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CLINICAL SUPPLEMENT: BACK - 2011 Herniated Nucleus Pulposus (HNP): 1. Disk herniations usually occur in posterolateral direction. The posterior direction is caused by loading of the spine and thinner posterior aspect to annulus fibrosis. The lateral direction is caused by the shape of the posterior longitudinal ligament which prevents direct posterior herniations in most cases. 2. Herniations usually affect the nerve exiting at the level of the disk herniation in the cervical and thoracic spine – C4/5 disk herniation will affect C5 nerve root, T1/2 disk herniation will affect T1 nerve root. 3. Herniations at lumbar disk levels do not usually affect the nerve exiting directly at that level because of the angle and position of exit of these nerves as they exit directly beneath the pedicle they essentially escape injury by the HNP. The nerve level that is usually affected is one level lower – L4/5 disk herniation will affect L5 nerve root, L5/S1 disk herniation will affect S1 nerve root. (see Relation of Spinal Nerve Roots to Vertebrae image in Netter’s Atlas) Spondylolysis/Spondylolisthesis: 1. Pars interarticularis is the region of the vertebra between the superior and inferior articular processes that make up the zygapophysial or facet joints. The pars interarticularis is on the lamina of the lumbar vertebrae and pedicle of the cervical vertebrae. 2. A unilateral fracture or defect in pars interarticularis = spondylolysis; A bilateral fracture or defect in both pars articularis = spondylolisthesis and is usually accompanied by forward translation (slippage) of the vertebral elements above the defects over the elements below the defects. (Please note, the wording of this latter term on p.85 of your text is somewhat misleading…rely on the definition given herein) Innervation of intervertebral disk/zygapophysial joint: Disk – sinuvertebral nerve from ventral ramus recurrent branch Joint – dorsal rami nerves Spinal cord ends at L1/2 vertebral level. Dural sac ends at S1/2 vertebral level. Innervation of suboccipital muscles via suboccipital nerve (posterior/dorsal ramus C1). Petit’s Hernia – lumbar hernia in lumbar (Petit’s) triangle. Spinal stenosis: narrowing of vertebral canal housing spinal cord, due to pathology in hypertrophied ligamentum flavum, or facet (zygapophysial) joint disease/degeneration. Typical symptoms – bilateral extremity pain and/or numbness, weakness. Scoliosis – pathological lateral bending of vertebral column Kyphosis – pathological excess of normal (primary) curvature seen in thoracic spine (hunchback). Lordosis – pathological excess of normal lordotic lumbar (secondary) curvature (swayback). MUSCLE STRENGTH TESTING GRADATION CHART MUSCLE GRADATIONS 5 = normal 4 = good 3 = fair 2 = poor 1 = trace 0 = zero DESCRIPTION (ROM=range of motion) Complete ROM against gravity with full resistance Complete ROM against gravity with some resistance Complete ROM against gravity Complete ROM against gravity eliminated Evidence of slight contraction, no joint movement No evidence of contraction, no joint movement REFLEX GRADING CHART (reported as 1/4, 2/4…) Grading Scale Description 0 1 2 3 4 Absent Hypoactive Normal Hyperactive without clonus Hyperactive with clonus Nerve Root Diagnostic Testing: C5: Motor – deltoid muscle, biceps brachii muscle Reflex – biceps brachii muscle tendon Sensory – lateral shoulder (skin over deltoid) and lateral arm C6: Motor – biceps brachii muscle, wrist extension Reflex – brachioradialis muscle tendon Sensory – lateral forearm, lateral palm including first digit and possibly second digit C7: Motor – triceps brachii muscle, wrist flexion Reflex – triceps brachii muscle tendon Sensory – middle finger C8: Motor – finger flexion Reflex – none Sensory – fifth digit and medial forearm, possibly 4th digit also T1: Motor – finger adduction/abduction Reflex – none Sensory – medial arm L4: Motor – tibialis anterior muscle Reflex – patellar tendon Sensory – medial leg, medial aspect foot including medial malleolus L5: Motor – extensor hallucis longus muscle, extensor digitorum longus; (walk on heels) Reflex – tibialis posterior muscle tendon Sensory – dorsum of foot S1: Motor – fibularis longus muscle, (walk on toes) Reflex – calcaneal (Achilles) tendon Sensory – lateral aspect foot