LUMBAR SPINE

By:VIDHUSHI VEDHARA M.P.T. Ortho 2nd yr

TOPICS COVERED
1 Anatomy 2 Biomechanics
Line of Gravity Osteokinematics Arthrokinematics Kinetics

3 PATHOMECHANICS

Typical lumbar vertebrae

BODY The body of the typical lumbar vertebra is massive, with a transverse diameter that is greater than the anterior diameter and height. The size and shape reflect the need to support great compressive loads caused by body weight, ground reaction forces, and muscle contraction. Arches Pedicles. The pedicles are short and thick and project posterolaterally. Laminae. The laminae are short and broad. Zygapophyseal Articular Processes (facets) both the superior and inferior Mamillary processes, which appear as small bumps, are located on the posterior edge of each superior zygapophyseal facet . The mamillary processes serve as attachment sites for the multifidus and medial intertransverse muscles.

Transverse Process. is long and slender and extends horizontally. Accessory processes, which are small and irregular bony prominences, are located on the posterior surface of the transverse process near its attachment to the pedicle. The accessory processes serve as attachment sites for the multifidus and medial intertransverse muscles. Spinous Process. The spinous process is broad and thick and extends horizontally. Vertebral Foramen. The vertebral foramen is triangular and larger than the thoracic vertebral foramen but smaller than the cervical vertebral foramen.

LUMBAR SPINE ANATOMY (Contd.)

The first four vertebrae are similar in structure. The fifth lumbar vertebra has structural adaptations for articulation with the sacrum. Characteristics of Lumbar Vertebrae: Have large vertebral bodies. Have short lamina and pedicles. Have mamillary and accessory processes. No costal facets. Facets: Sagittal. Good for flexion and extension but not rotation.

LUMBAR SPINE ANATOMY (Contd.)

LUMBAR SPINE ANATOMY (Contd.)

FIFTH LUMBAR VERTEBRA: It is a transitional vertebra. Differs from the rest in the fact that it has a wedge-shaped body wherein the anterior portion of the body is of greater height than the posterior portion. The L5/S1 Lumbosacral Disk is also wedge shaped. The spinous process is smaller than other lumbar spinous processes. The transverse processes are large and directed superiorly and posteriorly.

LUMBAR SPINE ANATOMY (Contd.)

LUMBAR SPINE ANATOMY (Contd.)

LUMBOSACRAL ARTICULATION: Formed by the fifth lumbar vertebra and first sacral segment. Lumbosacral Angle:
The first sacral segment, which is inclined slightly anteriorly and inferiorly, forms an angle with the horizontal called the lumbosacral angle. Size of the angle varies with the position of the pelvis and affects the superimposed lumbar curvature. An increase in this angle will result in an increase in the anterior convexity of the lumbar curve and will increase the amount of shearing stress at the lumbosacral joint.

LUMBAR SPINE ANATOMY (Contd.)

LUMBAR SPINE ANATOMY (Contd.)

Ligaments: Ligamentum Flavum Posterior Longitudinal Ligament Anterior Longitudinal Ligament Interspinous Ligaments Supraspinous Ligaments (terminates at L3 or L4) Zygapophyseal Joint Capsules

Ligaments specific to lumbar region : Iliolumbar Ligaments Thoracolumbar fascia

LUMBAR SPINE ANATOMY (Contd.)

Iliolumbar Ligaments
The iliolumbar ligaments consist of a series of bands that extend from the tips and borders of the transverse processes of L4 and L5 to attach bilaterally on the iliac crests of the pelvis . There are three primary bands: the ventral (or anterior) band the dorsal (or posterior) band,; the sacral band (sometimes called the lumbosacral ligament The iliolumbar ligaments as a whole are very strong and play a significant role in stabilizing the fifth lumbar vertebra (preventing the vertebra from anterior displacement) and in resisting flexion, extension, axial rotation, and lateral bending of L5 on S1.

LUMBAR SPINE ANATOMY (Contd.)

Fascia: Thoracolumbar Fascia: Three layers Anterior, Middle and Posterior Arise from transverse and spinous processes of the lumbar vertebrae Completely surrounds the muscles of the lumbar spine Anterior Layer derived from the fascia of the quadratus lumborum muscle and blends with the intertransverse ligaments Middle Layer Not well defined. Thought to lie posterior to the quadratus lumboram muscle. Attaches medially to the tips of the transverse processes and is continuous with the intertransverse ligaments.

