Biomechanics and pathomechanics of lumbosacral joint

Biomechanics and Pathomechanics of Lumbar and Sacral Joint

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

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

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

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

5. LUMBAR VERTEBRAE

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

7. TYPICAL LUMBAR VERTEBRAE Vertebral Foramen. The vertebral foramen is triangular and larger than the thoracic vertebral foramen but smaller than the cervical vertebral foramen.

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

9. STRUCTURE AND ITS FUNCTIONS

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

11. LUMBOSACRAL ANGLE 7/14/2021 4:15 PM 12

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

13. INTERVERTEBRAL DISC

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

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

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

17. LUMBAR SPINE LIGAMNETS

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

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

20. Ligaments Function Anterior longitudinal lig Limits extension Posterior longitudinal lig Limits forward flexion Ligamentum flavum Limits forward flexion Supraspinous ligament Limits forward flexion Interspinous ligaments Limit forward flexion Intertransverse ligaments Limit contralateral lateral flexion Iliolumbar ligament Resists anterior sliding of L5 & S1 21

21. ILIOLUMBAR LIGAMENT The iliolumbar ligaments consist of a series of bands that extend from the tips and borders of the transverse processes of L4 and L5 to attach bilaterally on the iliac crests of the pelvis . There are three primary bands: Ventral (or anterior) band : It runs from the ventral caudal aspect of the transverse process of L5 to the ventral surface of the iliac crest at the iliac tuberosity Dorsal (or posterior) band : It runs from the tip of the transverse process of L5 to the cranial part of the iliac crest at the iliac tuberosity Sacral band (sometimes called the lumbosacral ligament): It runs from the ventral aspect of the transverse process of L5 and the ala of the sacrum to the sacral surface of the iliac tuberosity of the iliac crest . The iliolumbar ligaments as a whole are very strong and play a significant role in stabilizing the fifth lumbar vertebra (preventing the vertebra from anterior displacement) and in resisting flexion, extension, axial rotation, and lateral bending of L5 on S1

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

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

24. THORACOLUMBAR FASCIA

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

26. MUSCLES OF LUMBAR REGION

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

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

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

30. Extensors: Longissimus , Iliocostalis , and Multifidus Groups ATTACHMENTS AND INNERVATION OF THE LONGISSIMUS THORACIS PARS LUMBORUM Inferior attachment: Posterior superior iliac spine Superior attachment: Transverse and accessory processes of the lumbar vertebrae Innervation : Dorsal rami of the lumbar spinal nerves Palpation: Cannot be separately identified deep to the thoracolumbar fascia.

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

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

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

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

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

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

37. QUADRATOUS LUMBORUM

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

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

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

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

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

43. SPINAL COUPLING Kinematic phenomenon in which movt of the spine in one plane is associated with an automatic movt in another plane Most consistent pattern involves an association between axial rotation and lateral flexion With lateral flexion, pronounced flexion and slight ipsilateral rotation occurs With axial rotation, however, substantial lateral flexion in a contralateral direction occurs 45

44. KINEMATICS LATERAL FLEXION : In the lumbar region, pure flexion and extension can occur, but coupled motions always occur with lateral flexion and axial rotation. With lateral flexion, pronounced flexion and slight ipsilateral rotation occurs. Lateral flexion and rotation are most free in the upper lumbar region and progressively diminish in the lower region. The largest lateral flexion ROM and axial rotation occurs between L2 and L3. Superior vertebra laterally tilts, rotates and translates over vertebra below during lateral flexion Annulus fibrosus is compressed on concavity of curve and stretched on convex side Nucleus pulposus migrate slightly towards convex side of bend The zygapophyseal joint capsules limit rotation in both the neutral and extended positions of the spine.

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

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

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

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

49. LUMBOPELVIC RHYTHM 7/14/2021 4:15 PM 51

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

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

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

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

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

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

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

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

58. SPINAL CORD AND PLEXUS Spinal cord ends at approximately L1–L2 Bundle of spinal nerves extends downward: cauda equina The Lumbar Plexus Formed by T12–L5nerve roots Supplies anterior and medial muscles of thigh region Posterior branches of L2–L4nerve roots form femoral nerve - Quadriceps 60

59. PATHOMECHANICS ENDPLATE FRACTURES: with the loss of nuclear fluid through the crack into the vertebral body (often forming Schmorl’s nodes), are very common compressive injuries and perhaps the most misdiagnosed. Loss of the nucleus pulposus results in a flattened interdiscal space that when seen on planar x-rays is usually diagnosed as a herniated disc. However, the anulus of the disc remains intact. It is simply a case of the nucleus squirting through the endplate crack into the cancellous core of the vertebra.

