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SPINE Volume 29, Number 2, pp 129138

2004, Lippincott Williams & Wilkins, Inc.

Tensile Transmission Across the Lumbar Fasciae in


Unembalmed Cadavers
Effects of Tension to Various Muscular Attachments

Priscilla J. Barker, BAppSc (Physio), Christopher A. Briggs, PhD, and Goce Bogeski, BSc (Hons)

myographic (EMG) findings suggest that transversus


Study Design. Traction was applied to muscles attach- abdominis (TrA) may contribute to the control of seg-
ing to the posterior and middle layers of lumbar fascia mental movement, potentially via the lumbar fasciae.6
(PLF, MLF). Effects on fasciae were determined via tensile
force measures and movement of markers.
This highlights the need to clarify the segmental attach-
Objectives. To document tensile transmission to the ments of TrA, related muscles and lumbar fasciae, as well
PLF and MLF when traction was applied to latissimus as their capacity to transmit tension to vertebrae.
dorsi (LD), gluteus maximus (GM), external and internal The middle (MLF) and posterior layers of lumbar fas-
oblique (EO, IO), and transversus abdominis (TrA) in un-
ciae (PLF) enclose the paraspinal muscles, fusing at the
embalmed cadavers.
Summary of Background Data. A previous study on lateral raphe where they provide attachment for TrA and
embalmed cadavers applied traction to muscle attach- part of internal oblique (IO)2,7 (Figure 1). The raphe has
ments while monitoring fascial movement but did not test also been reported to provide attachment for part of
TrA or the MLF. external oblique (EO)8 and latissimus dorsi (LD).2,9
Methods. The PLF and MLF were dissected then
marked on eight unembalmed cadavers. A strain gauge The MLF forms thickened fascial bands at its attach-
was inserted through fascia at L3; 10N traction was ap- ments to lumbar transverse processes.7,10 Tesh et al7,11
plied to each muscle attachment while photographs and used intra-abdominal balloons confined to the lumbar
tension measures were taken. Movement of fascial mark- region in an attempt to apply tension to the MLF indi-
ers was detected photographically. Fascial widths were
also measured.
rectly. They found that increasing pressure in the balloon
Results. Tension was clearly transmitted to fascial ver- affected the position of the trunk in the coronal plane,
tebral attachments. Tensile forces and fascial areas af- straightening it against considerable force. The authors
fected were highest for traction on LD and TrA in the PLF attributed this response to tension in the MLF (and TrA).
and for TrA in the MLF. Movement of PLF markers from
However, coronal plane testing was only performed in
tension on LD and TrA occurred bilaterally between T12
and S1. Effects from other muscles were variably bilateral, one cadaver,11 and no direct measurements of fascial
with those from GM and IO occurring below L3 and those tension were taken.
from EO occurring above L3. Tensile forces were rela- A factor that may influence transverse tension gener-
tively high in the MLF and its width was less than half that ation in the MLF and PLF (e.g., from contraction of the
of the PLF.
Conclusions. Low levels of tension are effectively
lateral abdominal muscles) is fascial width, i.e., from
transmitted between TrA and the MLF or PLF. Via them, vertebral processes to lateral raphe. The widths of lum-
TrA may influence intersegmental movement. [Key bar fasciae have not been comprehensively documented
words: lumbar fascia, tension, strain, transversus abdo- in a single sample. Existing descriptions from dissec-
minis, spinal stability] Spine 2004;29:129 138
tions12 and CT scans from three young adult males11
indicate that widths of the MLF and PLF may be similar,
The lumbar fasciae and their attaching muscles are pro- each approximately 9 cm per side.11,12 However, the
posed to support the spine by various mechanisms.1 8 transverse processes are clearly closer to the lateral raphe
Dissection studies have documented muscular attach- than the spinous processes (Figure 1), emphasizing the
ments and anatomic features of the fasciae, yet biome- need to further investigate fascial widths.
chanical investigation of these has been limited. Electro- Existing dissection studies describe the PLF compris-
ing two laminae2,8 that are increasingly fused below L1.1
Figure 2 presents a composite view of the muscular at-
From the Department of Anatomy & Cell Biology, University of Mel-
bourne, Victoria, Australia. tachments of the posterior layer.
Acknowledgment date: October 29, 2002. First revision date: May 28, Vleeming et al8 attempted to simulate the effect of
2003. Acceptance date: June 5, 2003. muscle contraction on the PLF in three embalmed cadav-
Supported by the Department of Anatomy & Cell Biology and an
Australian Physiotherapy Association (Victorian Branch) minor ers. Using grips they applied up to 50 N tension to tra-
scholarship. pezius, LD, gluteus maximus (GM), EO, IO and serratus
The manuscript submitted does not contain information about medical posterior inferior. Raster photography, a technique
device(s)/drug(s).
Professional Organization funds were received in support of this work. involving sequential photographs taken with and with-
No benefits in any form have been or will be received from a commer- out applied tension and compared against a reference
cial party related directly or indirectly to the subject of this manuscript. grid, was used to determine movement of fascial markers
Address correspondence to Priscilla J. Barker, BappSc, Department of
Anatomy & Cell Biology, University of Melbourne, Parkville, Victoria in response to applied tension. Their results indicated
3010 Australia; e-mail: p.barker@unimelb.edu.au. that both LD and GM transmitted tension to the PLF

129
130 Spine Volume 29 Number 2 2004

Figure 1. Lumbar fasciae: Typical depiction in cross section.


