1. Chapter 25
Lumbar Spine

2. Overview
At some time in their lives, 80% of the general population will experience some type of low back pain (LBP) - it is second only to the common cold as a reason for physician visits, and the most expensive source of compensated work related injury in modern industrialized countries
Despite the frequency of LBP and the many studies examining LBP, LBP is a difficult problem to investigate and several key issues concerning its occurrence, natural history and prognosis remain unanswered

3. Anatomy The lumbar spine consists of 5 lumbar vertebrae
Between each of the lumbar vertebrae is the intervertebral disc (IVD)
The articulations between two consecutive lumbar vertebrae form three joints
One joint is formed between the two vertebral bodies and the intervertebral disc (IVD)
The other two joints are formed by the articulation of the superior articular process of one vertebra and the inferior articular processes of the vertebra above.

4. Anatomy
Vertebra
In general, the lumbar vertebrae increase in size from L 1 to L 5 in order to accommodate progressively increasing loads

5. Anatomy The Zygapophyseal Joint
In the intact lumbar vertebral column, the primary function of the zygapophyseal joint is to protect the motion segment from anterior shear forces, excessive rotation, and flexion

6. Anatomy Ligaments Anterior longitudinal ligament (ALL)
Extends from the sacrum along the anterior aspect of the entire spinal column, becoming thinner as it ascends
Posterior longitudinal ligament (PLL)
Found throughout the spinal column, where it covers the posterior aspect of the centrum and IVD

7. Anatomy Ligaments Ligamentum flavum (LF) Interspinous ligament
Connects two consecutive laminae
Interspinous ligament
Connects two consecutive spinal processes
Supraspinous Ligament
Connects the tips of two adjacent spinous processes

8. Anatomy Ligaments Iliolumbar Ligament Pseudo ligaments
Functions to restrain flexion, extension, axial rotation, and side bending of L‑5 on S‑1
Pseudo ligaments
These ligaments, the intertransverse, transforaminal, and mamillo-accessory, resemble the membranous part of the fascial system separating paravertebral compartments, and do not have any mechanical function

9. Anatomy Muscles Quadratus Lumborum Lumbar multifidus (LM)
The importance of this muscle from a rehabilitation viewpoint is its contribution as a lumbar spine stabilizer
Lumbar multifidus (LM)
The lumbar multifidus is an important muscle for lumbar segmental stability through its ability to provide segmental stiffness and control motion

10. Anatomy Muscles Erector spinae
The erector spinae is a composite muscle consisting of the iliocostalis lumborum and the thoracic longissimus. Both of these muscles are subdivided into the lumbar and thoracic longissimii and iliocostallii

11. Anatomy Muscles Thoracolumbar fascia (TLF)
Assists the in transmission of extension forces during lifting activities
Stabilizes the spine against anterior shear and flexion moments

12. Anatomy
Nerve Supply
The nerve supply to the lumbar spine follows a general pattern
The outer half of the IVD is innervated by the sinuvertebral nerve and the grey rami communicants, with the posterior-lateral aspect being innervated by both the sinuvertebral nerve and the grey rami communicants. The lateral aspect receives only sympathetic innervation
The zygapophyseal joints are innervated by the medial branches of the dorsal rami

13. Biomechanics
Motions at the lumbar spine joints can occur in three cardinal planes:
Sagittal (flexion and extension)
Coronal (side bending)
Transverse (rotation)
Six degrees of freedom are available at the lumbar spine

14. Biomechanics
The amount of segmental motion at each vertebral level varies
Most of the flexion and extension of the lumbar spine occurs in the lower segmental levels, whereas most of the side bending of the lumbar spine occurs in the mid-lumbar area
Rotation, which occurs with side bending as a coupled motion, is minimal, and occurs most at the lumbosacral junction

15. Biomechanics
Flexion
At the vertebral level, flexion produces a combination of an anterior roll and an anterior glide of the vertebral body, and a straightening, or minimal reversal of, the lordosis
At L 4-5, reversal may occur, but at the L 5-S 1 level, the joint will straighten, but not reverse, unless there is pathology present

