A System of Orthopaedic Medicine

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A System of Orthopaedic Medicine

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A System of Orthopaedic Medicine

We dedicate this book to our long-suffering wives and children and thank them for their patience, understanding and support.

For Chllrchill Livingstone: Editorial Director, Health Professions: Mary Law Project Development Manager: Dinah Thorn Project Manager: Derek Robertson Designer: Judith Wright

A System of Orthopaedic Medicine o

with accompanying CD-ROM

Ludwig Ombregt MD (Editor-in-


Medical Practitioner in Orthopaedic Medicine, Kanegclll, Belgium; inlernation.:li Lecturer in O r th opaedic Medicine

Pierre Bisschop Ph siotherapisl specializing in Orthopaedic Medicine, Kncsselare, Belgium; International Lecturer in Orthopaedic Medicine

Herman J. ter Veer Physiotherapist specializing in Orthopaedic 1edicine and Manual Therapist, Deventcr, The Netherlands; International Lecturer in Orthopaedic Medicine

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SECOND EDITION ClIURClIILL LIVINGSTONE An imprint of EI.;evier Science Limited

© 1995 WB Saunders Company Limited © 2003, EI�vicr Science Limited. A II right!' re-,erVl.>d. The right!. of Ludwig Ombregl, Pierre Bis�hop ilnd Herman J. ler Veer to be identified as author., of thi., work hao:; been asserted by them in accordance with the Copyright, OCf.,igns and Patents Act 1988. No part of Ih13 publication may be reproduced, stored in a retrieval �ystem, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or olhen""i�, without either the prior permission of the publi..hers (Permission" Manager, Ebevier Science Limited, Independence Square West, Suite 300, The Curti.. Center, Philadelphia, PA 19106M3399, USA) or a licence per­ mitting restricted oopying in the United Kingdom i..sued by the Copyright Liccn"ing Agency, 90 Tottcnham Court Road, London W IT 4LP. First edition 1995 Second edition 2003 ISBN 0443 073708 British Library Cataloguing in Publication Data

A catalogue record for thi" book is ;lvailable from the Briti')h Library Library of Congress Cataloging in Publication Data

A catalog n,-'cord for this book b available from the Library of Congn:-'S� Note Medical knowledge i'i constantly changing. A" new informal1on become:, available, changes in treatment, proccciurt'S, equipment and the


of drug.,

become nccC'SScuy. The authors and the publisher::, have taken care to en..ure thai the infonnalion given in thi::, le>.t is accurate and up to date. However, readers are ..trongly advied to confinn that the information, e'ipecial1y with regard to drug u:,age, complies with the latest legislation and standards of practice.


_. policy kS to use piper manutlCtured from 1U1l1inlble lorHl'



China by RDc.. Lroup Umitl'?!:;,i� . "

Figure 50.12


Facet joints at L4-L5 and L5-S 1 .

ments could get pinched between the articular surfaces, which is then a probable source of backache.81-83 The facet joints are innervated from fibres of the medial branch of the dorsal root. The same nerve sup­ plies the inferior aspect of the capsule and the superior aspect of the joint below.84


The broad and thick anterior longitudinal ligament (Fig. 50.13) originates from the anterior and basilar aspect of the occiput and ends at the upper and anterior part of the sacrum. It consists of fibres of different lengths: some extend over four to five vertebral bodies; the short fibres

attach firmly to the fibres of the outermost annular layers and the periosteum of two adjacent vertebrae. The posterior longitudinal ligament (Fig. 50.14) is smaller and thinner than its anterior counterpart: 1.4 cm wide (versus 2 cm in the anterior ligament) and 1.3 mm thick (versus 2 mm). This is another fact in favour of the theory that the lumbar spine was originally designed to be a hor­ izontal hanging structure: to withstand extension strains, the back had to be stronger anteriorly than posteriorly.5 The posterior longitudinal ligament is narrow at the level of the vertebral bodies, and gives lateral expansions to the annulus fibrosus at the level of the discus, which bestow on it a denticulated appearance.85 Although the posterior ligament is rather narrow, it is important in preventing disc protrusion.86 Its resistance is the main factor in restricting posterior prolapse and accounts for the regular occurrence of spontaneous reduction in lumbago. This characteristic is also exploited in manipulative reduction, when a small central disc displacement is moved anteriorly when the ligament is tightened. That the ligament occupies only the midline of the vertebral column is one of the predetermining factors in the progression of sciatica: as a central protrusion enlarges, it tends to move in the direction of least resist­ ance - lateral to the ligament. Once free from ligamentous


---;tlrr\\--- 3

Figure 50.15

Figure 50.14

Posterior longitudinal ligament.

resistance, it further enJarges and starts to compress the nerve root. This anatomical evolution is mirrored in the change of the clinical picture: a central backache is replaced by a unilateral sciatica. The Ligamentum flavum (Fig. SO.IS) connects two con­ secutive laminae and has a very elastic structure with an elastin content of more than 80%.72 The lateral extensions form the anterior capsule of the facet joints and run further laterally to connect the posterior and inferior borders of the pedicle above with the posterior and supe­ rior borders of the pedicle below. These lateral fibres form a portion of the foraminaI ring and the lateral recess.87,88 The interspinous ligament (see Fig. SO.13) lies deeply between two consecutive spinal processes. Unlike the longitudinal ligaments it is not a continuous fibrous band but consists of loose tissue,89 with the fibres running obliquely from posterosuperior to anteroinfe­ rior.9o This particular direction may give the ligament a function over a larger range of intervertebral motion than if the fibres were vertical.91 The ligament is also bifid, which allows the fibres to buckle laterally to both sides when the spinous processes approach each other during extension.89 The supraspinous ligament is broad, thick and cord-like. It joins the tips of two adjacent spinous processes, and


(1) and ligamentum flavum


merges with the insertions of the lumbo-dorsal muscles. Some authors consider the supraspinous ligament not truly as a ligament, as it seems to consist largely of tendi­ nous fibres, derived from the back muscles.92 The effect of the supraspinous ligaments on the stability of the lumbar spine should not be underestimated.93 Because the ligament is positioned further away from the axis of rotation and due to its attachments with the thoracolum­ bar fascia,94 it will have more effect in resisting flexion than all the other dorsal ligaments. Pearcy95 showed that the distance between the tips of the spinous processes increases during full flexion by 360% at L3-L4 and 129% at LS-Sl. By contrast, the posterior longitudinal ligament only increases by SS% at L3-L4 and 34% at LS-Sl. This demonstrates the limiting effect of the ligament on the increasing posterior disc height during stooping. 'The importance of a strong supraspinous ligament in the prophylaxis of recurrent disc protrusions will be discussed later. The intertransverse ligaments are thin membraneous structures joining two adjacent transverse processes. They are intimately connected to the deep musculature of the back. The iliolumbar ligaments (Fig. SO.16) are thought to be related to the upright posture.96 They do not exist at birth but develop gradually from the epimysium of the quad­ ratus lumborum muscle in the first decade of life to attain full differentiation only in the second decade.97 The liga­ ment consists of an anterior and a posterior part.98 The anterior band of the iliolumbar ligament is a well-devel­ oped and broad band. Its fibres originate from the ante­ rior-inferior part of the LS transverse process from as far medially as the body of the LS vertebra to the tip of the transverse process and expands as a wide fan before


2 3



( a)

Figure 50.16

Iliolumbar ligaments: 1, anterior band; 2, posterior band.

inserting on the anterior part of the iliac tuberosity. The posterior band of the iliolumbar ligament originates from the apex of the L5 transverse process and is thinner than the anterior. It inserts on the iliac crest, behind the origin of the quadratus lumborum.99 The iliolumbar ligaments play an important role in the stability of the lumbosacral junction by restricting both side flexion and rotational movement at the L5-S1 joint and forward sliding of L5 on the sacrum.96,lOO,lOl The clin­ ical importance of this is that posterolateral disc protru­ sions at the level L5-S1 will not be followed by large lateral flexions of L5 on the sacrum. Marked adaptive deformity will therefore be absent here. Consequently, a large lateral tilt in a patient with acute backache means a displacement at L3-L4 or L4-L5, since these interverte­ bral joints can open up more easily.


The spine is unstable without the support of the muscles that power the trunk and position the spinal segments.102 Back muscles can be divided in four functional groups: flexors, extensors, lateral flexors and rotators (Fig. 50.17). The extensors are arranged in three layers: the most superficial is the strong erector spinae or sacrospinalis

(b) Figure 50.17 (a) Muscles of lumbar spine: 1, transversus abdominis, 2, internal oblique; 3, external oblique; 4, latissimus dorsi; 5, lumbar fascia; 6, erector spinae; 7, psoas; 8, quadratus lumborum. (b) Posterior layer of the thoracolumbar fascia: 1, thoracolumbar fascia; 2, fascia latissimus dorsi; 3, fascia of external oblique; 4, posterior superior iliac spine; 5, lateral raphe.

muscle. Its origin is in the erector spinae aponeurosis, a broad sheet of tendinous fibres attached to the iliac crest, the median and lateral sacral crests and the spinous processes of the sacrum and lumbar spine.103 The middle layer is the multifidus, which originates from the poste­ rior aspect of the sacrum and from the medial part of the iliac spine on the posterior superior aspect. It inserts into the lamina and the spinous processes. The third layer is made up of small muscles arranged from level to level, which have not only an extension function but are also rotators and lateral flexors. The extensor muscles are enveloped by the thoraco­ lumbar fascia (Fig. 50.17b) which in turn consists of three layers. The anterior layer is quite thin and covers the


anterior surface o f the quadratus lumborum. Medially, it is attached to the anterior surfaces of the lumbar transverse processes, and in the inter transverse space it merges with the intertransverse ligaments. The middle layer lies behind the quadratus lumborum muscle. Medially, it also continues into the intertransverse liga­ ment to attach to the lateral border of the lamina. The posterior layer covers the back muscles. It arises from the lumbar spinous processes and from the supraspinous ligaments to envelop the back muscles and blend with the other layers of the thoracolumbar fascia along the lateral border of the iliocostalis lumbo­ rum. The union of the fasciae is quite dense and forms a strong raphe (the lateral raphe104) which fuses with the fibres of transversus abdominis, internal oblique and latissimus dorsi muscles. The lateral raphe further inserts at the posterior segment of the iliac crest and the posterior superior iliac spine.IOS The flexors of the lumbar spine consist of an intrinsic (psoas and iliacus) and an extrinsic group (abdominal wall muscles). LateraL flexors and rotators are the internal and external oblique, the intertransverse and quadratus lumborum muscles. It should be remembered that pure lateral flexion is brought about only by the quadratus lumborum.


