Lumbar Instability

Original Editors - Anke Jughters

Top Contributors - Tessa de Jongh, Sam Van de Mosselaer, Anke Jughters, Andeela Hafeez, Admin, Kim Jackson, Lucinda hampton, Simisola Ajeyalemi, Rachael Lowe, Kai A. Sigel, WikiSysop, 127.0.0.1, Tony Varela, Elien Clerix, Vandoorne Ben, Liese Bosman, Shaimaa Eldib, Tony Lowe, Robert Pierce, Elaine Lonnemann and Mats Vandervelde  

Definition/Description[edit | edit source]

Segmental instability versus Clinical instability
Segmental instability is proposed to exist because of failure of the passive restraints (ie, the intervertebral disc, ligaments, and facet joint capsules) that function to limit segment motion Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
But the neuromuscular system might also play an important role in controlling segmental motion, a model of a spinal stabilization system was represented by 3 major subsystems. These systems contain the passive subsystem (consisting of vertebrae, facet joints, intervertebral discs, spinal ligaments, joint capsules and passive muscle support), the active subsystem (including the muscles and tendons surrounding the spinal column) and the neural control subsystem (force and motion transducers and the neural control centers). Spinal (lumbar) stability within this model hang on the correct functioning and interaction of all 3 subsystemsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. (Figure 1)
Segmental instability is defined “as a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain.”Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The neutral zone is defined as a portion of the total physiologic range of intervertebral motion. The total physiologic range involves a neutral zone and an elastic zone (Figure 2). The neutral zone, is the zone of movement close the neutral position of the segment, a zone in which movement occurs with little resistance. The elastic zone starts at the end of the neutral zone and stops at the end of physiologic range of motion Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Segmental instability is considered as an abnormal movement of one vertebra on another secondary due to an increase in the size of the neutral zone.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Spinal instability is defined as “an abnormal response to applied loads and is characterized by movement of spinal segments beyond the normal constrains” Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Clinically Relevant Anatomy
[edit | edit source]

The lumbar spine exists of five moveble vertebrae, called by L1 to L5 (Five moveable vertebrae (L1-L5) realize the lumbar spine.) These strong vertebrae are linked by multiple bony elements connected by joints capsules, flexible ligaments/tendens, large muscles, and high sensitive nerves.
The lumbar spine is intended to be very strong, so it can protect the sensitive spinal cord and spinal nerve roots. But, it’s also highly flexible for mobility of the back (flexion, extension, side bending and rotation). Having regard to the form of the joints in the lumbar region, flexion and extension the main motion directions. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
For more detailed anatomy:
[[The lumbar spine exists of five moveble vertebrae, called by L1 to L5 (Five moveable vertebrae (L1-L5) realize the lumbar spine.) These strong vertebrae are linked by multiple bony elements connected by joints capsules, flexible ligaments/tendens, large muscles, and high sensitive nerves. The lumbar spine is intended to be very strong, so it can protect the sensitive spinal cord and spinal nerve roots. But, it’s also highly flexible for mobility of the back (flexion, extension, side bending and rotation). Having regard to the form of the joints in the lumbar region, flexion and extension the main motion directions. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

For more detailed anatomy:

www.physio-pedia.com/Low_Back_Pain_and_Pelvic_Floor_Disorders

Epidemiology /Etiology
[edit | edit source]

The etiology of intervertebral disk degeneration is largely unknown, but it is thought that disk nutrition is involved (49,50). The normal intervertebral disk is avascular and receives its nutrition by passive diffusion from vessels in the endplate and around the annulus. In man, the relative contributions are unknown, but the importance of the vascular channels in the endplate has been stressed.[1][2]

Lumbar spinal instability may be caused by:
• degenerative disease
• postoperative status
• trauma to spine or its surrounding structures
• development disorders, like scoliosis and other congenital spine lesions
• infection
• tumors Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Also poor lifting technique such as forward-bend posture and asymmetric lifting is associated with Low Back Pain. A constant morphological modification of the spine alters the biomechanical loading from back muscles, ligaments, and joints, and can harvest back injuries.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleGranata et all., described that body mass, task asymmetry, and level of experience affected the scale and variability of spinal load during repeated lifting efforts.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In older people, bending and lifting activities produce loads on the spine that exceed the failure of vertebrae with low bone mineral density, which is linked with spinal degeneration. The degenerative transformation has influence on the intervertebral discs, ligament and bone.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


