"The iliolumbar ligaments" from Luc Peeters


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"The iliolumbar ligaments" from Luc Peeters

  1. 1. The iliolumbar ligaments – a literature studyLuc Peeters, MSc.Ost.1. IntroductionAs A.T.Still stated, anatomy is the most important basic medical science upon whichosteopathy is based. In this context the following literature study of the anatomy and theresultant biomechanics and palpation provides an update of anatomy and biomechanicalfunctional knowledge of the osteopath.2. DevelopmentLigaments normally develop during the late embryonal or early foetal period. After dissectionof 5 newborns Luk A.D. et al (1986) found no iliolumbar ligaments.These authors researched the anatomy and histology of the iliolumbar ligaments in cadaversof newborns to elderly specimens. They found the structure of the iliolumbar ligaments to bemuscular - not ligamentous - between the ages 10 and 20 years.The ligamentous structures were formed by metaplasia of certain fibres of the quadratuslumborum muscle. As of 20 years of age the definitive ligaments are formed. In oldercadavers degenerative changes were found in the iliolumbar ligaments. They concluded thatthe iliolumbar ligaments most likely play a stabilising role in the general lumbosacral stabilityin patients with disc degeneration, degenerative spondylolisthesis and pelvic unlevelling dueto neuromuscular scoliosis.Uhthoff H. (1993) studied 21 foetus cadavers younger than 11 weeks and identified noiliolumbar ligaments. In 12 older foetus cadavers (older than 11.5 weeks old) they found theiliolumbar structures, contradicting Luk et al (1986). The iliolumbar ligaments wererecognisable from the transverse process of L5 to the anterior surface of the ilium anddividend into anterior and posterior parts. These could clearly be separated from the quadratuslumborum, most notably due to different fibre orientation. In only 2 cases were the iliolumbarligaments found to be from the transverse process of L4 and clearly defined from theintertransverse ligaments.Pun W.K. et al (1987) studied the presence of iliolumbar ligaments in quadrupeds and inrhesus monkeys. The difference between both groups is that the rhesus monkeys frequently sitwhile the quadrupeds do not sit and therefore the spine remains horizontal. Iliolumbarligaments were found in the rhesus monkeys but not in the quadrupeds. The iliolumbarligaments bound the last, sometimes the second last lumbar vertebra to the ilia. Theyconcluded that the mechanical stress upon the lumbosacral structures due to the vertical sittingposition in the rhesus monkeys plays an important role in the formation of these ligaments.Jiang H. et al (1995) studied the presence of lateral ligaments in the spine of quadrupeds andin bipeds. They found anterior and posterior ligaments but no lateral ligaments in quadrupedscompared to the bipeds. Furthermore, scoliosis does not develop in quadrupeds but is a 1    
  2. 2. frequent occurrence in bipeds (Rogola and Drummond 1978). This suggests that the lateralligamentous structures play an important role in standing postures.3. AnatomyThe anatomic descriptions of the iliolumbar ligaments do not provide a unanimous view ofthese structures. More specifically, the attachments onto the ilium demonstrate significantvariation. Agur and Dalley (2004), Moore and Dalley (1999) describe the attachments asbeing onto the ilium. Hollinshead (1969) describes them as being onto the internal surface ofthe ilium. Boileau, Grant and Basmajian (1965), Hall-Craggs (1995) and Snell (1995)describe the attachment onto the iliac crest. Wood Jones (1953) describes the attachment asbeing the medial lip of the iliac crest. Romanes (1972), Woodburne and Burkel (1988)describe the attachment as onto the posterior surface of the internal lip of the iliac crest.Hanson and Sonesson (1994) describe the attachments as being the upper and anterior surfaceof the iliac tuberosity.In Gray’s Anatomy (1995) the iliolumbar ligaments are described as running from the tip