Fixed lumbar lordosis

Fixed lumbar hyperextension in lumbar osteochondrosis has a number of specific features. First of all, it is an unfavorable variant in diseases with severe pain syndrome, with a prolonged exacerbation, a negative patient reaction to traction therapy, to physical exercises associated with muscle stretching.

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

• Hyperextension in the knee joints. This does not occur only in those cases when 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 balance of the body.
• The pelvis, in relation to the emphasized straightened legs, appears to be “bulging” backwards, the upper part of the abdomen forwards, and the chest thrown back.
• When examining a patient from the back, lumbar hyperextension is not always determined, especially in obese subjects: the true configuration is masked by soft tissues. Because of this, curvimetric indicators are not always informative enough.
• The visible lumbar extensor muscles are in some cases quite sharply tense, on the sides of the emerging vertical depression both the multifidus muscles and the spinal extensor are well contoured - the "symptom of taut reins". In other cases, neither visually nor palpably can the tension of the superficial muscles be determined - the implementation of the lumbar hyperextension pose is a complex mechanism. And this pose is not realized by the tension of the long lumbar extensors alone.
• Extension in the lumbar region with fixed hyperextension is usually possible in a large volume. When the patient bends forward, he usually uses flexion in the hip joint for this bend. Sometimes at the beginning of the bending movement, the pelvis, after a series of lateral "compensatory" movements, protrudes back even more, lor-dosing increases, the extensor muscles of the lower back are strained. And only after this the patient bends due to the hip joints alone.
• Kyphosis is impossible either by active effort or by passive flexion of the trunk, either in a sitting or standing position or in a lying position. When the patient lies on his back, a palm can be placed under the lower back, and with passive or active flexion of the legs at the hip and knee joints, hyperextension does not disappear.
• In conditions of a normally functioning lumbar spine, hyperlordosis occurs when the body's center of gravity shifts forward. In this case, compensatory lumbar hyperextension is required to balance the body position (for example, with excessive fat deposition in the abdominal wall, after posterior hip dislocation, flexion contracture).
• Hyperextension also occurs above the level of spondylolisthesis of the V or IV vertebrae, when the center of gravity of the body shifts forward along with the forward slippage of the lower lumbar vertebra. A number of authors consider hyperlordosis not a consequence of the displacement of the vertebral body, but a background, a ground on which such a displacement often occurs.
• Slippage of the V or IV lumbar vertebra forward can occur for various reasons, and hyperlordosis occurs secondarily. The shift of the center of gravity forward (but already above the lumbar region) also occurs in thoracic kyphosis of various etiologies (for example, Scheuermann-May disease, senile kyphosis, etc.). When extending the lumbar spine, the tension of the dural sac and nerve root decreases. Arising as a symptom of compensation, lumbar hyperlordosis eventually leads to a number of pathological manifestations due to overload of the posterior sections of the spine (arches, spinous processes, intervertebral joints) and overstretching of the anterior sections.
• Great clinical significance is also attached to the interstitial diarthroses that arise with hyperlordosis, especially the joints that form under the same conditions between the tips of the articular processes and the bases of the arches. In all these joints, deforming arthrosis develops due to their early "wear and tear".
• In conditions of a 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 decreases significantly, the angle open to the front increases - the disc seems to gape. The posterior sections of the limbus are located horizontally, as if "grinding" each other through a compressed disc pad. Under these conditions, osteochondrosis occurs. The corresponding violation of the fixation capacity of the disc in the presence of hyperlordosis contributes to the displacement of the vertebrae - pseudospondylolisthesis is formed. Spondyloarthrosis also develops in the corresponding segments.
• With decompressed lordosis in the area of the lumbar vertebrae themselves, the lordosis not only does not increase, but even becomes somewhat smoother. The lumbosacral angle decreases, which ultimately results in extension with some backward deviation of the trunk. In these cases, psoitis, single or multiple (scalene) pseudospondylolisthesis with each higher vertebra sliding backwards in relation to the lower one, apparently due to the extensifying action of the large lumbar muscle, is observed.

Fixed lumbar hyperextension sometimes occurs with the same extension rigidity of the hip joint. This so-called extension lumbopelvic rigidity involves the following triad:

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

In this case, there is a limitation or impossibility of active or passive flexion in the hip joint of the leg extended at the knee joint - contracture of the hip extensor muscles. The resulting lumbar hyperextension is accompanied by a lowering of the symphysis and abduction of the ischial tuberosity backwards and upwards. Under these conditions, the sciatic nerve is stretched as if above the ischial tuberosity. In response to this, tension of the femoral muscles and slow development of true muscular-tendon ischiocrural and gluteal contracture occur. Hence the hip extension rigidity.

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

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