Biomechanics and pathomechanics of lumbosacral joint

BIOMECHANICS AND
PATHOMECHANICS OF
LUMBAR AND SACRAL JOINT
BY
DR N. SAI PRIYANKA

ANATOMY OF LUMBAR SPINE
• Lumbar spine comprises 5 vertebrae
• The first four lumbar vertebrae are similar in structure.
• The fifth lumbar vertebra has structural adaptations
for articulation with the sacrum.
• Anatomically, each vertebra consists of a large,
cylindrical vertebral body anteriorly, with a bony ring
or “neural arch” posteriorly

TYPICAL LUMBAR VERTEBRAE
BODY :
 The body of the typical lumbar vertebra is
massive, with a transverse diameter that is greater than
the anterior diameter and height.
ARCHES :
 PEDICLES :The pedicles are short andthick and project
posterolaterally.
 LAMINAE : The laminae are short and broad

 Zygapophyseal Articular Processes (facets):
o According to Bogduk, both the superior and inferior zygapophyseal
facets vary considerably in shape and orientation.
o Mamillary processes, which appear as small bumps, are located on the
posterior edge of each superior zygapophyseal .
o The mamillary processes serve as attachment sites for the multifidus
and medial intertransverse muscles.
o The inferior zygapophyseal facets are vertical and convex and face
slightly anteriorly and laterally.

 Transverse Process: It is long and slender and extends
horizontally.
 Accessory processes: are small and irregular bony
prominences, are located on the posterior surface of the
transverse process near its attachment to the pedicle.
 The accessory processes serve as attachment sites for the
multifidus and medial intertransverse muscles.
 Spinous Process :The spinous process is broad and thick and
extends horizontally.

• Vertebral Foramen. The vertebral foramen is triangular and
larger than the thoracic vertebral foramen but smaller than
the cervical vertebral foramen.

FIFTH LUMBAR VERTEBRAE
The fifth lumbar vertebra is a transitional vertebra and
differs from the rest of the lumbar vertebrae .
• BODY :It has a wedge-shaped body; anterior portion of the body height > than
the posterior portion.
• The L5/S1 lumbosacral disc also is wedge shaped.
• Superior discal surface area : L5 is about 5%greater [ >]than L3 and L4.
• Inferior discal surface area : L5 is less[ <] than other lumbar levels.
• L5Spinous process less [< ]other lumbar spinous processes
• Transverse processes are large and directed superiorly and posteriorly.

LUMBOSACRAL ANGLE
• The lumbosacral articulation is formed by the fifth lumbar vertebra and first
sacral segment.
LUMBOSACRAL ANGLE :
• The first sacral segment, which is inclined slightly anteriorly and inferiorly,
forms an angle with the horizontal called the lumbosacral angle.
• The size of the angle varies with the position of the pelvis and affects the
superimposed lumbar curvature.
• An increase in this angle will result in an increase in lordosis of the lumbar
curve and will increase the amount of shearing stress at the lumbosacral joint

LUMBOSACRAL ANGLE
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INTERVERTEBRAL DISCS
• The intervertebral discs of the lumbar region, differ from the discs
of the cervical region in that the collagen fibers of the anulus
fibrosus are arranged in sheets called lamellae .
• The lamellae are arranged in concentric rings that surround the
nucleus.
• Collagen fibers in adjacent rings are oriented in opposite
directions at 120 to each other.
• The advantage of the varying fiber orientation by layer is that the
anulus fibrosus is able to resist tensile forces in nearly all
directions.

INTERVERTEBRAL DISCS
• The lumbar intervertebral disks are the largest in the body
(as are the vertebral bodies).
• The shape of each disk is not purely elliptical but concave
posteriorly.
• This provides a greater cross-sectional area of anulus
fibrosus posteriorly and this increases ability to resist the
tension that occurs here with forward bending

ARTICULATIONS
• Interbody Joints :The interbody joints of the lumbar region are capable of translations and tilts in
all directions.
• Zygapophyseal Joints The zygapophyseal joints of the lumbar region, others, are true synovial
joints and contain fibroadipose meniscoid structures.
• The dorsal capsule has to be fibrocartilaginous in nature, which suggests that this portion of the
capsule is subject to compressive as well as tensile forces.
• The orientations of the adult lumbar zygapophyseal joints display great variability both between
individuals and within individuals; however, the majority of adults have a curved structure that is
biplanar in orientation.
• The anterior aspect of each joint remains in the frontal plane, and the posterior aspect lies close to
or in the sagittal plane.
• The frontal plane orientation provides resistance to the anterior shear that naturally is present in the
lordotic lumbar region.
• The sagittal plane orientation allows the great range of flexion and extension ROM and provides
resistance to rotation.

LIGAMENTS
Lumbar region consists of following ligaments :
• Ligamentum flavum
• Posterior Longitudinal Ligament [PLL]
• Anterior longitudinal ligament
• Interspinous ligament
• Supraspinous ligament
• Joint capsules

LIGAMENTS
• Supraspinous ligament :
 It is well developed only in the upper lumbar region and may terminate at L3,
although the most common termination site appears to be at L4.
 The ligament is almost always absent at L5/S1.
 The deep layer of the supraspinous ligament is reinforced by tendinous fibers of
the multifidus muscle.
 The middle fibers of the supraspinous ligament blend with the dorsal layer of
the thoracolumbar fascia.
• Intertransverse ligaments :
o These are not true ligaments in the lumbar area and are replaced by the
iliolumbar ligament at L4.

LIGAMENTS
• Posterior Longitudinal Ligament [PLL ]:
oIt is only a thin ribbon in the lumbar
region, whereas the ligamentum flavum is
thickened .
• Anterior longitudinal ligament is strong
and well developed in this region.

