Movement, Stability & Lumbopelvic Pain. Integration of Research and Therapy

610 Pages·2007·28.837 MB·English

by  Andry Vleeming, PhD, Vert Mooney, MD, and Rob Stoeckart, PhD (Eds.)

Contributors
MA Adams BSc PhD RL DonTigny PT
Senior Research Fellow, Department of Anatomy, Physical Therapist, Havre, Montana, USA
University of Bristol, Bristol, UK
S Gibbons BSc (Hons) PT MSc MCPA
PJ Barker BAppSc(Physio) PhD Stability Physiotherapy, Mt. Pearl, Newfoundland,
Senior Tutor, Department of Anatomy and Cell Biology, Canada
The University of Melbourne, Victoria, Australia
W Gilleard PhD
M Benjamin PhD Senior Lecturer in Biomechanics, School of Exercise
Professor of Musculoskeletal Biology and Sports & Sports Management, Southern Cross University,
Medicine Research, School of Biosciences, Cardiff Lismore, Australia
University, Cardiff, UK
S Gracovetsky PhD
CA Briggs BSc Dip Ed MSc PhD Retired, Concordia University, Montreal, QC, Canada
Associate Professor and Deputy Head, Department of
Anatomy and Cell Biology, The University of Melbourne, PW Hodges BPhty (Hons) PhD MedDr
Victoria, Australia Professor and NHMRC Principal Research Fellow,
Division of Physiotherapy, The University of Queensland,
L Chaitow ND DO Brisbane, Australia
Honorary Fellow, School of Integrated Health, University
of Westminster, London, UK; Editor-in-Chief, Journal of S Holm
Bodywork & Movement Therapies Professor, Department of Orthopaedics, Sahlgrenska
University Hospital, Goteborg, Sweden
J Cholewicki
Associate Professor, Department of Orthopaedics & B Hungerford PhD
Rehabilitation, Yale University School of Medicine, New Consultant Musculoskeletal Physiotherapist, Sydney
Haven, CT, USA Spine & Pelvis Centre, Drummoyne, NSW, Australia
HJ Dananberg DPM A Huson MD PhD
Podiatrist, private practice, Catholic Medical Centre, Professor Emeritus, Maastricht University, The
Bedford, New Hampshire, USA; Contributing Editor, Netherlands
Journal of the American Podiatric Medical Association
A Indahl MD PhD
L Danneels PT PhD Consultant, Specialist in physical medicine and
Professor of Rehabilitation Sciences and Physiotherapy, rehabilitation, Department of Physical Medicine and
Faculty of Medicine and Health Sciences, Ghent, Rehabilitation, Hospital for Rehabilitation, Stavern,
Belgium Norway
C DeRosa PT PhD RE Irvin DO
Professor of Physical Therapy, Northern Arizona Clinical Associate Professor, Dept of Osteopathic
University, Flagstaff, Arizona, USA Manipulative Medicine, College of Osteopathic Medicine,
Oklahoma State University Health Science Center, Tulsa,
PF Dijkstra MD DIC PhD Oklahoma, USA
Former Radiologist, Academic Medical Centre,
Amsterdam, The Netherlands; Former Head of E Jurriaans BSc MBChB DTM&H FRCR(UK) FRCP(C)
Department of Radiology, Jan van Breemen Institute for Associate Professor, McMaster University, Faculty of
Skeletal Disease, Amsterdam, The Netherlands Health Sciences, Hamilton, Ontario, Canada; Staff
Radiologist, St. Joseph’s Healthcare, Hamilton, Ontario,
P Dolan PhD Canada
Reader in Biomechanics, Department of Anatomy,
University of Bristol, Bristol, UK
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ix
Contributors
B Koes PhD JA Porterfi eld PT MA ATC
Professor of General Practice, Head of Research Owner, Rehabilitation and Health Center, Inc., Akron,
Department, Department of General Practice, Erasmus Ohio; CEO, Venture Practice Services Ltd., Akron, Ohio,
MC, University Medical Centre, Rotterdam, The USA
Netherlands
T Ravin MD
M Laslett PhD NZRP Dip MT Dip MDT Physician; President of the American Association of
Senior Clinician, PhysioSouth @ Moorhouse Medical Musculoskeletal Medicine, Denver, Colorado, USA
Clinic, Christchurch, New Zealand
R Stoeckart PhD
D Lee BSR FCAMT Department of Neuroscience, Erasmus MC, Rotterdam,
Clinical and Education Consultant, Diane Lee & The Netherlands
Associates, Canada
B Stuge PT PhD
