Spine Pathology
Dr Salameh Al dajah
Dr. Salameh Al Dajah 2014
Learning Objectives
• Identify spine anatomy related to spine
pathology
• Recognize intervertepral disc anatomy
(IVD)
• Recognize different spine pathology seen
by PT
• Recognize special test for different spine
pathology
• Perform treatment plans for different spine
pathology
Dr. Salameh Al Dajah 2014
Pathology of the spine
Introduction
The lumbar spine functions as a complex interplay
of musculoskeletal and neuro-vascular structures
creating a mobile, yet stable, transition between the
thorax and pelvis. The lumbar region repetitively
sustains enormous loads throughout one’s life time,
while still providing the mobility necessary to allow a
person to perform multi-tasks associated with daily
living. In addition, the lumbar spine provides the
fibro-osseous pathway for the inferior portion of the
spinal cord
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Classification of disorders of the
low back
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Congenital abnormality
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Deformities
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Lumbar vertebrae variation (anomalies)
Hmivertebra
Spinabifida
Scoliosis
Hyperlordosis
Kyphosis
Infections of bone
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Tuberculosis
Pyogenic infection
Dr. Salameh Al Dajah 2014
•
Arthritis of the spine
– RA
– OA
– Ankylosing spondylitis
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Osteochondritis (the cartilage or bone in a joint is inflamed)
– Scheurman’s disease
Dr. Salameh Al Dajah 2014
•
Mechanical derangements
– Prolapsed lumbar Intervertebral disc (IVD)
– Acute lumbago(disorder involving the muscles and bones)
– Spondylolysis(defect in the pars interarticularis of the
vertebral arch)
– Spondylolisthesis
– Spinal stenosis(narrowing of spinal canal)
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Tumors
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Spondylolisthesis
Dr. Salameh Al Dajah 2014
•
Chronic strains
– Lumbar ligamentus strain
– Coccydynia, (pain in the coccyx)
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Miscellaneous
– Fibrositis
– Senile osteoporosis
Dr. Salameh Al Dajah 2014
Pathology
• Hemi vertebra
• In this anomaly a vertebra is formed in one
lateral half only. The defect may occur at
any level of the spine. The body of the half
–vertebra is wedge-shaped, and the spine
is angled laterally at the site of the defect.
This anomaly is a rare cause of scoliosis.
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Spina bifida
The basic fault in spina bifida is a failure
of the embryonic neural plate to fold
over to form a closed neural tube, or of
mesodermal tissue fully to invest the
neural tube as it does in the normal
embryo to form the vertebral arch with
its spinous process, and the
surrounding muscles and ligaments.
Dr. Salameh Al Dajah 2014
Scoliosis
• Scoliosis, or lateral curvature of the
spine, may be
• idiopathic,
• congenital,
• neuromuscular in origin. Idiopathic
scoliosis is responsible for 85-95% of
all cases of scoliosis. It is classified
either structural or nonstructural
(temporary or compensatory).
Dr. Salameh Al Dajah 2014
• Nonstructural curves are flexible and
readily correct with side bending.
• It is may be due underlying disorder or a
result of muscle spasm due low back pain
• The diagnosis will be made by general
physical examination to the alignment of
the spine (Adam’s positions),
• and confirmed by standing plain x-ray film.
The spine may appear in S or C shape.
Dr. Salameh Al Dajah 2014
• When the scoliotic curvature disappears in
the adam’s position, the curves are mild to
moderate, or less than 25 degrees. These
curves have more of functional
components than structural component
and are amenable to conservative
management.
Dr. Salameh Al Dajah 2014
Treatment
• 1. Surgical
• 2. Conservative: this form of management utilize
therapeutic exercises and braces
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A. stretching exercise
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B. Mobility exercise
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C. Postural training
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D. Breathing and chest expansion training
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E. Use braces like Milwaukee distraction
brace
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Hyper Lordosis
• Para vertebral Muscle spasm
• Tightness of hamstring
• Weakness of the lower abdominal muscles
Dr. Salameh Al Dajah 2014
Lordosis
Dr. Salameh Al Dajah 2014
Ankylosing spondylitis
• This is a condition affects spinal column in
all three regions.
• There is a chronic inflammation
progressing slowly to bony ankylosis of the
joints of the spinal column and
occasionally of the major limb joints.
• It is a flexion deformity in the spinal
column.
• Usually start at the sacroiliac joint
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Complications
• Permanent stiffness
• Fixed flexion deformity of the spine
• Recurrent respiratory infection
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Special test
• Most effective method for diagnosis is
through assessing spine ROM and by Xray,
• A calcification connection between the
vertebrae will be noted in the X-ray.
