Cyriax ETGOM Korea Kang Joonhan D C Kang, Joonhan D.C.

Cyriax ETGOM Korea
Kang Kang, Joonhan DC D.C.

Lumbar Spine

1. More than 90% of all organic low back pain, with
or without radiation in the lower lime, is
attributable to disc protrusion
protrusion.
2 2. The cause of 10% lower back pain is that
intervertebral joint is insensitive to internal
derangement.(i.e. sciatica, hyperacute lumbago)
* disc protrusion 자체가 pain의 원인은 아니고
protrusion된 p 디스크가 디 가 dura나 나 nerve root를
compression했을 때만 증상이 나타난다. 즉 아무리 심
한 disc protrusion이라도 dural compression이 없으
면 bback k pain은 i 은 유발되지 않는다 않는다.

3 3. The Th pain i
mechanism is
ddural. l
Protruded disc
impinges dura
(back pain) and
dural sleeve which
enclosing nerve
root (sciatica).

* reducible disc: manipulation or traction
* irreducible disc: epidural local
anesthesia
* The cause of back pain is not a stiff joint
and weak muscle, so mobilization and
muscle strengthening exercise are no good
treatment method.

1. Pain
2. Paresthesia
3 3. Influence of coughing
4. Danger to the S4-root

1 1. level: central central, unilateral, unilateral bilateral
1) unilateral structure not cause of central back
pain pain, but disc protrusion can cause of
central/unilateral/bilateral back pain
2) upper lumbar disc protrusion is rare, rare if pain in
this region: first rule out other disease(i.e.
metastasis)
3) alternating buttock pain: rule out AS
4) bilateral root pain: first rule out
‘spondylolisthesis’, ‘metastasis’, ‘mushroom
phenomenon’ rather than disc protrusion.

5) Root pain vs vs. referred dural pain
- referred dural pain not radiates below
malleolus malleolus, so referred pain goes down below
malleolus due to root pain
- root pain; “first first low back pain, pain now only leg
pain”(paresthesia; P&N).
sign: sensory/motor/reflex change
- dural pain; “sometimes leg pain with constant
low back pain at same area”(segmental area (segmental pain).
sign: alterations in mobility(painful limitation of
SLR)

2. Backache/Root pain: chronology
1) backache: root pain이 나타나면 통증이 많이 경감
된다. Backache가 계속될 경우에는 spontaneous
recovery의 가능성은 없다 없다.
2) Primary posterolateral protrusion(PPLP): 언제나
nuclear type 이기 때문에 spontaneous recovery는
일어나지 않는다.

3. Attacks
1)stable fragment: (Tx; traction)
직업상 힘든 일을 하는 환자가 3-4년을 주기로 back
pain을 호소하는 경우는 stable disc이므로 reduction
을한다.
2) ) unstable fragment: g (Tx; ( reduction+
stabilization)
약간의 힘든 일만 하여도 3-4개월을 주기로 back pain
을 호소하는 환자의 disc는 unstable한 경우이므로
reduction을 한 후에도 back school, prophylaxia,
sclerosant infiltration을 이용하여 stabilization을 시
켜줘야 한다.

4 4. Periods between the attacks
Attack 사이에 증상이 완전히 없어진다
는 환자는 reduction 확률과 예후가 좋고,
attack 사이에 증상이 조금 남아 있는 환자는
reduction의 성공률과 예후가 불량하다.

1. pain(segmental pain)
2. Pins and needles
3. Numbness
4. Motor and sensory
deficit
5. OOnly l numbness b ( (n.
sheath가 없는 부위의
경우 경우, ii.e. e nerve trunk
부위)

1. Back: dural symptom (i.e. disc
protrusion)
p )
22. L Lower bbuttock: tt k SI joint j i t arthritis th iti
3. Lower limb: neuroma or PPLP
(p (primary ima posterolateral poste olate al protrusion)
p ot sion)

History is much more important than clinical pattern!!
1 1. PPain i i in the th S4 dermatome
d t
2. Greater pressure results in S4 symptom and sign
1) paresthesia in the genitals
2) weakness of the bladder and rectum
3) analgesia in the saddle area
3. No root sign
4. No gross articular limitation
5. 다음의 3가지 경우에는 반드시 S4 danger를 염두에 두어야
한다.
1) acute lumbago – 항상 large protrusion이므로
2) coccygonia – S4 pain(?)
3) bilateral sciatica – disc protrusion이 아닐 가능성이 더
높지만 예외적으로 large bilateral protrusion일 수도있다.

