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OMM Exam 2, Semester 2
Lumbar, Sacrum and Innominate
107
Medical
03/24/2012

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Term
When does the lumbar curve begin to develop?
Definition
lumbar curve = secondary curve
develops when the child begins to stand and walk
Term
normal angle of the lumbar curve (Ferguson's Angle)
Definition
30-40 degrees
Term
which movements are allowed and discouraged in lumbar spine?
Definition
allowed = back bending and moderate forward bending
discouraged = rotation and side bending
Term
orientation of the lumbar facets
Definition
Superior = BM (face posteriomedially)
Inferior = faces anterolaterally
Term
Batwing Deformity
Definition
sacralization of the lumbar spine = L5 fuses to the Sacrum
Term
lumbarization
Definition
S1 becomes 6th Lumbar vertebrae (separates from the sacrum)
Term
Wolfe's Law
Definition
bone formation occurs along lines of stress and areas of weakness
anterior triangle becomes weak link for compression fracture
Term
embryologic origin of the anulus and the nucleus pulposus
Definition
mesenchyme
notocord (ectoderm)
Term
embyrologic origin of the notocord
Definition
ectoderm
Term
anulus fibrosis
Definition
made of fibrocartilage
attachment to anterior and posterior logitudinal ligaments
Term
nucleus pulposus
Definition
surrounded by anulus fibrosus
allows reciprocal motion
has a high water content and is compressible
Term
anterior longitudinal ligament limits which motion?
Definition
extension
Term
the posterior longitudinal ligament limits which motion?
Definition
flexion
Term
which lumbar ligament is commonly strained in traumatic injuries?
Definition
iliolumbar ligaments
tender area = 1 in superior and medial to the PSIS
Term
Three types of fibers that make up the quadratus lumborum
Definition
1. costovertebral fibers
2. iliocostal fibers
3. iliovertebral fibers
Term
what muscle is the strongest flexor of the hig?
Definition
psoas
Term
Where do the left and right crus of the diaphragm attach to the lumbar spine?
Definition
left = L1-2
right = L1-3
Term
The Dirty "half-dozen"
Definition
"Failed Back Syndrome"
1. non-neutral (type 2) somatic dysfunction
2. Pubic Shear
3. extended sacrum
4. superior innominate shear
5. Anatomic short leg with pelvic tilt
6. psoas syndrome and supporting muscle dyfunction
Term
major causes of osteomyelitis
Definition
potts puffy tumor
staph infection
Term
major causes of uterosacral ligament traction
Definition
malposition
endometriosis
Term
Common cause of severe low back pain of sudden onset and without history of trauma
Definition
dissecting aortic aneurysm
Term
common cause of pain that wakes the patient up from sleep
Definition
malignancy until proven otherwise!
Term
common cause rapidly progressing neurological deficits
Definition
epidural abscess/infection
Term
Common cause of claudication symptoms with back pain
Definition
spinal stenosis
Term
what is the most common type of herniation and where?
Definition
posteriolateral herniation (narrow posterior longitudinal ligament)
most common levels = L4-5 and L5-S1
Term
How do you test L4?
Definition
1. foot inversion (Tibialis anterior)
2. patellar reflex
3. medial foot sensation
Term
How do you test L5?
Definition
1. Great toe extension
2. No reflex
3. dorsum of foot sensation
Term
How do you test S1?
Definition
1. Food eversion
2. Achilles tendon
2. lateral foot sensation
Term
Straight Leg Raise test
Definition
reproduces back pain
leg lifted straight up until there is pain
normal = 80 degrees
**When there is pain, lower the leg and dorsiflex the foot to stretch the sciatic nerve (Lasegue's) = pain with the sciatic nerve:
Term
results and interpretation of the straight leg raise test
Definition
0-35 degrees = some tension on sciatic nerve
35-70 degrees = maximally involves the sciatic nerve
>70 degrees = most likely joint pain
Term
Pain on both sides doing the straight leg raise test and the contralateral test may indicate what?
