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Transcript
ANATOMY OF THE LUMBAR SPINE
Lumbar Vertebra
The lumbar spine consists of five lumbar vertebrae, five corresponding intervertebral discs,
twelve zygapophyseal joints (T12-L1 to L5-S1), and multiple ligaments, muscular, and
neurological contributions (Table 10.1). The design of the lumbar spine allows viscoelastic motion,
absorbs energy, moves with six degrees of freedom, and has limited fatigue tolerance. These
functions depend on muscular, bone, and ligamentous components for mechanical tasks (1).
Table 10.1: General Information Regarding the Lumbar Spine Region.
Concept
Information
Bones
Number of dedicated
joints
Range of motion
Five primary bones of the lumbar spine
18 joints, 6 intervertebral, and 12 zygapophyseal
Theoretical resting
Position
Theoretical close-pack
Position
Theoretical capsular
pattern
Resting position = mid-way between flexion and extension
Lumbar spine range of motion
• Flexion = 50°
• Extension = 15°
• Rotation = 5°
• Lateral flexion = 20°
Close-pack position = extension
Capsular pattern = side bend and rotation equally limited, extension
The typical lumbar vertebrae display dramatic height increases when compared to the
thoracic spine. The lower vertebrae and discs are wedge shaped, lending to the natural postural
lordosis. The anterior aspect of the vertebrae is generally concave and the posterior aspects are
flattened and stable (1).
Lumbar vertebrae can be divided into three sections from anterior to posterior. The anterior
portion of the vertebral body is essentially flat on the superior and inferior surfaces and provides
contact points for the intervertebral disc (1). The middle section in the lumbar spine includes the
pedicles, which are strong posterior projections. The posterior portion of the vertebral body includes
the inferior and superior articular processes, the spinous processes, and the transverse processes.
The spinous processes are heavy and rectangular.
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
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The Vertebral and Intervertebral Foramen
The anterior wall of the vertebral canal is flattened, and the discs demonstrate no
propensity of bulging into the spinal canal. The anterior wall of the vertebral canal is formed by the
posterior surfaces of the lumbar vertebrae, and the posterior wall is formed by the lamina and
ligamentum flava of the same vertebrae (1). The disc surrounds the intervertebral foramen
anteriorly, the pedicle inferiorly and superiorly, and the zygapophyseal joints posteriorly (1).
Figure 10.1: The Intervertebral Foramen
Table 10.2: Joints of the Lumbar Spine.
Joint
Information
Intervertebral disc
•
•
Zygapophyseal (facet)
joints
•
The intervertebral disc (IVD) connects the bodies of adjacent
vertebrae together. It is classified as a symphysis or
amphiarthrosis
3 components: 1) Annulus: collagen makes up 50–70% of its
weight. Fibers are arranged in concentric rings around the nucleus.
These concentric sheaths are called lamellae. They are orientated
at an angle of 65–70° from the vertica,l with adjacent layers
running in opposite 65° orientations from the vertical (i.e., they
criss-cross). The outer portion of the annulus is the only innervated
portion of the disc. 2) nucleus: comprises the central portion of the
disc. There is no clear boundary between the nucleus and the
annulus. The nucleus is 70–90% water. 3) vertebral end plate: is
0.6–1 mm thick
The facets are oval in shape, are slightly curved or biplanar, and
are oriented parallel to the frontal plane. The facet orientation
angle changes with respect to the mid-sagittal plane (Bogduk):
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
© 2012 by Pearson Education, Inc., Upper Saddle River, NJ
•
o L1–2 = 15°
o L2–3 = 30°
o L3–S1 = 45°
Zygapophyseal joints take ~20% of the spinal weight-bearing load.
With flexion, you increase the weight bearing on the disc and
decrease the weight bearing on the facet joints
The Zygapophyseal Joints
The zygapophyseal joints, also known as facets or apophysial joints, are enclosed in a
fibrous capsule that contains menisci. The menisci are invaginations of the joint capsule and may
occasionally project into joint space (2). Facets do not have “free” motion as does the disc and are
limited both structurally and by the capsule. Movement is generally restricted to large sagittal
motions guided by the shape of the zygapophyseal joints.