Adapted from Williams et al.29 ALF, MLF, PLF anterior, middle
and posterior layers, respectively, of lumbar fascia; TrA trans-
verse abdominis; IO internal oblique; EO external oblique.

contralaterally: LD up to 2 cm past the midline and GM


up to 4 cm.8
Vleeming et al8 proposed that LD and GM may act
together during contralateral limb movements (e.g.,
swimming, running, or walking) to support the lumbar
spine and increase force closure at the sacroiliac joint.
Their study was, however, limited to embalmed speci-
mens, which are reported to poorly represent tissue bio-
mechanics in vivo.13 Furthermore, the attachment of
transversus abdominis (TrA) to the lumbar fasciae was
not tested, nor did the study document the segmental
levels affected when tension was applied on each muscle
attachment.8
The attachments of TrA (and/or IO) are of increasing Figure 2. The posterior layer of lumbar fascia. Muscular attach-
clinical interest. Intramuscular EMG studies indicate ments of the superficial (left) and deep (right) laminae. Adapted
that TrA has a relatively early onset of contraction before from existing studies.1,2,8 SCe splenius cervicis; Rh rhom-
trunk perturbations and rapid multidirectional limb boids; Tz trapezius; LD latissimus dorsi; SPI serratus
movements6,14,15 when compared with EO and IO. This posterior inferior; IO internal oblique; TrA transversus abdo-
minis; EO external oblique; GM gluteus maximus; Bi biceps
onset is reported to be delayed in patients with chronic femoris.
low back pain.15,16 Selective contraction of TrA before
limb movements has been proposed, via its fascial at-
tachments, to restrict excess lumbar intersegmental attachments of LD, GM, EO, IO, and TrA to the PLF
neutral zone17 movement and reduce the occurrence and/or MLF in unembalmed cadavers; 2) to document
of segmental injury.6,15 These mechanisms are discussed the effects on fasciae when tension was applied to these
in detail elsewhere.18 Clinical studies on the effect of muscles, with reference to segmental levels; and 3) to
specific exercise training of TrA (IO) in patients with document the widths of the MLF and PLF.
low back pain support the proposed importance of these Materials and Methods
muscle(s).19,20 Author groups differ, however, on the
Sample Characteristics. Eight unembalmed cadavers were
proposed mechanism. TrA is primarily proposed to con-
examined (6 female, 2 male). They had been refrigerated at 5
trol segmental movement,6 but IO may also play a role.20 C from within 48 hours of death for 7 to 36 days (average 23
Determining relative tensile forces generated in the days) before dissection. They were of mean age 83 years (range
fascia by applying tension to its attached muscles may 73101 years) and generally of slight build, of mean weight 56
help clarify the potential roles of muscles and fascia in kg (range 40 75 kg), with the two males being the heaviest.
support of the lumbar spine and sacroiliac joint. The One female cadaver had a surgical scar (for laminectomy) on
aims of this study were as follows: 1) to review muscular the left between L1 and L5.
Tension and Muscular Attachments Barker et al 131

Dissection, Clamping, and Testing Sequence. The cadav-


ers were positioned prone and their backs dissected, inferiorly
to the upper gluteal region and laterally to the abdominal wall
muscles. Muscles were separated so that each could glide inde-
pendently when traction was applied. The part of GM that
inserts into the PLF (~7 cm wide, between the posterior supe-
rior iliac spine and S3) was divided from the remainder of the
muscle (by two slits parallel with its fascicles) so that the
clamps could grip it separately. Similarly, divisions were made
to isolate the central part of the LD attachment (~7 cm wide,
closest to L3), so that it could fit into the clamp grips. The
cadaver was secured (with rope) firmly to the table at T6 and
S4, and tension was applied to several muscle attachments of
the PLF. Muscles were tested in the order LD or GM, then EO, Figure 3. Displacement and area mapping of latissimus dorsi. a:
IO, and TrA, with the obliques being incised laterally, reflected Experimental setup with 10 N applied tension moving fascial mark-
and preserved for testing at the MLF. The MLF was accessed by ers. Note the strain gauge inserted at L3. b: An arc is drawn
incising the PLF and removing underlying paraspinal muscles, around the most distant markers visibly moving toward the grips
but preserving the lateral raphe and its muscle attachments. with applied tension. The white line measures the distance at
which the farthest fascial displacement occurs. The total area of
Before testing, the extent of both fascial layers was marked fascia affected is bordered by the arc, reference scale bars, and
with dots using a permanent marker, as were their vertebral musculofascial junctions.
attachments.

