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Functional Anatomy of the Lumbar Spine

Functional Anatomy of the Lumbar Spine

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Functional Anatomy of the Lumbar Spine
Nabil A. Ebraheim, MD,* Ali Hassan, MD,
Ming Lee, MS,
and Rongming Xu, MD
 The dysfunction of the lumbar spine has a pivotal role in etiology of low back pain. A thorough knowledge of the functional anatomy of the lumbar spine is needed to aid inunderstanding the mechanisms that lead to low back pain and to provide rationale ofmanagement. This article reviews functional anatomy of the lumbar spine involving thebony structures, articulation, ligaments, muscles, blood supply, and neural structures.Semin Pain Med 2:131-137 © 2004 Elsevier Inc. All rights reserved.
anatomy, lumbar spine, low back pain
he dysfunction of the lumbar spine has a pivotal role inetiology of low back pain. A thorough knowledge of thefunctional anatomy of the lumbar spine is needed to aid inunderstanding of the mechanisms that cause low back painand to provide rationale of management. This article reviewsthe functional anatomy of the lumbar spine involving thebony structures, articulation, ligaments, muscles, blood sup-ply, and neural structures.
Osseous Structures
There are 5 lumbar vertebrae, followed by the sacrum. Eachlumber vertebra has 2 parts, the vertebral body and neuralarch. The vertebral body lies anteriorly, and its dimensionsgradually increase from cephalad to caudal. The neural archlies posterior to vertebral body and consists of a pair of pedicles emerging from the postero-lateral surface of the up-per portion of vertebral body that joins with paired laminae,which are located further posteriorly (Fig. 1). When viewedfrom above, the superior surface of vertebral body is widertransversely and resembles to kidney’s shape. The spinal ca-nalistriangular,whichismostdistinguishableattheL5level.The angled lateral borders of the spinal canal are called thelateral recesses, which constitute the bony canal of the spinalnerve root. Pedicles are short and have a slight medial incli-nation.In general, the pedicle width increases gradually from L1toL5butthepedicleheightvariesbetweenindividuals(Table1).
The pedicle lengths measured between the dorsal andventral cortex of the vertebra averages between 40 and 50mm. The medial inclination of the lumbar pedicle increasesconsistently from L1 to L5. The projection point of the pedi-cle axis is located above the midline of the transverse processat the levels above L4. At L4, the projection point is close tothe midline of the transverse process. At L5, this point islocated inferior to the midline of the transverse process.
The lamina is thicker and oriented in a more vertical di-rectioninthesagittalplaneascomparedwiththecervicalandthoracic spines. The lamina may be divided into 2 portions:the cephalic and caudal.
The cephalic portion is arched andhas a smooth inner surface, whereas the caudal portion has arough inner surface, which is the site for the attachment of the ligamentum flavum.The portion of the lamina between the superior and infe-riorarticularprocessesandjustbelowthelevelofthepedicleis the isthmus or pars interarticularis, which is the commonsite of stress fractures. The superior and inferior articularfacets are quite different from the cervical and thoracic re-gions, which are orientated in the sagittal plane. In lumberregion, the superior articular surface is concave and facesposteromedially, and the inferior articular surface is convexand faces anterolaterally. The facet angles relative to the sag-ittal plane ranges from 120° to 150°, with a trend of consis-tent decrease from L1 to L5.
From the junction of 2 lamina,a spinous process arises posteriorly. It is almost horizontal,quadrangular, and thickened along its posterior and inferiorborders.
Articulations and Ligaments
The articulations include the intervertebral disc anteriorlyand a pair of the facet or zygapophyseal joints posteriorly,reinforced by ligaments. The intervertebral discs, which are
*DepartmentofOrthopaedicSurgery,MedicalCollegeofOhio,Toledo,OH.†Department of Anesthesiology, Medical College of Ohio, Toledo, OH.‡Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhe- jiang, P.R. China. Address correspondence to Nabil A. Ebraheim, MD, Department of Ortho-paedic Surgery, Medical College of Ohio, 3000 Arlington Avenue, To-ledo, OH 43614.
1537-5897/04/$-see front matter © 2004 Elsevier Inc. All rights reserved.doi:10.1016/j.spmd.2004.08.004
avascular structures, are located in between adjacent verte-bral bodies and allow flexion, extension, and lateral bendingmotions. They mainly consist of a centrally located nucleuspulposus, the annulus fibrosus encircling the nucleus pulpo-sus, and cartilaginous end plates adjacent to the surfaces of the vertebral bodies (Fig. 2).The nucleus pulposus is composed mainly of mucoid ma-terial, which contains 70% to 90% water.
