Biomechanics of the Lumbar Spine

Malcolm H. Pope

The magnitude of low back pain i n terms of its occurrence and cost is reviewed. The
biomechanics of the lumbar spine are related to the functional anatomy. The disparate
functional mechanical requirements of the spine, support, mobility, housing, protec-
tion and control are reviewed. Typical forces one applies to the spine in activities of
daily living as well as i n mechanical overloads are discussed. The loads are broken down
into tensile, compressive, shear and torsional loads. The posterior elements, the ver-
tebral body and the intervertebral disc are reviewed separately and some implication
in terms of the aetiology of low back pain is given. Finally, the behavior of the unit (the
functional spinal unit) is discussed.
Ann Med Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/01/14

Key words: low back pain; biomechanics.

(Annals of Medicine 21: 347-351, 1989)

Introduction upper and lower extremities and the head. The mobili-
ty allows for the many physical tasks of daily living and
LOWback pain (LBp) is at epidemic proportions. It is work, but complicates spine structure. Thus, instead
a great burden both to industry and the medical corn- of a single rigid column, the Spine is a flexible stack
munity. In fact, some have called LBP the nemesis of
medicine and the albatross of industry.
It has been estimated that in the USA there are more
For personal use only.

than 2.5 million workers with LBP, of which 1.2 million

are disabled. LBP represents the diagnosis in 10 OO/ of
all chronic health conditions according to Kelsey and
White (1). They also estimate that approximately 2 OO/
of the workers in the United States have a compens-
able back injury each year, while Snook (2) found annual
rates to range from 1 O/O to 15 %.
The current annual cost of LBP in the USA is cur-
rently estimated to exceed 20 billion dollars per year.
However, only 25 YOof the cases account for 90 OO/ of
the c'ost. As the duration of disability increases, the
total cost accelerates. The trend is alarming. LBP
awards by the Social Security Administration have risen
by 2700 OO/ over the last 20 years (2).

Basic Anatomy and Function of the Spine

The spine has four major interrelated functions: 1) sup-
port, 2) mobility, 3) housing and protection, and 4) con-
trol. As a support structure, the spine functions as a
framework for the attachment of internal organs, the

From the University of Vermont College of Medicine,

Burlington, VT 05405, U.S.A.
Address: Malcolm H.Pope, M.D., Universityof Vermont Col-
lege of Medicine, Burlington, VT 05405, U.S.A.
Received: April 11, 1989.
Figure 1. Range of motion of the spine.