The spinal canal is made up of the canals of individual vertebrae so that bony segments alternate with interver­ tebral and articular segments. The shape of the transver­ sal section changes from round at Ll to triangular at L3 and slightly trefoil at L5 (see Fig. 50.2).106 The margins of the canal are an anterior wall and a posterior wall, connected through pedicles and inter­ vertebral foramina. The anterior waLL consists of the alternating posterior aspects of the vertebral bodies and the annulus of the intervertebral discs. In the midline these structures are covered by the posterior longitudinal ligament, which widens over each intervertebral disc. The posterior wall is formed by the uppermost portions of the laminae and the ligamenta flava. Because the superoinferior dimensions of the laminae tend to decrease at the L4 and L5 levels, the ligamenta flava consequently occupy a greater percentage of the poste­ rior wall at these levels.87 The poterolateral borders of the posterior wall are formed by the anterior capsule of the facet joint and the superior articular process, which is located well anterior of the articulating inferior articular process. The spinal canal contains the dural tube, the spinal nerves and the epidural tissue.


The dura mater is a thick membraneous sac, attached cra­ nially around the greater foramen of the occiput, where its fibres blend with the inner periosteum of the skull, and anchored distally to the dorsal surface of the distal sacrum by the filum terminale. The latter descends to the coccyx where its fibres merge with the connective tissue of the sacroiliac ligaments.107 The dural sac itself ends blind, usually at 52. There is an inconstant dural attach­ ment, the 'Hofmann complex',108 made of connective tissue bands and loosely joining the anterior dura to the vertebral column (Fig. 50.18). Ventral meningovertebral ligaments pass from the ventral surface of the dura to the posterior longitudinal ligament. They are variable in structure and may present either as tight bands, bifurca­ tions in Y shape or paramedian bands.109-111 Others reported on more lateral ligaments, passing from the lateral surface of the dural sac and blending with the periosteum of the pedicles.112-115 At the lumbar level, the dura contains the distal end of the spinal cord (conus medullaris, ending at Ll), the cauda equina and the spinal nerves, all floating and buffered in the cerebrospinal fluid. The lumbar roots have an intra- and extrathecal course. Emerging in pairs from the spinal cord, they pass freely through the sub­ arachnoid space before leaving the dura mater. In their

2 •

4 .,,'(I. ,



", "

Figure 50.18 1, The dura mater; 2, nerve root in the nerve root sleeve; 3, meningovertebralligaments; 4, posterior longitudinal ligament.


extrathecal course and down to the intervertebral foramen, they remain covered by a dural investment. At the L1 and L2 levels, the nerves exit from the dural sac almost at a right angle and pass across the lower border of the vertebra to reach the intervertebral foramen above the disc. From L2 downward, the nerves leave the dura slightly more proximally than the foramen through which they will pass, thus having a more and more oblique direction and an increasing length within the spinal canal. The practical implications of this oblique course of the roots are discussed later. The dura mater has two characteristics that are of cardinal clinical importance: mobility and sensitivity. DURAL MOBILITY

During spinal movements, the canal is subject to varia­ tions in length and shape. It is obvious that all varia­ tions in dimensions of the vertebral canal will influence its contents. The vertebral canal lengthens considerably during flexion: O'Connell1l6 showed by radiological measure­ ments that in full flexion the length of the cervical canal increases by 3 cm, compared with its neutral position. The dura mater, a structure situated in the vertebral canal but anchored at the top and at the bottom will conse­ quently move in the spinal canal. Breigll7 suggests that the dura mater unfolds and stretches. Other authors have found a gliding of the dural sac in relation to the spinal


canal during flexion and extension.118-121 Using gas myel­ ography, Decker122 showed that the dura moved towards the front of the canal during flexion: like a rubber band, it shifts towards a position of less tension, and is pulled against the anterior wall. Klein12 3 demonstrated an upwards displacement of the dura by more than 5 mm at L3 level during full flexion of the spine. Straight leg raising can put considerable traction on the dural sac. During this manoeuvre the L4, L5, Sl and S2 nerve roots are dragged downwards and forwards (Fig. 50.19). At the level of the intervertebral foramen, the degree of downwards movement is about 0.5 cm.124 In that the root is connected through its dural investment with the distal part of the dura, the latter will also be involved in the downwards movement. Therefore, straight leg raising drags on the dura mater and pulls it caudally, laterally and forwards. 123,125 During neck flexion and straight leg raising, the dura thus moves slightly in relation to the anterior wall of the spinal canal, despite some loose attachments between the posterior longitudinal ligament and the dural sac. Anatomical changes at the anterior walls, for instance a disc protrusion bulging dorsally into the canal, com­ presses the dura. Conversely it can be pulled against this protrusion, whether from below during straight leg raising or from above during neck flexion. The observa­ tion that the dura is mobile thus has considerable clini­ cal significance, in that increase of lumbar pain during neck flexion or during straight leg raising implicates the


Figure 50.19


Movement of nerve root and dura mater during straight leg raising.


dura mater a s the source. I n fact, these signs have been accepted for decades to be positive in meningeal irrita­ tion (Kernig's sign and neck retraction) but this mecha­ nism of dural pain was not elucidated until Cyriax's paper was published in 1945 . 126 In the differential diag­ nosis of lumbar pain syndromes 'dural signs' are extremely important in distinguishing a lesion in which the anterior part of the dura mater is involved (disc dis­ placements) from possible lesions at the posterior wall (facet joints and ligaments). DURAL SENSITIVITY

Clinical experiments have shown that the anterior part of the dura is sensitive both to mechanical and to chemical stimulation. 1 27,128 Back pain is also well known in the context of neurological diseases in which the dura becomes inflamed129 or compressed130 Further evidence for dural pain comes from neurosurgical studies that report relief of postlaminectomy pain after resection of the nerves to the dura.1 31 From the 1 950s, numerous neuroanatomical studies have been conducted that describe the innervation of the dural tube.1 32 Several authors have shown that the ventral half of the dura mater is supplied by small branches of the sinuvertebral nerve.133,1 34 Further work has confirmed that the innervation is from the sinu­ vertebral nerves and is confined to the anterior part of the dura only. 13 5 ,1 36 During the last decade, immunohistochemical studies clearly demonstrated a significant number of free nerve endings, containing substance P, calcitonin generated peptides and other neurotransmitters contributing to nociception.1 37,1 38 All these findings have been confirmed and extended recently so that the present concept is of a dense longitudinally orientated nerve plexus in the ventral spinal dura, extending over up to eight segments, showing a great deal of overlap between adjacent levels and crossing the midline.B9,14o The anterior part of the dura mater is thus innervated by a mesh of nerve fibres which belong to different and consecutive sinuvertebral nerves (Fig. 50.20). This probably explains the phenome­ non of 'dural pain', which is a pattern of large and broad reference of pain, covering different dermatomes, com­ monly found in low back syndromes. The patient then describes lumbar pain, radiating to the abdomen or up to the chest, to the groin or to the front of both legs . 141 NERVE ROOTS DEFINITION

The spinal cord terminates at the level of T12-Ll. Consequently the lower lumbar and sacral nerve roots

Figure 50.20 The anterior part of dura mater is innervated by a mesh of nerve fibres belonging to different and consecutive sinuvertebral nerves. 1, anterior part of the dura; 2, posterior part of the dura; 3, nerve root; 4, sinuvertebral nerve. Reproduced with permission from Groen.140

must run within the vertebral canal. The motor (ventral) and dorsal (sensory) rootlets that take their origin in an uninterrupted series of attachments at the ventrolateral and the dorsolateral aspects of the cord, run freely down­ wards through the subarachnoid space of the dural sac. The rootlets that form one 'nerve root' are gathered into pairs before they leave the dural sac. They do so by taking with them an extension of dura mater and arach­ noid mater, referred to as a 'dural sleeve'. The pair of roots, covered by dura mater is called the illtraspinal, intrathecal part of the spinal nerve. The pairs of spinal roots join at the level of the foramen. Immediately proximal to its junction with' the ventral root, the dorsal root forms an enlargement - the dorsal root ganglion - which contains the cell bodies of the sensory fibres in the dorsal root. Distal to the junction at the foramen, the dura mater merges with the epineurium of the spinal nerve. From here the extraspinal part of the spinal nerve begins.l13 BOUNDARIES

The entire course of the intraspinal part of the spinal nerve is enveloped by the radicular cana[142 or spinal nerve root canal,143 The term lateral recess has been applied to the bony boundaries of this radicular canal.144 The radicular canal is a small cone-shaped osteofibrous space, which begins at the point where the nerve root leaves the dural sac and ends at the lateral border of the intervertebral foramen. It thus shelters the complete extrathecal nerve root in its dural sheath. The direction of


the canal is caudal, lateral and slightly anterior. The ante­ rior wall is formed by the posterior aspects of the vertebral body and intervertebral disc, both partly covered by the posterior longitudinal ligament. The posterior wall is the ligamentum flavum, the lamina and the corresponding superior articular facet. The medial wall is the dura mater. The lateral aspect of the radicular canal is formed by the internal aspect of the pedicle and is continuous with the intervertebral foramen. The length of the radicular canal increases from L3 to 51, so making the L5 and 51 roots more liable to com­ pression. The L3 nerve root travels behind the inferior aspect of the vertebral body and the L3 disc. The L4 nerve root crosses the whole vertebral body to leave the spinal canal at the upper aspect of the L4 disc. The L5 nerve root emerges at the inferior aspect of the fourth lumbar disc and crosses the fifth vertebral body to exit at the upper aspect of the L5 disc (Fig. 50.21).1 45,146 Further clinical applications of this downward direction of the nerve roots are: • • •

At L4 levet a disc protrusion can pinch the fourth root, the fifth root or, with a larger protrusion, both roots. At L5 level, a disc can compress the fifth root, the first sacral root or both. Root L5 can be compressed by an L4 or an L5 disc.

