LUMBAR SPINE I

By:
Yosra Mohammed Hussien - OPT
LECTURE OBJECTIVES:
By the end of this lecture student should be able to:
1. Outline anatomical & biomechanical considerations of the lumbar spine
2. Define low back pain (LBP) and related terminology
3. Identify different types & possible causes of LBP
4. Explain the pathophysiology of LBP
5. Determine differential diagnosis of LBP
ANATOMY OF THE LUMBAR
SPINE
The spinal column can be divided into 2 functional units:
 The anterior column supports weight (vertebral bodies, intervertebral discs,
ligaments).
 The posterior column contains the spinal canal
 The posterior neural arch (spinal canal) formed by the two pedicles,
transverse processes, lamina and spine along with the posterior surface of
the vertebral body
The human spine serves to provide structural support and bony protection of the
spinal cord.
 Spinous
process
Lamina

OSTEOLOGY
Transvers
e process

Spinous process: Superior Pedicle

 Is a broad linear structure (good site to mobilize from). articular
 At the same level of transverse process and body. facet
Laminae:
 Broad, short and strong.
 Form the posterior portion of the vertebral arch. Body
 Form the posterior part of the spinal canal padded with ligamentum flavum.
 Superficial, so laminectomy is a common surgery esp. for spinal canal stenosis.

Transverse processes:
 Long and slender.
 Horizontal in upper three lumbar vertebrae and incline a little upward in the lower two.
 Lie anterior to the articular facets.
 Mostly not palpable except of L3 in skinny population.
`
Pedicles:
 Are very strong directed backward from the upper vertebral body.
 Sometimes used as portal into vertebral body for fixation with pedicle screws or cementation of bone
such as with kyphoplasty or vertbroplasty.
The superior and inferior articular facets:
 Well defined projected upward and downward from the junctions of pedicles and lamina.
 Forming facet joints.
 The superior facets are concave look backward and medially, and the inferior facets are convex look
forward and laterally.
Facet joints:
 Are synovial joints.
 Posterior to the intervertebral foramen so it affects it very much.
 Directed 45 º in the sagittal plane and 90 º in the horizontal plane.
Vertebral body:
 Large, wider side to side than front to back, little thicker in front than in back, and flattened or slightly
concave from above and below.
 Outer surface is cortical bone and inner is cancellous type.
 In between lie intervertebral discs.
SOFT
TISSUES
Intervertebral discs:
 Consists of annulus fibrosus is multilaminar,
every lamina has its direction to resist
compressive and tensile forces.
 And nucleus pulposus (GAGs) act as shock
absorber.
 Its posterolateral portion is the thinnest
weakest portion.
Ligaments:
 Body is supported from front and back by anterior and posterior longitudinal
ligaments respectively.
 Ligamentum flavum binds the two lamina together.

 Interspinous ligament bind the spinous processes.

 Supraspinaous ligament bind the tips of spinous processes

 All serve for stability

Musculature:
 Lattismus dorsi.

 Erctor spinae (multifidus, longisimus, Iliocostalis

lumborum).
 Transversospinals (Interspinous, intertransversus,
rotators).
 Quadratus lumborum

 Abdominal muscles (rectus abdominis, obliqus

externus, obliqus internus, transversus
abdominis)
BIOMECHANICS OF THE
LUMBAR
Osteokinematics:
SPINE
 Flexion: 50º
 Extension: 15º
 Lateral flexion: 20º
 Axial rotation: 5º
Arthrokinematics:
1. Facet joint arthrokinematics:
 Flexion - superior and anterior glide
 Extension – inferior glide
 Lateral flexion – inferior glide in ipsilateral facet, superior glide in contralateral facet
 Axial rotation – separation in ipsilateral facet, approximation in contralateral facet
2. Body arthrokinematics:
 Extension – shift anteriorly
 Flexion – shift posteriorly
LOW BACK PAIN
2nd most common cause for office visit.
60-80% of population will have lower back pain at some time in their
lives.
Each year, 15-20% will have back pain.
Most common cause of disability for persons < 45 years
Costs to society: $20-50 billion/year
DIFFERENTIAL DIAGNOSIS OF
LBP
1. Mechanical or nerve compression > 90%
 Degenerative (disc, facet, ligament)
 Peripheral nerve compression (disc herniation)
 Spinal stenosis
 Cauda equina syndrome

2. Others:
 Neoplastic (primary, metastatic, MM)
 Infectious (osteomyelitis, TB)
 Metabolic (osteoporosis)
 Spondyloarthropathies (ankylosing spondylitis)
 Referred (aortic aneurysm, renal, ureters, …etc.)
 Traumatic #
RED FLAGS
1. New onset of back pain if aged < 10 or > 60 yrs
2. Previous history of carcinoma
3. History of osteoporosis or prolonged steroid use & minor trauma
4. History of HIV or immune suppression
5. Back pain with new systematic sinister features which themselves need
investigation, e.g. weight loss, loss of appetite
6. Non mechanical low back pain esp. with significant night pain or thoracic pain
7. Rapid onset of lower limb neurological symptoms
8. Bladder & bowel dysfunction
 MECHANICAL BACK PAIN
Definition: Is the general term that refers to any type of back pain caused by placing abnormal stress
and strain on muscles of the vertebral column.
 Typically, mechanical pain results from bad habits, such as poor posture, poorly-designed seating and incorrect bending
and lifting motions.
 It is back pain that NOT due to prolapsed disc or any other clear pathology.