Dr. Salameh Al Dajah 2014
Treatment
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Treat the symptoms (localized pain)
Maintain activity
encourage extension exercise
Active and positioning exercise to stretch
shortened anterior ligaments
• Hydrotherapy may be the best modality followed
by extension exercise
• In addition, patient need Non-steroidal anti
inflammatory drugs prescribed by his doctor
Dr. Salameh Al Dajah 2014
Scheuermann’s vertebral
Osteochondritis
• The vertebral bodies ossify from three
centers. A primery center at the middle of
the vertebral body, and secondary centers
at the upper and lower surfaces. These
secondary centers, known as the ring
epiphyses, appear at about the time of
puberty in the cartilaginous end-plates that
separate the vertebral bodies from the
adjacent intervertebral disc.
Dr. Salameh Al Dajah 2014
Diagnosis and Treatment
• Diagnosis by X-ray and history of the
symptoms
• Treatment may include
• Rest to avoid stress fracture of the
vertebral body
• Braces to protect the affected segments
• Strengthening exercises for the back
muscle (extension exercises)
Dr. Salameh Al Dajah 2014
Lumbar Intervertebral disc prolapse
• The Intervertebral disc is the source of most low
back pain.
• Of disc lesions in the lumbar spine, 95% occur at
the fourth and fifth spaces.
• With normal aging and repetitive trauma,
progressive degeneration of the nucleus pulpous
occurs.
• The disc protrusion of a young adult is likely to
be traumatic.
• Protrusion of nuclear material usually occurs in
the area of greatest weakness at the posteriorlateral aspect of the disc
Dr. Salameh Al Dajah 2014
• If the protrusion at the midline, roots on both
sides may be involved If it is large enough,
• the compression may affect on the cauda
equine.
• Pain in the segmental distribution of a root is the
hall-mark of root compression syndrome.
• Pain in the spine and restriction of spinal
movement are common
Dr. Salameh Al Dajah 2014
• Pain that radiates down the leg follows the
primary anterior division of the nerve
• and may be localized by the patient anywhere in
the distribution of the root.
• This root pain is aggravated by spinal
movement, like rolling in the bed.
• Pain is also aggravated by local pressure over
the nerve or the muscle and after prolonged
sitting.
• Parasthesia in root distribution is common and
usually experienced distally in the foot.
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Treatment
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Muscle relaxing through different modalities
Extension exercise (Meckinzy exercise)
Postural training
Limit the extension exercise if there is a facet joint (Z
Joint) involvement
Instruct patient to limit his sitting posture and encourage
walking
Patient may benefit from hydrotherapy
Patient may benefit from strengthening of the back
muscles
Avoid manipulation in the acute stage
Bed rest may help at the acute stage
Advise patient when he lies down to bend the hip and
knees to keep the Dr.
back
muscle relaxed.
Salameh Al Dajah 2014
Spondylolisthesis
• Congenital Spondylolisthesis consist of
structural anomalies of the lumbo-sacral junction
resulting in inadequate mechanical support to
prevent forward slipping of L5 on S1 vertebra.
• It may be due traumatic fracture of the spinous
process of L5 as a result of a fall from a height
or due degenerative changes involved the facet
joint and the disc material.
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Treatment
• Hydrotherapy to improve muscle spasm
• Abdominal strengthening exercise (William
flexion exercise)
• Avoid spine extension exercise or
activities involving extension
Dr. Salameh Al Dajah 2014
Cirvical Spine
Assessment and management for
cervical spine conditions
Dr. Salameh Al Dajah 2014
Cervical rib
• It is a congenital overdevelopment of the
costal process of the seventh cervical
vertebra
• The subclavian artery and the lowest
trunks of brachial plexus arch over the first
rib, and may be squeezed and damaged.
The motor symptoms may include
Dr. Salameh Al Dajah 2014
Pathology
• The subclavian artery bends over and passes
through a sulcus in the first rib.
• Brachial plexus lies stretched and lies tautly
without bony protection in this region.
• Anterior scalene syndrome and the
costoclavicular syndrome (cervical rib)
compression are two conditions recognized as
thoracic outlet syndrome.
• X -ray is essential to determine the presence of
the cervical rib, but it is not a prove that it is the
cause of the symptoms.
Dr. Salameh Al Dajah 2014
Symptoms
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weakness of the hand muscle
Inability to perform fine movement
Numbness at the lateral side of the hand and
forearm
Vascular manifestation ranges from cyanosis
of the forearm to gangrene in the hand
Sensory disturbances can occur in either a
dermatome distribution or in the destruction of
the peripheral nerves are suspected
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Cervical spondylosis
Assessment
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History (increasing neck pain, may radiating to
the upper extremities)
Observe the neck posture (head forward,
rounded shoulders)
Palpation (M. Spasm, Swelling, Dislocation)
ROM
MMT
Neurological tests
Special tests
Dr. Salameh Al Dajah 2014
• Muscle spasm: It comes with any
abnormality in the neck. It is a protective
reaction
• Indicated in X ray (Lateral view) by
straightening of the spine and diminished
the C curve in the neck. It causes
limitation in all ROM, especially with
rotation, flexion and hyper extension.