( a)

It should, however, be remembered that aberrant courses and anastomoses exist between the lumbar nerve roots147 which may be present in about 4% of the population.148 The intervertebral foramen149 is the point of emergence of the spinal nerve from the canal (Fig. 50.22). It is located in a sagittal plane, so it can be demonstrated perfectly on a plain lateral radiograph. The foramen is limited cranially by the upper pedicle and caudally by the pedicle below. The anterior wall corresponds to the posterior aspect of the vertebral body and the disc. The posterior wall of the intervertebral foramen is formed by the articular facets. The size of the fClramen increases from T12-Ll to L4-L5, but the foramen L5-51 is the smallest of all and is located slightly more anteriorly.


The radicular canal contains the intraspinal extrathecal nerve root. The nerve root consists of a sheath (dural sleeve) and the fibres. Each structure has a specific behaviour and function, responsible for typical symp­ toms and clinical signs (see Box 50.1). From a clinical point of view, disorders of the outer investment cause pain and loss of mobility, whereas problems with the



Dura -------9 Subarachnoid space --�='!\Pia -------t----\\ Dorsal root ----="=�\\. Ventral root ----�,__ Dorsal root ganglion


Dural sleeve Spinal nerve

Sinuvertebral nerve



----I I-tI I



Figure 50.21

(a) Course of the lumbar nerve roots; (b) anatomy of the nerve root.

Ventral ramus Dorsal ramus

718 S E CT I O N T E N - T H E L U M BA R SPI N E

Figure 50.23

The relationship between the nerve root and dural sheath: dural pouch; 3, dural sleeve of nerve root .

1, dura mater; 2,

Figure 50.22

Intervertebral foramina.

Box 50. 1 Nerve root behaviour Sheath


Respo n s i b l e for:

Respons i b l e for:

Seg me ntal pain


M o b i l ity

C o n d u ctivity

arachnoid space forms a bilaminar tube within the root sleeve as a whole.150 At the foramen, the epidural tissue becomes more con­ densed and forms a loose ligamentous fixation of the epineural sheath to the bony boundaries of the interver­ tebral foramen. A stronger ligament (the so-called 'lateral root ligament'; Fig. 50.24), connecting the epineural sheath to the pedicle, has also been described.151 It has been suggested that the fixation of the dural sleeve, together with the anterior attachment of the dura to the posterior longitudinal ligament could be of some impor­ tance in the mechanism of sciatica.152 Simple mechanical

nerve root itself cause symptoms and signs manifest in the territory of its supply. Pressure and inflammation of the sheath first provokes pain and impaired mobility but more substantial compression of the root will also affect the nerve fibres, which leads to paraesthesia and finally to interference with conduction. The dural sheath The dural sheath (Fig. 50.23) starts as a funnel-shaped pouch, enclosing the anterior and posterior roots at their exit from the dural sac. The dural nerve root sleeve proper is formed at the end of this short pouch and con­ tinues distally to the foramen, where it merges with the connective tissue sheath of the ganglion and the spinal nerve. The dural investment of the nerve root therefore does not extend beyond the lateral border of the vertebral foramen. In this sleeve, the anterior and posterior roots no longer lie free but are firmly bound to the dural sleeve by the arachnoid membrane. In other words, the sub-

Figure 50.24

The lateral root ligament.


analysis suggests that pressure applied to the nerve root by a' disc protrusion is determined by the extent of the dural ligament fixation rather than by the compression of the root against the posterior wall. The dural investment of the nerve root is, as is the dural sac, sensitive and mobile. Although the intervertebral foramen represents a point of relative fixation of the nerve, some caudal migration of the latter remains possible.153 Distal traction on the sciatic nerve and lumbosacral plexus thus pulls the nerve root downwards and drags on the dural sheath and the dura. This occurs during straight leg raising, when the nerve roots of L4, LS, Sl and S2 are moved down­ wards at the level of the intervertebral foramen.124,154,155 The main range of motion of the Sl root is 4 mm, of LS 3 mm and of L4 1.5 mm. Straight leg raising does not pull directly on the L3 root. This structure can only be moved caudally during knee flexion in the prone position, which stretches the femoral nerve.156 It is not possible to test the mobility of the S3 and S4 roots, because they do not reach the lower limb. Because of the downward and anterior direction of the nerve roots and the relative fixation of the dural invest­ ment at the anterior wall, a downwards movement of the nerve always involves anterior displacement, which pulls the root against the posterolateral aspect of disc and vertebra. Restriction of nerve root mobility therefore always means anterior compression of the root. Internal rotation of the hip during straight leg raising adds more tension to the lumbosacral plexus and nerve roots.157 To clinicians this is not surprising, because it is common to see patients with considerable limitation of straight leg raising, actively rotating their hips laterally when it is performed, thus protecting the inflamed root against further traction. Cyriax drew attention to two interesting phenomena in relation to the mobility of the nerve root sheath, ncfmely the existence of a painful arc and the aggravation of the pain during neck flexion. ISS Mobility.

It is a common clinical finding that patients with sciatica show momentary pain during straight leg raising: there is pain only in a certain sector of movement (usually between 45 and 60°). The most acceptable explanation for this curious sign is that a small discal bulge exists over which the root slips and thereafter the rest of the movement is painless. This painful arc during straight leg raising always implies a small disc displacement and is a good indication that reduction by manipulation or traction is possible. The dural sheath can also be stretched from above. As we have seen previously (in the section on dural mobility), the dura can slip upwards during neck flexion. If a pain brought on by straight leg raising is



aggravated b y neck flexion, the tissue thus stretched must run in a continuous line from the lumbosacral plexus to the neck. Only the dura mater and its continuations, the dural investments, can possibly be stretched from above and below at the same time. Sensitivity of the dural investment. Dural root sheaths are innervated by the sinuvertebral nerve,135 and each sheath receives branches from the nerve of the corre­ sponding side and level only (Fig. 50.25). In contrast to the anterior aspect of the dural sac, anastomoses between branches of adjacent sinuvertebral nerves do not exist. Pain originating from the dural sheath is therefore strictly segmental and follows the corresponding dermatomes in the limb.159 Compression of the spinal nerve beyond the interver­ tebral foramen does not generate pain but only pins and needles, numbness and paresis. This is the case when a disc protrusion has passed very laterally, when the fifth lumbar nerve is compressed between a corporo­ transverse ligament and the ala of the sacrum,52 or in some spondylolitic compressions of the nerve root. Experience during the performance of a sinuvertebral block also confirms the insensitivity of the nerve root fibres. When the needle, just before touching the


�+-- 2




Figure 50.25 Innervation of the nerve root sheath: 1, posterior ramus; 2, anterior ramus; 3, sinuvertebral nerve; 4, dura mater; 5, posterior longitudinal ligament.


posterior aspect of the vertebral body, brushes against the nerve root, no pain but a sharp 'electric' shock results. As the dural investment of the root ends at the same level, it must be concluded that the latter is responsible for the radicular pain in sciatica . I ss Nerve root The structure of the nerve root differs from that of the peripheral nerves in three ways: the epineurium is less abundant, the fasciculi do not branch and the perineurium is missing. Thus, compared with a periph­ eral nerve, the parenchyma of the nerve root is more susceptible to injury, by either mechanical or chemical irritation.1 60 Irritation of the parenchyma leads to paraesthesia. Unlike 'radicular' pain, which is merely a symptom of compression of the dural sheath, pins and needles indicate that the nerve fibres are irritated as well. Paraesthesia is thus a symptom of direct involvement of the nerve root . Further irritation and destruction of the neural fibres leads to interference with conduction, resulting in a motor and/or sensory deficit. That the motor and sensory components of the nerve root remain com­ pletely separated during the course of the nerve root along the radicular canal has some clinical conse­ quences: it is possible for a nerve root compression to cause a pure motor paresis or a pure sensory deficit. If pressure is exerted from above, sensory impairment may result, whereas an impingement from below can induce a motor paresis. A larger protrusion, pressing between two roots, can result in a motor palsy of the root above, together with a sensory deficit of the nerve root below (Fig. 50.26). Controversy still exists over the mechanism of nerve root compression by a protruded disc. Inman and Saunders1 61 stated that the nerve root is rarely 'com­ pressed' between anterior and posterior wall, but is merely brought under tension by the disc herniation.

Figure 50.26

Protrusion pressing between two roots.

