The Lumbar Spine

CHAPTER 11

The Lumbar Spine

Introduction

Lumbar spine manipulation (LSM) is an intervention commonly used by practitioners of different professions (e.g. osteopathy, chiropractic and physical therapy) to treat low back pain (LBP). In patients with LBP, LSM is shown to result in rapid and prolonged reductions in spinal pain and disability (Cleland et al., 2006). In addition, the therapy is considered relatively safe and effective in the treatment of individuals with LBP, because serious complications following LSM are rare. According to Oliphant (2004), the rate of serious adverse event due to LSM is 1 per 3.7 million. However, since LBP is a disorder with variable etiologies, it is of critical importance for a practitioner to diagnose the exact spinal pathology accurately before performing spinal manipulation (Majlesi et al., 2008).

Therefore, this chapter is written to describe common injuries to the lumbar spine, the red flags for serious pathology and appropriate special tests to diagnose serious pathology in the region. In addition, this chapter will also describe various lumbar joints and their range of motion.

Joints

The anatomy of the lumbar spine is complex. It is made up of five moveable vertebrae (designated L1 to L5), the intervertebral discs, large muscles, flexible ligament or tendons and highly sensitive nerves. The lumbar vertebrae are characterised by their large, thick vertebral bodies, short spinous processes and thin transverse processes. They are distinguished from their other spinal counterparts by the absence of transverse foramina and costal facets (Standring, 2008).

Functionally, the lumbar spine is designed to be incredibly strong, flexible and stable. It protects the spinal cord and spinal nerve roots by allowing a wide range of motions and serving to help support the weight of the body (Kishner, Moradian and Morello, 2014).

Table 11.1 The joints of the lumbar spine
Joint name	Description	Function
Symphyseal joints	•Also known as secondary cartilaginous joints •Formed between the bodies of adjacent vertebrae of the vertebral column	•Serve to allow small movement between the adjacent vertebrae •Support the body during high-impact activities or when carrying heavy objects
Zygapophyseal joints	•A set of synovial joints that are formed joining the superior and inferior articular processes of two neighbouring vertebrae	•Serve to restrain the amount of flexion and anterior translation of the vertebral segment •Guide/allow simple gliding movements •Facilitate rotation
Fibrous joints	•Formed when the adjacent bones of the vertebral column are directly connected to one another by fibrous connective tissue •Join the laminae, transverse and spinous processes of the lumbar vertebrae	•Serve to hold the vertebral column in position
Sources: OpenStax (2013); Standring (2008); Watson, Paxinos and Kayalioglu (2009)

Range of Motion

In general, the movements available at the lumbar spine are principally flexion, extension, lateral flexion and axial rotation. Flexion and extension usually occur due to a combination of rotation and translation in the sagittal plane between each vertebra (Hansen et al., 2006).

However, the movements at the lumbar spine are difficult to measure clinically, because they vary considerably from person to person. Moreover, a number of factors also play a part while measuring the range of motion, including age, sex, genetics, pathology and ligamentous laxity (McKenzie and May, 2003).

Table 11.2 Range of motion in the lumbar spine
Motion type	Range of motion
Flexion	40–60°
Extension	20–35°
Lateral flexion	15–20°
Rotation	3–18°
Source: Adapted from Magee (2014)

Table 11.3 Segmental range of motion in males aged 25 to 36 years (based on three-dimensional radiography technique)
Mean range (in degrees)
Interspace	Flexion	Extension	Flexion and extension	Lateral flexion		Axial rotation
Interspace	Flexion	Extension	Flexion and extension	Left	Right	Left	Right
L1–L2	8	5	13	5	6	1	1
L2–L3	10	3	13	5	6	1	1
L3–L4	12	1	13	5	6	1	2
L4–L5	13	2	16	3	5	1	2
L5–S1	9	5	14	0	2	1	0
Sources: Pearcy and Tibrewal (1984); Pearcy, Portek and Shepherd (1984)

Common Injuries

Injuries to the lumbar spine are not rare. They usually occur when external forces applied on the vertebral column go beyond its strength and stability. Common causes of injuries include a fall, violent activity, motor vehicle accident, sport accident and penetrating trauma. Most often, lumbar spine injuries show up with a mild muscle sprain or strain. Severe injuries of the lumbar region include various types of fracture, spondylolisthesis and disc herniations (Dunn, Proctor and Day, 2006).

Table 11.4 Common injuries of the lumbar spine
Injury	Characteristics
Muscle strain	•Generally refers to an injury to a muscle or tendon in the lumbar region •Typical symptoms include local bruising without radiculopathy •Symptoms are often exacerbated by twisting, bending and weight bearing
Lumbar disc herniation	•Usually occurs due to wear and tear of the disc •Incidence rate is high in individuals who are exposed to substantial axial loading, rotation and flexion •Symptoms include dull or sharp pain, sciatica, muscle spasm or cramping, numbness and weakness, and loss of leg function •More common in athletes and older adults
Spondylolisthesis	•Usually occurs at L–5 (L5–S1) •Often results from activities that involve repetitive hyperextension and axial loading •Common symptoms include LBP without radiculopathy •Symptoms may be exacerbated by extension •More common in adolescents and young athletes
Compression fracture	•Causes the anterior part of the vertebra to break and lose height •Usually a stable fracture, as it does not move the bones out of their places •Does not cause neurologic problems •Commonly occurs in osteoporosis patients
Vertebral body fracture	•Usually occurs due to a high-energy accident or osteoporosis •Symptoms include pain or the development of neural deficits such as numbness, weakness, tingling, spinal shock and neurogenic shock •More common in the thoracolumbar region •More predominant in men than women
Sources: Dunn et al. (2006); Ombregt (2013)

Red Flags

Red flags help to identify serious pathology in patients with lumbar pain. If a red flag symptom is found in a patient, the practitioner should prioritise sound clinical reasoning and exercise utmost caution, so that the patient is not placed at risk of an undue adverse event following LSM.

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