Lumbar Spine Problems PDF

DR. MONA SELIM By the end of this lecture, the student should be able to: Memorize the related clinical anatomy. Memorize the related clinical biomechanics. Define low back pain syndrome. Describe the pathological based classification of LBP and common pathological conditions. Identify the re...

DR. MONA SELIM By the end of this lecture, the student should be able to: Memorize the related clinical anatomy. Memorize the related clinical biomechanics. Define low back pain syndrome. Describe the pathological based classification of LBP and common pathological conditions. Identify the red flags of lumbar spine. How can the orientation of the facet joints direct the lumbar spine motions? What are the common types of pain? What are the common lumbar pathological conditions?  The Vertebral Column  The vertebral column Function:  It transmit the weight of the upper body to the lower limbs,  protect the spinal cord  help in gait and movement of the trunk.  So it gives stability, flexibility and protection.  It consists of a series of 33 vertebrae and 23 intervertebral discs.  These 33 bones are divided into five categories cervical,  thoracic, lumbar, sacral, and coccygeal.  Spinal Curves Primary and secondary curves (2 lordotic and 2 kyphotic curves) The colored areas represent the two primary curves.  A. The anterior portion of a vertebra is called the vertebral body. B. The posterior portion of a vertebra is called the vertebral The pars interarticularis is the portion of the laminae or neural arch. The neural arch is further divided into the between the articular processes. pedicles and the posterior elements.  In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad.  20% to 25% of the total length of the vertebral column.  Cartilaginous Endplates line the ends of each vertebra and help hold individual discs in place.  Each disc contains a tire-like outer band (called the annulus fibrosus) that encases a gel-like substance (called the nucleus pulposus). A. The addition of an intervertebral disk allows the vertebra to tilt, which dramatically increases ROM at the inter-body joint. B. Without an intervertebral disk, only translatory motions could occur. EFFECT OF POSTURE ON DISCAL PRESSURE Lumbar Nerve Roots  Nerve roots exit the spinal canal through small passageways between the vertebrae and discs.  Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots (Radiculopathy).  Lumbar Ligaments Ligamentum flavum: (runs from lamina to lamina on the posterior aspect of the vertebral canal) limits flexion. Supraspinous and interspinous ligaments: limit flexion Intertransverse ligaments: limits contralateral lateral flexion Anterior longitudinal ligament: limits extension or excessive lordosis Posterior longitudinal ligament: limits flexion and reinforces annulus fibrosus Capsule of the apophyseal (facet) joint: strengthens and supports the apophyseal joint iliolumbar lig. :( Stabilize L5/S1) Lumbar Ligaments The anterior and posterior longitudinal ligaments are located on the anterior and posterior aspects of the vertebral body, respectively.  Lateral flexion and rotation of the vertebra are limited by tension in the inter-transverse ligament on the convexity of the curve. Anterior longitudinal ligament Posterior longitudinal ligament (PLL). (ALL).  Facet Joint (Zygapophyseal, or apophyseal facet) Function: FJ play an important role in load transmission Provide a posterior load-bearing helper  Stabilizing the segmental motion in flexion and extension Shares in load –bearing on lumbar region (20% to 25%) can reach 70% with degeneration of the intervertebral disc.  with increased extension or lordosis, Also, with degeneration of the intervertebral disk the FJ will assume more of the compressive load.  The sagittal plane orientation of lumbar FJ allows the great range of flexion and extension ROM and provides resistance to rotation.  The orientation of the lumber facet joints The superior facets face medially and backward and, in general, are concave.  