1. Spine Pathology
Dr Salameh Al dajah
Dr. Salameh Al Dajah 2014

2. Learning Objectives Identify spine anatomy related to spine pathology
Recognize intervertepral disc anatomy (IVD)
Recognize different spine pathology seen by PT
Recognize special test for different spine pathology
Perform treatment plans for different spine pathology
Dr. Salameh Al Dajah 2014

3. Pathology of the spine Introduction
The lumbar spine functions as a complex interplay of musculoskeletal and neuro-vascular structures creating a mobile, yet stable, transition between the thorax and pelvis. The lumbar region repetitively sustains enormous loads throughout one’s life time, while still providing the mobility necessary to allow a person to perform multi-tasks associated with daily living. In addition, the lumbar spine provides the fibro-osseous pathway for the inferior portion of the spinal cord
Dr. Salameh Al Dajah 2014

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8. Classification of disorders of the low back
Congenital abnormality
Lumbar vertebrae variation (anomalies)
Hmivertebra
Spinabifida
Deformities
Scoliosis
Hyperlordosis
Kyphosis
Infections of bone
Tuberculosis
Pyogenic infection
Dr. Salameh Al Dajah 2014

9. Osteochondritis (the cartilage or bone in a joint is inflamed)
Arthritis of the spine RA OA
Ankylosing spondylitis
Osteochondritis (the cartilage or bone in a joint is inflamed)
Scheurman’s disease
Dr. Salameh Al Dajah 2014

10. Mechanical derangements
Prolapsed lumbar Intervertebral disc (IVD)
Acute lumbago(disorder involving the muscles and bones)
Spondylolysis(defect in the pars interarticularis of the vertebral arch)
Spondylolisthesis
Spinal stenosis(narrowing of spinal canal)
Tumors
Dr. Salameh Al Dajah 2014

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12. Spondylolisthesis
Dr. Salameh Al Dajah 2014

13. Chronic strains Miscellaneous Lumbar ligamentus strain
Coccydynia, (pain in the coccyx)
Miscellaneous
Fibrositis
Senile osteoporosis
Dr. Salameh Al Dajah 2014

14. Pathology Hemi vertebra
In this anomaly a vertebra is formed in one lateral half only. The defect may occur at any level of the spine. The body of the half –vertebra is wedge-shaped, and the spine is angled laterally at the site of the defect. This anomaly is a rare cause of scoliosis.
Dr. Salameh Al Dajah 2014

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16. Spina bifida
The basic fault in spina bifida is a failure of the embryonic neural plate to fold over to form a closed neural tube, or of mesodermal tissue fully to invest the neural tube as it does in the normal embryo to form the vertebral arch with its spinous process, and the surrounding muscles and ligaments.
Dr. Salameh Al Dajah 2014

17. Scoliosis Scoliosis, or lateral curvature of the spine, may be
idiopathic,
congenital,
neuromuscular in origin. Idiopathic scoliosis is responsible for 85-95% of all cases of scoliosis. It is classified either structural or nonstructural (temporary or compensatory).
Dr. Salameh Al Dajah 2014

18. Nonstructural curves are flexible and readily correct with side bending.
It is may be due underlying disorder or a result of muscle spasm due low back pain
The diagnosis will be made by general physical examination to the alignment of the spine (Adam’s positions),
and confirmed by standing plain x-ray film. The spine may appear in S or C shape.
Dr. Salameh Al Dajah 2014

19. When the scoliotic curvature disappears in the adam’s position, the curves are mild to moderate, or less than 25 degrees. These curves have more of functional components than structural component and are amenable to conservative management.
Dr. Salameh Al Dajah 2014

20. Treatment
1. Surgical
2. Conservative: this form of management utilize therapeutic exercises and braces
A. stretching exercise
B. Mobility exercise
C. Postural training
D. Breathing and chest expansion training
E. Use braces like Milwaukee distraction brace
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25. Hyper Lordosis Para vertebral Muscle spasm Tightness of hamstring
Weakness of the lower abdominal muscles
Dr. Salameh Al Dajah 2014

26. Lordosis
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27. Ankylosing spondylitis
This is a condition affects spinal column in all three regions.
There is a chronic inflammation progressing slowly to bony ankylosis of the joints of the spinal column and occasionally of the major limb joints.
It is a flexion deformity in the spinal column.
Usually start at the sacroiliac joint
Dr. Salameh Al Dajah 2014

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29. Complications Permanent stiffness Fixed flexion deformity of the spine
Recurrent respiratory infection
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31. Special test
Most effective method for diagnosis is through assessing spine ROM and by X-ray,
A calcification connection between the vertebrae will be noted in the X-ray.
Dr. Salameh Al Dajah 2014

