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