Lumbar SpineLumbar Spine

Dr. Sue ShapiroDr. Sue Shapiro

Associate ProfessorAssociate Professor

Barry UniversityBarry University

Lumbar Spine Bony Lumbar Spine Bony AnatomyAnatomy

5 lumbar vertebrae5 lumbar vertebrae Massive vertebrae Massive vertebrae

bodies with the bodies with the width greater than width greater than the anterior-the anterior-posterior diameterposterior diameter

L4 &5 slightly L4 &5 slightly wedge-shaped & wedge-shaped & anterior convexity anterior convexity (anterior pelvic tilt) (anterior pelvic tilt) these features these features stabilize and stabilize and accommodate the accommodate the increasing body increasing body weight supported at weight supported at the end of spinal the end of spinal columncolumn

Facet Joints of Lumbar SpineFacet Joints of Lumbar Spine Articular process have a Articular process have a

distinct concave-convex distinct concave-convex arrangement: inferior arrangement: inferior facet sits medial to the facet sits medial to the superior while superior superior while superior facet faces medial and facet faces medial and posterior and is concave posterior and is concave the inferior is convex and the inferior is convex and faces anterior and faces anterior and laterally- this limits laterally- this limits rotation f the lumbar and rotation f the lumbar and facilitates flexion, facilitates flexion, extension and side extension and side bendingbending

Lumbar Spine FacetsLumbar Spine Facets

Lumbar Superior FacetsLumbar Superior Facets Superior facet serve Superior facet serve

as attachment for as attachment for MultifidusMultifidus

Multifidus muscle has Multifidus muscle has the same mechanical the same mechanical function as the function as the semispinalis capitis semispinalis capitis muscle of cervical muscle of cervical spine; they are spine; they are primary extensors of primary extensors of the lumbar and the lumbar and cervical spinecervical spine

Spinous Process Orientation in Spinous Process Orientation in Lumbar SpineLumbar Spine

Lumbar spine spinous Lumbar spine spinous process have process have horizontal and horizontal and extended posterior extended posterior orientation making it orientation making it possible to insert a possible to insert a needle b/t the needle b/t the adjacent vertebrae at adjacent vertebrae at L3 & L4 for CSF – know L3 & L4 for CSF – know as the lumbar as the lumbar puncturepuncture

Sacral SpineSacral Spine

Wedged structure made Wedged structure made up of 5 fused vertebraeup of 5 fused vertebrae

Superior it articulates Superior it articulates with the L5 vertebraewith the L5 vertebrae

Inferior with coccyx and Inferior with coccyx and Laterally with the iliumLaterally with the ilium This articulation is This articulation is

considered to be the considered to be the keystone of pelvic archkeystone of pelvic arch

Sacral Spine Anterior /Posterior Sacral Spine Anterior /Posterior ViewView

There is a separate anterior and posterior foramina There is a separate anterior and posterior foramina where the sacral nerves exit. The anterior divisions exit where the sacral nerves exit. The anterior divisions exit from anterior sacral foramen and give rise to the sciatic from anterior sacral foramen and give rise to the sciatic nervenerve

L5 S1 JunctionL5 S1 Junction Intervertebral disc Intervertebral disc

located b/t L5 & sacrum located b/t L5 & sacrum is very thick especially is very thick especially in anterior borderin anterior border

This is where the This is where the lumbarsacral angle is lumbarsacral angle is formedformed

The most notoriously The most notoriously frequent site for pain in frequent site for pain in the low backthe low back

An increase in lumbar An increase in lumbar lordosis or increase lordosis or increase pelvic tilt of the pelvis pelvic tilt of the pelvis results in an increased results in an increased lumbosacral angle. lumbosacral angle. Whereas a decreased in Whereas a decreased in lumbosacral angle is lumbosacral angle is due to posterior tilt of due to posterior tilt of pelvispelvis

Lumbar SacralizationLumbar Sacralization 55thth lumbar vertebra lumbar vertebra

may be fused at the may be fused at the lumbosacral joint lumbosacral joint

The transverse The transverse processed forms a processed forms a pseudoarthrosis at pseudoarthrosis at its point of contact its point of contact with the sacral wingwith the sacral wing

The L3,4 nerve The L3,4 nerve roots may become roots may become irritated on left irritated on left lateral flexion due lateral flexion due to mechanical to mechanical irritationirritation

Lumbar SacralizationLumbar Sacralization

SpondylolisthesisSpondylolisthesisDue to anterior Due to anterior

shearing of L5 on the shearing of L5 on the sacrum there is a sacrum there is a tendency toward tendency toward anterior anterior displacement of displacement of lumbar facetslumbar facets

Spondylolisthesis Spondylolisthesis refers to anterior refers to anterior displacement of one displacement of one vertebra upon the vertebra upon the subjacent vertebra subjacent vertebra and is seen at the and is seen at the lumbosacral lumbosacral articulation.articulation.