LUMBAR SPINE ANATOMY (Contd.)

Posterior Layer It s superficial lamina is continuous with LATISSIMUS DORSI, GLUTEUS MAXIMUS and indirectly with EXTERNAL OBLIQUE ABDOMINIS and TRAPEZIUS. Most of the fibres of the superficial lamina derive from the aponeurosis of the latissimus dorsi and attach to the interspinous ligaments and spinous processes cranial to L4. Caudal to L4/L5 the superficial lamina is generally inly loosely attached to midline structures. Fibers cross to the contralateral side where they attach to the sacrum, posterior superior iliac spines and iliac crest. The two laminae of the posterior layer fuse with the middle layer to form a dense raphe to which the Tranversus Abdominis muscle is attached.
(* Raphe:- A seam; the line of union of the halves of various symmetrical parts)

LUMBAR SPINE ANATOMY (Contd.)

LUMBAR SPINE BIOMECHANICS

Line Of Gravity: Passes through the bodies of the lumbar vertebrae (according to Kendall).

LUMBAR SPINE BIOMECHANICS (Contd.)

Arthrokinematics:-

LUMBAR SPINE BIOMECHANICS (Contd.)

GLIDING

AXIAL DISTRACTION AND COMPRESSION

ANTERO-POSTERIOR TRANSLATION

TILTING OR SIDE-TOSIDE ROTATION

ROTATION

ANTERO-POSTERIOR ROTATION

LUMBAR SPINE BIOMECHANICS (Contd.)

MOTION Gliding or Side-to-Side Translation Axial Distraction and Compression or Superior and Inferior Translation Antero-Posterior Translation Tilting or Side-to-Side Rotation Rotation Tilting or Antero-Posterior Rotation AXIS Antero-Posterior Axis PLANE Frontal Plane

Vertical Axis

Transverse Plane

Frontal Axis Antero-Posterior Axis Vertical Axis Frontal Axis

Sagittal Plane Frontal Plane Transverse Plane Sagittal Plane

LUMBAR SPINE BIOMECHANICS (Contd.)

LIGAMENT FUNCTION Limits forward flexion and resists separation of the laminae REGION Axis (C2) to Sacrum. Thin, broad and long in cervical and thoracic regions and thickest in lumbar region Axis (C2) to Sacrum. Broad in the cervical and thoracic regions and narrow in the lumbar region C2 to Sacrum. Well developed in cervical, lower thoracic and lumbar regions Primarily in lumbar region Thoracic and Lumbar (C7-L3 or L4). Weak in lumbar region Strongest in cervicothoracic junction and in the thoracolumbar region Lower lumbar region Ligamentum Flavum

Posterior Longitudinal Ligament

Limits forward flexion and reinforces posterior portion of the annulus fibrosus Limits extension and reinforces anterolateral portion of annulus fibrosus and anterior aspect of the intervertebral joints Limit forward flexion Limit forward flexion

Anterior Longitudinal Ligament Interspinous Ligament Supraspinous Ligament Zygapophyseal Joint Capsule Iliolumbar Ligament

Resist forward flexion and axial rotation Resists anterior sliding of L5 on S1

ORTHOKINEMETICS During flexion :

the body of the upper vertebra tilts and slides gently anteriorly in the direction reducing the thickness of the intervertebral disc anteriorly and increasing it posteriorly. The disc therefore becomes wedge-shaped with its base facing posteriorly and the nucleus pulposus is driven posteriorly stretching the posterior fibres of the annulus fibrosus. As a result the ligaments of the joints between the articular processes are maximally stretched as well as all the ligaments of the vertebral arch-the ligamentum ft.avum, the interspinousligament , the supraspinous ligament and the posterior longitudinal ligament. These stretched ligaments finally limit flexion .

During extension
the body of the upper vertebra tilts and moves posteriorly in the direction of the arroW E. the disc is ft.attened posteriorly and expanded anteriorly The nucleus is pushed anteriorly, stretching the anterior fibres of the annulus and the anterior longitudinal ligament while relaxing the posterior longitudinal ligament. the articular processes of the lower and upper vertebrae become more tightly interlocked and the spinous processes touch one another. Hence extension is limited by the bony structures of the vertebral arch and the tension developed in the anterior longitudinal ligament.

