Band 5 IST

3/11/09

Ronan Donohoe

LUMBAR SPINE THEORY
• • • • 5 vertebrae with intervening discs from the lower thoracic spine to sacrum Most load bearing structures in the skeletal system Lordotic in shape which gives it resilience and helps to protect against compressive forces Origin of most back pain o lifetime prevalence of up to 84% (Airaksinen et al., 2004) o 13.5% of incapacity benefits in 2004 (CSP, 2006) o direct medical costs est £1.6 billion, overall cost to the economy varied between £6.6 billion to £12.3 bn Maniadakis and Gray, 2000) o strong evidence psychosocial factors linked to transition from acute to chronic LBP (lasting over 12 weeks) (Kendall & Linton, 1998)

Anatomy

Basic anatomy of lumbar vertebra
• • Largest body/disc, lamina and pedicles short and thick for load bearing Articular processes facet joints aligned more vertically allowing flexion/extension but little rotation -

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Band 5 IST Label the following structures:

3/11/09

Ronan Donohoe

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Range of Movement

Cx Tx Lx

Flexion 50 45 60

Extension 60 5 25

Side flexion 45 45 25

Rotation 80 30 ? 1.5

Muscles of the Lumbar Spine Can be divided into 3 groups based on position and function: 1. Psoas major. Attaches directly to the vertebral bodies anterolaterally and acts as a primary flexor muscle of the hip joint. 2. Quadratus lumborum and the lateral intertransversarii. Attach to and cover the transverse processes anteriorly. They act as lateral flexors. 3. Interspinales, intertransversarii mediales, multifidi, lumbar erector spinae (longissimus and iliocostalis). They attach directly to the lumbar vertebrae and act as extensor muscles Thoracolumbar Fascia (TLF) - Tough fibrous sheet covering the back, tensioned by muscles above, the side & below. Through it, these muscles transmit their power across the whole spine. - Tensioning the TLF using TrA reduces vertebal displacement when the spine is loaded in flexion but increases displacement when loaded in extension. (See Norris, 20008)

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Band 5 IST

3/11/09

Ronan Donohoe

Transversus abdominus – (TrA) O: Iliac crest, inguinal ligament, lumbar fascia, and cartilages of inferior six ribs I: Xiphiod process, linea alba, and pubis A: compresses abdomen, important in core stability,

Gross structure of the intervertebral disc
Three basic components: • annulus fibrosis (outer part) - tough circular exterior composed of concentric sheets of collagen fibers (lamellae) • nucleus pulposus (inner part) - loose network of fibers suspended in a mucoprotein gel. • Cartilaginous end plate – attaching to body above & below Annulus fibrosus • consists of water and collagen fibres arranged in sheets and concentric rings surround the nucleus • Collagen fibres lie at an angle of 65-70 from vertical and firmly attach to the body above • Each successive layer alternates the the collagen fibres thus resisting movement both vertically and horizontally & providing stability against shear & torsion

and below direction of

Nucleus pulposus (“jam in the donught”) • is a semifuid gel comprising 40- 60% of the disc, consists of 70-90% water - decreases with age • confers properties of a fluid on the nucleus • pressure therefore in one direction results in deformation and application of pressure in all directions without reduction in volume • this property enables it to both accommodate to movement and to transmit some of the compressive load from one vertebrae to the next. NB: Lumbar spinal discs are avascular and depend on fluid exchange by passive diffusion. Regular movement & activity are vital for this!

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Band 5 IST Ligaments • anterior longitudinal • posterior longitudinal • articular capsules • ligamentum flava • interspinous ligts • supraspinous ligts • intertransverse ligts • transforaminal ligts • ligamentum flavum ligts

3/11/09

Ronan Donohoe

Dermatomes / Myotomes The most common sites for a herniated lumbar disc are L4-5 and L5-S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee

Articulations • Intervertebral joint - Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together. • Zygapophyseal (facet) joint- synovial joint between superior and inferior articular process. Interlocking in vertical plane in lumbar spine. Prevent rotation in the transverse plane, whilst allowing sagittal rotation (flexion and extension) and a small amount of frontal rotation (lateral bending)

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Band 5 IST

3/11/09

Ronan Donohoe

Intradiscal pressures Relative increases and decreases in intradiscal pressure in relation to different body positions. Note that seated and bending postures apply more pressure to the disc than do standing and recumbent positions. This explains the exacerbation of symptoms of herniated disc when patients are in the former positions.