Common Causes of Common Causes of SpondylolisthesisSpondylolisthesis

1. Most common 1. Most common cause is a defect cause is a defect in the bony in the bony region between region between the superior and the superior and inferior articular inferior articular processes of the processes of the vertebrae (pars vertebrae (pars interarticularis)interarticularis)

2. a fracture – 2. a fracture – stress fracturesstress fractures

3. an elongated 3. an elongated pediclepedicle

Scotty Dog DeformityScotty Dog Deformity Classification of SpondylopathiesClassification of Spondylopathies

Spondylitis- Inflammation of Spondylitis- Inflammation of the vertebraethe vertebrae

Spondylosis- Arthritis or Spondylosis- Arthritis or osteoarthritis of the osteoarthritis of the vertebrae resulting in vertebrae resulting in pressure being placed o the pressure being placed o the vertebral nerve rootvertebral nerve root

Spondylolisthesis- Forward Spondylolisthesis- Forward slippage of a vertebra o the slippage of a vertebra o the one below it ( may occur one below it ( may occur secondary to spondylolysis in secondary to spondylolysis in which the fx of pars which the fx of pars interarticularis resultsinterarticularis results

Spondylolysis- Degeneratio of Spondylolysis- Degeneratio of a vertebra structure a vertebra structure secondary to repetitive secondary to repetitive stress, most commonly stress, most commonly affecting the pars affecting the pars interarticularis but with no interarticularis but with no displacement of the vertebral displacement of the vertebral body.body.

SpondylolisthesisSpondylolisthesis

Sacroiliac JointSacroiliac Joint Fusion of first 3 sacra vertebrae and iliumFusion of first 3 sacra vertebrae and ilium Movement of sacrum on the ilium is referred to as Nutation Movement of sacrum on the ilium is referred to as Nutation

( flexion) or countranutation (extension)( flexion) or countranutation (extension) Movement of ilium on the sacrum is referred to as torsion – Movement of ilium on the sacrum is referred to as torsion –

Anterior torsion occurs when the ASIS moves forward and Anterior torsion occurs when the ASIS moves forward and down ; posterior torsion occurs when the ASIS moves upward down ; posterior torsion occurs when the ASIS moves upward and back and back

Lumbosacral TrunkLumbosacral Trunk LST is in close LST is in close

approximation to the approximation to the LSJ and can cause LSJ and can cause compression injuries compression injuries that may cause that may cause muscle spasms. muscle spasms.

Since L4 & L5 are the Since L4 & L5 are the principal constituents principal constituents of the sciatic nerve of the sciatic nerve (L4-S3) any irritation (L4-S3) any irritation can cause Sciatica can cause Sciatica

Spinal Nerves and PlexusSpinal Nerves and Plexus There are 31 pairs of There are 31 pairs of

spinal nervesspinal nerves They form networks of They form networks of

nerves or plexus -5 nerves or plexus -5 plexusesplexusesCervical Plexus- C1-C4Cervical Plexus- C1-C4

Brachial Plexus-C5- T1Brachial Plexus-C5- T1 Lumbar plexus L1-L4Lumbar plexus L1-L4 Sacral plexus L4- S4Sacral plexus L4- S4 Coccygeal plexus S4-Coccygeal plexus S4-

S5S5

CoccyxCoccyx Composed of 3-5 fused Composed of 3-5 fused

vertebral bodies that vertebral bodies that have no vertebral archhave no vertebral arch

11stst coccygeal vertebra coccygeal vertebra is the largest and is the largest and articulates with the articulates with the sacrum at the sacrum at the sacrococcygeal junctionsacrococcygeal junction

Serves as a bony origin Serves as a bony origin for muscles of the for muscles of the pelvic diaphragmpelvic diaphragm

Falls on to the coccyx Falls on to the coccyx can be very painful and can be very painful and necessitate coccyx necessitate coccyx excision for pain reliefexcision for pain relief

