Movements of the lumbar spine

Chapter 8 Movements of the lumbar spine



The principal movements exhibited by the lumbar spine and its individual joints are axial compression, axial distraction, flexion, extension, axial rotation and lateral flexion. Horizontal translation does not naturally occur as an isolated, pure movement, but is involved in axial rotation.



Axial compression


Axial compression is the movement that occurs during weight-bearing in the upright posture, or as a result of contraction of the longitudinal back muscles (see Ch. 9). With respect to the interbody joints, the weight-bearing mechanisms of the intervertebral discs have already been described in Chapter 2, where it was explained how the nucleus pulposus and anulus fibrosus cooperate to transmit weight from one vertebra to the next. It is now appropriate to add further details.


During axial compression, both the anulus fibrosus and nucleus pulposus bear the load and transmit it to the vertebral endplates (see Ch. 2). In a normal disc, the outermost fibres of the anulus do not participate in bearing the load. Otherwise, the compression load is borne uniformly across the inner, anterior anulus and nucleus, but with a peak stress over the inner, posterior anulus (Fig. 8.1).24 In older discs this posterior peak is larger.3,4



Compression squeezes water out of the disc.57 Under a 100 kPa load, the nucleus loses some 8% of its water and the anulus loses 11%.810 The loss of water results in a relative increase in the concentration of electrolytes remaining in the disc, and this increased concentration serves to re-imbibe water into the disc once compression is released.9


Under compression, the vertebral bodies around a disc approximate and the disc bulges radially.6,8,11 The vertebral bodies approximate because the vertebral endplates bow away from the disc.1113 Indeed, the deflection of each endplate is almost equal to half the displacement of the vertebrae.12 This amounts to a strain of approximately 3% in the endplate.12 The disc bulges because, as the anulus loses height peripherally, the redundant length must somehow be accommodated, i.e. the lamellae of the anulus must buckle. Nuclear pressure normally prevents buckling inwards, leaving outward radial bulging as the only means of accommodating loss of disc height. The bulging is greater anteriorly than at the posterolateral corner of the disc, and induces a strain in the anulus fibrosus of about 2% per mm loss of disc height.14 Removing part of the nucleus (as occurs in discectomy) increases both the loss of disc height and the radial bulge.15


The load on the endplate during compression is evenly distributed over its surface, there being no greater load over the nucleus pulposus than over the anulus fibrosus.16 The endplate bows, however, because its periphery its strongly supported by the underlying cortical bone of the vertebra, whereas its central portion is supported by the slightly weaker trabecular bone of the vertebral body. This trabecular support is critical to the integrity of the endplate.


When excessive loads are applied to normal intervertebral discs, the trabeculae under the endplates fracture and the endplates themselves fracture, typically in their central region, i.e. over the nucleus pulposus, rather than over the anulus.5,1720 With the application of very great loads the entire endplate may fracture.1921


In this context, it is noteworthy that the endplates are the weakest components of the intervertebral disc in the face of axial compression. Provided the anulus is healthy and intact, increasing the load causes one or other of the endplates to fail, by fracturing, sooner than the anulus fibrosus fails, by rupturing.5,19,20 This phenomenon has particular ramifications in the pathology of compression injuries of the lumbar spine and disc degradation (see Ch. 15), and has its basis in the relative strengths of the anulus fibrosus and the bone of the vertebral body. Calculations have shown that the anulus fibrosus can withstand a pressure of 3.2 × 107 Nm−2 but cancellous bone yields at 3.4 × 106 Nm−2.8 Consequently, endplates would be expected to fail sooner than the anulus fibrosus when the disc is subjected to axial compression.


With respect to the vertebral bodies, in adults under the age of 40, between 25% and 55% of the weight applied to a vertebral body is borne by the trabecular bone;11,22,23 the rest is borne by the cortical shell. In older individuals this proportion changes, for reasons explained in Chapter 13. Overall, the strength of a vertebral body is quite great but varies considerably between individuals. The ultimate compressive strength of a vertebral body ranges between 3 and 12 kN.24,25 This strength is directly related to bone density24,26,27 and can be predicted to within 1 kN on the basis of bone density and endplate area determined by CT scanning.28 It also seems to be inversely related to physical activity, in that active individuals have stronger vertebrae.29


Another factor that increases the load-bearing capacity of the vertebral body is the blood within its marrow spaces and intra-osseous veins (see Ch. 11). Compression of the vertebral body and bulging of the endplates causes blood to be extruded from the vertebra.6 Because this process requires energy, it buffers the vertebral body, to some extent, from the compressive loads applied to it.20


During compression, intervertebral discs undergo an initial period of rapid creep, deforming about 1.5 mm in the first 2–10 min depending on the size of the applied load.3032 Subsequently, a much slower but definite creep continues at about 1 mm per hour.32 Depending on age, a plateau is attained by about 90 min, beyond which no further creep occurs.31