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Cervical disc prolapse
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General appearance
Assessment
Palpation
Radiating pain, and numbness to the
upper extremities
• Findings (AROM, MMT, Neurological
tests, and special test
Dr. Salameh Al Dajah 2014
Three levels of disc disease
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Normal disc
protrusion/ prolapse
Extrusion
Sequestration
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Special tests
• Distraction test: Test for foramin
encroachment and facet capsulitis
• Jackson compression test: Test for nerve
root compression, space occupying
lesions, DJD
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Jackson test procedure
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dejerine’s sign Procedure
• Coughing, sneezing, and straining during
defecation may aggravate radiculitis
symptoms
• This aggravation results from the
mechanical obstruction of spinal fluid flow
Dr. Salameh Al Dajah 2014
Treatment plan
• Muscle relaxation (modalities, isometric
exercises),
• May use cervical traction and postural
training,
• May involve manual mobilization if there is
no osteophite
• May use cervical soft collar
Dr. Salameh Al Dajah 2014
Treatment plan For Disc
prolaps: may include

Muscle relaxation to Include
• Intermittent traction in neutral position (manual or
mechanical)
• Modalities (hot pack, US, IF, TENS, Use what is
available)
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Muscle strengthening and ROM to
• Retain mobility (AROM to ARROM, isometric exercise, )
• At the beginning use hard cervical collar
• Encourage patient to use suitable pillow when sleep
Dr. Salameh Al Dajah 2014
Vertebral artery insufficiency
• Pathology
• Cervical muscle spasm cause neck
straitening, which results in stretching and
narrowing of the vertebral artery and
decrease the blood flow to the posterior
parts of the brain
Dr. Salameh Al Dajah 2014
Symptoms
• Main complaint will include headache and
dizziness in addition to the pain in the
neck and upper trapezius due muscle
spasm.
• X ray shows neck straightening at the level
of C4-C7 due the muscle spasm
Dr. Salameh Al Dajah 2014
Special tests
• Barre-Lieou sign
• Deklyn’s
Dr. Salameh Al Dajah 2014
Barre-Lieou sign
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The examiner instructs the patient to slowly rotate the
head from side to side while in seated position, or
supine with the head extended out of the table
(Hallpike maneuver) This maneuver will cause
compression of the vertebral arteries
Vertigo, dizziness, visual disturbances, nausea,
syncope, and nystagmus are signs of positive test
A positive findings strongly indicate a buckling of the
ipsilateral vertebral artery
Dr. Salameh Al Dajah 2014
Dekleyn’s test procedure
• With the patient in the supine position and the
patient head off the table, the examiner instruct
patients to hyperextend and rotate the head and
hold this position for 15-45 seconds, repeat this
maneuver to the other side
• Vertigo, blurred vision, nausea, syncope, and
nystagmus are signs of positive test
Dr. Salameh Al Dajah 2014
Treatment plan: may include
• Modalities for muscle relaxation
• Retain C curve By using special pillow, and
extension mobilization for C4-C7
• Avoid traction
• Manual mobilization to retain neck extension
(normal posture)
• No need for cervical collar
• Encourage AROM, and isometric neck exercise
(extension > flexion)
Dr. Salameh Al Dajah 2014
Brachial plexus tension test
• The examiner passively elevate the patient’s shoulders
through abduction
• the elbows are extended to a point just short of the onset
of pain and are maintained in that position
• The shoulders are externally rotated to the point just
short of the onset of pain and maintained
• Reproduction of symptoms suggests cervical spine
disorders, most likely C5 nerve root
• When flex cervical spine from this position, symptoms
will increase
Dr. Salameh Al Dajah 2014
Bikele’s sign
Procedure
• With the arm held upward and backward and the
elbow fully flexed, the patient extends the elbow
• If such movement meets with resistance and
increases ridiculer pain from the cervicodorsal
region, the test is positive
• This sign indicate there is brachial plexus
neuritis or meningitis because this maneuver
stretches the brachial plexus nerve roots
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Cervical muscles,and ligament
Pathology
• Wrhy neck: Derangement of the cervical facet joints as
a result of sudden movement or sleeping on wrong
position. The symptoms may last 3-4 days
• Whiplash: sudden and fast neck movement forward and
backward (acceleration and deceleration), which may
cause ligamentus and muscles strains or sprains.
Symptoms may last for weeks and may worsen. It may
cause acute c. disc prolaps. This is seen mostly in head
to tail Car accidents.
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Five levels of neck Muscles and
ligaments injuries
Dr. Salameh Al Dajah 2014