1. Dr. Sue Shapiro Associate Professor Barry University
Lumbar Spine
Dr. Sue Shapiro
Associate Professor
Barry University

2. Lumbar Spine Bony Anatomy
5 lumbar vertebrae
Massive vertebrae bodies with the width greater than the anterior-posterior diameter
L4 &5 slightly wedge-shaped & anterior convexity (anterior pelvic tilt) these features stabilize and accommodate the increasing body weight supported at the end of spinal column

3. Facet Joints of Lumbar Spine
Articular process have a distinct concave-convex arrangement: inferior facet sits medial to the superior while superior facet faces medial and posterior and is concave the inferior is convex and faces anterior and laterally- this limits rotation f the lumbar and facilitates flexion, extension and side bending

4. Lumbar Spine Facets

5. Lumbar Superior Facets
Superior facet serve as attachment for Multifidus
Multifidus muscle has the same mechanical function as the semispinalis capitis muscle of cervical spine; they are primary extensors of the lumbar and cervical spine

6. Spinous Process Orientation in Lumbar Spine
Lumbar spine spinous process have horizontal and extended posterior orientation making it possible to insert a needle b/t the adjacent vertebrae at L3 & L4 for CSF – know as the lumbar puncture

7. Sacral Spine Wedged structure made up of 5 fused vertebrae
Superior it articulates with the L5 vertebrae
Inferior with coccyx and
Laterally with the ilium
This articulation is considered to be the keystone of pelvic arch

8. Sacral Spine Anterior /Posterior View
There is a separate anterior and posterior foramina where the sacral nerves exit. The anterior divisions exit from anterior sacral foramen and give rise to the sciatic nerve

9. L5 S1 Junction
Intervertebral disc located b/t L5 & sacrum is very thick especially in anterior border
This is where the lumbarsacral angle is formed
The most notoriously frequent site for pain in the low back
An increase in lumbar lordosis or increase pelvic tilt of the pelvis results in an increased lumbosacral angle. Whereas a decreased in lumbosacral angle is due to posterior tilt of pelvis

10. Lumbar Sacralization
5th lumbar vertebra may be fused at the lumbosacral joint
The transverse processed forms a pseudoarthrosis at its point of contact with the sacral wing
The L3,4 nerve roots may become irritated on left lateral flexion due to mechanical irritation

11. Lumbar Sacralization

12. Spondylolisthesis
Due to anterior shearing of L5 on the sacrum there is a tendency toward anterior displacement of lumbar facets
Spondylolisthesis refers to anterior displacement of one vertebra upon the subjacent vertebra and is seen at the lumbosacral articulation.

13. Common Causes of Spondylolisthesis
1. Most common cause is a defect in the bony region between the superior and inferior articular processes of the vertebrae (pars interarticularis)
2. a fracture – stress fractures
3. an elongated pedicle

14. Scotty Dog Deformity Classification of Spondylopathies
Spondylitis- Inflammation of the vertebrae
Spondylosis- Arthritis or osteoarthritis of the vertebrae resulting in pressure being placed o the vertebral nerve root
Spondylolisthesis- Forward slippage of a vertebra o the one below it ( may occur secondary to spondylolysis in which the fx of pars interarticularis results
Spondylolysis- Degeneratio of a vertebra structure secondary to repetitive stress, most commonly affecting the pars interarticularis but with no displacement of the vertebral body.

15. Spondylolisthesis

16. Sacroiliac Joint Fusion of first 3 sacra vertebrae and ilium
Movement of sacrum on the ilium is referred to as Nutation ( flexion) or countranutation (extension)
Movement of ilium on the sacrum is referred to as torsion – Anterior torsion occurs when the ASIS moves forward and down ; posterior torsion occurs when the ASIS moves upward and back

17. Lumbosacral Trunk
LST is in close approximation to the LSJ and can cause compression injuries that may cause muscle spasms.
Since L4 & L5 are the principal constituents of the sciatic nerve (L4-S3) any irritation can cause Sciatica

18. Spinal Nerves and Plexus
There are 31 pairs of spinal nerves
They form networks of nerves or plexus -5 plexuses Cervical Plexus- C1-C4
Brachial Plexus-C5- T1
Lumbar plexus L1-L4
Sacral plexus L4- S4
Coccygeal plexus S4-S5

19. Coccyx
Composed of 3-5 fused vertebral bodies that have no vertebral arch
1st coccygeal vertebra is the largest and articulates with the sacrum at the sacrococcygeal junction
Serves as a bony origin for muscles of the pelvic diaphragm
Falls on to the coccyx can be very painful and necessitate coccyx excision for pain relief