SM Levin MD FACS Senior Researcher, Institute of Nursing & Health
Director, Ezekiel Biomechanics Group, McLean, VA, USA Sciences, University of Oslo, Norway
CO Lovejoy MA PhD B Sturesson MD PhD
University Professor of Anthropology, Department of Head of Spine Unit, Department of Orthopaedics,
Anthropology and Division of Biomedical Sciences, Kent Angelholm Hospital, Angelholm, Sweden
State University and Northeast Ohio Universities College
of Medicine, Ohio, USA M van Tulder PhD
Professor, Institute for Research in Extramural Medicine
AT Masi MD DRPH (EMGO) and Institute for Health Sciences (HIS), VU
Professor of Medicine, University of Illinois College of University Medical Centre, Amsterdam, The Netherlands
Medicine at Peoria (UICOMP), Illinois, USA
DM Urquhart BPhysio(Hons) PhD
SM McGill Dept of Epidemiology & Preventive Medicine, Monash
Professor, Faculty of Applied Health Sciences, Dept of University, Victoria, Australia
Kinesiology, University of Waterloo, Ontario, Canada
LMG Vancleef MSc
V Mooney MD Dept Medical, Clinical and Experimental Psychology,
Clinical Professor of Orthopaedics, USSD, Private Maastricht University, The Netherlands
Practitioner, San Diego, California, USA
J Viti
G Lorimer Moseley PhD BAppSc(Phty)(Hons) Assistant Professor, University of St. Augustine for
Nuffi eld Medical Research Fellow, Centre for fMRI of Health Sciences, St. Augustine, Florida, USA
the Brain and Dept of Human Anatomy & Genetics,
University of Oxford, UK JWS Vlaeyen PhD
Dept Medical, Clinical and Experimental Psychology,
G Müller Maastricht University, The Netherlands
Orthopaedic Surgeon, Sports Medicine, Manual Therapy,
Chairman of Rueckenzentrum Am Michel, Hamburg, A Vleeming PhD
Germany Clinical Anatomist and Founder, Spine and Joint Center,
Rotterdam, The Netherlands
JMD O’Neill MB BAO BCh MRCPI MSc FRCR(UK)
Assistant Professor, McMaster University, Faculty of NK Vøllestad PhD
Health Sciences, Hamilton, Ontario, Canada; Staff Professor, Head of Institute of Nursing & Health
Radiologist & Director – Musculoskeletal Imaging, St. Sciences, University of Oslo, Norway
Joseph’s Healthcare, Hamilton, Ontario, Canada
FH Willard PhD
HC Östgaard MD PhD Professor, College of Osteopathic Medicine, Family
Associate Professor, Chief of Dept of Orthopaedics, Medicine, University of New England, Biddeford, Maine,
Sahlgren University Hospital, Molndal, Sweden USA
SV Paris PT PhD FAPTA
President, University of St. Augustine for Health
Sciences, St. Augustine, Florida, USA
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Preface
There are a large number of books dealing with and several others. In the book they are grouped
the lumbar spine and pelvis, so why this book into the following parts:
on Movement, Stability and Lumbopelvic Pain? This 1. Biomechanical, clinical–anatomical and
question is pertinent as there are several excellent evolutionary aspects of lumbopelvic pain and
books available which cover these topics. Our dysfunction
reasons are diverse. 2. Insights in function and dysfunction of the
Firstly, several distinguished scientists, physicians lumbopelvic region
and other specialists have lately provided evidence- 3. Diagnostic methods
based, relevant new data on the lumbopelvic 4. Guidelines
area. This forces us to look afresh at the adequacy 5. Effective training and treatment
of current diagnostic and therapeutic methods. 6. Integrating different views and opinions when
Secondly, most books deal either with the low back dealing with a complex system.
or with the pelvic girdle; our aim is to collect all The studies reviewed in this book refl ect the
relevant material in one book. Thirdly, most books specialties of the contributors, their back grounds,
on the subject are written by one expert or by a small styles, approaches and specifi c ideas about how
team of experts. This makes it diffi cult to get a grip lumbopelvic structures func tion and dysfunction.
