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The Role of the Muscles in Functional Stability of the Lumbar Spine

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The Role of the Muscles in Functional Stability of the Lumbar Spine 193 THE ROLE OF THE Aspects Spine Surgery: Current Minimally Invasive MUSCLES IN FUNCTIONAL STABILITY OF THE LUMBAR SPINE 32A Beril Dogu MD, Julide Oncu MD, Banu Kuran MD The Lumbar Vertebra The Anatomy of the Lumbar Vertebral Column The lumbar vertebral column has five active verte- he lumbar portion of the vertebral column brae. The sizes of these vertebrae increase as we pro- has an ideal structure aiming at maintain- ceed distally. The lumbar vertebra constitutes 25% T ing stability and mobility. This region has a of the whole backbone length. When approached solid structure designed to carry the weights of the from the lateral, it has an angulation with a poste- head, the neck, the trunk and the extremities. The rior concavity called the lumbar lordosis.3 Most of pains associated with this region are very common the bone structures contained in the lumbar verte- complaints affecting 80% of the population at least brae are cancellous bones creating vulnerability for one time during their lifetimes. 1 collapses due to trauma or osteoporosis. Thin but The functional unit of the backbone is the small- dense cortical bone usually proliferates around liga- est segment that provides for all the mechanical fea- ment attachment sites forming osteophytes as a result tures of the vertebral column. Functional spinal unit of aging. Neural arch consists of pedicles, superior consists of two neighboring vertebrae, between them and inferior facet joints and laminas. The localiza- lies the intervertebral disc to the anterior and bilat- tion of facet joints change based on the level of the eral facet joints to the posterior forming a triple joint vertebra. At the midthoracic region, they are located complex.2 Functional spinal unit has two segments: on the frontal plane whereas at the lumbar region the anterior (static) and the posterior (dynamic). The they are on the sagittal plane. This allows for antero- anterior segment consisting of the two neighboring posterior sliding of the facet joints thereby increasing vertebral bodies and the intervertebral discs between the flexion and the extension capacity of the lower them has the responsibility to bear weight and to lumbar region. The superior facet joint is smaller give flexibility to the vertebral column. The posterior than the inferior. It has a concave cartilaginous ar- segment protects the neural structures and controls ticular surface and it forms the ceiling of the lateral 2,3 the movements of the lumbar region. recess. This is where the nerve root leaves the cen- Lumbar spine has 3 basic biomechanical tral canal and enters the neural foramen. The pedi- functions.4,5 cles form the base and the ceiling of the neural fo- 1. Transfers any external load carried by the head ramen. The laminas complete the neural arch from and the upper part of the trunk and any related the posterior. This part protects the neural struc- bending momentums to the pelvis. tures and is the site for the attachment of paraspi- 2. It allows for movements between the head, the nal muscles. Laminas have very limited contribu- trunk and the pelvis. tions on the spinal stability. If they are affected by 3. Maintains the integrity of the spinal cord and pre- fractures or removed during surgery (laminectomy), vents any forces or movements that might cause this does not lead to any spinal instability. The pedi- damage. cle and the facet carry only 20% of any vertical load. Beril Dogu MD, Julide Oncu MD, Banu Kuran MD 194 The remaining 80% of this load is absorbed by the Ligaments 1,3 intervertebral discs. The ligaments of the lumbar region resist to stretch- The bodies of the lumbar vertebrae are typically ing and tensile forces. Their main responsibility is wide and in the form of a kidney, the pedicles are to prevent any excessive movement and to main- inclined to the posterior, the laminas are thick, the tain stability.8 Furthermore, the capsule and the liga- vertebral foramina have triangular shapes, the trans- ments contain proprioceptive sensory receptors that verse processes are thin and long, the spinous pro- are associated with the movement.9 Except for lig- cesses are short and wide extending to the poste- amentum flavum, most ligaments consist of colla- rior. Upper joint surfaces face the anterior, inferior gen fibers. Ligamentum flavum on the other hand joint surfaces face the lateral. The joints surfaces of has high percentage of elastic fibers.10, 11 the lumbar vertebra for the costae and the associated ALL extends from the skull to the sacrum on the 6 transverse processes do not have foramina. anterior surface of the vertebral column like a con- tinuous band; it attaches tightly to the lateral sides of Intervertebral Discs the anterior surfaces of the vertebral bodies and has The intervertebral discs are the