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Cox > Final > Flashcards

Final Flashcards

1
Q

T/F

Transitional segments are one of the most common causes of recurring LBP

A

TRUE

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2
Q

What kind of congenital anomaly is considered a predisposing factor for LBP?

A

transitional segments

**requires greatest number of days/visits to attain maximum relief

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3
Q

T/F

Transitional segments are not contraindicated for side posture

A

FALSE

contraindicated for rotational manipulation

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4
Q

What low back pathology does transitional segments make the patient prone to?

A

50% have scoliosis
1/3 have disc lesions
2/3 have SI joint sclerosis
Degenerative changes at L1/S1

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5
Q

What is lumbarization?

A

6 lumbar segments

** causes greater mechanical stress

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6
Q

What is sacralization?

A

4 lumbar segments

** unlikely to cause symptoms due to increased stability in lumbar spine

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7
Q

What is Bertolotti’s Syndrome?

A

unilateral lumbarization or sacralization

**alters spinal biomechanics resulting in instability and stress, more likely to have a disc herniation level ABOVE with radicular component

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8
Q

4 types of lumbosacral transition segments

A

Type I - Dysplasic transverse process (spatula TPs)
Type II - Incomplete lumbarization/sacralization (new joint)
Type III - Complete lumbarization/sacralization (fused)
Type IV - Mixed (1 side joint, 1 side fused)

A = unilateral
B = bilateral
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9
Q

Which type of transitional segment is the worst?

A

Type II because severe aberrant motion

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10
Q

Which type of transitional segment has the highest incidence of disc herniation?

A

Type II A or B

**all other types do NOT produce any higher incidence of herniation

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11
Q

Which types of transitional segments have highest incidence and severity of LBP and buttock pain?

A

Type II and Type IV

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12
Q

What at home therapy is recommended for transitional segments?

A

Hot/Cold therapy

**10 min heat - 10 min cold - 10 min hot - 3x per day

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13
Q

Which resists shear of lumbar bodies more - facets or disc?

A

Facets (78%)

** disc (23%)

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14
Q

Where is the pars located in the lumbar bodies?

A

Between the lamina and pedicle (in the transverse plane) and the superior and inferior articular process (in sagittal plane)

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15
Q

Define insthmus

A

a narrow strip of tissue joining 2 larger parts

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16
Q

What is a pars defect?

A

fracture lamina dividing neural arch

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17
Q

Is the spinal canal widened or smaller with a pars defect?

A

widened

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18
Q

Is the spinal canal widened or smaller with degenerative spondylolisthesis?

A

smaller

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19
Q

T/F

There has NEVER been someone born with a pars defect

A

TRUE

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20
Q

Does a developing pars have a synchondrosis?

A

NO - it is a fully ossified structure at birth

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21
Q

What is the etiology of a pars defect?

A

stress or fatigue fracture, repetitive stress on normal bone allowing fracture

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22
Q

What is “pending” spondylolysis/listhesis?

A

bone marrow edema adjacent to the pars or hidden within intact pars on it’s way of becoming a defect

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23
Q

What is the difference between sondylolisthesis and spondylolysis?

A 
listhesis = forward slippage
lysis = fracture, no displacement
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24
Q

What ortho test indicates acute facet syndrome or a “hot pars”?

A

Stork test

**standing on one leg, grab other bent leg, extend backwards

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25
Q

Case management for positive stork test?

A

Stop athletic activity and brace for 90-120 days (3-4 months)

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26
Q

Is there a genetic susceptibility of spndylolysis/listhesis?

A

Yes - study in 2 sets of identical twins suggest genetic component

**autosomal dominant = only need general from 1 parent

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27
Q

2 types of true lytic spondylolisthesis

A
  1. Developmental (genetic)

2. Acquired (repetitive trauma or single force)

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28
Q

In 1963, Newman classified 6 types of spondylolisthesis

A
  1. Dysplastic (congenital hypoplastic facets)
  2. Isthmic (most common, pars defect)
  3. Degeneration (age, microfractures)
  4. Post-traumatic (fx in bony arch other than pars)
  5. Pathologic (disease, tumor)
  6. Iatrogenic (fusion causing more stress on segment above)
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29
Q

Most common type of spondylolisthesis

A

Isthmic

**2nd MC is degenerative

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30
Q

Incidence of spondylolisthesis in general population? in young athletes?

