Chapter 25

Chapter 25Chapter 25

Lumbar SpineLumbar Spine

OverviewOverview At some time in their lives, 80% of the At some time in their lives, 80% of the

general population will experience some type general population will experience some type of low back pain (LBP) - it is second only to of low back pain (LBP) - it is second only to the common cold as a reason for physician the common cold as a reason for physician visits, and the most expensive source of visits, and the most expensive source of compensated work related injury in modern compensated work related injury in modern industrialized countriesindustrialized countries

Despite the frequency of LBP and the many Despite the frequency of LBP and the many studies examining LBP, LBP is a difficult studies examining LBP, LBP is a difficult problem to investigate and several key issues problem to investigate and several key issues concerning its occurrence, natural history and concerning its occurrence, natural history and prognosis remain unansweredprognosis remain unanswered

AnatomyAnatomy

The lumbar spine consists of 5 lumbar The lumbar spine consists of 5 lumbar vertebraevertebrae

Between each of the lumbar vertebrae is the Between each of the lumbar vertebrae is the intervertebral disc (IVD)intervertebral disc (IVD)

The articulations between two consecutive The articulations between two consecutive lumbar vertebrae form three jointslumbar vertebrae form three joints– One joint is formed between the two vertebral One joint is formed between the two vertebral

bodies and the intervertebral disc (IVD)bodies and the intervertebral disc (IVD)– The other two joints are formed by the The other two joints are formed by the

articulation of the superior articular process of articulation of the superior articular process of one vertebra and the inferior articular processes one vertebra and the inferior articular processes of the vertebra above. of the vertebra above.

AnatomyAnatomy

VertebraVertebra– In general, the lumbar vertebrae In general, the lumbar vertebrae

increase in size from L 1 to L 5 in increase in size from L 1 to L 5 in order to accommodate progressively order to accommodate progressively increasing loadsincreasing loads

AnatomyAnatomy

The Zygapophyseal JointThe Zygapophyseal Joint – In the intact lumbar vertebral In the intact lumbar vertebral

column, the primary function of the column, the primary function of the zygapophyseal joint is to protect the zygapophyseal joint is to protect the motion segment from anterior shear motion segment from anterior shear forces, excessive rotation, and forces, excessive rotation, and flexionflexion

AnatomyAnatomy

LigamentsLigaments– Anterior longitudinal ligament (ALL)Anterior longitudinal ligament (ALL)

Extends from the sacrum along the Extends from the sacrum along the anterior aspect of the entire spinal anterior aspect of the entire spinal column, becoming thinner as it ascendscolumn, becoming thinner as it ascends

– Posterior longitudinal ligament (PLL)Posterior longitudinal ligament (PLL) Found throughout the spinal column, Found throughout the spinal column,

where it covers the posterior aspect of where it covers the posterior aspect of the centrum and IVD the centrum and IVD

AnatomyAnatomy

LigamentsLigaments– Ligamentum flavum (LF)Ligamentum flavum (LF)

Connects two consecutive laminaeConnects two consecutive laminae

– Interspinous ligament Interspinous ligament Connects two consecutive spinal Connects two consecutive spinal

processesprocesses

– Supraspinous LigamentSupraspinous Ligament Connects the tips of two adjacent Connects the tips of two adjacent

spinous processes spinous processes

AnatomyAnatomy

LigamentsLigaments– Iliolumbar LigamentIliolumbar Ligament

Functions to restrain flexion, extension, axial Functions to restrain flexion, extension, axial rotation, and side bending of L‑5 on S‑1rotation, and side bending of L‑5 on S‑1

– Pseudo ligamentsPseudo ligaments These ligaments, the intertransverse, These ligaments, the intertransverse,

transforaminal, and mamillo-accessory, transforaminal, and mamillo-accessory, resemble the membranous part of the fascial resemble the membranous part of the fascial system separating paravertebral compartments, system separating paravertebral compartments, and do not have any mechanical functionand do not have any mechanical function

AnatomyAnatomy

MusclesMuscles– Quadratus LumborumQuadratus Lumborum

The importance of this muscle from a The importance of this muscle from a rehabilitation viewpoint is its rehabilitation viewpoint is its contribution as a lumbar spine stabilizercontribution as a lumbar spine stabilizer

– Lumbar multifidus (LM)Lumbar multifidus (LM) The lumbar multifidus is an important The lumbar multifidus is an important

muscle for lumbar segmental stability muscle for lumbar segmental stability through its ability to provide segmental through its ability to provide segmental stiffness and control motionstiffness and control motion

AnatomyAnatomy

MusclesMuscles– Erector spinaeErector spinae

The erector spinae is a composite The erector spinae is a composite muscle consisting of the iliocostalis muscle consisting of the iliocostalis lumborum and the thoracic longissimus. lumborum and the thoracic longissimus. Both of these muscles are subdivided Both of these muscles are subdivided into the lumbar and thoracic longissimii into the lumbar and thoracic longissimii and iliocostalliiand iliocostallii

AnatomyAnatomy

MusclesMuscles– Thoracolumbar fascia (TLF)Thoracolumbar fascia (TLF)

