Title: Bone Wizardry / OMM Mastery / 4.Lumbar Spine
Tags: #BW_OMM::Region::Lumbar #BW_OMM::Type::Cloze BoneWizardry bonewizardry-free omm omt #Lumbar #Anatomy #Facet #Muscles #PsoasSyndrome #Mechanics #SpinaBifida #Appendicitis #CaudaEquinaSyndrome #Disc #Fergusons #Herniated #L5 #LumbosacralAngle #Nerve #ReviewQuestions #SpinalStenosis #Spondylolisthesis #Spondylolysis #Treatment
On every note of this deck, unless a note says otherwise:
Topic: Lumbar Spine
Review Links: - Bone Wizardry lumbar dysfunctions
- Practice: Lumbar Spine QBank
Show outside sources
- MET for low back pain
- MET for pelvic dysfunction
- AAFP acute low back pain

Q: The lumbar spine has [...] vertebrae. Their broad, quadrangular spinous processes make them easy to identify on plain film or at the table.
A: five
Bone Wizardry Lock: Fryette is a mechanics shortcut, not a chant. Neutral groups rotate and sidebend opposite; non-neutral single segments rotate and sidebend same.

Q: Lumbar vertebral bodies are built wide to handle primarily [...] compressive loads from the weight above.
A: longitudinal
Q: The posterior longitudinal ligament runs [...] down the back surface of the vertebral bodies inside the canal.
A: vertically
Q: By the time it reaches L4-L5, the posterior longitudinal ligament is half the width it measures at [...].
A: L1
Q: That lateral thinning leaves the posterolateral disc poorly covered, making the lumbar levels prone to [...].
A: disc herniations
Comment 2: This ligament begins to narrow at the lumbar region.
Comment 3: The narrowing means the posterolateral disc wall gets less support from L1 down to L5. Most lumbar herniations track posterolaterally for this reason.
Bone Wizardry Lock: Fryette is a mechanics shortcut, not a chant. Neutral groups rotate and sidebend opposite; non-neutral single segments rotate and sidebend same.

Q: In the thoracic and lumbar region a nerve root will exit the intervertebral foramen [...] its corresponding vertebrae
A: below
Q: The L4 nerve root will exit the spinal column [...] L4 and L5.
A: between
Q: The spinal cord usually terminates between [...] and [...].
A: L1; L2
Comment: For example, the L4 nerve root will exit the spinal column between L4 and L5.
Comment 3: Descending nerve roots grow progressively longer before reaching their exit. By the lumbar levels they emerge near the top of the foramen, just above the disc.
Bone Wizardry Lock: The cord ends at L1-L2. Below that, roots travel to reach their foramen one level below their number. L4 exits between L4 and L5. That offset is why a disc at L3-L4 hits the L4 root, not L3.

Q: The erector spinae group is made up of what muscles?
1. [...]
2. [...]
3. [...]
A: Spinalis; Iliocostalis; Longissimus
Bone Wizardry Lock: Three columns, lateral to medial: Iliocostalis, Longissimus, Spinalis. ILS or SIL - pick your mnemonic. The lateral column runs from ilium to ribs; the medial hugs the spinous processes.

Q: What muscle is the primary flexor of the hip?
[...]
A: Iliopsoas
Q: A positive [...] test is commonly seen with iliopsoas dysfunctions
A: Thomas
Q: The L4-L5 intervertebral disc is near the level of the [...] crests
A: iliac
Q: [...] intervertebral disc are at the level of the iliac crest
A: L4-L5
Q: T10 dermatome at the [...], is anterior to the L3 and L4 intervertebral disc.
A: umbilicus
Q: T10 dermatome at the umbilicus, is anterior to the [...] and [...] intervertebral disc.
A: L3; L4
Bone Wizardry Lock: The iliac crest sits at L4-L5. The Thomas test catches iliopsoas tightness by flattening the lumbar lordosis - the hip that stays flexed cannot compensate anymore. T10 dermatome at the umbilicus puts you anterior to L3-L4.