The facets flatten anteroposterior and run slightly dorsally and upward (1). The
zygapophyseal joints and the surrounding structure represent attachment sites for several
intertransverse ligaments and muscles. The intertransverse ligaments attach to each transverse
process and limit side flexion to the opposite side. The transverse process of L5 attaches to the
medial portion of the iliac crest by several strong strands of the iliolumbar ligament, which tends to
ossify at older ages. The anterior portions of the lumbar facets orient coronally (promote side-bend
forces). The posterior facets face sagittal and resist rotation and side-bend forces (2).
Figure 10.2: Zygapophyseal Joints of the Lumbar Spine
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© 2012 by Pearson Education, Inc., Upper Saddle River, NJ
The Intervertebral Disc (Interbody Joints)
The intervertebral disc functions as a shock absorber and a deformable space, and resists
compressive forces of the spine. There are three major components of the disc; 1) the annulus
fibrosis, 2) the nucleus pulposis and 3) the cartilaginous end plate. The nucleus pulposis accounts
for up to 50 percent of the disc area and includes collagen fibers without specific orientation. The
major constituents include proteoglycans, collagen, and water.
The nucleus is responsible for nutrient transport via osmosis of the middle cartilaginous end
plate and articulation with the disc. The actual compression tolerance is derived from the properties
in the water (at lower levels) through proteoglycans imbibitions of joint fluid. The nucleus transfers
much of the weight to the annulus when loads are high or when damage has occurred to the
intervertebral segment.
The annulus gradually blends into the nucleus in a gradual transition rather than an abrupt
transition between two separate structures (3). The annulus consists of multiple concentric rings
called lamellae, which provide tension in all directions when force is encountered. The lamellae
consist of concentric-oriented rings, lying at a 30-degree plane from the horizon (4). Lamellae are
designed to counter compression, side bending, shear, and distraction forces. Nerve endings in the
outer border of the annulus are responsible for pain generation and somatic referral of symptoms.
The disc integrates with the vertebrae at the cartilaginous end plate. The inner twothirds of
the disc attach to the cartilaginous end plate, while the outer two-thirds attach to the intervertebral
body. The cartilaginous end plate is responsible for nutrient transfer to the disc from the vertebral
body and becomes thicker and less permeable with increasing age. This structure is composed of
hyaline cartilage and is thicker and more calcified at the periphery (5). The vertebral end plate also
contributes in confining the annulus and nucleus (6).
The intervertebral disc is the major load-bearing and motion control element in lateral and
anterior shear, axial compression, flexion, and side flexion. The intervertebral disc guides the
motion of rotation, while the facet restricts motion beyond disc boundaries (7,8). This is in contrast
to the facet, which contributes to motion control during posterior shear, extension, and axial torsion.
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During lateral and anterior shear with high external forces, the facets may transmit a portion of the
load (8).
In a healthy lumbar spine, the disc evenly transmits forces to the ligaments of the back
(specifically, the anterior longitudinal ligament and the posterior longitudinal ligament), through an
interplay of the thoracolumbar fascia and abdominal musculature (8,9). In the nondamaged disc, up
to 85 percent of the movement is controlled through the interplay of disc dispensation. A damaged
disc will encounter a different percentage, typically dispensing force to the facets and other
supportive structures including the vertebral end plate. The vertebral end plate is the most
significant potential point of weakness and is the quickest healing area of the lumbar disc segment
(1). Unfortunately, no known clinical examination features outline vertebral end plate damage; thus,
these impairments may remain undetected.
