Fixed lumbar lordosis

Fixed lumbar hyperextension in lumbar osteochondrosis has a number of specific features. This is, first and foremost, an unfavorable course for diseases with severe pain syndrome, with a prolonged course of exacerbation, a patient's negative response to traction therapy, and physical exercises associated with muscle stretching.

When external examination of a patient with a fixed hyperextension, the following most often attracts attention.

• Hyperextension in the knee joints. This is not found only in cases where the knee joints are included as an additional link in the kinematic chain of the spine for the purpose of additional compensation for the disturbed body balance.
• The pelvis in relation to the straightened legs is "protruded" posteriorly, the upper part of the abdomen is forward, and the thorax is thrown backward.
• When examining the patient from the back, the lumbar hyperextension is not always determined, especially in obese subjects: the true configuration is masked by soft tissues. Not always because of this is quite informative and curvimetric indicators.
• The visible muscles-extensors of the loin in some cases are strained quite sharply, along the sides of the looming vertical groove both the multi-parted muscles are well contoured, and the back straightener is a "symptom of strained reins". In other cases, neither visual, nor palpation is determined the tension of the superficial muscles realization of the posture of lumbar hyperextension - a complex mechanism. And this posture is realized not at the expense of only the tension of the long extensors of the waist.
• Extension in the lumbar region with a fixed hyperextension is usually possible in a large volume. When the patient leans forward, he usually uses for this inclination flexion in the hip joint. Sometimes at the beginning of the pelvic tilt movement after a series of lateral "compensatory" movements even more backwards, the lor-dosing increases, the extensor muscles of the waist taut. And only after that the patient bends at the expense of only the hip joints.
• Kifozirovanie it is impossible neither at the expense of active effort, nor at attempts of passive bending of a trunk, neither in a sitting or standing position, nor in a prone position. When the patient lies on his back, you can bring your palm under your lower back, and with passive or active leg bending in the hip and knee joints, the hyperextension does not disappear.
• In a normal functioning lumbar spine, hyperlordosis occurs when the center of gravity of the body moves forward. In order to balance the position of the body, compensatory lumbar hyperextension is required (for example, with excessive deposition of fat in the abdominal wall, after a posterior dislocation of the thigh, flexion contracture).
• Hyperextension occurs also above the level of spondylolisthesis of V or IV vertebrae, when along with the slip of the lower lumbar vertebra, the center of gravity of the body is displaced forward. A number of authors consider hyperlordiasis not as a consequence of displacement of the vertebral body, but as a background, soil on which such displacement often occurs.
• Slipping V or IV of the lumbar vertebra forward can occur for various reasons, and hyperlordosis arises again. The displacement of the center of gravity forward (but already above the lumbar region) occurs also in thoracic kyphoses of various etiologies (for example, Sheyerman-May disease, senile kyphosis, etc.). When extending in the lower back, the tension of the dural sac, the nerve root, is reduced. Arising as a symptom of compensation, lumbar hyperlordosis eventually leads to a number of pathological manifestations due to an overload of the posterior parts of the spine (arches, spinous processes, intervertebral joints) and overstretch of the forequarters.
• A great clinical importance is also attached to the interstitial diarthrosis arising during hyperlordosis, especially articulations between the tips of the articular processes and the bases of the arches, which is formed under the same conditions. In all these joints due to their early "wear" develops deforming arthrosis.
• In the conditions of the normal lumbar spine, lumbar hyperlordosis is possible with any thoracic kyphosis (for example, with syringomyelic).
• Dynamic loads affect mainly the posterior sections of the intervertebral discs: their height is greatly reduced, the angle opened anteriorly - the disk seems to gap. The rear parts of the limbus are located horizontally, as if "rubbing" each other through a compressed disk pad. In these conditions there is an osteochondrosis. The corresponding violation of the fixation capacity of the disk in the presence of hyperlordosis promotes the displacement of the vertebrae - pseudospendolisthesis is formed. Spondyloarthrosis also develops in the respective segments.
• When decompressed lordosis in the area of the lumbar vertebrae, lordosis not only does not increase, but even somewhat smoothes. The lumbosacral angle decreases, due to which, in the final analysis, there is an extension with some deviation of the trunk back. In these cases psoy, single or multiple (staircase) pseudo-spondylolisthesis are noted with slipping of each superior vertebrae posterior to the underlying vertebral column, apparently due to the extensor action of the large lumbar muscle.

Fixed lumbar hyperextension is sometimes found with the same extensor rigidity of the hip joint. This so-called extensor lumbar-hip rigidity provides the following triad:

• fixed hyperlordosis;
• symptom of the "board" and
• sliding gait.

At the same time, there is a limitation or impossibility of active or passive flexion in the hip joint of the leg unbent in the knee joint - the contraction of the thigh extensor muscles. The resulting lumbar hyperextension is accompanied by the lowering of the symphysis and the removal of the sciatic hillock posteriorly upwards. In these conditions, the sciatic nerve is stretched allegedly over the ischial tuberosity. In response, the tension of the femoral muscles and the slow development of the true muscle-tendon ishiokrural and gluteal contracture occur. Hence the hip extensor rigidity.

Thus, hyperextension is undoubtedly capable of playing a protective role. This protective role is especially clear in young people who develop lumbosacral extension rigidity. They do not have a gross disk pathology. In patients with herniated disc, hyperlordosis does not provide a reduction in pain and other clinical manifestations from the very beginning. Perhaps the tension of the loins extensor muscles carries a protective load in the so-called "soft protrusions", when in patients with favorable compensatory kyphosis (not lordosis!) The torso of the trunk is still limited. Tonic reactions of the extensor muscles of the lumbar muscles fix the posture of the patient mainly pathological, and not protective (in patients with the affected disc). Pathological not only because it is unfavorable with respect to its static characteristics, but also because it does not provide a reduction in pain. The conclusion is that with this option and for therapeutic purposes, hyperlordosis should not be maintained - it should be overcome.

[1], [2], [3], [4], [5]