 Dull back-ache aggravated by activity.

 No neurological, radiological signs & no restriction.

 Common with young age.

Treatment: symptomatic (analgesics, PT)

Prognosis: may resolve in 4-6 weeks or become chronic.

LUMBAR DISC HERNIATION
Definition: tear in annulus fibrosus allows protrusion of nucleus pulposus
causing either central, posterolateral or lateral disc herniation.
Most commonly at L5-S1 > L4-L5 > L3-L4
It could be:
 Degenerative
 Discitis
 Acute disc disease (traumatic)
 Annular fissure
 Cauda equina
 IMAGING
Normal X-ray & CT-scan.

Diagnosed with discography

Intra-discal pressure: Supine<standing<

sitting

Bending forward increases pressure

Bending forwards With a weight causes

further increase.
DEGENERATIVE DISC DISEASE
Aging or excessive loading gradually lead to abnormal stresses on disc which weaken it.
 One level --------- excessive loading
 Multiple level ---------- aging
 Decrease disc space in radiology
 Local or referred neurological symptoms
 Pain at the end range.

ACUTE DISC PROLAPSE:

 Traumatic (sudden onset)
 With or without annulus tear
 Rotational force is the most common cause.
 High neurological manifestations according to the site and level
PATHOLOGY OF THE
INTERVERTEBRAL DISK
Injury and Degeneration of the Disk.
Herniation: a general term used when there is any change in the
shape of the annulus that causes it to bulge beyond its normal
perimeter.
• Protrusion: nuclear material is contained by the outer layers of
the annulus and supporting ligamentous structures.
• Prolapse: frank rupture of the nuclear material into the
vertebral canal.
• Extrusion: extension of nuclear material beyond the confines of
the posterior longitudinal ligament or above and below the disk
space, but still in contact with the disk
• Free sequestration: the extruded nucleus has separated from
the disk and moved away from the prolapsed area
DISCITIS
Inflammation of disc due to abnormal position of the vertebra which abnormally load the
disc and cause chemical reaction that release mediators act on Sino vertebral nerve”
sensory” causing pain and numbness (radiculopathy)------ Grade 1

Inflammation + dural reaction------ Grade 2

Mechanical compression-------- Grade 3

 Special testing by:

 SLR (+ve)

 Reaction time “motor” (+ve)-----compression

 Reflexes (hyperreflexia)------- disc herniation

CLINICAL FEATURES OF DISC
DISEASE:
1. Back dominant pain or leg pain
2. Tenderness between the spines at affected level(s)
3. Muscle spasm with or without loss of normal lumbar lordosis
4. Neurological disturbance is segmental according to the affected level
5. Motor weakness (L4, L5, S1)
6. Diminished reflexes (L4, S1)
7. Paresthesia (L4, L5, S1)
 SCIATICA
Definition: irritation of sciatic nerve due to edema or
mechanical compression on the nerve root by the herniated
disc.
It’s more commonly be unilateral and if bilateral one side
is more affected than the other
It occurs in level of L4,5 & L5,S1 disc lesion
Common symptoms of sciatica include:
• Burning or tingling back pain down the leg
• Severe shooting pain that makes it difficult to stand up
• Weakness, numbness, or difficulty moving the leg or foot
• SLR test is +++(ve)
•DD: piriformis syndrome.
PSYCHOGENIC LBP
A psychosomatic illness

Physical manifestation that supposed psychological cause with

excluded by medical examination
Hoover’s test differentiate malingering from sciatica
PHYSIOTHERAPY TREATMENT
Treatment is symptomatic
1. Mobilization
2. Manipulation
3. Positioning “4-5 hours/ day)
4. Myofascial release
5. Core stabilization
6. Balance And Proprioception.
7. Postural Re-education
8. Endurance training
9. Advices
If the patient improved; continue PT program, if NOT refer to surgery.
CORE STABILIZATION EX.
BALANCE & PROPRIOCEPTIVE
TRAINING
ENDURANCE &
STABILIZATION EX.
CORRECT
ERGONOMICS
ADVICES FOR LBP
1. Weight reduction
2. Chair with 120º inclination
3. Pillow at lumbar curve while sitting
4. Chairs with arm supports
5. Avoid heavy lifting
6. Avoid high contact sports
7. Sleep in firm mats
8. Raise your foot while tying shoes
9. Correct carrying ergonomics:
 Bent with knees
 Distribute weight equally in two sides
CAUDA EQUINA SYNDROME
1. Bladder and bowel incontinence
2. Perineal numbness
3. Bilateral sciatica
4. Lower limb weakness “one > other”
5. Crossed straight-leg raising sign

 Scan urgently and operate urgently if a large central disc is revealed.

THANK
YOU