Minimally Invasive Spine Surgery: Current Aspects 193 - Most of Most 3 the the the the f f tional tional c un f lumbar spine he role o role he T the bone structures contained in for the lumbar - verte vulnerability creating bones cancellous are brae Thin but due or to trauma osteoporosis. collapses result a as liga- around proliferates bone usually cortical dense osteophytes forming sites attachment ment superior pedicles, of consists arch Neural aging. of and inferior facet and laminas. The the of localiza- level the on based change joints located facet of tion are they region, midthoracic the At . region at lumbar the whereas plane on frontal the increasing antero for allows plane. This they are on the sagittal thereby joints facet the of sliding posterior lower the of capacity extension the and flexion the the posterior. This part protects the neural struc- tures and is the site for the attachment of paraspi- nal muscles. Laminas have very limited - contribu by affected are If they stability. spinal on the tions (laminectomy), surgery during removed or fractures load. this does not lead to any spinal instability. The pedi- vertical any of 20% only carry facet the and cle of the whole backbone length. When approached from the lateral, it has an angulation with a poste- rior concavity called the lumbar lordosis. lumbar region. The superior facet is smaller than the inferior. It has a lateral concave the cartilaginous of ar- ceiling the forms it and surface ticular recess. This is where the nerve root leaves the cen- tral canal and enters the neural foramen. The pedi- cles form the base and the ceiling of from the arch neural fo- neural the complete laminas The ramen. The The Lumbar Vertebra The lumbar has five active - verte pro- increase as we brae. The sizes of these vertebrae 25% constitutes vertebra lumbar The distally. ceed stability o stability Beril Dogu MD, Julide Oncu MD, Banu Kuran MD les in in les c us 2,3 A m 1 4,5 Functional spinal unit has two segments: segments: two has unit spinal Functional

2 he lumbar portion of the vertebral column column of vertebral the portion he lumbar has an ideal a structure has aiming region at This - maintain mobility. and stability ing

Lumbar spine has 3 basic biomechanical

The functional unit of the backbone is the small- The functional unit of the backbone is the 32 trunk and the . Maintains the integrity of the spinal cord and pre- cause might that movements or forces any vents damage. Transfers any external load carried by the head carried load any external Transfers related any and trunk of the part upper the and bending momentums to the pelvis. It allows for movements between the head, the solid structure designed to carry the weights of the the of weights the carry to designed structure solid The and the extremities. the trunk the neck, head, common very are region this with associated pains least at population the of 80% affecting complaints one time during their lifetimes. 3. 2. 2. functions. 1.

give flexibility to the vertebral column. The posterior posterior The them has column. the responsibility to vertebral bear the to weight and to flexibility give controls and structures neural the protects segment the movements of the lumbar region. T The The Anatomy of the Lumbar Vertebral Column tures of the vertebral column. Functional spinal unit unit fea- est segment that provides for all the mechanical spinal Functional column. them vertebral the of between tures vertebrae, neighboring two of consists joint lies triple the a to the anterior forming and bilat- posterior the to joints facet eral complex. the anterior (static) and the posterior (dynamic). The The (dynamic). posterior the and (static) anterior the neighboring two the of between consisting segment discs anterior intervertebral the and bodies vertebral 194 Minimally Invasive Spine Surgery: Current Aspects verse processes are thin and long, the spinous pro- spinous the long, and thin are processes verse vertebral foraminahave triangularshapes,thetrans- inclinedthetoposterior, thelaminas arethick, the wideandtheinformkidney, aof thepedicles are aging this decreases down to 65% and water is re- is water and 65% to down decreases this aging the water content of the disc is