Nerves of the Lumbar Spine
The spinal nerves of the lumbar spine subdivide into ventral and dorsal rami. Each spinal
nerve lies within the intervertebral foramen and is numbered according to the vertebra above the
nerve. Subsequently, the L4 nerve root runs below the L4 vertebra, in between L4 and L5. Each
spinal nerve arises from a ventral and a dorsal nerve root, which meet to form the spinal nerve in
the intervertebral foramen (1). Each dorsal root communicates to a dorsal root ganglion that
contains the cell bodies of the sensory fibers of the dorsal roots. The dorsal root transmits sensory
fibers, while the ventral root primarily transmits motor fibers (10). Each spinal nerve exits the
intervertebral foramen with dural structures, an extension of the dura mater and arachnoid mater,
commonly referred to as the dural sleeve (10). In the intervertebral foramen, the amount of space is
extremely limited; thus, the structures in this region are predisposed to problems associated with
space-occupying lesions.
Branching from each ventral rami are sinuvertebral nerves that are considered mixed
(motor and sensory) nerves. The sinuvertebral nerve complex innervates the posterior longitudinal
ligament and the outer border of the annulus, and contributes fibers to the joint capsule and
articular facet. Posteriorly, the lumbar spine is innervated by branches of the dorsal rami that run to
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
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the zygapophyseal joints and muscles. Anterior and posterior plexuses innervate the anterior
longitudinal ligament (ALL) and posterior longitudinal ligament (PLL), additionally supplying
innervation to the intervertebral disc and periosteum of the vertebral bodies (1,10). This complex
innervation pattern reduces the likelihood of unambiguous pain-referral patterns from one specific
structure (Table 10.3).
Table 10.3: Nerve Root Muscular Innervation of the Lumbar Spine.
Nerve Root
L1-L2
Test Action
Hip flexion
L3
Knee extension
L4
Ankle dorsiflexion
L5
Toe extension
S1
S2
Ankle DF, eversion,
hip extension, knee
flexion
Knee flexion
S3
---
Muscles
Psoas, iliacus, sartorius, gracilis, pectineus, adductor
longus, and adductor brevis
Quads, adductor longus, adductor magnus, and adductor
brevis
Tibialis anterior, quadriceps, tensor fascia latae, adductor
magnus, obturator externus, and tibialis posterior
Extensor hallucis longus, extensor digitorum longus, glut
medius and minimus, obturator internus, semimemb and
semitend, peroneus tertius, and popliteus
Gastroc and soleus, glut maximus, obturator internus,
piriformis, biceps femoris, semitendinosis, popliteus,
peroneus longus and brevis, and extensor digitorum brevis
Biceps femoris, piriformis, soleus, gastroc, flexor digitorum
longus, flexor hallucis longus, and intrinsic foot muscles
Intrinsic foot muscles (except abductor hallucis), flexor
hallucis longus, flexor digitorum brevis, and extensor
digitorum brevis
Ligaments of the Lumbar Spine
Numerous ligaments restrain free motion (Table 10.4). The anterior longitudinal ligament
(ALL) and posterior longitudinal ligament (PLL) interconnect the vertebral bodies and are deeply
associated with the annulus fibrosis of the discs. The ALL serves primarily to resist vertical
separation of the anterior ends of the vertebral bodies and resists anterior bowing during extension
movements (1). The PLL also resists separation of vertebrae and aids in posterior support with the
intimate connection with the annulus fibrosis (1).
Posterior ligaments include the ligamentum flavum, the interspinous ligaments, and the
supraspinous ligament. The ligamentum flavum is a short, thick ligament that joins each lamina of
consecutive vertebrae. This ligament also resists separation of vertebrae, although the exact
mechanics of the ligament are unknown (1,5). The interspinous ligaments connect adjacent spinous
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processes and most likely resist separation of the spinous processes. The supraspinous ligament
attaches to the posterior ends of the spinous processes and are likely heavily embedded with
proprioceptive nerve endings (11). In general, the posterior spinous ligaments are slack in upright
standing but will tighten during forward flexion and rotation.
The iliolumbar ligaments are well-developed ligaments, are anterior, superior, and vertical
in nature, and are one of few structures that actually cross the sacroiliac joint (12). Bogduk and
Twomey (12) outlined five separate bands of the iliolumbar ligament, which traverse from the
transverse process of L5 to the quadratus lumborum, the iliac crest, and the posterior aspect of the
iliac tuberosity. The iliolumbar ligament ossifies by the fifth decade and is demarcated from the
quadratus lumborum muscle (13). The iliolumbar ligament appears to restrict sagittal nutation and
counternutation of the sacroiliac (12,14).