Q: In facet [...], lumbar facet joints are more closely aligned to the coronal plane.
A: tropism
Q: In facet tropism, lumbar facet joints are more closely aligned to the [...] plane.
A: coronal
Comment: Normal lumbar facets orient posteriorly and medially in the sagittal plane. Tropism shifts them toward the coronal plane, loading the disc asymmetrically and predisposing to facet and disc degeneration. Patients typically report one-sided low back pain that worsens with bending or twisting.
Bone Wizardry Lock: Normal lumbar facets run sagittally (posterior and medial). Tropism shifts them toward the coronal plane, creating unequal loading across the disc. That asymmetry is the link to spondylolisthesis and facet degeneration.

Q: What is considered the most common anomaly in the lumbar spine?
[...]
A: Facet tropism
Q: [...]- a bony deformity in which one or both of the transverse processes of L5 are long and articulate with the sacrum
A: Sacralization
Q: Sacralization- a bony deformity in which one or both of the transverse processes of [...] are long and articulate with the sacrum
A: L5
Comment: This may also predispose to early degenerative changes
Comment 2: About 3.5% of the population has sacralization. That structural fusion alters load distribution and accelerates disc degeneration at the L4-L5 level.
Bone Wizardry Lock: Facet tropism leads lumbar anomalies. After that, sacralization (L5 fusing to sacrum) is more common than lumbarization (S1 separating). Both disrupt lumbosacral mechanics and hasten degeneration at the junction.

Q: [...] - most often occurs from the failure of fusion of S1 with the other sacral segments.
A: Lumbarization
Q: Lumbarization - most often occurs from the failure of fusion of [...] with the other sacral segments.
A: S1
Q: Which is more common, Sacralization or Lumbarization?
[...]
A: Sacralization
Comment: Sacralization is more common than lumbarization. Both are transitional anomalies at L5-S1 that can alter pelvic mechanics and load distribution.
Bone Wizardry Lock: Two opposite failures at L5-S1: sacralization adds a lumbar-level segment to the sacrum; lumbarization frees S1 to act like a lumbar vertebra. Sacralization runs more common. Both shift lumbosacral mechanics.

Q: [...] - a developmental defect in which the posterior vertebral arch fails to close, leaving the lamina open.
A: Spina Bifida
Bone Wizardry Lock: Spina bifida is failed closure of the posterior arch. The clinical impact depends entirely on what protrudes through that gap - nothing, meninges, or meninges plus cord.

Q: Spina bifida [...] - the arch fails to close but nothing herniates. The typical clue is a patch of coarse hair over the defect site.
A: occulta
Q: Spina bifida [...] - meninges herniate through the open arch, but the cord stays in the canal.
A: meningocele
Q: Spina bifida [...] - both meninges and nerve roots herniate through the defect, producing neurological involvement.
A: meningomyelocele
Comment: Rarely associated with neurological deficits.
Comment 3: Associated with neurological deficits.
Bone Wizardry Lock: Think by what herniates: occulta (nothing, just a hairy patch), meningocele (meninges only, cord intact), meningomyelocele (meninges plus roots, expect neuro deficits). Severity tracks content.

Q: The major motion of the lumbar spine is [...] and [...]
A: flexion; extension
Bone Wizardry Lock: Lumbar facets sit in the sagittal plane, which allows flexion and extension but blocks significant rotation. That is why lumbar rotation injuries are usually disc problems, not facet glides.

Q: Sidebending of L5 will cause a sacral oblique axis to be engaged on the [...] side.
A: same
Q: Sidebending of [...] will cause a sacral oblique axis to be engaged on the same side.
A: L5
Q: Rotation of L5 will cause the sacrum to rotate toward the [...] side.
A: opposite
Q: Rotation of [...] will cause the sacrum to rotate toward the opposite side.
A: L5
Comment: L5 rotation carries the sacrum the opposite direction. Keep sidebend and rotation in separate buckets - they drive sacral motion in opposite relational directions.
Comment 3: L5 sidebend pulls the sacral oblique axis to that same side, setting up the axis the sacrum will rotate around.
Bone Wizardry Lock: L5 and sacrum: sidebend pulls the oblique axis to the same side; rotation sends the sacrum the opposite way. Same-side axis, opposite-side sacral rotation - track them separately or you will mix them up.