60. EXAGGERATED LORDIDIS : Abnormal exaggeration of lumbar curve Weakened abdominal muscles Tight hip flexors, tensor fasciae latae , and deep lumbar extensors Increase compressive stress on posterior elements Predisposing to low back pain 62

61. SWAY BACK Increased lordotic curve and kyphosis Weak : lower abdominals, lower thoracic extensors, hip flexors Tight : hip extensors,lower lumbar extensors,and upper abdominals

62. 7/14/2021 4:26 PM 64

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

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

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

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

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

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

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

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

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

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

73. LUMBAR SPONDYLOLISTHESIS 7/14/2021 4:15 PM 75

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

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

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

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

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

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

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

81. Malignant tumours Malignant tumours : Multiple myeloma is the commonest primary malignancy of the spine. Metastatic deposits are extremely common in the spine because of its rich venous connections, especially with the vertebral venous plexus. Pain often precedes X-ray evidence of a metastatic deposit. By the time a deposit is visible on X-ray, the tumour has replaced about 30 per cent of the bony content of the vertebra. A bone scan can detect the lesion earlier. 7/14/2021 4:30 PM 83

82. SACRAL JOINT

83. SACRUM VERTEBRAE Five sacral vertebrae are fused to form the triangular or wedge-shaped structure that is called the sacrum. The base of the triangle, which is formed by the first sacral vertebra, supports two articular facets that face posteriorly for articulation with the inferior facets of the fifth lumbar vertebra. The apex of the triangle, formed by the fifth sacral vertebra, articulates with the coccyx 85

84. 7/14/2021 4:15 PM 86

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

86. 7/14/2021 4:15 PM 88

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

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

89. 7/14/2021 4:15 PM 91

90. The interosseous sacroiliac ligaments This constitute the major bonds between the sacrum and the ilia,are considered to be the most important ligaments directly associated with the SIJs. The ligaments are composed of superficial and deep portions, which are divided into superior and inferior bands. The superficial bands unite the superior articular processes and lateral crests of the first two sacral segments to the ilia . This portion of the interosseous ligament is referred to as the short posterior sacroiliac ligament. The deeper portions of the interosseous sacroiliac ligament extend from depressions posterior to the sacral articular surface to depressions on the iliac tuberosities . The posterior sacroiliac ligaments connect the lateral sacral crests to the posterior superior iliac spines and iliac crests. 7/14/2021 4:15 PM 92

91. LIGAMENTS DORSAL SACROILIAC LIGAMENTS : The paired long dorsal sacroiliac ligaments have superior attachments to the posterior superior sacroiliac spines (PSISs) and adjacent parts of the ilium . Inferiorly, the ligaments are attached to the lateral crest of the third and fourth sacral segments. The medial fibers are connected to the deep lamina of the posterior layer of the thoracolumbar fascia and the aponeurosis of the erector spinae (ESA). The sacrospinous ligaments connect the ischial spines to the lateral borders of the sacrum and coccyx. The sacrotuberous ligaments connect the ischial tuberosities to the posterior spines at the ilia and the lateral sacrum and coccyx. The sacrospinous ligament forms the inferior border of the greater sciatic notch; the sacrotuberous ligament forms the inferior border of the lesser sciatic notch 7/14/2021 4:15 PM 93

92. 7/14/2021 4:15 PM 94

93. MUSCLES 7/14/2021 4:15 PM 95

94. SYMPHYSIS PUBIS ARTICULATION The symphysis pubis is a cartilaginous joint located between the two ends of the pubic bones. The end of each pubic bone is covered with a layer of articular cartilage and the joint is formed by a fibrocartilaginous disk that joins the hyaline cartilage-covered ends of the bones. The disk has a thin central cleft, which in women may extend throughout the length of the disk. The three ligaments that are associated with the joint are the superior pubic ligament, the inferior pubic ligament, and the posterior ligament. The superior ligament is a thick and dense fibrous band that attaches to the pubic crests and tubercles and helps support the superior aspect of the joint. The inferior ligament arches from the inferior rami on one side of the joint to the inferior portion of the rami on the other side and thus reinforces the inferior aspect of the joint. The posterior ligament consists of a fibrous membrane that is continuous with the periosteum of the pubic Kapandji described the muscle expansions as forming an anterior ligament consisting of expansions of the transversus abdominis , rectus abdominis , internal obliquus abdominis , and adductor longus . 7/14/2021 4:15 PM 96