Tensile Force Measures. A buckle strain gauge21 consisting Fascial Widths. Photographs were taken on the first test at
of Entran semiconductor strain gauges (ESB-020350, Entran both 0 N and 10 N using a digital camera (Nikon D1, Nikon
Devices Inc.; Fairfield, NJ) mounted on an E-shaped force Corp., Tokyo, Japan) from a fixed height with a 50-mm refer-
transducer was used in connection with a cathode ray oscillo- ence scale bar positioned parallel to the fascia. Photographs for
scope (type 502 Dual Beam Oscilloscope, Tektronix Inc., Bea- each muscle were then aligned on computer using Adobe Pho-
verton, OR) and then calibrated. The buckle strain gauge was toshop 5.0 (Adobe Systems Inc., San Jose, CA). The widths of
calibrated, using a rubber band and digital hand-held spring the PLF and MLF were each measured from photographs taken
balance (accuracy 0.1 N: Shimpo F GC-50, 500 N force Dig- during testing of TrA with 10 N tension applied, using long
ital Force Gauge, Testequip 2000; Osaka, Japan) from 0 to 10 reference scale bars (calibrated with the 50-mm scale bar; i.e.,
N (at 1 N intervals). The output, representing tensile force, was 0.5 mm). Measurement was taken between the edge of the
(spinous or transverse) process of L3 and the lateral raphe. The
recorded in millivolts. The average of these calibration values,
width from vertebral processes to the musculotendinous junc-
performed on both sides at 10 N, was later used to convert the
tion of TrA was also taken at this level, and repeat width mea-
fascial tensile force measures in approximate Newtons.
sures were performed on three cadavers.
Two small horizontal slits were made 3 to 5 mm apart in the
lumbar fasciae at L3 and the prongs of the buckle threaded
Fascial Displacement. Fascial movement was determined by
through them: adjacent to the L3 spinous process in the poste-
magnifying the aligned (0 N and 10 N) images to life size and
rior layer and to the L3 transverse process in the MLF. The alternating between them. An arc was drawn around the most
buckle remained in this location throughout, with the fascia distant markers, visibly moving toward the grips (and away
being gently repositioned at the base of the buckle before test- from their adjacent, more distal markers), so that dots to either
ing each muscle. LD or (alternately) GM, then EO, IO, and TrA side of the arc separated with the 10 N applied traction. Fur-
were each gripped close to (2 cm) their fascial attachment thest fascial displacement measures were taken of the distance
using two 23-cm Doyen intestinal clamps oriented perpendic- (in centimeters) between the grips and the most distant detect-
ular to muscle fascicle direction and fixed together by cable ties. able point of fascial displacement on the arc, using a long ref-
Tension was applied to this gripping system by three hooked erence scale bar aligned between the midpoint of the grips and
chains linked centrally on a metal ring. Two hooks were at- the midpoint of the arc (Figure 3). Mean contralateral displace-
tached to the grips, one around each cable tie, and the third ment was similarly measured along this line, between the mid-
connected to the hand-held spring balance. Tension was ap- line and the arc.
plied in the direction of the attaching muscle fascicles while
fascial tensile force measures were taken at 1 N intervals and Fascial Areas. To determine the total area of fascia affected
photographs at 10 N intervals. Tensile force measures were (e.g., from arc to musculotendinous junction), lines were
taken three times on each side up to 10 N, since the thinnest drawn from each end of the arc to the edges of the grips and the
attachments tended to tear at 10 to 15 N. On the final measure, intervening musculofascial junctions traced (Figure 3). This
tension was slowly increased from 10 N and recorded in 5 N fascial area was then imported into an image analysis program
increments to failure. The maximum load required to tear the (NIH Image; U.S. National Institutes of Health; http://
muscle and, if possible, the maximum fascial tensile force val- rsb.info.nih.gov/nih-image/) and the scales were again cali-
ues were recorded. TrA, IO, and EO attachments were gener- brated to calculate the fascial area affected. The vertebral levels
ally not tested to capacity at the PLF but preserved for testing at and side(s) on which fascial movement occurred were also
the MLF. During the latter and where feasible, they were re- noted, as was any fascial movement across the vertebral pro-
gripped at the same location. cesses. The latter values, for muscles that consistently displaced
132 Spine Volume 29 Number 2 2004

