Transcript Lumbar Spine

Chapter 25
Lumbar Spine
Overview
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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
Anatomy
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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.
Anatomy
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Vertebra
– In general, the lumbar vertebrae increase
in size from L 1 to L 5 in order to
accommodate progressively increasing
loads
Anatomy
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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
Anatomy
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Ligaments
– Anterior longitudinal ligament (ALL)
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Extends from the sacrum along the anterior
aspect of the entire spinal column, becoming
thinner as it ascends
– Posterior longitudinal ligament (PLL)
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Found throughout the spinal column, where it
covers the posterior aspect of the centrum
and IVD
Anatomy
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Ligaments
– Ligamentum flavum (LF)
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Connects two consecutive laminae
– Interspinous ligament
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Connects two consecutive spinal processes
– Supraspinous Ligament
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Connects the tips of two adjacent spinous
processes
Anatomy
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Ligaments
– Iliolumbar Ligament
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Functions to restrain flexion, extension, axial rotation,
and side bending of L-5 on S-1
– Pseudo ligaments
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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
Anatomy
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Muscles
– Quadratus Lumborum
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The importance of this muscle from a
rehabilitation viewpoint is its contribution as a
lumbar spine stabilizer
– Lumbar multifidus (LM)
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The lumbar multifidus is an important muscle
for lumbar segmental stability through its
ability to provide segmental stiffness and
control motion
Anatomy
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Muscles
– Erector spinae
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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
Anatomy
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Muscles
– Thoracolumbar fascia (TLF)
Assists the in transmission of extension forces
during lifting activities
 Stabilizes the spine against anterior shear and
flexion moments
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Anatomy
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Nerve Supply
– The nerve supply to the lumbar spine follows a
general pattern
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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
Biomechanics
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Motions at the lumbar spine joints can
occur in three cardinal planes:
– Sagittal (flexion and extension)
– Coronal (side bending)
– Transverse (rotation)
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Six degrees of freedom are available at
the lumbar spine
Biomechanics
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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
Biomechanics
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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
Biomechanics
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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
Biomechanics
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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
Examination
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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
Examination
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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
Examination
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Systems Review
– It must always be remembered that pain
can be referred to the lumbar spine area
from pathological conditions in other
regions
Examination
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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
Examination
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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
Examination
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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
Examination
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Combined motion testing
– Using a biomechanical model
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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
Examination
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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.
Examination
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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
Examination
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Position Testing
– Position testing in the lumbar spine is an
osteopathic technique used to determine
the level and type of zygapophyseal joint
dysfunction
Examination
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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.
Examination
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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
Intervention Strategies
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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
Intervention Strategies
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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
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Intervention Strategies
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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
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