remnants of the noto- a wide surface.6 ALL is responsible for limiting the chord and are found in between the vertebral bodies extension. As it has nociceptive and proprioceptive Minimally Invasive Spine Surgery: Current Aspects Spine Surgery: Current Minimally Invasive consisting of fibrocartilagenous structures. They are innervation, if extension injuries cause damage to the thicker at areas where the vertebral column is more ALL, pain ensues.1 It is the most important ligament mobile like the cervical and the lumbar regions.6 for the stabilization of the lumbar vertebra.4 Nucleus pulposus is an ovoid structure having PLL is wider in the upper lumbar region while yellowish color and it consists of gelatinous muco- getting narrower and weaker in the lower lumbar re- protein. A fibrous structure called annulus fibrosus gion; at L5-S1 space, its thickness decreases by 50%.4 made up of collagen fibrils surround and strengthen This ligament extends on the posterior surface of the the nucleus.3 Collagen bands extend in an oblique vertebral column from the skull to the sacrum like a manner between the neighboring vertebral bodies. band and attaches to the posterior sides of the discs.6 The inclinations of the fibers are opposite to each It has two layers as the superficial and the deep. Su- other on the neighboring lamellae. The fibers at the perficial fibers are like bands on the midline. Deep periphery attach tightly to the anterior and the pos- fibers are shorter and they extend to the lateral part terior longitudinal ligaments of the spinal column.3,6 of the annulus fibrosus fibers of the intervertebral disc by getting wider. PLL receives its sensory in- Lumbar disc structures are thinner on the ante- nervation from the recurrent meningeal nerve. Neu- rior contributing to the formation of the lumbar lor- rotransmitters like substance P and neoromodulators dosis. In early decades of life, we see the entry and like encephalins are contained within the terminal fi- exit of thin blood vessels into the discs. In the com- bers of the sinovertebral nerve innervating PLL and ing three decades, these vascular structures obliter- they render PLL quite sensitive to pain.1 ate. Following this event, the nutrition of the disc is maintained only by the lymphatics and the osmo- Ligamentum flavum extends from the anterior in- sis of the extracellular fluid. In young individuals, ferior portion of an upper vertebral lamina to the the water content of the disc is around 80-90%, with posterior superior portion of a lower vertebral lam- aging this decreases down to 65% and water is re- ina. It is bilaterally located. It covers the posterior placed by fibrous cartilage.3,6,7 Intervertebral discs part of the vertebral canal. Its thickness increases are shock absorbers for the vertebrae and they con- as we proceed from cervical to lumbar. During an- stitute 20-25% of its length in young individuals; to- terior flexion and erect posture it protects the pos- gether with the decrease in water content due to ag- terior elements and maintains stability. During the ing, this percentage decreases as well (3). Aging also flexion of the vertebral column it prevents the ver- damages the collagen fibers of the annulus and the tebral bodies from separating from each other, its nucleus pulposus that is under pressure can no lon- length increases during flexion and shortens dur- 5,11,12 ger be protected. The discs get thinner as we age, ing extension. their flexibility is decreased and it becomes difficult Supraspinous ligament covers the surfaces of the to distinguish the annulus from the nucleus.6 spinous processes.2 It is the only segmental ligament The role of the muscles in functional stability of the lumbar spine 195 pertaining to the posterior column. Its function is extend upwards and divide into three columns un- Aspects Spine Surgery: Current Minimally Invasive to prevent extreme flexion.5 It generally ends at the der the 12th costa.5,14 (Figures 1 and 2) level of L4. This ligament is then replaced by erec- Iliocostalis (lateral band) attaches to costal angles 1 tor spina and thoracolumbar fascia. and extends to the level of C4-C6. It has lumborum, Interspinous ligament lies between the two spinous thoracis and cervicis portions.5,14 processes. It consists of anterior, middle and pos- Longissimus (intermedial band) is placed in the mid- terior portions. This ligament also prevents the dle. It has thoracis, cervicis and capitis portions. Ex- extreme flexion of the spinal column. Its sensory tending upwards from T1, it attaches to the trans- innervation is through mechanoreceptors and no- verse processes of all the vertebrae.5,14 ciceptive nerve endings; that is why it causes back Spinalis (medial band) is the most inwardly lo- pain when injured.1 cated. While its medial border attaches to the pos- Intertransverse ligament extends in between the terior processes of the thoracic vertebrae, its lateral transverse processes of neighboring vertebrae.
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