20. Ligaments of the Lumbar Spine
Anterior Longitudinal Lig- It’s narrow in the Cs region, increases in width in the lumbar spinal column. Prevents anterior disc protrusion
Posterior Longitudinal LIg.- it’s widest in C spine but narrows in the thoracic and lumbar spine- only ½ as wide in lumbar spine as in C spine which is a problem for posterior stability of disc and shifting in L spine

21. Ligaments of the Lumbar Spine
Ligamentum flavum – bridges the space b/t adjacent laminae and is highly elastic preventing the chance that lig. Will buckle into the spinal canal
Interspinous Lig. Broad and thick, resist separation of the spinous processes therefore limiting flexion of the lumbar segments
Supraspinous ligament- most outward lig. That terminates at L4 in 22% of individuals and completely lacking at L5-S1. It limits forward bending of the lumbar spine

22. Iliolumbar Ligaments

23. Sacroliliac Ligaments

24. LUMBAR DISC
Lumbar disc are significantly thicker and have a greater cross section
Provide 1/3 of the length in the lumbar spine compared to 1/5 in cervical and thoracic spine

25. Herniated Disc Classifications
Protruded- some eccentric accumulation of the nucleus with slight deformity of annulus
Prolapsed- definite deformity as it works its way through the fiber of annulus
Extruded - nuclear material comes into the spinal canal and runs the risk of impinging adjacent nerve roots
Sequestrated- nuclear material has separated from the disc itself and potentially migrates

26. Degenerated Disc Disc herniation can be acute or stress related
Most show signs of previous degeneration
Most common lumbar disc herniation are between L4-L5 and L5-S1
Next most common herniations are lower two cervical discs

27. Disc Impingement Symptoms
Intervertebral discs are not innervated thus do not cause pain , it is sensory nerves supplying the ligaments, bony structures, spinal cord or spinal nerves that produce both sensory and motor symptoms
Depending on where herniation takes place the myotome and dermatome patterns associated with the nerve root will cause symptoms

29. Spinal Sternosis
Defined as a loss of cerebrospinal fluid around the spinal cord due to deformation of the spinal cord, or a narrowing of the neural canal
Common symptom is bilateral leg weakness and numbness with or without sciatica: neg SLR; + pain on prolonged spine extension exacerbated with ipsilateral trunk lateral flexion

30. Combination of Disc Degeneration and Spinal Sternosis or Spondylosis

31. Orthopedic Test for Disc Pathology
Well Leg Raise Test
Milgram Test
Valsalva’s Test
Naffzinger Test

32. Sciatica
Defined as compression and/or inflammation of a spinal nerve making up the sciatic nerve due to a herniated disc, annular tear, myogenic or muscle-related disease, spinal sternosis, facet joint arthropathy, or compression from the piriformis muscle
Typically, if related to herniated disc, radiating leg pain is greater than back pain and increases with sitting and leaning forward , coughing, sneezing and straining
Pain is produced during ipsilateral SLR
With annular tears, back pain is more prevalent and exacerbated with SLR
Different from spinal sternosis because back pain starts usually after walking a limited distance and concomitantly increases as distance increases . Pain is not reproduced with SLR but can be reproduced with prolonged spine extension, which is relieved with spine flexion

34. Orthopedic Test to Evaluate Sciatica
Straight Leg Raise “Lasegue Test”
Kernig/Brudzinski Test
Bowstring Test (Cram Test)
Slump Test

35. Low Back Pain (LBP)
60 to 80% of the population experiences LBP at some time in their lives
Males and females appear to be equally susceptible
LBP is second only to the common cold as the leading cause of lost work time
Back injuries dominate claims for worker’s compensation
LBP accounts for 10% of all chronic health problems and is ranked 11th among causes for hospitalization in the US
Most cases are idiopathic or unknown origin
Mechanical stress is the primary causal mechanism
Most common among runners , soccer, field hockey , lacrosse, rowers
Mechanism of injury is tight hip flexors, hamstring which produce a forward body lean leading to anterior pelvic tilt and hyperlordosis of the lumbar spine

36. Lumbar Contusion, Strains, and Sprains
Soft tissue injuries are the most common injuries in the lumbar spine
MOI – Lumbar muscles develop tension to counteract the forward bending moment of the entire trunk when the trunk is in flexion, they are susceptible to strain
Symptoms: Localized pain, increasing with active and resistive motion, radiating pain and neurological deficits

37. Abdominal Muscle Strains

38. Hip Flexor Muscles

39. Erector Spinae and Multifidus Muscles