Table 1. Fascial Displacement Table 2. Fascial Areas and Tensile Forces (L and R) at
10N Tension
Fascial Displacement Mean (n 16 sides) at
10N applied tension Tensile Force in Fascia
Muscle Area (cm2) at L3 (N)
Attachment* Furthest (cm) Contralateral (cm)
n Mean Range n Mean Range
TrA 16 3 4 2.5
LD 14 2 42 Posterior layer
EO 10.5 2.5 1 1.5 LD* 8 61 4876 7 4.9 1.214.2
GM 10 3.5 2.5 1.5 TrA 8 59 2288 7 2.2 0.45.0
IO 9 4.5 12 GM 8 31 171 7 0.8 0.11.8
TrA 2 9 1.5 IO 7 25 449 7 1.5 0.24.4
IO 2 6 1.5 EO 8 15 636 7 0.7 0.12.8
EO 2 64 Middle layer
* Abbreviations for muscles as given in Figure 2. TrA2 8 14 821 7 3.9 1.58.1
IO2 7 7 521 5 1.4 0.62.6
EO2 7 7 020 6 0.9 0.13.1
* LD area is likely greater than indicated as its gripped area was restricted.
fascia bilaterally, were pooled and averaged. On two cadavers,
displacement and area measures were repeated three times.
between 0 and 10 N at the level of L4, was 0 to 3 mm,
Statistical Analysis. For each muscle tested on each side, the with mean value (pooled for LD, GM, and TrA) 1.4
resultant fascial tensile forces and movement were analyzed. 0.7 mm.
Where fascial tensile force readings did not demonstrate a se-
quential increased output with applied tension, they were ex- Fascial Areas
cluded from analysis. This occurred in the eighth cadaver, fol- Displacement of fascial markers in the posterior layer
lowing replacement of a strain gauge, limiting the tensile force indicated that traction on the attachments of TrA and
data to results from seven cadavers. These values were con- LD affected the greatest areas of fascia (Table 2). Tension
verted to approximate Newtons of tensile force by multiplying on these two muscles always resulted in fascial move-
each by the constant (2.76) obtained from the average calibra- ment bilaterally between T12 and S1. Traction on the
tion value at 10 N. attachments of IO and GM caused fascial movement be-
Paired samples t tests were used to detect differences be- low L3 (to S1 and S3, respectively), although the bilateral
tween left and right sides for tensile force and area measures effect varied; traction on GM moving the attached fascia
and results from both sides pooled. Paired sample correlations
bilaterally in 14 of 16 sides and traction on IO moving it
were then used to detect any correlation between tensile force
and area measures. The average (pooled) fascial area measures
bilaterally in 8 of 16 slides. Traction on EO affected a
affected by each muscle were compared using a one-way anal- smaller area of fascial markers between L1 and L3 and
ysis of variance. Following a significant result, fascial area was typically unilateral (9 of 16 sides) in its effect.
means affected by tension on each muscle were compared using In the MLF, traction to the attachment of TrA dis-
a Tukeys multiple comparison test at P 0.05.22 This process placed markers across the entire fascial region (from
was similarly applied to fascial tensile force measures. T12L1 to L5S1), while traction to IO moved markers
below L3 and traction to EO moved markers above L3.
Results
In all cases, a smaller area of fascia was affected than in
There were no apparent trends between area or tensile the posterior layer, and all effects were unilateral, mov-
force measures and sex, age, weight, or time since death. ing ipsilateral markers as far as the tips of lumbar trans-
The cadaver with the left lumbar surgical scar had intact verse processes. The fibrous thickenings of the MLF that
spinous processes and equal widths of fasciae on both attach to the transverse processes were particularly
sides. It demonstrated minimal differences between sides prominent during tensile transmission.
on all measures.
Tensile Force Measures
Fascial Widths Applying 10 N tension to the LD attachment resulted in
Mean widths of the MLF and PLF at L3 (from vertebral the highest tensile force in the PLF at L3 (4.9 N), fol-
processes to lateral raphe) were 2.6 cm and 7.1 cm ( 0.5 lowed by TrA (2.2 N), IO, GM, and then EO (Table 2).
cm), respectively. The mean distances from transverse Tensile force values from traction on TrA, IO, and EO
and spinous processes to the musculotendinous junction were generally higher in the middle layer but followed a
of TrA were 7 cm and 11 cm ( 0.9 cm), respectively. similar trend in both MLF and PLF, with TrA transmit-
ting most tension to fascia at L3, followed by IO, and
Fascial Displacement
then EO (3.9, 1.4, and 0.9 N, respectively).
In all cases, fascial markers were displaced toward the
grips. The mean farthest distances at which fascial dis- Statistical Analysis
placements took place (from the grips) are presented in Paired samples t tests indicated no significant difference
Table 1. Errors between repeat displacement measure- between left and right sides for tensile force or area mea-
ments (on two cadavers) were 1.5 cm. The actual sures, so results for the two sides were pooled before
movement of PLF markers across the midline, observed further analysis.
Tension and Muscular Attachments Barker et al 133

Table 3. Tukeys Multiple Comparisons of Fascial Areas Comparison of Fascial Areas and Tensile Forces
and Fascial Tensile Forces Area and tensile force measures are compared in Figure
4. Both measures varied considerably between cadavers
Comparisons between mean areas (cm2)*
LD TrA GM IO EO TrA IO EO (by up to 1.74 N and 24 cm2), but errors between repeat
2 2 2 measurements were comparatively small, up to 0.77 N
61.2 58.5 31.8 25.4 15.1 14.7 8.1 7.7 for tensile forces and 7 cm2 for areas. Although fascial
tensile forces (at L3) showed similar trends to fascial area
measures, they did not correlate significantly. Differences
Comparisons between mean fascial tensile forces (N)* between them were greatest in the MLF, where tensile
LD TrA TrA IO IO 2 EO GM EO
2 2 forces tended to be larger and affected relatively small
4.9 3.9 2.2 1.5 1.4 0.9 0.8 0.7 areas.
Maximum Fascial Tensile Forces
* Means arranged in order from greatest to least, nonsignificant differences There were fewer results for maximum tension values
(P 0.05) linked via lines.22
before failure; however, these indicated that highest ten-
sions could be applied to GM, then LD, TrA, EO, and
then IO (Table 4). By contrast, the tensile forces gener-
One-way analysis of variance indicated differences ex- ated in the fasciae during application of maximum ten-
isted between mean areas affected by different muscles. sion were, in descending order: LD, TrA, IO, GM, and
Tukeys multiple comparison indicated that mean areas EO in the posterior layer and TrA2, IO2, and EO2 in the
for LD and TrA were significantly greater than all other MLF. Tensile force values generated by maximum ten-
means but not significantly different from each other (Ta- sion on TrA, IO, and EO in the posterior layer are not
ble 3). The mean fascial area affected by GM was not true maxima, as their attachments were only tractioned
significantly greater than areas affected by IO or EO in to failure in the middle layer.
the posterior layer, or TrA in the middle layer (TrA2),
Discussion
but it was greater than areas affected by the obliques in
the MLF (IO2 and EO2). Other areas were not statisti- Fascial Widths
cally different. Width measures between the L3 transverse process and
One-way analysis of variance for tensile forces indi- lateral raphe indicate that the MLF is relatively narrow
cated difference(s) existed between the fascial tensile (mean 2.6 cm) but is continuous beyond the lateral raphe
forces produced at L3 by tension on different muscles. for approximately 4.5 cm as the TrA aponeurosis. This
Tukeys multiple comparison indicated mean tensile distance contrasts with earlier descriptions of 9 cm,11,12
force produced by LD at L3 was significantly greater indicating that these studies may have reported the fas-
than mean tensile forces for GM and EO but that there cial width as the distance between transverse processes
were no other significant differences between means and the musculotendinous junction of TrA. Width values
(Table 3). for both MLF and PLF in the current study are relatively