16. Biomechanics Extension
Pure extension involves a posterior roll and glide of the vertebra, and a posterior and inferior motion of the zygapophyseal joints, but not necessarily a change in the degree of lordosis

17. Biomechanics Axial Rotation
Axial rotation of the lumbar spine amounts to approximately 13° to both sides
The greatest amount of segmental rotation, about 5° occurs at the L 5 and S 1 segment

18. Examination
The physical examination of the lumbar spine must include a thorough assessment of the neuromuscular, vascular and orthopedic systems of the hip, lower extremities, low back and pelvic regions

19. Examination
History
The clinician should establish the chief complaint of the patient, in addition to the location, behavior, irritability, and severity of the symptoms
Although dysfunctions of the lumbar spine are very difficult to diagnose, the history can provide some very important clues

20. Examination Systems Review
It must always be remembered that pain can be referred to the lumbar spine area from pathological conditions in other regions

21. Examination Observation
Observation involves an analysis of the entire patient as to how they move, and respond in addition to the positions they adopt
Although spinal alignment provides some valuable information, a positive correlation has not been made between abnormal alignment and pain

22. Examination Palpation
Whenever it is performed, palpation of the lumbar spine area should be performed in a systematic manner, and should be performed in conjunction with palpation of the hip and pelvic area

23. Examination Active range of motion
Normal active motion, which demonstrates considerable variability between individuals, involves fully functional contractile and inert tissues, and optimal neurological function
It is the quality of motion and the symptoms provoked, rather than the quantity of motion that is more important

24. Examination Combined motion testing Using a biomechanical model
A restriction of cervical extension, side bending and rotation to the same side as the pain is termed a closing restriction. This restriction is the most common pattern producing distal symptoms. However, a limitation in cervical flexion accompanied by the production of distal symptoms can also occur
A restriction of cervical flexion, side bending and rotation to the opposite side of the pain is termed an opening restriction

25. Examination Key muscle tests
The key muscle tests examine the integrity of the neuromuscular junction and the contractile and inert components of the various muscles
With the isometric tests, the contraction should be held for at least five seconds to demonstrate any weakness
If the clinician suspects weakness, the test is repeated 2-3 times to assess for fatiguability, which could indicate spinal nerve root compression.

26. Examination Sensory testing
The clinician checks the dermatome patterns of the nerve roots, as well as the peripheral sensory distribution of the peripheral nerves
Dermatomes vary considerably between individuals

27. Examination Position Testing
Position testing in the lumbar spine is an osteopathic technique used to determine the level and type of zygapophyseal joint dysfunction

28. Examination
Passive Physiological Intervertebral Mobility testing (PPIVM)
These are most effectively carried out if the combined motion tests locate a hypomobility, or if the position tests are negative, rather than as the entry tests for the lumbar spine
Judgments of stiffness made by experienced physical therapists examining patients in their own clinics have been found to have poor reliability.

29. Examination Passive Accessory Intervertebral Movement test (PAIVM)
Passive accessory intervertebral movement tests investigate the degree of linear or accessory glide that a joint possesses, and are used on segmental levels where there is a possible hypomobility, to help determine if the motion restriction is articular, peri-articular or myofascial in origin

30. Intervention Strategies
The optimal intervention for patients with acute back pain remains largely enigmatic
A number of clinical studies have failed to find consistent evidence for improved intervention outcomes with many intervention approaches

31. Intervention Strategies
Acute phase
Goals
Decrease pain, inflammation, and muscle spasm
Promote healing of tissues
Increase pain-free range of segmental motion
Regain soft tissue extensibility
Regain neuromuscular control
Allow progression to the functional stage

32. Intervention Strategies
Functional phase
Goals:
Correction of imbalances of strength and flexibility
Incorporate neuromuscular re-education
Strengthening of entire kinetic chain
Postural correction and retraining
To initiate and execute functional activities without pain and while dynamically stabilizing the spine in an automatic manner