There is a 50–70% chance of a person having LBP pain during his or her lifetime, with a prevalence of about 18%. Specific causes for most LBP are not known. Although negative social interaction (for example, dissatisfaction at work) has been found to relate to chronic LBP, a significant portion of the prob-lem is of mechanical origin. It is often referred to as clinical spinal instability. There have been several similar studies over the past 50 years, but the results have been unclear. In association with back or neck pain, some investigators found increased motion[3][4], whereas others found decreased motion . Some reasons for the uncertainties have been the varia-bility in the voluntary efforts of the subjects to produce spinal motion, the presence of muscle spasm and pain during the radiographic examination, lack of appropriate control subjects matched in age and gender, and the lim-ited accuracy of in vivo methods for measuring motion. 

Characteristics/Clinical Presentation[edit | edit source]

Commonly a history of lower back pain, which may or may not be accompanied by sciatica (with or without neurological signs).
Lumbar pain is often relived by rest or by waring a support, but may recur with a small amount of movement, such as a twist or sprain.
Pain made worse by maintaining one posture for a long period of time (standing or sitting).
Pain is usually relieved by mobilisation or manipulation, often with complete resolution of leg pain and neurological symptoms. However, relief is temporary, giving way to recurring pain a few days later with no obvious triggers.
In some patients, a steadily increasing lumbosacral ache when extremes of spinal movement are sustained for more then 15 seconds
Some patients may also report a painful arc with lumbar flexion or coming out of flexion.
In some cases, lumbar instability may cause a ‘catch’ in the back or even a ‘locking’ sensation.[5]

Differential Diagnosis[edit | edit source]

• Intervertebral disc prolapse
• Muscle injury Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Muscle_Injuries

• Muscle strain Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Muscle_Strain

• Ligamentous overload
• Postural overstretching
• Spondylosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Lumbar_Spondylosis

• Arthrosis of the spinal joints
• Lumbar spine fracture
www.physio-pedia.com/Lumbar_Spine_Fracture
• Kidney problem
• Spondylolisthesis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Spondylolisthesis

• Hypermobility syndrome
www.physio-pedia.com/Hypermobility_Syndrome

• Spinal tumor Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Dysfunction
• Osteoporosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Osteoporosis

• Sciatica Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Sciatica

• Degenerative disc disease Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Degenerative_Disc_Disease

• Rheumatoid arthritis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Rheumatoid_Arthritis

• Urinary tract infection Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Nephrolithiasis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Nephrolithiasis_(Kidney_Stones)

• Abdominal aortic aneurysm
• Referred visceral dysfunctions
• Lumbar degenerative joint disease
• Lumbar compression fracture
www.physio-pedia.com/Lumbar_compression_fracture

• Lumbar facet arthropathy
• Abnormalities of the lumbar nerve roots
• Degenerative synovial cysts
• Extraspinal causes
• Infection
• Inflammatory conditions
• Metastic neoplasms
• Connective tissue disease
• Metabolic disease
• Myelitis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Seronegative arthritic diseases

Diagnostic Procedure[edit | edit source]

→ neutral radiography:

Shows many indirect signs that are associated with spinal instability:
1. Moderate disc degeneration with mild space narrowing, osteosclerosis and osteophytosis of the vertebral end plates (Kirkaldy-Willis 1985[6])
2. Presence of traction spur, which is a particular type of osteophyte that is located 2-3 mm from the end plate and has a horizontal orientation. (Remy et al 2001[7])
3. Intervertebral vacuum phenomenon is due to rupture of the insertion of Sharpey’s fibres and may be the result of vertebral instability (Alam 2002[8])

→ functional radiography
This is the perfect method to show intervertebral instability or abnormal motion between two vertebrae. Dynamic radiographs obtained in both flexion and extension, prove to be a simple and reliable method to determine motion segment instability and can also indicate the lesions located in specific areas based on the ‘‘dominant lesion’’ concept (Dupuis et al 1985[9]).

→ computed tomography
This technique is aimed at demonstrating a gap in the facet joints during rotation of the trunk, which is an indirect sign of spinal instability.
→ magnetic resonance imaging

MRI claimed to be the best method to find lumbar instability. However, symptoms may not always be defined to morphological lesions such as disc herniation, foraminal stenosis or stenosis of the spinal canal but rather to segmental instability (Alam 2002[10]). Identifying patients with an increased chance of instability on MR imaging can be clinically relevant and can influence indications for functional radiographs.