around 80-90%, theextracellularsiswithof fluid.young Inindividuals, osmo- the and lymphatics the by only maintained ate. Following this event, the nutrition of the disc obliter- is structures vascular these decades, three ing com - the In discs. the into vessels blood thin of exit dosis.In early decades of life, we see the entry and rior contributingtotheformationoflumbarlor- nucleus. the made up of collagen fibrils surround andprotein. strengthen A fibrous structure called annulusmuco- gelatinous fibrosusof consists it and color yellowish mobile like the cervical and the lumbar regions. lumbar the and cervical the like mobile thicker at areas where the vertebral column is more consisting of fibrocartilagenous structures. Theychord are and are found in between the vertebral bodies The intervertebral discsaretheremnantsof Discs Intervertebral foramina. have not do processes transverse the lumbar vertebra for the costae andjoint thesurfaces associatedface thelateral. The joints surfaces of rior.Upper joint surfaces poste- face thethe anterior, to inferior extending wide and short are cesses discs. intervertebral Theremaining 80%ofthis load isabsorbed bythe Beril DoguMD,JulideOncuBanuKuranMD to distinguish the annulus from the nucleus. the from annulus the distinguish to their flexibility is decreased and it becomes difficultprotected.beger discs thinnerTheage,getweas nucleus pulposusthatisunder pressurecannolon- damagesthe collagen fibers of the annulus and the ing, this percentage decreases as well (3). gether withthedecreaseinwater contentduetoag- Aging also stitute 20-25%ofitslengthinyoungindividuals;to- con- they and vertebrae the for absorbers shock are cartilage. fibrous by placed terior longitudinal of thespinal column. pos- the and anterior the to tightly attach periphery other on the neighboring each to lamellae.opposite are Thefibers fibersthe at theof inclinations The mannerbetween theneighboring vertebral bodies. The bodies of the are typically Lumbar disc structures are thinner on the ante- the on thinner are structures disc Lumbar Nucleuspulposus isanovoid structure having 3 Collagen bandsextend obliquean in 1,3 3,6,7 Intervertebral discs discs Intervertebral 6 6 noto- 6 3,6 for the stabilization of the lumbar vertebra. lumbar the of stabilization the for they render PLL quite sensitive to pain. to sensitive quite PLL render they bers of the sinovertebral nerve innervating PLL andlike encephalins arecontained withintheterminal fi- rotransmitters like substance P andnervation fromtherecurrentmeningealnerve. Neu- neoromodulatorsin- sensory its receives PLL wider. getting by disc annulustheoffibrosus fibersintervertebraltheof fibers are shorter and they extend to the lateral part perficialfibers are like bands onthe midline. Deep It hastwolayers asthesuperficial and thedeep.Su- band andattachestotheposteriorsidesofdiscs. vertebral column from the skull to the sacrum likeThis a extends on the posterior surface of the are associated with the movement. the with associated are ments contain proprioceptive sensory receptors that has high percentage of elastic fibers. elastic of percentage high has genfibers. Ligamentum flavum theonother hand colla- of consist ligaments most flavum, amentum a wide surface. wide a the anterior surfaces of the vertebral bodies and hastinuous band; it attaches con- tightlya like column vertebral the toof thesurface anterior lateral sides of spinous processes. gion; atL5-S1 space, its thickness decreases by50%. narrowergetting andweaker lower inthe re- lumbar tain stability. main- to and movement excessive any prevent to tensileanding forces. Theirmainresponsibility is - tostretch resist region lumbar ofthe The ligaments Ligaments ing extension. ing dur- shortens and flexion during increases length its other, each from separating from bodies tebral ver- the prevents it column vertebral the of flexion teriorelements andmaintains stability. pos- Duringthe theprotects it posture erect and flexion terior an- During lumbar. to cervical from proceed we as increases thickness Its canal. vertebral the of part posterior the covers It located. bilaterally is It ina. lowervertebrallam- a of portion superior posterior the to lamina vertebral upper an of portion ferior ALL, painensues. innervation, if extension injuriesextension. cause damageAsit has nociceptive to theand proprioceptive ALL extends from the skull to the sacrum on the Supraspinous Ligamentum flavumextendsfromtheanteriorin- iswiderPLL intheupper lumbar region while 8 Furthermore, thecapsule and theliga- 5,11,12 6 ALLis responsible for limiting the 1 2 It is the most important ligament Itisthemostimportantligament It is the only segmental ligament Itistheonlysegmental ligament coversthesurfaces theof 9 Except for lig- for Except 10,

