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Chapter 25

Chapter 25. Lumbar Spine. Overview.

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Chapter 25

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  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

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