1. Dural Concept
2. Ligamentous Concept
3 3. Stenotic Concept

*Lumbago Lumbago and backache originate when a
subluxated fragment of disc tissue impinges on
the sensitive dura matter
*Disc degeneration and disc displacements are of
themselves painless events.
*Dura matter is sensitive and translates
deformations of the posterior border of the disc
iinto t pain i
(1) BBackache k h
(2) Lumbago
(3) Sciatica
S i i

Small posterior shift of disc
material이 경막을 지속적 혹 혹은 간헐 헐
적으로 압박할 때 발생
요통은 일측성, 양측성, 중심 혹은 여
기 저기에 옮겨 다니며 나타날 수 있다
(가끔은 둔부나 허벅지에도 나타난다)
요통이 갑자기 발생하면 annular
type이고 서서히 심해지면 nuclear
type이다
통증이 어떤 특정한 자세나 동작 시 심
해진다(앉아 있을 때, 앉자 있거나 누
워있다가 일어날 때)
Dural Sx은 있을수도있고없을수도
있다
DDural l sign은 i 은 보통 나타나지 않는다 않는다.

Dural symptom
Lumbar pain on
coughing,sneezing,Valsalva
Dural Dural sign
Lumbar pain on straight-leg raising
and neck fle flexion
ion

Articular sign: Partial articular pattern.
Flexion is most painful p and limited also
extension and side flexion is limited.
Painful arc: Frequently, a painful arc is
encountered, with a transient pain
somewhere at at mid range

치료
1. Manipulation; annular type, painful arc가 있거
나 통증있는 반대편으로 반대편 측굴 하는 것이 더 힘들 때,노인 때, 인
일 때 도수치료가 효과적이다
2. Traction: nuclear type일 때나 도수치료가 효과 없
을 때 사용
3. Epidural injection: 통증이 너무 심하거나, 야간요
통이 있을 때, Bruised dura일 때
SSclerosing l i IInjection: j i 계속 재발 시 시, self-reducing
lf d i
nuclear protrusion, 야간이나 아침 요통
예후
대부분 저절로 좋아지지만 재발하는 경우는 만성화 되
기 쉽다

1. BBruised i d Dura: D
Pt. complaints of a constant ache in the
bback k which hi h i is unaltered lt d b by any position iti or
movement, but coughing and sneezing
may aggravate pain pain.
Clinical exam. reveals nothing.
Thi This h has induced i d d inflammation i fl ti of f th the dura d
matter.
EEpidural id l iinjection j ti with ith procane 00.5% 5% i is
indicated.

2. Nocturnal or morning backache:
Backache confined to night g and every y
morning is woken in early hours because
of increasing g and severe backache.
But pain quickly eases once upright.
This occurs in middle aged and explained
by increase in intradiscal oncotic pressure
at an early stage of degeneration
degeneration.
Epidural injection succeed in about 70%.
In case of fail injection do ligamentous
sclerosis.

3. Nuclear self-reducing disc:
Th The patient ti t i is young(20-40) (20 40)
No or mild pain during day or moving but
more pain i in i the th evening i then th when h go to t
bed pain ceases in about an hour: nuclear
self self-reducing reducing disc protrusion not reduction
No manipulation or traction
St Stabilization: bili ti prophylaxis, h l i postural t l
advices, sclerosing infiltration

Annular Type:
- During activity activity, a sudden snap was
felt and agonizing pain in the back.
- Coming up after bending, rising
from a chair or picking up a light
object.
- Initially, pain back to buttock, later
radiates adiates mo more e unilaterally.
nilate all
- Spread to groin, abdomen,
downward to one or both legs and
t to th the ankle. kl
- A typical statement in acute
lumbago is that pain is aggravated
bby sitting i i and d bbending di fforward. d
- Most characteristic sensation in
acute lumbago is sharp twings.