Others have observed that the extrathecal, intraspinal nerve root is relatively fixed to the anterior wall and the intervertebral foramen by the dural ligamentous complex and the foraminal complexlS4,162 (see p. 718). Therefore, this particular part of the root cannot easily slip away from a disc protrusion and is tethered over it, and a pressure-induced nerve lesion can develop.152 These anatomical findings probably help to explain why the magnitude of signs and symptoms in sciatica do not necessarily correspond to the magnitude of the disc protrusion and also why many asymptomatic protru­ sions exist. The amount of interference with conduction is related to the degree of the compressing force, which in turn depends not only on the magnitude of the pro­ trusion but also on the tightness of the dural fixation to anterior wall and intervertebral foramen. The involvement of nerve fibres is tested during clin­ ical examination: resisted movements and the reflexes test the integrity of the motor fibres, while cutaneous analgesia indicates loss of sensory conduction. Interference with conduction suggests that an attempt to achieve reduction by manipulation or traction will fail. In general, a disc lesion affects only one nerve root and the neural effects are rather subtle. As described above, combinations of sensory and motor effects or their independent existence may occur. It is also possi­ ble for two roots to be pinched by one disc protrusion, which can be the case at the L4 level where a combined fourth-fifth palsy can occur, probably resulting in a drop foot, or at the L5 level where a combined fifth lumbar-first sacral deficit can occur. Massive pressure may finally cause ischaemic root atrophy and then complete loss of sensitivity of the sheath occurs. Reflex hamstring contraction to protect the nerve root no longer takes place and straight leg raising becomes full range, despite the massive disc protrusion and the complete lesion. Conclusion For clinical purposes it is as well to divide the compo­ nents of the nerve root into an external aspect (the sheath), which is mobile and is responsible for pain, and an internal aspect (the nerve fibres), which serves con­ duction only. To do so helps to distinguish symptoms and signs of each, so permitting a good assessment of the location of a lesion, the magnitude of compression and the degree of functional incapacity (see Box 50.2). In nerve root compressions by a displaced disc, the development of symptoms and signs allows the anatom­ ical changes in the radicular canal to be followed: slight pressure will only involve the sheath of the �oot (Fig. 50.27), giving rise to pain in the corresponding dermatome and probably impaired mobility, reflected by alterations in straight leg raising. Greater pressure will


Box 50.2 Neurological deficit at each level , L 1 Compression of the L 1 root produces neither paraesthesia nor muscle weakness and cuta neous a n a lgesia is only found below the inner half of the i n g u i n a l l i g a ment

L2 Involvement of the L2 root causes p a raesthesia a n d a n a lgesia over t h e a nterior aspect o f t h e t h i g h , from the groi n to the pate l l a . M uscle wea kness is found i n the psoas.


result in pressure on nerve fibres, reflected in paraesthe­ sia at the distal end of the dermatome. Clinical examina­ tion will now reveal not only interference of mobility but also impaired conduction - a sensory deficit and / or loss of motor power. Greater pressure causes root atrophy, which results in loss of sensitivity of the dural sheath and gives a painless straight leg raising test. At the same time the sensory deficit and motor palsy become com­ plete (see Fig. 50.30).

L3 Interference of conduction in the L3 root causes paraesthesia at the anterior a spect of the leg from the dista l t h i rd of the thigh, over the knee a n d the lower leg, down to the a n kle. Cuta neous a n a l gesia exte nds from the pate l l a a l ong the front a n d the i n n e r aspects of the leg, a n d ends j ust a bove the a n k l e . The wea k muscles a re psoas a n d q u ad r i ceps a n d the knee jerk is slugg ish or absent. '

L4 Compression of L4 has the following c l i n ica l s i g ns: paraesthesia at the outer leg and the b i g toe, sensory deficit at the lateral aspect of the lower leg, over t h e foot u p to the b i g toe, a n d wea kness of the extensor h a l l ucis and the t i b i a l i s anterior m uscles.

L5 I nvolvement of the L5 root res u lts in p a raest h e s i a at the outer leg, t h e front of the foot and t h e b i g a n d two adjacent toes, a n d cuta neous a n a l gesia of t h e o u t e r leg, the dorsum of t h e foot a n d t h e i n n e r t h ree toes. Weakness is found at t h e exte nsor h a l l uc i s


The virtual space between the dural sac, the dural sheaths of the nerve roots, and the spinal canal is the epidural space. This space is quite narrow because the dural sac lies very close to the boundaries of the vertebral canal and is filled with a network of loose connective tissue, fat, arteries and a dense network of veinsJ63 The sinuvertebral nerve is in the anterior half of the epidural space. The venous system is extensive and valveless, with multiple cross connections. Batson1 64 has described retrograde venous flow from the lower pelvis to the lumbosacral spine, which probably provides the route for metastases and infections spreading from the pelvic organs to the spine.

long us, the peroneal a n d g l uteus med i us m uscles.

51 Compression of the S1 n e rve root shows the fol lowing signs: paraesthesia at the two outer toes, n u m bness at the calf, the heel and the latera l aspect of the foot. The weak muscles a re the calf muscles, the h a mstring, the g l uteus maximus and the peronei

52 Involvement of the S2 root results in p a raesthesia at the heel a n d cuta neous a n a lgesia at the poster i o r aspect of the t h i g h, the calf a n d the h e e l . The calf m u sc l es, the ha mstri ngs a n d the g l utea l mass a re wea k .

53 Neural deficits can not be detected i n S 3 lesions 54 Parenchymatous lesions of the S4 root res u lt in paraesthesia in the peri neum, vag i n a o r pen is, a n a l a n a l g esia, a n d funct i o n a l d i sorders o f t h e bladder a n d


The spine is innervated by the sinuvertebral nerve and the posterior primary ramus. All the tissues lying poste­ rior to the plane of the intervertebral foramina at each level (i.e. the facet, the vertebral arch, the related tendi­ nous and aponeurotic attachments and the flaval and interspinous ligaments) are innervated from the posterior primary rami. Those anterior to the intervertebral foram­ ina (longitudinal ligaments, anterior dura and dural sleeves) are supplied by branches of the sinuvertebral nerves (Wyke, cited by Cyriax165).

rectum, u s u a l l y i ncontinence




+ +

(paraesthesia) palsy ±

pain + / ­ (paraesthesia) palsy + +

Figure 50.27 Symptoms and signs of a compressed nerve root vary according to the intensity of compression.

The sinuvertebral nerve was first described by Luschka in 1850.166 It emerges from the anterior aspect of the spinal nerve, distal to the nerve ganglion, and receives some sympathetic branches from the ramus communi­ cans.22 In the fetus the nerve is composed of several filaments which may become bound together during later life, to form the adult sinuvertebral nerve.J 32 The composite nerve is between 0.5 and 1 mm thick,167 passes through the intervertebral foramen and points upwards around the base of the pedicle, to pass along the cranial side of the corresponding disc to reach the

722 S E CT I O N T E N - T H E L U M BAR S P I N E

medial aspect of the posterior longitudinal ligament. Here it divides into ascending, descending and trans­ verse branches, which anastomose with the sinuverte­ bral nerves of the contralateral side and with those from adjacent levels. Therefore, instead of a recognizable nerve trunk, the sinuvertebral nerve is represented by a network of overlapping fine filaments from different levels and from both sides (Fig. 50.28).168 Branches of the sinuvertebral nerve supply the verte­ bral body, the outermost layers of the annulus fibrosus, the posterior longitudinal ligament, the anterior aspect of the dural sac and the dural investments around the nerve roots. Branches of the sinuvertebral nerve also surround the blood vessels of the vertebral canal. The posterior aspect of the dura is devoid of nerve endings.

There is still disagreement as to whether the ligamen­ tum flavum and the lamina are innervated by the sinu­ vertebral nerve.


Distally from the intervertebral foramen, the spinal nerve divides into a large anterior branch and a smaller posterior ramus (Fig. 50.29). The latter divides almost immediately into a medial and a lateral branch,1 69 although a smaller intermediate branch has also been identified.84 The medial branch descends posteriorly to the trans­ verse process, where it lies in a groove formed by the junction of the superior articular and transverse processes. A strong fibrous band transforms this osseous groove into an osteofibrous tunnel. At this level a branch innervates the inferior part of the articular capsule of the facet joint. The nerve continues its course caudally on the lamina, to supply the dorsal muscles and the superior part of the articular capsule of the facet joint of the level below.17o Each medial branch thus supplies the facet joints above and below its course. Consequently, each facet joint is innervated by two consecutive medial branches. I 71,I 72 The lateral branch of the posterior ramus emerges between the deep layer of the lumbodorsal fascia and the lateral edge of the lamina. It supplies the muscles and the fascia. The lateral branches of the ramus posterior have cutaneous nerves and reach distally as far as the greater trochanter.134


Figure 50.28 Dural nerve branches. 'Cut pedicle of a vertebral arch; cv, vertebral body; di, intervertebral disc; drg, spinal ganglion; rv, ventral ramus of spinal nerve. Reproduced with permission fro m Groen GJ ( 1 990).

Figure 50.29 Posterior primary ramus: 1 , medial branch; 2, lateral branch; 3, sinuvertebral nerve.








Motor deficit

Sensory deficit

Reflex disturbances




Inner half inguinal ligament







Femoral stretch

Figure 50.30



Psoas quadriceps








Tibialis anterior, Extensor hallucis longus

Symptoms and signs of nerve root compression at each level.

Knee jerk

Knee jerk













None (femoral stretch )







Nerve fibres




Extensor hallucis longus, Peronei, Gluteus medius

Ankle jerk


Nerve fibres



Figure 50.30







Signs Motor deficit

Sensory deficit

Reflex disturbances



Peronei, Calf muscles, Hamstrings, Gluteal muscles



Calf muscles, Hamstrings, Gluteal muscles














Ankle jerk

Ankle jerk


the affected intervertebral joint opens, i.e. gives the loose fragment room to move.


The manipulation is usually carried out during trac­ tion. This tautens the posterior longitudinal ligament and causes suction in the disc so exerting a centripetal force (Fig. 59 .3) .