on the vast wealth of information available. Finally, Several chapters were written by authors with a
and probably most importantly, notwithstanding all unique concept about the origin of pain and dys-
efforts to treat patients adequately, large numbers function of lumbopelvic structures and about the
of patients still suffer chronically from low back therapy requested. In a way this is hazardous since
pain and/or pelvic girdle pain. It is our hope and certain authors were invited, not because of their
ambition to provide, together with all contributors, evidence-based approach, but since in the opinion
an integrated book that can be of help to people of the editors their audacious and sometimes
involved in the diagnosis or treatment of patients controversial ideas merit attention. Their concepts
with lumbopelvic pain. should invite sound research that can confi rm,
The contributors to this book include scientists refute, or adapt the ideas presented. We are
of internationally renowned clinical groups and convinced that the wealth of information presented
departm ents dealing with basic sciences. Their by the contributors will help to create rational and
contributions are from differ ent disciplines effective treatment programs for the management
embracing anthropology, ortho pedic surgery, bio- of lumbopelvic pain and dysfunction.
mecha nical engineering, chiropractic practice,
anatomy, osteopathy, physical therapy, podiatry, Andry Vleeming, Vert Mooney and
gynecology, rehabi litation medicine, epidemiology Rob Stoeckart
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SECTION ONE
C H A P T E R
1
The muscular, ligamentous, and neural
structure of the lumbosacrum and its
relationship to low back pain
FH Willard
INTRODUCTION
The lumbosacral spinal column performs a key role in the transfer of
weight from the torso and upper body into the lower extremities, both
in static positions and during mobility. The primary bony structures
involved in this force transduction are: five lumbar vertebrae, a sacrum,
two innominate bones, and the two femoral heads. Critical to the stability
of these bony components is a complex arrangement of dense connective
tissue. Although typically described as separate entities in most textbooks
of anatomy, these fibrous, soft-tissue structures actually form a continuous
ligamentous stocking in which the lumbar vertebrae and sacrum are
positioned. The major muscles representing the prime movers in this
region – such as the multifidus, gluteus maximus, and biceps femoris
– have various attachments to this elongated, ligamentous stocking. The
muscular and ligamentous relationships composing the lumbosacral
connection are of extreme importance in stabilizing the lumbar vertebrae
and sacrum during the transfer of energy from the upper body to the
lower extremities. This arrangement has been termed a ‘self-bracing
mechanism’ (Vleeming et al 1995c) and, as such, its dysfunction is critical
to the failure of the lower back.
A critical relationship also exists between the neural components of
the lumbosacral region and the surrounding ligamentous structures.
Traumatic, infl ammatory, and degenerative disease processes affect the
structure of the lumbosacral region and impact on the surrounding nerves.
Current research, using immunohistochemical techniques to identify
specific types of axons, suggests that all of these connective tissue structures
receive a supply of small-caliber, primary afferent fibers (A(cid:98) and C-fibers),
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6 Movement, Stability and Lumbopelvic Pain
typical of those involved in nociception. Irritation Ventral Capsular Neural arch
of these primary afferent nociceptive axons initiates ligaments ligaments ligaments
the release of neuropeptides that interact with
fibroblasts, mast cells, and immune cells present Superior
articular
in the surrounding connective tissue (Levine et al
process
1993). The resultant cascade of events, referred to as
a neurogenic infl ammatory response, is thought to Transverse
play a major role in degenerative diseases and the process
development of low back pain (Garrett et al 1992,
Kidd et al 1990, Schaible et al 2005, Weidenbaum &
Farcy 1990, Weinstein 1992). Sensitization of these
small-caliber, primary afferent fibers, along with
sensitization of their central connections in the dorsal
horn of the spinal cord, appears to play a crucial
role in the evolution of chronic painful conditions Inferior articular
(Coderre et al 1993, Ji et al 2003, Woolf & Chong process Spine
1993). This chapter examines recent advances in Accessory
our knowledge of the lumbosacral region structural process
architecture, pathology, and innervation. Fig. 1.1 A lateral view of a lumbar vertebra illustrating the
position of the neural arch ligaments, capsular ligaments,
and ventral ligaments.
