Chapter 1: Spinal Conditions

• May be related to sudden trauma, chronic or sustained overload, or abnormal muscle biomechanics secondary to faulty function (abnormal joint or muscle biomechanics)
• Commonly will resolve without intervention
• If trauma is too great or related to chronic etiology, patient will benefit from intervention

Made by clinical examinatio through comparing results of flexibility (AROM/PROM), resistitve tests, and palpation

• Acetaminophen (pain)
• NSAIDs (pain and/or inflammation
• Corticosteroids injection or by mouth
• Muscle relaxants (Flexeril (cyclobenzaprine) or Valium (diazepam)
• Trigger point injections

• Biomechanical faults correced with joint mobs
• Pt education regarding elimination of harmful positions and postural reeducation
• Spinal manipulation for pain inhibition generally indicated

• Etiology thought to be congenitally defective pars interarticularis
• Spondylolysis: fracture of the pars interarticularis with positive "Scotty dog" sign on oblique radiographic view of spine
• Spondylolisthesis: actual anterior or posterior slippage of one vertebra on another, following bilatearl fracture of pars interarticularis
• Spondlolisthesis graded from 1 (25% slippage) to 4 (100% slippage)

• Plain film (oblique to see fx and lateral to see slippage)
• Clinical exam = stork test

• Acetaminophen for pain
• NSAIDs for pain and/or inflammatio
• Corticosteroid injection or by mouth
• Muscle relaxants
• Trigger point injections

• Joint mobs to correect biomechanical faults
• Exercise should focus on dynamic stabilization of trunk (emphasis on abdominals)
• Avoid ext and other positiosn that add ress to defect (ext, ipsilateral side bend, contralateral rotation)
• Pt education regarding elimination of ext positions and postural reeducation
• Boston brace and TLSO have traditioally been use but frequency is decreasing
• Spinal manipulatio may be contraindicated, particularly at level of defect

• Etiology: congenital narrow spinal canal or intervertebral foramen, coupled with hypertrophy of spinal lamina and ligamentum flavum or facets
• Result of age-related degenerative process or disease
• Results in vascular and/or neural compromise
• Signs and symptoms = B pain and paresthesia in back, buttocks, thighs, calves, and feet; pain decreases in flex, increases in ext; pain increases with walking and relieved with prolonged rest

• Plain Films
• MRI
• CT Scan
• Occasionally myelography is helpful
• Clinical exam includes bicycle (van Gelderens test) - helps differentiate condition from intermittent claudication

• Acetaminophen for pain
• NSAIDs for pain and/or inflammatio
• Corticosteroid injection or by mouth
• Muscle relaxants
• TP injections

• Joint mobs to correct biomechanical faults
• Flexion-based exercises
• Exercises that promote dynamic stability throughout trunk and pelvis
• Avoid ext and other positios that narrrow spinal canal or intervertebral foramen (ipsilat side bend and ipsilat rotation)
• Manual traction/mechanical traction (cspine positioned at 15 deg of flex to provide optimum intervertebral foraminal opening; contraindications include hypermobility, pregnancy, RA, downs syndrome, or any other systemic disease that affects ligamentous integrity)

• Internal structure of disc annulus is disrupted
• External structures remain normal
• Most common in lumbar region
• Symptoms = deep, achy pain; increased pain with movement
• No objective neurological findings
• Pt may have referred pain in LE

• CT Discogram
• MRI
• (Cannot be diagnosed by regular CT or myelogram)

• Acetaminophen for pain
• NSAIDS for pain and/or inflammation
• Muscle relaxants
• TP injectios
• Corticosteroid injection or by mouth

• Joint mobs to correct biomechanical faults
• Spinal manipulation may be contraindicated
• Pt education regarding proper body mechanics, positios to avoid, limited repetitive bending/twisting, limiting UE overhead and sitting activities, and carrying heavy loads

• Most commonly observed disc disorder of lspine due to three structural deficiencies:
• Post disc is narrower in height than ant disc
• Post longitudinal ligament is not as strong and only centrally located in lumbar spine
• Posterior lamellae of annulus are thinner

• Etiology = overstretching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures (from high compression forces or repetitive microtrauma)
• Results in loss of strength, radicular pain, paresthesia, and inability to perform ADLs

MRI

• Acetaminophen for pain
• NSAIDs (pain and/or inflammation)
• Muscle relaxants
• TP injections
• Corticosteroid injection or by mouth