95. KINEMATICS The SIJs permit a small amount of motion that varies among individuals. The SIJs are linked to the symphysis pubis in a closed kinematic chain, and therefore any motion occurring at the symphysis pubis is accompanied by motion at the SIJs and vice versa. NUTATION AND COUNTERNUTATION : Nutation is the term commonly used to refer to movement of the sacral promontory of the sacrum anteriorly and inferiorly while the coccyx moves posteriorly in relation to the ilium . Counternutation refers to the opposite movement, in which the anterior tip of the sacral promontory moves posteriorly and superiorly while the coccyx moves anteriorly in relation to the ilium The change in position of the sacrum during nutation and counternutation affects the diameter of the pelvic brim and pelvic outlet. During nutation , the anteroposterior diameter of the pelvic brim is reduced and the anteroposterior diameter of the pelvic outlet is increased. During counternutation the reverse situation occurs. The anteroposterior diameter of the pelvic brim is increased, and the diameter of the pelvic outlet is decreased. These changes in diameter are of particular importance during pregnancy and childbirth, and it is possible that the most motion that occurs at the SIJs may occur in pregnancy and childbirth, when the joint structuresunder hormonal influence and ligamentous structures are softened 7/14/2021 4:15 PM 97

96. KINEMATICS Using manual pressure on specially cut cadavers, Sashin found an average of 4 degrees of motion in women under 30, more so in pregnant women. 7/14/2021 4:15 PM 98

97. PHYSIOLOGICAL CHANGES DURING PREGNANCY During pregnancy, relaxin , a polypeptide hormone is produced by the corpus luteum and decidua . This hormone is thought to activate the collagenolytic system, which regulates new collagen formation and alters the ground substance by decreasing the viscosity and increasing the water content. The action of relaxin is to decrease the intrinsic strength and rigidity of collagen and is thought to be responsible for the softening of the ligaments supporting the SIJs and the symphysis pubis. Consequently, the joints become more mobile and less stable, and the likelihood of injury to these joints is increased. The combination of loosened posterior ligaments and an anterior weight shift caused by a heavy uterus may allow excessive movement of the ilia on the sacrum and result in stretching of the SIJ capsules. 7/14/2021 4:15 PM 99

98. KINETICS 7/14/2021 4:15 PM 100

99. KINETICS Stability of the SIJs is extremely important because these joints must support a large portion of the body weight. In normal erect posture, the weight of head,arms , and trunk (HAT) is transmitted through the fifth lumbar vertebra and lumbosacral disk to the first sacral segment. The force of the body weight creates a nutation torque on the sacrum. Concomitantly, the ground reaction force creates a posterior torsion on the ilia . The countertorques of nutation and counternutation of the sacrum and posterior torsion of the ilia are prevented by the ligamentous tension and fibrous expansions from adjacent muscles that reinforce the joint capsules and blend with the ligaments. lilolumbar ligaments have a significant role in stabilizing the SIJ as well as the lumbosacral junction. The ventral band of the iliolumbar ligament is of particular importance in restricting sagittal plane SIJ mobility. 7/14/2021 4:15 PM 101

100. KINETICS Also, tension developed in the sacrotuberous , sacrospinous , and anterior sacroiliac ligaments counteracts the nutation of the sacrum, However,the sacrotuberous and interosseous ligaments compress the SIJ during nutation . The long dorsal sacroiliac ligament is under tension in counternutation and relaxed in nutation . The interosseous sacroiliac ligament binds the ilium to the sacrum. Surface irregularities and texture of the SIJs also contribute to stability of the joint in the adult. Shearing forces are created at the symphysis pubis during the single-leg-support phase of walking, as a result of lateral pelvic tilting. In a normal situation, the joint is capable of resisting the shearing forces, and no appreciable motion occurs. If, however, the joint is dislocated, the pelvis becomes unstable during gait, with increased stress on the sacroiliac and hip joints as well as the vertebral column. 7/14/2021 4:15 PM 102

101. DYSFUNCTIONS OF PELVIC COMPLEX SACRAL DYSFUNCTIONS Flexion(nutation)Dysfunction : In this the sacral base has relative antero -inferior movement & lordosis at the lumbosacral junction becomes prominent. Extension(counternutation)Dysfunction : In this the sacral base has relative postero -superior movement & the lumbosacral junction is relatively flat.