Creep underlies the variation in height changes undergone by individuals during activities of daily living. Over a 16-hour day, the pressure sustained by intervertebral discs during walking and sitting causes loss of fluid from the discs, which results in a 10% loss in disc height10 and a 16% loss of disc volume.33 Given that intervertebral discs account for just under a quarter of the height of the vertebral column, the 10% fluid loss results in individuals being 1–2% shorter at the end of a day.3436 This height is restored during sleep or reclined rest, when the vertebral column is not axially compressed and the discs are rehydrated by the osmotic pressure of the disc proteoglycans.10 Moreover, it has been demonstrated that rest in the supine position with the lower limbs flexed and raised brings about a more rapid return to full disc height than does rest in the extended supine position.36


The pressure within intervertebral discs can be measured using special needles,3739 and disc pressure measurement, or discometry, provides an index of the stresses applied to a disc in various postures and movements. Several studies have addressed this issue although for technical reasons virtually all have studied only the L3–4 disc.


In the upright standing posture, the load on the disc is about 70 kPa.38 Holding a weight of 5 kg in this posture raises the disc pressure to about 700 kPa.38,40 The changes in disc pressure during other movements and manoeuvres are described in Chapter 9.


Although the interbody joints are designed as the principal weight-bearing components of the lumbar spine (see Ch. 2), there has been much interest in the role that the zygapophysial joints play in weight-bearing. The earliest studies in this regard provided indirect estimates of the load borne by the zygapophysial joints based on measurements of intradiscal pressure, and it was reported that the zygapophysial joints carried approximately 20% of the vertical load applied to an intervertebral joint.37 This conclusion, however, was later retracted.41


Subsequent studies have variously reported that the zygapophysial joints can bear 28%42 or 40%43 of a vertically applied load. To the contrary, others have reported that ‘compression did not load the facet joints … very much’,44 and that ‘provided the lumbar spine is slightly flattened … all the intervertebral compressive force is resisted by the disc’.45


Reasons for these differences in the conclusions relate to the experimental techniques used and to the differing appreciation of the anatomy of the zygapophysial joints and their behaviour in axial compression.


Although the articular surfaces of the lumbar zygapophysial joints are curved in the transverse plane (see Ch. 3), in the sagittal and coronal planes they run straight up and down (although see Ch. 11). Thus, zygapophysial joints, in a neutral position, cannot sustain vertically applied loads. Their articular surfaces run parallel to one another and parallel to the direction of the applied load. If an intervertebral joint is axially compressed, the articular surfaces of the zygapophysial joints will simply slide past one another. For the zygapophysial joints to participate in weight-bearing in erect standing, some aberration in their orientation must occur, and either of two mechanisms may operate singly or in combination to recruit the zygapophysial joints into weight-bearing.


If a vertebra is caused to rock backwards on its intervertebral disc without also being allowed to slide backwards, the tips of its inferior articular processes will be driven into the superior articular facets of the vertebra below (Fig. 8.2). Axial compression of the intervertebral joint will then result in some of the load being transmitted through the region of impaction of the zygapophysial joints. By rocking a pair of lumbar vertebrae, one can readily determine by inspection that the site of impaction in the zygapophysial joints falls on the inferior medial portion of the facets. Formal experiments have shown this to be the site where maximal pressure is detected in the zygapophysial joints of vertebrae loaded in extension.46



Another mechanism does not involve the zygapophysial joint surfaces but rather the tips of the inferior articular processes. With severe or sustained axial compression, intervertebral discs may be narrowed to the extent that the inferior articular processes of the upper vertebra are lowered until their tips impact the laminae of the vertebra below (Fig. 8.3).47 Alternatively, this same impact may occur if an intervertebral joint is axially compressed while also tilted backwards, as is the case in a lordotic lumbar spine bearing weight.4649 Axial loads can then be transmitted through the inferior articular processes to the laminae.



It has been shown that under the conditions of erect sitting, the zygapophysial joints are not impacted and bear none of the vertical load on the intervertebral joint. However, in prolonged standing with a lordotic spine, the impacted joints at each segmental level bear an average of some 16% of the axial load.45,48 In this regard, the lower joints (L3–4, L4–5, L5–S1) bear a relatively greater proportion (19%), while the upper joints (L1–2, L2–3) bear less (11%).48 Other studies have shown that the actual load borne by impaction of inferior articular processes varies from 3–18% of the applied load, and critically depends on the tilt of the intervertebral joint.49 It has also been estimated that pathological disc space narrowing can result in some 70% of the axial load being borne by the inferior articular processes and laminae.45