Ann M e d 21
 348
of rigid vertebrae with flexible discs in between. The
largest motions of the lumbar spine are in forward
bending (flexion) and backward bending (extension).
The other motions of importance are axial rotation and
lateral bending (Fig. 1). More complex motions involve
combinations of forward flexion, bending to the side
and twisting.
The housing function of the spine is one of protec-
tion of the spinal cord and nerves as they pass from
the head to their exit from the spinal canal to other
parts of the body. The spinal canal transverses verti-
cally from the skull to the coccyx and functions as a
conduit to protect the spinal cord and its nerve roots
(Fig. 2). Since the spinal cord terminates at the first or
second lumbar vertebra, this housing also protects
nerve roots caudal to the terminal part of the cord.
The motion of each segment is controlled actively
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by muscles and passively by ligaments. These soft tis-
sue control elements attach directly to vertebral bodies
and laminae and t o bony processes and the pelvis.
These elements support the spine similar t o the way
cables support a radio tower.
A downward force perpendicular to the surface of
the upper vertebra compresses the disc and causes it
to bulge. As the compressive load increases, pressure
within the disc also increases. If the compressive force
is increased, failure eventually occurs. In the labora-
tory, application of compressive load results in failure
of the vertebral endplate, usually towards its center.
For personal use only.
This injury mechanism is common when a person falls,
landing in the seated posture, producing the so-called
compression fracture.
The second type of loading is termed tension. Ten-
sions tend to pull apart the structure being loaded and
decrease the cross-sectional area of the structure. De-
pending on the material which makes up the structure,
tension loading may produce an elastic recoil. In the
spine, the ligaments are loaded in tension. In spinal ex-
LAMINA f ROOF A sive and shear forces in the facets while the latter
SPINOUS PROCESS
WAl.LS
BODY I FOUNDATION
TRANSVERSE PROCESSES
Figure 2. Construction of the vertebrae.
Ann Med21
Pope
tension, the anterior ligaments are loaded in tension
while in flexion, the posterior ligaments are stretched.
Overstretching any ligament may cause rupture either
of individual ligament fibers or of the entire ligament.
Collectively, these failures are termed sprains. When
there is a major spinal trauma, such as might occur in
a severe fall or vehicular injury, ligaments do rupture
completely and may be accompanied by frank disloca-
tion of the vertebra.
Twisting motions of the spine produce strains in the
tissues. In the normal lumbar spine, the facets tend to
restrict torsion. In the laboratory, application of the tor-
sional stresses produce fragmentation and disruption
of the disc. This may be one of the earliest causes of
acute low back episodes.
Shear loading is produced by translation motion of
structures. For example, as the spine flexes, there is
a tendency for a vertebra to slide forward relative to
its next lowest neighbor. Shear stresses occur in the
lumbar spine because of the lordoctic curvature of this
region.
The Vertebral Bodies
The vertebral bodies are the key element in the load-
bearing system of the spine. The core of the vertebral
body is made primarily of cancellous bone which has
a honeycomb-like constructure. Since bone grows in
directions to withstand the forces normally applied, the
directions of trabeculae tell us what are the normal
forces being seen by the vertebra.
The vertically directed trabeculae support the com-
pressive loads in the vertebral body. At the upper and
lower surfaces of the body there are oblique trabecu-
lae sweeping up or down to aid in this compressive load
bearing function. These trabeculae come together at
the pedicles to resist the tensile forces there. The
trabeculae sweep up and down to the superior and in-
ferior facets, and outwards to the spinous process. The
former trabeculae are oriented to support the compres-
trabeculae are oriented to withstand the tensile and
bending forces applied to the spinous process.
The pressure is higher in the center of the end plate
during compressive loading, a common site for failure.
The failure results from the nucleus of the disc ruptur-
ing the endplate. This may be a significant problem for
those who have diminished bone strength such as
occurs in osteoporosis. In osteoporosis there is a
reduction of bone volume, and an increased risk of frac-
ture with smaller external loads. Since the vertebrae
are filled with blood, it is possible they behave like
hydraulically strengthened shock absorbers under sud-
denly applied loads.
The Posterior Elements and the Facet Joints
Posteriorly, the vertebral arch attaches to the vertebral
body. The vertebral arch is made of the pedicles,
lamina, facet joints and spinous processes. At the site
where the lamina takes origin from the pedicles, the
lamina is narrowed, an area referred to as the pars in-
 Spine biomechanics
terarticularis or isthmus. Whereas pedicles rarely frac-
ture, the pars is a frequent site of a fracture, apparent-
ly secondary to fatigue of bone rather than a sudden
or acute fracture. The facet joints are extensions of the
lamina and are covered with hyaline cartilage on their
articulating surfaces. These articulations between one
vertebral articula process and its neighbour are termed
the facet joints. The facets are particularly important
in resisting torsion and shear, but also play a role in
compression.
Normally, the facets and discs contribute about
80 O h of the torsional load resistance, with the facets
contributing one-half of that amount. Approximately
25 OO/ of the axial compressive load is transmitted
through the facets. This load bearing is markedly
reduced by excision of a single facet. This implies
some kind of wedging mechanism in which both facet
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joints are responsible for force transmission. The load
in the vertebrae is altered when the facets are
maloriented.
The amount of load bearing by the facet joints is
related to whether the motion segment is loaded in flex-
ion or extension. Thus, the difference in intradiscal
pressures between erect sitting and erect standing can
be explained by load bearing of the facet joints while
in extension or lordosis. Theoretically then, the disc
would be protected from both torsional and compres-
sive loads when the motion segment is in extension
(or lordosis). However, excessive loading of the spine
For personal use only.
in extension may cause failure of this secondary load-
bearing mechanism; that is, loads transmitted through
the facet joints may produce high strains in the pars
interarticularis leading to spondylolysis.
The tip and edges of the spinous process are joined
by the interspinous and supraspinous ligaments. Be-
cause they are far from the disc and therefore act on
long moment arms, these ligaments have an important
functional role in resisting spine flexion. Similarly, in-
tertransverse ligaments join the transverse processes
of the vertebra.
The capsular structures around the apophyseal or
facet joints are of functional importance in LBP. These
capsules include separate thickenings which are at the
front and back and have different functional roles.
These capsular ligaments limit the excursion of the
facetjoints. They are richly supplied with pain-sensitive
nerve endings but the facet joints themselves have no
nerves. Therefore, pain from degenerated joints would
have to be initiated by a mechanical strain or chemi-
cal irritation of these capsular structures.
The lntervertebral Disc
The disc forms the primary articulation between the ver-
tebral bodies. It apparently has a major role in weight
bearing since the area increases as a direct function
of body mass over the whole mammalian family (3). The
function of loadbearing in shear, compression, and tor-
sion is shared between the discs and the facet joints
which collectively form the so-called three joint com-
plex.
The disc, which is avascular, is composed of two
morphologically separate parts. The outer part, the an-
3
349
nulus fibrosus, is made up of about 90 sheets laminat-
ed over each other. Each sheet is made of collagen
fibres that are oriented vertically at the peripheral lay-
er but become progressively more oblique with each
underlying sheet. The fibres in adjacent sheets run at
angles of about thirty degrees to each other. Fibres at
different lamellae often cross the lamella to fuse with
the adjacent one. The lamination of the annular layers
strengthens the annulus much like the plies strengthen
an automobile tire. The central apart of the disc, the
nucleus pulposus, is nearly 90 '10 water, with the re-
maining structure being comprised of collagen and pro-
teoglycans. In the young healthy disc, a positive pres-
sure is present within the nucleus pulposus at rest and
increases as the loads are applied to the spine. This
pressure approximates to 1.5 times the mean applied
pressure over the entire area of the endplate.(4). Disc
pressures have been extensively studied in various
postures and seating configurations.
lntradiscal pressures are significantly greater in the
flexed posture in both cervical and lumbar discs. This
has a tension increasing effect on the disc collagen
fibers analogous to increasing the tension in a taut wire
by pushing on it from the side (4-9).
In axial compression, the increased intradiscal pres-
sure is counteracted by annular fiber tension and disc
bulge, rather analogous to inflating a tire. Some disc
space narrowing also occurs. In flexion, extension and
lateral bending, the same process occurs, although
usually focusing on a specific segment of the circurn-
ference of the disc.
In axial rotation (i.e., torsion of the disc), the annu-
lar fibers in one direction are stretched significantly
whereas those on the opposite side are shortened or
crimped. Mathematical models based on the geometry
of the lumbar disc demonstrate that torsion produces
stress concentration at the region of the posterior later-
al annulus which is a common site of disc herniation
(10-12). Torsional loading of spinal segments in vitro
produces fissures in the annulus in the same
posterolateral location. This fissuring may be accom-
panied by tracking of the nuclear material. These
events are thought to be one of the common early
causes of acute low back pain. Acute ruptures of discs
can be produced in the laboratory by combining flex-
ion and lateral bending motions. In flexion, the disc
may be more susceptible to compression, torsion, and
shear loads because the facet joints are relatively dis-
sengaged and therefore carry a lesser load.
Farfan (13) believes that compression failures pro-
mote disc degeneration. The adult disc is avascular,
and endplate microfractures can result in vascular in-
growth and concommitant formation of granulation tis-
sue. As a result, the chemistry of the disc and the
mechanical behavior of the constituents may be al-
tered.
Motion Segment Behavior
Extensive studies have been performed assessing the
mechanical characteristics of the spinal motion seg-
ments. Reviews of this work (14-1 7) show that the mo-
tion segment is viscoelastic, absorbs energy, moves
Ann Med 21
 350 Pope

