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LSp from Magee Orthopaedic Examination

Function LSP supports the upper body and transmits weight to the lower limbs. What other structures should be included in an LSp exam? Hip, SI, Back exam Hip lumbar, SI should always be examined in sequential order because it can be difficult to ascertain where pain is occurring from With a normal intact disc the facets should carry about 20-25% axial load but may reach 70% with degeneration of a disc Where on the vertebra are the facets located? In Pars Articularis / Arch of the vertebra Spondylosis (degeneration of IV disc) can lead to which other conditions? 1. 2. Spondylarthrosis degeneration of facets Spondilolysisdefect in pars articularis or arch of the vertebra

Describe the orientation and surfaces of the LSp facets? The superior facets face medially and backwards and are general concave The inferior facets face lateral and forwards and are convex There are however abnormalities that can occur in the shapes of the facets especially at L5 S1

What level are the LSp TPs in relation to the SPs? In the LSp the TPs are at the level as the SPs Which movements can occur in the LSp? Flex, Ext, Side Bending. Rotation is minimal and is always accompanied by a shearing force If a capsule is restricted sidebending and rotation are equally limited? If only one facet joint in the Lsp has a capsular restriction then the decrease in ROM is minimal

Lumbralization of S1 = 6 Lumbar vertebra

SacralizationLSp = 4 mobile Lumbar vertebra Functions of the disc: shock absorbtion, holds the vertebra, allows movement between the vertebra. The lateral aspects of the disc are innervated by branches of the anterior & grey rami communicantes.

What are End Plates? Thin layers of cartilage covering the inferior & superior surface of the vertebral body.

Name the pain sensitive structures around the disc: anterior & pos longitudinal lig. Vertebral body (outer fibres of annulus), nerve root, verterbral body , cartilage of the facet & capsule.

4 problems of the disc all of which can cause pain: Prolapse: only outer most fibres of annulus fibrosus contain the nucleus Herniation: Annulus is perforated and the pulposis moves to the epidural space Sequestration: free nuclear material

Which disc is most at risk and why? L5-S1 because its angle is greater than any other disc, it has more weight on it than other discs, COG passes right through the body, it is transition from a mobile segment to a fixed one When an L4-L5 disc protrudes what nerves is it likely to push on? those below that level because the nerves above have already left the spinal canal. It is rare for a disc protrusion to push on the nerve at the same level.. Eg the L5 nerve root its more likely to be compresed by the L4(/L5) disc. If a disc protrusionis present and lateral to the nerve root then side flexion to that side increase pain and radicular symptoms on that side What is Myelopathy? Disease of the spinal cord. Myelopathy is defined clinically by presence of bilateral upper motor neuron signs (pathological hyper-reflexia and weakness), usually accompanied by bilateral sensory deficits, or sensory level, and bowel/bladder symptoms. What are the types? Traumatic: Spinal Cord Injury Inflammatory: Myelitis Vascular Myelopathy

Pt Hxx from Magee If there are no radicular symptoms below the knee it often becomes difficult for the examiner to determine where in the spine the problem is. Only about 15% of cases can have a definitive diagnosis. Do we agree with this?

The more specific the pain the easier it is to localize the area of pathology. Unilateral pain with no referral below the knee may be caused by muscle strain, ligamentous sprain or, facet joints or SI joints. Sounds reasonable. This is mechanical LBP used to be called lumbago. With these injuries there is seldom perepheralisation of the symptoms.

NOT SURE IF I AGREE WITH THE FOLLOWING - If mms and ligs are effected range of movement will decrease & repetitive movement will increase the pain. With facets the ROM will remain the same (it may be restricted from the beginning) the pain remains the same with repeated movements.

Pain on standing that improves with walking and pain on forward flexion with no substantial mms tenderness suggests disc involvement. Classical increased pain on sitting, lifting, twisting and flexing. Some experts feel that the only definitive sign of disc problems is neurological symptoms below the knee. However isolated back and buttock pain can also be disc (such as protrusion).

Lumbar & SI pain tends to refer to the buttock & posterior thigh (though sometimes lateral thigh). Hip pain tends to be in the groin & anterior thigh but can also be referred to the knee

Why do we ask about Coughing? Sneezing? Deep Breathing? Laughing? All increase in the intrathecal pressure (the pressure inside the coveing of the spinal cord and indicate the problem is in the LSp and effecting neurotissue

If pain is persistent or if it increases while the patient is in the supine position then you should consider: neurogenic lesions, SOL such as infection, swelling or tumour (pain can raditate to the LSp from pathological conditions as well as from direct mechanical reasons).

Postural or static mms often react to spine pathology through tightening through spams or shortening. Where as dynamic or phasic mms tend to respond with atrophy Pressure no nerve root = parathesia (P&N) tingling or numbness or if greater pressure, weakness Why is cauda equiba considered a medical emergency? Because of potential long-term bowel & bladder problems and erectile dysfunction 3 things that can cause weakness to a muscle? Injury to a muscle, injury to its nerve supply or reflex inhibition caused by pain Where does the cauda equine begin? At L1/2 disc. It is rare for a disc protrusion to push on the nerve at the same level.. Eg the L5 nerve root iis more likely to be compresed by the L4(/L5) disc

LSp conditions which may also cause problems with micrtruition: Cauda equine, tabes dorsalis (demylenation of afferent neurons in dorsal column), myelopathy, tumour). Alos disc protusion or spinal stenosis may casue the following symptoms with no back pain or leg pain: urinary retention, loss of desire or loss of awareness to void

Psychosocial issues & chronic LBP 2 important questions: 1. 2. During the past month , have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things?

If Pt confirms either of these questions then they should be monitored closely if progress does not occur you should consider Psychosocial referral

Red Flags for the LSp Presentation age <20 y/o or onset >55years Trauma Constant, progressive, non-mechanical pain Hxx of carcinoma, systemic steroids, osteoporosis drug abuse or HIV Systemically unwell weight loss Persisting sever restriction of Lumbar spine flexion Widespread neurological symptoms Structural deformity ESR > 25

Observation What is Instability jog? sudden movement on active movement which may occur as a ripple of muscles or sudden movement Indicatees an unstable segment or if pt reports something slipping out

How should a patients LSp ideally return from flexion? When returning from flexion the pt first posteriorly rotates the hips & pelvis during the first 45 degrees of flexion, then the low back resumes its lordosis for the 45 degrees. In flexion there should be a 7-8cm increase from the SPs of T1 to S1 SB can be measured by the distance of the finger tips to the floor If a sharp angulation of the lumbar spine occurs in any of the active movements it may indicate hypomobility below the level or hypermobility above the level.

Quick test of lower extremities. Test ankle, knees and hips. Pt squats as low as possible bounces three times then returns to normal. Not to be done with young healthy pt only!

Where does the majority of movement occur in the LSp? occurs between L4/5 & L5/SI.