Outcome Measures
[edit | edit source]

Prone_Instability_Test

generalized LLS

aberrant motion with trunk ROM

Medical Management
[edit | edit source]

In acute overt instability, stabilization of the spine is required in all cases. In this context, medical treatment refers to the use of external bracing for spine stabilization. If instability is due to an osseous fracture, if the fracture fragments can be reduced to near-anatomic alignment, and if there is no significant neural compression after reduction, the patient may be treated nonsurgically with a brace until the fracture heals.

In anticipated instability (eg, extensive discitis and osteomyelitis treated with debridement, decompression and antibiotics), bracing may be used as a temporary means of stabilization, before fusion is undertaken or until spontaneous fusion occurs.[11]In chronic overt instability and covert instability, medical treatment plays a more prominent role. If not at risk for imminent neurological deterioration, the patients with these forms of instability generally undergo conservative (nonsurgical) treatment first. Fusion is reserved for those in whom conservative treatment fails.

medication:Analgesics, anti-inflammatories, muscle relaxants, tricyclic antidepressants, anti-epileptics.

Surgerical management[edit | edit source]

Once the decision has been made to fuse a particular spine segment, there may be several surgical methods to accomplish this task. After a particular method is selected, the etiology of instability is no longer relevant, as the technical steps would be the same.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Posterior and posterolateral noninstrumented lumbar fusion The lumbar spine is exposed in standard fashion through a posterior midline incision. Bilateral exposure of the laminae is extended further laterally to completely expose of the facet joints and transverse processes of the vertebrae to be fused. Usually, a decompressive laminectomy is carried out to treat neural compression. In this process, medial facetectomies may be carried out to fully decompress the lateral recesses, if necessary. The transverse processes, lateral aspect of the facet joints and the synovial facet surfaces are decorticated with a high-speed drill.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Instrumented lumbar fusion with pedicle screws

The spine is exposed (and decompressed if necessary) as for a noninstrumented fusion. Pedicle screws are inserted into the pedicles above and below the motion segment to be fused. The main concern during pedicle screw insertion is to avoid breach of the pedicle wall and injury to the exiting nerve root. If a laminectomy or upper laminotomy has been carried out, it is possible to visualize or palpate the medial and inferior surfaces of the pedicle, which are in contact with the nerve root. In this case, only lateral fluoroscopy is necessary to guide the entry and trajectory of the screw in the sagittal plane. If the pedicle has not been exposed by laminectomy/laminotomy, AP and lateral fluoroscopy are usually used. The inferior-lateral aspect of the pedicle can also be exposed by subperiosteal dissection from a lateral approach along the base of the transverse process.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Physical Therapy Management
[edit | edit source]

Why is there so much ado about the Transversus Abdominis and Lumbar Multifidus? They are both primary stabilizers, meaning they are responsible for stabilizing and approximating joints. The most important things that characterize them are following qualities: they are located close to the joint, they lie deep, are slow twitch, consist of short fibers and reasonable fatigue resistant. With muscle imbalance they tend to weaken and lengthen[12]

Often, it has been assumed that Lumbar Multifidus and Transversus Abdominis co-contraction is required for lumbar stability and that it has to be maintained with patients suffering from low back pain[13] Co-contraction occurs in periods of time but it is not necessary for stability. In preparation for the disruption to the spine from a movement of an extremity (ex. arm movement). Transversus Abdominis and Lumbar Multifidus are active but in a non-direction-specific feed forward manner. The contraction does not happen simultaneously, however the mechanical effects occur roughly at the same time. This can be explained by the fact that the Transversus Abdominis has a longer electromechanical delay than that of the Lumbar Multifidus, because of its long elastic anterior fascias. Transversus Abdominis is earlier active, so that compensates for the longer delay. So the two discussed muscles don’t maintain tonic co-contraction. Therapeutic exercise programs which involve training co-contraction of the Transversus Abdominis and Lumbar Multifidus, are not going to be capable of restoring typical activation patterns. Nonetheless, the co-contraction training may be necessary to restore intervertebral control which can be caused by an underlying osseoligamentous deficiency[14][15]