Nuclear Type:
가벼운 요통이 있고
난뒤몇시간/수일 뒤
에(주로 ( 자고 일어난
다음날 아침) 점점 통
증이 극심해 진다.
Mixed Type:
갑자기 요통이 발생
하여 점차 심해지는
경우이다 경우이다.

치료를 치료를 하던 안 하던 대부분 22-6 6 주 내에 저절로
회복된다. 그러나 자주 재발한다
가끔은 가끔은 요통이 없어지며 sciatica로 i ti 로 발전되기도
한다
치료 치료
-Hyperacute일때는epidural injection후
bbed d rest t 2-3일 2 3일 후 조기 ambulation시킨다.
b l ti 시킨다
- Annular type: manipulation
- Nuclear type: manual stretching or
Mckenzie mobilization(No traction!!!)

No physical findings
Deep Deep pain in sacral area
Pain and paresthesia in penis, vagina,
rectum t
Numbness Numbness in saddle area
Bowel and bladder
pproblem(incontinence) oblem(incontinence)

MECHANISM
(a) posterior disc
displacement remains
under PLL
(b) intradiscal pressure
remains high and pushed
more laterally toward less
residence site.
(c) herniates into the lateral
compartment of the
epidural space where it
compresses nerve root root.
* This is the typical
development of SPLP of
sciatica.

Sciatica 증상과 증후의 severity는
protruded p material의 의 크기뿐 기뿐 아니라
soft/hard 정도, nerve root의 IVF 상에
서 bone에 fixation정도 fixation정도, neural
inflammation 정도 등에 의해 결정된다.
그러므로 단순히 방사선학상(MR scan)의
protrusion 정도에 의해 sciatica의
severity를 결정하여서는 안되고 병력과
이학적 소견을 견을 종합하여 판단해야 한다. 한다

CAUSE CAUSE
1. D/Dx from disc protrusion
2 2. Sciatica S i ti i in elderly는 ld l 는 주 주로 llateral t l recess
stenosis에 의함
3 3. Bilateral sciatica는 massive protrusion이나 2
disc protrusions, spondylolisthesis(젊은
이),stenosis(노인)인 경우가 많다
4. Alternating sciatica는 sacroiliac arthritis를 의
심
5. 요통과 sciatica가 동시에 점점 심해질 경우는 심각
한 pathology를 의심해야 한다

Antalgic posture
Lateral type: yp antalgic g away y painful p side
Axillary type: antalgic toward painful side
flexed posture;very difficult to treat
예후;
Spontaneous recovery is the rule(6-
12months) due to disc shrinkage and root
atrophy
h

Not case of Spontaneous recovery:
* radicular pain과 함께back pain이나
gluteal l t l pain이 i 이 존재하는 경우
* 나이가 많은 환자(lateral recess
stenosis 가 같이존재)
* bilateral root pain 시

Repositioning(30%에서 효과 있다)
manipulation은 6개월이하의 신경근통증, protrusion이
크지 않을때(neurologic deficit이 없을때), 60세 이상
의 노인환자의 sciatica sciatica, 재발성 sciatica에 적용
nuclear protrusion일때는 견인 치료
Desensitization
neurological g deficit이 이 있거나 요통없이 통없이 root pain만 p 만 있
는경우, 6개월 이상된 sciatica, bruised root(root
pain without physical sign)일때 epidural injection
적용하고 epidural injection에 반응없고 반응없고,노인환자의
노인환자의
sciatica, L2,L3 root pain일 때는nerve root
infiltration을 적용한다

척추의 후 지지구조물(후관절, 각종 후방인대)에
기인한 통증
자세 증후군과 기능부전 증후군으로 나눈다
정상 정상 조직에 장기간 과도한 부하(bent finger
혹은 장시간 구부정하게 앉아 있을때)가 걸려서
생기는 것이 자세성 통증
비정상적인 조직(늘어난 인대나 염증생긴 관절
낭)에 정상적인 부하가 걸릴때 생기는 것이 기능
부전성 통증이다

(1) ( ) Symptoms y p
- vague lumbar pain produced by the maintenance of
position
-relationship l ti hi bbetween t dduration ti of f posture t and d degree d of f
pain
- pain p is abolished by y change g of position p
- pain is not referred below the upper buttocks
- dural symptoms are absent
(2) Signs
- Note: full range of movement, no pain
(3) Treatment
- self-treatment and prophylaxis: back school
- sclerosing: g injections j