Q: The lumbosacral angle is formed by the intersection of a [...] line and the line of [...] of the sacrum.
A: horizontal; inclination
Q: The lumbosacral angle is normally between [...]° and [...]°
A: 25; 35
Q: An increase in Ferguson's angle causes a [...] stress placed on the lumbosacral joint, often causing low back pain.
A: shear
Q: An [...] in Ferguson's angle causes a shear stress placed on the lumbosacral joint, often causing low back pain.
A: increase
Comment: Also called Ferguson's angle. Normal range is 25 to 35 degrees. Above that range, the sacrum tips forward and axial load becomes shear.
Bone Wizardry Lock: Ferguson's angle normal range: 25 to 35 degrees. Increase it and vertical load at the lumbosacral joint converts to shear. That shear is the mechanism behind lumbosacral low back pain from increased lordosis.

Q: A herniated disc in the lumbar region will exert pressure on the nerve root of the vertebrae [...].
A: below
Q: A herniated disc typically presents with numbness, tingling, or shooting pain that radiates down the [...]
A: leg
Q: A herniated disc will have a positive [...] test
A: straight leg raise
Q: The gold standard to diagnose a herniated disc is an [...]
A: MRI
Q: Herniated disc may be treated initially with [...] techniques, followed by gentle [...].
A: indirect; direct
Q: [...] is relatively contraindicated in patients with herniated disc
A: HVLA
Comment: For example, a herniation between L3 and L4 will affect the nerve root of L4
Bone Wizardry Lock: Lumbar disc herniates posterolaterally and hits the root exiting one level below. Straight leg raise confirms it. Start OMT indirect, then gentle direct once acute phase settles. HVLA is relatively contraindicated.

Q: [...] syndrome: a flexion contracture of the iliopsoas that develops when prolonged postures keep the muscle in a shortened position.
A: Psoas
Q: Psoas syndrome: a [...] contracture of the iliopsoas that develops when prolonged postures keep the muscle in a shortened position.
A: flexion
Bone Wizardry Lock: Psoas syndrome is posture-driven: the hip flexor locks short from sustained positions like prolonged sitting. The high lumbar flexion somatic dysfunction you find above it is a downstream consequence.

Q: What is the number 1 organic cause of psoas syndrome?
[...]
A: Appendicitis
Comment: Organic causes include:
1. Appendicitis
2. Sigmoid colon dysfunction
3. Ureteral calculi
4. Ureter dysfunction
5. Metastatic carcinoma of the prostate
6. Salpingitis
Bone Wizardry Lock: When a patient has psoas syndrome without a mechanical trigger, think viscera. The psoas runs adjacent to the appendix, right ureter, sigmoid, and pelvic organs. Appendicitis tops the organic list because of that anatomical proximity.

Q: Counterstrain to the anterior [...] tenderpoint is very effective for psoas syndrome followed by muscle energy or HVLA to the high lumbar dysfunction.
A: iliopsoas
Comment: Stretching an acute psoas spasm may cause it to further spasm. Only stretch chronic psoas spasms.
Bone Wizardry Lock: Lead with counterstrain to calm the acute spasm before anything else. Stretching an acute psoas spasm makes it contract harder. Once the tenderpoint releases, follow up with MET or HVLA at the high lumbar dysfunction.

Q: [...]: narrowing of the spinal canal or intervertebral foramina, usually from degenerative changes, that crowds the nerve roots and less often the cord itself.
A: Spinal Stenosis
Q: Spinal stenosis location of pain is usually [...] back to [...] leg/legs
A: low; lower
Q: Pain caused by spinal stenosis is worsened by [...], such as when standing, walking or lying supine.
A: extension
Q: Radiology of spinal stenosis will have [...] and decreased intervertebral disc space
A: osteophytes
Q: Radiology of spinal stenosis will have osteophytes and [...] intervertebral disc space
A: decreased
Q: If conservative therapies are not effective in treating spinal stenosis, an [...] injection may be used.
A: epidural steroid
Comment: Pathogenesis: Degenerative changes in the lumbar spine can include:
1) Hypertrophy of the facet joints.
2) Calcium deposits within the ligamentum flavum and the posterior longitudinal
ligament.
3) Loss of intervertebral disc height.
Comment 6: Surgical laminectomy with decompression is indicated if above fails
Bone Wizardry Lock: Stenosis narrows the channel the roots run through. Extension closes it further, which is why these patients lean forward and feel better sitting. Epidural steroids are the next step when conservative care fails; laminectomy follows if those do not work.