with six degrees of freedom (three translations and
three rotations), exhibits coupled motion (motion in one
direction affects motion in others), has limited fatigue
tolerance and depends upon its boney and ligamentous
components for mechanical tasks.
Early work concentrated on the effects of single
loads or torques applied to the motion segment. Re-
cently, researchers have been studying the three
dimensional effects of loads and torques applied in
three dimensions (9, 18-21).
Motion segments have been shown by ourselves (22)
and by others to exhibit coupled behavior (Fig. 3). A
point has been reported (22) where coupled flexion-
extension and lateral bending rotations are minimized.
This is termed the balance point and it is a reliable and
repeatable indicator of the characteristics of the speci-
men. It exhibited significant changes in location only
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vertebral motion segment to a known load history in-
cluding a simulated one-hour static seated load ex-
posure, and a one-hour seated load exposure to the
conservative vibration accelerations of the International
Standards Organization (ISO; 1978) 8-hour “fatigue,
decreased proficiency” limit at the five hertz frequen-
cy. There was significant softening in the segment’s
coupled compliance characteristics as a result of static
or cyclic loading simulations.
Experimental observations revealed that under cer-
tain conditions the motion segment exhibited a sud-
den, large (to physiologic limits), combined (flexion and
lateral bend) rotation response to axial loading. This
rapid reorientation may be a mechanism for a rapidly
occurring postero-lateral disc herniation.

in response to sustained static, cyclic or brief overload

combined f lexion-bendinglcompressive loading condi- Acknowledgement
tions. The specimen also exhibited frank coupled ro-
tations when it was loaded at points away from the bal- The NIDRR through the Vermont Rehabilitation En-
ance point. In these studies we have demonstrated a gineering Center is acknowledged for its continuing
mechanical cause and effect response of the isolated support.

Segment response to load

For personal use only.

Main and coupled effects

* 0.2
rn Lateral translation
Q)

g 0.1 - Axial rotation Flexion-extension

Q) / rotation \
U
v

c o
.-+
0
Q
-0.1
2 \ Anterior-Dosterior Y
L transtation
0
h -0.2
E
E
W
Vertical translation
-0.3
.-c
0
Q
-0.4
c
F!
-0.5
0 0.2 0.4 0.6 0.8 1.o
Vertical force (N) at balance point (thousands)
Figure 3. Typical translation and rotation responses of a motion segment (L2-3) to a com-
pressive load applied at the original balance point. Where the slopes (m) in mmlN or deglN and
correlation coefficients (r) of the linear regressions (of the data less than 1 mm or 1”) through
each of the response curves are as follows:
Lateral translation: (m = -.00018, r = -.91);
Vertical translation: (m = .00048, r = .99);
Anterior-posteriortranslation: (m = .00009, r = 34);
Flexion-extension rotation: (m = 0.0, r = -.12);
Axial rotation: (m = --.00002, r = -.74);
Lateral bend rotation: (m = -.00001, r = -.17).
Note also the negligible rotations resulting from vertical load applied at the balance point.

Ann Med 21
 Spine biomechanics
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Ann Med 27