(1) ( ) Facet jo joints s
1) Presentation
- localized and unilateral or
bil bilateral t l never central t l llumbar b
pain
2) ) Clinical examination
- full range of movement with
convergent or divergent pain
- ddural l and d radicular di l signs i are
absent
3) ) Treatment
- infiltration of the posterior
capsule with a corticosteroid
suspension or phenol

(2) ( ) Iliolumbar Ligament g
1) History
- uni, or bilateral localized pain at
l lower llumbar b area. Pain P i may
spread along iliac crest to groin.
2) ) Clinical examination
- no deviation in standing
- full range of movement
- side flexion away from painful side
can cause pain. Also pain at the
end of flexion or extension.
3)Treatment
- consists of three weekly
infiltrations with sclerosing solution
at the insertion of the ligament

(3) Supraspinous and
Interspinous Ligament
1) History
- localized and central pain started
after hyperextension strain
- pain does not spread over a large
area.
- standing and extension cause
discomfort
- no dural symptoms
2) Clinical examination
- extension causes local pain
- SSometimes ti the th end d of f flexion fl i is i
painful
- Both side flexions are free
3) Treatment
- local infiltration of triamcinolone

11. DDevelopmental l l stenosis i the h
laminae, pedicles and
posterior articular processes
are increased in size
2. Degenerative stenosis
results from gross
anatomical
changes(hypertrophy of the
articular facets facets,
osteophytosis, thickening of
the ligamentum flava) or
ddegenerative ti
spondylolisthesis.

1. Symptoms
- bilateral chronic and vague sciatica associated with
numbness and weakness of the leg; neurologic intermittent
claudication
- pain is brought on by walking and relieved by rest , stooped
posture or sitting.
- pain on recumbency in the prone position but not on riding a
bike
2. Signs
- difficult in standing erect, adopts a ‘simian stance’ with
flattened lumbar lordosis and knee slightly flexed.
- SLR is normal as are reflexes.
3. Treatment
- Non-operative Non-operative, conservative tx. tx should be used first and
includes relative rest and NSAID.
- pelvic tilt exe. to reduce lumbar lordosis

1. Lateral l recess stenosis
is more common than
the spinal stenosis
2. Pathological g changes g
- subarticular entrapment
- pedicular kinking
- foraminal
enchroachment
-postsurgical i l fib fibrosis i and d
stenosis
- lateral compression of
L5

2 2. Symptoms; S no dural d l symptoms
- most patients are over 70
- unilateral sciatica(sometimes bilateral) during standing standing,
walking and extension relived by flexion.
- noctunal pain caused by an increased lordosis in the prone
position iti
- unlike disc protrusion, no change in symptoms over time;
neither degree g nor localization, , even over years y
3. Signs
- almost complete absence of signs and clinical exam. normal
- ext. and side flex. Toward painful side increase pain
4. Treatment
- improved by reducing lumbar lordosis
- nerve root infiltration with 20mg triamcinolone

1. Posterocentral
2. Posterolateral
3. Anterior
4 4. Vertical
5. Circular

1. Backache
- A small annular, nuclear or mixed protrusion
compressing i th the ddura matter. tt
- Pain is central or bilateral
- Sli Slight ht partial ti l articular ti l pattern, tt d decrease lumbar l b
mvt.
minor or negative dural sign sign, no root sign
- Painful arc: favoural
De Deviation: iation protrusion p ot sion is longe longer; mo more e
manipulation sessions will be required

2. Acute lumbago
-Large g annular, nuclear or mixed protrusion
compressing the dura matter.
- Constant pain
- Partial articular pain with gross articular
limitation, possibly a deviation lateral or in flexion
- Certainly dural symptom and signs
- Clinical picture of an acute lumbago, without
ddural l symptoms or signs, i is i not caused d by b a disc di
protrusion

3. Rupture of the posterior longitudinal
ligament g
- Massive protrusion of the entire
intradiscal content content, leading to a
cauda equina syndrome.
- Particular danger to the S4-root
(urgent surgery)

R Root t pain i results lt f from
pressure of the
prolapsed l d or protruded t d d
disc against the dural
sleeve l of f the th nerve root t
and the subsequent
iirritation it ti of f th the llatter. tt
This may be primary or
secondary. y