Ligamentous structure of the
lumbar region
et al 1990a, 1990b) in vivo they grade together at
The various ligaments of the lumbar vertebral their boundaries to unite and function as a single
column form a continuous, dense, connective-tissue unit. To demonstrate this concept, the osseous
stocking surrounding the vertebrae and extending components of the neural arch were removed with
into the sacral area. For ease of description, the minimal disturbance to the associated ligamentous
vertebral connective tissue sheath can be divided structures (Figs 1.4 and 1.5). The unitary nature
into three parts: (1) the neural arch structures; of the supraspinous and intraspinous ligaments
(2) the capsular structures; and (3) the ventral or and of the ligamentum fl avum is obvious because
vertebral body structures (Fig. 1.1). However, it these soft tissue structures maintain their continuity
should be noted that the partitions between each despite the lack of supporting osseous material.
of these three divisions are for convenience only,
as the connective tissue of the dorsal and ventral Ligamentum fl avum
components is essentially continuous across the
The ligamentum fl avum, located between individual
pedicles of the vertebrae.
laminae, represents a medialward continuation
of the articular capsule of the facet joint (Fig. 1.4).
Neural arch ligaments This elastic ligament forms a significant portion of
the roof of the spinal canal. Superiorly, it attaches
The neural arch of each lumbar vertebra is composed to the anterior surface of the lamina above and
of the pedicles, laminae, transverse processes, inferiorly it establishes a cup-like grasp on the
and spine (Figs 1.1 and 1.2). Two major ligaments superior margin of the lamina below (Olszewski et
participate in surrounding the neural arch: the al 1996). The medial fibers of the ligament bridge
ligamentum fl avum and the interspinous ligament; the gap between the laminae of adjacent vertebra,
two additional small ligaments are also described: fusing with the interspinous ligament, whereas
the supraspinous ligament posteriorly and the the lateral fibers attach to the facet joint capsule
intertransverse ligament laterally. To view the (Figs 1.4B and 1.5; see also Behrsin & Briggs 1988,
ligaments of the neural arch, the multifidus muscle Bogduk & Twomey 1991, Ramsey 1966). This
must be completely removed from the lumbosacral distensible ligament is composed of elastic fibers
region (Figs 1.2 and 1.3). Although most of these (80%) and collagenous fibers (20%), the elastic
ligaments have a distinct biochemical make-up fibers imparting the ligament its yellow color
when analyzed in isolation (Ballard & Weinstein and fl exible nature (Bogduk & Twomey 1991). A
1992, Fujii & Hamada 1993, Fujii et al 1993, Yahia significant function for the ligamentum fl avum is
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7
The muscular, ligamentous, and neural structure of the lumbosacrum
second component can be related to an age-related
loss of elastic fibers and elasticity of the ligamentum
fl avum, contributing to their progressive loss of
tension in the elderly (Nachemson & Evans 1968,
Ramsey 1966). Specifically, there is a decrease in
Lo
elastic fibers and a concomitant increase in the
density of collagen fibers, along with a shift to
high-molecular-weight proteoglycans (Kashiwagi
S 1993, Okada et al 1993). These events favor the
deposition of calcium (Kashiwagi 1993), thus nearly
all fl aval ligaments in a sampling of patients with
lumbar spinal stenosis had histological signs of
ossification (Schrader et al 1999). Calcification
of the ligament leads to its hypertrophy and to
subsequent lumbar spinal stenosis (Yoshida et al
1992). These age-related changes in the liga m entum
Ic fl avum have been related to spe cific neurologic
sequelae such as the cauda equina syndrome and
lumbar radiculopathy (Baba et al 1995, Ryan 1993).
Whereas ossification of the ligament is associated
with increasing age and the presence of cauda
equina syndrome, chondrogenesis in the ligament
appears more associated with the presence of
spondylolisthesis (Okuda et al 2004). Finally, failure
Mu
of the elastic properties of this ligament has also
been related to the development of adolescent
idiopathic scoliosis (Hadley-Miller et al 1994).