Table 10.4: Ligaments and Connective Tissue of the Lumbar Spine.
Name
Location
Function
Ligament flavum
Located between the anterior
surfaces of lamina (i.e., is in the
canal, posterior aspect).
Located between the spinous
processes
Limits flexion
Intertransverse ligament
Located between the transverse
processes
Limits side bending
Posterior longitudinal
ligament
Covers posterior vertebral bodies
inside the vertebral canal
Stabilizes and limits extension
Anterior longitudinal
Ligament
Covers the anterior vertebral
bodies
Stabilizes and limits extension
Capsule and zygapophyseal
joints
Surrounds each zygapophyseal
joint
Supports and stabilizes the facet
joints
Iliolumbar ligament
Located between the L5 transverse
process to the sacrum (iliac crest
area)
Restricts side flexion and
stabilizes the lumbopelvic
complex
Supra- and interspinous
ligaments
Limits flexion
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
© 2012 by Pearson Education, Inc., Upper Saddle River, NJ
Muscular Stabilization of the Spine
Stability of the lumbar spine is a joint responsibility of the passive and active structures of
the lumbar spine. Studies have suggested that the multifidi are responsible for postural,
multidirectional, and individual segmental control (15–17). The multifidi are the largest and most
medial of the lumbar paraspinal muscles, originating from a spinous process and spreading
caudolaterally from the mid-line, and inserting into the mamillary processes of the facet joint, the
iliac crest, and the sacrum. The multifidi maintain lumbar lordosis by acting like a bowstring
transmitting some of the axial compression force to the ALL. These muscles protect discs by
preventing unwanted wobbling movements associated with torsion and flexion.
The transverse abdominus plays an important role in dynamic isometric stabilization during
twisting and rotation motions (18–21). Selected authors have suggested that, for individuals with
passive spine instability, sagittal torsion or rotation strains are more responsible for damaging
structures than linear forces (22). The hypothesized contribution occurs through increasing the
stiffness of lumbar spine (i.e., increasing intra-abdominal pressure and tensioning the
thoracolumbar fascia resisting torsion). The transverse abdominus increases in stiffness in
anticipation of limb movement and limits intersegmental translation and rotational forces. This
action may provide a more stable lever with the other trunk muscles (21).
Other contributors to spine movement and stability include the erector spinae, external and
internal obliques, and the thoracolumbar fascia. The thoracolumbar fascia that inserts on the
gluteus maximus and latissimus dorsi and integrates with the deep lamina of the inferior aspect of
the lumbar pedicle works in concert with the lumbar musculature to stabilize during dynamic
movement. The internal and external obliques work in concert with the thoracolumbar fascia to
stabilize the core pressure but are primarily prime movers of diagonal rotational motions and poor
stabilizers of the lumbar spine. The erector spinae consist of the longissimus thoracic and
iliocostalis lumborum groups (23). Van Dieën et al. (24) reported that subjects with low back pain
demonstrated a higher recruitment of the lumbar erector spinae in an effort to increase stability.
The psoas major is not a significant contributor to spine stability and is primarily a hip flexor
(23). The psoas fibers originate near the anterior spine (T12 through L4-5) and transverse process
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
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and inserts on the hip. This lever mechanism is too inefficient to produce lumbar movement (23).
Many clinicians misperceive the role of the psoas as a significant contributor to low back pain.
Bogduk states, “The isometric morphology of the psoas indicates that the muscle is designed
exclusively to act on the hip” (23). Although a maximum contraction can increase intradiscal loads
(23), this muscle may not contribute to stabilize the spine.
Summary
•
•
•
•
Much of low back movement is controlled and guided by the intervertebral disc.
The shape of the lumbar vertebral body and disc promotes a natural lordosis.
The orientation of the facets limits lumbar rotation and aids in stability during rotation.
Several muscles of the lumbar spine are the primary source of dynamic stability,
functioning as prime movers and stabilizers.
