THE SPINE

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THE SPINE
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Spinal Regions

• Cervical - 7 vertebrae
• Thoracic - 12 vertebrae
• Lumbar - 5 vertebrae
• Sacral - 5 fused vertebrae
• Coccyx - 4 fused vertebrae

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Functions of the Spine

• Spinal cord protection
• Muscle attachments
• Curves provide shock absorbing capabilities
• Movements- flexion, extension, lateral flexion

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THE SPINAL MOVEMENT SYSTEM

• The SMS is the basic functional unit of the
  spine. It consists of the adjacent halves of two
  (2) vertebrae, the interposed disc and facet
  joints as well as the supporting ligaments,
  muscles, blood vessels and neural structures.

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Thoracic Region

• Articulate with ribs
• Articulating surfaces facets or demifacets
• T1- T10 articulate with the tubercles and heads
  of ribs
• T11-T12 articulate only with the rib heads
• Movement is limited

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Lumbar Region

• The facet angles allow for more flexion
  extension movement
• Bigger stronger vertebrae

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Sacrum

• S1-S5 (fused)
• Female sacrum is shorter, wider, and more curved
  between S2 and S3
• Anterior 4 transverse lines (mark the joining of
  the vertebral bodies)
• Anterior sacral foramina communicates with the
  posterior sacral foramina through which nerves
  and blood vessels pass

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Parts of Typical Vertebrae

• Body
• Thick, disk-shaped anterior portion of the
  vertebrae
• Weight bearing portion
• Separated by cartilaginous intervertebral discs
• Vertebral Arches
• Formed by the pedicles, laminae
• Boundaries for the vertebral foramen with the
  body
• Surrounds the spinal cord
• Combined to form the spinal canal

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Vertebrae cont.

• Vertebral Notches
• Each pedicle has a superior and inferior notch
• When stacked they form the intervertebral
  foramen- allows passage of a single spinal nerve
• Processes
• 7 arise from the vertebral arch
• Transverse (2)- serves as muscle attachments
• Spinous (1)- serves as muscle attachments
• Superior articular (2)- forms joints with
  vertebra above
• Inferior articular (2)- forms joints with
  vertebra below
• articulation surfaces are called facets

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The Disc

• The principle function of the disc is to transmit
  shock and the load of the spine. Each disk is
  made up of two parts
• The hard, tough outer layer is the annulus, which
  surrounds a mushy, moist center called the
  nucleus. The outer annulus has approximately
  12-16 fiber rings that provide the stability to
  the disc and keep is resistant to tearing when
  rotated or pressured from front bending, side
  bending or extended as in back bending.
• The disc is water filled and thus is effected by
  age and weight. The disc compresses slightly when
  weight bearing and refills with fluid when the
  load bearing pressures are released. (lying down)
  The disc has some ability to heal itself if it is
  not too damaged. However, the healing process is
  slow, 6 months to 1 year.
• The nucleus provides a ball bearing type of
  effect. It is approximately 75 water.

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Ligaments

• Provide the CNS with information about body
  position. (Mechanoreceptors.)
• The ligaments maintain joint integrity and allow
  movement. They have poor blood supply and are
  thus slow healing.
• Anterior longitudinal ligament - this ligament
  strengthens the disc anteriorly
• Posterior longitudinal ligament - strengthens the
  disc posteriorly
• Interspinous ligaments tie the spinous processes
  together. Allow for forward bending.
• Pars Interarticularis ligament problems are often
  precursors to disc problems. If you have some
  laxity in a ligament, then the rotation forces on
  the disc become to great and a tear of the
  annulus is likely. Signs and symptoms of a
  ligamentous problem may include the inability to
  sit comfortably, aching, deep soreness, no
  neurological findings and symptoms typically
  increase with fatigue.

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Muscles of Thoracic Spine

• Flexion of Thoracic Spine rectus abdominus,
  external and internal abdominal oblique
• Extension of Thoracic Spine Longissimus
  thoracis, Interspinalis
• Rotation and Side flexion of Thoracic Spine
  Longissimus thoracis, internal abdominal oblique,
  external abdominal oblique, transverse abdominis
• Levator Scapulae
• Rhomboids
• Trapezius
• Serratus anterior, posterior, superior

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Muscles of Lumbar Spine

• Forward Flexion psoas major, rectus abdominis,
  external and internal abdominal oblique
• Extension latissimus dorsi, erector spinae,
  quadratus lumborum, gluteus maximus
• Side Flexion latissimus dorsi, erector spinae,
  quadratus lumborum, psoas major, external
  abdominal oblique
• Rotation transversalis

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Nerves
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Nerves Cont.
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Lumbar Plexus