Assists the in transmission of extension Assists the in transmission of extension forces during lifting activities forces during lifting activities

Stabilizes the spine against anterior Stabilizes the spine against anterior shear and flexion moments shear and flexion moments

AnatomyAnatomy

Nerve SupplyNerve Supply– The nerve supply to the lumbar spine The nerve supply to the lumbar spine

follows a general patternfollows a general pattern The outer half of the IVD is innervated by the The outer half of the IVD is innervated by the

sinuvertebral nerve and the grey rami sinuvertebral nerve and the grey rami communicants, with the posterior-lateral aspect communicants, with the posterior-lateral aspect being innervated by both the sinuvertebral being innervated by both the sinuvertebral nerve and the grey rami communicants. The nerve and the grey rami communicants. The lateral aspect receives only sympathetic lateral aspect receives only sympathetic innervationinnervation

The zygapophyseal joints are innervated by the The zygapophyseal joints are innervated by the medial branches of the dorsal rami medial branches of the dorsal rami

BiomechanicsBiomechanics

Motions at the lumbar spine joints Motions at the lumbar spine joints can occur in three cardinal can occur in three cardinal planes: planes: – Sagittal (flexion and extension)Sagittal (flexion and extension)– Coronal (side bending)Coronal (side bending)– Transverse (rotation)Transverse (rotation)

Six degrees of freedom are Six degrees of freedom are available at the lumbar spineavailable at the lumbar spine


The amount of segmental motion at The amount of segmental motion at each vertebral level varieseach vertebral level varies– Most of the flexion and extension of the Most of the flexion and extension of the

lumbar spine occurs in the lower lumbar spine occurs in the lower segmental levels, whereas most of the segmental levels, whereas most of the side bending of the lumbar spine occurs in side bending of the lumbar spine occurs in the mid-lumbar areathe mid-lumbar area

– Rotation, which occurs with side bending Rotation, which occurs with side bending as a coupled motion, is minimal, and as a coupled motion, is minimal, and occurs most at the lumbosacral junctionoccurs most at the lumbosacral junction


FlexionFlexion– At the vertebral level, flexion produces a At the vertebral level, flexion produces a

combination of an anterior roll and an combination of an anterior roll and an anterior glide of the vertebral body, and a anterior glide of the vertebral body, and a straightening, or minimal reversal of, the straightening, or minimal reversal of, the lordosislordosis

– At L 4-5, reversal may occur, but at the L At L 4-5, reversal may occur, but at the L 5-S 1 level, the joint will straighten, but 5-S 1 level, the joint will straighten, but not reverse, unless there is pathology not reverse, unless there is pathology presentpresent


ExtensionExtension– Pure extension involves a posterior Pure extension involves a posterior

roll and glide of the vertebra, and a roll and glide of the vertebra, and a posterior and inferior motion of the posterior and inferior motion of the zygapophyseal joints, but not zygapophyseal joints, but not necessarily a change in the degree necessarily a change in the degree of lordosisof lordosis


Axial RotationAxial Rotation– Axial rotation of the lumbar spine Axial rotation of the lumbar spine

amounts to approximately 13° to amounts to approximately 13° to both sidesboth sides

– The greatest amount of segmental The greatest amount of segmental rotation, about 5° occurs at the L 5 rotation, about 5° occurs at the L 5 and S 1 segmentand S 1 segment

ExaminationExamination

The physical examination of the The physical examination of the lumbar spine must include a lumbar spine must include a thorough assessment of the thorough assessment of the neuromuscular, vascular and neuromuscular, vascular and orthopedic systems of the hip, orthopedic systems of the hip, lower extremities, low back and lower extremities, low back and pelvic regionspelvic regions


HistoryHistory– The clinician should establish the The clinician should establish the

chief complaint of the patient, in chief complaint of the patient, in addition to the location, behavior, addition to the location, behavior, irritability, and severity of the irritability, and severity of the symptomssymptoms

– Although dysfunctions of the lumbar Although dysfunctions of the lumbar spine are very difficult to diagnose, spine are very difficult to diagnose, the history can provide some very the history can provide some very important cluesimportant clues


Systems ReviewSystems Review– It must always be remembered that It must always be remembered that

pain can be referred to the lumbar pain can be referred to the lumbar spine area from pathological spine area from pathological conditions in other regionsconditions in other regions


ObservationObservation– Observation involves an analysis of Observation involves an analysis of

the entire patient as to how they the entire patient as to how they move, and respond in addition to the move, and respond in addition to the positions they adoptpositions they adopt

– Although spinal alignment provides Although spinal alignment provides some valuable information, a some valuable information, a positive correlation has not been positive correlation has not been made between abnormal alignment made between abnormal alignment and painand pain


PalpationPalpation– Whenever it is performed, palpation Whenever it is performed, palpation

of the lumbar spine area should be of the lumbar spine area should be performed in a systematic manner, performed in a systematic manner, and should be performed in and should be performed in conjunction with palpation of the hip conjunction with palpation of the hip and pelvic areaand pelvic area


