Spinal Clinical Reasoning

Is spinal pain linked to a specific cause?

NO

Most don’t have a specific cause

• Can’t be verified w/ imaging

• Decisions based on reasoning

Are bio factors the only important predictors of LBP onset + prognosis?

NO

Overall health, thoughts, emotions and life circumstances

Social status

Your patient can’t flex L spine….

What might be going on?

What to do next?

What else do I need to know: pain level, inert vs contractile?

Non-specific Diagnosis

Condition w/o known cause

Ex. Articular, neuromotor, neurodynamic

Articular non-specific diagnosis

Passive

Inert, non contractile, joint

Neuromotor non-specific diagnosis

Contractile

Nerves controlling motor

Specific Diagnosis

Have known cause

Matches imaging findings

Ex. spondylosis, radiculopathy, stenosis, spondylolysis, spondylolysthesis

What is Spondylosis?

Degenerative

Changes in spinal discs + facet joints

How does Spondylosis show on imaging?

Disc + facet degen

Bone spurs

Narrowing of SC canal

• Shorter disc height

Clinical presentation of Spondylosis

AM stiffness

Less ROM

What is stenosis?

Narrowing of central or lateral part of SC (intervetebral foramen)

How does stenosis show on imaging?

Reduced space for SC + nerves

What is myelopahty?

Neurological dysfxn of SC due to compression, injury, or disease

Results in impaired motor, sensory, or autonomic fxn

• Reflex lost

Leads to stenosis + compression

How does myelopathy show on imaging?

The cause of compression/irritation may be shown

• Stenosis

• Herniated disc

• Bone spur

• Instability

• Thickening of spinal ligaments

Degenerative Cervical Myelopathy

Degenerative changes/trauma in C spine = compression of SC

Causes

• Static: physical compression due to disc, ligamentous hypertrophy [dries and thickens], osteophytes

• Dynamic: segmental hypermobility/instability: spondylolisthesis, subluxation, joint degen

What is radiculopahty?

Neurological dysfxn of nerve root due to compression, inflammation or injury

How does radiculopathy show on imaging?

Cause of compression or irritation

• Herniated disc or bone spur

• LOWER MOTOR NEURON (L spine only)?

What are the Wainner’s Cluster tests and +ve signs?

1. ULTT (median nerve bias): reproduces symptoms, side diff, changes w/ neck side flex

2. Cervical rotation: <60 rotation of affected side

3. Distraction: eases symptoms

4. Spurling’s test: provokes symptoms

Then can test myotomes, dermatomes and reflexes to determine level affected

Spondylolysis

Break in pars interarticularis

• Causes Spondylolisthesis

On imaging: Fx of pars interarticularis

Spondylolisthesis

Anterior translation of vertebrae relative to one below

On imaging: see anterior translation

How to assess Articular system

AROM/OP

PROM

• Osteokineamtics

  • Passive physiological intervetebal movements

Passive Accessory Movements

• Assess arthorkinematics or glides

• Same as PAM in periphery

  • Central vs Unilateral PAs

What influences the articular motion?

Anatomical: shape of C0-1C2, C3-7, periarticular tissues

• Taught ligaments, #, loose capsules

• Facet angle dictates movement

Joint biomechanics: what we expect @ joint

• Movement of C0-1 & C1-2

Age-related changes: meniscus changes, discs and facets, spinal movement diff

What action does C0-1 do?

Flex and extend

• Nodding

What does C1-2 do?

Rotation

Shape of C3-7

2 facet joints agnled @ 45 deg

Main movements of C3-7

• Flex + extend

• Side flex + rotation happen @ same time!

Which way do C-facets move during flexion

Up

Which way do C-facets move during extension

Down

Osteokinematics

Movement of bones in space relative to planes of movement

Arthrokinematics

Movement of joint surfaces relative to each other (roll, glide)

Osteokinematics of Flexion

Rotates forward 35-50°

Osteokinematics of extension

Backwards rotation 55-60°

Arthrokinematics of C flexion

Top facets glide superior on bottom vertebra

• Diversion/open

• Ex. C4 glide superior on C5

Arthrokinematics of C extension

Top facets glide inferior on bottom

• Converge/close

• Ex. C4 glides inferiorly on C5

Right Side bend arthrokinematics

L facet of top vertebra move superiorly (open/diverge)

R facets of top vertebra move inferiorly (converge)

Right Rotation arthrokinematics

L facet of top vertebra move superiorly (open/diverge)

R facets of top vertebra move inferiorly (converge)

Age related changes that infleunce articular motion

• Discs: Lose water + collagen

  • Lose height + elasticity

  • Brittle

• Facet joints: Cartilage thins, arthritic changes

• Vertebral bodies: Bone density decline, osteophytes

• Ligaments: stiffen + thicken [wider]

• Narrowing of canal + foramina

Osteokinematics of Facet joints for flex/ext

1. Both sides diverge

2. Both side converge

L1-5 Shape + movement

1. Shape: 2 facets, sagittal plane (90)

2. Flex/ext, side flex.

• Rotation limited

L Spine related changes

Loss of disc height + OA narrows the lateral recess + foramen

• Degeneration appear earliest @ L4/5 L5/S1

ROM declines w/ age in all directions

• Don’t treat MRI

L spine Osteokinematics flexion

Forward rotation (40-60)

L spine Osteokinematics extension

Backwards rotation (20-35)

Arthrokinematics of L spine Flexion

Facets of top glide superior on bottom one

Diverge/open

• Ex. L4 glide superior on L5

Arthrokinematics of L spine extension

Facets of top glide inferiorly on bottom vertebra

Close/converge

• Ex. L4 glides inferior on L5

L Spine Side bend arthorkinematics

R side bend converges R facets; diverges L

L side bend converges L facets; diverges R

Does L spine rotate?

