Spinal Stability

Tara Jo Manal PT, SCS, OCS

Clinical Instability

■ Loss of the ability of the spine under

physiologic loads to maintain its pattern of
displacement so that there is no initial or
additional neurological deficit, no major
deformity, and no incapacitating pain

.. White and Panjabi

Clinical Instability

■ Anatomic Considerations
■ Biomechanical Factors
■ Clinical Considerations
■ Treatment Considerations
■ Recommended Evaluation system
■ Recommenced management
- Recorded cases of patient post -polio with
cervical paralysis and no instability if bones and
ligaments remain intact
 Biomechanics of Spinal @
Cord and Nerve Roots
■ Cord does not slide up and down (v.small)
■ Accordion like- lengthen on one side and
shorten on the other (ie sidebending)
■ Greatest stretching occurs between C2 and
T1 (<20%)
■ Injury is due to loss of cord elasticity,
displacement or space occupying lesions
■ High compliance in the axial plane, less in
the horizontal plane

Types of Instability

■ Kinematic
- Motion increased
- Instantaneous axes of rotation altered
- Coupling characteristics changed
- Paradoxical motion present
■ Component Instability
- Trauma
- Tumor
- Surgery
- Degenerative changes
- Developmental chages

C0-C1

■ Unstable in childhood
■ Dislocations are
generally fatal
■ Instability identified by
x-ray
- Rotation >8° is
pathological
- Translation > 1 mm
 C1-C2

■ Instability due to dens

fracture
■ Vertebral translation or
Rotation
■ Bone spur
■ Little contribution of the
facet capsule
compared to dens and
ligamentous ring
■ Alar liqament test
- C1-C2 > 56 IS
abnormal

Jefferson Fracture

C1 Ring Distruption. overhang of lateral masses of C2

C2-T1 @
I

■ Failure consists of
injury to posterior and
anterior elements
■ Unilateral facet
- Root symptoms
■ Bilateral facet
- Spinal medullary ir1Jury
■ Burst Fracture
- Horizontal displacement
- Spinal cord 1niury
 Recognizing Instability

■ History of a flexion injury

■ Widening of interspinous space
■ Subluxation of a facet joint
■ Compression fracture of adjacent vertebrae
■ Loss of normal cervical lordosis

Thoracic Instability

■ T1-T10 ■ T11-L 1
■ Overall greater ■ Spinal cord damage
stiffness with injury ~4%
■ Spinal cord damage
with injury ~10%

Lumbar Instability

■ L 1-S 1
■ 3% Fracture and dislocation have
neurological signs
■ Disconnect between displacement and
neurological signs
■ >4.5mm or 15%
■ Facet has a crucial role in stability (rot and
SB)
~-;;, Stabilization of the Spine@

■ Passive system

■ Active system

■ Neural control

Muscular Control of the ~:~

Spine
■ Rotatores and lntertransversarii

■ Function primarily as force transducers

■ Position Sensors
■ Electrically silent with large rotations
(involving Abs)

Muscular Control of the @

Spine
■ Extensors - Longissimus , lliocostalis
■ Thoracic area ~75% slow twitch fibers
■ Lumbar area ~50% mix
■ Lumbar area- in flexion provide a
compressive force in the lumbar to limit
shear
 Muscular Control of the \I,~
Spine
■ Extensors - Multifidi

■ Span only a few joints

■ Produce extensor torque/resistance
■ Only small amounts of rotation or SB
■ Contribute to correction or support

Muscular Control of the w:

Spine
■ Abdominal Muscles
■ Rectus
- Major trunk fle xor
- Active with sit-up and cu rl-ups
- Little to no evidence to support upper/lower
differentiation

Muscular Control of the @

Spine
■ Abdominal Wall- Ext/Int Oblique

■ Torso Rotation and Lateral flexion

 Muscular Control of the ~:
Spine
■ Abdominal Wall-Transverse abdominis

■ Beltlike support and generation of intra-

abdominal pressure
■ Delayed onset during ballistic movements in
patient's with LBP

Muscular Control of the ~

Spine
■ Psoas
■ Primarily hip flexor
■ Compressive force to spine during
contraction
■ Questionable contribution to spine stability
• If so, under high hip fl exor forces

Muscular Control of the ~

Spine
■ Quadratus Lumborum

■ Highly involved with spine stabilization

■ Active in flexion , extension and SB
■ During Lifting , increased oblique activity
followed increases in QL
 Muscular Control of the Qj
Spine
■ Deep Rotators- position sensors
■ Extensor Group
- Generate large extensor moments
- Generate posterior shear
- Affect one or two segments

Co-activation of the
Muscular Spine
.. . ,._
• 90N force (201bs)
creates buckling
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r.~.-...;
.

without muscu lar

forces
.
• Co-contraction
increases suppo rt
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against buckling J li!!r'~t"'•
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Muscular Stability Qi)

■ Continuous contraction
■ ~ 10% MVIC of abdominals
■ No single muscle is critical one
@ Joint Shear Testing (;)

Generalized @
Ligamentous Laxity
■ Elbow Hyperextension > 10°
■ Passive Hyperextension of 5 th finger >90°
■ Abduction of thumb to forearm
■ Knee Hyperextension > 10°
■ Forward flexion hands to floor (knees ext)

■ Tested Billateral: Total score: /9

Neutral Spine
 Abdominal Bracing ~

Curl-up Beginner

■ Maintai1n lordosis with hands

■ Attempt to lift head (little to no motion)
■ Raise head and shoulders (no cervical flexion)
■ One leg fle xed one extended

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~ Curl-up Intermediate

■ Elbows off the table

 Curl-up Advanced

■ Fingers on forehead

~ Side Bridge Remedial ~

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Gi) Side Bridge Reverse ~

■ Lift legs off the bed

/<onrtnwdJ
 Side Bridge Knees
Flexed
■ Knees flexed

@ Side Bridge Intermediate@

■ Legs extended

@ Side Bridge Intermediate(;)

Variation
■ Legs extended
■ Rolling of torso on legs
 the siM br~ is totr.ansfff from ~ el
wtlilrM>domiNllybrKing(a,b,and cl rat
edly hilting the hips off the floor into the
En- ttwlt the rib~ is brKed to the
this rigidity Is , , , . i ~ through the
i.ide to the other. Stil hicJlwr i.wli. ol
~ rNChed with the (ft( on a labile wrf
GtlHlift. and McGill, 2000).

Birddog, Remedial Q
■ Hands and knees.
ra ise one hand off bed
■ Progress to hand and
opposite knee

Birddog , Beginner's

■ Raise one arm or leg at

a time
., :... Birddog, Intermediate ~·

■ Raise one arm and leg

at a time
■ Hold 6-8 seconds

Birddog, Advanced

■ Raise one arm or leg at

a time
■ Avoid Returning to the
bed. sweep and
resume

Isometric Rotation

■ Isometric
lsomE Activity