Definition
a space-occupying lesion (disc)
Term
Hoover test
Definition
test for malingerers (people faking it)
Patient supine and physician holds beneath the patient's calcaneus
when the pt tries to raise one leg, there should be contralateral pressure on the opposite heel if the person is trying
Term
Kernig Test
Definition
stretches the spinal cord
patient is supine and forcibly flexes head onto chest
pain down to the low back or in the leg means meningeal irritation
Term
Thomas test
Definition
assessment for contralateral restricted or shortened iliopsoas muscle
flex one thigh up to abdomen/chest
considered positive if opposite knee lifts off the table
can be active or passive
Term
Piriformis syndrome
Definition
SX: Hip/buttocks pain with radiation to calf and foot
EX: Decreased IR and Adduction
CS points: mid-ole sacrum, piriformis muscle, posterioromedial trochanteric points
Term
which organs and body parts receive sympathetic innervated from T12-L2
Definition
left colon
bladder
prostate
lower extremity
Term
spondylolisthesis
Definition
forward splippage of one vertebral body on the one below it (usually due to fracture in the pars interarticularis)
L4/5 most common
50% is asymtomatic until age 20 or >
pain quality and location: aching pain in low back, buttocks and posterior thigh
Term
signs and symptoms of spondylolisthesis
Definition
1. increased pain with extension based activities
2. B/L tight hamstrings
3. Stiff legged, short stride, waddling type gail
4. Usually no neurological deficits
5. Positive vertebral step-off sign over spinous process
Term
Four types of spondylolisthesis
Definition
1. Dysplastic (congenital)
2. Isthemic = development of stress fracture of pars interarticularis
3. Degenerative
4. Traumatic = acute stress to pars (can cause disc herniation)
5. Iatrogenic = from surgery or unknown causes
Term
spondylolysis
Definition
a fracture, defect or separation of the pars interarticularis of the vertebral arch
Term
Which vertebral defect is called "spotty dog" and why?
Definition
Term
grading of spondylolisthesis
Definition
Grade 1 = 0-25%
Grade 2 = 25-50%
Grade 3 = 50-75%
Grade 4 = >75%
Term
Treatment of Spondylolisthesis
Definition
weight loss
exercises
OMT
over 25% watch, consult if progression or neuological changes
Term
spondylosis
Definition
degenerative changes within the intervertebral disc and adjacent structures (facets, foramina)
Term
Cauda Equina syndrome
Definition
pressure on the nerve roots of the cauda equina usually due to massive central disc herniation
Term
symptoms of cauda equina syndrome
Definition
sharp low back pain
saddle anesthesia
decreased DTRs
decreased rectal sphincter tone
loss of bowel and bladder function/control
Term
treatment of cauda equina syndrome
Definition
emergent surgical decompression of cauda equina
Term
Spina Bifida
Definition
developmental anomaly
defect in closure of lamina of the vertebral segment
usually in the lumbar spine
Term
types of spina bifida
Definition
1. Occulta = no herniation, may see a coarse patch of hair over site on PE, neuological defects rare
2. Meningocele = herniation of the meninges through the defect
3. Meningomyelocele = herniation of both meninges and nerve roots through the defect; associated with neuological defects
Term
pathogenesis of spinal stenosis
Definition
1. hypertrophy of facet joints
2. calcium deposits in ligamentum flavum and posterior longitudinal ligament
3. loss of intervertebral disc height
Term
signs and symptoms of spinal stenosis
Definition
aching, shooting pain and/or paresthesias in the low back to lower leg or legs
pain is worsened by extension
Term
treatment of spinal stenosis
Definition
OMT to decreased restriction and improve ROM
NSAIDS, steroids, epidurals, laminectomy
Term
Iliosacral dysfunctions
Definition
Reflect appendicular problems
involve innominate and pubes
positive standing flexion test (from tight psoas muscles)
Term
Sacroiliac dysfunctions
Definition
reflex axial problems
involve sacrum in relation to ilia and lumbars
positive seated flexion (forward bending) test
Term
how does the pubic symphysis location differ in inflare and outflare of the pelvis?