Active range of motionActive range of motion– Normal active motion, which Normal active motion, which

demonstrates considerable variability demonstrates considerable variability between individuals, involves fully between individuals, involves fully functional contractile and inert tissues, functional contractile and inert tissues, and optimal neurological functionand optimal neurological function

– It is the quality of motion and the It is the quality of motion and the symptoms provoked, rather than the symptoms provoked, rather than the quantity of motion that is more quantity of motion that is more importantimportant


Combined motion testingCombined motion testing– Using a biomechanical modelUsing a biomechanical model

A restriction of cervical extension, side bending A restriction of cervical extension, side bending and rotation to the same side as the pain is and rotation to the same side as the pain is termed a termed a closingclosing restriction. This restriction is restriction. This restriction is the most common pattern producing distal the most common pattern producing distal symptoms. However, a limitation in cervical symptoms. However, a limitation in cervical flexion accompanied by the production of distal flexion accompanied by the production of distal symptoms can also occursymptoms can also occur

A restriction of cervical flexion, side bending A restriction of cervical flexion, side bending and rotation to the opposite side of the pain is and rotation to the opposite side of the pain is termed an termed an openingopening restriction restriction


Key muscle testsKey muscle tests– The key muscle tests examine the integrity The key muscle tests examine the integrity

of the neuromuscular junction and the of the neuromuscular junction and the contractile and inert components of the contractile and inert components of the various musclesvarious muscles

– With the isometric tests, the contraction With the isometric tests, the contraction should be held for at least five seconds to should be held for at least five seconds to demonstrate any weaknessdemonstrate any weakness

– If the clinician suspects weakness, the test If the clinician suspects weakness, the test is repeated 2-3 times to assess for is repeated 2-3 times to assess for fatiguability, which could indicate spinal fatiguability, which could indicate spinal nerve root compression.nerve root compression.


Sensory testingSensory testing– The clinician checks the dermatome The clinician checks the dermatome

patterns of the nerve roots, as well patterns of the nerve roots, as well as the peripheral sensory as the peripheral sensory distribution of the peripheral nervesdistribution of the peripheral nerves

– Dermatomes vary considerably Dermatomes vary considerably between individualsbetween individuals


Position TestingPosition Testing– Position testing in the lumbar spine Position testing in the lumbar spine

is an osteopathic technique used to is an osteopathic technique used to determine the level and type of determine the level and type of zygapophyseal joint dysfunctionzygapophyseal joint dysfunction


Passive Physiological Intervertebral Passive Physiological Intervertebral Mobility testing (PPIVM)Mobility testing (PPIVM) – These are most effectively carried out if the These are most effectively carried out if the

combined motion tests locate a combined motion tests locate a hypomobility, or if the position tests are hypomobility, or if the position tests are negative, rather than as the entry tests for negative, rather than as the entry tests for the lumbar spinethe lumbar spine

– Judgments of stiffness made by experienced Judgments of stiffness made by experienced physical therapists examining patients in physical therapists examining patients in their own clinics have been found to have their own clinics have been found to have poor reliability.poor reliability.


Passive Accessory Intervertebral Passive Accessory Intervertebral Movement test (PAIVM)Movement test (PAIVM)– Passive accessory intervertebral Passive accessory intervertebral

movement tests investigate the degree of movement tests investigate the degree of linear or accessory glide that a joint linear or accessory glide that a joint possesses, and are used on segmental possesses, and are used on segmental levels where there is a possible levels where there is a possible hypomobility, to help determine if the hypomobility, to help determine if the motion restriction is articular, peri-articular motion restriction is articular, peri-articular or myofascial in originor myofascial in origin

Intervention Intervention StrategiesStrategies The optimal intervention for The optimal intervention for

patients with acute back pain patients with acute back pain remains largely enigmaticremains largely enigmatic

A number of clinical studies have A number of clinical studies have failed to find consistent evidence failed to find consistent evidence for improved intervention for improved intervention outcomes with many intervention outcomes with many intervention approachesapproaches

Intervention Intervention StrategiesStrategies Acute phaseAcute phase

– GoalsGoals Decrease pain, inflammation, and muscle Decrease pain, inflammation, and muscle

spasmspasm Promote healing of tissuesPromote healing of tissues Increase pain-free range of segmental Increase pain-free range of segmental

motionmotion Regain soft tissue extensibilityRegain soft tissue extensibility Regain neuromuscular controlRegain neuromuscular control Allow progression to the functional stageAllow progression to the functional stage

Intervention Intervention StrategiesStrategies Functional phaseFunctional phase

– Goals:Goals: Correction of imbalances of strength and Correction of imbalances of strength and

flexibilityflexibility Incorporate neuromuscular re-educationIncorporate neuromuscular re-education Strengthening of entire kinetic chainStrengthening of entire kinetic chain Postural correction and retrainingPostural correction and retraining To initiate and execute functional To initiate and execute functional

activities without pain and while activities without pain and while dynamically stabilizing the spine in an dynamically stabilizing the spine in an automatic manner automatic manner

Chapter 25

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