Ligaments of the Lumbar Ligaments of the Lumbar SpineSpine

Anterior Longitudinal Lig- Anterior Longitudinal Lig- It’s narrow in the Cs It’s narrow in the Cs region, increases in width region, increases in width in the lumbar spinal in the lumbar spinal column. Prevents anterior column. Prevents anterior disc protrusiondisc protrusion

Posterior Longitudinal LIg.- Posterior Longitudinal LIg.- it’s widest in C spine but it’s widest in C spine but narrows in the thoracic and narrows in the thoracic and lumbar spine- only ½ as lumbar spine- only ½ as wide in lumbar spine as in wide in lumbar spine as in C spine which is a problem C spine which is a problem for posterior stability of for posterior stability of disc and shifting in L spine disc and shifting in L spine

Ligaments of the Lumbar Ligaments of the Lumbar SpineSpine

Ligamentum flavum – Ligamentum flavum – bridges the space b/t bridges the space b/t adjacent laminae and is adjacent laminae and is highly elastic preventing highly elastic preventing the chance that lig. Will the chance that lig. Will buckle into the spinal canalbuckle into the spinal canal

Interspinous Lig. Broad Interspinous Lig. Broad and thick, resist separation and thick, resist separation of the spinous processes of the spinous processes therefore limiting flexion of therefore limiting flexion of the lumbar segments the lumbar segments

Supraspinous ligament- Supraspinous ligament- most outward lig. That most outward lig. That terminates at L4 in 22% of terminates at L4 in 22% of individuals and completely individuals and completely lacking at L5-S1. It limits lacking at L5-S1. It limits forward bending of the forward bending of the lumbar spinelumbar spine

Iliolumbar LigamentsIliolumbar Ligaments

Sacroliliac LigamentsSacroliliac Ligaments

LUMBAR DISCLUMBAR DISC

Lumbar disc are Lumbar disc are significantly significantly thicker and thicker and have a greater have a greater cross sectioncross section

Provide 1/3 of Provide 1/3 of the length in the length in the lumbar the lumbar spine compared spine compared to 1/5 in to 1/5 in cervical and cervical and thoracic spinethoracic spine

Herniated Disc Herniated Disc ClassificationsClassifications

Protruded- some eccentric accumulation of the Protruded- some eccentric accumulation of the nucleus with slight deformity of annulusnucleus with slight deformity of annulus

Prolapsed- definite deformity as it works its way Prolapsed- definite deformity as it works its way through the fiber of annulusthrough the fiber of annulus

Extruded - nuclear material comes into the spinal Extruded - nuclear material comes into the spinal canal and runs the risk of impinging adjacent nerve canal and runs the risk of impinging adjacent nerve rootsroots

Sequestrated- nuclear material has separated from Sequestrated- nuclear material has separated from the disc itself and potentially migratesthe disc itself and potentially migrates

Degenerated DiscDegenerated Disc Disc herniation can Disc herniation can

be acute or stress be acute or stress relatedrelated

Most show signs of Most show signs of previous previous degenerationdegeneration

Most common Most common lumbar disc lumbar disc herniation are herniation are between L4-L5 and between L4-L5 and L5-S1L5-S1

Next most common Next most common herniations are lower herniations are lower two cervical discs two cervical discs

Disc Impingement Disc Impingement SymptomsSymptoms

Intervertebral discs are not innervated thus do not cause pain , it is Intervertebral discs are not innervated thus do not cause pain , it is sensory nerves supplying the ligaments, bony structures, spinal sensory nerves supplying the ligaments, bony structures, spinal cord or spinal nerves that produce both sensory and motor cord or spinal nerves that produce both sensory and motor symptomssymptoms

Depending on where herniation takes place the myotome and Depending on where herniation takes place the myotome and dermatome patterns associated with the nerve root will cause dermatome patterns associated with the nerve root will cause symptoms symptoms

Spinal SternosisSpinal Sternosis

Defined as a loss of cerebrospinal fluid around the spinal cord due to Defined as a loss of cerebrospinal fluid around the spinal cord due to deformation of the spinal cord, or a narrowing of the neural canaldeformation of the spinal cord, or a narrowing of the neural canal

Common symptom is bilateral leg weakness and numbness with or Common symptom is bilateral leg weakness and numbness with or without sciatica: neg SLR; + pain on prolonged spine extension without sciatica: neg SLR; + pain on prolonged spine extension exacerbated with ipsilateral trunk lateral flexionexacerbated with ipsilateral trunk lateral flexion