Figure 4. Fascial area and tensile force measures at 10 N. The areas of lumbar fasciae displaced and tensile forces developed in fasciae
with 10 N applied tension to attached muscles. Tensile force indicates the transverse component of tensile force at L3. Abbreviations
for muscles as given in Figure 2.
134 Spine Volume 29 Number 2 2004

Table 4. Maximum Applied Tension and Resultant Maximum Fascial Tensile Forces
Posterior Layer of Lumbar Fascia Middle Layer

LD TrA GM IO EO TrA 2 IO 2 EO 2

n sides/14 10 11 6 3 6 10 3 3
Maximum applied 33.1 (2040) 25.0* (2040) 45.0 (3070) 13.1* (1020) 21.2* (2030) 33.8 (2050) 16.5 (1030) 23.3 (2050)
tensile force
(N) (range)
Maximum fascial 6.4 (0.518.8) 4.6* (0.18.1) 1.0 (0.12.1) 4.2* (0.15.7) 0.8* (0.12.1) 5.2 (0.410.5) 4.4 (0.35.0) 2.8 (0.44.9)
tensile force
(N) (range)
* Value not true maximum.

low because of the use of aged specimens with smaller were consistent with the order of area measures in the
body build but may also be slightly reduced by not ac- current study (EO GM; Table 5). Displacement mea-
counting for fascial curvature. This factor was mini- sures may have been overestimated for EO in this study
mized by taking measures during application of 10 N because of difficulties gripping the muscle attachment in
tension. The conditions had the advantage of more isolation from its costal attachment and aligning grips
closely replicating an isolated, submaximal contraction perpendicular to their tensile force on the PLF. Fascial
of TrA, which is how tension on the fasciae has been area measurements corrected this limitation by exclud-
proposed to influence the neutral zone.23 ing all other tissue (than fascia) and provided relatively
Results indicate that, under these conditions, the MLF different results for EO ( IO and GM). Area results are
provides a more direct route from the lateral raphe for thus considered by the authors to be more accurate and
contraction of TrA to potentially influence vertebral in keeping with those of Vleeming et al.8
movement. This proposal is supported by the limited The actual displacement of PLF markers across the
data from Tesh et al in lumbar intra-abdominal balloon spinous processes was consistent with observations of
studies,7,11 in which tension generated by the MLF (from Tesh11 that up to 3 mm fascial movement occurred away
increased pressure in the balloon) was proposed to pro- from the L4 spinous process when increasing intra-
vide a substantial (14.5 Nm) resistance to lateral flexion abdominal pressure to 60 mm Hg. Although the MLF
torque, even if the PLF was cut. attachments were not similarly mobile across the trans-
Fascial Displacement verse processes, in some cases (for both PLF and MLF),
The greatest fascial displacement was through the at- application of tension slightly moved the entire vertebral
tachments of TrA and LD, followed by EO, GM, and IO. column. This was corrected as much as possible by image
Displacements were found to be equal or greater in mag- alignment.
nitude than those of Vleeming et al8 despite the current Every muscle tested in this study produced fascial dis-
study applying only one fifth of the tension (Table 5). placement. Contralateral effects were observed (collec-
Specimens in both studies were elderly, and although tively) between T12 and S3, up to 4 cm from the midline.
Vleeming et al8 tested a smaller (n 3) sample, the main Vleeming et al8 reported that, in embalmed cadavers,
difference was in the embalmed status of cadavers. The traction to muscles resulted in contralateral fascial move-
substantially lower tension required to displace fascia in ment only below the level of L4, with traction to GM
this study is consistent with reports that embalmed tissue causing the greatest contralateral movement (up to 4 cm
is up to 5 times stiffer than unembalmed.13 from the midline) followed by LD (up to 2 cm). The
The order of displacement results differed from the authors attributed the ease of tensile transmission across
order of area results with regard to EO. Fascial displace- the midline at these lower levels to the fascia having loose
ment from tension on EO was larger than that from or absent attachments to spinous processes and supraspi-
tension on IO and GM, yet the area of fascia affected by nous ligaments below L4.8 This is supported by indepen-
it was smaller. Displacement values of Vleeming et al8 dent studies.2,24
Since embalming increases collagen cross-linkage,25 it
may have resulted in greater fixative effects above L4,
Table 5. Comparative Fascial Displacement
where more dense fibrous tissue exists. This may explain
Fascial Displacement (cm) why bilateral effects were less apparent above this level in
the Vleeming et al8 study. Unembalmed data in the cur-
Muscle Current Study (n 8) Vleeming et al8 (n 3)
Attachment (10N applied tension) (50N applied tension)
rent study more closely reflect the in vivo mobility of the
PLFs midline attachments. Data indicate that, in a lum-
LD 14 2 810 bar extension position, with absence of tone in enclosed
EO 10.5 2.5 04 or attached muscles, these tissues demonstrate some de-
GM 10 3.5 47
gree of mobility across the midline at all lumbar and
Tension and Muscular Attachments Barker et al 135

Figure 5. The lumbar fasciae in cross section. a: At the level of L4. b: At the level of L2. Note IOs attachment to the lateral raphe. Note
EOs attachment to the lateral raphe. Ps psoas; QL quadratus lumborum; Mf multifidus. Abbreviations for muscles as given in Figure
2).