Most o f our techniques are non-specific long-lever manipulations: the force is exerted on a part of the body some distance away from the area where it is expected to have its beneficial effect. Leverage enables the manipula­ tor to apply more force at the affected level. The normal joints are moved as far as they can go. The posterior lon­ gitudinal ligament becomes taut. At the moment resist­ ance of the blocked joints and the taut ligament is felt, a quick additional thrust is given, to act at the affected level. Manipulation of the lumbar spine is either quickly successful or fails. If, after one or two manoeuvres performed in a certain direction, signs and symptoms remain unaltered, another direction or another technique is tried. If these also prove ineffective, manipulative treat­ ment is abandoned. I f, by contrast, manipulation has led to reduction, both local and referred d iscomfort cease. Previously painful movements become normal immedi­ ately. So it is the patient, rather than the manipulator, who judges the effect of treatment. Most other manipulative schools claim to work more selectively, i.e. on the affected level only. They claim to have developed the clinical skills to localize, by palpa­ tion, the exact site of the ' fixation' or 'locking'. Several studies have failed, however, to demonstrate the reliabil­ ity of this.52-57 We support the conclusion of McKenzie58 that demystification of spinal manipulative therapy is an

urgent priority. Both chiropractice and osteopathy thrive by creating the impression that there is something complex and exclusive about the practice of passive end­ range motion that only chiropractors or osteopaths can understand or have the skills to ' feel'. They generate the belief that, in order to become skilled in the understand­ ing and delivery of spinal manipulative therapy, it is necessary to undergo 3 or 4 years of training.59 This suggestion is undermined by the fact that the majority of lay manipulators in Britain have never had any tuition at all and yet have amassed many satisfied clients and also very rarely figure in actions for damages.2o The main advantages of the methods discussed in this book are, first, that they are much simpler but at least as effective as those advocated by chiropractors and osteopaths. Second, it takes only about 180 hours of tuition, provided that the student has completed medical or physiotherapy studies. In orthopaedic medicine, the manoeuvres are always intended to relieve the actual cartilaginous displacements. This is in contradiction to other methods, where a proto­ col of regular or intermittent manipulation sessions is commonplace. The type of displacement as well as the patient has to be assessed before any kind of mani pulative manoeuvre is undertaken. •

The displacement should be cartilaginous, not too large and not placed too far laterally. Soft nuclear protrusions are

seldom reduced by manipulation unless they are small and very recent and the technique of manipulation is changed to sustained pressure. If the consistency of the

Figure 59.3 Effects of long-lever manipulations. Positioning of the spine 'opens' the intervertebral space. A combination of traction and rotation produces a torque with tautening of the posterior longitudinal ligament and helicoidal traction on the lateral part of the annulus.


displacement is not quite clear, with symptoms and signs pointing in opposite directions, it is worth while making one attempt at manipulation. During the first session it is usually quickly apparent whether reduction by this means will prove feasible or not. If it fails, traction is substituted the next day. Reduction of cartilage displacements, together with full relief of symptoms and signs, has proved to be possible in two-thirds of all cases of backache and in one-third of all cases of sciatica.6o Just about half of all lumbago cases are relieved in one treatment.61,62 T17e patient must be mentally stable and keen to get well. If this psychogenic aspect is neglected, on some occa­ sions a patient may be treated who claims to have been made worse by a type of therapy that is regarded in retrospect as unacceptable. Hence it is important to avoid these active methods of treatment when the patient's attitude appears to be more important than the minor mechanical disorder found on examination.

INDICATIONS FOR MANIPULATION History and clinical examination almost always supply sufficient information to select those cases suited to manipulation (see Box 59.3, p. 879).

Acute annular lumbago. The attack is initiated by a click in the lower back, followed by a sudden agonizing lumbar pain fixing the back in slight flexion or lateral deformi ty. The pain radiates in an extrasegmental way and there are marked dural signs and symptoms. Reduction should always be attempted, except in hyperacute cases, where the attempt proves impossible to bear. An epidural injection is then substituted and fol­ lowed by manipu lation the next day. If such an injection is refused, it is still possible for the patient to recover in about a fortnight by bed rest and the use of McKenzie's extension mobilizations58 and anti-deviation techniques. The moment the process has ceased to be hyperacute, treatment by manipulation can be tried again. Backache. Acute or recurrent backache that has started suddenly usually responds well to manipulative treat­ ment. There are a number of symptoms and signs that are indications to expect that manipulation will be successful. The description of a click and sudden pain in the back on bending forward or on coming upright from a forward-bent or sitting position indicates displacement of a small cartilaginous fragment. Another ' favourable symptom' is the patient's age because, over the age of 60, nuclear protrusions no longer occur and a hard and mobile fragment of disc material is very likely. ' Favourable signs' are: (a) a partial articular pattern in which some movements are only painful at extreme

Box 59.1 Symptoms and signs favouring manipulative treatment of backache Favourable symptoms

Favourable signs

Patient over 60 years Sudden onset of pain: On bending forward Or on coming up

Partial articular pattern Side flexion away from the painful side hurts most Painful arc with or without momentary deviation Absence of gross deviation Absence of gross limitation on movement

range, for example flexion, extension and side flexion away from the painful side; (b) the existence of a painful arc with or without momentary deviation; (c) absence of gross deviation caused by muscle spasm on standing or during as much flexion as the patient is capable of; (d) absence of gross limitation on movement - gross devia­ tion or limitation of movement always requires several sessions of manipulation (Box 59.1). However, some small protrusions do not respond well to manipulation. Patients under 60 years of age and in whom the pain is greatest on pinching the lesion by side flexion towards the painful side are usually ' unfavourable'. If such a manoeuvre causes pain in the lower limb instead of the lumbar region or upper buttock, manipulation nearly always fails. A better response will be achieved with traction.

Sciatica. Reduction proves possible in about a third of all patients with sciatica. Again several symptoms and signs indicate those patients who can be expected to respond well (Box 59.2). Patients with mixed protrusions. If neither the symptoms and signs nor the patient's age establish the consistency of the displaced fragment, manipulation should be tried first: it is quickly clear whether this is effective or not. In contrast, traction usually requires a week before efficacy can be determined.

Box 59.2 Symptoms and signs favouring manipulative treatment of sciatica Favourable symptoms

Favourable signs

Backache still continues after root pain has begun Root pain is recent

Lumbar extension and side flexion hurt in the back not in the limb Absence of deviation or muscle spasm Straight leg raising is only moderately limited, with absence of spasm of the hamstring muscles ' Absence of neurological deficit


Patients over the age of 60. The rules that determine a nucl�ar or an annular lesion are no longer applicable over the age of 60 years. The nucleus has become hard and dry and will react correspondingly. Bed rest is wholly ineffec­ tive because there is no great d ifference in intradiscal pressure on lying and standing and as the tension of the posterior longi tudinal ligament lessens, it becomes elon­ gated and loses its ability to apply a correcting centripetal force. Hence all discodural or discoradicular interactions in this age group are best treated by manipulation, as this is the only way to achieve reduction. However, for elderly patients, manipulative treatment should also be adapted. This means that only one or two manipulations are performed during a session. The inter­ val between two sessions is also extended, say to once a week. The intensity of each technique should not be changed, however, otherwise the centripetal forces acting on the joint at the moment of manipulative thrust are too small to influence a displacement. Lumbar manipulations are not contraindicated in osteoporosis. However, some techniques are not used for fear of fracturing a bone.



Box 59.3 Manipulation Indications Acute annular lumbago Backache with favourable symptoms/signs Sciatica with favourable symptoms/signs Mixed protrusions Patient over 60 years

Contraindications Danger to S4 roots Anticoagulant therapy Aortic graft Last month of pregnancy Weakened body structures Muscle spasm Seriously neurotic patients

Not useful Too painful Too large a protrusion Too soft Too long a duration of root pain Compression phenomena After laminectomy. protrusion at the same level Unfavourable articular signs in: Backache Sciatica Primary posterolateral protrusion

CONTRAIND ICAT IONS These may be divided into circumstances in which manipulation is absolutely contraindicated and those in which manipulation is of no use although not harmful to the patient (see Box 59 .3) . Appropriate selection of patients and choice of techniques can avoid such serious complications as have been reported.63,64

Absolute contraindications Da nger to the fourth sacral roots. 65-67 Although these roots lie in the centre of the spinal canal, well protected by the posterior longitudinal ligament, they may be threatened by a massive central lumbar disc prolapse which has caused considerable bulging and possibly partial rupture of the posterior longitudinal ligament. Manipulation may rupture this ligament completely, causing extrusion of the entire disc. The important symptoms of an S syndrome are rapid 4 progression of bilateral sciatica and neurological symp­ toms in both legs. Pain and paraesthesia in the perineum, rectum, genitals or anus are other symptoms suggesting this menacing lesion. Finally bladder weakness, causing frequency of micturition without a strong urge, loss of rectal tone and faecal incontinence result. Acute lumbago and bilateral sciatica with compres­ sion of the nerve roots at the same level are examples of a large central protrusion in which bulging of the pos­ terior longitudinal ligament is to be expected. Such a protrusion may also cause spinal claudication. These

patients have symptoms during walking, immediately relieved by lying down.68 In all these conditions, a high-force rotational tech­ nique in the side-lying position could rupture the last protecting fibres of the posterior longitudinal ligament with massive extrusion of the entire disc.

Anticoagulant medication. Manipulation of patients on anticoagulant therapy may lead to an intraspinal haematoma.69 A patient who has a clotting abnormality should also not be subjected to forceful manipulations. Aortic g raft. Although there has not been a report of damage at the junction of a graft in the aorta by manipu­ lation, its presence is reasonably regarded as a contra­ indication to any forceful manipulation - rotations or extension thrusts. Final month of p reg nancy. During the final month of pregnancy, lumbar manipulation is impracticable. Rest in bed or epidural local anaesthesia are alternative pos­ sibilities. There is no bar to manipulation during the first 4 months; after this, extension techniques which necessitate a prone-lying position are omitted . Manipulation should not be employed at any time if there is any predisposition to miscarriage. Wea kened bon e structure . This includes unstable fractures, severe osteoporosis, osteomyelitis, multiple myeloma and bony tumours.