Combination of Disc Combination of Disc Degeneration and Spinal Degeneration and Spinal Sternosis or SpondylosisSternosis or Spondylosis

Orthopedic Test for Disc Orthopedic Test for Disc PathologyPathology

Well Leg Raise TestWell Leg Raise Test Milgram TestMilgram Test Valsalva’s TestValsalva’s Test Naffzinger TestNaffzinger Test

SciaticaSciatica Defined as compression and/or inflammation of a Defined as compression and/or inflammation of a

spinal nerve making up the sciatic nerve due to a spinal nerve making up the sciatic nerve due to a herniated disc, annular tear, myogenic or muscle-herniated disc, annular tear, myogenic or muscle-related disease, spinal sternosis, facet joint related disease, spinal sternosis, facet joint arthropathy, or compression from the piriformis arthropathy, or compression from the piriformis musclemuscle

Typically, if related to herniated disc, radiating Typically, if related to herniated disc, radiating leg pain is greater than back pain and increases leg pain is greater than back pain and increases with sitting and leaning forward , coughing, with sitting and leaning forward , coughing, sneezing and strainingsneezing and straining

Pain is produced during ipsilateral SLRPain is produced during ipsilateral SLR With annular tears, back pain is more prevalent With annular tears, back pain is more prevalent

and exacerbated with SLRand exacerbated with SLR Different from spinal sternosis because back pain Different from spinal sternosis because back pain

starts usually after walking a limited distance and starts usually after walking a limited distance and concomitantly increases as distance increases . concomitantly increases as distance increases . Pain is not reproduced with SLR but can be Pain is not reproduced with SLR but can be reproduced with prolonged spine extension, reproduced with prolonged spine extension, which is relieved with spine flexionwhich is relieved with spine flexion

Orthopedic Test to Evaluate Orthopedic Test to Evaluate SciaticaSciatica

Straight Leg Raise “Lasegue Test”Straight Leg Raise “Lasegue Test” Kernig/Brudzinski TestKernig/Brudzinski Test Bowstring Test (Cram Test)Bowstring Test (Cram Test) Slump TestSlump Test

Low Back Pain (LBP)Low Back Pain (LBP) 60 to 80% of the population experiences LBP at some 60 to 80% of the population experiences LBP at some

time in their livestime in their lives Males and females appear to be equally susceptibleMales and females appear to be equally susceptible LBP is second only to the common cold as the leading LBP is second only to the common cold as the leading

cause of lost work timecause of lost work time Back injuries dominate claims for worker’s compensationBack injuries dominate claims for worker’s compensation LBP accounts for 10% of all chronic health problems and LBP accounts for 10% of all chronic health problems and

is ranked 11is ranked 11thth among causes for hospitalization in the US among causes for hospitalization in the US Most cases are idiopathic or unknown origin Most cases are idiopathic or unknown origin Mechanical stress is the primary causal mechanism Mechanical stress is the primary causal mechanism Most common among runners , soccer, field hockey , Most common among runners , soccer, field hockey ,

lacrosse, rowers lacrosse, rowers Mechanism of injury is tight hip flexors, hamstring which Mechanism of injury is tight hip flexors, hamstring which

produce a forward body lean leading to anterior pelvic produce a forward body lean leading to anterior pelvic tilt and hyperlordosis of the lumbar spinetilt and hyperlordosis of the lumbar spine

Lumbar Contusion, Strains, and Lumbar Contusion, Strains, and SprainsSprains

Soft tissue injuries are the most common Soft tissue injuries are the most common injuries in the lumbar spineinjuries in the lumbar spine

MOI – Lumbar muscles develop tension to MOI – Lumbar muscles develop tension to counteract the forward bending moment counteract the forward bending moment of the entire trunk when the trunk is in of the entire trunk when the trunk is in flexion, they are susceptible to strainflexion, they are susceptible to strain

Symptoms: Localized pain, increasing with Symptoms: Localized pain, increasing with active and resistive motion, radiating pain active and resistive motion, radiating pain and neurological deficitsand neurological deficits

Abdominal Muscle StrainsAbdominal Muscle Strains

Hip Flexor MusclesHip Flexor Muscles

Erector Spinae and Multifidus Erector Spinae and Multifidus MusclesMuscles