ofthe lower anterior part of the transverse process of L5 with a weak part from the tip of thetransverse process of L4 to lateral/ posterior, attaching onto the anterior/upper surface of theiliac crest. A lower part of the ligament is also described from the tip of the transverse processof L5 to the anterior surface of the sacrum.Luk K.D. et al (1986) found the iliolumbar ligaments to be two different bands, bothbeginning from the tip of the transverse process of L5 (Figure 1). The anterior part liespredominantly in the coronal plane to terminate into the periosteum of the anterior edge of theiliac crest. The posterior part runs oblique and posterior to insert into the posterior surface ofthe iliac crest. The quadratus lumborum (B) lies between both parts. The psoas (A) lies on theanterior surface of the ligament and the erector spinae (C) upon the posterior side. Figure 1 - Two bands attaching onto the tip of the transverse process L5In their study they found that these structures in newborns were muscular while between theages of 20-40 years muscular fibres were still found between the ligamentous fibres. As fromthe age of 50 years clear degeneration and fatty infiltrations were seen. Such fatty infiltrationswere more evident in women than men.The change from muscular to collagen fibres occurs as from the transverse process andgradually spreads towards the iliac crest. 2    
  3. 3. Bassadonna et al (1996) described the anterior part of the iliolumbar ligament as broad andflat, from the inferior, lateral part of the tip of the transverse process spreading to anterior partof the iliac tuberosity, caudal from the posterior part of the ligament. The posterior part of theligament descends form the apex of the tip of the transverse process of L5 to the iliac crest(anterior edge to apex). The posterior part is thinner and rounder than the anterior part.Fujiwara et al (2000) studied the morphology, the length and the width of the iliolumbarligaments and could identify two different types:Type A: (74) the anterior and posterior parts were in different directions.Type B: (32) the anterior and posterior parts were in the same direction.The angle of the posterior part of the type A ligament was orientated more to posterior thanthat of the type B ligament. The posterior part was also shorter and orientated more toposterior in males than in females.Rucco et al (1996) analysed 15 volunteers via MRI. They found that the part of the iliolumbarligament that originated from the transverse process of L5 consists of two bands (anterior andposterior). The anterior band is flat and broad and has two anatomical varieties: type 1,originating from the anterior part of the inferolateral surface of the transverse process of L5and attaches broadly onto the iliac tuberosity; type 2, originates from the anterior, lateral andposterior part of the inferolateral surface of the transverse process of L5 and attaches broadlyonto the anterior part of the iliac tuberosity.The posterior band attaches onto the apex of the transverse process of L5 and is fusiform. Itruns to the anterior edge of the apex of the iliac crest.In the transverse plane the anterior band is in a horizontal line through the transverse processof L5 and the posterior band forms an angle of 45 -55° (open posterolateral). In the coronalplane the iliolumbar ligament shows more variation related to the size of the vertebra. If L5 issituated low in the pelvis the iliolumbar ligaments are longer and more oblique while if the L5is situated high in the pelvis the iliolumbar ligaments are shorter and more horizontal. Theposterior band is thinner and rounder than the anterior band, which leads to moresusceptibility for over-stretch and torsion. This is a likely explanation for the painfuliliolumbar ligament syndrome.Hanson et al (1998) found that the length of the iliolumbar ligaments was also differentbetween races. Negroid subjects had longer (mean 61.6 mm) iliolumbar ligaments thanCaucasian subjects (mean 33.2 mm). This difference was demonstrated in both sexes. Oneband was more common amongst negroids where as caucasions demonstrated a split into twobands.4. Biomechanics and function4.1. Influence upon the iliosacral stability 3    