Ligaments Function
Anterior longitudinal lig Limits extension
Posterior longitudinal lig Limits forward flexion
Ligamentum flavum Limits forward flexion
Supraspinous ligament Limits forward flexion
Interspinous ligaments Limit forward flexion
Intertransverse ligaments Limit contralateral lateral
flexion
Iliolumbar ligament Resists anterior sliding of L5 &
S1
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ILIOLUMBAR LIGAMENT
• The iliolumbar ligaments consist of a series of bands that extend from the tips and borders
of the transverse processes of L4 and L5 to attach bilaterally on the iliac crests of the pelvis .
• There are three primary bands:
 Ventral (or anterior) band : It runs from the ventral caudal aspect of the transverse process of
L5 to the ventral surface of the iliac crest at the iliac tuberosity
 Dorsal (or posterior) band : It runs from the tip of the transverse process of L5 to the cranial
part of the iliac crest at the iliac tuberosity
 Sacral band (sometimes called the lumbosacral ligament): It runs from the ventral aspect of
the transverse process of L5 and the ala of the sacrum to the sacral surface of the iliac
tuberosity of the iliac crest .
• The iliolumbar ligaments as a whole are very strong and play a significant role in stabilizing
the fifth lumbar vertebra (preventing the vertebra from anterior displacement) and in
resisting flexion, extension, axial rotation, and lateral bending of L5 on S1

THORACOLUMBAR FASCIA
• The thoracolumbar fascia (also called the lumbodorsal
fascia) consists of three layers: the
Posterior Layer
 Middle layer and
Anterior layer

• The posterior layer :
It is large, thick, and fibrous and arises from the spinous processes and
supraspinous ligaments of the thoracic, lumbar, and sacral spines.
The posterior layer gives rise to the latissimus dorsi cranially, travels caudally
and blends with the fascia of the contralateral gluteus maximus and forms the
lateral raphe at the lateral aspect of the erector spinae.
The internal abdominal oblique and the transversus abdominal muscles arise
from the lateral raphe.
• Middle layer :
The posterior layer becomes the middle layer and travels medially again along
the anterior surface of the erector spinae and attaches back to the transverse
processes and intertransverse ligaments of the lumbar spine.
 These two layers completely surround the lumbar extensor muscle group.

• ANTERIOR LAYER :
 The anterior layer of the thoracolumbar fascia is derived from the fascia of the
quadratus lumborum muscle, inserts into the transverse processes of the lumbar
spine, and blends with the intertransverse ligaments.
• The anterior layer : acts as the “passive part” serves to transmit tension produced
by a contraction of the hip extensors to the spinous processes.
• The passive part : act as the “active part , activated by a contraction of the
transversus abdominis muscle, which tightens the fascia.
• The fascia transmits tension longitudinally to the tips of the spinous processes of
L1/L4 and may help the spinal extensor muscles to resist an applied load.
• Both the gluteus maximus and contralateral latissimus dorsi tensed the superficial
layer and provided a pathway for the mechanical transmission of forces between
the pelvis and the trunk.

MUSCLES OF LUMBAR SPINE
ANTERIOR MUSCLES
• Rectus abdominis
• External oblique
• Internal oblique
• Transversus abdominis muscles
• Psoas major
LATERAL MUSCLES :
• Quadratus Lumborum
Erector spinae
• Iliocostalis,
• longissimus
• spinalis

MUSCLES
ATTACHMENTS AND INNERVATION OF THE ROTATORES
• Inferior attachment: Superior and posterior portion of the transverse process of one vertebra
• Superior attachment: Inferior and lateral border of the lamina of the vertebra immediately above the
• Inferior attachment. The rotatores lie deep to the multifidus. The rotatores are less fully developed in
the lumbar than in the thoracic region.
• Innervation: Dorsal rami of spinal nerves
ATTACHMENTS AND INNERVATION OF INTERTRANSVERSARII
• Inferior attachment: Transverse process of one vertebra
• Superior attachment: Transverse process of the vertebra above. In the lumbar region there are two sets of
muscles, medial and lateral, each lying posterior to the ventral ramus. The lateral lumbar portion is
further divided into ventral and dorsal sections.
• Innervation: The nerve supply for the medial portion of the muscle is the dorsal ramus of the associated
spinal nerve, while the lateral lumbar portion is innervated by the ventral ramus of the spinal nerve.

FUNCTION OF THE
ROTATORES AND INTERTRANSVERSARII
• It is suspected that these “muscles” are actually
length transducers, and thereby position sensors,
sensing the positioning of each spinal motion
unit.
• It is very likely that these structures are affected
during various types of manual therapy with
the joint at end range of motion.

EXTENSORS: LONGISSIMUS, ILIOCOSTALIS,
AND MULTIFIDUS GROUPS
ATTACHMENTS AND INNERVATION OF THE
LONGISSIMUS THORACIS PARS LUMBORUM
• Inferior attachment: Posterior superior iliac spine
• Superior attachment: Transverse and accessory
processes of the lumbar vertebrae
• Innervation: Dorsal rami of the lumbar spinal nerves
• Palpation: Cannot be separately identified deep to
the thoracolumbar fascia.

ATTACHMENTS AND INNERVATION OF THE ILIOCOSTALIS LUMBORUM
Iliocostalis lumborum pars thoracis:
• Inferior attachment: Crest of the ilium from the
• posterior superior iliac spine laterally approximately 5 cm
• Superior attachment: Angles of all 12 ribs
• Palpation: Palpable with other erector spinae along thoracic vertebrae.
Iliocostalis lumborum pars lumborum:
• Inferior attachment: Iliac crest
• Superior attachment: Transverse processes of the first four lumbar vertebrae
and thoracolumbar fascia
• Innervation: Dorsal rami of the thoracic and lumbar spinal nerves
• Palpation: Cannot be separately identified deep to the thoracolumbar fascia.

ATTACHMENTS AND INNERVATION
OF THE MULTIFIDUS
• Inferior attachment: Posterior surface of the sacrum, aponeurosis of the
erector spinae muscles, posterior superior iliac spine (PSIS) and
sacroiliac ligaments, and mamillary processes of the lumbar vertebrae
• Superior attachment: Superficially to the third or fourth vertebra
above, intermediately to the second or third vertebra above, and deeply
to the vertebra directly above the inferior attachment. The multifidus
muscles lie deep to the semispinalis and erector spinae muscles.
• Innervation: Dorsal rami of the spinal nerves
• Palpation: Not palpable.