It is thus evident that weight-bearing occurs through the zygapophysial joints only if the inferior articular processes impact either the superior articular facets or the laminae of the vertebra below. Variations in the degree of such impactions account for the variations in the estimates of the axial load carried by the zygapophysial joints,49 and explain why the highest estimates of the load borne are reported in studies in which the intervertebral joints have been loaded in the extended position.42,43,5052


Although the preceding account of axial compression emphasises the role of the discs and zygapophysial joints in weight-bearing, other components of the lumbar spine also participate. The shape of the lordotic lumbar spine allows the anterior longitudinal ligament and the anterior portions of the anuli fibrosi to be involved in weight-bearing. Because of the curvature of the lordosis, the posterior parts of the intervertebral discs and the zygapophysial joints are compressed, but the anterior ligaments are stretched. Axial loading of a lordotic spine tends to accentuate the lordosis and, therefore, to increase the strain in the anterior ligaments. By increasing their tension, the anterior ligaments can resist this accentuation and share in the load-bearing.


In this way, the lordosis of the lumbar spine provides an axial load-bearing mechanism additional to those available in the intervertebral discs and the zygapophysial joints. Moreover, as described in Chapter 5, the tensile mechanism of the anterior ligaments imparts a resilience to the lumbar spine. The energy delivered to the ligaments is stored in them as tension and can be used to restore the curvature of the lumbar spine to its original form, once the axial load is removed.



Fatigue failure


Repetitive compression of a lumbar interbody joint results in fractures of the subchondral trabeculae and of one or other of the endplates. This damage occurs at loads substantially less than the ultimate compression strength of these structures, and well within the range of forces and repetitions encountered in activities of daily living, work and sporting activities.


Loads of between 37% and 80% of ultimate compression strength, applied at 0.5 Hz, can cause subchondral fractures after as few as 2000 or even 1000 cycles.53 Loads between 50% and 80% of ultimate stress can cause subchondral and other vertebral fractures after fewer than 100 cycles.26


The probability of failure is a function of the load applied and the number of repetitions. Loads below 30% ultimate stress are unlikely to result in failure, even after 5000 repetitions; increasing the load increases the probability of failure after fewer repetitions.24 At loads of 50–60% of ultimate stress, the probability of failure after 100 cycles is 39%; at loads of 60–70% ultimate strength, this probability rises to 63%.24 The lesions induced range from subchondral trabecular fractures to impressions of an endplate, frank fractures of an endplate and fractures of the cortical bone of the vertebral body.24 Repetitions of 100 and up to 1000 are within the calculated range for a variety of occupational activities, as are loads of 60% ultimate stress of an average vertebral body.24


Endplate fractures result in a loss of disc height17 and changes in the distribution of stress across the nucleus and anulus. The stress over the nucleus and anterior anulus decreases, while that over the posterior anulus rises.1,11 This increase in stress causes the lamellae of the anulus to collapse inwards towards the nucleus, thereby disrupting the internal architecture of the disc.11 Thus, even a small lesion can substantially compromise the normal biomechanics of a disc. The clinical significance of these phenomena is explored further in Chapter 15.



Axial distraction


Compared to axial compression and other movements of the lumbar spine, axial distraction has been studied far less. One study provided data on the stress–strain and stiffness characteristics of lumbar intervertebral discs as a whole, and revealed that the discs are not as stiff in distraction as in compression.51 This is understandable, for the discs are designed principally for weight-bearing and would be expected to resist compression more than tension. In a biological sense, this correlates with the fact that humans spend far more time bearing compressive loads – in walking, standing and sitting – than sustaining tensile loads, as might occur in brachiating (tree-climbing) animals.


Other studies have focused on individual elements of the intervertebral joints to determine their tensile properties. When stretched along their length, isolated fibres of the anulus fibrosus exhibit a typical ‘toe’ region between 0% and 3% strain, a failure stress between 4 and 10 MPa, and a strain at failure between 9% and 15%; their stiffness against stretch ranges from 59 to 140 MPa.54 If the anulus is tested while still attached to bone and distracted along the longitudinal axis of the vertebral column, as opposed to along the length of the fibres, the failure stress remains between 4 and 10 MPa but the stiffness drops to between 10 and 80 MPa.55 These tensile properties seem to vary with location but the results between studies are conflicting. Isolated fibres seem to be stiffer and stronger in the anterior region than in the posterolateral region of the disc, and stiffer in the outer regions of the anulus than in the inner regions.1 On the other hand, in intact specimens, the outer anterior anulus is weaker and less stiff than the outer posterior anulus.55


The capsules of the zygapophysial joints are remarkably strong when subjected to longitudinal tension. A single capsule can sustain 600 N before failing.56 Figuratively, this means that a pair of capsules at a single level can bear twice the body weight if subjected to axial distraction.