Q: [...]: anterior slippage of one vertebral body relative to the vertebra below it.
A: Spondylolisthesis
Q: Spondylolisthesis: [...] slippage of one vertebral body relative to the vertebra below it.
A: anterior
Q: Which lumbars are most susceptible to spondylolisthesis?
[...] or [...]
A: L4; L5
Q: Pain due to spondylolisthesis is often felt in the low [...], [...] and/or posterior [...]
A: back; buttock; thigh
Q: Pain due to spondylolisthesis is often increased with [...]-based activities
A: extension
Q: HVLA is [...] in cases of spondylolisthesis
A: contraindicated
Comment 3: Usually due to fatigue fractures in the pars interarticularis of the vertebrae
Comment 6: Most can be managed with conservative management (weight loss, avoid wearing high heels, and avoid flexion based exercises).
The goal of manipulation is to reduce lumbar lordosis and somatic dysfunction.
Bone Wizardry Lock: HVLA is off the table when a vertebra has already slipped forward. L4 and L5 are the most common levels, usually from pars interarticularis fatigue fractures. Manage conservatively: reduce lordosis, avoid high heels, and avoid flexion-based exercise.

Q: [...]: a stress fracture or defect, usually at the pars interarticularis, with no anterior displacement of the vertebral body.
A: Spondylolysis
Q: Spondylolysis: a stress fracture or defect, usually at the [...], with no anterior displacement of the vertebral body.
A: pars interarticularis
Q: Since [...] lumbar x-rays will not reveal any slippage with spondylolysis, [...] views will identify the fracture of the pars interarticularis.
A: lateral; oblique
Q: Diagnose:
1. Spondylolisthesis with [...] x-rays
2. Spondylolysis with [...] x-rays
A: lateral; oblique
Comment: Symptoms and treatment are similar to spondylolisthesis.
Bone Wizardry Lock: Spondylolysis is the crack; spondylolisthesis is the slip. Both look alike clinically. The imaging distinction is the boards hook: lateral X-ray catches the slip, oblique views catch the pars defect.

Q: Patient presents with the complaint of saddle anesthesia, decreased deep tendon reflexes, decreased rectal sphincter tone, and loss of bowel and bladder control. What is their likely diagnosis?
[...] syndrome
A: Cauda Equina
Q: Treatment of cauda equina syndrome is emergent [...].
A: surgical decompression
Comment 2: If surgery is delayed too long, irreversible paralysis may result.
Bone Wizardry Lock: Saddle anesthesia with bowel and bladder loss is a surgical emergency. Every hour without decompression raises the risk of permanent paralysis. This is not a case for manipulation.

Q: Which nerve root exits the intervertebral foramen between the L4 and L5 vertebrae?
[...]
A: L4
Q: A posterior herniation of the meninges and the nerve roots through a defect in a lumbar vertebral body is called?
[...]
A: Spina bifida meningomyelocele
Q: The main motion of the lumbar spine is?
[...]
A: flexion/extension
Q: The anterior displacement of one vertebral body in relation to the one below is known as: [...]
A: spondylolisthesis
Q: Degenerative changes within the intervertebral disc and ankylosing of adjacent vertebral bodies is known as: [...]
A: Spondylosis
Bone Wizardry Lock: L4 exits at the L4-L5 foramen. Know the trio: spondylosis is disc degeneration plus vertebral ankylosis, spondylolisthesis is the slip, spondylolysis is the crack without the slip. Lumbar primary motion is flexion and extension.