Unfortunately, there is little or no regenerative
Fig. 1.2 The three lumbar paravertebral muscles in a capacity in the elastic tissue of the ligamentum
male. On the individual’s right side is the iliocostalis muscle fl avum; thus a damaged ligament is replaced by a
(Ic) laterally and the longissimus muscle (Lo) medially. Note dense connective tissue cicatrix (Ramsey 1966).
that the spinalis muscle (S) does not extend into the lumbar
region beyond L2 or L3. On the individual’s left side, the
iliocostalis and longissimus have been removed to reveal Interspinous ligament
the medially positioned multifidus muscle (Mu). Arrows
The interspinous ligament extends between borders
top and bottom are aligned along the spinous processes
of the spines of adjacent vertebrae (Figs 1.5 and
of the thoracic and lumbar vertebrae (midline). The thick
1.6). Its anterior border is a continuation of the
lumbar multifidus muscle is seen differentiating into the thin,
ligamentum fl avum. The posterior border of the liga-
fl attened semispinalis muscle at the superior end of the
lumbar vertebral column (asterisk). ment thickens to form the supraspinous liga ment,
which is, in turn, anchored to the thoracolumbar
fascia. The orientation of fibers in the interspinous
to provide a roof for the vertebral canal that will ligament has been given multiple, confl icting
not buckle during extension–fl exion movements descriptions. In humans, the ligament can best be
of the vertebral column (Bogduk & Twomey 1991). described as a fan (Fig. 1.6; see also Fig. 1.11 below).
At rest (in a neutral position), the ligaments have The narrow or proximal end of the fan blends with
a pretension, ideally keeping the ligaments from the ligamentum fl avum and contains elastic fibers
buckling (Nachemson & Evans 1968). (Yahia et al 1990b), whereas the broad end of the
Despite the elasticity of the ligamentum fan extends in a posterior direction towards the
fl avum, it is known to be a significant source of tips of the spines and is composed primarily of
root compression in the lumbar region (Okuda et collagen fibers. In the center of the ligament, the
al 2005). A component of this neural compression collagen fibers are oriented parallel to the vertebral
appears to be related to buckling of the ligament spines; distally, the peripheral collagen fibers fl are
inferiorly secondary to age-related intervertebral posterocranially and posterocaudally (Aspden et al
disc collapse or other degenerative processes. A 1987, Hukins et al 1990). This fan-like arrangement
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8 Movement, Stability and Lumbopelvic Pain
S
A B
Fig. 1.3 The multifidus muscle and its bed. (A) The pyramidal-shaped multifidus muscle is demonstrated between the four
arrowheads (S, lumbar spinous processes). (B) The multifidus muscle has been removed to reveal a continuous ligamentous
stocking surrounding the neural arch components of the lumbar vertebrae (between arrowheads). On the sacrum, only the
deepest laminae of the multifidus remain (asterisk).
allows the ligament to expand without rupture as the ligament and evidence for degenerative
the vertebral spines separate during fl exion. The events in the interspinous ligament has recently
fibers of this ligament are described as resisting been demonstrated with CT and MRI imaging
the separation of the vertebral spines during (Jinkins 2004). All of these pathologic events
fl exion (Bogduk & Twomey 1991); however, the occurring to the interspinous ligament should
most likely function of these ligaments, given diminish the ability of the thoracolumbar fascia to
their anteroposterior fiber orientation, is to act as infl uence the alignment of the lumbar vertebrae, and
an anchor, transmitting the anteroposterior pull of thereby increase their risk of destructive injury.
the thoracolumbar fascia, into which it is attached
via the supraspinous ligament (Hukins et al 1990),
Supraspinous ligament
into an increased tension in the ligamentum fl avum
(Fig. 1.7). This increased tension would assist in The supraspinous ligament lies along the posterior
preventing the latter ligament from buckling onto border of the interspinous ligament (Fig. 1.8).
the spinal cord and would also serve to assist in Throughout its lumbar course, it is tightly adherent
alignment of the lumbar vertebrae. Chondrocytes to the posterior border of the lumbar spines and
are present along the osseous borders of the interspin- to the interspinous ligament. This creates an
ous ligaments and age-related chondrification of interspinous–supraspinous thoracolumbar (IST) liga-
the interspinous ligament occurs after the third mentous complex that anchors the major fascial
decade of life (Yahia et al 1990b). Degenerative planes of the back to the lumbar spines. Traction
processes in the motion segment of the vertebrae placed on the thoracolumbar fascia will destroy
appear to coincide with the chondrification of the thoracolumbar sheath before it will separate
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9
The muscular, ligamentous, and neural structure of the lumbosacrum
LF
FJ
sd
IS
A B
Fig. 1.4 The ligamentous stocking of the lumbar vertebrae. (A) This orientation photograph is a posterior view of the
lumbar spinal column, similar to that in Fig. 1.3. The spinous processes, laminae, and inferior articular processes of the facet
joint have been removed. (B) Detailed view of the ligamentous stocking illustrating the ligamentum fl avum (LF) extending
between the interspinous ligament (IS) medially and the facet joint capsule (FJ) laterally. The arrowhead indicates the same
facet joint capsule in both photographs. The epidural space and spinal dural (sd) can be seen between the fl aval ligaments.