the inferior facets face laterally and forward and are convex The facets orientation: The superior facets face medially and backward and, in general, are concave. The inferior facets face laterally and forward and are convex A. Sagittal plane orientation of the lumbar zygapophyseal facets favors the motions of flexion and extension. B. Frontal plane orientation of the thoracic zygapophyseal facets favors lateral flexion. Resting position: Midway between flexion and extension Close packed position: Full extension Capsular pattern: Side flexion and rotation equally limited, extension Coupling mechanism: In the lumbar spine, the movement of side bending is coupled with rotation. Because of the position of the facet joints, both side flexion and rotation occur together. According to Fryette, this coupling is: contralateral in neutral ipsilateral in flexed or extended posture  Lumbar Vertebrae Movements Motions occur in at the lumbar spine joints in three cardinal planes: –Sagittal (flexion and extension) –Coronal (side bending) –Transverse (rotation( A. During flexion. The anterior tilting and gliding cause compression and bulging of the anterior annulus fibrosus and stretching of the posterior annulus fibrosus &Nucleus pulposus migrates posteriorly. B. In extension, the superior vertebra tilts and glides posteriorly over the vertebra below. The anterior annulus fibrosus are stretched, and the posterior portion of the disk bulges posteriorly &Nucleus pulposus migrates anteriorly. Lateral flexion and rotation are most free in the upper lumbar region and progressively diminish in the lower region. The largest lateral flexion ROM and axial rotation (which occurs with side bending as a coupled motion) occurs between L2 and L3. Most of the flexion and extension of the lumbar spine occurs in the lower segmental levels (L4 and S1)  Lumbar Flexion &Extension ROTATION (RIGHT) SIDE BENDING (RIGHT): Lumbar Flexion:  Inferior facet of superior Inferior facet of superior vertebra glides facet joint open on right up and forward on superior facet of  vertebra upglides on left inferior vertebra. (ipsilateral) and closes on (contralateral) and downglides on Spinal canal and intervertebral foramen  left (contralateral) right (ipsilateral) lengthen and open Lumbar Extension  Right intervertebral Right intervertebral foramen Inferior facet of superior vertebra glides foramen opens, left closes, left intervertebral foramen down and backward on superior facet of intervertebral foramen inferior vertebra opens closes Spinal canal and intervertebral foramen Coupled with contralateral ROT close Coupled with contralateral SB in neutral and ipsilateral in neutral and ipsilateral ROT out SB out of neutral of neutral POSITIONAL DISTRACTION Positional distraction is an alternative to lumbar traction that can be performed both in the clinic and at the patient’s home. Advantages: it can isolate the spinal level to maximally open the effected neuroforamen, it can be made at home by tightly rolling a pillow in a sheet, and it is under the control of the patient combines isolated lumbar flexion, lateral flexion away from the targeted neuroforamen, and rotation toward the affected side focused to a spinal segment via manual therapy techniques can maximally open a targeted neuroforamen. The treatment sessions typically last 10 to 20 minutes, and the patient can perform the procedure at home three to six times per day. Lumbar Musculature – Erector spinae It is consisting of:  the iliocostalis lumborum  the thoracic longissimus.  Functions as a dynamic stabilizing force and secondarily as an extensor.  The superficial layer runs from the ribs and thoracic transverse processes inserts into the spinous processes of the lower lumbar spine, sacrum, and iliac crest  Deep layer arise from the ilium and insert on the lumbar transverse processes –Lumbar multifidus (LM(  It is an important muscle for lumbar segmental stability.  Originates from the sacrum and the transverse processes of the lumbar spine. Inserts into the spinous process lumbar to cervical spine. Functions to extend the spine. Psoase major Muscle: Action-Through their conjoined tendon, psoas major and iliacus: Flex and medially rotate the hip joint.  cause anterior ilial rotation and thus lumbar spine extension( lordosis). Also provides stability to the lumbar spine  Quadratus Lumborum It acts as a lumbar spine stabilizer. Its action: Individually: 1-laterally flexes the trunk to the same side. 2-when standing on one leg it acts to help prevent the pelvis dropping on the unsupported side. 3- When both sides work together they help extend the lumbar spine. LATISSIMUS DORSI Functions to medially rotate, adduct, and extend the shoulder. Assists in lateral flexion and hyperextending the spine, as well as anteriorly tilting the pelvis. The coupled action of the latissimus dorsi, contralateral gluteus maximus, and tension through the thoracolumbar fascia will compress the lumbosacral region and impart stability  Thoracolumbar fascia (TLF( Assists the in transmission of extension forces during lifting activities Stabilizes the spine against anterior shear and flexion moments. The fascia gives rise to the latissimus dorsi, the gluteus maximus, the internal and external abdominal oblique, and the transversus abdominis.  