Lumbar Spine, Pelvic, and Hip Injuries
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This is Chapter 26 from RC’s best-selling book:
Second Edition ~ Wiliams & Wilkins
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Chapter 26: LUMBAR SPINE, PELVIC, AND HIP INJURIES
The subluxation of lumbar facet structures, states Howe, is a part of all lumbar dyskinesias and must be present if a motor unit is deranged. In a three-point articular arrangement, such as at each vertebral motor unit, no disrelationship can exist that does not derange two of the three articulations. Thus, determination of the integrity or subluxation of the facets in any given motor unit is important in assessing that unit’s status.
Any method of spinographic interpretation which utilizes millimetric measurements from any set of preselected points is most likely to be faulty because structural asymmetry and minor anomaly is universal in all vertebrae. However, the estimation of the integrity of facet joints is a reliable method of assessing the presence of intervertebral subluxation. An evaluation of the alignment of the articular processes comprising a facet joint may be difficult from the A-P or P-A view alone when the plane of the facet facing is other than sagittal or semisaggital. In this case, oblique views of the lumbosacral area are of great value in determining facet alignment since the joint plane and articular surfaces can nearly always be visualized.
When one cannot visually identify disrelationships of the facet articular structures, Howe suggests use of Hadley’s S curve. This is made by tracing a line along the undersurface of the transverse process at the superior and bringing it down the inferior articular surface. This line is joined by a line drawn upward from the base of the superior articular process of the inferior vertebrae of the lower edge of its articular surface. These lines should join to form a smooth S. If the S is broken, subluxation is present. This A-P procedure can be used on an oblique view.
To help differentiate the low back and sciatic neuralgia of a facet syndrome to that of a disc that is protruding:
l. With the patient standing with feet moderately apart, the doctor from behind the patient firmly wraps his arms around the patient’s pelvis and firms his lateral thigh against the back of the patients’ pelvis. The patient is asked to bend forward. If it is a facet involvement, the patient will feel relief. If it is a disc that is stressed, symptoms will be aggravated.
2. In facet involvement, the patient seeks to find relief by sitting with feet elevated and resting upon a stool, chair, or desk. In disc involvement, the patient keeps knees flexed and sits sideways in his chair and moves first to one side and then to the other for relief. If lumbosacral and sacroiliac pain migrates from one to the other side, it is suspected to be associated with arthritic changes.
Lumbosacral instability is a mechanical aberration of the spine which renders it more susceptible to fatigue and/or subsequent trauma by reason of the variance from the optimal structural weight-bearing capabilities. Hariman states that between 50% and 80% of the general population exhibit some degree of the factors which predispose to instability whether by reason of anomalous development of articular relationships or altered relationships due to trauma or disease consequences. It is the most common finding of lumbosacral roentgenography and often brought to light after an athletic strain.
Disturbance of the physiologic response of the spinal motor unit is the primary finding with the sequela of “stress response syndrome” which may take the form of any degree between sclerosis of a tendon to and including an ankylosing hypertrophic osteophytosis or arthrosis. Frequent trauma to the articular structures as a result of excessive joint motility results in repetitive microtrauma. The scope of involvement and the tissue response is determined by the type and severity of the instability.
Signs and Symptoms. Unusual early fatigue is a constant symptom, and this leads to strain, sprain, and subsequent disc pathologies. Symptom susceptibility increases with the age of the individual. Postural evaluation is especially important in the physical diagnosis of the sequelae as well as to an extra-spinal causation (eg, anatomic short leg).
Roentgenographic Considerations. Roentgen diagnosis is the only sure manner of delineating the type and severity of the underlying productive agent of the condition of instability. There is no characteristic finding except the recognition of the various anomalies and pathologies present. Care should be taken to include the entire pelvis in this determination as, for instance, a sacroiliac arthrosis may lead to instability.
Management. This condition often requires supportive therapies such as heel lifts and/or orthopedic belts in addition to specific adjustive therapy directed toward stabilization of the motor unit. Hariman feels the prognosis is excellent with adjustive and supportive management. High doses of vitamin C with calcium and magnesium have also proved helpful in disc conditions. Efforts and counsel should be directed to minimize the production of future microtrauma. Loss of stability and compensation due to injury in the future may be expected to reproduce symptoms in an exaggerated form.
Basic Neurologic Aspects of Lumbar Subluxation Syndromes
Disturbances of nerve function associated with subluxation syndromes manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve or nerve root disorders, or of a reflex nature.
NERVE ROOT INSULTS
When direct nerve root involvement occurs on the posterior root of a specific neuromere, it manifests as an increase or decrease in awareness over the dermatome; ie, the superficial skin area supplied by this segment. Typical examples might include forminal occlusion or irritating factors exhibited clinically as hyperesthesia, particularly on the:
(1) anterolateral aspects of the leg, medial foot, and great toe, when involvement occurs between L4-L5; and
(2) posterolateral aspect of the lower leg and lateral foot and toes when involvement occurs between L5-S1.
In other instances, this nerve root involvement may cause hypertonicity and the sensation of deep pain in the musculature supplied by the neuromere; for example, L4 and L5 involvements, with deep pain or cramping sensations in the buttock, posterior thigh and calf, or anterior tibial musculature. In addition, direct pressure over the nerve root or distribution may be particularly painful.
Reflexes. Nerve root insults from subluxations may also be evident as disturbances in motor reflexes and/or muscular strength. Examples of these reflexes include the deep tendon reflexes such as seen in reduced patella and Achilles tendon reflexes when involvement occurs between L4-L5. These reflexes should also be compared bilaterally to judge whether hyporeflexia is unilateral; unilateral hyperreflexia is highly indicative of an upper motor neuron lesion.
Atrophy. Prolonged and/or severe nerve root irritation may also cause evidence of trophic changes in the tissues supplied. This may be characterized by obvious atrophy which would be rare in athletics. Such a sign is particularly objective when the circumference of an involved limb is measured at the greatest girth in the initial stage and this value is compared to measurements taken in later stages.
Kemp’s Test. While in a sitting position, the patient is supported by the examiner who reaches around the patient’s shoulders and upper chest from behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing his palm on his buttock and sliding it down the back of his thigh and leg as far as possible. The maneuver is similar to that used in cervical compression. If this compression causes or aggravates a pattern of radicular pain in the thigh and leg, it is a positive sign and indicates nerve root compression. It may also indicate a strain or sprain and thus be present when the patient leans obliquely forward or at any point in motion.
Since the elderly weekend athlete is less prone to an actual herniation of a disc due to lessened elasticity involved in the aging process, other reasons for nerve root compression are usually the cause. Degenerative joint disease, exostoses, inflammatory or fibrotic residues, narrowing from disc degeneration, tumors –all must be evaluated.
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