On T
-weightedmagnetic resonance imaging, the nucleus pulposus showshyperintensity signal (white). The percentage of the water inthe nucleus pulposus gradually decreases with aging. Afterthe fifth decade, the nucleus pulposus becomes less distin-guishable from the annulus fibrosis due to the loss of water.The loss of water could be the major factor responsible fordisc degeneration, presented by the decrease in height of thedisc.The annulus fibrosus consists mainly the collagenous fi-bers and looks like a laminated structure surrounding thenucleus pulposus. The posterior portion of annulus fibrosusisthinnerascomparedwithitsanteriorportion.Thefibersof the lamellae are arranged obliquely in concentric rings thatoverlap one another. The peripheral fibers of the annulusfibrosus insert into the cartilaginous end plates and anteriorandposteriorlongitudinalligaments.Intheposteriorportionof the disc, the fibers run in a more vertical direction.
 Athinner posterior annulus fibrosus and a more vertical ar-rangementofthefiberscouldaccountforincreasedincidenceof posterior or posterolateral disc herniation as compared
Figure 1
The superior, posterior, and lateral views of the lumbar vertebra.
Table 1
Anatomic Parameters of Lumbar Pedicle (Mean
SD, mm)
L1 15.4
2.8 8.7
2.3 15.9
0.8 8.6
0.9 14.1
1.3 7.5
1.5L2 15.0
1.5 8.9
2.2 14.9
0.5 8.3
0.7 14.0
1.2 8.2
1.3L3 14.9
2.4 10.3
2.6 14.4
0.6 10.2
0.6 13.9
1.4 9.8
1.1L4 14.8
2.1 12.9
2.1 15.5
0.5 14.1
0.3 12.8
1.7 12.7
1.9L5 14.0
2.3 18.0
4.1 19.6
0.9 18.6
1.0 11.4
1.4 18.0
PH, pedicle height; PW, pedicle width.
N.A. Ebraheim et al 
withanteriorherniation.Discherniationsarecommonlyseenin the lumbar spines at the levels ofL4 to 5 and L5 to S1. Thecartilaginous end plate that is located between the vertebralbody and disc, functions as a growth plate and transfusesnutrients from the vertebral body to the disc.
Facet Joints
Facet joint (zygapophyseal or synovial joint) consists of theadjacent inferior and superior articular processes and thearticular capsule. The articular surfaces are covered by hya-line cartilage, which allows sliding motion occurring in theposterior arch of the spinal column. The articular capsulesare thin, and have an inner synovial and an outer fibrousmembrane. They are attached peripheral to the articular sur-facesofthefacetjoints.Inthelumbarregionnarrowingofthe joint space, thinning of articular cartilage, and hypertrophyof the subarticular cortical bone are the frequently observedchanges due to aging process.
There are several ligaments that play an important role instabilization of the spines as one unit. These include theanterior and posterior longitudinal ligaments, ligamentumflava or yellow ligaments, supraspinous and interspinous lig-aments (Fig. 3).The anterior longitudinal ligament is a strong band thatattaches to the whole anterior aspect of the vertebral bodiesand intervertebral discs from the skull down to the upperpart of sacrum. It is thicker anteromedially and thinner lat-erally. Its most superficial fibers are the longest and extendover 3 to 4 vertebrae. Its deepest fibers extend over 2 verte-brae and are firmly attached to the inferior margin of the onevertebraandtothesuperiormarginofthenext.Limitationof extension of the spinal column is the main function of theanterior longitudinal ligament.Opposingtheanteriorlongitudinalligament,theposteriorlongitudinal ligament attaches to the posterior aspect of thevertebral bodies and discs, from the occipital bone to thesacrum. It is broad and uniform in the cervical region, but inthe thoracic and lumber regions it is narrow over the middleof the vertebrae and broad over the discs. In the region of theintervertebral foramen, the posterior longitudinal ligamentextends laterally and fuses with the lateral extensions of theanterior longitudinal ligament. Similar to the anterior longi-tudinal ligament, the superficial fibers of the posterior longi-tudinalligamentextendover3to4vertebrae,andthedeeperfibers bridge merely the adjacent vertebrae. The role of theposterior longitudinal ligament is to stabilize the spinal col-umn during flexion.The ligamentum flava are present in between the laminaeofadjacentvertebraeandfusewitheachotherinthemidline.They are mainly composed of the yellow elastic fibers, whichrun in vertical direction. The attachments of the ligamentumflavum extend from the lower portion of the anterior surfaceof the upper laminae to the upper portion of the posteriorsurface of the lower laminae, covering whole interlaminar
Figure 2
The sagittal and transverse sections of the lumbar disc.
Functional anatomy of the lumbar spine 

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