  4. 4. Goudzwaard et al (2003) found that following severing of the iliolumbar ligaments the rangeof motion of the iliosacral joint was significantly higher. According to that study the anteriorpart of the ligament provides the strongest influence upon this mobility. They suggested that itis highly likely that surgical severing of this ligament during lumbosacral surgery couldexplain post-operative symptoms and instability. Figure 2 - Posterior part directly along the plane of the IS joint The direction of the posterior part of the iliolumbar ligament is directly along the plane of the iliosacral joint (Figure 2). It also provides a compressing/coaptating function for the iliosacral joint.4.2. Influence upon the stability and mobility of L5 and L44.2.1. In flexion/extensionSnijders (2004) suggests that the iliolumbar ligaments plays an important role in the motion ofthe lumbosacral junction in the sagittal plane. Counter-nutation places the ligaments understretch and nutation shortens it. In osteopathic terms this means that an unstable pelvisinvolves shortening of the ligaments and a fixed pelvis involves ligaments under stretch.4.2.2. During anterior glideAihara et al (2000) fixed the sacrum and ilia in 5 fresh cadavers with spondylolysis of L5.They induced varying flexion/extension and left/right rotation force upon L4 and L5 inflexion/extension, before and after severing of the iliolumbar ligaments. They found thatflexion and axial rotation is strongly regulated by the iliolumbar ligaments, most notably bythe posterior part of the ligaments. They concluded that the integrity of the iliolumbarligaments, certainly the posterior part, determines the stability of the lumbosacral junction(Figure 3), as well as the grade of anterior glide of L5 upon the sacrum. 4    
  5. 5. While providing local treatment for an anterolysthesis of L5 this fact must always be kept inmind. In this case the iliolumbar ligaments must not be placed under extreme stretch so thataddition anterior glide is avoided. Figure 3 - Side view of spondylolysis4.3. Biomechanics in the frontal planeThe iliolumbar ligaments have a stabilising capacity in the frontal plane at the spinal levels ofL5 and L4 (Figure 4). While the iliolumbar ligaments are not always attached to the transverseprocess of L4, the stabilising capacity is continued to L4 via the intertransverse ligaments(Figure 5 & 6). The stabilising function allows approximately 8° of left sidebending and 8° ofright sidebending. More sidebending than this means likely over-stretch of the ligaments. 5    
  6. 6. Figure 4 - Stability in the frontal plane Figure 5 - Anatomical variants Figure 6 - Anatomical variants4.4. Biomechanics in the sagittal planeThe iliolumbar ligaments stabilise the lower lumbar spine in the sagittal plane (Figure 7).They act to control the flexion/extension mobility of L4 and most importantly L5.During flexion the iliolumbar ligaments are under stretch while they shorten during extension. 6    
  7. 7. Figure 7 - Stabilising function in flexion/extension4.5. Biomechanics in the horizontal planeIn the horizontal plane the iliolumbar ligaments also have a stabilising role and limit therotation of L5 (Figure 8). In this way the facet joints are protected from intense and repetitivecompression. In cases of severed iliolumbar ligaments, facet degeneration is frequently found. Figure 8 - Horizontal view of the posterior section5. Pathology5.1. Disc degeneration 7    