OF THE RECTUS ABDOMINIS
• Inferior attachment: Pubic crest and adjacent symphysis
• Superior attachment: Fifth, sixth, and seventh costal cartilages
and anterior surface of the xiphoid process.The rectus
abdominis widens as it ascends and contains three transverse
tendinous intersections that adhere to the rectus sheath. One of
the intersections is at the umbilicus, one at the end of the
xiphoid, and the third one midway in between these two.
• Innervation: Ventral rami of lower six or seven thoracic spinal
nerves
• Action : trunk flexion and rib depressors

OF THE EXTERNAL OBLIQUE , INTERNAL OBLIQUE
ATTACHMENTS AND INNERVATION OF THE EXTERNAL OBLIQUE
• Inferior attachment: Anterior two thirds of the outer lip of the iliac crest and aponeurosis
• Superior attachment: Outer surfaces of lower eight ribs, interdigitating with serratus anterior and latissimus dorsi. The external oblique
runs in an inferior
• and anterior direction and is the largest and most superficial of the three muscles of the abdominalwall (external oblique, internal oblique,
and transversusabdominis).
• Innervation: Ventral rami of lower six thoracic spinalnerves
• Action :trunk flexion , conttralateral trunk rotation ,Increase intra abdominal pressure , rib depresion nd spinal stabilization .
ATTACHMENTS AND INNERVATION OF THE INTERNAL OBLIQUE
• Palpation: May be palpable in thin individuals with well-developed muscles interdigitated with the serratus anterior on the lateral side of
the trunk.
• Inferior attachment: Thoracolumbar fascia, anterior two thirds of the intermediate line of the iliac crest,lateral two thirds of the inguinal
ligament, and the fascia on the iliopsoas muscle
• Superior attachment: Inferior borders and tips of the last three or four ribs and cartilage and the aponeurosis. The internal oblique runs
superiorly and anteriorly and is thinner and lies beneath the external oblique.
• Innervation: Ventral rami of lower six thoracic and first lumbar nerves
• Action : trunk flexion , ipsilateral trunk rotation ,Increase intra abdominal pressure , rib depresion nd spinal stabilization .

ATTACHMENTS AND INNERVATION OF THE TRANSVERSUS
ABDOMINIS
• Superior attachment: Deep surfaces of the costal cartilages of the lower six
ribs, interdigitating with the diaphragm, thoracolumbar fascia between iliac
crest and 12th, anterior two thirds of the inner lip of the iliac crest, lateral
one third of the inguinal ligament, and fascia over the iliacus muscle
• Inferior attachment: The pubic crest and the aponeurosis that fuses with the
posterior layers of the aponeurosis of the internal oblique. The transversus
abdominis is the innermost of the three muscles of the abdominal wall.
• Innervation: Ventral rami of lower six thoracic and first lumbar spinal
nerves
• Palpation: Not palpable

ATTACHMENTS AND INNERVATION OF THE QUADRATUS LUMBORUM
• Inferior attachment: Iliolumbar ligament, posterior iliac crest,
transverse processes of lower lumbar vertebrae
• Superior attachment: Medial one half of the lower border of the 12th
rib, transverse processes of upper lumbar vertebrae and 12th thoracic
vertebra.
• The quadratus lumborum lies between the anterior and middle layers
of the thoracolumbar fascia, anterior to the erector spinae muscles and
posterior to the abdominal organs.
• Innervation: Ventral rami of the 12th thoracic and,upper three or four
lumbar spinal nerves
• Palpation: Not palpable.

QUADRATOUS LUMBORUM
• If lateral flexion occurs from erect standing, force
of gravity will continue motion, and contralateral
quadratus lumborum will control movement by
contracting eccentrically.
• If the pelvis is free to move, quadratus lumborum
will “hike the hip” or laterally tilt pelvis in frontal
plane

KINEMATICS
• The lumbar region is capable of movement in
Flexion
Extension
lateral flexion and
rotation.
• The lumbar zygapophyseal facets favor flexion and
extension, because of the predominant sagittal plane
orientation.

KINEMATICS
• FLEXION :
 Flexion of the lumbar spine is more limited than extension
 Anterior tilting and gliding of superior vertebra occurs during flexion
 Increases diameter of intervertebral foramina
 During flexion and extension, the greatest mobility of the spine occurs between L4 and S1 -
the area that must support the most weight.
 Flexion generates compression forces on anterior side of disc tending to migrate nucleus
pulposus posteriorly
 When the lumbar spine is flexed, the ROM in rotation is less than when the lumbar spine is in
the neutral position.
 The posterior anulus fibrosus and the PLL seem to play an important role in limiting axial
rotation when the spine is flexed.

KINEMATICS
• EXTENSION :
 During extension there will be increase in lumbar lordosis
Posterior tilting ,gliding of superior vertebrae takes place
during extension
 Lumbar extension reduces the diameter of intervertebral
foramina
During lumbar extension nucleus pulposus , displaces anteriorly

KINEMATICS
•ROTATION :
Rotation causes movement of vertebral arch in opposite direction
Ipsilateral facet joints go for gapping and contralateral facet
joints for impaction
Axial rotation to right, between L1 and L2 for instance,
 occurs as left inferior articular facet of L1 approximates or
 compresses against left superior articular facet of L2.

SPINAL COUPLING
 Kinematic phenomenon in which movt of the spine in one plane
is associated with an automatic movt in another plane
Most consistent pattern involves an association between axial
rotation and lateral flexion
 With lateral flexion, pronounced flexion and slight ipsilateral
rotation occurs
With axial rotation, however, substantial lateral flexion in a
contralateral direction occurs
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KINEMATICS
• LATERAL FLEXION :
 In the lumbar region, pure flexion and extension can occur, but coupled motions always
occur with lateral flexion and axial rotation.
 With lateral flexion, pronounced flexion and slight ipsilateral rotation occurs.
 Lateral flexion and rotation are most free in the upper lumbar region and progressively
diminish in the lower region.
 The largest lateral flexion ROM and axial rotation occurs between L2 and L3.
 Superior vertebra laterally tilts, rotates and translates over vertebra below during
lateral flexion
 Annulus fibrosus is compressed on concavity of curve and stretched on convex side
 Nucleus pulposus migrate slightly towards convex side of bend
 The zygapophyseal joint capsules limit rotation in both the neutral and extended positions of
the spine.

KINEMATICS
• The integration of motion of the pelvis about the hip joints with
motion of the vertebral column not only increases the ROM available
to the total column but also reduces the amount of flexibility required
of the lumbar region.
• Hip motion may even, eliminate the need for full lumbar flexion,
which would serve a protective function by protecting the anulus
fibrosus and posterior ligaments from being fully lengthened.
• A restriction of motion at either the lumbar spine or at the hip joints
may disturb the rhythm and prevent a person from reaching the toes.
• Restriction of motion at one segment also may result in hypermobility
of the unrestricted segment.

LUMBOPELVIC RHYTHM
• It is the coordinated, simultaneous activity of lumbar flexion and anterior tilting
of the pelvis in the sagittal plane during trunk flexion and extension called the
combined lumbar and pelvic motion lumbar-pelvic
• As the head and upper trunk initiate flexion , the pelvis shifts posteriorly to
maintain the center of gravity over the base of support.
• The first part of bending forward consists of lumbar flexion, followed next by
anterior tilting of the pelvis at the hip joints.
• A return to the erect posture is initiated by posterior tilting of the pelvis at the
hips, followed by extension of the lumbar spine.
• The initial pelvic motion delays lumbar extension until the trunk is raised far
enough to shorten the moment arm of the external load, thus reducing the load on
the erector spinae.