32. Treatment Treat the symptoms (localized pain) Maintain activity
encourage extension exercise
Active and positioning exercise to stretch shortened anterior ligaments
Hydrotherapy may be the best modality followed by extension exercise
In addition, patient need Non-steroidal anti inflammatory drugs prescribed by his doctor
Dr. Salameh Al Dajah 2014

33. Scheuermann’s vertebral Osteochondritis
The vertebral bodies ossify from three centers. A primery center at the middle of the vertebral body, and secondary centers at the upper and lower surfaces. These secondary centers, known as the ring epiphyses, appear at about the time of puberty in the cartilaginous end-plates that separate the vertebral bodies from the adjacent intervertebral disc.
Dr. Salameh Al Dajah 2014

34. Diagnosis and Treatment
Diagnosis by X-ray and history of the symptoms
Treatment may include
Rest to avoid stress fracture of the vertebral body
Braces to protect the affected segments
Strengthening exercises for the back muscle (extension exercises)
Dr. Salameh Al Dajah 2014

35. Lumbar Intervertebral disc prolapse
The Intervertebral disc is the source of most low back pain.
Of disc lesions in the lumbar spine, 95% occur at the fourth and fifth spaces.
With normal aging and repetitive trauma, progressive degeneration of the nucleus pulpous occurs.
The disc protrusion of a young adult is likely to be traumatic.
Protrusion of nuclear material usually occurs in the area of greatest weakness at the posterior-lateral aspect of the disc
Dr. Salameh Al Dajah 2014

36. the compression may affect on the cauda equine.
If the protrusion at the midline, roots on both sides may be involved If it is large enough,
the compression may affect on the cauda equine.
Pain in the segmental distribution of a root is the hall-mark of root compression syndrome.
Pain in the spine and restriction of spinal movement are common
Dr. Salameh Al Dajah 2014

37. Pain that radiates down the leg follows the primary anterior division of the nerve
and may be localized by the patient anywhere in the distribution of the root.
This root pain is aggravated by spinal movement, like rolling in the bed.
Pain is also aggravated by local pressure over the nerve or the muscle and after prolonged sitting.
Parasthesia in root distribution is common and usually experienced distally in the foot.
Dr. Salameh Al Dajah 2014

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40. Treatment Muscle relaxing through different modalities
Extension exercise (Meckinzy exercise)
Postural training
Limit the extension exercise if there is a facet joint (Z Joint) involvement
Instruct patient to limit his sitting posture and encourage walking
Patient may benefit from hydrotherapy
Patient may benefit from strengthening of the back muscles
Avoid manipulation in the acute stage
Bed rest may help at the acute stage
Advise patient when he lies down to bend the hip and knees to keep the back muscle relaxed.
Dr. Salameh Al Dajah 2014

41. Spondylolisthesis
Congenital Spondylolisthesis consist of structural anomalies of the lumbo-sacral junction resulting in inadequate mechanical support to prevent forward slipping of L5 on S1 vertebra.
It may be due traumatic fracture of the spinous process of L5 as a result of a fall from a height or due degenerative changes involved the facet joint and the disc material.
Dr. Salameh Al Dajah 2014

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44. Treatment Hydrotherapy to improve muscle spasm
Abdominal strengthening exercise (William flexion exercise)
Avoid spine extension exercise or activities involving extension
Dr. Salameh Al Dajah 2014

45. Assessment and management for cervical spine conditions
Cirvical Spine
Assessment and management for cervical spine conditions
Dr. Salameh Al Dajah 2014

46. Cervical rib
It is a congenital overdevelopment of the costal process of the seventh cervical vertebra
The subclavian artery and the lowest trunks of brachial plexus arch over the first rib, and may be squeezed and damaged. The motor symptoms may include
Dr. Salameh Al Dajah 2014

47. Pathology
The subclavian artery bends over and passes through a sulcus in the first rib.
Brachial plexus lies stretched and lies tautly without bony protection in this region.
Anterior scalene syndrome and the costoclavicular syndrome (cervical rib) compression are two conditions recognized as thoracic outlet syndrome.
X -ray is essential to determine the presence of the cervical rib, but it is not a prove that it is the cause of the symptoms.
Dr. Salameh Al Dajah 2014

48. Symptoms weakness of the hand muscle
Inability to perform fine movement
Numbness at the lateral side of the hand and forearm
Vascular manifestation ranges from cyanosis of the forearm to gangrene in the hand
Sensory disturbances can occur in either a dermatome distribution or in the destruction of the peripheral nerves are suspected
Dr. Salameh Al Dajah 2014

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51. Cervical spondylosis Assessment
History (increasing neck pain, may radiating to the upper extremities)
Observe the neck posture (head forward, rounded shoulders)
Palpation (M. Spasm, Swelling, Dislocation)
ROM
MMT
Neurological tests
Special tests
Dr. Salameh Al Dajah 2014

