Lumbar Region

lumbar region vertebrae features

sagittal plane oriented facets, thick pedicle, large VB

thoracolumbar junction facet orientation

some patients have a quick transition of facet orientation leading to a pivot point where you may get lots of flexion and extension

hyperlordosis at T12-L1, especially in neurological population can be due to

quick orientation change of facets, and tight hip flexors causing rest of lumber spine to be forward, so all extension is happening at T12-L1 (dont have abdominal strength usually to offset this) (stretch hip flexors and strengthen abdominal muscles)

the L5-S1 apophyseal joint is

oriented to stop L5 from sliding down the sacrum

sacrohorizontal angle

30-40 degrees, when larger and hyperlordotic L5 is getting excessively pulled by gravity forward - anterior tilt

a greater sacrohorizontal angle means

more compression at the facets (especially L5-S1)

ALL in lumbar region is

thicker and holding L5 in place, iliolumbar ligament also stabilizes

spondylolisthesis

fracture at the "neck" where facet articulates allowing anterior slippage of superior vertebral body, ALL and interbody joint/disc are disrupted anteriorly

flexion/extension at lumbar

gliding up/down

lateral flexion at lumbar

ipsilateral inferior glide, contralateral superior glide

rotation at lumbar

ipsilateral gapping, contralateral approximation

lumbar flexion available

40-50

lumbar extension available

15-20 (limited by facet articulation)

in flexion of lumbar spine, the load shifts from

away from apophyseal joints to compression on the anterior discs, tension placed on posterior ligaments

with flexion of lumbar spine, IVD/nucleus pulposis is

compressed into a posterior direction - risk impingement at nerves with posterior bulge

with flexion of lumbar spine, intervertebral foramen is

expanding (11-20%)

if a patient feels better in lumber flexion

not a disc issue

if a patient feel pain radiating down back and leg with flexion

disc bulge onto nerve root is likely

nucleus pulposis slowly oozes

away from the direction of side bending

effect of flexion on nucleus pulposis

deformed/pushed posteriorly

effect of flexion on annulus fibrosis

posterior side strtched

effect of flexion on apophyseal joint

capsule stretched, minimizes facet contract, unloaded

effect of flexion on intervertebral foramen

widened

effect of flexion on PLL, ligamentum flavum, interspinous ligament, supraspinous ligament, spinal cord/cauda equina

increased tension

effect of flexion on ALL

decreased tension

most common region of herniated nucleus pulposus

posterior-laterally at the lumbar region (no costocorporeal joint to protect)

begin treatment of a herniated nucleus pulposus with

extension to relieve nerve root pain, stretch anteriorly

with enough disc degeneration

nucleus pulposis is gone and nothing can bulge (some strategies recommend waiting)

options for herniatioins

epidural, disectomy, wait, etc.

lumbar extension causes the intervertebral foramen to

get smaller/more compressed

lumbar extension causes facets and spinous processes to

articulate more, increase load/compression

lumbar extension effect on nucleus pulposis

nucleus pulposis pushed anterior from posterior disc compression (would give pain relief for flexion pain patients)

with tight hip flexors, the spine must compensate by

extending to stay upright, keeps pt in anterior tilt, increased lordosis os lumbar spine, squishes back of disc and pushes nucleus pulposis anteriorly, IV foramen smaller

with anterior pelvis til, L5 has

increased desire to slide

mckenzie extension exercises

prone to prone cobra - tightens extensor ligaments (PLL) which can prevent the posterior bulge with flexion

lumbopelvic rhythm with trunk flexion

70 degrees at hip, 40 degrees at lumbar spine for 110 degrees total to touch toes

with tight hip extensors, trunk flexion occurs via

excessive lumbar flexion and limited hip flexion

with tight back extensors, trunk flexion occurs via

excessive hip flexion and limited lumbar flexion

phases of trunk extension

primarily glute max and hamstring extension in early phase with nice IMA into posterior tilt, progress to primarily lumbar extensors into extension with less external torque, no external torque at neutral

flexing the hip =

anterior tilt of pelvis (ASIS and femur closer)

you can anteriorly tilt the pelvis and

flex or extend the lumbar spine

in sitting with anterior tilt

increased lumbar lordosis/extended lumbar spine, disc pushed anteriorly, intervertebral foramen smaller

laying supine holding knee

puts pelvis into posterior tilt

to test for anterior pelvic tilt

thomas test and check for lumbar lordosis - tight hip flexors pull pelvis into anterior tilt

hip extension =

posterior pelvic tilt (ASIS away from femur)

in sitting, posterior pelvic tilt

lumbar spine flexion/decreased lordosis, glutes/hip extensors pull into posterior pelvic tilt

lumbar axial rotation available

5-7

lumbar lateral flexion available

20

most cervical flexion/extension occurs at

C5-C6 at 20 degrees

the lower thoracic vertebrae have

greater flexion/extension due to changing facet orientation

area with most axial rotation

between C1 and C2 at 40 degrees