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


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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Sep 17, 2017 | Posted by in MANUAL THERAPIST | Comments Off on The Lumbar Spine

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Table 11.5 Red flags for serious pathology in the lumbar spine


Condition


Signs and symptoms