During lateral flexion

the body of the upper vertebra tilts ipsilaterally while the disc becomes wedge-shped with its base facing contralaterally and the nucleus is slightly displaced contralaterally. T he contralateral intertransverse ligament is stretched while the ipsilateral ligament relaxes . When view from the back the articular processes slide relative to each other so that the ipsilateral process of the upper vertebra is raised while the contralateral process is lowered (9). This leads at the same time to relaxation of the contralateral ligamenta flava and of the capsular ligament of the joint between the articular processes and to stretching of these structures ipsilaterally.

During rotation
It must be stressed that the centre of this cylinder does not coincide with the centre of the vertebral plateaus, so :that, when the upper vertebra rotates on the lower vertebra this movement of rotation occurs about the former centre and the upper vertebra is found to slide over the lower vertebra . The disc (D) is not called into action during axial rotation and this theoretically should allow a greater range of movement. the shearing forces involved limit the range so that rotation of the lumbar column is minimal both segmentally and globally.

LUMBAR SPINE BIOMECHANICS (Contd.)

Osteokinematics:
MOVEMENT Forward Flexion Extension Axial Rotation Side Flexion RANGE 40 30 10 20-30 MUSCLES RESPONSIBLE Rectus Abdominis, Vertebral fibres of Ilio-Psoas Erector Spinae, Multifidus, Semispinalis Multifidus with opposite Internal Oblique and External Oblique Iliocostalis Lumborum, Longisimus Lumborum, Multifidus, External and Internal Obliques and Quadratus Lumborum

The orientation of the zygapophyseal facets from L1-L4 limits lateral flexion and rotation. The orientation of the lumbar zygapophyseal facets favors flexion and extension.

LUMBAR SPINE BIOMECHANICS (Contd.)

Flexion of the lumbar spine is more limited than extension and, normally, it is not possible to flex the lumbar region to form a kyphotic curve. The amount of flexion varies at each interspace of the lumbar vertebrae, but most of the flexion takes place at the lumbosacraljoint.
REGION L1-L2 L2-L3 L3-L4 and L5-S1 RANGE OF FLEXION 8o 9o 12o

LUMBAR SPINE BIOMECHANICS (Contd.)

During flexion and extension the greatest mobility of the spine occurs between L4 and S1, which is the area which must support the most weight. During everyday bending and lifting tasks, the flexion moment acting on the lumbar spine at L5-S1 has been estimated to be about 18Nm. In an erect standing posture, pressures on the lower disks are much greater than the weight of the body, and these pressures increase with movement and muscle contraction. Lateral flexion and axial rotation of the lumbar vertebrae are most free in the upper lumbar region and progressively diminish in the lower region. The largest lateral flexion ROM and axial rotation occurs between L2 and L3.

LUMBAR SPINE BIOMECHANICS (Contd.)

Rotation of the vertebra in the upper area is accompanied by movement of the spinous process toward the concavity of the lateral flexion curve, which is similar to rotation in the lower thoracic region. Little or no lateral flexion or rotation is possible at the lumbosacral joint because of the most common orientation of the zygapophyseal joints at 45o to the sagittal plane.

LUMBAR SPINE BIOMECHANICS (Contd.)

LUMBAR-PELVIC RHYTHM: Cailliet described a specific instance of coordinated, simultaneous activity of lumbar flexion and anterior tilting of the pelvis in the sagittal plane during trunk flexion and extension. He called the combined lumbar and pelvic motion, lumbar-pelvic rhythm. The activity of bending over to touch one s toes with knees straight depends on the lumbar-pelvic rhythm.
1. The first part of bending forward consists of lumbar flexion. 2. This is followed by anterior tilting of the pelvis at the hip joints. 3. A return to the erect posture is initiated by posterior tilting of the pelvis at the hips followed by extension of the lumbar spine. 4. The initial pelvic motion delays lumbar extension until the trunk is raised far enough to shorten the moment arm of the external load thus reducing the load on the erector spinae muscle.

LUMBAR SPINE BIOMECHANICS (Contd.)