the IST complex (Fig. 1.8). Thus it is possible for plates surrounded by a dense connective-tissue
the interspinous and supraspinous ligaments to act fibrous capsule (Lewin et al 1962). The plates are
as force transducers, translating the tension of the curved such that the inferior articular process (from
thoracolumbar fascia, developed in the extremities the above vertebrae) presents a convex process
and torso, into the lumbar vertebral column. At to the concave superior articular process (of the
lower lumbar levels, the supraspinous ligament vertebrae below) (Fig. 1.9). These joints contain a
becomes progressively less organized as it grades true synovial space, a connective tissue rim and a
into the distal attachments of the thoracolumbar complicated array of surrounding adipose tissue
fascia, and in some individuals it might not be pads and fibroadipose menisci (Engel & Bogduk
recognizable caudal to L4 (Bogduk & Twomey 1982). The articular surface of the facet joints is
1991). This ligament often presents with fatty covered with a hyaline cartilage. The joint capsule
involution late in life (Heylings 1978) and can also represents a connective-tissue bridge between the
ossify (Mine & Kawai 1995). neural arch ligaments and those of the vertebral
body. As such, the capsule is encased in a thin
Articular capsular ligament sheet of dense, irregular investing fascia, which
is continuous dorsally with that surrounding the
The articular processes of the lumbar vertebrae ligamentum fl avum and ventrally with the investing
form the facet or zygapophyseal joints. Each joint fascia of the vertebral body. The capsule itself has
consists of two opposed and vertically oriented two components: an outer layer of dense connective
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10 Movement, Stability and Lumbopelvic Pain
LS
FJ
IS
sd SS
LF
LF
LS
IS
Fig. 1.5 Lateral view of the lumbar ligamentous stocking. Fig. 1.6 A magnified view of the interspinous ligament.
The facet joint (FJ) is the same as the marked FJ in Fig. The lumbar spinous processes (LS) are seen superior and
1.4B. The continuity of the fl aval ligament (LF) with the facet inferior to the ligament. Note the fan-like orientation of the
joint capsule and interspinous ligament (IS) is indicated by collagenous fibers in the ligament. The proximal end of the
the arrowheads. The spinal dura (sd) can be seen in the ligament is continuous with the ligamentum fl avum (LF)
epidural space. and the distal end of the ligaments is embedded in the
supraspinous ligament (SS). This latter structure is attached
to the thoracolumbar fascia. This arrangement would serve
to transform any increased tension in the thoracolumbar
tissue and an inner layer composed of elastic fibers
fascia into increased tension on the ligamentum fl avum,
similar to the ligamentum fl avum (Yamashita et
resulting in an alignment of the lumbar vertebrae
al 1996). The outer layer is composed of dense,
(see Fig. 1.7).
regularly arranged connective tissue in which the
predominant orientation of the collagenous fibers is
orthogonal to the joint line, the plane on which the fl avum. It is weakest around the superior recess,
two facet plates oppose each other (Fig. 1.10). The which can burst from effusion during arthrography
capsule is bound tightly to the articular processes (Dory 1981). The inferior border of the capsule
with the exception of its inferior and superior is continuous with the ligamentum fl avum, the
recesses, each of which consists of a loosened medial border with the periosteum of the lamina,
fold in the capsule wall (Figs 1.9C and 1.11). This and the lateral border with the periosteum of the
arrangement of the capsule allows for a gliding pedicle and body.
movement in the sagittal plane but restricts its range The intervertebral disc and its two associated
of motion in the horizontal plane. Each recess has a facet joints make up a triad representing the load-
small defect that is capable of transmitting fat from bearing joint surfaces at each lumbar vertebral
the capsular space outward (Bogduk & Twomey level (Lewin et al 1962). Logic suggests that
1991). The capsule is reinforced dorsally by the anatomical abnormalities or degenerative changes
multifidus muscle and ventrally by the ligamentum of one component would lead to changes in other
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