Muscle spasm. Forced movements should never b e used when there is obvious muscle spasm, which may indicate some kind of joint irritability, fracture or metastasis. Therefore, any sign of muscle spasm at the moment the lumbar spine is positioned and the manipulator starts to stress the affected intervertebral joint, should be taken as a sign to stop the procedure immediately. Of course, such a warning sign should already have been detected by an adequate clinical examination. Menta l state. Seriously mentally disturbed patients should not be treated by manipulation, even if there is an underlying disc protrusion which seems suitable for manipulative treatment. The symptoms largely exist in the patient's mind and indicate certain needs - compen­ sation or protection - and it can be expected that manip­ ulation will fai l or even aggravate the disorder. In addition, an obsessional neurosis about vertebral dis­ placement may result. This not only may make manipu­ lation troublesome to undertake but also may cause the patient to blame the treatment for making matters worse.


Too much pai n. In hyperacute lumbago manipulation is impossible because of unbearable pain at any attempted movement. These patients are best treated by the imme­ diate induction of epidural anaesthesia and manipulation is postponed until dural irritation has mostly ceased. Too large a protrusion. There are two categories. Protrusions causing impaired root conduction. All such protrusions are impossible to reduce either by manipula­ tion or traction. If clinical signs of muscle weakness, cuta­ neous analgesia or reflex disturbances are p resent, the protrusion is too large (and located too far laterally) to be replaced.38,67,7o-73 Epidural local anaesthesia is the treat­ ment of choice. Sciatica with an excessive flexion or side flexion deformity.

In such cases, an attempt to move in the contrary direction causes pain to shoot down the leg. Laminectomy or chemonucleolysis is indicated.

Too soft a protrusion. Nuclear protrusions causing back­ ache and sciatica do not respond to manipulation (except in small and very recent cases, and provided that the manipulation technique is changed to sustained pres­ sure). The consistency of the protrusion is too soft to be influenced by a quick thrust. Traction is the treatment of choice. The history is rather typical and usually identifies this type of disc lesion. Acute nuclear lumbago is also an example of a protru­ sion too soft to manipulate with a thrust. The history is of pain that began gradually, after doing much stooping and

lifting, and became slowly worse over the next few hours. The following morning the patient wakes unable to get out of bed because of severe lumbar pain. The patient is always under 60 years old and, although manipulation is indicated, it must be exerted by sustained pressure. If this makes the patient better, techniques in the supine, side­ lying, and standing positions to correct a persisting lateral deviated position of the trunk should follow (see pp. 890-892). Alternatively, an epidural injection can be tried, again followed the next day by manoeuvres to correct a lateral deformity. However, if these measures all fail, constant pelvic traction in a supine position and continued for some days is called for, slowly changed to periodic half an hour daily traction. Extension mobilizations, as rec­ ommended by McKenzie,58 have also been found to be effective, a treatment explained by him on the hypothesis that the flow or displacement of fluid, nucleus or sequestrum can occur within the intact annulus of the intervertebral disc as a result of prolonged or repetitive loading. This most commonly occurs with flexion loading. He recommends well-defined extension forces in order to reverse the direction of flow or displacement.

Too long a duration of root pain. In patients under 60 years, 6 months of root pain has been shown to be the limit for manipulative reduction. However, if back­ ache persists together with root pain, manipulation should be tried because these patients often do not recover spontaneously. Compression phenomena. Central stenosis, lateral recess stenosis and the 'self-reducing' disc protrusion do not respond to manipulative treatment. In stenosis, the under­ lying condition is the reason that attempted manipulation or traction fails.71,74, 75 The self-reducing disc protrusion, with symptoms at the end of the day only, may be reduced by manipulation but will prove to be transient anyway.38 After laminectomy. New protrusions, at the same level, are seldom successfully reduced by manipulation. Traction is often more effective. Unfavourable articular signs in a patient under 60 years. In backache, side bending towards the painful side is an unfavourable sign for manipulation but this does not apply in lumbago. If any movement other than flexion hurts in the lower limb instead of the back, manipulation is almost certain to fail. If an attempted extension manipulation gives rise to root pain, the manoeuvre should be discontinued, for the protrusion is pressed harder against the nerve root. ,

Primary posterolateral protrusions. These protrusions all consist of nuclear material and therefore cannot be reduced by manipulation (see p. 756).



Lumbar manipulation is quite safe.63,76 The most fre­ quently reported serious complication is further prolapse of a herniated disc, resulting in a cauda equina syn­ drome. A comprehensive search of online and biblio­ graphical databases traced 61 cases of cauda equina syndrome as a complication of spinal manipulation, its incidence being estimated to be less that 1 per 1 million treatments?7 Most of the incidents were described in patients undergoing manipulation under anaesthesia or chiropractic adjustments?8 Long-lever, high-force rota­ tion techniques in side-lying position are regarded as responsible. This is only partly true: the underlying cause is the lack of adequate examination to rule out unsuitable disorders. If, in contrast, manipulative procedures are instituted after a thorough examination, those described in this·book have never led to severe accidents. The main advantages of these manipulations are: • • •

A great deal of traction is used to exert a strong centripetal force on the intervertebral joint. Movements towards flexion, which can intensify potentially harmful centrifugal forces, are excluded. Each manoeuvre is followed by a fresh assessment of dural, root and articular signs, which affords a clear pointer to what has happened inside the joint and what the next step should be.

Other complications, such as sprains of the costoverte­ bral and costochondral junctions or fractures of a trans­ verse process, are less serious and either the result of poor technique or inappropriate indications. Should they happen, spontaneous recovery is to be expected after a short period of, say, 4-8 weeks.

However, examination during the next consu ltation shows that symptoms and signs have decreased or even disappeared. Therefore patients should be warned of some after-pain, which is due to muscular and / or capsular-ligamentous reactions. It disappears within 2-3 days and is unrelated to the lesion. Elderly patients can safely be manipulated. However, the number of manoeuvres during one session should be confined to, say, two or three. In these patients high-force long-level techniques should also be omitted.


Acute lumbago. If there is no deviation on standing or in the maximal forward bent position and the lumbago is of recent date, 50% will get well with one treatment.61,62 Potter73 noted 93% of such patients either fully recovered or much improved following manipulation. Backache. Uncomplicated low back pain of recent onset seems to be significantly more responsive to manipula­ tion than are chronic cases.29,73,74,79-82 However, a report37 suggests that manual therapy also produces better results than physiotherapy or medication in cases with a dura­ tion of 1 year or longer. The beneficial effect of manipula­ tion is particularly significant in low back pain with limited straight leg raising.83 Sciatica. One report has claimed the immediate complete recovery of 18 chronic cases out of 50 with unilateral sci­ atica after one manipulative session.6o This result was confirmed by J. Cyriax (personal communication, 1982). Others found up to 75% of their patients with uncompli­ cated sciatica to recover or improve considerably on spinal manipulations.39,62,7o,73,83

SIDE EFFECTS, RE MARKS AND PRECAUTIONS If it becomes clear, after the history and clinical examina­ tion, that the orthopaedic problem is less important than the psychological one, the patient is best left untreated. Even if such a patient can be helped, the improvement will not persist. The moment it is realized that there are adverse consequences of the symptoms ceasing, a post­ manipulative mental crisis is to be expected, blaming the treatment. If the backache is not of organic origin, manipulation will surely be of no help. Frequently these patients get years of futile treatment, which harms the reputation of manipulation. Manipulation should cause only minor discomfort, which is due to stretching effects on soft tissue structures. In acute lumbago a more gentle start is often necessary, to assess the patient's reaction and to gain their confidence. Sometimes the patient leaves a session pain free but, for the following 2 days, a rather strong reaction follows.

MANIPULATION TECHNIQUES The manipulative techniques used in orthopaediC medi­ cine can be divided into three groups: • • •

Rotation Extension Antideviation.

After a detailed description of each technique, the reader will find a ' practitioner's checklist' regarding choice of technique, assessment of progress, repetition of techniques and the course of a manipulative session. Symbols have proved useful to register the employed techniques. These are given for each technique.

Rotation techniques Rotation strains have been shown to be very effective in reducing displacements at a low lumbar level. A session


o f manipula tion therefore always starts with these manoeuvres. First a 'stretch' is performed, being the smallest rotation strain. The patient lies with the painful side u ppermost in order to bring the joint surfaces apart on the side of the displacement. Then, if necessary, this technique is followed by stronger rotations, using the femur as a lever. However, the latter techniques are impracticable in patients with arthritis at the hip or in elderly patients in whom osteoporosis is suspected. If the displacement lies centrally, straight leg raising may indi­ cate which side should be treated first. However, in the absence of any symptom or sign to indicate the side, either side can be treated and the manipulator proceeds by trial and error. Five different rotation techniques are described, all of which are used frequently. +R- Stretch. The straight arrow symbolizes 'stretch'. The R indicates that the patient lies on the right-hand side. The direction of the arrow to the left indicates that the patient's trunk is rotated to left posteriorly. The couch should be stable and adjustable to about 30 cm height. Using a high couch makes it impossible to aid the d istraction of body weight, which in turn decreases the effect of manipulation. The patient lies on the painless side. The upper thigh is flexed to a right angle with the under leg extended. The manipulator stands behind the patient, level with the patient's waist. One hand is placed in front of the shoulder and rotates the thorax backwards and upwards as far as it will go. At the same time, the heel of the other hand, placed against the greater trochanter, rotates the pelvis forward and downward to the same extent. This brings the joint surfaces apart on the side of the displacement. By using the body weight and leaning well over the patient, the manipulator obtains considerable distraction at the lumbar joints. At the moment the limit of tissue tension is felt, the body is pushed forwards on the verti­ cally outstretched arms to apply overpressure (Fig. 59.4). At that moment a 'click' or 'snap' is nearly always heard and felt, after which the result of the manipulation is assessed.