11 1 4 6 4

Minimally Invasive Spine Surgery: Current Aspects 195 - 5,14 5,15 5,14 1 and 2) (Figures

5,14 5,14 costa. th The role of the muscles in functional stability of the lumbar spine stability of in functional of the muscles The role Erector spinalis muscles (1) muscles spinalis Erector attaches to costal angles angles Iliocostalis to (lateral costal band) attaches - Multifidus generates form the multipennate mus Longissimus (intermedial band) is placed in the mid- Longissimus (intermedial Spinalis (medial band) is the most inwardly lo- * Deep posterior muscles in and are involved are shorter muscles These and extends to the level of C4-C6. It has lumborum, lumborum, has It C4-C6. of level the to extends and thoracis and cervicis portions. extend upwards extend and upwards divide into three columns un- der the 12 cated. While its medial border attaches to lateral its the pos- vertebrae, thoracic the of processes terior border is free. tending upwards from T1, it attaches to the trans- verse processes of all the vertebrae. col- of the vertebral the laminas cle series that covers attach fascicles to four Three C2-L5. between umn dle. It has thoracis, cervicis and capitis portions. Ex the axial rotation of the vertebra. Figure 1: (The figure is obtained from reference number 17) 5 1 It generally ends at the the at ends generally It 5 5,11 13 consists of fibers that are per- 1 5,6 ex- Capsular ligament Intertransverse Intertransverse ligament extends in between the lies between the two spinous spinous two the between lies * Superficial posterior posterior Superficial * They are collectively level level of L4. This ligament is then replaced by erec- tor spina and thoracolumbar fascia. crum, the sacroiliac liga- ment and the medial por- they crest; iliac the of tion called as erector spina. They They spina. erector as called two last the from originate the all vertebrae, thoracic lumbar vertebrae, the sa- tomically they can be di- vided into two as the ante- rior and the posterior. dynamic stability of the vertebral column and its movement control. Ana- These are the most im- portant elements of the Muscles from Originating Muscles the Lumbar Vertebra transverse transverse processes of neighboring vertebrae. It controls the lateral flexion. ciceptive nerve endings; that is why it causes back back it causes is why that endings; nerve ciceptive pain when injured. terior portions. This ligament also prevents the prevents also ligament This portions. terior extreme flexion of the spinal column. Its sensory innervation is through mechanoreceptors and no- processes. It consists of anterior, middle and pos- pertaining pertaining to the posterior column. Its function is to prevent extreme flexion. tends from the from tip of tends the the of processes transverse right and the left L5 - ver It crest. iliac the to tebrae the on pelvis the stabilizes lumbosacral spine. pendicular to the sides of the processes to processes of the joint sides the facet pendicular the in tighter and shorter is It surface. joint the and to facets the allows It regions. lumbar and thoracic slide during all the movements of the spine. muscles 196 Minimally Invasive Spine Surgery: Current Aspects be one more pair between the last thoracic vertebra withinfivethelumbar vertebrae. Rarelythere can tivelumbar vertebrae. There are usually four pairs consecu - of processes spinous the between in tend vertebra. neighboring the of process the transverse process of one vertebra to thetween spinous the eleventh and the twelfth. It extends from first andthesecondvertebra, whilethelastoneisbe- of these on each side. The first one is in between the foundonly in the thoracic region. There are twelve Beril