A

5.8%

13-14%

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31
Q

Scotty dog anatomy

A 
ear - superior articular process
nose - TP
eye - pedicle
neck - pars 
collar = fracture
front foot - inferior articular process
body - lamina
back foot - inferior articular process
tail - superior articular process
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32
Q

Which pedicle are you looking at with LAO?

A

Right pedicle

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33
Q

Which pedicle are you looking at with RPO?

A

Right pedicle

34
Q

T/F

Tearing of annular fibers and PLL must occur in order for vertebral body to slip forward

A

TRUE

** tearing is relative to grade of slippage

35
Q

T/F

Most spondylolisthesis have no history of precipitating event

A

FLASE

**50% of patients remember an event

36
Q

T/F

Spondylolisthesis can cause cauda equina syndrome

A

TRUE

37
Q

Name some anatomical structures that are stressed/irritated leading to nociceptive pain in degenerative spondylolisthesis

A 
T12/L1 Facets
Disc
PLL
ALL
Dura
Vertebral bone and periosteum
38
Q

What is Maigne’s Syndrome?

A

T12/L1 spondylolisthesis with subluxation

**mediated by the Superior Cluneal Nerves (L1-L3) supplying upper buttock

39
Q

T/F

Spondylolisthesis is the MC cause of LBP in children and adolescents.

A

TRUE

40
Q

T/F

The severity and frequency of LBP correlates with the degree of slippage.

A

FLASE

**it does NOT correlate

41
Q

T/F

There is no evidence of a higher incidence related to genetics and hereditary.

A

FLASE

**much greater within family tress than within the general public

42
Q

Degenerative cervical spondlolisthesis is defined as vertebral placement greater than ____mm.

A

2mm

  • *MC in C4/C5 and C5/C6
  • *Instability is more than 3mm
43
Q

T/F

Grade spondlolisthesis according to Myerding grading system

A

TRUE

1: 0-25%
2: 25-50%
3: 50-75&
4. 57-100%
- from posterior aspect of body above

44
Q

T/F

A significant degree of spondylolytic spondylolisthesis patients have highly abnormal paradoxical movements of a lytic segment

A

TRUE

**in Flexion, lytic segments translates forward than rocks BACKWARDS rather than forward as you would expect

45
Q

T/F

Spondylolisthesis is more unstable at L5 than L4

A

FALSE

**L4 is more unstable than L5

46
Q

What is the management for an asymptomatic spondylolisthesis?

A

leave it alone!

**and those with LBP and/or leg pain respond best to conservative care

47
Q

What does the lower lumbar palpate with a spondylolisthesis?

A

“step-off” where the segment’s neural arch above slides anterior

48
Q

Lab protocol for spondylolisthesis

A

foam roll under unstable segment to stabilize and reduce lumbar lordosis, SCP is the spinous above spondy

49
Q

MC segment in lytic spondylolisthesis? in degenerative spondylolisthesis?

A

lytic: L5
degenerative: L4

50
Q

Degenerative spondylolisthesis constitutes 25% of all spondylolisthesis and is MC in which population?

A

older than 50 yo, female, black

51
Q

Retrolisthesis is the result of _____ degernation and is the _____ chiropractic model of subluxation

A

result of disc degeneration - annular and PLL tear

the Gonstead model

52
Q

Define: spondyloptosis

A

100% slippage of vertebra compared to one below

**paralytic, high speed accident

53
Q

Patient management for degenerative/unstable spondylolisthesis

A
  • Brace 24/7 until 50% approved
  • usually about 6-8 weeks to stabilize
  • common to have slight recurrences while complete healing is taking place
54
Q

Risk of vertebral artery syndrome vs cervical disc surgery

A

vertebral artery syndrome causing stroke: 2:1,000,000

cervical disc surgery causing paralysis - 15,000:1,000,000

55
Q

T/F

Lumbar facet syndrome is a defined clinical pathology

A

FALSE

**No predictable combination of clinical features defining facet syndrome, no objective/subjective signs to differentiate z-joint, posterior mm, or other structures causing pain

56
Q

Criteria for dx of sciatic radiculopathy due to herniated disc (5 signs)

A
  1. leg pain > LBP
  2. paresthesia along dermatome
  3. +SLR by 50% or less, or +Cross Over
  4. 2 neurologic signs (mm wasting, motor weakness, sensory deficit, decreased reflex)
    • image study
57
Q

T/F

There are clear clinical signs of a facet lesion, but not a disc herniation.

A

FLASE

  • *no clear clinical signs for facet
  • *disc signs: SLR, neuro, leg pain, etc.
58
Q

what is a meniscoid?