1. Primary posterolateral protrusion(PPLP)
- Primary sciatica; root compression without
ddural l compression. i
- Pain starts in the limb, without backache,
however a cough or sneeze hurts in the leg
- Pain irritates distally, spreads proximally,
remains radicular; numbness in the heel, heel later
spreading to an ache in the calf and thigh.
- calf ache when sitting is prolonged.
- The moment patient stands up the pain
disappears pp

- Young adult(18-35 y.)
- Limitation of flexion with unilateral
limitation of straight-leg raising,
possibly a lateral deviation, deviation rarely a
neurulogical deficit
- Nuclear protrusion: no
manipulation

2. Secondary posterolateral protrusion(SPLP)
- Secondary sciatica; root compression after
ddural l compression i
- backache first which later changes into pain in
the limb with backache disappearing
disappearing.
- much more common than primary sciatica
- After disappearance of dural pain pain, unilateral
sciatica under 60 has a tendency to spontaneous
recovery in 8-12 8 12 months
- L3 protrusion is much more comfortable in
flexion than L4 or L5

L3 protrusion p is much more comfortable in flexion
than L4 or L5
Manipulation of a 50 years old pt. may be easier
than pt. is only 35 y.; diminished water content of
the nucleus
Beyond 60 a posterolateral protrusion, due to
diminished articular mobility, is generally smaller
and lies closer to the midline(less limitation SLR
and neurological deficit).
Rule of spontaneous recovery in 8-12 8 12 months
does not apply above age 60.
Above 60: epidural anaesthesia less efficient
sinuvertebral nerve block more efficient

11. SScheuermann`s h ` disease di
- adolescent:
osteochondrosis(14-18
os eoc o d os s( 8
y.) mostly seen in mid
and lower thoracic and
upper lumbar
- erosion in the ant.
Vertebral body from a
nuclear l fragment f t of f disc di
- no symptoms but
predisposes p p to repeated p
attacks of disc
protrusion; kyphotic
segment

2. Limbus vertebra -
adolescent:
- high oncotic and
hydrostatic pressure, the
young disc sometimes
invades the vertebral
endplates. d l t
- nucleus pulposus may
then move forwards bt bt.
Cartilaginous endplate and
bone bo e of o the e vertebral e eb a body. body

3. Mushroom
phenomenon:
- Complete erosion of
disc in an elderly
patient.
- entire intradiscal
content has moved
forward and is kept in
place by two
enormous osteophyte.
- PLL hhas become b too
long and compress
dura or root in
standing.

1. Schmorl`s ` node
- Adolescent disorder,
mostly tl i in th the lower l
thoracic and upper
lumbar spine spine.
- A nuclear fragment
of disc lodges itself in
the vertebral body;
this is visible on
medical imaging but
causes no symptoms.

2. Biconvex disc
- The intradiscal
pressure b becomes
greater than pressure
in the bone, bone which
lead to a biconvex disc
and a diabolo-shaped
vertebral body.
- Due to osteomalacia
or osteoporosis.

Disc Disc degeneration
degeneration,
weakening and
drying y g out, , with
osteophytosis which
reduces mobility.
Favourable
evolution(the disc is
b better kept k in i place, l
less possibility of
protrusion) protrusion), except
posterior
ostephytosis.

1. Backache
2. Acute lumbago
3 3. Sciatica

Reduction: protrusion reduces
spontaneously
Resorption: fragment lies too far out, loses
its nutrient synovial y fluid and slowly y
shrinks.
Erosion: Erosion: protrusion nests itself in a
vertebral body
Ischemic Ischemic root atrophy: pain ceases but the
neurological deficit is maximal

1 1. Backache
(1) Little tendency to spontaneous recovery
b because of f the h small ll protrusion i remains i
at intraaticular
(2) Between 50-60 years old: tend to
attack decreased or disappeared.
2 2. Acute lumbago
Most of them are spontaneously recovered
after 11-2 2 weeks weeks.