  8. 8. In cadavers with disc degeneration of L4-L5 more than L5-S1 the anterior and posterior bandsof the iliolumbar ligaments were generally shorter and thicker. In cadavers with discdegeneration of L5-S1 more than L4-L5 the ligaments were noticeably longer. From theseobservations Aihata (2002) concluded that short strong iliolumbar ligaments protect the discof L5-S1 against degeneration. Fujiwara (1999) made the same conclusions in another study.Ahn et al (2002) used MRI examinations to conclude that it is not actually the length of theiliolumbar ligaments but the left/right asymmetry in the orientation of the ligaments that playsthe most important role in unilateral disc herniation of L5-S1.5.2. Over-stretchLigamentous tension can lead to ligamentous complaints. Specifically, lower lumbar kyphosisleads - even without the factor of bodyweight - to over-stretch according to Snijders (2004)who advises a sitting posture that is not in kyphosis but more straight-back or with a lumbarsupport.According to Sims and Moorman (1996) microtraumas of the iliolumbar ligaments are oftenthe cause of chronic lower back pain. The ligaments have significant nociceptive innervationand are placed under stretch during sacral flexion (sacrum posterior, fixed pelvis).Keel (2007) showed this in a case study.Hirschberg (1979) described the “Iliac Crest Syndrome” in which the patient complains aboutunilateral pain over the iliac crest. The pain can also present bilaterally and occurs mostlyafter long periods of sitting and / or bending forwards.Chronic over-stretch or traumatic over-stretch can lead to inflammation. This can in turn leadto periostitis, even osteitis at the insertion of the involved ligament. Traumatically this canoccur in sports (such as gymnastics) where extreme motions of the lumbosacral junction andlegs are required.5.3. Influence on the spinal ganglion of nerve root L5Briggs and Chandraraj (1995) dissected 65 cadavers and identified the iliolumbar ligaments inall specimens. In 34% of the cases the ligament made contact with the ventral ramus of L5 andin 9% there was a clear presence of flattening and compression of the ramus. The nerve wasthen clearly thickened and showed an increase in perineural connective tissue. The cells in thespinal ganglion were smaller than normal and surrounded by connective tissue, most notablyat the peripheral part of the spinal ganglion.In the cases where compression of the spinal nerve L5 was found, a narrowed lumbosacralspace was also identified. The disc was also seen to be degenerated in these cases. On thesame side, fibrotic changes of the facet joint were found. Therefore, compression of the spinalganglion can occur not only in the intervertebral foramen but also just distal from theforamen.5.4. Calcification 8    
  9. 9. After dissecting 22 cadavers aged over 60 years, Luk et al (1986) found degeneration of theiliolumbar ligaments in 70% of the cases. Some of the examples were even calcified.This means that the osteopath must be careful if manipulating this region in this age group.In the November 2004 edition of “The European Guidelines for the Management of ChronicNon-specific Low Back Pain” it was advised against using prolotherapy (sclerosinginjections) for the iliolumbar ligaments.6. Provocation and palpationThe palpation of the iliolumbar ligaments (Photo 1 & 2) is not simple due to their position;deep to the posterior muscles and fascia and ventral to the iliac crest.The iliolumbar ligaments are associated with the inferior insertion of the thoracolumbar fasciaand the quadratus lumborum muscle, which also complicates the palpation (Bogduk (1997),Frazer (1940), Fujiwara et al, (2000), Pool-Goudzwaard et al (2001), Shellshear andMacintosh (1949), Williams et al, (1995)).The direct palpation from posterior to anterior is made very difficult by the presence of thethoracolumbar fascia, the erector spinae and the quadratus lumborum. A more lateralapproach avoids the erector spinae. However the latissimus dorsi, transverse abdominal,external oblique and quadratus lumborum muscles cannot be avoided.Palpation from the lateral edge of the paravertebral muscles to ventral/medial and caudal isthe best choice. It is important to position the patient so that the muscles superficial to theligament are as relaxed as possible.The palpation of the iliolumbar ligaments can be done with the patient sitting (Photo 1) withslight lumbar lordosis while supporting themselves with the hands behind the back or with thepatient prone (Photo 2) with the hips in slight extension or in the so-called sphinx position.The pain provoked by this palpation is not sharp but deep and aching. As well as the pain, theelasticity of the ligament can also be evaluated. Elasticity loss can indicate retraction, tensionor even calcification of the ligament. 9    