• Supplies the anterolateral abdominal wall,
  external genitals, and part of the lower limb
• L1- iliohypogastric(muscles of anterolateral
  abdominal wall skin of inf. Abdomen and
  buttock), ilioinguinal
• L2- genitofemoral(cremaster muscle skin over
  middle ant. Surface of thigh, scrotum in male,
  and labia majora in female)
• L3- lateral cutaneous nerve of thigh(skin over
  lateral, anterior, and posterior aspects of
  thigh)
• L4- femoral(flexor muscles of thigh and extensor
  muscles of leg skin over anterior and medial
  aspect of thigh and medial side of leg and foot),
  obturator(adductor muscles of leg skin over
  medial aspect of thigh)
• L5- lumbosacral trunk

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Sacral and Coccygeal plexuses
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Nachemson's Disc Pressure Studies

• Supine - 25 of standing
• Standing - 100
• Forward bending - 150
• Forward bending with a weight - (10lbs) - 220
• Sitting - 140
• Sitting and lifting a weight - 185
• Sit ups - 210
• Supine with legs supported - 35
• Most patients with a disc would rather stand than
  sit. Sitting puts an axial load on the spine and
  thus loads the disc more than standing.

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Reflexes   L3-4 patellar tendon L4-5 muscle
test, extensor hallucis longus, anterior
tibialis L5-S1 Achilles tendon reflex S2-3-4
are the bowel and bladder control nerves  
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L4   Muscle - anterior tibialis Reflex -
patellar reflex Sensation - medial side of the
leg and foot  L5   Muscle - Extensor hallucis
longus Reflex - None Sensation - top of the
foot S1   Muscle - peroneus longus and
brevis Reflex - Achilles Sensation - lateral
leg and foot
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Injuries and Syndromes of the Spine   Facet
dysfunction Myofascial sites SI joint
dysfunction Ligamentous weakness Instability Di
sc Dysfunction Spondylolisthesis Spondylosis
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Fractures Acute Stress Compression Stenosis
Elevated first rib Thoracic outlet
syndrome Scoliosis
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Normal curves   When using a plumb line, the ear,
ac joint, greater trochanter of the hip, anterior
knee, and lateral malleolus should line up
vertically. When these structures line up it
creates natural curves in the spine, the cervical
area curves in, the thoracic area curves out, the
lumbar area curves back in and the sacral area
curves out again. An increased thoracic or sacral
curve is called kyphosis. An increased cervical
or lumbar curve is called lordosis.
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Abnormal Curvatures

• Scoliosis- abnormal lateral curvature
• Kyphosis- hunchback abnormal thoracic
  curvature
• Lordosis- swayback abnormal lumbar curvature

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Abnormalities   Scoliosis is a lateral curvature
of the spine which usually has a childhood onset.
It can be corrected by strengthening the convex
musculature (if the curvature is not too severe.)
Stretching the concave muscles and using muscle
stimulation at night. Activity if fine as long as
the patient is asymptomatic and the angular
curves are not progressing.  
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Spondylosis   Is a fracture of the Pars
articularis in the lumbar spine which does create
some instability and pain. Specific exercise can
help, sports can be continued with modifications
of exercises, specifically weight training. (
elimination of squats and power cleans, hitting
the sled, etc. any exercises that cause hyper
extension of the back and pain.) Confirmation via
x-ray is necessary, oblique views in which a
"Scotty Dog" is present are necessary. If the dog
has a band or collar on, this represents a
fracture of the Pars.
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Spondylolisthesis   This is a progressive form of
spondylosis where the lumbar vertebrae displaces
on the one below it, this normally occurs at
L4/5. This condition can cause pressure on the
lumbar nerve roots and heavy physical labor or
athletics may be contraindicated. The body will
slide forward on the inferior disc and vertebral
body. This causes strain / sprain on the
ligamentous tissues as well as closing the neural
foraminal spaces.
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A herniated disc is a bulging disc, which can
impinge on the spinal nerves. Depending upon the
degree of herniation, the patient may be pulled
from activity until therapy and exercises can
slowly advance the patient to an activity level
that they can tolerate. Avoid any activities that
aggregate neuro symptoms. A ruptured disc usually
is very painful with associated paresthesia and
paralysis and requires surgery. Back surgery
patients may take from 6 to 18 months to rehab
and some never fully recover to their pre op
form.
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Arthritic changes in the facets and vertebrae can
be disabling and painful. The swelling is
secondary to the arthritis but it can impinge
nerves and stretch ligaments. Long term changes
include degenerative changes and
exostoses.   Soft tissue problems in the muscles
and ligaments of the spine are treated like those
in other areas, but the need to rest the muscles
of the low back may have greater need than
resting the muscles of the leg. The muscles of
the back almost never rest whether the patient is
sitting, lying down, or standing. Muscle injuries
were previously thought to stand alone, however,
recent research has shown that often the muscle
spasm is a sequela to ligamentous and or disc
trauma.
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Ligament Injury
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Back Evaluation Tests     Kernig / Brudzinski
Test   The patient is lying supine with their
hands cupped behind the head. The practitioner is
standing next to the patient. The patient is
asked to flex the C-Spine by lifting the head.
Each hip is flexed separately to less than 90
degrees. The opposite leg remains on the table.
Pain that radiates into the lower extremity with
neck and hip flexion is deemed a positive
finding. The pain is usually relieved when the
knee is flexed. The origin of the pain is nerve
root irritation, meningeal irritation and dural
irritation that is increased as a result of
stretching the spinal cord.
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Distraction test   Pull the vertebrae apart,
increased pain indicates tight muscles, tendons
or ligaments.   Compression test   Push the
vertebrae together, increased pain or radiating
pain implies a possible disc, swelling, or facet
problems.   Valsalva test   As the patient to
hold their breath and then bear down as if
attempting to move their bowels. A
space-occupying lesion (disc) will cause pain at
the site of protrusion.
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Thomas test   This tests for hip flexor
tightness. Have the patient draw both knees to
the chest while laying down, then drop one leg to
the table, the hamstring of the dropped leg
should reach the table, if it does not, the hip
flexor muscles are too tight and are effecting
the biomechanics of the back by pulling the
pelvis forward an increasing the lordosis.
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Gaenslen test   Is performed the same way that
the Thomas test is except that the extended leg
is allowed to fall off of the exam table. This
forces the pelvis to rotate and compress the si
joint on the dropped side. Pain is indicative of
SI problems.
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Pelvic compression and distraction   Tests the
SI joint. The test is performed by applying
pressure to the ASIS to distract the SI joints or
by pushing on the ASIS to compress the SI
joint.   Figure 4 or Fabere test   Tests for SI
joint compression. Have the patient drag one heel
up the opposite leg and then let the bent leg
fall into abduction and external rotation. Pain
on the same side indicates a sensitive SI joint.
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One Leg Standing (stork)   Tests for lumbar
segmental rotation and places stress on the Pars
interarticularis thus testing for a spondylosis
resulting from an acute or stress fracture.
This test has significant clinical correlation.