Limited

5° total bc in the sagittal plane

Referral pain patterns for Facet joint

Cervical and lumbar areas

What is somatic referral pain? How to describe it?

Deep, achy, diffuse

ONLY PATCH OF PAIN, not down limb

How to assess articular focused issues?

1. Pattern of movement loss or painful movements?

   1. Closing: pain w/ extension or side bend TOWARDS the painful side

   2. Opening: pain w/ flex/side bend AWAY from the painful side - diversion

2. Pain distribution fit facet referral pain?

3. Do passive accessory movements @ level reproduce symptoms or show stiffness?

Factors influence mangement strategies

Severity/irritability

Fxnl limitations + patient goals

Key impairments contributing to fxnl limitations: can’t flex knee = can’t tie shoe

Stage of healing

Red flags

Overall health

Patient preferences, values, beliefs, readiness

Environmental + contextual factors

• Work, access to care

Rx Strategies

Movements in a specific direction

• Target restricted movements or pattern of movement loss

• Neck rotation, lumbar flex in lying, prone press ups

Passive mobs: PAMS

• Address pain/stiffness @ level

• High irritability → Grade 1-2 settle pain

• Low irritability → Grade 3-5 for stiffness

Reassess

• RETEST movement that reproduced symptoms

How to INFORMALLY assess Neuromotor control

Observe static posture

Activation: identify under/over active mms

Balance

Coordination: dynamic posture, squat, sit-stand, gait, lie-to-sit, 4-point kneel

Proprioception (+agility)

• Ex. SLB

Modify form to reduce symptoms

How to FORMALLY assess neuromotor control

Activation: Craniocervical flexion test

• Tests activation + endurance of deep neck flexors

Endurance

• Head lift test: Deep + superficial neck flexors

• Cervical extensor endurance test: deep + superficial neck extensors

Proprioception

• C-joint position error test

  • Head relocation

Craniocervical flexion + cervical flexion

Chin tuck + head lift

Recruits most

Cervical Flexion uses what mm?

Big cervical flexors

Craniocervical flexion

Just chin tuck, no head lift; nod head

Deep neck flexors

Contracts in absence of big contractors

Cervical extensor endruance test

Edge of bed

Deep sub-occipital neck mm

Hold C spine in position

Recruits deep + superficial layer

L spine deep mm + fxn

Transverse + Multifidus

Low-level activation, endurance

L spine superficial/global mm + fxn

• Erectors

• Obliques

• Rectus abdominus

Coordinates movement, stabilizers and movers

Informal assessment of Lumbar Neuromotor Impairments

Static posture: mm bulk

Activation: under/over active mm

Coordination: dynamic posture [squat, sit-to-stand, gait, lie-to-sit, 4 patient kneeling]

Form modification to reduce symptoms

Strength + endurance

Assess pelvic floor

Formal Testing for Lumbar Neuromotor Impairments

Activation: TrA

Coordination:

• Fxnl test (bird dog)

• Active SLR

Proprioception: Lumbar reposition sense

Straight leg raise assesses what? What to look for?

Coordination

Lumbo-pelvic hip complex

Watch for:

• Symmetry and compensatory strategies

  • Breath hold

  • Hollowing of abs

  • Flattening L spine

  • Rotation of lumbopelvic spine

Bird dog assesses what?

Coordination

4-point kneeling

Watch for:

• Excessive lumbo-pelvic spine

• Breath-holding

How to Assess Transversus Abdominis Activation

Palpate mm [medial to ASIS]

Assess contraction; hold for 10s

Watch for:

• Breath hold

• Hollow abdomen

• Flattening of L spine

Rx for neuromotor

Modify static + dynamic postures to encourage non-painful patterns

Activation and coordination training

• Frequent + meaningful

• Internal → external cues

• 5-10s holds x 5-10 reps

  • Progress range and fxn

Mm performance: strength + endurance

Whole kinetic chain

Tailor to patient’s goals, movement patterns, symptom provocation and capacity

Neurodynamics determine what?

How well nerves slide and lengthen as you move

Doesn’t necessarily mean there’s a pathological issue

Assess MECHANOSENSITIVITY

• Symptom provocation

• Conduction loss will be +ve

Neuromechanosensitivity

Sensitivity of neural tissue to movement and tension

• Neurodynamic tests would provoke symptoms

• Irritated neural tissue

Neurodynamic and Neurosensitivity Tests for L spine

SLR

Slump

Neurodynamic and Neurosensitivity Tests for C spine

ULTT

• Medial, radial, ulnar bias

+ve Neurodynamics Test require what 3 things?

1. Reproduces symptoms

2. Changes w/ structural differentiation [i.e. relieves neck tension in slump]

3. Differs from the other side

What is structural differentiation?

Add or relieve tension on 1 side

• Pull on nerve from somewhere else

See if it worsens or relieves symptoms

Ex. SLR +dorsiflex

What does dermatomes, myotomes and reflxes test?

Nerve conduction

Loss of fxn

Rx for Neurodynamic

Treat root cause of neuromechanosensitivity

• Stiff joint, mm guard, swelling

Does by irritability

• High: sliders + positions unload nerve

• Low: progress to tension

Educate on nerve sensitivity.

• AVOID sustained provocative positions

How to triage cases?

• Specific or non-specific presentation

• Red flags?

• What system is driving symptoms?

  • Articular, neuromotor, neurodynamic

• Biopsychosocial factors?

• Assess first?

• What Rx?