upper sacral levels. If muscles with contralateral effects eral raphe to the PLF,12 or of TrA and IO having more
contracted bilaterally in vivo, one might cumulative fas- limited attachments to the PLF.7 Traction on TrA af-
cial tension to be generated on both sides. fected the PLF to the level of T12 and may explain the
occurrence of inferolateral fibers in the PLF below this
Fascial Areas and Attachments
level,1,10 which have previously been attributed to GM8
Application of just 10 N tension to the attachments of
(the latter being effective on the PLF only to the level of
LD and TrA caused bilateral displacement of approxi-
L3). This study also highlights that diagrams of the lum-
mately 60 cm2 of the PLF throughout the lumbar region
bar fasciae in cross section typically represent them be-
(T12S1). These areas were significantly greater than all
low the level of L3, since EOs attachment is usually not
others (P 0.05). The total fascial area affected by LD is
shown (Figure 1). Figure 5 depicts the lateral raphe and
likely to be even greater (and more extensive into tho-
its attachments above versus below L3. The observation
racic and sacral regions) than indicated, as the gripped
that TrA and IO affected fasciae to the level of S1 indi-
part of its attachment was restricted in the present study.
cates that these muscles may act via fasciae across the
Tension to GM caused bilateral effects in the lower lum-
lumbosacral junction and are consistent with observa-
bar region (L3S3) in 7 of 8 cadavers. These results sup-
tions that aponeurotic fibers from IO may be traced,
port the Vleeming et al8 proposal that LD and GM may
via the PLF, to the spinous process of S1.12
act across the midline, lumbar spine, and sacroiliac joint
Fascial tension in the posterior layer was often trans-
via the PLF.8 Results also indicate that TrA is the only
mitted across and between its attachments to spinous
lateral abdominal muscle capable of influencing all lum-
processes, with markers moving up to 3 mm. By contrast,
bar vertebral segments via both the PLF and MLF. Its
the vertebral attachments of the MLF appear more fixed,
fascicles26 also align well with inferolateral fibers that
transmitting tension directly to the transverse processes.
have been described below T12 in both layers.1,10
This is in keeping with descriptions from other
Both oblique muscles attach to vertebrae via the PLF
studies.7,10
and MLF: IO below L3 and EO above it. The attach-
ments of EO are in agreement with studies on the poste- Tensile Force Measures
rior8 and middle1,10 layers, although are in contrast with Tensile force values (N) should be treated with caution
findings of Bogduk and MacIntosh.2 The attachment of due to differences between the calibrated material and
EO to lumbar fasciae is often not reported in current fascia; rubber having been used for consistency and ease
texts2729 while some older texts differ regarding the at- of gripping. In addition, tensile force measures are lim-
tachments of IO.12,30 In the current study, IO and EO ited to the horizontal component of tension generated in
attached to both fascial layers on all 16 sides and all a small in situ sample of the fascia at L3. In vivo, a
attachments demonstrated tensile transmission. vertical or gain component would also be generated
TrA, IO, and EO acted on similar segmental levels via due to the oblique fibers, so forces may differ to those
both layers of lumbar fasciae, indicating a common at- indicated, but measures are intended primarily to pro-
tachment to the two layers via the lateral raphe. This vide a comparison between muscles. Study parameters
supports typical depictions of the lateral raphe29,30 and were chosen to best enable the detection and comparison
contradicts descriptions of IO attaching behind the lat- of tensile forces from various attachments with minimal
136 Spine Volume 29 Number 2 2004

