lumbar spine theory

Band 5 IST 3/11/09 Ronan Donohoe

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LUMBAR SPINE THEORY• 5 vertebrae with intervening discs from the lower thoracic spine to sacrum• Most load bearing structures in the skeletal system• Lordotic in shape which gives it resilience and helps to protect against

compressive forces• Origin of most back pain

o lifetime prevalence of up to 84% (Airaksinen et al., 2004)o 13.5% of incapacity benefits in 2004 (CSP, 2006)o direct medical costs est £1.6 billion, overall cost to the economy

varied between £6.6 billion to £12.3 bn Maniadakis and Gray, 2000)o strong evidence psychosocial factors linked to transition from acute

to chronic LBP (lasting over 12 weeks) (Kendall & Linton, 1998)

Anatomy

Basic anatomy of lumbar vertebra• Largest body/disc, lamina and pedicles short and thick for load bearing• Articular processes facet joints aligned more vertically allowing

flexion/extension but little rotation

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Label the following structures:

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Range of Movement

Flexion Extension Side flexion RotationCx 50 60 45 80Tx 45 5 45 30Lx 60 25 25 ? 1.5

Muscles of the Lumbar SpineCan be divided into 3 groups based on position and function:

1. Psoas major. Attaches directly to the vertebral bodies anterolaterally andacts as a primary flexor muscle of the hip joint.

2. Quadratus lumborum and the lateral intertransversarii. Attach to and coverthe transverse processes anteriorly. They act as lateral flexors.

3. Interspinales, intertransversarii mediales, multifidi, lumbar erector spinae(longissimus and iliocostalis). They attach directly to the lumbar vertebrae andact as extensor muscles

Thoracolumbar Fascia (TLF)- Tough fibrous sheet covering the back, tensioned by muscles above, theside & below. Through it, these muscles transmit their power across the wholespine.- Tensioning the TLF using TrA reduces vertebal displacement when thespine is loaded in flexion but increases displacement when loaded inextension. (See Norris, 20008)


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Transversus abdominus – (TrA)O: Iliac crest, inguinal ligament,lumbar fascia, and cartilages ofinferior six ribsI: Xiphiod process, linea alba, andpubisA: compresses abdomen, importantin core stability,

Gross structure of theintervertebral disc Three basic components:• annulus fibrosis (outer part) - tough circular exterior composed of

concentric sheets of collagen fibers(lamellae)

• nucleus pulposus (inner part) - loosenetwork of fibers suspended in amucoprotein gel.

• Cartilaginous end plate – attaching tobody above & below

Annulus fibrosus• consists of water and collagen fibres

arranged in sheets and concentric ringssurround the nucleus

• Collagen fibres lie at an angle of 65-70 fromvertical and firmly attach to the body above and below

• Each successive layer alternates the direction ofthe collagen fibres thus resisting movementboth vertically and horizontally &providing stability against shear & torsion

Nucleus pulposus (“jam in the donught”)• is a semifuid gel comprising 40- 60% of the disc, consists of 70-90% water

- decreases with age• confers properties of a fluid on the nucleus• pressure therefore in one direction results in deformation and application

of pressure in all directions without reduction in volume• this property enables it to both accommodate to movement and to transmitsome of the compressive load from one vertebrae to the next.

NB: Lumbar spinal discs are avascular and depend on fluid exchange bypassive diffusion. Regular movement & activity are vital for this!


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Ligaments• anterior longitudinal• posterior longitudinal• articular capsules• ligamentum flava• interspinous ligts• supraspinous ligts• intertransverse ligts• transforaminal ligts• ligamentum flavum ligts

Dermatomes / MyotomesThe most common sites for a herniated lumbar disc are L4-5 and L5-S1,resulting in back pain and pain radiating down the posterior and lateral leg, tobelow the knee

Articulations• Intervertebral joint - Each disc forms a cartilaginous joint to allow slight

movement of the vertebrae, and acts as a ligament to hold the vertebraetogether.

• Zygapophyseal (facet) joint- synovial joint between superior and inferiorarticular process. Interlocking in vertical plane in lumbar spine. Preventrotation in the transverse plane, whilst allowing sagittal rotation (flexion andextension) and a small amount of frontal rotation (lateral bending)


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Intradiscal pressuresRelative increases and decreases in intradiscal pressure in relation todifferent body positions. Note that seated and bending postures apply morepressure to the disc than do standing and recumbent positions. This explainsthe exacerbationof symptoms ofherniated discwhen patients arein the formerpositions.