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Straight Leg raise test (Hoover Test)   Tests
the flexibility of the hamstring muscles and the
possibility of sciatica. Have the patient
dorsiflex their foot, straighten his knee and
lift his leg as far as possible. Pain in the
hamstrings is indicative of tightness pain in
the buttocks indicates sciatica (sciatic nerve
pain). Pain on the opposite side of the SLR
indicates a space-occupying lesion. (Disc) The
inability to raise the leg may be indicative of
weakness due to a neuromuscular weakness. A
positive test is noted if the practitioner does
not feel pressure under the non raised leg.
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Ober's test   This test checks the length of the
tensor fascia latae or the I.T. band. Have the
patient lie on the side, stabilize his pelvis,
bend the top knee and have him touch the table
behind him, if the leg floats and does not go
down to the table, the tensor fascia is tight.
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Slump Test   The patient is seated on the edge of
a table with the legs supported. The first
segment is to have the patient slump the
shoulders and back into thoracic and lumbar
flexion. The head and neck are not flexed at this
time. The head and neck are then flexed and the
legs extended. Pain and or discomfort should be
expected in the areas behind the knees and in the
mid back, however, if pain or symptoms are noted
at any time during the segmented testing, the
examiner does not need to progress to the next
level. (Magee, 9-40)
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Trendelenburg Test   The patient is standing
supported on both legs. Have them raise one leg
thus standing on one foot.  
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Range of motion   Test the ROM in all three 3
planes of motion. You should record the rom,
strength, and quality of these movements. Also
note any guarding that may take place. Look to
Detect any abnormal movements or structural
findings such as kyphosis, lordosis, or
scoliosis.
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Manual muscle tests   There is a specific test
for all the muscles in the abdomen and low back.
Test all the muscles of the upper thigh and hip
also. Perform all of the tests and then repeat
several of them on the major muscle groups to see
if increased repetitions and thus fatigue are
indicated. Take a detailed history of past
painful patterns, medication, and any special
tests performed by the physicians in the
past.   Check the patient's posture and leg
length. Check the posture from the front, side,
and back. Check the leg length.
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True leg length - measured from the ASIS to the
medial malleolus.   Apparent or functional leg
length - measured from the umbilicus to the
medial malleolus. If apparent leg length is off
and true leg length is ok, then there is an
imbalance in the pelvis area.  
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Gait analysis   Bad gait patterns and posture can
lead to back problems. Make sure that walking
patterns are not aggravating the back
problem.   Lifestyle changes   Do not be afraid
to tell your patient that they may have to change
some of there habits or lose weight in an effort
to help their back. Consult with their physician
before sharing such "news" so that the entire
health care team is on the same page.   Patients
with back pain do not sleep on their stomachs. If
side sleeping, they should put a pillow between
their legs to maintain a level pelvis.  
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Weight Room and Lifting Mechanics   Spondylosis /
spondylolisthesis patients should not squat and
or power clean in the weight room. Hamstring curl
machines should have a bend back surface to
eliminate the lower back from those lifts.
  Rules   Maintain an anterior curve in the
spine. (head up position) Do not twist while
lifting Use legs. Not back to lift. Keep
objects close to the body.   There is no evidence
that lifting belts prevent injury. They may help
a patient return from injury. They do however
help to promote proper lifting techniques due to
their width.