disruption to the fasciae. When compared at 10 N applied Maximum tensile forces did not increase proportion-
tension, the highest fascial tensile forces resulted from ten- ally with applied tension and were generally smaller than
sion to LD and TrA in the PLF and to TrA in the MLF, with expected from the increased applied load. This may be
smaller tensile forces being generated by tension on the ob- explained by failure of individual muscle fascicles. Al-
liques and GM (Figure 4). Approximately 50% of the ap- though high maximum tensile forces could be applied to
plied force to LD was transmitted to the fascia at L3, and the attachments of GM and EO, these sites were located
this was the only tensile force that differed significantly relatively far from the strain gauge site, with tension not
from other values (GM and EO; Table 3). being transferred to the fascia (Table 5). In addition,
Tensile force measures are largely related to each mus- some adjacent muscle fascicles (with strong bony attach-
cle attachment and the position and orientation of the ments) may have been gripped. Future studies should
strain gauge. For example, LD had the closest attach- take particular care to isolate the fascial attachment
ment (and grip site) to L3, whereas GMs attachment only.
was comparatively distant from it, so the tensile force
Sample Characteristics and Fascial Tension
able to be detected from tension on GM was low. The L3
The lack of apparent association between weight, age, or
level was chosen for its central location in the fascia and
time since death and tensile force or area measures was
a horizontal orientation for the buckle since both MLF
unexpected. Wide interindividual variation has been ob-
and PLF fiber directions are more horizontal than verti-
served for fascial thickness,10 fibrosity,1 muscular at-
cal and all attaching muscles tested had a horizontal
tachments,2 and tensile effect of muscle attachments on
component to their fiber direction.
the PLF.8 The MLF has been observed to vary in thick-
In the MLF, tensile forces from tension on TrA, IO,
ness and fibrosity between sides.10 In previous work,1 it
and EO were relatively high. They most likely reflect the
was proposed that fascial changes may be associated
closer location of the gauge to the lateral raphe (and
with increased weight and force transmission; however,
shorter width of the MLF) and may be partly attributable
that was not supported by this study. Of interest, the
to the more fixed attachments of the MLF to transverse
freshest cadavers demonstrated comparatively low
processes, or to its more transverse fiber orientation.10
fascial tensile forces and tolerated small maximum ap-
Regardless of the mechanism, the MLF is clearly better
plied traction loads before tearing. Unembalmed cadav-
structured to transmit (submaximal) transverse tensile
ers appear, on a biomechanical basis, to be appropriate
forces from TrA at this level.
for testing musculofascial attachments at low loads for
Comparison of Areas and Tensile Forces some weeks after death.
Tensile forces at 10 N tension showed similar trends to
Methodologic Considerations
area results, indicating that the buckle position and ori-
Findings of fascial area and tensile force from the current
entation were appropriate and represent the effect of
study may differ from those expected in a younger pop-
most muscles (with the exception of GM) on the fasciae.
ulation because of changes associated with ageing, in-
However, tensile force and area measures did not corre-
cluding disc space narrowing, reduced lumbar lordosis,
late significantly. This was most likely because of the
muscle atrophy, changes in collagen composition, and
limitations of using a fixed position and orientation of
cross-linking. Duration of storage of the specimens fol-
the gauge and because of differences in widths of the two
lowing death and limitations of force calibration may
layers since these factors affected tensile force measures
have also affected absolute values. However, since mus-
and/or area measures differently. Tensile force measures
cle attachments remain constant with age, storage and
may also have varied at different spinal levels; in some
different positions of the spine, their effects via fasciae at
cases, tension was visibly unevenly distributed through-
segmental levels, as documented in this sample, are still
out fascia above or below the gauge.
representative. A moderate decrease in the failure
Maximum Tensile Forces strength of connective tissue is generally noted with age-
Where possible, attachments were stressed to produce ing,3133 but this would be expected to have minimal
maximum fascial tensile forces. Many muscles tore as effect at the submaximal loads used in the current study.
the final fascial tensile force reading was taken, limiting In addition, any variations in tissue stiffness associated
the number and accuracy of these results. When applying with ageing would be expected to affect all muscle at-
40 N tension to LD and TrA, mean transverse tensile tachments similarly and not to influence their relative
forces of 6.4 N and 4.6 N, respectively, were generated in tensile force values.
the PLF at L3, while applying 50 N tension to TrA gen- Despite variability in the location of grips, the limita-
erated a mean tensile force of 5.2 N in the MLF. The tions of visual mapping of fascial marker movement
range of maximum values was considerable, with LD and variation in area and tensile force results between
and TrA generating up to 19 N and 8 N in the posterior cadavers, all specimens showed similar trends. Further-
layer, respectively, and TrA up to 9.5 N in the middle more, errors between repeat measurements were small.
layer. In all cases, the attaching muscle fascicles tore (just This observation supported measurement techniques
proximal to the grip site) at maximum tension, rather and indicated that repetitive application of force was
than the fascia itself. In no cases did the grips slip. unlikely to have caused tissue damage. Since a submaxi-
Tension and Muscular Attachments Barker et al 137

mal force was applied, no tissue damage was expected;


however, as a precaution, repetitions were used consis-
tently for all muscles tested.
The functional implications of this study are limited to
passive tensile capacity of individual attachments under
specific test conditions, so should be considered together
with reported electromyographic behavior of these mus-
cles acting in concert in vivo. Although muscle bellies
function to shorten and transmit tension to their attach-
ing tendons and aponeuroses, transmission is neither
passive nor uniformly distributed. Factors such as muscle
cross-sectional area, physiologic cross-sectional area
(fascicle length), variations in fascicle direction, timing of
onset, type and rate of contraction, and whether actions
are unilateral or bilateral must also be considered when Figure 6. Estimated maximum MLF hoop stress per segment at-
estimating the forces that muscles may generate. tributable to intra-abdominal pressure (IAP). Adapted from Tesh.11
Despite its limitations, this study is useful in indicating Assuming the abdomen acts as a pressurized thin walled vessel,
then the maximum hoop stress per spinal level attributable to it will
the relative tensile capacity of various attachments on the
be as follows:
lumbar fasciae in unembalmed specimens. It also defines Hoop stress (p r)/t
the segments of the spine likely to be influenced by each Where:
muscle via its fascial attachments. P maximum IAP
200 mm Hg (Morris et al40)
Implications for Sacroiliac Stability 26.6 103 N/m2 (after converting: 0.2 mm Hg (13.6 103)
Despite proposals that the PLF, with its attached (LD kg/m3 Hg 9.8 m/s2)
and GM) muscles may contribute to compression of the r radius of abdominal cavity
0.12 m (Tesh11)
sacroiliac joint,8 this study found the effects of tension on
t thickness of abdominal wall
LD (and TrA) only extended via the PLF to fascial mark- Force area hoop stress
ers at S1, limiting their potential to affect this joint. By (p r l t)/t
contrast, tension on GM was found to displace PLF Where:
markers to as low a level as S3. Both GM and LD, how- l length of MLF over one spinal level 0.015 m (Tesh11)
Fprl
ever, tend to be recruited in a phasic fashion for partic-
26.6 103 N/m2 0.12 m 0.015 m
ular activities34 while the EMG features of TrA may in- 48.0 N/segment
dicate a role in control of neutral zone movement both in total force in MLF
the lumbar spine and at the sacroiliac joint. Increasing
importance is being attributed to TrA in control of move-
tachments to all lumbar vertebral processes. By contrast,
ment at the sacroiliac joints, but via its anterior iliac
EO and IO are only capable of affecting the upper or
attachments.35 These, however, are direct rather than via
lower lumbar segments (via lumbar fasciae), respec-
the lumbar fasciae.
tively. TrA also generated greater tensile forces in fasciae
Implications for Lumbar Segmental Stability than the obliques. In addition, the results suggest that
The magnitudes of forces (10 N) used in the current fasciae may be particularly well structured to tolerate
study are approximately 20% of those estimated by small tensile loads, since fascial tensile forces increased
mathematical analysis to be generated in the MLF at with applied tension on most muscles up to 10 N, but not
each segment (48 N) during maximal intra-abdominal proportionally above this.
pressure (Figure 6). They are similar to those potentially The lumbar fasciae form a likely mechanism for TrA
generated in the MLF and PLF by tonic contraction of to influence the segmental neutral zone, and it appears
TrA that occurs in healthy subjects before trunk petur- the MLF, with its short width and firm attachments to
bations6,14,15,23,36,37 and are proposed to influence the transverse processes, may provide the most efficient
segmental neutral zone.6,14,15,36 Limitation of neutral route. Motion segment studies performed during appli-
zone movement is recognized to be important in injury cation of tension indicate that the PLF has the capacity to
prevention,17,38 with biomechanical models predicting influence early range intersegmental movement in the
that very small amounts (3%) of maximum muscle con- sagittal plane.11 The MLF might be predicted to have a
traction may be sufficient to restore segmental stability.38 similar effect on segmental neutral zone movement, with
This study was designed to simulate the effects of iso- a particular advantage in the transverse plane. Overall,
lated muscle tension. When TrA contracts before limb the results of this study also provide anatomic and bio-
movements,6,14,15,36 it may act briefly on the vertebrae in mechanical support for the basis of exercises incorporat-
relative isolation (along with the deep fascicles of multi- ing submaximal contraction of TrA.37,39 Such exercises
fidus).36 Even the small amounts of tension applied in are frequently recommended for management and pre-
this study through TrA were transmitted via fascial at- vention of low back pain.
138 Spine Volume 29 Number 2 2004