• Exercise to promote dynamic stability throughout trunk and pelvis and provide optimarl stimulus for regeneration of disc
• Positional gapping for 10 minutes to increase space within region of space occupying lesion
• If L posterolateral lumbar herniation is present = have pt sidelying on R side with pillow under R trunk (accentuates trunk SB R), flex both hips and knees, rotate trunk to L (or pelvis to R) - pt can be taught to perform this at home
• Spinal manipulatio may be contraindicated - particularly at level of herniation
• Pt educatio regarding proper body mechancis, positions to avoid, limiting repetitive bending and twisting movements, limiting UE overhead and sitting activities, and carrying heavy leads
• Manual and/or mechanical traction (cspine at 15 deg of flex to provide optimal intervertebral foraminal opening; contraindications include hypermobility, pregnancy, RA, downs, or any systemic disease that affects ligamentous integrity)
• Efficacy of traction for intervetnion of disc conditions currently under scrutiny

• More commonly observed in the cspine but also seen in lumbar
• Etiology: overstretching and/or tearing of annular rings, vertebral endplate, and/or ligamenous structures (PLL) from high compressive forces and/or long-term postural malalignment
• Results in loss of strength, radicular pain, paresthesia, inability to perform ADLs, and possible compression of spinal cord
• Pt exhibits CNS symptoms (hyperreflexia and positive Babinski)

MRI

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation
• Muscle relaxants
• TP injections
• Corticosteroid injection or by mouth

Refer to posterolateral intervention

Very rare due to structural integrity of anterior intervertebral disc

• Etiology = part of normal aging process due to weight bearing properties of facets and intervertebral joints
• Results in bone hypertrophy, capsular fibrosis, hypermobility or hypomobility of joint, and proliferation of synovium
• Symptoms = reduction in mobility of the spine, pain, and possible impingement of associated nerve root --> results in loss of strength and paresthesias

• Plain film imaging
• Clinical exam = lumbar quadrant test

• Acetaminophen for pain
• NSAIDs for pain/inflammation
• Muscle relaxants
• TP injections
• Corticosteroid injection or by mouth

• Exercise to promote dynamic stability throughout trunk and pelvis and provide optimal stimulus for regeneration of facet cartilage and/or capsule
• Joit mobs to correct biomechanical faults
• Spinal manipulation may be useful

• Caused by abnormal movement of fibroadiopose meniscoid in facet during extension (from flex)
• Meniscoid does not properly reenter joint cavity and bunches up - becomes a space-occupying lesion (distends capsule and causes pain)
• Flex most comfortable for pts, ext increases pain

Lumbar quadrant test

• Acetaminophen for pain
• NSAIDs for pain/inflammation
• Muscle relaxants
• TPinjections
• Corticosteroid injection or by mouth

Positional facet joint gapping and/or manipulation are appropriate

• Formerly known as whiplash
• Occurs when excess shear and tensile forces are exerted on cervical structures
• Structures injured may include facets/articular processes, facet joint capsules, ligaments, disc, ant/post muscles, fx to odontoid process and SP, TMJ, sympathetic chain ganglia, spinal and cranial nerves

• Early = headaches, neck pain, limited flexibility, reversal of lower cervical lordosis and decrease in upper cervical kyphosis, vertigo, change in vision and hearing, irritability to noise and light, dysesthesias of face and B UEs, nausea, difficulty swallowing, and emotional lability
• Late = chronic head and neck pain, limitation in flexibility, TMJ dysfunction, limited tolerance to ADLs, disequilibrium, anxiety, and depression
• Common clinical findings = postural changes, excessive muscle guarding with soft tissue fibrosis, segmental hypermobility, and gradual development of restricted segmental motion, cranial and caudal to injury (segmental hypomobility)

• Plain film imaging
• CT scan
• MRI

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation
• Muscle relaxants
• TP injections
• Corticosteroid injection or by mouth

• Spinal manipulation generally indicated
• Correctional of muscle imbalances and biomechanical faults using strengthening, endurance, coordination, and flexibility exercises
• Joint mobs to correct joint restrictions
• Progression to functional training
• Pt education regarding elimination of harmful positions and postural reeducation
• Manual and/or mechanical traction (cspine at 15 degrees of flex, contraindicatiosn include joint hypermobility, pregnancy, RA, downs, and other systemic diseases that affect ligamentous integrity)

An abnormal increase in ROM at a joint due to insufficeint soft tissue control (i.e. ligamentous, discal, and/or muscle)

Plain film imaging (particularly dynamic flex/ext views)

