LUMBAR SPINE

Bony Anatomy Made of two parts - vertebral body and vertebral arch Pedicles – attach body to arch

Bony Anatomy Vertebral foramen – space where spinal nerves exit Articular process (facets) – junction of pedicle and laminae

Bony Anatomy Pars interarticularis – area between facets Transverse process – attachment site for muscles Spinous process – attachment site for muscles and ligaments

Vertebral Ligaments Anterior longitudinal Posterior longitudinal extends anterior region of spine thin in cervical and thickens as it moves inferior strongly attaches to periosteum (membrane that snugly covers the bones) Posterior longitudinal extends skull to sacrum widest in cervical region loosely attaches to vertebral bodies

Spinous Ligaments Interspinous ligaments Intertransverse ligaments between spinous processes Intertransverse ligaments between transverse processes

Intervertebral Disc Makes up ¼ of the spine Components Nucleus Pulposus Annulus Fibrosus

Nucleus Pulposus Occupies central portion of disc Large water content and small amount of collagen fibers Highly viscus; strong affinity to water (hydrophilic) Water amount decreases with age Creates internal disc pressure – pushes against vertebrae and annulus fibrosus major function is to redistribute compressive forces pathology = herniation

Annulus Fibrosus made up of concentric fiberous rings Firmly attached to vertebral body Movements of compression, torsion, and shearing to spine increase tension on annulus Pressure of nucleus is important because it maintains pressure on annulus which enhances stability

Types of Disc Pathology Protrusion disc bulges (nucleus pulposus) posterior without rupture of annulus Extrusion annulus fibrosus is perforated and disc material moves into epidural space

Extrusion

Activites that increase disc pressure Coughing Walking Side Bending Small jumps Laughing Lifting with knees bent Forward bending Lifting 20 lbs. with back bent and knees straight 5% 15% 25% 40% 40-50% 73% 150% 169%

Range of Motion Flexion Extension Lateral Flexion Rotation 40-60 20-35 15-20 3-18

Myotomes L2 L3 L4 L5 S1 S2 Hip Flexion Knee Extension Ankle Dorsiflexion Great Toe Extension Ankle Eversion Knee Flexion

Dermatomes L2 Mid-Anterior Thigh L3 Medial Knee L4 Medial Ankle L5 Dorsal Ankle Lateral Ankle Posterior Thigh

Reflex L3-L4 Patella S1 Achilles Tendon

Special Tests

Straight Leg Raise lie supine, lift leg by supporting foot, knee straight If experience pain, lower leg and dorsiflex foot If pain is induced, (+)tight hamstrings

Well straight leg raise raise uninvolved leg (+) If pain, possible herniated disc

Hoovers test lie supine and place heels into hands have patient lift leg opposite heel should drop in hand (+) inability to lift the leg may reflect a neuromuscular weakness or to determine malingering

Kernig Test lie supine with hands cupped behind head lift leg to no more then 90 degrees flexion of hip and knee, flex head to chest Positive finding – pain with stretched spinal cord, nerve root impingement

Valsalva Maneuver Subject should be seated Take a deep breath and hold while bearing down as if having a bowel movement (+) increased pain due to intrathecal pressure, possible herniated disc, tumor, lesion.

Stork Standing Test stand on involved leg and lean back (+) pain on ipsilateral leg standing causes most pain with ipsilateral fractures

Babinski Test draw line up plantar surface of foot calcaneus to forefoot; toes spread (+) no movement of the toes indicative of a central nervous disorder

Bowstring Test Subject is supine Passively perform a straight leg raise on the involved side, if pain is experienced, flex the subject’s knee to 20 degrees in attempt to reduce pain. Then apply pressure in the popliteal area in attempt to reproduce the radicular pain (+) painful radicular reproduction following popliteal compression indicates tension on the sciatic nerve

Slump Test Subject sits in chair or at the end of the table, hands behind their back Slump over having shoulders relaxed Actively flex chin to chest Passively extend knee And return to normal (+) if symptoms are increased in the slumped position and decreased as the subject moves neck out of flexion