Definition
it doesn't--remains the same
Term
Standing Flexion test
Definition
patient stands barefoot
dr monitors PSIS's
pt flexes maximally w/o bending knees
positive = side where the PSIS moves furthest
purpose = identifies side of iliosacral somatic dysfunction
"Gold standard" test for iliosacral SD
Term
superior transverse axis
Definition
cranial-sacral axis
Term
middle transverse axis (motion)
Definition
forward/backward bending of sacrum
Term
inferior transverse axis
Definition
rotation of the innominants relative to the sacrum
Term
6 types of innominate SD
Definition
1. superior shear (upslip)
2. inferior shear (downslip)
3. posterior rotation
4. anterior rotation
5. lateral (outflare)
6. medial (outflare)
Term
superior innominate shear (upslipped)
Definition
shear betwen the innominate and sacrum
symptoms seen on side of dyfunction:
- iliac crest more superior
- ASIS more superior
- PSIS more superior
- pubic ramus more superior (tubercle)
- medial malleolus cephalad (short leg)
often associated with pelvic pain or low back pain
may be caused by fall on one ischial tuberosity (trauma)
Term
Inferior innominate shear (downslipped)
Definition
shear between the innominate and sacrum
rare and walking tends to reduce it
symptoms on side of dysfunction:
- iliac crest more inferior
- ASIS more inferior
- PSIS more inferior
- pubic ramus more inferior
- medial malleolus inferior (long leg)
may be associated with pelvic or low back pain
Term
Posterior Innominate (Ilial) Rotation
Definition
Rotated posteriorly around transverse axis compared to other innominate
Symptoms on side of dysfunction:
- ASIS more superior
- PSIS more inferior
- medial malleolus superior (short leg)
inguinal/groin pain and knee pain may occur
resistant to anterior rotation of the pelvis
Term
muscles involved in dysfunction of a posterior innominate rotation
Definition
rectus femoris (causes the inguinal/groin pain)
sartorius (causes knee pain)
Term
Posterior rotators of the innominate
Definition
gluteus maximus
semitendinosis
biceps femoris
semimembranosis
piriformis (weak)
external abdominal oblique muscle
Term
Anterior Innominate Rotation
Definition
Rotated anteriorly around transverse axis compared to other innominate
symptoms on side of dysfunction:
- ASIS more inferior
- PSIS more superior
- medial malleolus inferior (long leg)
hamstring tightness
posterior thigh pain
resistant to posterior rotation of pelvis
Term
anterior ilium rotators
Definition
tensor facial latae muscle
quadratus lumborum
iliocostal muscles
internal abdominal oblique muscles
latissumus dorsi muscle
Term
Inflare
Definition
wider sacral sulus
positive standing flexion test
ASIS closer to midline (medial)
Term
outflares
Definition
smaller sacral sulcus
positive standing flexion test
ASIS further from midline (lateral)
Term
Abducting muscles of the hip
Definition
gluteus maximus, medius and minimus
Term
Motion of pubes
Definition
rotate about transvers axis
may shear superior/inferior with rest of innominate
anterior/posterior shears are rare; result from significant trauma
Term
superior pubic symphysis muscles
Definition
rectus abdominus
pyramidalis muscle
Term
Superior pubic shear
Definition
pubic bone moves superior on one side
symptoms on side of dysfunction:
- ASIS superior (or equal)
- PSIS inferior (or equal)
- right pubic tubercle/rami would be superior
Term
Ferguson's angle
Definition
an angle formed parallel to the floor and the sacral baase
typically 35 degrees
used on lateral x-ray to determine hyperlordosis of lumbar spine
Term
Dysfunction of what sacral ligment causes type 2 mechanics?
Definition
sacrotuberous ligament
Term
three "true" ligaments that suspend the sacrum in between the innominates
Definition
anterior sacroiliac
interosseus sacroiliac
posterior sacroiliac
Term
3 accessory ligaments that suspend the sacrum in between the innominates
Definition
1. sacrotuberous
2. sacrospinous
3. iliolumbar (prone to irritation)
Term
sacroiliac joint
Definition
L or C shaped
convex ventrally, concave on the sacrum
no direct muscular attachment
final fusion does not occur until mid 20s
Term
sacroiliac joint
Definition
L or C shaped (has short upper arm and longer lower arm); angle forms at S2
convex ventrally, concave on the sacrum
no direct muscular attachment
final fusion does not occur until mid 20s
allows joint stability in flexion or extension
Term
sympathetic innervation of the pelvic viscera
Definition
T12-L2
Term
parasympathetic innervation of the pelvic viscera
Definition
S2-4
Term
which disease can make the psoas contract and cause problems in the innominate and sacrum?