BIOMECHANICS OF THE LUMBAR SPINE
The lumbar spine has six degrees of freedom and is generally described by movements
associated with flexion, extension, rotation, and side flexion (Table 10.5).
Table 10.5: Specific Biomechanics and Movement of the Lumbar Spine
Region
Flexion
Biomechanics and Movement
•
•
•
Extension
•
•
•
•
The lower lumbar segments rotate forward from a backward tilted
position (reducing umbar lordosis). The lumbar lordosis typically will
only reach the neutral position and rarely achieves a kyphosis.
The superior vertebra rotates anteriorly in the sagittal plane on the
inferior vertebra, raising the inferior articular process of the superior
vertebra upward and slightly backward, and opening a small gap
between the superior and inferior articular facets. Anterior sagittal
plane translation then occurs (as a result of gravity or muscular
contraction), closing this gap. Impaction of the inferior facet against
the anteromedial portion of the superior facet restricts anterior
sagittal plane translation. Tension of the articular capsule also limits
flexion
The sacrum nutates the forward nodding movement of the sacrum
between the hip bones (innominates) with the sacral base moving
anterior and inferior and the sacral apex moving posterior and
superior
Consists of a posterior sagittal plane rotation combined with a small
posterior sagittal plane translation
The facet joints have a limited role in restricting extension
The ALL and annulus restrict extension along with SP approximation
The canal spinal and the intervertebral foramen diameter decrease
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
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by up to 20%
Side flexion
•
•
Rotation
•
•
The ipsilateral superior facet slides down the adjacent inferior facet,
while the contralateral superior facet slides upward in relation to the
contralateral inferior facet
Can be thought of as unilateral flexion on the contralateral side and
unilateral extension on the ipsilateral side
Impaction of the contralateral articular facets limit axial extension
The joint space is very narrow; therefore, ROM permitted is small
Many manual therapy disciplines base specific mobilization and manipulation techniques
on selected theories of lumbar coupling direction, theories that are often inconsistently reported
(25). Biomechanical analysis including investigation of coupled motion is often reported as an
essential concept to low back evaluation (26–30). The two principle components of lumbar coupling
are quantity of motion, used in detection of hypo and hypermobility, and direction of coupling
behavior. The most controversial of the two assessment methods is the theory of directional lumbar
coupling, a theory based on the invalidated premise that a “normal” lumbar coupling pattern exists
in nonpathological individuals (31–33). It has been suggested that the link between pathology of the
lumbar spine may be best represented by addressing the pattern or direction of coupling behavior
(30,34–39).
Coupled motion is the rotation or translation of a vertebral body about or along one axis
that is consistently associated with the main rotation or translation about another axis (39). During
movement, translation occurs when movement is such that all particles in the body at a given time
have the same direction of motion relative to a fixed coordinate system (39). With movement,
rotation occurs as a spinning or angular displacement of the vertebral body around some axis.
Historic, foundational works on coupling mechanics used observation or controversial twodimensional (2-D) radiographic imagery (30). Past 2-D studies involved cadaveric tissue, X-rays of
live subjects, or single X-rays of segments, and used a small sample of subjects (30,40). Prior to
1969, only 2-D studies were executed for spinal coupling, signifying that any study performed prior
to 1969 encompassed these errant methods (30). 2-D imagery leads to magnification errors,
projection of translations as rotations, and misleading results (30,40). Theories such as Fryette’s
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laws I and II of the lumbar spine have not held up well to modern science and are generally
recognized by researchers as incorrect (25,30).
Contemporary studies use three-dimensional (3-D) assessment, which more accurately
measures the six degrees of freedom associated with coupling motion (25). All of the studies
reported no coupling present in at least some of the specimens or subjects at L1-2, with two
reported opposite results (25). Inconsistency is also present at L2-3 and L3-4 where results are split
between no report of coupling, opposite rotational coupling with side bending, and both (25).
The spinal levels of L4-5 and L5-S1 exhibited the greatest degree of variability. Two studies
reported that no coupling was present at L4-L5, three others recognized opposite rotational
coupling with side bending, and one indicated same-side rotational coupling with side bending (25).