DoguMD,JulideOncuBanuKuranMD on each side of the vertebral column. vertebral the of side each on tebrae. In the lumbar region we see them as tending betweenone thetransverse processesofthever- pair sacrum. the and vertebra lumbar fifth the between or vertebra lumbar first the and level. lumbar the at sacrum the of tion por- posterior processandthe mamillary the and to level,tothe transverse process atthe thoracic level ciclesattacharticulartheto processcervicalthe at fas- the of ends other the process, spinous each to * Anterior muscles Anterior * Intertransversaris ex- They fascicles. muscle short has Interspinalis Rotators lie under the multifidus muscle and are Figure 2: Figure is the small muscle group ex- group muscle small the is Erector spinal muscles (2) (The figures are obtained from reference no 17) no reference from obtained are figures (The (2) muscles spinal Erector 14 5,14 14 15 and quadratus lumborum. quadratus and seentheexternalas surface theabdominalof be wall can abdominis rectus the of border lateral The left. the and right the as parts two into it divides extending alongside the abdominal wall. Linea alba muscles. nis abdomi- transversus and oblique internal harbors andexternal oblique muscles, while abdominis the deep rectus layer of consists layer superficial The muscles Abdominal vertebra. lumbar lower the to crest iliac the from extends It spine. lumbar the to next and cavity dominal fossa. iliac muscleahaving triangulara shapefillsitandthe tachesto the minor tubercle of the femur. Iliacus is at- and capsule joint hip the of portion anterior the through passes it ligament inguinal the derneath un- from and downwards extends It column. bral verte- the of portion lumbar the from starts it cle; is a long and smooth muscle muscle smooth and long a is abdominis Rectus ab- the behind located is lumborum Quadratus psoas major is a long andfusiformmus- psoasmajorisalong Iliopsoas; Anterior muscles of the lumbar vertebra are psoas 16,17 16,17 13 Minimally Invasive Spine Surgery: Current Aspects 197 The superficial superficial The 20 19,20 The most superficial and the most most the and superficial most The 19,20 19 15 The role of the muscles in functional stability of the lumbar spine stability of in functional of the muscles The role Core muscles consist of two different types of the of components vital are muscles Abdominal Posterior layer consists of the tendonPosterior of the layer latis - The part called the core originates from the tho- oblique muscle is the external oblique and it is influ- ential in the control of the pelvic tilt. components of the multifidus muscles take part in part take muscles multifidus the of components whereas lordosis lumbar of control the and rotation ture formed by the internal oblique and the trans- thoracolumbar through muscles abdominis versus fascia plays a role in increasing the intraabdomi- nal pressure. muscle fibers: slow and fast twitching fibers. Slow Slow fibers. twitching fast and slow fibers: muscle muscles layer deep the in found are are fibers They twitching system. muscle local movements, the to belong they and intersegmental the control they and short they respond to the changes in posture are and extrin- group this in included muscles The muscle, loading. sic oblique internal muscles, multifidus lumbar transversus abdominis, posterior intertransversaris, The interspi- psoas. the of fibers posterior and nalis as regarded - portion of the longissimus attach to the lumbar ver is it features, certain its to due and tebra fibers twitching Fast muscles. local the of member a belong to the global system muscles that lie super- ficially. These muscles are rectus abdominis, exter- nal oblique muscle, and erector spina and quadra- arm momentum long a forming By lumborum. tus of the and movements to the torque it contributes vertebral column. forms a belt around the abdomen. The rim struc- terior ligament of the lumbar spine due to its at- tachment. body. When it contracts together with the muscle groups the thoracolumbar fascia acts as a propri- oceptor providing information about the position of the body. core structure. Transversus abdominis is of utmost utmost of is abdominis Transversus structure. core Except effect. of stabilizing its and because course importance horizontal a follows it fibers lower its for simus dorsi aponeurosis. These tendons cover the cover tendons These aponeurosis. dorsi simus they midline the on and muscles lumbar ipsilateral processes spinous sacral and lumbar the approach the from coming fibers the with meeting whereby a is only retinaculum not layer This side. opposite of lumbar muscles but also an extension of the pos- racolumbar fascia namely “the lumbar belt of cre- cre- the body like a rim and ation”. This fascia covers lower the and upper the between connection a ates 15 The thora- The 13 14,18 table 1. 