surrounds the erector spinae and the multifidus muscles of the lumbar region.  The muscles attachments are significant in that tensile forces can be exerted on the thoracolumbar fascia through muscle contraction of these muscles.  Tension on the thoracolumbar fascia will produce a force that exerts compression of the abdominal contents.  LOW BACK PAIN (LBP)  In 90% of patients, LBP resolves within 6 weeks (self-limited).  In another 5% of patients, the pain resolves by 12 weeks after initiation.  Less than 1% of back pain is due to "serious" spinal disease (e.g., tumor, infection).  Most patients with LBP have one or more of these symptoms:  1. Back pain.  2. Leg pain.  3. Neurologic symptoms.  4. Spinal deformity. Mechanical Low Back Pain  The pain is "mechanical"-that is, it varies with physical activity (e.g., prolonged sitting, bending forward) and with time (Referred pain).  This pain is located in the lumbosacral region buttocks, and thighs to the knee, with no radiation to foot or toes. Nerve root pain (Radiculopathy/Sciatica): pain, paresthesia, or other changes in cutaneous sensation located in the leg or foot area but believed to be of spinal origin  It may arise from disc herniation, spinal stenosis, Nerve root inflammation, tumors, Piriformis Syndrome or postoperative scarring.  Numbness and paresthesia in the same nerve root distribution. (Radicular symptoms)  Motor, sensory, or reflex changes are classically affected (Radicular signs)  Risk factor Evidence Age Increased risk until age 50, then relative risk decreases in men but increases in women Heavy manual labor. Repetitive lifting and twisting. Postural stress. Whole body vibration. Monotonous work. Poor physical fitness. Poor or inadequate trunk strength. Smoking. Psychological factors Stress, anxiety, depression associated with work-related LBP  Stages of Low Back Pain Acute:Less than 4 weeks Sub-acute:Between 4 – 12 weeks Chronic: More than 12 weeks  Our approach to deal with LBP is to first rule out emergent or non musculoskeletal causes of LBP.  Once this is done, the appropriate examinations and tests are performed to confirm or rule out mechanical, nerve root, tumor, infec- tious, traumatic, systemic, or inflammatory etiology  Red Flags: Indicate Probable Serious Spinal Pathology Presentation age 70 yr. Spinal fracture Widespread neurologic History of trauma (including minor falls or heavy lifts for individuals symptoms. who have osteoporosis or are elderly) Cauda Equina Syndrome: Constant, progressive, non mechanical pain. Previous history of: urinary retention/ Carcinoma. incontinence. Prolonged use of steroids bowel incontinence. back-related infection (spinal osteomyelitis) progressive motor Fever. weakness in the legs or gait Recent infection (e.g., urinary tract or skin). disturbance ( drop foot). Systemically unwell Inflammatory Disorders Weight 1oss. (Ankylosing Spondylitis) The Lower crossed syndrome:  is the result of muscle strength imbalances in the lower segment. These imbalances can occur when muscles are constantly shortened or lengthened in relation to each other that can lead to low back pain.  The weak muscles were the abdominals and gluteus maximus,  The strong muscles were the hip flexors (primarily iliopsoas) and the back extensors (increasing lumbar lordosis).  The weak gluteals result in over activity of the hamstrings and erector spinae to assist hip extension and to pull the pelvis backward to compensate for the anterior tilting.  Weakness of gluteus medius results in increased activity of the quadratus lumborum and tensor fasciae latae on the same side.  This syndrome is often seen in conjunction with upper crossed syndrome.  The two syndromes together are called the layer syndrome  Nerve Root Impingement: Narrowing of intervertebral foramen: ◦  Stenosis  Facet joint degeneration  Herniated intervertebral disc  Degenerative lumbar Spinal canal stenosis  Lumbar stenosis is caused by reduction of the space available for nerve elements  Spinal canal stenosis is rare in young and middle-aged patients but may occasionally be seen in older athletes. It is characterized by:  Pain aggravated by standing or walking.  