Conclusion 14. Cresswell AG, Grundstrom H, Thorstensson A. Observations on intra-


abdominal pressure and patterns of abdominal intra-muscular activity in
Low levels of tension are effectively transmitted between man. Acta Physiol Scand. 1992;144:409 418.
15. Hodges PW, Richardson CA. Delayed postural contraction of transversus
transversus abdominis and the middle or posterior layers abdominis in low back pain associated with movement of the lower limb.
of lumbar fascia. Via them, transversus abdominis may J Spinal Disord. 1998;11:46 56.
influence intersegmental movement. 16. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar
spine associated with low back pain: a motor control evaluation of transver-
sus abdominis. Spine. 1996;21:2640 2650.
17. Panjabi MM. The stabilizing system of the spine: II. Neutral zone and insta-
Key Points bility hypothesis. J Spinal Disord. 1992;5:390 396.
18. Barker PJ, Briggs CA. The lumbar fasciae and spinal stability. In: Boyling JD,
Lumbar fasciae in unembalmed cadavers was Jull GJ, eds. Grieves Modern Manual Therapy of the Vertebral Column, 3rd
dissected. ed. Edinburgh: Harcourt Health Sciences, 2003, in press.
Low level tension on attached muscles produces 19. Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing
exercises for first-episode low back pain. Spine. 2001;26:E243E248.
fascial tensile force and movement. 20. OSullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing
Results indicate how muscles and fasciae may exercise in the treatment of chronic low back pain with radiologic diagnosis
affect the lumbar spine. of spondylolysis or spondylolisthesis. Spine. 1997;22:2959 2967.
21. Behrsin JF. The Morphology of the Lumbar Spinal Ligaments and Their
Transversus abdominis can influence all lumbar Stress Response During Physiological Movements, Masters Thesis. Mel-
segments via the lumbar fasciae. bourne: University of Melbourne, Anatomy & Cell Biology, 1988:9398.
22. Zar JH. Biostatistical Analysis, 4th ed. Upper Saddle River, NJ: Prentice
Acknowledgments Hall, 1999.
23. Hodges PW, Cresswell A, Thorstensson A. Preparatory trunk motion accom-
The authors thank John Behrsin (Wickham Road Phys- panies rapid upper limb movement. Exp Brain Res. 1999;124:69 79.
iotherapy) for loan of equipment, Colin Anderson, Ian 24. Rissanen PM. The surgical anatomy and pathology of the supraspinous and
Story, and Roger Hughes for academic advice, Stuart interspinous ligaments of the lumbar spine with special reference to ligament
ruptures. Acta Orthop Scand Suppl. 1960;46:199.
Thyer for photography, Matt Jackson, Trevor Allen, 25. Chapman JA, Tzaphlidou M, Meek KM, et al. The collagen fibril: a model
Ivica Grkovic, and Scott Robbins (University of Mel- system for studying the staining and fixation of a protein. Electron Microsc
bourne) for technical assistance, and Donna Urquhart, Rev. 1990;3:143182.
26. Urquhart DM, Barker PJ, Hodges PW, et al. Regional morphology of tran-
Marius Fahrer, and Rita Bruns (University of Mel- versus abdominis, obliquus internus and obliquus externus abdominis.
bourne) and Michael Adams (University of Bristol) for 2003: In press.
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