14,18 18 18 The functions of the lumbar region muscles and and muscles region lumbar the of functions The lies underneath the internal internal the underneath lies abdominis Transversus Internal oblique is a wide and thin muscular layer External oblique is the most superficial and the columbar fascia consists of 3 layers. Its anterior and and anterior Its layers. 3 of consists fascia columbar middle layers cover the psoas and quadratus lum- with one the is layer posterior The muscles. borum spina erector the covers layer This functions. critical along- and multifidus and joins with the middle layer side the lateral border of the erector spina. As the thoracolumbar - fascia is attached to transver it muscles, abdominal and internal sus abdominis belt. lumbar and like an abdominal acts Thoracolumbar Thoracolumbar Fascia racolumbar fascia, 2/3 anterior portion of the iliac ligament. of part the and inguinal 2/3 crest lateral and to the anterior. It at- The fibers extend upwards costae three last of the borders lower to the taches linea process, xiphoid the parts, cartilage their and alba and the pubic symphisis. anterior half of the the of iliac end crest. lower Most The of the aponeurosis. fibers large a with end spine iliac superior the between is that aponeurosis and the pubic tubercle folds on itself to form the in- guinal ligament. extends by opening like a fan and the and attaches tubercle pubic to alba, linea the process, xiphoid widest of all the muscles. Its muscular layer starts starts layer Its muscular of all the muscles. widest It costae. eight lower the of surfaces outer the with and is called as linea semilunaris. This muscle - at and to the fifth inferiorly to crest the pubic taches and seventh costal cartilages and the xiphoid pro- cess superiorly. their innervations are shown on oblique muscle. It is a thin muscle with a horizontal horizontal a with muscle thin a is It six muscle. last the oblique of surfaces inner the from starts It course. of the iliac surface 2/3 anterior vertebrae, cartilage ligament. inguinal the of surface outer 1/3 and crest the and alba linea process, xiphoid the to attaches It mingle fibers tendinous lower The symphisis. pubic with the similar fibers of the internal oblique mus- attaches that tendon conjunctivus the form and cle to the pubic crista and linea pectinea. located underneath the external oblique muscle with with muscle oblique external the those to underneath located perpendicular direction a in extending fibers of the external oblique muscle. It starts at the tho- 198 Minimally Invasive Spine Surgery: Current Aspects to innervate the rotator and interspinalis tachesmuscles; to the spinous process and then nerveterior innervates first at that multifidus the it continues pos- primary L3 the of branch medial the ample, ex- For joint. facet the of innervation sensory the vationof the multifidus muscle after performing inner- motor the for provides branch medial The vertebralcolumn and the postvertebral muscles. nerves distribute into the posterioruses. The elements primary ofposterior the branches of the rior branches toform thelumbar and sacral plex- spinal ante- other with together comes branch anterior into anterior and posterior branches. The formprimary the mixed spinal nerve. Spinal nerveposterior divides roots join within the neuralrating foramenfrom thespinal cord, andtheanterior andthe nervates the erector spina muscle. spina erector the nervates gion muscles are shown on shown are muscles gion foramen to form the spinal nerves. spinal the form to foramen posteriorrootsthatcometogether neural the at segments.Cauda equina consists