Spinal Hypermobility and Instability

• Vertebral body osteophyte formation due to Wolff's Law 
• "Osis" = diseased/abnormal condition
• Bone growth can interfere w/ exiting nerve root (stenosis)

• "Lysis" = loosening
• "Scotty dog with a collar"

• "Listhesis" = slippage
• "Scotty dog decapitated"

• I = 1-25% displacement
• II = 25-50% displacement
• III = 50-75% displacement
• IV = 75-100% displacement
• V = <100% (spondyloptosis)

Standing flexion radiograph: gold standard for diagnosis

• Occurs due to change in geometry of facets w/ severe degeneration
• Occurs w/o fracture
• Posterior arch encroaches on spinal cord (central cord compression)
• Females > 60 @ higher risk (due to spinal arthritis)

• Hypermobility syndrome
• Causes a defect in a glycoprotein involved in a variable expressed elastic connective tissue fibers
• Skin & dura excessively mobile, but hypo elastic
• Excessive growth of long bones t/o body
• Characteristically tall height, long limbs, large hands/feet, and narrow face
• Complications: lungs (pneumothorax), aorta (aneurysm), eyes (cataracts), scoliosis due to laxity

• a.k.a. Cutis hyperelastica
• A group of several inherited CT disorders related to a collagen synthesis abnormality
• Arterial dissection = most common cause of death

• Classical: skin involvement, ranges form mild to moderate

Joint hypermobility w/ less severe skin manifestations; joint instability and chronic musculoskeletal pain are prominent

Blood vessels and organs are fragile and prone to rupture; >80% develop life-threatening complications by age 40

Progressive A-P scoliosis, severe muscle weakness, fragile eyes, <60 cases reported

Extremely loose joints and dislocations, involves both hips, ~ 30 cases reported

Extremely fragile and sagging skin, only ~10 cases reported

• Classical
• Hypermobility
• Vascular
• Kyphoscoliosis
• Arthrochalasis
• Dermatosparaxis

• A group of genetic disorders affecting CT, specifically collagen
• Hallmarks: underdeveloped mid facial bones, various ocular problems, hearing loss, joint pain and hypermobility

• More common!
• Pain and generalized hypermobility in multiple joints w/o systemic rheumatologic disease
• Thought to be an inherited CT disorder
• May increase risk for joint injury
• Severity diminishes w/ age

• Can you put your hands and feet flat on the floor?
• Can you hyperextend your elbows?
• Can you hyperextend your knees?
• Can you put your thumb to your forearm?
• Can you bend your pinky back at least 90 degrees?

Threshold for joint laxity ranges from 4-6 points (not sufficient for a diagnosis of BJHS)

(for diagnosis of BJHS)

• Major criteria:
• Beighton score of at least 4/9
• Arthralgia for >3 months in >4 joints

• Minor criteria:
• Beighton score of 1-3
• Arthralgia on 1-3 joints
• History of joint dislocation
• >3 soft tissue lesions
• Marfan-like habits
• Skin striae, hyperextensibility, or scarring
• Eye signs, lid laxity
• History of varicose veins, hernia, visceral prolapse

Diagnosis: (at least) 2 major and 0 minor, 1 major and 2 minor, or 0 major and 4 minor

• RA
• Osteogenesis Imperfecta
• Systemic Lupus Erythmatosis
• Polio
• Down Syndrome
• Morquio Syndrome
• Cleidocranial Dysostosis
• Myotonia Congenita

• Neurological deficit
• Major deformity: gross deformity the pt finds intolerable
• Incapacitating pain: unable to be controlled by non-narcotic drugs

• Greater joint accessory motion (joint play)
• Greater joint angular ROM
• Larger neutral zone

• Loss of physiological motion
• Loss of accessory motion at the involved segment
• Increased pain at end range
• Tissue texture abnormalities
• Presence of positional faults

• Increased segmental mobility
• Full general spine mobility (may be limited if muscle guarding is present)
• Pain produced by prolonged stretch
• Muscle stiffness follows prolonged stretch (relieved by exercise/movement)
• Ligamentous tenderness in the accessible ligaments
• Joint predisposed to joint locking
• Aberrant motion/devation during ROM assessment
• Full flexion w/ difficulty returning to upright stance (knee flex/thigh climbing)
• Excelling but short-lived relief w/ manipulation
• Hx of trauma, w/ each onset becoming more trivial
• Frequent self-manipulators
• Difficulty holding head up

• Sacrum = keystone (of the tall arch)
• Gravity wedges sacrum between ilia
• Tightens SI ligaments (ant, post, deep)
• Force vector through femoral neck stabilizes the SIJ

• (muscle guarding) 
• Erector spinae
• Glut max
• Latissimus dorsi
• Biceps femoris
• Transverse abdominis
• Internal obliques

• Muscles spasm
• Increased muscle tone
• Increased subconscious attention
• Decreased threshold of recruitment