"IIV Practitioner's checklist • Ang les of rotation should be equal • Hands positioned with fingers pointing in the d i rection

of movement • Elbows extended • Equal amount of pressure on both hands • Body weight over the patient but assess, depend i n g on

bui ld, for exam p le, with l ig htly built patients • Man i pu l ation is a stretch, not a rotation

Figure 59.4


1't Leg crossed over. The curved arrow symbolizes a ' leg crossed over' . The direction of the arrow, to the left, indicates that the patient's trunk is rotated to the left pos­ teriorly. The letter R indicates that the patient lies on the right-hand side. The couch should be stable and adjusted to about 60 cm height. The patient lies supine about 20 cm or a hand's breadth from the edge of the couch. The manipulator stands on the painless side, level with the patient's waist, facing the feet. With both hands flexing the thigh on the far side up to 90° and drawn for­ wards, the pelvis and lower back are rotated towards the operator. In this way, hip adduction is avoided. The ipsi­ lateral knee of the manipulator is applied to the pelvis, if necessary, to prevent the patient from falling from the couch. Next, the contralateral forearm is turned into supination and the palm of the hand applied to the outer side of the knee. The other hand pushes the patient's far shoulder flat on the couch (Fig. 59.5). Then rotation of the


( a) Figure 59.5



(b) Leg crossed over: (a) with the leg forwards to rotate the pelvis; (b) shortly before manipulation.

pelvis is continued until tissue tension is felt to be maximal. At that moment, rotation is forcibly increased by pressing the patient's knee strongly and with high velocity towards the floor, using the thigh as a lever. At the same moment, the other hand maintains the position of the patient's far shoulder (if possible) flat on the couch.

� Leg crossed over with side flexion . The curved arrow to the left symbolizes a ' leg crossed over' with rotation of the trunk left posteriorly. The oblique arrow to the right indicates that the lumbar spine is in a side-bent position, bent to the right. The R represents the position of the patient, on the right-hand side at the moment of manipulation. This manoeuvre is a variation on the previous ' leg crossed over' technique and also achieves side flexion. The patient lies supine, both legs flexed and crossed, the

tillV Practitioner's checklist • This man i p u l ation creates max i m u m rotation but l ittle

d istracti o n • U s e o f leverage a n d g ravity means that o n ly m i nimal

force on the knee is needed In stiff patients it is i m possible to hold the far shou l der on the couch; with the pelvis rotated as described, the far shoulder is more or less off the couch and held i n that position • The degree to which the leg is flexed depends on posture i n the stand ing position: i n patients who show considerable forward and/or lateral deviation of the l umbar spi ne, the hip must be well flexed, u p to 120· if necessary, thus end-feel is reached more effectively, making the man i p u l ation more l i kely to be successfu l; patients without deviation are often best treated at first with the th igh brou g ht up to rather less than 90· •


leg o n the painful side u nderneath. The manipul ator stands on the pai nless side, level with the patient's waist. Holding the patient's knees i n the hands, the manipulator moves the patient's hips into 90° of flexion. Then both legs are twisted, in order to tilt the pelvis lat­ erally and open up the lumbar spine on the painful side. This position is maintained at full range. The hand th at has been on the patient's uppermost knee is now freed to fix the far shoulder on the couch. The side-bent posi­ tion of the lumbar spine is ensured by the manipulator's thorax and abdomen, which are used to engage the knee from the side. Next, rotation is stepped up slowly:

under the influence of gravity the legs turn in the direc­ tion of the floor until the limit of tissue tension is felt at the end of range. At that moment the manipulator 'S thigh, engaging the uppermost knee from the side, has taken over to secure the side-bent position of the lumbar spine. Lastly, the hand at the knee is supinated to increase the manipulative force. M anipul ation is performed by pressing the knee quickly downwards (Fig. 59.6) . At the same moment, the other hand is used to maintain the position of the patient's far shoulder flat on the couch, if possible. Rotation is thus forced during side flexion.




Figure 59.6 Leg crossed over with side flexion: (a) flexion of the hips and knees

and side flexion of the pelvis; (b) rotation of the pelvis; (c) manipulation.


�IIII Practitioner's checkl ist ,


• This manoeuvre must not be performed in arthritis of

the h i p and in the elderly, where osteoporosis is to be expected • Hi p of the leg underneath shou ld be flexed to 900 • Lateral flexion should be mai ntained u ntil and inclusive of the final th rust • Man ipu lation creates a q uick but short downward thrust, without releasing the patient's far shoulder

-A* Reverse stretch. The straight arrow again symbol­ izes a 'stretch' but its direction to the right indicates that the patient's trunk is now rotated right posteriorly. The R ind icates that the patient lies on the right-hand side. The couch is adjusted to about 30 cm height. The patient lies on the pain-free side, close to the edge of the couch where the manipulator stands. The patient's upper hip is extended, the lower flexed to about 45° in order to stabilize this position. The upper arm hangs off the couch, the lower lies behind the back. The manipulator stands behind the patient, distal to the pelvis and facing the patient's head. The ipsilateral hand takes hold at the anterior iliac spine and twists the pelvis backwards as far


as it will go. In this position, the manipulator 'S arm is fully pronated, with the hand placed against the anterior aspect of the anterior iliac spine, pushing the pelvis downwards and backwards. The other hand is placed against the scapula and pushes the thorax upwards and forwards (Figure 59.7). Next, by leaning well over the patient, the joints are distracted by moving both hands in opposite directions, until tissue tension is felt to be maximal. Manipulation is performed by jerking the body downwards over the rigid arms. It is best to apply this overpressure at the moment of expiration.

�IIII Practitioner's checklist • Pelvis must be rotated well backward, otherwise the

• • • •

manipu lation compresses the pelvis instead of stretc h i n g the l umbar j o i nts Angles of rotation should be equal Same amount of pressure is used by both hands Elbows are extended at the moment of final thrust Body weight is brought well over the patient to reinforce the stretch but adapted accord i n g to the patient's constitution Man i pu l ation is a stretch, not a rotation

( b)

(a) Figure 59.7


Reverse stretch: (a) the ipsilateral hand twists the pelvis backwards; (b) manipulation.


� Reverse rotation with thigh. The curved arrow sym­ bolizes rotation; its direction to the right means that the patient's trunk is rotated right posteriorly. The R indi­ cates that the patient lies on the right-hand side. The couch is adjusted to about 60 cm height. The patient lies on the pain-free side, the upper leg extended, the lower hip flexed to 60°, with the lower arm behind the back. The manipulator stands behind the patient, level with the lumbar spine. The upper thigh is grasped at the knee with the ipsilateral hand and flexes the hip to 90° and abducts the thigh horizontally. As a result the pelvis is twisted as far as it will go. The other hand is placed against the scapula and pushes the upper thorax to the couch (Fig. 59.8). While maintaining pressure on the thorax, the patient's upper thigh is now brought to 60° of flexion and full abduction. In some cases it is also neces­ sary to put a knee against the patient's lower buttock, to prevent the pelvis from slipping backwards. At the moment the manipulator feels the limit of tissue tension, manipulation is performed by a sharp and short rotation of the manipulator'S body. This forces the arm at the thorax down, at the same time as it jerks the thigh back­ wards. Strong rotation and extension occur in the lumbar joints. It is obvious that this manipulation must not be per­ formed in the elderly or in patients with arthritis of the hip or osteoporosis.

ments. The impulse separates L5 from Sl in a cranial direction, instead of compressing the dorsal parts of the joint. In acute lumbago and when extension pressure causes pain to shoot down the limb, extension techniques are contraindicated. Deviation, as an expression of a large displacement, provides an indication that these techniques will almost certainly fail. If a heavily built manipulator is dealing with a light patient, leaning on the patient's back using the whole weight of the body may give rise to strong resistance and therefore the amount of weight applied should be reduced.

U Central pressure. The straight arrow symbolizes the extension technique, which is exerted centrally. The level at which the manoeuvre is performed is indicated by L5. The patient lies prone on a firm couch adjusted to about 30 cm height. The manipulator stands level with the lumbar spine, facing the patient, with the knees

tI"� Practitioner's checklist • Suitable technique for l i g htly bu i lt manipu lators • Contraind icated in h i p lesions, elderly patients and

osteoporosis • Upper thigh is in not less than 60·

Extension techniques These techniques are very effective in small cartilagi­ nous d isplacements that cause backache, especially in elderly patients and in those with persistent minor pro­ trusions following incomplete reduction by a stretch in rotated position. The techniques are milder than those performed with rotation strains and may substitute the latter in osteoporosis. However, they affect one segment only. During the manoeuvre it is thought that interspinous pressure moves two adjacent vertebrae apart, so tighten­ ing the posterior longitudinal ligament and causing suction in the disc - a centripetal force which may reverse a displacement. The shape of the facets of L5-S1, which are more in a frontal plane, contributes to the better results achieved at this level than at the other lumbar seg-

Figure 59.8

Reverse rotation with thigh.


against the edge of the couch. One hand is placed with its ulnat border at the interspace of two adjacent spinous processes (normally between Sl and L5). The other rein­ forces it with the heel pressing on the radial and the thumb pressing on the dorsal and ulnar sides of the lower hand (Fig. 59.9). To prevent any contact with the iliac bones, it is useful to use the right hand, standing at the patient's left-hand side, and to turn this hand through about 45°. With the upper limbs extended and kept rigid, the manipulator leans well on to the patient's back and extends the knees, one after the other. From this moment the body weight presses full on the patient's back and results in a maximum tissue tension.