of anterior and bra. It continuesverte - asL2 theof caudalevel equinathe at in theends lowermedullaris Conus Region Lumbar the of Innervation The movements. extremity the thesemuscles were shown to have delays before sufferingals frombackpain,movementsthe in individu- In individuals. healthy in movements shouldermovements beforeand110ms theleg musclesareshowncontractto beforems30 the tum arms. Transversus abdominis and multifidus momen- limited otherspinalmusclesviatheir by the deep ones control the movements performed Beril DoguMD,JulideOncuBanuKuranMD bines with a sympatheticbineswitha branchcoming ofout com- foramen intervertebral the within nerves mary posteriorbranches. is innervated bythemedialbranches ofthreepri- theupperfacet joint. Thatwhythefacetisjoint thelower facet joint and anascending branch to inglevel nerves andsends inferioran branch to neighbor- the of branches medial the with mizes anato- makes it course, this of Because arch. rior spinous processandtheperiosteumofposte- ament, ligamentum flavum, posterior part oflig- thesupraspinous the ligament, interspinous the of innervations sensory the by followed is this The functions and innervations of lumbar re- lumbar of innervations and functions The A branch coming out of the mixed spinal spinal mixed the of out coming branch A 1,15 19-21 Thelateralbranchin- and 1 tables 1 13

After sepa- After figure 3. figure - T Movement Anterior flexion Anterior Extension Lateral flexion Lateral Rotation

able 1: able Themovements theoflumbar vertebral column muscles and their innervations their and muscles Muscle 6. Intertransversaris 6. 5. Transversusabdominis oblique abdominal Internal 4. oblique abdominal External 3. abdominis Rectus 2. major Psoas 1. 2. Erector spina Erector 2. dorsi Latissimus 1. 8. Gluteus maximus Gluteus 8. Rotators 7. Multifidus 6. lumborum Quadratus 5. Interspinalis 4. 3. Transversospinalis 2. Erector spina Erector 2. dorsi Latissimus 1. 7. External abdominal oblique abdominal External 7. major Psoas 6. lumborum Quadratus 5. 4.Intertransversari 3. Transversalis 2. Rotators 2. 1. Transversalis 3. Multifidus 3. thoracis longissimus lumborum iliocostalis thoracis longissimus lumborum iliocostalis innervation Nerveroot L1-L5 T7-T12,L1 T7-T12,L1 T7-T12 T6-T12 L1-L3 L1-L3 (C6-C8)Thoracodorsal L1-L5 L1-L3 L1-L5 L1-L5 L1-L5 L1-L4 T12, L1-L5 L1-L5 L1-L3 (C6-C8)Thoracodorsalis L1-L5 L1-L3 T7-T12 L1-L3 L1-L4 T12, L1-L5 L1-L5 L1-L5 L1-L5 L1-L5 Minimally Invasive Spine Surgery: Current Aspects 199 2,5,9 9 The role of the muscles in functional stability of the lumbar spine stability of in functional of the muscles The role The venous blood coming out of the last plaques plaques last the of out coming blood venous The the coccyx come from the small segmentary arteries arteries segmentary small the from come coccyx the originating from the medial sacral artery. drains into the internal vertebral plexus found in be- drains into the internal vertebral - Internal ve the vertebrae. and the duramater tween valve have nous plexus not makes do an anastomosis with the exter- plexuses These plexus. venous veins nal intervertebral the into drain Plexuses a systems. of absence The the cava. in vena the into drain relationship these and close the for provides system valve venous circulation between the pelvis and the the lum- to metastases the easing thereby region bosacral lumbosacral region from the pelvic region. 1,9 The movements of the lumbar vertebra and the associated muscles (The figure is obtained from reference 7) is obtained from reference (The figure muscles and the associated vertebra of the lumbar 3: The movements Figure The The Blood Supply of the Lumbar blood Region the supply aorta the from originating Arteries and blood the while sacrum vertebrae, lumbar four the to first the vertebra; lumbar fifth the of supplies riosteum of the vertebral bodies, epidural venous plexus and the anterior surface potential of the are spinal dura- structures these all why is That mater. sources of back pain. the ramus communicans and returns into the canal. canal. the into returns and communicans ramus the nerve meningeal recurrent the is called nerve This or the sinovertebral nerve. 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