Lumbar Spine

1
Chapter 25

• Lumbar Spine

2
Overview

• At some time in their lives, 80 of the general
  population will experience some type of low back
  pain (LBP) - it is second only to the common cold
  as a reason for physician visits, and the most
  expensive source of compensated work related
  injury in modern industrialized countries
• Despite the frequency of LBP and the many studies
  examining LBP, LBP is a difficult problem to
  investigate and several key issues concerning its
  occurrence, natural history and prognosis remain
  unanswered

3
Anatomy

• The lumbar spine consists of 5 lumbar vertebrae
• Between each of the lumbar vertebrae is the
  intervertebral disc (IVD)
• The articulations between two consecutive lumbar
  vertebrae form three joints
• One joint is formed between the two vertebral
  bodies and the intervertebral disc (IVD)
• The other two joints are formed by the
  articulation of the superior articular process of
  one vertebra and the inferior articular processes
  of the vertebra above.

4
Anatomy

• Vertebra
• In general, the lumbar vertebrae increase in size
  from L 1 to L 5 in order to accommodate
  progressively increasing loads

5
Anatomy

• The Zygapophyseal Joint
• In the intact lumbar vertebral column, the
  primary function of the zygapophyseal joint is to
  protect the motion segment from anterior shear
  forces, excessive rotation, and flexion

6
Anatomy

• Ligaments
• Anterior longitudinal ligament (ALL)
• Extends from the sacrum along the anterior aspect
  of the entire spinal column, becoming thinner as
  it ascends
• Posterior longitudinal ligament (PLL)
• Found throughout the spinal column, where it
  covers the posterior aspect of the centrum and
  IVD

7
Anatomy

• Ligaments
• Ligamentum flavum (LF)
• Connects two consecutive laminae
• Interspinous ligament
• Connects two consecutive spinal processes
• Supraspinous Ligament
• Connects the tips of two adjacent spinous
  processes

8
Anatomy

• Ligaments
• Iliolumbar Ligament
• Functions to restrain flexion, extension, axial
  rotation, and side bending of L-5 on S-1
• Pseudo ligaments
• These ligaments, the intertransverse,
  transforaminal, and mamillo-accessory, resemble
  the membranous part of the fascial system
  separating paravertebral compartments, and do not
  have any mechanical function

9
Anatomy

• Muscles
• Quadratus Lumborum
• The importance of this muscle from a
  rehabilitation viewpoint is its contribution as a
  lumbar spine stabilizer
• Lumbar multifidus (LM)
• The lumbar multifidus is an important muscle for
  lumbar segmental stability through its ability to
  provide segmental stiffness and control motion

10
Anatomy

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

11
Anatomy

• Muscles
• Thoracolumbar fascia (TLF)
• Assists the in transmission of extension forces
  during lifting activities
• Stabilizes the spine against anterior shear and
  flexion moments

12
Anatomy

• Nerve Supply
• The nerve supply to the lumbar spine follows a
  general pattern
• The outer half of the IVD is innervated by the
  sinuvertebral nerve and the grey rami
  communicants, with the posterior-lateral aspect
  being innervated by both the sinuvertebral nerve
  and the grey rami communicants. The lateral
  aspect receives only sympathetic innervation
• The zygapophyseal joints are innervated by the
  medial branches of the dorsal rami

13
Biomechanics

• Motions at the lumbar spine joints can occur in
  three cardinal planes
• Sagittal (flexion and extension)
• Coronal (side bending)
• Transverse (rotation)
• Six degrees of freedom are available at the
  lumbar spine

14
Biomechanics

• The amount of segmental motion at each vertebral
  level varies
• Most of the flexion and extension of the lumbar
  spine occurs in the lower segmental levels,
  whereas most of the side bending of the lumbar
  spine occurs in the mid-lumbar area
• Rotation, which occurs with side bending as a
  coupled motion, is minimal, and occurs most at
  the lumbosacral junction

15
Biomechanics

• Flexion
• At the vertebral level, flexion produces a
  combination of an anterior roll and an anterior
  glide of the vertebral body, and a straightening,
  or minimal reversal of, the lordosis
• At L 4-5, reversal may occur, but at the L 5-S 1
  level, the joint will straighten, but not
  reverse, unless there is pathology present