Common postural deficits

Centre of gravity: The line of gravity of passes ventral to the fourth lumbar vertebral body Functional Scoliosis – ensure to assess for corrective orthotics

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Band 5 IST

3/11/09

Ronan Donohoe

Common conditions
• • • • • • • Spondylosis Spondyloysthesis Ankylosing spondylitis Nerve root pain Cauda Equina Red Flags – Briefly – to be done Feb 9th Yellow Flags - ABCDEFW

Spondylolysis (scottie dog fracture) • Defect in pars interarticularis (Unilateral) • Major cause of lower back pain in children and adolescents • Unilateral Pars defect is the result of a fatigue fx from repetitive hyperextension • Most common in gymnasts and football lineman Spondylolisthesis • Bilateral Pars Interarticularis defect • Forward slippage of one vertebra on another • Usually L5-S1 Ankylosing spondylitis (bamboo spine) • Men, 3rd to 4th decade of life • Insidious onset of back and hip pain • Morning stiffness • Spine becomes rigid (ankylosed) • Progressive spinal flexion deformities (may progress to a chin-on-chest deformity) • Systemic effects Nerve root pain • Unilateral leg pain > back pain • Pain radiating to foot / toes with numbness in same distribution • Nerve irritation signs – reduced SLR reproducing leg pain • Motor, sensory or reflex change – limited to 1 nerve root • Resonable prognosis – 50% recover from acute attack within 6/52 Herniated Nucleosus pulposis (HNP) vs. Spinal Stenosis • HNP/Spinal Stenosis Comparisons • Age: 30-50 vs >50 • Sciatica: Classic for HNP vs Atypical for Stenosis • Aggravated: Flexion/Sitting vs Extension & Standing • Nerve Tension Signs (SLR): Usual vs Unusual • Prognosis: Worse, More Chronic in Stenosis HNP/Spinal Stenosis Treatment: Decompression, Laminectomy, Foraminotomy, Fusion

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Band 5 IST

3/11/09

Ronan Donohoe

Other Treatments • Mobilisation • Core Strengthening –Trans abs • McKenzke Red flags Possible serious spinal pathology, (cauda equina syndrome, spinal fracture, cancer or infection) Fill in the boxes: C.E., # or Ca below • • • • • • • • • • • • • Saddle anaesthesia Age onset <20 of >55 Violent trauma Constant, progressive, non mechanical pain Thoracic pain PMH - carcinoma Systemic steroids Drug abuse, HIV Weight loss Recent onset of bladder or dysfunction Persisting severe restriction of Lx Flexion Widespread neurology Structural deformity

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ACTION: Usually immediate referral to hospital. Yellow flags - ABCDEFW Psychosocial determinants of chronicity, barriers to recovery & return to work. Attitudes, Behaviours, Compensations, Diagnosis, Emotions, Family and Work ACTION: Screening by a suitably qualified health professional using a questionnaire or interview technique, which then informs treatment and rehabilitation planning. Other flags: Orange Flags Relate to serious psychological and psychiatric illness. E.g. diagnosis or suspicion of psychosis, suicidal tendencies or addictive behaviours such as alcoholism. ACTION: Referral on to GP, Clinical Psycholgist or Psychiatrist or Hospital for further assessment Blue Flags Blue Flags are usually considered to be the perceptions of the situation by the employee or the employer Black Flags Black flags are societal or cultural factors that can be an obstacle to recovery and return to work e.g. welfare system Pink Flags "good" flags - positive things that will help a person to return to work and recovery.

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Band 5 IST References:

3/11/09

Ronan Donohoe

Images: Various, from Google images. Airaksinen, O., Brox, J.I., Cedraschi, C. Hildebrandt, J., Klaber-Moffett, J., Kovacs, F., Mannion, A.F., Reis, S., Staal, J. B., Ursin, H. and Zanoli, G. (2004) European guidelines for the management of chronic non-specific low back pain [online]. European Commission, Research Directorate General, [cited on 03 March 2008] Available from World Wide Web: <http://www.backpaineurope.org/web/files/WG2_Guidelines.pdf>. Burton, A. K., Balagué, F., Cardon, G., Eriksen, H. R., Henrotin, Y., Lahad, A., Leclerc, A., Müller, G., van der Beek, A. J., Henrotin, Y., Hänninen, O., and Harvey, E. (2004) European guidelines for prevention in low back pain [online]. European Commission, Research Directorate General, [cited on 1/3/08]. Available from the World Wide Web: <http://www.backpaineurope.org/web/files/WG3_Guidelines.pdf>. Chartered Society of Physiotherapy (2006) Clinical guidelines for the physiotherapy management of persistent low back pain - part 2 Exercise. London: Chartered Society of Physiotherapy. Clinical Standards Advisory Group (1994a) Back pain: report of a CSAG committee on back pain. London: HMSO. Dagenais, S., Caro, J. and Haldeman, S. (2008) A systematic review of low back pain cost of illness studies in the United States and internationally. The spine journal: official journal of the North American Spine Society, 8(1), pp.820. Donohoe, R. (2008) A study to investigate the ability of recently qualified physiotherapists to recognise known psychosocial risk factors in patients presenting with subacute low back pain. Unpublished Thesis. Manchester Manchester Metropolitan University, 2008. Kendall, N. A. S., Linton, S. J. and Main, C. (1998) Psychosocial Yellow Flags for acute low back pain: ‘Yellow Flags’ as an analogue to ‘Red Flags’. European Journal of Pain, 2, pp.87-89. Norris, C. M. (2008) Back Stability: Integrating Science and Therapy, 2nd ed. Maniadakis, N. and Gray, A. (2000) The economic burden of back pain in the UK. Pain, 84(1), pp.95-103.

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