Pain radiates into buttocks and lower extremities (neurogenic claudication).  Pain reduced by forward lumbar flexion (take time).  Reduced spinal mobility.  Causes or Types of Lumbar Spinal Stenosis A. Congenital/developmental: Idiopathic B. Acquired: Spondylosis (bone spurs) Spondylolisthesis Scoliosis Ossification of the posterior longitudinal lig. Hypertrophied Ligamentum flavum Hypertrophied facet joints Herniated disc Definition Abnormal rupture of the soft gelatinous central portion of the disc (nucleus pulposus) through the surrounding outer ring (annulus fibrosus).  In about 95% of all disc herniation cases, the L4-L5 or L5- S1 disc levels are involved.  75% of lumbar herniated discs spontaneously resolve within 6 months.  Leg pain and paresthesia are more symptomatic than the back pain. MRI lumbar image: L5/S1 disc has suffered a 9mm disc extrusion (red arrow) that is not contained by the PLL L4/5 disc has suffered a smaller 4mm disc protrusion (green arrow) that is contained by the PLL L3/4 (blue arrow) is completely normal and has no disc material projecting posteriorly into the epidural space Note: L3/4 disc is white in color, which indicates it is non-degenerated (i.e., full of water and healthy proteoglycan) Herniated discs (L4/5 & L5/S1) are "black" which indicates disc desiccation (lack of water and proteoglycan)  Lumbar Spondylosis  The term spondylosis is used to describe various degenerative disorders of the spine. ◦ Disc Degeneration:  Age: 45/65y  -Onset: Gradual with not known cause -Loss of water from nucleus pulposus  ↓ cushioning ability  ↑ stress load on annulus fibrosus  Small tears occur to annulus (scar tissue formation – not as strong as normal tissue)  Bulging of nucleus pulposus  Narrowing of the inter-vertebral space  Approximation of the facet joints ◦ Pathology of facet joints – 40% of all chronic low back pain ◦ signs/symptoms: ◦ pain is typically aggravated by lumbar extension (which compresses the posteriorly located joint). ◦ pain relieved by lumbar flexion (which separates the joint surfaces). ◦ The diagnosis is clinical ◦ Pain often occurs acutely with extension and rotation of the lumbar spine (quadrant test).   No localizing neurologic symptoms  The pain usually presents as non radiating lumbar spine.  Sudden attach of LBP (Steadily increasing pain is more common with disc lesions).  High response to facet manipulation.  Risk Factors Advanced age Intervertebral Disc Degeneration Degenerative spondylolisthesis  Spondylolysis: ◦ Best defined as a stress fracture of the pars Interarticularis (area between inferior and superior articular facets) ◦ MOI – repetitive stress common in young children who perform repetitive flexion and extension of the spine (e.g., gymnasts).  Unilateral or bilateral defects  low back and occasionally posterior buttock and thigh pain with no neurologic deficit.  spondylos, meaning vertebra  Listhesis: means slipping of one vertebra on another  Posterior portion of the vertebrae, laminae, inferior articular surfaces, spinous process separates from vertebral body ◦ Progression of spondylolysis → separation of vertebrae (superior vertebrae slides anteriorly on the one below it) ◦ Epidemiology: Most prevalent in women and adolescents and Young gymnasts Signs/symptoms:  Restricted range of motion of the low back. This is a very important finding in evaluating children.  Sacral prominence with a palpable "step-off."  lumbar lordosis is lost (lumbosacral kyphosis).  75% have low back pain.  Many people have no symptoms at all  Often back spasms.  Localized low back pain (↑ during/after activity)  Pain with extension  Treatment:  Pain relief, arrest of slip progression, and minimizing deformity.  lumbar stabilization exercises, stretching (back muscles, hamstrings and hip flexors) and strengthen abdominal muscles ex. Lateral view of the lumbar spine: Bilateral break in the pars interarticularis (spondylolysis - black arrow) L5 vertebral body (red arrow) has slipped forward on the S1 vertebral body (blue arrow – spondylolisthesis) Normal pars interarticularis - white arrow. Degree of forward slippage is equal to about 1/4 to 1/2 of the AP diameter of S1 (Grade1-Grade 2 spondylolisthesis)