""II Practitioner's checklist • Wei g ht appl ied shou l d be adapted when a heavily bui lt

manipu lator deals with a l i g ht patient: one or even both knees remain in a flexed position and lean against the edge of the couch • Lean well over the patient • Arms extended and kept rigid • If pressure of body weight shoots a pain down the l imb, stop the man i p u lation

At the moment the patient relaxes and some exten­ sion has been achieved, the final thrust is given by


( a)

Figure 59.9 (a, b) Central pressure; (c) the ulnar border of the hand is placed between two adjacent spinal processes.



bending the head and thorax abruptly forward. Usually a thud is felt or a click is heard if the manipulation is successful.


U n i l ateral p ressure. The a rrow symbolizes an extension technique and also that pressure is exerted unilaterally, according to the direction of the arrow. The level at which the manoeuvre is performed is indicated by L5. If repeated central pressure has neither fully relieved the patient nor made the problem worse, this technique is used immediately after central pressure. The manipulator stands on the patient's painful side although, if the pain is central, there will be no indica­ tion whether to start on the right or on the left. The wrist of the ipsilateral hand is extended and the prominent pisiform bone is used to exert localized and unilateral pressure at the base of the spinous process of L5 or L4. It is necessary to lean well over the patient, in order to press in a slightly oblique d irection (Fig. 59. 1 0 ) . The other hand reinforces the pressure, using the heel to press on the manipulating hand. In order for the manip­ ulator to stay well balanced, both legs are moved slowly backwards at the moment the body moves forwards. The knees or thighs should stay in contact with the edge of the couch. Manipulation is all but identical to the previous technique, except that the thrust is now directed medially as well as downwards, which opens the joint on the p ainful side, at the same time also exert­ ing some rotational stress and strong extension.

vV� Practitioner's checklist • Arms kept rigid • The centre of g ravity moves beyond the centre of the

patient's body • Knees or t h i g hs stay in contact with the couch • F i n a l th rust at the moment the patient relaxes and a l l

the slack i n the tissue has been taken u p • I f pressure o f body weig ht shoots a p a i n down t h e l i mb,

stop the m a n i p u lation

Q + thigh II Uni lateral pressure with thigh I . The

arrow symbolizes extension with unilateral pressure. The level at which the technique is performed is indi­ cated by L4 / 5. Thigh I indicates the first variation of the technique. This is a much stronger technique which follows the previous extension manoeuvres but is undertaken only if partial reduction has been achieved and repetition affords no further improvement. In the absence of any

benefit, it is unwise to continue with this technique or the next one. The patient lies prone and near to the edge of a low couch. The manipulator stands on the pain-free side, level with the pelvis. With the ipsilateral hand the front of the knee is grasped at the painful side around its lateral aspect. The ulnar border of the other hand is placed just above the posterior spine of the ilium. Then the hip is extended and strongly adducted by leaning heavily towards the patient's head (Fig. 59. 11 ). This opens the joint on the side where the d isplacement lies. Manipulation is performed by a quick rotation of the manipulator 's trunk towards the patient's head. In this way, the unilateral downwards pressure of the lumbar hand, and the pull upwards of the hand on the knee, is considerably intensified . This results in a combined movement of hyperextension, side flexion and rotation at the lower lumbar joints.

vV� Practitioner's checklist


• Only use if the previous extension manoeuvres have

a l ready achieved some reduction • Not possible i n a lesion of the h i p joint • Size of the patient should be comparable to that of the

m a n i pu lator

Q + thigh I

Unilateral pressure with thigh II. Dealing with a heavily built patient, added force can be exerted by employing the knee; however, this technique should not be adopted if the previous extension strains have led nowhere. The patient lies in the same position as in the previous technique. The manipulator stands on the painful . side. With the contralateral hand, the front of the patient's knee around its medial aspect is grasped and the thigh is extended and adducted until the pelvis rises just off the couch. The palm of the other hand is placed on the sacrospinalis muscle covering the fourth and fifth lumbar levels on the painful side, with the forearm fully supinated (Fig. 59.12). The manipulative thrust is per­ formed by pressing the ipsilateral knee with the hand at the same time as the patient's thigh is forced into full extension and adduction. A forced extension at the lower lumbar joints results.

tIV� Practitioner's checklist • Use only if central a nd u n i l atera l pressure tech n iques

have ach ieved some reduction and the manipu lator is dea l i n g with a heavi ly built patient • Not possible in a lesion of the hip joint




Figure 59.10 at the base.

(a) x

(a) Unilateral pressure; (b) the prominent pisiform bone is placed

R Uni lateral distraction. The crossed arrows symbolize distraction. The letter R indicates that the manoeuvre is performed on the patient's right-hand side. This technique is indicated if the previous manoeu­ vres towards extension have helped but reduction has still not been fully achieved. It may also serve to remove a generalized ache that results from any manipulative manoeuvre. The patient lies prone and side flexes the body to open the joint on the painful side as far as possible. The manipulator stands on the concave side, facing the

patient, with the arms crossed and the elbows bent almost to a right angle. The heel of one hand is placed against the iliac crest, j ust lateral to the sacrospinalis muscle. The heel of the other hand is placed just under the lowest ribs (Fig. 59. 1 3). To p revent the skin from being strained at the moment of manipul ation, the skin is first pulled u pwards with the lower hand, while the upper hand does the same downward s. Manipulation is now performed by repeated (1 0-20 ti mes) forward movements of the trunk, keeping the elbows rigid . Th is

Figure 59.1 1

Figure 59.12

Unilateral pressure with thigh I.

Unilateral pressure with thigh II.


Figure 59.13

Unilateral distraction.

forces the hands apart and imparts rhythmic further dis­ traction together with some extension at the lumbar level.

Antideviation techniques These techniques are applied in backache and lumbago with an adapted postu re, caused by posterocentral disc protrusions. The previous rotation and / or extension techniques will have already eased the pain but when the patient stands for a few moments, the tilt of the trunk to one side quickly returns, as a result of persistent one­ sided muscle spasm . On examination, side flexion towards the contralateral convex side, and sometimes extension, is still limited . Three techniques can be used: • • •

Side bending in the supine position. Rotation-distraction in side lying. Side gliding, standing.

l' Side bending. The curved arrow symbolizes side bending. A bar at the arrowhead indicates the sustained maintenance of the position. The patient lies supine with both legs flexed and crossed, the leg on the concave side of the lumbar spine underneath. The manipulator stands on the convex side, level with the pelvis. With one hand the upper knee is pushed away from, while the other is used to pull the lower knee towards (Fig. 59.14). This simultaneous action tilts the pelvis and achieves full side flexion at the lumbar spine in the previously b locked direction. It is quickly repeated a number of times, whereafter the pressure is maintained for a few seconds. When there has been a pre­ vious nuclear protrusion, the extreme of range is better maintained for a minute or so. This position is consoli-

Figure 59.14

Side bending.

dated either by assistance of the manipulator'S ipsilateral knee, pushing from a distal position against the patient's ischial tuberosity or by the contralateral knee pushing from a lateral position against the patient's pelvis. The manipulation is repeated until the patient can keep the trunk in a neutral position on standing.

� Rotation-distraction. The straight arrow symbolizes distraction, the curved arrow rotation. The bars at the arrowheads indicate that the technique is performed in a sustained manner. The R indicates that the patient lies on the right-hand side. The patient lies on the side of the lumbar convexity with the upper thigh flexed to about 60°, thereby rotating the pelvis to just more than 90°. The manipulator stands in front of the patient, distal to the pelvis and facing the patient's head. The thigh of the uppermost lower limb is clasped between the manipulator 'S knees, just proximal to the patient's knee, to secure the position of the pelvis.


Both hands are placed at one side of the upper thorax. Correction of the lateral tilt is achieved by pushing against the patient's thorax in an upwards and back­ wards direction (Fig. 59.15). This correcting force should be sustained as long as the patient can endure it. The manipulator must stand well balanced to prevent the entire body weight from pressing on the patient. After some repetitions the patient is re-examined in the stand­ ing position. The manoeuvre is repeated until correction has been achieved or until repetition affords no further benefit.


Side gliding. Two straight arrows pointing to the convex curves of a scoliotic spine symbolize the side gliding. The bars at the arrowheads indicate that the technique is performed in a sustained manner. The patient stands upright, the feet about 20 cm apart to provide a stable base, with the elbow held against the lower rib cage on the side of the lumbar concavity. The manipulator stands on the same side and presses the thorax against the patient's elbow, with the hands placed on the far side of the patient's pelvis. Correction and even slight overcorrection is achieved slowly, by pressing the thorax against the patient's elbow,



simultaneously pulling the pelvis from the far side towards the manipulator (Fig. 59. 1 6 ) . This pressure should be maintained for a couple of minutes and is repeated several times. It is essential that the movement is side gliding rather than side bending. Once the spine is upright, an attempt is made to restore lordosis. To this end the patient is brought into the cor­ rected position again and asked to let the hips move for­ wards at the same time as the trunk bends backwards. In this way, the body stays well balanced all the time. This movement is repeated, until the range of extension is restored. It will take at least three to four consecutive daily ses­ sions to produce a lasting result. In addition, it is essen­ tial to instruct the patient in self-correction (Fig. 59. 17). Standing in front of a full-length mirror, one hand is placed against the lower lateral rib cage at the concave side of the lumbar tilt. The other hand is placed on the opposite lateral iliac crest. Then the patient performs the side gliding movement of the pelvis in the restricted direction so as to correct the deformity. Once this has been achieved, a controlled extension movement is per­ formed: the patient supports the trunk by placing the hands at the lower back and slowly bends backwards as far as is comfortable. These exercises should be repeated every hour.

�IIII Practitioner's checklist • Correction i nvolves side g l iding. not side bending

The course of a manipulative session is summarized in Figure 59. lB. MANIPULATION PROCEDURE

Choice of technique •

• • •

Figure 59.15