Definition
pancreatitis
Term
which disease is also referred to as left-handed appendicitis?
Definition
Diverticulitis
Term
Sacral axes
Definition
1. Transverse = superior, middle, inferior
2. Verticle
3. Anterior posterior
4. Oblique = right and left
Term
Motion and location of superior transverse sacral axis
Definition
Above S2
cranial primary respiratory mechanism creates motion around this axis
Term
Motion and location of middle transverse sacral axis
Definition
At S2
forward and backwards bending
Term
Motion and location of inferior transverse sacral axis
Definition
Below S2
rotation of the innominates
Term
Sacral dysfunctions
Definition
1. Bilateral flexed sacrum
2. Oblique axis dysfunctions
3. Sacral shears (unilateral flexion)
Term
In neutral mechanics, the sacrum rotates ______ relative to the oblique axis
Definition
same direction
Term
In non-neutral mechanics, the sacrum rotates ______ relative to the oblique axis
Definition
opposite direction
Term
Two phases of walking cycle
Definition
1. Stance phase (60%) = limb contacting ground; 20% is double stance
2. Swing phase (40%) = limb advancing (not on ground)
Term
How is the sacrum affected during walking cycle?
Definition
right rotation on right oblique axis, then left on left oblique axis (reversible, neutral oblique mechanics)
Term
How is the lumbar spine affected during the walking cycle?
Definition
induces side bending of the lumbar spine towards the side of weight bearing leg
Term
How is the ilium affected during the walking cycle?
Definition
anterior rotation of the weight bearing ilium and posterior rotation of the opposite ilium
Term
pubic symphysis
Definition
fibrocartilanginous joint that has motion determined by its anatomic shape, ligaments and muscular attachment (which can rotate it accordingly)
motion occurs at a transverse axis during normal gain
abduction dysfunction normal during pregnancy and childbirth
Term
Braggard's test
Definition
lower leg slightly and dorsiflex the foot
if negative: pain from straight leg raise test may be secondary to tight hamstring
Term
which pelvic ligament divides the greater and lesser sciatic foramen?
Definition
sacrospinous ligament
Term
primary pelvic muscles
Definition
levator ani
coccygeus muscle
(make up the pelvic diaphragm)
Term
secondary pelvic muscles
Definition
these have a partial attachment to the true pelvis
iliopsoas
obturator internus
piriformis
Term
piriformis muscle (origin, insertion, action and innervation)
Definition
origin = inferior anterior aspect of the sacrum
insertion = greater trochanter of the femur
action = externally rotates, extends thigh and abducts thigh with hip flexed
innervation = S1 and S2
Term
11% of the population will have either the entire or peroneal portion of the sciatic nerve running through which muscle?
Definition
piriformis
Term
four types of sacral motion
Definition
1. respiratory motion = occurs about the superior transverse axis of the sacrum (moves posterior during inhalation, and anterior during exhalation)
2. inherent (craniosacral) motion = occurs about the transverse axis (craniosacral flexion = counternutates, carniosacral extension = nutates)
3. Postural motion = occurs at the middle transverse axis of the sacrum (flexion = sacral base moves anterior, extension = posterior)
4. Dynamic motion = motion that occurs during ambulation (engages two sacral oblique axes)
Term
bilateral sacral flexion is a common dysfunction in which patients?
Definition
post-partum women due to birth mechanics
Term
how will weight bearing on the left leg affect L5 and the sacrum?
Definition
L5 will sidebend to the Left and rotate opposite the sacrum (right)
sacrum rotates toward the left
Term
sacroiliac dysfunction will result from a problem with which part of the body?
Definition
sacrum
Term
ilisacral dysfunction will result from a problem with which part of the body?
Definition
innominate
Term
L5 in relation to the sacrum
Definition
sidebends towards the oblique axis
rotates opposite the sacral base