The same two studies which found no coupling at previous segments found no coupling at L5-S1,
three others found opposite rotational coupling to side bending, and one found both opposite and
no coupling (25).
Recent in vivo and in vitro studies find coupling pattern disparities specifically when dealing
with symptomatic patients with low back pain (27,34,47–50). According to Panjabi et al. (51),
“diseases and degeneration affect the physical properties of the spinal components (ligaments,
discs, facet joints, and vertebral bodies), which, in turn, alter the overall spinal behavior.” Current
research addresses the contribution of coupling motion from the disc and the facets (25). An in vivo
study (52) found that a narrowed intervertebral disc led to increased lateral bending, increased disc
shear at the level of abnormality, and asymmetric coupling patterns throughout adjacent functional
spine units. Lower lumbar levels (L3-4, L4-5) increased their coupling behavior and range while
decreasing at higher levels (L1-2, L2-3). Surgical fusion created increased mobility immediately
above the fused site (53). The coupling movement was abnormal and relied heavily on increased
motion in the posterior facet joints and shear of the intervertebral discs. Posterior-lateral disc
removal in vitro does significantly affect normal spinal kinematics. The alteration is not only present
in the single functional spinal unit but also the neighboring joints (38). Chronic back pain
diagnoses such as postlaminectomy, postdiscectomy, and disc degeneration leads to variability in
in vivo coupling at lower levels of the lumbar spine (37).
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
© 2012 by Pearson Education, Inc., Upper Saddle River, NJ
There seems to be little evidence to support that knowledge of lumbar spine coupling
characteristics are important in understanding and treating patients with low back pain (29). Many
manual therapy techniques use coupling-based mobilizations and the validity of this approach is
questionable. Several authors have suggested that the use of symptom reproduction to identify the
level of pathology is the only accurate assessment method (54–60). Because no pathological
coupling pattern has shown to be consistent, an assessment method in absence of symptom
reproduction may yield inaccurate results. Therefore, biomechanical coupling theory may only be
useful if assessed with symptom reproduction within a clinical examination (61). There is little
evidence to support a limited focus on biomechanical coupling patterns; therefore, techniques that
are based on this “theory” are excluded from this textbook.
Table 10.6: Serious, Specific Low Back Diseases (70).
Category
Specific Disorders
Examples of Disorders
1) Nonmechanical
spine disorders (+
1%)
Neoplasia
Metastases, lymphoid tumor, spinal cord
tumor
Infective spondylitis, epidural abscess,
endocarditis, herpes zoster, Lyme disease
Ankylosing spondylitis, psoriatic arthritis,
reactive arthritis, Reiter’s syndrome,
inflammatory bowel disease)
Prostatitis, endometriosis, pelvic inflammatory
disease
Nephrolithiasis, pyelonephritis, renal papillary
necrosis
Aortic aneurysm
Infection
Seronegative
spondyloarthritides
2) Visceral
disease (1–2%)
Pelvic
Renal
Aortic aneurysm
Gastrointestinal
3) Miscellaneous
Paget’s disease
Pancreatitis, cholecystitis, peptic ulcer
disease
Paget’s disease
Parathyroid disease
Parathyroid disease
Hemoglobinopathies
Hemoglobinopathies
Range of Motion
Troke et al. (62) report global flexion and extension range-of-motion values of 72 degrees
to 40 degrees of flexion and 29 degrees to 6 degrees of extension. Their findings suggest that
range of motion declines with age changes from 16 to 90 years. These findings are in accordance
Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E
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with others who have reported similar numbers and similar declines with advancing age (63,64).
Rotation and side flexion have also been studied extensively.
Summary
•
•
•
Little to no evidence exists to support the use of directional lumbar coupling biomechanics
for manual therapy techniques.
The use of coupling assessment as a basis for treatment is neither scientific nor evidence
based, and therefore may be inappropriate for certain patients.
The majority of segmental range of the motion in the lumbar spine occurs within a sagittal
plane, followed by coronal, and lastly, transverse.
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