16
Biomechanics

• Extension
• Pure extension involves a posterior roll and
  glide of the vertebra, and a posterior and
  inferior motion of the zygapophyseal joints, but
  not necessarily a change in the degree of
  lordosis

17
Biomechanics

• Axial Rotation
• Axial rotation of the lumbar spine amounts to
  approximately 13 to both sides
• The greatest amount of segmental rotation, about
  5 occurs at the L 5 and S 1 segment

18
Examination

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

19
Examination

• History
• The clinician should establish the chief
  complaint of the patient, in addition to the
  location, behavior, irritability, and severity of
  the symptoms
• Although dysfunctions of the lumbar spine are
  very difficult to diagnose, the history can
  provide some very important clues

20
Examination

• Systems Review
• It must always be remembered that pain can be
  referred to the lumbar spine area from
  pathological conditions in other regions

21
Examination

• Observation
• Observation involves an analysis of the entire
  patient as to how they move, and respond in
  addition to the positions they adopt
• Although spinal alignment provides some valuable
  information, a positive correlation has not been
  made between abnormal alignment and pain

22
Examination

• Palpation
• Whenever it is performed, palpation of the lumbar
  spine area should be performed in a systematic
  manner, and should be performed in conjunction
  with palpation of the hip and pelvic area

23
Examination

• Active range of motion
• Normal active motion, which demonstrates
  considerable variability between individuals,
  involves fully functional contractile and inert
  tissues, and optimal neurological function
• It is the quality of motion and the symptoms
  provoked, rather than the quantity of motion that
  is more important

24
Examination

• Combined motion testing
• Using a biomechanical model
• A restriction of cervical extension, side bending
  and rotation to the same side as the pain is
  termed a closing restriction. This restriction
  is the most common pattern producing distal
  symptoms. However, a limitation in cervical
  flexion accompanied by the production of distal
  symptoms can also occur
• A restriction of cervical flexion, side bending
  and rotation to the opposite side of the pain is
  termed an opening restriction

25
Examination

• Key muscle tests
• The key muscle tests examine the integrity of the
  neuromuscular junction and the contractile and
  inert components of the various muscles
• With the isometric tests, the contraction should
  be held for at least five seconds to demonstrate
  any weakness
• If the clinician suspects weakness, the test is
  repeated 2-3 times to assess for fatiguability,
  which could indicate spinal nerve root
  compression.

26
Examination

• Sensory testing
• The clinician checks the dermatome patterns of
  the nerve roots, as well as the peripheral
  sensory distribution of the peripheral nerves
• Dermatomes vary considerably between individuals

27
Examination

• Position Testing
• Position testing in the lumbar spine is an
  osteopathic technique used to determine the level
  and type of zygapophyseal joint dysfunction

28
Examination

• Passive Physiological Intervertebral Mobility
  testing (PPIVM)
• These are most effectively carried out if the
  combined motion tests locate a hypomobility, or
  if the position tests are negative, rather than
  as the entry tests for the lumbar spine
• Judgments of stiffness made by experienced
  physical therapists examining patients in their
  own clinics have been found to have poor
  reliability.

29
Examination

• Passive Accessory Intervertebral Movement test
  (PAIVM)
• Passive accessory intervertebral movement tests
  investigate the degree of linear or accessory
  glide that a joint possesses, and are used on
  segmental levels where there is a possible
  hypomobility, to help determine if the motion
  restriction is articular, peri-articular or
  myofascial in origin

30
Intervention Strategies

• The optimal intervention for patients with acute
  back pain remains largely enigmatic
• A number of clinical studies have failed to find
  consistent evidence for improved intervention
  outcomes with many intervention approaches

31
Intervention Strategies

• Acute phase
• Goals
• Decrease pain, inflammation, and muscle spasm
• Promote healing of tissues
• Increase pain-free range of segmental motion
• Regain soft tissue extensibility
• Regain neuromuscular control
• Allow progression to the functional stage

32
Intervention Strategies

• Functional phase
• Goals
• Correction of imbalances of strength and
  flexibility
• Incorporate neuromuscular re-education
• Strengthening of entire kinetic chain
• Postural correction and retraining
• To initiate and execute functional activities
  without pain and while dynamically stabilizing
  the spine in an automatic manner