52. Muscle spasm: It comes with any abnormality in the neck
Muscle spasm: It comes with any abnormality in the neck. It is a protective reaction
Indicated in X ray (Lateral view) by straightening of the spine and diminished the C curve in the neck. It causes limitation in all ROM, especially with rotation, flexion and hyper extension.
Dr. Salameh Al Dajah 2014

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55. Cervical disc prolapse
General appearance
Assessment
Palpation
Radiating pain, and numbness to the upper extremities
Findings (AROM, MMT, Neurological tests, and special test
Dr. Salameh Al Dajah 2014

56. Three levels of disc disease
Normal disc
protrusion/ prolapse
Extrusion
Sequestration
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58. Special tests
Distraction test: Test for foramin encroachment and facet capsulitis
Jackson compression test: Test for nerve root compression, space occupying lesions, DJD
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60. Jackson test procedure
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62. Dejerine’s sign Procedure
Coughing, sneezing, and straining during defecation may aggravate radiculitis symptoms
This aggravation results from the mechanical obstruction of spinal fluid flow
Dr. Salameh Al Dajah 2014

63. Treatment plan Muscle relaxation (modalities, isometric exercises),
May use cervical traction and postural training,
May involve manual mobilization if there is no osteophite
May use cervical soft collar
Dr. Salameh Al Dajah 2014

64. Treatment plan For Disc prolaps: may include
Muscle relaxation to Include
Intermittent traction in neutral position (manual or mechanical)
Modalities (hot pack, US, IF, TENS, Use what is available)
Muscle strengthening and ROM to
Retain mobility (AROM to ARROM, isometric exercise, )
At the beginning use hard cervical collar
Encourage patient to use suitable pillow when sleep
Dr. Salameh Al Dajah 2014

65. Vertebral artery insufficiency
Pathology
Cervical muscle spasm cause neck straitening, which results in stretching and narrowing of the vertebral artery and decrease the blood flow to the posterior parts of the brain
Dr. Salameh Al Dajah 2014

66. Symptoms
Main complaint will include headache and dizziness in addition to the pain in the neck and upper trapezius due muscle spasm.
X ray shows neck straightening at the level of C4-C7 due the muscle spasm
Dr. Salameh Al Dajah 2014

67. Special tests
Barre-Lieou sign
Deklyn’s
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68. Barre-Lieou sign
The examiner instructs the patient to slowly rotate the head from side to side while in seated position, or supine with the head extended out of the table (Hallpike maneuver) This maneuver will cause compression of the vertebral arteries
Vertigo, dizziness, visual disturbances, nausea, syncope, and nystagmus are signs of positive test
A positive findings strongly indicate a buckling of the ipsilateral vertebral artery
Dr. Salameh Al Dajah 2014

69. Dekleyn’s test procedure
With the patient in the supine position and the patient head off the table, the examiner instruct patients to hyperextend and rotate the head and hold this position for seconds, repeat this maneuver to the other side
Vertigo, blurred vision, nausea, syncope, and nystagmus are signs of positive test
Dr. Salameh Al Dajah 2014

70. Treatment plan: may include
Modalities for muscle relaxation
Retain C curve By using special pillow, and extension mobilization for C4-C7
Avoid traction
Manual mobilization to retain neck extension (normal posture)
No need for cervical collar
Encourage AROM, and isometric neck exercise (extension > flexion)
Dr. Salameh Al Dajah 2014

71. Brachial plexus tension test
The examiner passively elevate the patient’s shoulders through abduction
the elbows are extended to a point just short of the onset of pain and are maintained in that position
The shoulders are externally rotated to the point just short of the onset of pain and maintained
Reproduction of symptoms suggests cervical spine disorders, most likely C5 nerve root
When flex cervical spine from this position, symptoms will increase
Dr. Salameh Al Dajah 2014

72. Bikele’s sign Procedure
With the arm held upward and backward and the elbow fully flexed, the patient extends the elbow
If such movement meets with resistance and increases ridiculer pain from the cervicodorsal region, the test is positive
This sign indicate there is brachial plexus neuritis or meningitis because this maneuver stretches the brachial plexus nerve roots
Dr. Salameh Al Dajah 2014

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75. Cervical muscles,and ligament Pathology
Wrhy neck: Derangement of the cervical facet joints as a result of sudden movement or sleeping on wrong position. The symptoms may last 3-4 days
Whiplash: sudden and fast neck movement forward and backward (acceleration and deceleration), which may cause ligamentus and muscles strains or sprains. Symptoms may last for weeks and may worsen. It may cause acute c. disc prolaps. This is seen mostly in head to tail Car accidents.
Dr. Salameh Al Dajah 2014

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78. Five levels of neck Muscles and ligaments injuries
Dr. Salameh Al Dajah 2014