And what about the relationship between these two muscles and the prognostic factors that predict clinical success with stabilizing programs? There are five useful factors, namely age<40y, average straight leg raise range of motion >91°, presence of aberrant movement with lumbar spine flexion, a positive prone instability test[16] and at last the existence of segmental hypermobility[17]  The connection between the prognostic factors and clinical success with stabilizing programs was supported through their relationship with Lumbar Multifidus activation. Even after controlling for the effects of sex, current pain level, BMI, fear-avoidance beliefs and prior history of low back pain, the relationship kept upright. In addition to this, there was no significant relation found between the factors and Transversus Abdominis muscle activation. You have to take notice of the fact that the study, which investigated this relation, has not examined the feed forward behavior of Transversus Abdominis. The relationship between the prognostic factors and this aspect of Transversus Abdominis function remains unknown. Thus the findings of this study provide evidence that shows the importance of restoring Lumbar Multifidus function in patients with low back pain. However, examination of other muscle functions (ex. feed forward behavior) may cause a more extensive understanding[18]

Therapy Exercises for Lumbar Instability

Resources
[edit | edit source]

http://www.allaboutbackandneckpain.com/understandingconditions/segmentalinstability.asp

http://back-in-business-physiotherapy.com/physiotherapy-teaching/clinical-instability-of-the-lumbar-spine

Recent Related Research (from Pubmed)
[edit | edit source]

Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1X3iPH1T_Q46BOv5FNkJFsK1JFmtizHcll3VxmJrGNBHOLIUs-|charset=UTF-8|short|max=10: Error parsing XML for RSS

References
[edit | edit source]

  1. ↑ Urban JP, Holm S, Maroudas A, Nachemson A. Nutrition of the intervertebral disc: effect of fluid flow on solute transport. Clin Orthop Relat Res 1982; 170: 296–302.
  2. ↑ Brown MF, Hukkanen MV, McCarthy ID, et al. Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease. J Bone Joint Surg Br 1997; 79: 147–153. CrossRef, Medline
  3. ↑ J. Dvorak, J.A. Antinnes, M. Panjabi, et al. Age and gender related normal motion of the cervical spine, Spine 17 (suppl. 10) (1992) S393–S398
  4. ↑ J. Dvorak, M.M. Panjabi, D. Grob, et al. Clinical validation of functional flexion/extension radiographs of the cervical spine, Spine 18 (1993) 120–127.
  5. ↑ https://www.medisavvy.com/lumbar-instability/
  6. ↑ Kirkaldy-Willis W. Symposium on instability of the lumbar spine : Introduction. Spine 1985; 10: 254-55.
  7. ↑ Remy S Nizard, Marc Wybier, Jean-Denis Laredo. Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis. Radiol Clin North Am 2001; 39(1): 55-71
  8. ↑ Alam A., Radiological evaluation of lumbar intervertebral instability. Methods in Aerospace medicine 46(2), 2002
  9. ↑ Pierre R Dupuis, Ken Yong-Hing, J David Cassidy, William H Kirkaldy Willis. Radiological diagnosis of degenerative lumbar spinal instability. Spine 1985; 10((3): 262-76
  10. ↑ Alam A., Radiological evaluation of lumbar intervertebral instability. Methods in Aerospace medicine 46(2), 2002
  11. ↑ http://emedicine.medscape.com/article/1343720-treatment
  12. ↑ Norris CM. Back stability, integrating science and therapy, human kinetics, second edition; 2008; 62
  13. ↑ Taylor J., Twomey L. Physical Therapy of the low back, Churchill, third edition; 2000; 201-247
  14. ↑ Moseley G., Hodges PW., Gandevia S. deep and superficial fibers of the lumbar multifidus are differentially active during voluntary arm movements, Spine 2002; 27; 29-36
  15. ↑ Hodges PW., Richardson CA. Feed forward contraction of transversus abdominis is not influenced by the direction of arm movement, Experimental Brain research 1997; 114; 262-270
  16. ↑ Hicks GE., Fritz JM., Delitto A., McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program, Arch Phys Med Rehabilitation 2005; 86; 1753-1762
  17. ↑ Fritz JM., Whitman JM., Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med rehabilitation 2005; 86; 1745-1752
  18. ↑ Herbert JJ., Koppenhaver SL., Magel JS., Fritz JM. The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med Rehabilitation 2010; 91; 78-85
Retrieved from "https://www.physio-pedia.com/index.php?title=Lumbar_Instability&oldid=142347"