What ligaments are located in the

lumbar spine?

1. Ligamentum Flavum

2. Anterior Longitudinal Ligament

3. Posterior Longitudinal Ligament

4. Interspinous Ligaments

5. Iliolumbar Ligament

6. Supraspinal Ligament

Ligament that runs between the lamina from the axis vertebrae to the sacrum

Connects the lamina and fused with the facet joint capsules

3 layers thick...

Superficial to Lumbar muscles...

Contain autonomic innervation of myofibrils...

Connection points transfer forces in variety of directions

Right Facet Joint

Left Facet Joint

Intervetebral Disc

up glide

(Open)

down glide

(Close)

Concave

Face medially and slightly posteriorly

Convex

Face laterally and slightly anterior

Facet joints are surrounded by a.....

This provides attachement for what muscle?

Ligamentous capsule

Multifidus

Sidebending

(Lateral Flexion)

Fryette's First Law

(Neutral Mechanics)

Fryette's Second Law

(Non-Neutral Mechanics)

Annulus Fibrosis

Nucleus Pulposus

rotation

the cross hatching causes each layer of the annulus fibrosis to resist rotation in opposite directions

1-3 degrees per vertebral segment

5-18 degrees total

Flexion

(40-60 degrees)

Erector Spinae

Iliocostalis Lumborum

Longissimus

Spinalis Thoracic

Psoas

Multifidus

Rotatores

Rectus Abdominus

Internal & External Obliques

Transverse Abdominus

Pelvic Cross Syndrome

Tight & Weak Muscles

TIGHT:

Iliopsoas

Hamstring Tension

Erector Spinae

LENGTHENED & WEAK

Abdominals

Gluteals

Intervertebral Disc Damage (Herniation)

Nerve Root Impingement

Spondylosis, Spondylolysis, Spondylolithesis

Facet Syndome

Fracture (Overload or Tumor)

At risk from 20-50 years old

greatest risk in early 30's

Morning

increased water content in the morning so there is a greater pressure in the disc

Slippage of Vertebra

Grades 1 (25%) & 2 (26-50%) can be managed conservitavely

Grades 3 (51-75%) & 4 (76-100%) are candidates for surgery

Osteomyelitis

(Bone Infection)

1% of all skeletal infections

May afflict vertebral body, interveterbal disc, or spinal canal

Localized or Metastized  through blood stream or lymphatics

Direct infection from trauma, surgery, discography, intravenous or intradural cathetreization

Age (very young and elderly)

IV drug users

Diabetes

Renal Failure

Spinal Surgery

Insidious

Progressive onset of back pain (non-mechanical)

Fever

Weight loss

Percussive Tenderness

Muscle Spasm (>90%)

Occasional Neurologica Changes (<10%)

inflammatory arthritis

common involvement with spinal structures

primary concern with cervical spine due to frequency of C1/C2 instability with sub-axial subluxation and brainstem compression/death

Chronic

Seronegative inflammatory disease that affects the SI Joints, Hips, and Spine

Males > Females

Insidious onset of buttock, heel, and lumbar pain

Loss of motion

Reduced  Lordosis

Pain subsides following complete ankylosis of the spine

Symptoms- Unilateral low back pain to bilateral LE dysfunction including pain, weakness, and sensory loss

Central canal or foraminal canal

Congenital or Acquired

Most often seen in elderly patients

Insidious, Progressive onset of symptoms

Worse with extension/standing

Better with sitting, lying, flexion

Stand in flexed position for relief

Decline of bone density

Occurs in aging population

Prevelant in post-menopausal women

often present as vertebral compression fracture in elderly

Smoking

Alcohol

Inactivity

Calcium Deficiency

Age > 50

History of Cancer

Unexplained Weight Loss

Failure of Conservative Care

Cauda Equina Syndrome- Urinary Retention

0% to 20%- Minimal Disability

21% to 40%- Moderate Disability

41% to 60%- Servere Disability

61% to 80%- Crippled

81% to 100%- bed-bound or exaggerating symptoms

Lumbosacral Examination:

Muscle Balance Testing

Modified 3 Muscle Kendall Test

Rectus Femoris

Iliopsoas

IT/TFL

Ankle plantar flexion

Ankle Eversion

Hip Extension

Position patient into trunk extension, side-bending, nad rotation which closes down the intervertebral foramen on tested side

Stabilize head

+ test = local, referred, radicular pain

Do a Bilateral comparison

Straight Leg Raise

(Lasegue Test)

Passive flex patients hip until pain reported in leg or low back

pull back on straight leg raise until symptoms abolish

Perform dorsiflexion or neck flexion

+ test = leg &/or low back pain indicative of adverse neural tension

Pain occuring greater than 70 degrees hip flexion implicates lumbar &/or SI joint pathology

Slumped sitting with hands behind back

Maximally flex neck

Flexed Trunk

Ankle Dorsiflexion

Knee Extension

+ test = pain or parasthesia in leg &/or low back

symptoms remain = soft tissue restriction

symptoms abolish = Adverse Neural Tension

Stabilize patients pelvis as knee is passively flexed

+ test = pain &/or paraesthesias along femoral nerve distribution

Bowstring Test

(Cram Test)

Therapist does a straight leg raise until symptoms are produced

Flexes knee to 20 degrees which abolishes symptoms

Apply pressure to the popliteal space

+ test = pain/paraesthesia in leg &/or low back implicating adverse neural tension of sciatic nerve

Patient Supine with lower extremities relaxed

Therapist puts hands under calcaneous bilaterally

Patient asked to alternately perform straight leg raise

+ test for malingering- inability of the therapist to percieve pressure of the opposite calcaneous into palm while performing SLR

Therapist palpates bilateral PSIS

Patient asked to flex at the trunk while maintaining knee extension

+ test = 1 PSIS moving first and moving farther into elevation than opposite side indication hypomobility of Iliosacral joint on side that moves first

Patient starts at edge of plinth

Bring knee to chest

Lye back onto plinth

Assess for ability of posterior thigh of testing leg to touch plinth & knee to achieve 90 degrees of flexion

Inability of above implicates tightness of the iliacus/psoas & rectus femoris

Patient prone

Therapist passively flexes knee assessing for anterior pelvic tilt on ipsilateral side

Implicates rectus femoris tightness if assymetrical

If direction of perference found, start with repeated motions

Avoid positions/movements that increase symptoms

decreased intensity in pain

decreased frequency in pain

Able to do more with same amount of pain

decrease in pain medications

Lack of extension

Lack of Adduction

Lack of Internal Rotation