LUMBOPELVIC RHYTHM
• The trunk continues to forward bend , being controlled by the extensor muscles of the spine , until at
approximately 45.
• At this point for an individual with relatively normal flexibility , the posterior ligaments become taut
, and the facets of the zygapophyseal joints approximate.
• Both of these factors provide stability for the intervertebral joints , and the muscles relax.
• Once all of the vertebral segments are at the end of the range and stabilized by the posterior
ligaments and facets , the pelvis begins to rotate forward(anterior pelvic tilt),being controlled by the
gluteus maximus and the hamstring muscles.

LUMBOPELVIC RHYTHM
• The pelvis continues to rotate forward until the full length of the muscle is reached.
• Final range of motion (ROM) in forward bending is dictated by the flexibility of the
various back extensor muscles and fasciae as well as the hip extensor muscles.
• The return to the upright position begins with the hip extensor muscles rotating the pelvis
posteriorly through reverse muscle action (posterior pelvic tilt) then the back extensor
muscles extending the spine from the lumbar region upward.

LUMBOPELVIC RHYTHM
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LUMBOPELVIC VARIATIONS
• Variations in the normal synchronization
of this activity occur because of training
(as with dancers and gymnasts) , faulty
habits , restricted muscle or fascia length ,
or injury and faulty proprioception.

LUMBOPELVIC COMPENSATIONS
• As anterior pelvic tilt and therefore the sacral base
angle increases , the lumbar spine must compensate by
commensurately increasing its lordosis ; similarly ,if
the sacral base angle decreases,the lumbar spine
compensates by decreasing its lordosis.
• Altered lordotic posture is considered to be unhealthy.

• Increased lordosis is unhealthy because it shifts weight
bearing from the discs towards the facet joints, which are
not adapted to accept this increased compression force.
• Decreased lordosis is unhealthy because it results in a
decreased ability of lumbar spine to absorb shock.

• Examining the usual balance , it is most typical for hip
flexors and trunk extensors to be tight and anterior
abdominal wall and gluteal muscles to be weak.
• Hence this can be treated by relaxing the tight soft
tissues and lengthening it.
• Whereas weak muscles need to be strengthened so that
their baseline tone increases.

KINETICS
• Compression :
 One of the primary functions of the lumbar region is to provide support for
the weight of the upper part of the body in static as well as in dynamic
situations.
The increased size of the lumbar vertebral bodies and discs in comparison with
their counterparts in the other regions helps the lumbar structures support the
additional weight.
 The lumbar region must also withstand the tremendous compressive loads
produced by muscle contraction.
Lumbar interbody joints shared 80% of the load, and the zygapophyseal facet
joints in axial compression shared 20% of the total load.

KINETICS
This percentage can change with altered mechanics: with
increased extension or lordosis, the zygapophyseal joints
will assume more of the compressive load.
Also, with degeneration of the intervertebral disc, the
zygapophyseal joints will assume increased compressive
load.
Changes in position of the body will change the location of
the body’s line of gravity and thus change the forces acting
on the lumbar spine.

KINETICS
• Shear :
 In the upright standing position, the lumbar segments are subjected to anterior shear forces
cause by the lordotic position, the body weight, and ground reaction forces
 This anterior shear or translation of the vertebra is resisted by direct impaction of the
inferior zygapophyseal facets of the superior vertebra against the superior zygapophyseal
facets of the adjacent vertebra below.
 The effectiveness of the zygapophyseal joint in providing resistance to anterior translation
during flexion depends on the extent to which the inferior vertebra’s superior facets lie in
the frontal plane and face posteriorly.
 The more that the superior zygapophyseal facets of an adjacent inferior vertebra face
posteriorly, the greater the resistance they are able to provide to forward displacement
because the posteriorly facing facets lock against the inferior facets of the adjacent superior
vertebra.

NERVE SUPPLY TO LUMBAR SPINE
• The nerve supply to the lumbar spine follows a general
pattern.
• The outer half of the IVD is innervated by the
sinuvertebral nerve and the grey rami communicants,
with the posterolateral aspect being innervated by both
the sinuvertebral nerve and the grey rami
communicants.
• The lateral aspect receives only sympathetic
innervation.

SPINAL CORD AND PLEXUS
• Spinal cord ends at approximately L1–L2
• Bundle of spinal nerves extends downward: cauda equina
The Lumbar Plexus
• Formed by T12–L5nerve roots
• Supplies anterior and medial muscles of thigh region
• Posterior branches of L2–L4nerve roots form femoral nerve -
Quadriceps
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PATHOMECHANICS
ENDPLATE FRACTURES:
• with the loss of nuclear fluid through the crack into the vertebral
body (often forming Schmorl’s nodes), are very common
compressive injuries and perhaps the most misdiagnosed.
• Loss of the nucleus pulposus results in a flattened interdiscal space
that when seen on planar x-rays is usually diagnosed as a herniated
disc.
• However, the anulus of the disc remains intact. It is simply a case
of the nucleus squirting through the endplate crack into the
cancellous core of the vertebra.

EXAGGERATED LORDIDIS :
• Abnormal exaggeration of lumbar curve
• Weakened abdominal muscles
• Tight hip flexors, tensor fasciae latae,
and deep lumbar extensors
• Increase compressive stress on posterior elements
• Predisposing to low back pain
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SWAY BACK
• Increased lordotic curve and kyphosis
• Weak : lower abdominals, lower thoracic
extensors, hip flexors
• Tight : hip extensors,lower lumbar extensors,and
upper abdominals

LUMBAR DISC PROLAPSE
• The term 'prolapsed disc' means the protrusion or extrusion of the nucleus pulposus through
a rent in the annulus fibrosus.
• It is a sequence of changes in the disc, which ultimately lead to its prolapse.
• The site of exit of the nucleus is usually posterolateral on one or the other side.
• Occasionally, it can be central (posterior-midline) disc prolapse.
• The type of nuclear protrusion may be:
• a protrusion, an extrusion or a sequestration.
• A dissecting extrusion, (an extrusion with disc material between the body of the vertebra
and posterior longitudinal ligament, stripping the latter off the body), may occur.
• The commonest level of disc prolapse is between L4-L5 in the lumbar spine.
• In the lumbar spine, it is uncommon above L3–L4 level.

