Spinal Hypermobility and Instability

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  1. Spondylosis
    • Vertebral body osteophyte formation due to Wolff's Law 
    • "Osis" = diseased/abnormal condition
    • Bone growth can interfere w/ exiting nerve root (stenosis)
  2. Spondylolysis
    • "Lysis" = loosening
    • "Scotty dog with a collar"
  3. Spondylolisthesis
    • "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
  4. Degenerative Spondylolisthesis
    • 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)
  5. Marfan Syndrome
    • 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
  6. Ehlers-Danlos Syndrome (EDS): Definition
    • 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
  7. Ehlers-Danlos Syndrome: Classical Type
    • Classical: skin involvement, ranges form mild to moderate
  8. Ehlers-Danlos Syndrome: Hypermobility Type
    Joint hypermobility w/ less severe skin manifestations; joint instability and chronic musculoskeletal pain are prominent
  9. Ehlers-Danlos Syndrome: Vascular Type
    Blood vessels and organs are fragile and prone to rupture; >80% develop life-threatening complications by age 40
  10. Ehlers-Danlos Syndrome: Kyphoscoliosis Type
    Progressive A-P scoliosis, severe muscle weakness, fragile eyes, <60 cases reported
  11. Ehlers-Danlos Syndrome: Arthrochalasis Type
    Extremely loose joints and dislocations, involves both hips, ~ 30 cases reported
  12. Ehlers-Danlos Syndrome: Dermatosparaxis Type
    Extremely fragile and sagging skin, only ~10 cases reported
  13. Ehlers-Danlos Syndrome: Types (6)
    • Classical
    • Hypermobility
    • Vascular
    • Kyphoscoliosis
    • Arthrochalasis
    • Dermatosparaxis
  14. Stickler Syndrome
    • A group of genetic disorders affecting CT, specifically collagen
    • Hallmarks: underdeveloped mid facial bones, various ocular problems, hearing loss, joint pain and hypermobility
  15. Benign Joint Hypermobility Syndrome
    • 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
  16. Beighton Hypermobility Scale
    • 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)
  17. Brighton Criteria
    (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
  18. Other Conditions Associated w/ Joint Hypermobility
    • RA
    • Osteogenesis Imperfecta
    • Systemic Lupus Erythmatosis
    • Polio
    • Down Syndrome
    • Morquio Syndrome
    • Cleidocranial Dysostosis
    • Myotonia Congenita
  19. Clinical Instability (based on surgeon's perspectives)
    • Neurological deficit
    • Major deformity: gross deformity the pt finds intolerable
    • Incapacitating pain: unable to be controlled by non-narcotic drugs
  20. Lax ligaments allow:
    • Greater joint accessory motion (joint play)
    • Greater joint angular ROM
    • Larger neutral zone
  21. Intervertebral Hypomobility
    • Loss of physiological motion
    • Loss of accessory motion at the involved segment
    • Increased pain at end range
    • Tissue texture abnormalities
    • Presence of positional faults
  22. Intervertebral Hypermobility
    • 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
  23. Form Closure (standing/kneeling)
    • 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
  24. Stabilization via the Active Subsystem: Force Closure
    • (muscle guarding) 
    • Erector spinae
    • Glut max
    • Latissimus dorsi
    • Biceps femoris
    • Transverse abdominis
    • Internal obliques
  25. Neural Stabilization
    • Muscles spasm
    • Increased muscle tone
    • Increased subconscious attention
    • Decreased threshold of recruitment
Card Set:
Spinal Hypermobility and Instability
2014-02-13 16:05:37
Spinal Hypermobility Instability
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