  10. 10. Photo 1 - Palpation of the patient sitting Photo 2 - Palpation of the prone patientThe pain from the provocation should not be confused with pain that is due to entrapment ofthe dorsal ramus L1 or L2 nerve roots (Figure 9). These nerves cross the iliac crestapproximately 7 cm from the middle line and run through a osteofibrous opening whereentrapment is possible. Maigne et al (1991) first discovered these entrapment locations. Figure 9 - Palpation in case of nerve entrapment7. ConclusionThe iliolumbar ligaments play an important role in the stabilisation of L5; most notablylimiting the flexion.In the frontal plane they also act to stabilise the L5 and L4.In cases of spondylolysis of L5 they are the only limiting factor for the anterior glide of the L5.Symmetrical length and quality acts to protect the facet joints from compression during axialrotation.They also function to stabilise the iliosacral joints by compressing them.The iliolumbar ligaments are frequently the painful structure in lumbosacral lower back pain.They can be over-stretched due to a flexion lesion of L5 or due to a fixed pelvis (sacrumposterior) and can be retracted due to an extension lesion of L5 or due to an unstable pelvis(sacrum anterior).They are placed under stretch during kyphotic sitting and can be injured and even tear duringsports that require extreme motion of the lumbosacral junction.In cases of tearing or weakening of the iliolumbar ligament, the facet joint loses its protectionagainst compression and thus degeneration occurs more rapidly. 10    
  11. 11. Tearing or weakening will also result in lost iliosacral joint coaptation whereby hypermobilityin the joint can result, with more rapid degeneration.They play an essential protective role for the disc.8. Bibliography 1. Ahn K.H., Kim H.S., Yun D.H. & Hong J.H. (2002) The Relationship between the Lower Lumbar Disc Herniation and the Morphology of the Iliolumbar Ligaments using Magnetic Resonance Imaging. J Korean Acad Rehabil Med. Aug;26(4): 439- 444. 2. Aihara T., Takahashi K., Yamagata M., Moriya H. & Tamaki T. (2000) Biomechanical functions of the iliolumbar ligament in L5 spondylolysis. Journal of Orthopaedic Science, Volume 5, Number 3. 3. Aihara T., Takahashi K., Ono Y. & Moriya H. (2002) Does the morphology of the iliolumbar ligament affect lumbosacral disc degeneration? Spine. Jul 15;27(14): 1499- 1503. 4. Agur A.M.R. & Dalley A.F. (2004) Grant’s atlas of anatomy (11th ed.) London: Lippincott, Williams and Wilkins, p.298-299. 5. Basadonna P.T., Gasparini D. & Rucco V. (1996) Iliolumbar ligament insertions. In vivo anatomic study. Spine. Oct. 15;21(20):2313-2316. 6. Boileau Grant J.C. & Basmajian J.V. (1965) Grant’s method of Anatomy (7th ed.) Baltimore: Williams and Wilkins, p.320. 7. Bogduk N. (1997) Clinical anatomy of the lumbar spine and sacrum. Edinburgh: Churchill Livingstone, p. 49-51,111. 8. Briggs C.A. & Chandraraj S. (1995) Variations in the lumbosacral ligament and associated changes in the lumbosacral region resulting in compression of the fifth dorsal root ganglion and spinal nerve. Clin Anat. 8(5): 339-346. 9. Broadhurst N. (1989) The iliolumbar ligament syndrome. Australian Family Physician p. 518: 522. 10. Brukner P. & Khan K. (2001) Clinical Sports Medicine. Sydney: The McGraw-Hill Companies Inc, p. 362-374. 11. Frazer J.E. (1940) The anatomy of the human skeleton. London: J.A. Churchill Ltd, p. 135. 12. Fujiwara A., Tamai K., Kurihashi A., Yoshida H. & Saotome K. (1999) Relationship between morphology of iliolumbar ligament and lower lumbar disc degeneration. J Spinal Disord. 1999 Aug;12(4):348-352. 11    