TREATMENT
PRINCIPLES OF TREATMENT:
• Aim of treatment is to achieve remission of symptoms, mostly possible by conservative means.
• Cases who do not respond to conservative treatment for 3-6 weeks, and those presenting with cauda equina
syndrome may require operative intervention.
CONSERVATIVE TREATMENT :This consists of the following:
• Rest: It is most important in the treatment of a prolapsed disc. Rest on a hard bed is necessary for 2-3 weeks.
• Drugs: These consist mainly of analgesics and muscle relaxants.
• Physiotherapy

SCIATICA
• This is usually associated with low back pain, but may be the sole presenting
symptom.
• The pain radiates to the gluteal region, the back of the thigh and leg.
• The pattern of radiation depends upon the root compressed.
• In S1 root compression, the pain radiates to the postero-lateral calf and heel.
• In L5 root compression the pain radiates to the antero-lateral aspect of the leg and
ankle.
• In a disc prolapse at a higher level (L2-L3 etc.), the pain may radiate to the front of
the thigh.
• Often the radiation may begin on walking, and is relieved on rest (neurological
claudication)

LOW BACK PAIN
• onset :may be acute or chronic.
• An acute backache is severe with the spine held rigid by muscle
spasm, and any movement at the spine painful.
• The patient may be able to go about with difficulty.
• In extreme cases, he is completely incapacitated, any attempted
movement producing severe pain and spasm.
• In chronic backache, the pain is dull and diffuse, usually made worse
by exertion, forward bending, sitting or standing in one position for a
long time.
• It is relieved by rest.

FLAT BACK POSTURE
• Relative decrease in lumbar lordosis (20°),
• COG shifts anterior to lumbar spine and
hips

PARS INTERARTICULARIS
FRACTURE
• Region between superior and inferior articular
facets
• Weakest bony portion of vertebral neural arch

COMPRESSION FRACTURES
• These fractures occur commonly in the thoraco-
lumbar region.
• Treatment depends upon the severity of compression.
• It is important to be suspicious of any underlying
pathology.
• Diseases such as early secondary deposits in an
elderly, may produce a fracture spontaneously, in one
or multiple vertebrae.

LUMBAR SPONDYLOSIS
• This is a degenerative disorder of the lumbar spine characterised clinically by an insidious onset of pain and
stiffness and radiologically by osteophyte formation.
CAUSE :
• Bad posture and chronic back strain is the commonest cause.
• Other causes are, previous injury to the spine, previous disease of the spine, birth defects and old
intervertebral disc prolapse.
• Clinical features:
 Symptoms begin as low backache, initially worst during activity, but later present almost all the time.
 There may be a feeling of ‘a catch’ while getting up from a sitting position, which improves as one walks a
few steps.
 Pain may radiate down the limb up to the calf (sciatica) because of irritation of one of the nerve root.
 There may be complaints of transient numbness and paraesthesia in the dermatome of a nerve root, commonly
on the lateral side of leg or foot (L5, S1 roots) respectively

LUMBAR SPONDYLOSIS
• TREATMENT:
In the acute stage, bed rest, hot fomentation and analgesics
are advised.
As the symptoms subside, spinal exercises are advised. In
some resistant cases, a lumbar corset may have to be used at
all times.
Spinal fusion may occasionally be necessary.

LUMBAR SPONDYLOLISTHESIS
• Spondylolisthesis is forward displacement of a vertebra over the one below it ,commonly occurs between L5-S1,
and between L4-L5.
• Occasionally, the displacement is backwards (retrolisthesis).
CAUSES :
• Isthmic: This is the commonest type overall. The lesion is in the pars interarticularis*. Three subtypes are
recognised:
• Lytic: Fatigue fracture of the pars inter articularis
• Intact but elongated pars interarticularis
• Acute fracture of the pars interarticularis.
• Dysplastic: In this, the least common type, there is a congenital abnormality in the development of the vertebrae,
so that one vertebra slips over the other.
• Pathological: This type results from a generalised or localised bone disease weakening the articulation between the
vertebrae. Traumatic: This is a very rare type, where one vertebra slips over other following an injury.
• Degenerative: commonly in elderly people. The posterior facet joints becomes unstable because of osteoarthritis,
and subluxate. Vertebral displacement is occasionally backwards rather than forwards (retrolisthesis).
Displacement is usually not severe, and neurological disturbance is unusual.

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Clinical features:
• The isthmic type of spondylolisthesis presents in adolescents and young adults.
• The degenerative type occurs in old age.
• The presenting symptom is usually backache, with or without sciatica.
• Symptoms become worse on standing or walking.
• Sometimes, there may be neurological symptoms in the lower limbs.
TREATMENT
• For a mild symptomless spondylolisthesis, no treatment is required.
• When symptoms are mild, they are adequately relieved by conservative methods,Conservative
methods consist of rest and external support to the affected segment followed by flexion
exercises.
• The patient is advised to change his job to a physically less demanding one.
• Operative methods consist of decompression of the compressed nerves if any, followed by fusion
of the affected segments of the spine.
• This is commonly achieved by fusion between the transverse processes of adjacent vertebrae
(intertransverse fusion).

LUMBAR FACET PATHOLOGY
• Lumbar facet arthropathy, also called facet joint arthritis or facet joint
syndrome, refers to lower back pain caused by inflammation of the
facet joints
• Pain and tenderness at the location of the involved facet joint
• Lower back pain that radiates to the buttocks and upper thigh area
• Muscle spasms
• Difficulty sitting for extended periods
• Difficulty performing overhead activities
• A “cracking” sensation when moving the spine

LUMBAR CANAL STENOSIS
• Narrowing of the spinal canal may occur in the whole of the lumbar spine (e.g.,
achondroplasia), or more often, in a segment of the spine (commonly in the lumbo-sacral
region).
• Stenosis may be in all parts of the canal or only in the lateral part; the latter is called as
root canal stenosis.
• It may give rise to pressure or tension on the nerves of the cauda equina or lumbar nerve
roots.
• CLINICAL FEATURES :
 Typically, the patient complains of pain radiating down the lower limbs on walking some
distance, and is relieved on taking rest for a few minutes (neurological claudication).
• Diagnosis is confirmed by a CT scan or MRI.
• Treatment is by decompression of the spinal canal or root canal, as the case may be.