A

fibroadispose structure to maintain synovial fluid between articular cartilage, ensures lubrication and proper mechanical function (like in the knee)

59
Q

Etiology of facet joint pain (8)

A
  1. capsular tear
  2. capsule deformation
  3. castle synovial inflammation
  4. castle avulsion and articular cartilage damage
  5. articular micro-fractures
  6. OA
  7. capsule sprain/synovial impingement
  8. meniscoidal entrapment/extrapment*
60
Q

When are chemokines released?

A

During a capsular tear, damaged tear releases chemicals lowering nociceptors threshold for activation - also stimulates angiogenesis and neo-vascularization

61
Q

T/F

Biomechanial dysfunction and hyper mobility causes z-joint capsule inflammation and nociceptive pain.

A

TRUE

62
Q

One z-joint capsule is avulsed and the other z-joint undergoes cartilage compression fracture - Which model?

A

Farfan Torsion Model

63
Q

What is facet joint “spearing” from whiplash?

A

when superior articular process collides with inferior articular process - because the instantaneous axis of rotation is shortened causing aberrant motion

64
Q

T/F

Meniscoidal entrapment/extrapment is the most common cause of non-complicated acute onset LBP and muscle spasm.

A

TRUE

**benefit well from chiropractic adjustments

65
Q

Meniscoid: AKAs, location, why they are pain sensitive

A
  • AKAs: meniscus, fibroadipose pad, intra-articular synovial folds (IASF)
  • located: all spinal levels but most developed in cervical and lumbars
  • contain free nerve endings causing nociceptive pain
  • vary in number, size and shape throughout spine
66
Q

Most common areas for facet tropism?

A
  1. thoaraco-lumbar
  2. cervico-thoracic
  3. lumbo-sacral

**can occur anywhere

67
Q

Sensory nerve supply to z-joints

A

medial branch of posterior primary division of dorsal ramus from level above, same segment, and level below

i.e. for L4 facet - supplied by L3/L4/L5

68
Q

Lumbar spine weight bearing load:
_____% on body - disc - body
____% on 2 articular facets

A

80% on body - disc - body (anterior column)

20% on 2 articular facets (posterior column)

69
Q

How much% is added to z-joint weight bearing with DDD?

A

47-70%

70
Q

What ROM causes facet loading?

A

direct axial loading and extension/rotation

**flexion/rotation does NOT cause facet joint loading

71
Q

How is facet shear loading varied throughout lumbar spine?

A

shear load, AKA translation or slide, is resisted as facet angels become more coronal compared to sagittal down lumbar spine

72
Q

What are the 3 stages of the degenerative cascade triad?

A

Stage 1: dysfnuction (trauma and cumulative stress)
Stage 2: Instability (capsular laxity) leads to mild **symptoms into severe LBP episode
Stage 3: Stabilization (spurring, sclerosis, hypertrophy)

**Dr. Kirkaldy-Willis

73
Q

X-ray lines for facet syndrome? (3)

A

Macnab’s
Van Akkerveekens Lines
Sacral Base Angle

74
Q

Macnabs Line

A

hyperextension subluxation

inferior endplate line, superior endplate line, should cross posterior to facets - if line crosses more anterior, the greater the facet syndrome

75
Q

Van Akkerveekens Lines

A

stability of facets, determine potential damage of PLL and annulus fibrosis

3mm or greater indicates damage

76
Q

Sacral Base Angle

A

compressive loading to discs or facets

Normal is 41 degrees
increase = shifting weight posterior onto facets
decrease = shift weight anterior onto body

77
Q

T/F

L5/S1 is MC site of problems in vertebral column due to many factors

A

TRUE

  • bears most weight, smallest disc in lumbars, smallest IVF, transition segment, etc.
78
Q

T/F

Referred pain can be used reliably to infer exact location (which facet) is source of pain

A

FALSE

  • *referred pain in lumbars is NOT reliable
  • *any referred sensation in to lower extremity with noted motor/neuro changes = disc lesion
79
Q

Referred vs radicular pain

A

referred - no neuro, LBP > leg pain, faster response

radicular - neuro signs in later stage, leg pain > LBP, slower response

80
Q

What is in indicator for immediate spinal de-compressive surgery?

A

loss of neurological function

81
Q

T/F

Disc surgery does not appear to return patients to works any faster or prevent long term disability than any other non-operative treatments

A

TRUE

Cox (2 decks)

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