1.Pain
(1)Unilateral root pain(no backache any more is
mostly spontaneously recovered within 8-
12months – count from the moment pt. loses
hi his backache b k h and d feels f l only l pain i down d th the limb. li b
If some backache remain, there be no
spontaneous recovery recovery.
(2)L3 disc protrusion is recovered faster than L4 or
L5. 5
(3)A large protrusion(with neurologic deficit)
recovers more quickly q y than a protrusion p without
deficit

2 2. Neurological deficit
(1)Motor deficit
1)Aft 1)After 6-12months 6 12 th later l t f from the th maximal i l root t
pain, muscle strength is become normal
* maximal root pain: no change of SLR while
testing twice per week.
2)monoarticular deficit will be recovered
completely.
3)deficit involved two roots is mostly recovered
but remains weakness as sign and symptoms.
4)tibialis anterior(L4), peronei(L5-S1) are
recovered d completely l t l bbut t EHL(L4 EHL(L4-5) 5) remains i
slight ms. Weakness.

(2)Sensory deficit
recover time is unknown
(3)Jerk
1)knee jerk: always recovered
within a year
2)ankle jerk: recovered 50%

Diagnosis is most important!
important!
Traction

acute lumbago with/without deviation
ddaviation i ti = l large protrusion t i
*small protrusion: deviation in standing
disappear in full flexion
deviation in full flexion, not in normal
standing: manipulation
secondary yp posterolateral protrusion(SPLP)
p ( )
- manipulation
primary posterolateral protrusion(PPLP) -
traction
manipulation more efficient as age
advances

educible – manipulation or traction
irreducible – epidural p local anaesthesia
unfavourable articular signs in backache
under 60(nuclear protrusion) - traction
1 1. extension or side flexion hurts in the
lower limb instead of in the back – traction
2. side d fl flexion towards d the h painful f l side d
increase the backache - traction

Distance between vertebral bodies increases:
traction of 10-30kg increases each joint space
by 1.5mm
Suction Suction draws protrusion towards centre of the
joint: intra discal negative pressure and PLL
tauten may be produced during sustained
traction
Posterocentral protrusion responds better to
Posterocentral protrusion responds better to
traction.

1. Lumbar nuclear disc protrusion
2. Mixed protrusion(partly annular, partly nuclear)
3. S4 pain: only a very cautious attempt
4. Upper lumbar disc protrusion(L1 and L2):have
more nuclear l t type th than l lower lumbar l b
5. Recurrent disc protrusion at the same level after
laminectomy
6. PPLP which lasted less than three months.
7 nfa o able a tic la signs in backache nde
7. unfavourable articular signs in backache under
60(nuclear protrusion)

1. Acute lumbago(annular or nuclear):each mvt.
Causes twinges in the back and or the lower
limb limb. During traction feel comfortable but when
tension is released much worse.
22. Patient over 60-65 60 65 years of age age.
3. Sciatica with neurological deficit(sensory or/and
motor)
4. Sciatica with gross deviation sideways or in
flexion.
5. Sciatica with persisted for six months in a patient
under 60.

6. PPLP of over three months` ` standing
7. Pregnancy
8. Respiratory or cardiac insufficiency: patient does
not tolerate the thoracic harness.
9 9. Patient P ti t with ith a cold: ld cough h or sneeze during d i
traction can be very painful.
10 10. Immediately after a manipulation session. session
11. Any situation in which traction cannot be given
comfortably
comfortably.

1. Continuous traction is better than intermittent
traction.
22. TTraction ti f force of f 10-30kg 10 30k results lt in i a widening id i
of about 1.5mm(L/S).
33. At least 30 30-35kg 35kg are need to have a beneficial
effect in the lumbar spine(25% of body weight).
44. Duration: 1) 30-45 30 45 minutes
2) 1st session – 35kg 20mins
3) 2nd 3) 2 session – 25 30 35mins
nd session – 25, 30, 35mins
increase slowly.
4) 5 times/week times/week, 22-3 3 weeks
5. If no improvement after 3weeks: stop traction.

1. Tension should be released gradually: e.g. 65kg
in two minutes
2 2. Release R l traction t ti harness h
3. Patient has to perform some movement before
stand up up.
1) flexing and extending a knee
2) pelvic rotation with both knees together
3) lifting pelvis off the couch
4 4. For Fo the next ne t 10mins or o so, so sitting should sho ld not be
allowed: patient dresses in standing and goes
for a little walk before driving home home.

Kang, Joonhan D.C.