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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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Label the following structures:

Range of Movement

Flexion Extension Side flexion Rotation


Cx 50 60 45 80
Tx 45 5 45 30
Lx 60 25 25 ? 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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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 and below
• Each successive layer alternates the direction of
the collagen fibres thus resisting movement
both vertically and horizontally &
providing stability against shear & torsion

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

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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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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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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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 .
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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References:

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.8-
20.

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.