LUMBAR STRAINS
• Back strain (acute or chronic):
• The terms back strain and back sprain are often used interchangeably.
• Most often this arises from a ‘trauma’ sustained in daily routine activities rather than from a
definite injury.
• People prone to back strain are athletes, tall and thin people, those in a job requiring
standing for long hours and those working in bad postures.
• Sedentary workers and women after pregnancy are also frequent candidates for back strain.
• Acute ligament sprain may occur while lifting a heavy weight, sudden straightening from
bent position, pushing etc.
• Treatment is ‘non-specific’

PATHOMECHANICS
• LUMBARIZATION : Occasionally, the junction
between the first and second sacral vertebrae fails to
fuse, creating a condition known as lumbarization.
This results in six mobile lumbar vertebrae.
• SACRALIZATION :In some cases, the lumbosacral
junction fuses during growth and development,
resulting in sacralization of L5. This results in only
four mobile lumbar vertebrae.

BAASTRUPS DISEASE
• Repetitive contact of the spinous
processes during the extremes of
lumbar extension can lead to a
periostitis called kissing spine or
Baastrup’s disease, with resulting
ligamentous laxity and hypermobility of
the segment

TUMOURS
Benign tumours:
• These are uncommon.
• Osteoid osteoma is the commonest benign tumour of the spine.
• It causes severe back pain, especially at night.
• Typically the pain is relieved by aspirin.
• The tumour, usually the size of a pea, is found in the pedicle or lamina.
• Haemangioma also occurs in the vertebral body.
• Meningioma is a common intradural, extra-medullary tumour which presents with back pain
or radiating pain.

MALIGNANT TUMOURS
Malignant tumours:
• Multiple myeloma is the commonest primary malignancy of the spine.
• Metastatic deposits are extremely common in the spine because of its
rich venous connections, especially with the vertebral venous plexus.
• Pain often precedes X-ray evidence of a metastatic deposit.
• By the time a deposit is visible on X-ray, the tumour has replaced
about 30 per cent of the bony content of the vertebra.
• A bone scan can detect the lesion earlier.
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SACRUM VERTEBRAE
• Five sacral vertebrae are fused to form the triangular
or wedge-shaped structure that is called the sacrum.
• The base of the triangle, which is formed by the first
sacral vertebra, supports two articular facets that face
posteriorly for articulation with the inferior facets of
the fifth lumbar vertebra.
• The apex of the triangle, formed by the fifth sacral
vertebra, articulates with the coccyx
85

SACRO ILIAC JOINT ARTICULATIONS
• The two SIJs consist of the articulations between the left and right articular
surfaces on the sacrum (which are formed by fused portions of the first, second,
and third sacral segments) and the left and right iliac bones .
• The SIJs are unique in that both the structure and function of these joints change
significantly from birth through adulthood.
Articulating Surfaces on the Sacrum :
• The articulating surfaces on the sacrum are auricular (C)-shaped and are located on
the sides of the fused sacral vertebrae lateral to the sacral foramina.
• The fetal and prepubertal surfaces are flat and smooth, whereas the postpubertal
surfaces are marked by a central groove or surface depression that extends the
length of the articulating surfaces.
• The articular surfaces are covered with hyaline cartilage. The overall mean
thickness of the sacral cartilage is greater than that of the iliac cartilage.
87

SACROILIAC JOINT ARTICULATIONS
Articulating Surfaces on the Ilia :
• The articular surfaces on the ilia are also C-shaped.
• In the first decade of life, the iliac joint surfaces are smooth and flat and covered with
fibrocartilage.
• The type of cartilage covering the iliac articular surfaces in the adult continues to be a
matter of debate. The cartilage is different in gross appearance and is thinner than the
sacral articular cartilage. It was usually described as fibrocartilage.
• However, type II collagen, which is typical of hyaline cartilage, has been identified in
the iliac cartilage
• After puberty, the joint surfaces develop a central ridge that extends the length of the
articulating surface and corresponds to the grooves on the sacral articulating surfaces
89

LIGAMENTS
• The anterior, interosseous, and posterior sacroiliac ligaments are directly associated with the SIJs.
• A separate portion of the posterior sacroiliac ligament is called either the long posterior sacroiliac ligament
or the long dorsal sacroiliac ligament.
 The iliolumbar ligaments, which connect the fifth lumbar vertebra to the sacrum and
 the sacrospinous ligaments, and
 the sacrotuberous ligaments, which connect the sacrum to the ischium, are indirectly associated with the
SIJs .
Sacroiliac Ligaments :
• Extend from the iliac crests to attach to the tubercles of the first four sacral vertebrae.
• Reinforced by fibrous expansions from the quadratus lumborum, erector spinae, gluteus maximus, gluteus
minimus, piriformis, and iliacus muscles, contribute to the joint’s stability.
• The fascial support is greater posteriorly than anteriorly because more muscles are located posteriorly.
• The anterior sacroiliac ligaments are considered to be capsular ligaments because of the ligaments’ intimate
connections to the anteroinferior margins of the joint ilia to the sacrum capsules.
90