Common postural deficits

Centre of gravity: The line of gravity of passes ventral to the fourth lumbarvertebral bodyFunctional Scoliosis – ensure to assess for corrective orthotics


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Common conditions• Spondylosis• Spondyloysthesis• Ankylosing spondylitis• Nerve root pain• Cauda Equina• Red Flags – Briefly – to be done Feb 9th• Yellow Flags - ABCDEFW

Spondylolysis (scottie dog fracture)• Defect in pars interarticularis (Unilateral)• Major cause of lower back pain in children and

adolescents• Unilateral Pars defect is the result of a fatigue fx from

repetitive hyperextension• Most common in gymnasts and football lineman

Spondylolisthesis• Bilateral Pars Interarticularis defect• Forward slippage of one vertebra on another• Usually L5-S1

Ankylosing spondylitis (bamboo spine)• Men, 3rd to 4th decade of life• Insidious onset of back and hip pain• Morning stiffness• Spine becomes rigid (ankylosed)• Progressive spinal flexion deformities (may progress to a chin-on-chest

deformity)• Systemic effects

Nerve root pain• Unilateral leg pain > back pain• Pain radiating to foot / toes with numbness in same distribution• Nerve irritation signs – reduced SLR reproducing leg pain• Motor, sensory or reflex change – limited to 1 nerve root• Resonable prognosis – 50% recover from acute attack within 6/52

Herniated Nucleosus pulposis (HNP) vs. Spinal Stenosis• HNP/Spinal Stenosis Comparisons• Age: 30-50 vs >50• Sciatica: Classic for HNP vs Atypical for Stenosis• Aggravated: Flexion/Sitting vs Extension & Standing• Nerve Tension Signs (SLR): Usual vs Unusual• Prognosis: Worse, More Chronic in Stenosis

HNP/Spinal Stenosis Treatment:Decompression, Laminectomy, Foraminotomy, Fusion


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Other Treatments• Mobilisation• Core Strengthening –Trans abs• McKenzke

Red flagsPossible serious spinal pathology, (cauda equina syndrome, spinal fracture,cancer or infection) Fill in the boxes: C.E., # or Ca below

• Saddle anaesthesia• Age onset <20 of >55• Violent trauma• Constant, progressive, non mechanical pain• Thoracic pain• PMH - carcinoma• Systemic steroids• Drug abuse, HIV• Weight loss• Recent onset of bladder or dysfunction• Persisting severe restriction of Lx Flexion• Widespread neurology• Structural deformity

ACTION: Usually immediate referral to hospital.

Yellow flags - ABCDEFWPsychosocial determinants of chronicity, barriers to recovery & return to work.Attitudes, Behaviours, Compensations, Diagnosis, Emotions, Family andWorkACTION: Screening by a suitably qualified health professional using aquestionnaire or interview technique, which then informs treatment andrehabilitation planning.

Other flags:Orange FlagsRelate to serious psychological and psychiatric illness. E.g. diagnosis orsuspicion of psychosis, suicidal tendencies or addictive behaviours such asalcoholism. ACTION: Referral on to GP, Clinical Psycholgist or Psychiatrist orHospital for further assessmentBlue FlagsBlue Flags are usually considered to be the perceptions of the situation by theemployee or the employerBlack FlagsBlack flags are societal or cultural factors that can be an obstacle to recoveryand return to work e.g. welfare systemPink Flags"good" flags - positive things that will help a person to return to work andrecovery.

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References:

Images: Various, from Google images.

Airaksinen, O., Brox, J.I., Cedraschi, C. Hildebrandt, J., Klaber-Moffett, J.,Kovacs, F., Mannion, A.F., Reis, S., Staal, J. B., Ursin, H. and Zanoli, G.(2004) European guidelines for the management of chronic non-specific lowback pain [online]. European Commission, Research Directorate General,[cited on 03 March 2008] Available from World Wide Web:<http://www.backpaineurope.org/web/files/WG2_Guidelines.pdf>.

Burton, A. K., Balagué, F., Cardon, G., Eriksen, H. R., Henrotin, Y., Lahad,A., Leclerc, A., Müller, G., van der Beek, A. J., Henrotin, Y., Hänninen, O.,and Harvey, E. (2004) European guidelines for prevention in low back pain[online]. European Commission, Research Directorate General, [cited on1/3/08]. Available from the World Wide Web:<http://www.backpaineurope.org/web/files/WG3_Guidelines.pdf>.

Chartered Society of Physiotherapy (2006) Clinical guidelines for thephysiotherapy management of persistent low back pain - part 2 Exercise.London: Chartered Society of Physiotherapy.

Clinical Standards Advisory Group (1994a) Back pain: report of a CSAGcommittee on back pain. London: HMSO.

Dagenais, S., Caro, J. and Haldeman, S. (2008) A systematic review of lowback pain cost of illness studies in the United States and internationally. Thespine journal: official journal of the North American Spine Society, 8(1), pp.8-20.

Donohoe, R. (2008) A study to investigate the ability of recently qualifiedphysiotherapists to recognise known psychosocial risk factors in patientspresenting with subacute low back pain. Unpublished Thesis. ManchesterManchester Metropolitan University, 2008.

Kendall, N. A. S., Linton, S. J. and Main, C. (1998) Psychosocial Yellow Flagsfor acute low back pain: ‘Yellow Flags’ as an analogue to ‘Red Flags’.European Journal of Pain, 2, pp.87-89.

Norris, C. M. (2008) Back Stability: Integrating Science and Therapy, 2nd ed.

Maniadakis, N. and Gray, A. (2000) The economic burden of back pain in theUK. Pain, 84(1), pp.95-103.

lumbar spine theory

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