102. PUBIC SYMPHYSIS DYSFUNCTIONS Clinical presentations of this dysfunctions are : Pubic pain & tenderness associated with lower back pain, specially in sacroiliac area. Difficulty/pain rolling over in bed. Difficulty/pain with stairs, getting in & out of cars, sitting down or getting up, bending, lifting etc. “Clicking” in the pelvis when walking. Feeling like hip is out of place during walking. Bladder dysfunction i.e. temporary incontinence at change in position. Knee pain or pain in some other areas can sometimes also be a side effect of pelvis problems . 7/14/2021 4:15 PM 104

103. Mechanical dysfunctions of pubic symphysis : Inferior pubic shear (inferior pubis) : A somatic dysfunction in which one side of pubic symphysis to the contralateral side as the result of a shearing in the sagittal plane. Superior pubic shear (superior pubis) : reciprocal of inferior pubis. SIJ has been implicated as the primary pain source in 10% to 25% of the patients with low back pain. During pregnancy 20% to 80% of women experience low back or post pelvic pain frequently arising from SIJ only. 7/14/2021 4:15 PM 105

104. 7/14/2021 4:15 PM 106

105. Mechanical dysfunctions of pubic symphysis : SYMPHYSIOLYSIS : Daily pain in pubic symphysis only confirmed by objective findings. It is not an actual lysis but the nomenclature is used as a classification of pregnant women with pelvic pain. ONE-SIDED SACROILIAC SYNDROME : Daily pain from one SIJ alone. DOUBLE-SIDED SACROILIAC SYNDROME : Daily pain from both SIJs, confirmed by objective findings. 7/14/2021 4:15 PM 107

106. PIRIFORMIS SYNDROME Piriformis muscle originates from the anterior part of sacrum , part of spine in gluteal region & from superior margin of greater sciatic notch. It’s a neuromuscular disorder that occurs when sciatic nerve is compressed or irritated by piriformis muscle. This causes pain, tingling & numbness in buttocks and along the course of sciatic nerve. Results from anatomical variations in muscle-nerve relationship, or from overuse or strain. 7/14/2021 4:15 PM 108

107. PIRIFORMIS SYNDROME 7/14/2021 4:15 PM 109

108. SI JOINT DEGENERATION Degenerative arthrosis of the joint commences at an early age, affecting the iliac cartilage to a greater extent than its sacral counterpart…whatever stresses the joint is subjected to, it would seem that the sacral hyaline cartilage has a better capacity to resist degenerative changes than the iliac fibrocartilage .” It was found that, with increasing age, the surfaces of both sides of the sacroiliac joint degenerate and become irregular, leading to inter- articular fibrous adhesions, further limiting motion. However, “the iliac cartilage exhibited more advanced changes of cartilage degeneration, with the surface becoming irregular, fibrillated, and eroded. The cartilage began to diminish in thickness…the joint cavity began to fill with greater quantities of amorphous, cellular debris.” 7/14/2021 4:15 PM 110

109. HYPOMOBILITY AND HYPERMOBILITY Initially, sprained sacroiliac ligaments allow the joint surfaces to separate slightly more than normal, causing hypermobility . The smooth gliding in all directions changes to a pivoting aberrant motion. With the development of the ridge and groove , the sacrum moves in a distinct pattern, in accordance with their shapes. However, when the joint surfaces separate enough to move out of alignment, the main ridge, and/or smaller ridges, may move out of their respective grooves, and wedge out of position, causing hypomobility . Therefore, one can have both hypomobility and hypermobility within the same joint  7/14/2021 4:15 PM 111

110. SACROILIAC NUTATION The Serola Theory, as a response to a right sacroiliac nutation lesion, the sacrum is pulled into some degree of counternutation on the right, indefinitely, unless the sacroiliac joint is properly stabilized and healed, which is extremely rare, but possible. Instead of healing, the body adapts; the pelvis will torque, the spine will twist, the extremities will rotate, and joints will move in asymmetrical patterns, etc The effect can be seen distant to the sacroiliac joint and even on the opposite side. The structural alterations that develop eventually spread throughout the musculoskeletal system and forms the basis for many chronic dysfunctions, including those to the spine and extremities . Time and uneven contraction patterns produce chronic dysfunction. 7/14/2021 4:15 PM 112