THE INTEROSSEOUS
SACROILIAC LIGAMENTS
• This constitute the major bonds between the sacrum and the ilia,are considered to be the
most important ligaments directly associated with the SIJs.
• The ligaments are composed of superficial and deep portions, which are divided into
superior and inferior bands.
• The superficial bands unite the superior articular processes and lateral crests of the first
two sacral segments to the ilia.
• This portion of the interosseous ligament is referred to as the short posterior sacroiliac
ligament.
• The deeper portions of the interosseous sacroiliac ligament extend from depressions
posterior to the sacral articular surface to depressions on the iliac tuberosities.
• The posterior sacroiliac ligaments connect the lateral sacral crests to the posterior superior
iliac spines and iliac crests.
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LIGAMENTS
DORSAL SACROILIAC LIGAMENTS :
• The paired long dorsal sacroiliac ligaments have superior attachments to the posterior
superior sacroiliac spines (PSISs) and adjacent parts of the ilium.
• Inferiorly, the ligaments are attached to the lateral crest of the third and fourth sacral
segments.
• The medial fibers are connected to the deep lamina of the posterior layer of the
thoracolumbar fascia and the aponeurosis of the erector spinae (ESA).
• The sacrospinous ligaments connect the ischial spines to the lateral borders of the sacrum
and coccyx.
• The sacrotuberous ligaments connect the ischial tuberosities to the posterior spines at the
ilia and the lateral sacrum and coccyx.
• The sacrospinous ligament forms the inferior border of the greater sciatic notch; the
sacrotuberous ligament forms the inferior border of the lesser sciatic notch
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SYMPHYSIS PUBIS ARTICULATION
• The symphysis pubis is a cartilaginous joint located between the two ends of the pubic bones.
• The end of each pubic bone is covered with a layer of articular cartilage and the joint is formed by a
fibrocartilaginous disk that joins the hyaline cartilage-covered ends of the bones.
• The disk has a thin central cleft, which in women may extend throughout the length of the disk.
• The three ligaments that are associated with the joint are the superior pubic ligament, the inferior pubic
ligament, and the posterior ligament.
• The superior ligament is a thick and dense fibrous band that attaches to the pubic crests and tubercles and
helps support the superior aspect of the joint.
• The inferior ligament arches from the inferior rami on one side of the joint to the inferior portion of the rami
on the other side and thus reinforces the inferior aspect of the joint.
• The posterior ligament consists of a fibrous membrane that is continuous with the periosteum of the pubic
• Kapandji described the muscle expansions as forming an anterior ligament consisting of expansions of the
transversus abdominis, rectus abdominis, internal obliquus abdominis, and adductor longus.
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KINEMATICS
• The SIJs permit a small amount of motion that varies among individuals.
• The SIJs are linked to the symphysis pubis in a closed kinematic chain, and therefore any motion occurring at the
symphysis pubis is accompanied by motion at the SIJs and vice versa.
NUTATION AND COUNTERNUTATION :
• Nutation is the term commonly used to refer to movement of the sacral promontory of the sacrum anteriorly and
inferiorly while the coccyx moves posteriorly in relation to the ilium.
• Counternutation refers to the opposite movement, in which the anterior tip of the sacral promontory moves
posteriorly and superiorly while the coccyx moves anteriorly in relation to the ilium
• The change in position of the sacrum during nutation and counternutation affects the diameter of the pelvic brim
and pelvic outlet.
• During nutation, the anteroposterior diameter of the pelvic brim is reduced and the anteroposterior diameter of the
pelvic outlet is increased.
• During counternutation the reverse situation occurs. The anteroposterior diameter of the pelvic brim is increased,
and the diameter of the pelvic outlet is decreased.
• These changes in diameter are of particular importance during pregnancy and childbirth, and it is possible that the
most motion that occurs at the SIJs may occur in pregnancy and childbirth, when the joint structuresunder
hormonal influence and ligamentous structures are softened
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KINEMATICS
• Using manual pressure on specially cut cadavers,
Sashin found an average of 4 degrees of motion
in women under 30, more so in pregnant women.
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PHYSIOLOGICAL CHANGES DURING
PREGNANCY
• During pregnancy, relaxin, a polypeptide hormone is produced by the corpus
luteum and decidua.
• This hormone is thought to activate the collagenolytic system, which regulates
new collagen formation and alters the ground substance by decreasing the
viscosity and increasing the water content.
• The action of relaxin is to decrease the intrinsic strength and rigidity of collagen
and is thought to be responsible for the softening of the ligaments supporting the
SIJs and the symphysis pubis.
• Consequently, the joints become more mobile and less stable, and the likelihood of
injury to these joints is increased.
• The combination of loosened posterior ligaments and an anterior weight shift
caused by a heavy uterus may allow excessive movement of the ilia on the sacrum
and result in stretching of the SIJ capsules.
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KINETICS
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KINETICS
• Stability of the SIJs is extremely important because these joints must support a large
portion of the body weight.
• In normal erect posture, the weight of head,arms, and trunk (HAT) is transmitted
through the fifth lumbar vertebra and lumbosacral disk to the first sacral segment.
• The force of the body weight creates a nutation torque on the sacrum.
• Concomitantly, the ground reaction force creates a posterior torsion on the ilia.
• The countertorques of nutation and counternutation of the sacrum and posterior
torsion of the ilia are prevented by the ligamentous tension and fibrous expansions
from adjacent muscles that reinforce the joint capsules and blend with the ligaments.
• lilolumbar ligaments have a significant role in stabilizing the SIJ as well as the
lumbosacral junction. The ventral band of the iliolumbar ligament is of particular
importance in restricting sagittal plane SIJ mobility.
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KINETICS
• Also, tension developed in the sacrotuberous, sacrospinous, and anterior sacroiliac ligaments
counteracts the nutation of the sacrum,
• However,the sacrotuberous and interosseous ligaments compress the SIJ during nutation.
• The long dorsal sacroiliac ligament is under tension in counternutation and relaxed in
nutation.
• The interosseous sacroiliac ligament binds the ilium to the sacrum.
• Surface irregularities and texture of the SIJs also contribute to stability of the joint in the
adult.
• Shearing forces are created at the symphysis pubis during the single-leg-support phase of
walking, as a result of lateral pelvic tilting.
• In a normal situation, the joint is capable of resisting the shearing forces, and no appreciable
motion occurs. If, however, the joint is dislocated, the pelvis becomes unstable during gait,
with increased stress on the sacroiliac and hip joints as well as the vertebral column.
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DYSFUNCTIONS OF PELVIC
COMPLEX
SACRAL DYSFUNCTIONS
1. Flexion(nutation)Dysfunction: In this the sacral base has relative
antero-inferior movement & lordosis at the lumbosacral junction
becomes prominent.
2. Extension(counternutation)Dysfunction : In this the sacral base
has relative postero-superior movement & the lumbosacral
junction is relatively flat.