A restriction of motion at either the lumbar spine or at the hip joints may disturb the rhythm and prevent a person from reaching her/his toes. Restriction of motion at one segment also may result in hypermobility of the unrestricted segment.
RANGE 0-15 Degrees After 15 Degrees >15 Degrees MOVEMENT L5 + Sacrum (Nutation) L5 alone Sacrum comes back (CounterNutation)

LUMBAR SPINE BIOMECHANICS (Contd.)

LUMBAR-PELVIC RHYTHM

Kinetics :
COMPRESSION : The lumbar region must also withstand the tremendous compressive loads produced by muscle contraction. Experimental testing of 10 cadaver spines subjected to 1000-N compressive loading demonstrated that the lumbar interbody joints shared 80% of the load, and the zygapophyseal facet joints in axial compression shared 20% of the total load. This percentage can change with altered mechanics: with increased extension or lordosis, the zygapophyseal joints will assume more of the compressive load. Also, with degeneration of the intervertebral disk, the zygapophyseal joints will assume increased compressive load. Lumbosacral loads in the erect standing posture were in the range of 0.82 to 1.18 times body weight, whereas lumbosacral loads during level walking were in the range of 1.41 to 2.07 times body weight (an increase of 56.3%). Changes in position of the body will change the location of the body s line of gravity and thus change the forces acting on the lumbar spine.

Shear: In the upright standing position, the lumbar segments are subjected to anterior shear forces cause by the lordotic position, the body weight, and ground reaction forces . This anterior shear or translation of the vertebra is resisted by direct impaction of the inferior zygapophyseal facets of the superior vertebra against the superior zygapophyseal facets of the adjacent vertebra below.

PATHOMECHANICS OF LUMBAR SPINE

INTERVERTEBRAL DISC PROLAPSE TYPES :

When compressed axially the substance of the nucleus pulposus can stream out in various directions. If the annulus is still strong the increase in pressure within the disc can cause the vertebral plateaus to give way. This corresponds to intravertebral prolapse the annulus fibres begin to degenerate after 25 years of age allowing tearing of fibres within each of its layers. Therefore under axial stress the nuclear material can stream out through the torn annulus . This streaming of nuclear material can be concentric or more often radial. Anterior prolapse is the rarest. Posterior prolapse is the most frequent, especially posterolateral prolapse. Thus, when the disc is crushed , part of the nuclear substance streams out anteriorly or more often posteriorly and can thus reach the posterior edge of the disc to touch the posterior longitudinal ligament .

 the streamer, still awiched to the nucleus, gets trapped uhder the posterior longitudinal ligament very often it breaks through the posterior longitudinal ligament and may lie within the vertebral canal-i.e., the so-called free type of disc prolapse. the nuclear streamer is trapped under the posterior longitudinal ligament and the streamer, after reaching the deep aspect of the posterior longitudinal ligament, ;Hides either superiorly or inferiorly This is a case of subligamentous prolapse. It is only when the herniating nucleus presses against the deep surface of the posterior longitudinal ligament that the nerve endings of the ligament are stretched causing low back pain (lumbago). Finally compression of the nerve roots by the herniating disc causes nerve root pain, i.e., sciatica.

DICS prolapse occurs in three stages :

Disc prolapse usually follows lifting of a weight with the trunk flexed forward.
During the first stage trunk flexion flattens the discs anteriorly and opens out the intervertebral space posteriorly. During the second stage , as soon as the weight is lifted, the increased axial compression force crushes the whole disc and violently drives the nuclear substance posteriorly until it reaches the deep surface of the posterior longitudinal ligament. During the third stage with the trunk nearly straight, the path taken by the herniating mass is closed by the pressure of the vertebral plateaus and the hernia remains trapped under the posterior longitudinal ligament. This causes the acute pain felt in the loin or lumbago which corresponds to the initial phase of the lumbago-sciatica complex. This initial acute lumbago can regress spontaneously or with treatment but, as a result of repeated trauma, the hernia grows in size and protrudes more and more into the vertebral canal. At this point it comes into contact with a nerve root, often one of the nerve roots of the sciatic nerve

FRACTURES :
VERTEBRAL END PLATE FRACTURES COMPRESSION FRACTURES THE BURST FRACTURE OF 5TH LUMBAR VERTEBRA GROSS FRACTURE DISLOCATIONS OF LUMBAR SPINE LAP BELT INJURIES

VERTEBRAL END PLATE FRACTURES