111. SACROILIAC SPRAIN Sacroiliac sprain can change coordination patterns in many muscles which, by their attachments to the sacrum and pelvic bones, can act through various vectors and levers to alter posture and joint angles throughout the musculoskeletal system. These distortions can occur whether the muscles directly cross the sacroiliac joint, as in the knee, or do not directly cross the sacroiliac joint, as in the ankle , or temporal mandibular joint . 7/14/2021 4:15 PM 113

112. LIGAMENT SPRAIN Ligaments Sprain in Nutation : When the force is greater than the ligaments can withstand, they sprain, and the joint goes past its normal end point. Failure of this mechanism to maintain ligamentous integrity is the weight bearing lesion of the sacroiliac joint, which is named the Sacroiliac Nutation Syndrome. The central spring in the shock absorber system is damaged and the normal mechanism of force transference becomes compromised 7/14/2021 4:15 PM 114

113. ANKYLOING SPONDYLITIS This is a chronic progressive inflammatory disease of the sacroiliac joints and the axial skeleton. Causes : Causes are unknown. It is found to be strongly associated with HLA-B27 genetic marker (about 85 percent). The infective triggers are certain gram-negative organisms more so Klebsiella . Age/sex Common in young male adults (M : F = 10:1). Pathology :The initial inflammation of the joints is followed by synovitis , arthritis, and cartilage destruction, fibrous and later bony ankylosis . The joints commonly affected are SI joints, spine, hip, and knee and manubrium sterni . Clinical Features ; The patient usually complains of early morning stiffness and pain in the back. Morning stiffness: Present ,Effect of inactivity :Aggravates pain ,Effect of physical: Relieves pain ,activity ; Limitation of spine In all directions Treatment : • General measures: This is extremely important and consists of the following measures: – Patient education – Family education – Genetic counseling – Avoid smoking – Regular exercises, especially swimming is of tremendous help – Physiotherapy and joint exercises – Occupational therapy. • Conservative treatment: This consists of rest, NSAIDs ( indomethacin ), physiotherapy, back exercises, etc. Radiotherapy may also help. • Surgical treatment : Consists of spinal osteotomy to correct spine deformity, total hip replacement and total knee replacement for hip and knee joint ankylosis . 7/14/2021 4:15 PM 115

114. CAUDA EQUINA LESION Cauda equina syndrome is seen in injuries below the level of first lumbar vertebra. It is essentially injury to the nerve roots below L1. Causes : • Tumors of the spine. • Pott’s disease. • Protrusion of disk—large midline disk prolapse at 4-5. • Fracture dislocation of the thoracolumbar spine. Clinical Features :The patient complains of back pain, perineal pain, difficulty in micturition, impotence in male, etc. Sensory signs : The most salient feature of a cauda equina lesion is an area of saddle-shaped hyperesthesia and later anesthesia (involving buttocks, anus and perineum). Motor signs: Flaccid paralysis below the knee. Reflexes: Ankle jerk is lost and the knee jerk is increased due to the weakness of the opposing hamstrings. Bladder symptoms: Common problems are retention of urine with overflow. Even after a severe cauda equina , lesion reflex micturition is established later, reflex being mediated through the vesical plexus. Anal sphincter relaxation: leading to incontinence of the bowels. 7/14/2021 4:15 PM 116

115. 7/14/2021 4:15 PM 117

116. CAUDA EQUINA SYNDROME Treatment : Prompt surgical intervention is the treatment of choice. This consists of operative stabilization of the fractures, bowel, back and bladder care . 7/14/2021 4:15 PM 118

117. REFERENCES Kinesiology The Mechanics and Pathomechanics of Human Movement : Carol A. Oatis Second Edition . Joint Structure and Function: A Comprehensive Analysis : CYNTHIA NORKIN- Fourth Edition . Orthopaedic Examination,Evaluation , and Intervention :MARK DUTTON SecondEdition Textbook of Orthopedics : JOHN EBNEZAR – FOURTH EDITION Essential Orthopaedics :J. Maheshwari –FOURTH EDITION https://www.serola.net/research-category/sij-degeneration/ 7/14/2021 4:15 PM 119

118. THANK YOU 7/14/2021 4:15 PM 120