o pain radiating in the center of their chest, about 3 inches below their xiphoid process. What organ typically refers pain here?

Duodenum, head of pancrease

A pt c/o pain radiating in their LEFT side along their lower rib region. What organ refers pain here?

Spleen

A pt c/o pain radiating in their LEFT lower back and wraps around toward their groin along their inguinal region. What organ refers pain here?

Kidney and ureter

What age ranges are associated with RED FLAGS in pt with LBP?

<20 and >50

A history of IV drug use or corticosteroids AND/OR failure to improve after 1 month for pt’s with low back pain are considered what?

Red flags

What organ most commonly mimics LBP?

Kidney issues

What key description is a good way to differentiate between LBP and kidney referred pain?

If changing positions alleviates it, it is likely LBP

What tests are typically used to rule in kidney issues? (hint: there are 5)

US, CT scan, urine tests, blood tests, and Kidney Percussion test

How do you perform the Murphy’s punch sign? (aka kidney percussion test)

A firm thud is provided by PT over costovertebral angle. Positive if reproduction of pain (could be servere pain)

What lab value when elevated is a sign of cancer?

ESR (erythrocyte sedimentation rate)

When is imaging recommended for cancer patients?

If 2 historical factors and > 20mm/hr ESR

Are older men or women more likely to have abdominal aortic aneurysms?

Men (4-8%)

What are the initial presentations of abdominal aortic aneurysms?

Abdominal pain and backaches

How do you diagnose an abdominal aortic aneurysm?

Palpation deep and left of midline, then evaluating lateral extent of pulse with pads of fingers. Positive if strong pulse in addition to risk factors

What are the 3 risk factors (not including the palpation test) which could mean abdominal aortic aneurysm?

Male, >60, smoker, and sudden onset of back and/or groin pain

What is considered the terminal end of the spinal cord? Where is it located?

Conus medullaris; L1 typically

A pt presents with LBA, unilateral sciatica on their LEFT side which they states has caused leg weakness into that side. They demonstrate diminished DTRs on L leg. They c/o sexual dysfunction. What is their likely diagnosis if you also discovered they have saddle anesthesia?

Cauda Equina Syndrome

A pt presents with bladder dysfunction (specifically urinary overflow and difficulty initiating flow), bowel dysfunction (constipation), and a positive babinski reflex test. What condition do they likely have?

Conus Medullaris Syndrome

What spinal levels are common for compression fx?

T12, L1, and L5

What are the 4 main red flags associated with a compression fracture in the lumbar spine?

1. >70 yrs

2. Female

3. Corticosteroid use

4. Trauma
   

What percentage of patients with osteomyelitis in other body parts can eventually develop it in their spine?

40%

Where are the 5 most common sites for spinal infections?

1. Direct injury

2. UTI

3. Indwelling urinary catheters

4. Skin infections

5. IV drug injection sites

What is the imaging tool of choice for determining a spinal infection? What blood test marker?

MRI; ESR and C-reactive proteins

If someone believes pain is harmful or they want to avoid movements that are associated with pain, what outcome measure should you give them?

FABQ

If a pt struggles with “thinking the worst” or has low compliance with exercise, or has a low educational background, or just expect a “quick fix” … what outcome measure should you give them?

PCS (Pain Catastrophizing Scale)

What is the PHQ2?

A screen for depression by asking about feeling down, depressed AND having little interest, pleasure within the past month

Define spinal stenosis

Narrowing of the spinal canal

What is are the 3 types of spinal stenosis? Which is the most common?

Degenerative, congenital, or traumatic; degenerative

What causes degenerative spinal stenosis?

Hypertrophy of facet joints, capsule, and ligamentum flavum

Describe neurogenic claudication and what condition it is most associated with

Vague cramping, aching, or burning pain in back, buttock and legs. Exasperated by standing/walking and relieved by resting/sitting or spinal flexion; spinal stenosis

Why does spinal flexion of the lumbar spine decrease neurogenic claudication signs?

It increases the AP diameter of the IV canal

What image is best choice for determining spinal stenosis?

MRI

What is the Bicycle Test (of Van Gelderen)?

Test for neurogenic intermittent claudication

How do you perform the Bicycle Test (of Van Gelderen)?

Pt peddles on exercise bike with accentuated lumbar lordosis, then pt leans forward and continues pedaling.

If the Bicycle Test (of Van Gelderen) part 1 is positive, but part 2 is negative, what does this mean?

Vascular claudication

If the Bicycle Test (of Van Gelderen) part 1 and 2 are positive, what does this mean?

Neurogenic claudication

What spinal disorder is associated with the “shopping cart” sign?

Spinal stenosis

Define spondylosis:

Normal degenerative changes of SC which if progresses can lead to radiculopathy

Define spondylolysis:

A defect of the pars interarticularis

What condition is known as the “Scottie Dog” fracture?

Spondylolysis

How is spondylolysis caused?

Repetitive trauma fatigue fracture via forced extension and rotation

How long does it take for spondylolysis to heal?

Acute = 68% healing (unilaterally 4x more likely); chronic = 0% chance w/out sx intervention