However, the significance of these results lies not so much in the ability of elements of the lumbar spine to resist axial distraction but in their capacity to resist other movements that strain them. The anulus fibrosus will be strained by anterior sagittal rotation and axial rotation, and the zygapophysial joint capsules by anterior sagittal rotation. Those movements are considered below.


There has been one study57 that has described the behaviour of the whole (cadaveric) lumbar spine during sustained axial distraction, to mimic the clinical procedure of traction. Application of a 9 kg weight to stretch the lumbar spine results in an initial mean lengthening of 7.5 mm. Lengthening is greater (9 mm) in lumbar spines of young subjects, and less in the middle-aged (5.5 mm) and the elderly (7.5 mm). Sustained traction over 30 min results in a creep of a further 1.5 mm. Removal of the load reveals an immediate ‘set’ of about 2.5 mm, which reduces to only 0.5 mm by 30 min after removal of the load. Younger spines demonstrate a more rapid creep and do not show a residual ‘set’. The amount of distraction is greater in spines with healthy discs (11–12 mm) and substantially less (3–5 mm) in spines with degenerated discs.


Some 40% of the lengthening of the lumbar spine during traction occurs as a result of flattening of the lumbar lordosis, with 60% due to actual separation of the vertebral bodies. The major implication of this observation is that the extent of distraction achieved by traction (using a 9 kg load) is not great. It amounts to 60% of 7.5 mm of actual vertebral separation, which is equivalent to about 0.9 mm per intervertebral joint. This revelation seriously compromises those theories that maintain that lumbar traction exerts a beneficial effect by ‘sucking back’ disc herniations, and it is suggested that other mechanisms of the putative therapeutic effect of traction be considered.57


The other implication of this study relates to the fact that the residual ‘set’ after sustained traction is quite small (0.5 mm), amounting to about 0.1 mm per intervertebral joint. Moreover, this is the residual set in spines not subsequently reloaded by body weight. One would expect that, in living patients, a 0.1 mm set would naturally be obliterated the moment the patient rose and started to bear axial compression. Thus, any effect achieved by therapeutic traction must be phasic, i.e. occurring during the application of traction, and not due to some maintained lengthening of the lumbar spine.



Flexion


During flexion, the entire lumbar spine leans forwards (Fig. 8.4). This is achieved basically by the ‘unfolding’ or straightening of the lumbar lordosis. At the full range of forward flexion, the lumbar spine assumes a straight alignment or is curved slightly forwards, tending to reverse the curvature of the original lordosis (see Fig. 8.3). The reversal occurs principally at upper lumbar levels. Reversal may occur at the L4–5 level but does not occur at the L5–S1 level.58,59 Forward flexion is therefore achieved for the most part by each of the lumbar vertebrae rotating from their backward tilted position in the upright lordosis to a neutral position, in which the upper and lower surfaces of adjacent vertebral bodies are parallel to one another. This relieves the posterior compression of the intervertebral discs and zygapophysial joints, present in the upright lordotic lumbar spine. Some additional range of movement is achieved by the upper lumbar vertebrae rotating further forwards and compressing their intervertebral discs anteriorly.



It may appear that during flexion of the lumbar spine, the movement undergone by each vertebral body is simply anterior sagittal rotation. However, there is a concomitant component of forward translation as well.59,60 If a vertebra rocks forwards over its intervertebral disc, its inferior articular processes are raised upwards and slightly backwards (Fig. 8.5A). This opens a small gap between each inferior articular facet and the superior articular facet in the zygapophysial joint. As the lumbar spine leans forwards, gravity or muscular action causes the vertebrae to slide forwards, and this motion closes the gap between the facets in the zygapophysial joints (Fig. 8.5B). Further forward translation will be arrested once impaction of the zygapophysial joints is re-established, but nonetheless a small forward translation will have occurred. At each intervertebral joint, therefore, flexion involves a combination of anterior sagittal rotation and a small amplitude anterior translation.



The zygapophysial joints play a major role in maintaining the stability of the spine in flexion, and much attention has been directed in recent years to the mechanisms involved. To appreciate these mechanisms, it is important to recognise that flexion involves both anterior sagittal rotation and anterior sagittal translation, for these two components are resisted and stabilised in different ways by the zygapophysial joints.


Anterior sagittal translation is resisted by the direct impaction of the inferior articular facets of a vertebra against the superior articular facets of the vertebra below, and this process has been fully described in Chapter 3. This mechanism becomes increasingly important the further the lumbar spine leans forward, for with a greater forward inclination of the lumbar spine, the upper surfaces of the lumbar vertebral bodies are inclined downwards (Fig. 8.6), and there will be a tendency for the vertebrae above to slide down this slope.


Jan 17, 2016 | Posted by in MUSCULOSKELETAL IMAGING | Comments Off on Movements of the lumbar spine
Premium Wordpress Themes by UFO Themes