PUBIC SYMPHYSIS DYSFUNCTIONS
Clinical presentations of this dysfunctions are :
• Pubic pain & tenderness associated with lower back pain, specially in sacroiliac area.
• Difficulty/pain rolling over in bed.
• Difficulty/pain with stairs, getting in & out of cars, sitting down or getting up,
bending, lifting etc.
• “Clicking” in the pelvis when walking.
• Feeling like hip is out of place during walking.
• Bladder dysfunction i.e. temporary incontinence at change in position.
• Knee pain or pain in some other areas can sometimes also be a side effect of pelvis
problems.
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MECHANICAL DYSFUNCTIONS OF
PUBIC SYMPHYSIS :
• Inferior pubic shear (inferior pubis) : A somatic dysfunction
in which one side of pubic symphysis to the contralateral
side as the result of a shearing in the sagittal plane.
• Superior pubic shear (superior pubis) : reciprocal of inferior
pubis.
• SIJ has been implicated as the primary pain source in 10% to
25% of the patients with low back pain.
• During pregnancy 20% to 80% of women experience low
back or post pelvic pain frequently arising from SIJ only.
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MECHANICAL DYSFUNCTIONS OF
PUBIC SYMPHYSIS :
• SYMPHYSIOLYSIS : Daily pain in pubic symphysis only confirmed by
objective findings. It is not an actual lysis but the nomenclature is used as a
classification of pregnant women with pelvic pain.
ONE-SIDED SACROILIAC SYNDROME : Daily pain from one SIJ alone.
DOUBLE-SIDED SACROILIAC SYNDROME : Daily pain from both SIJs,
confirmed by objective findings.
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PIRIFORMIS SYNDROME
• Piriformis muscle originates from the anterior part of sacrum, part
of spine in gluteal region & from superior margin of greater sciatic
notch.
• It’s a neuromuscular disorder that occurs when sciatic nerve is
compressed or irritated by piriformis muscle.
• This causes pain, tingling & numbness in buttocks and along the
course of sciatic nerve.
• Results from anatomical variations in muscle-nerve relationship, or
from overuse or strain.
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PIRIFORMIS SYNDROME
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SI JOINT DEGENERATION
• Degenerative arthrosis of the joint commences at an early age, affecting the iliac
cartilage to a greater extent than its sacral counterpart…whatever stresses the
joint is subjected to, it would seem that the sacral hyaline cartilage has a better
capacity to resist degenerative changes than the iliac fibrocartilage.”
• It was found that, with increasing age, the surfaces of both sides of the sacroiliac
joint degenerate and become irregular, leading to inter-articular fibrous
adhesions, further limiting motion.
• However, “the iliac cartilage exhibited more advanced changes of cartilage
degeneration, with the surface becoming irregular, fibrillated, and eroded.
• The cartilage began to diminish in thickness…the joint cavity began to fill with
greater quantities of amorphous, cellular debris.”
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HYPOMOBILITY AND
HYPERMOBILITY
• Initially, sprained sacroiliac ligaments allow the joint surfaces to separate
slightly more than normal, causing hypermobility.
• The smooth gliding in all directions changes to a pivoting aberrant motion.
• With the development of the ridge and groove , the sacrum moves in a
distinct pattern, in accordance with their shapes.
• However, when the joint surfaces separate enough to move out of
alignment, the main ridge, and/or smaller ridges, may move out of their
respective grooves, and wedge out of position, causing hypomobility.
• Therefore, one can have both hypomobility and hypermobility within the
same joint
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SACROILIAC NUTATION
• The Serola Theory, as a response to a right sacroiliac nutation lesion, the sacrum
is pulled into some degree of counternutation on the right, indefinitely, unless
the sacroiliac joint is properly stabilized and healed, which is extremely rare, but
possible.
• Instead of healing, the body adapts; the pelvis will torque, the spine will twist,
the extremities will rotate, and joints will move in asymmetrical patterns, etc
• The effect can be seen distant to the sacroiliac joint and even on the opposite
side.
• The structural alterations that develop eventually spread throughout the
musculoskeletal system and forms the basis for many chronic dysfunctions,
including those to the spine and extremities .
• Time and uneven contraction patterns produce chronic dysfunction.
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SACROILIAC SPRAIN
• Sacroiliac sprain can change coordination patterns in
many muscles which, by their attachments to the
sacrum and pelvic bones, can act through various
vectors and levers to alter posture and joint angles
throughout the musculoskeletal system.
• These distortions can occur whether the muscles
directly cross the sacroiliac joint, as in the knee, or do
not directly cross the sacroiliac joint, as in the ankle ,
or temporal mandibular joint .
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LIGAMENT SPRAIN
Ligaments Sprain in Nutation :
• When the force is greater than the ligaments can withstand, they
sprain, and the joint goes past its normal end point.
• Failure of this mechanism to maintain ligamentous integrity is the
weight bearing lesion of the sacroiliac joint, which is named the
Sacroiliac Nutation Syndrome.
• The central spring in the shock absorber system is damaged and the
normal mechanism of force transference becomes compromised
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ANKYLOING SPONDYLITIS
• This is a chronic progressive inflammatory disease of the sacroiliac joints and the axial skeleton.
• Causes : Causes are unknown. It is found to be strongly associated with HLA-B27 genetic marker (about 85
percent). The infective triggers are certain gram-negative organisms more so Klebsiella. Age/sex Common in
young male adults (M : F = 10:1).
• Pathology :The initial inflammation of the joints is followed by synovitis, arthritis, and cartilage destruction,
fibrous and later bony ankylosis. The joints commonly affected are SI joints, spine, hip, and knee and
manubrium sterni.
• Clinical Features ; The patient usually complains of early morning stiffness and pain in the back. Morning
stiffness: Present ,Effect of inactivity :Aggravates pain ,Effect of physical: Relieves pain ,activity ; Limitation
of spine In all directions
• Treatment : • General measures: This is extremely important and consists of the following measures: – Patient
education – Family education – Genetic counseling – Avoid smoking – Regular exercises, especially
swimming is of tremendous help – Physiotherapy and joint exercises – Occupational therapy. • Conservative
treatment: This consists of rest, NSAIDs (indomethacin), physiotherapy, back exercises, etc. Radiotherapy may
also help.
• Surgical treatment: Consists of spinal osteotomy to correct spine deformity, total hip replacement and total
knee replacement for hip and knee joint ankylosis.
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CAUDA EQUINA LESION
• Cauda equina syndrome is seen in injuries below the level of first lumbar vertebra. It is essentially injury to the
nerve roots below L1.
Causes :• Tumors of the spine. • Pott’s disease. • Protrusion of disk—large midline disk prolapse at 4-5. • Fracture
dislocation of the thoracolumbar spine.
Clinical Features:The patient complains of back pain, perineal pain, difficulty in micturition, impotence in male, etc.
Sensory signs: The most salient feature of a cauda equina lesion is an area of saddle-shaped hyperesthesia and later
anesthesia (involving buttocks, anus and perineum).
Motor signs:Flaccid paralysis below the knee.
Reflexes: Ankle jerk is lost and the knee jerk is increased due to the weakness of the opposing hamstrings.
Bladder symptoms: Common problems are retention of urine with overflow. Even after a severe cauda equina,
lesion reflex micturition is established later, reflex being mediated through the vesical plexus.
• Anal sphincter relaxation: leading to incontinence of the bowels.
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CAUDA EQUINA SYNDROME
Treatment :
• Prompt surgical intervention is the
treatment of choice.
• This consists of operative stabilization of
the fractures, bowel, back and bladder care
.
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REFERENCES
• Kinesiology The Mechanics and Pathomechanics of Human
Movement : Carol A. Oatis Second Edition .
• Joint Structure and Function: A Comprehensive Analysis : CYNTHIA
NORKIN- Fourth Edition .
• Orthopaedic Examination,Evaluation, and Intervention :MARK
DUTTON SecondEdition
• Textbook of Orthopedics : JOHN EBNEZAR – FOURTH EDITION
• Essential Orthopaedics :J. Maheshwari –FOURTH EDITION
• https://www.serola.net/research-category/sij-degeneration/
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THANK YOU
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