• Acetaminophen for pain
• NSAIDS for pain and/or inflammation
• Muscle relaxants
• TP injections
• Sclerosing injections
• Corticosteroid injection or by mouth

• Pain reduction modalities to reduce irritability of structures
• Passive ROM within normal range of movement
• Passive stabilization with corsets, splints, casts, tape and collars
• Increase strength/endurance/coordination, especially in multifidus, abdominals, extensors, and gluteals (control posture)
• Regain muscle balance
• Pt education regarding postural reeducation, limiting excessive overloading, limiting sustained activities, and limiting end range postures

• Cause and specific pathology unknown
• Since this is a joint, it may become inflamed, develop degenerative changes, or develop abnormal movement patterns
• Anatomically and functionally, SIJ is closely related to lspine (thorough exam of both regions is indicated if pt presents with pain in either)

• Plain film imaging
• MRI
• Occasionally,, double-blind injectios may be used to assist in making the diagnosis (first injection is provocative in nature and second is analgesic) -- if increased "same" pain with 1st injectin and decreased pain followign second, joint is determined to be pathological
• Clinicial exam = Gillets test, Ipsilateral ant rotation test, Gaenslens test, Long-sitting (supine to sit) test, Goldthwaits test

• Acetaminophen for pain
• NSAIDs for pain and/or inflammation
• Muscle relaxants
• TP injections
• Corticosteroid injecton or by mouth

• Spinal manip such as SIJ gapping is generally indicated to inhibit pain, reduce muscle guarding, and resotre normal joint motion
• Correction of muscle imbalnaces throughout pelvis using strengthening, endurance, coordinaton, and flexibility exercises to gain restoration of normal function
• Joint mobs for joint restrctions
• Pt education on elimination of harmful positions and posrual reeducation
• SI bls may be useful in some patients

• Disorders of nerves, soft tissues, and bones precipitated or aggravated by repeated exertions or movements of the back, occuring most often in the workplace
• Repetitive trauma disorders account for 48% of all reported occupational diseases
• Diagnosis difficult, wth up to 85% of back pain nondiagnosed
• Typically causes one of the conditions previously listed above = muscle, disc, and/or joint impairment
• Intervention should focus on prevention, onsisting of education
• Vocational factors include physically heavy static work psotures, lifting, frequent bending and twisting, repetitive work and vibration

Chronic disability may be reduced by enrollment in a work-conditioning program (includes pt education, aerobic exercises, general strengthening, and functional stability exercises that promote endurance for work-related activity)

• May be primary or metastatic
• Primary: multiple myeloma (most common primary bone tumor), Ewing's sarcoma, malignant lymphoma, chondrosarcoma, osteosarcoma, and chondromas
• Metastatic: has primary sites in lung, prostate, breast, kidney, and thyroid
• Pt history should always include questios about prior episode of cancer
• Signs/symptoms = pain that is unvarying and progressive, not relived with rest or analgesics, and more pronounced at night

• Plain film imaging
• CT
• MRI
• Laboratory tests

• Esophageal cancer symptomatology may include pain radiating to the back, pain with swallowing, dysphagia, and weight lsos
• Pancreateic cancer symptomatology inclues deep, gnawing pain that may radiate from chest to back
• Diagnostic tests = plain film imaging, CT, MRI, Laboratory tests

• Acute pancreatitis: may manifest itself as mid-epigastric pain radiating through to the back
• Cholecystitis: may present with abrupt, severe, abdominal pain and R upper quadrant tenderness, nausea, vomiting and fever
• Diagnositc tests = plain film imaging, CT, MRI, laboratory tests

• Heart and lung disorder can refer pain to chest, back, neck, jaw, and UE
• Abdominal aortic aneurysm (AAA) usually appears as nonspecific lumbar pain
• Diagnostic tests = plain film imaging, CT, MRI, laboratory tests
• Will be identified as pain during examinatio of abdominal region

• Kidney, bladder, ovary, and uterus disorders can refer pain to trunk, pelvis and thighs
• Diagnostic tests = plain film imaging, CT, MRI, laboratory tests

• Common signs/symptoms = joint noise (clicking, popping, and/or crepitation), joint locking, limited flexibility of jaw, lateral devation of madible during depression or elevation, decreased strength/endurance of muscles of mastication, tinnitus, HA, forward head posture, and pain with movement of mandible
• C-spine must be thoroughly examined due to close biomechanical and functional relationships bewteen TMJ and cervical region
• Many pts with TMJ have a component of cervical dysfunction (3 categories)