  12. 12. 13. Fujiwara A, Tamai K, Yoshida H, Kurihashi A, Saotome K,An HS & Lim T.H. (2000) Anatomy of the iliolumbare ligament. Clinical Orthopaedics and Related Research 380: 167-172. 14. Grays Anatomy Williams en Warwick (1995) The Anatomical Basis of Medicine and Surgery. 38th British Edition Churchill Livingstone. 15. Hall-Craggs E.C.B. (1995) Anatomy as a basis for clinical medicine. London: Williams and Wilkins, p. 283. 16. Hanson P. en Sonesson B. (1994) The anatomy of the iliolumbare ligament. Archives of Physical Medicine and Rehabilitation 75: 1245-1246. 17. Hanson P., Magnusson S.P., Sorensen H. & Simonsen E.B. (1998) Differences in the Iliolumbar Ligament and the Transverse Process of the L5 Vertebra in Young White and Black People. Acta Anatomica 1998;163: 218-223 18. Hirschberg G.G., Froetscher L. & Naeim F. (1979) Iliolumbar syndrome as a common cause of low back pain: diagnosis and prognosis. Arch Phys Med Rehabil. 60 (9): 415-419. 19. Hollinshead W.H. (1969) Anatomy for Surgeons. Volume 3. The back and limbs. London: Harper and Row, p. 644. 20. Jiang H., Moreau M., Raso J., Russell G. & Bagnal K. (1995) A comparison of spinal ligaments- differences between bipeds and quadrupeds. Journal of Anatomy 187 p.85-91. 21. Keel J.C. (2007) Injections for Chronic Iliolumbar Syndrome: Case Control Study Archives of Physical Medicine and Rehabilitation, Volume 88, Issue 9, Page E70. 22. Kennedy E., Cullen B., Abbott J.H., Woodley S. & Mercer S.R. (2004) Palpation of the iliolumbare ligament. New Zealand Journal of Physiotherapy 32(2) 76-79. 23. Luk K.D., Ho H.C. & Leong J.C. (1986) The iliolumbar ligament. A study of its anatomy, development and clinical significance Journal of Bone and Joint Surgery - British Volume, Vol 68-B, Issue 2, 197-200. 24. Maigne J.Y. & Maigne R. (1991) Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study. Arch Phys Med Rehabil. 1991 Sep; 72(10): 734-737. 25. Moore K.L. & Dalley A.F. (1999): Clinically oriented anatomy (4th ed.) London: Lippincott Williams and Wilkins, p. 335. 26. Pool-Goudzwaard A.L., Kleinrensink G.J., Snijders C.J., Entius C. & Stoeckart R. (2001) The sacroiliac part of the iliolumbar ligament. Journal of Anatomy 199: 457-463. 12    
  13. 13. 27. Pool-Goudzwaard A., Hoek van Dijke G., Mulder P., Spoor C., Snijders C. & Stoeckart P. (2003) The iliolumbar ligament: its influence on stability of the sacroiliac joint. Clinical Biomechanics,Volume 18, Issue 2, Pages 99-105. 28. Pun W.K., Luk K.D.K., & Leong J.C.Y. (1987) Influence of the erect posture on the development of the lumbosacral region. Journal of Surgical and Radiologic Anatomy, Volume 9, Number 1, March, Springer-Paris. 29. Rogola, E.J., Drummond, D.S. & Gurr, J. (1978). Scoliosis: Incidence and natural history, Journal of Bone and Joint Surgery, 60A, 173. 30. Romanes G.J. (1972) Cunningham’s textbook of anatomy. London: Oxford University Press, p.169, 236. 31. Rucco V., Basadonna P.T. & Gasparini D. (1996) Anatomy of the iliolumbar ligament: a review of its anatomy and a magnetic resonance study. Am. J. Phys. Med. Rehabil. 1996 Nov-Dec; 75(6): 451-455. 32. Shellshear J.L. & Macintosh N.W.G. (1949) Surveys of Anatomical Fields. Sydney: Grahame Book Company, p. 21- 29. 33. Simms J.A. & Moorman S.J. (1996) The role of the iliolumbar ligament in low back pain Medical Hypotheses, Volume 46, Issue 6, June 1996, Pages 511-515. 34. Snell R.S. (1995) Clinical Anatomy for Medical Students. London: Little, Brown Company, p. 292-293. 35. Snijders C.J., Hermans P.F.G., Niesing R., Spoor C.W. & Stoeckart R. (2004) The influence of slouching and lumbar support on iliolumbar ligaments, intervertebral discs and sacroiliac joints. doi: 10.1016/j.clinbiomech. 36. Uhthoff H.K. (1993) Prenatal development of the iliolumbar ligament. J. Bone Joint Surg. Br. Jan;75(1):93–95. 37. Woodburne R.T. & Burkel W.E. (1988) Essentials of Human Anatomy (8th ed.) Oxford: Oxford University Press, p. 559-560. 38. Wood Jones F. (1953) Buchanan’s Manual of Anatomy. London: Balliere, Tindall and Cox, p. 954-955. 13