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Update

Segmental Instability of the Lumbar Spine


Key Words: Back, Pain, Spine, Trunk.

Author Information

Julie M Fritz, PT, ATC, is Assistant Professor, Department of Physical Therapy, School of Health and
Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (USA)
(jmfst46+@pitt.edu). Address all correspondence to Ms Fritz.

Richard E Erhard, DC, PT, is Assistant Professor, Department of Physical Therapy, School of Health
and Rehabilitation Sciences, University of Pittsburgh, and Director of Physical Therapy and
Chiropractic Services, Spine Specialty Center, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Brian F Hagen, PT, is Clinical Assistant Professor, Department of Physical Therapy, School of Health
and Rehabilitation Sciences, University of Pittsburgh, and Director of Outpatient Orthopaedic
Rehabilitation, CORE Network, Pittsburgh, Pa.

[Fritz JM, Erhard RE, Hagen BF. Segmental instability of the lumbar spine. Phys Ther. 1998;78:889-
896.]

Numerous clinical Low back pain (LBP) is a pervasive problem in modern societies, but
findings are identifying a specific pathoanatomical cause is not possible in a
proposed to be majority of cases.1 Patients for whom a specific pathoanatomical
diagnostic of diagnosis cannot be made are often described as having "mechanical"
lumbar segmental LBP. Many researchers and clinicians suggest that segmental instability
of the lumbar spine is a possible pathomechanical mechanism
instability.
underlying mechanical LBP.1–3 Segmental instability of the lumbar
spine, however, remains a controversial and poorly understood topic.4
The purpose of this update is to review the current literature on
segmental instability of the lumbar spine, with special emphasis on
Panjabi's theory of the "neutral zone" and how that relates to physical
therapy.

Basic Biomechanics of the Lumbar Spine

The lumbar spine, although often described as a single functional unit, is composed of 5 vertebrae
forming what are called "motion segments" connected in series.5 Each motion segment consists of 2
adjacent vertebral bodies and the connecting ligaments.6 Spinal motion segments represent the smallest
segments of the spine exhibiting biomechanical characteristics similar to those of the entire spine.5

Translation and rotation can occur at each spinal motion segment.5 Translation occurs when a shear
force causes one vertebra to move parallel to the adjacent vertebra. Rotation is the spinning of one

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vertebra about a stationary axis relative to the adjacent vertebra caused by a torque. Translation and
rotation occur at each motion segment during lumbar spine movements in any of the cardinal body
planes.7 For example, lumbar flexion involves anterior translation and rotation, and lumbar extension
involves posterior translation and rotation of each lumbar motion segment in the sagittal plane.7,8 The
maintenance of stability of the lumbar spine during movements, therefore, requires the coordinated
movements of multiple motion segments, and a lack of stability may potentially occur at any lumbar
segment in either translational or rotational movements, or both.9

Definitions of Clinical Instability

Segmental instability occurs when an applied force produces displacement of part of a motion segment
exceeding that found in a normal spine.10,11 Several researchers5,12–14 have defined normal segmental
motion in the lumbar spine. Most initial experiments were performed in vitro on cadaveric lumbar
spines. Based on the results of these studies, the most commonly cited thresholds for segmental
instability were (1) a sagittal-plane translation of at least 3 mm, or 9% of the vertebral body width, on
either a flexion or extension radiograph, and (2) a sagittal-plane rotation of greater than 9 degrees for the
lumbar motion segments between L1 and L5.11–13 More recently, researchers4,14–17 have studied the
motion characteristics of the lumbar spinal segments in vivo by taking radiographs of subjects with the
spine in neutral, flexed, and extended positions. These researchers4,15,17 found large variability in the
segmental motions of individuals without LBP. Hayes et al17 found that 42% of subjects without LBP
had at least one lumbar motion segment with at least 3 mm of sagittal-plane translation. Based on the
results of in vivo studies, some authors5,18 have recommended that the criteria for diagnosing segmental
instability be increased to 4 to 4.5 mm, or 10% to 15% of vertebral body width, of sagittal-plane
translation. Thresholds for rotational instability, according to White and Panjabi,5 are greater than 15
degrees at L1 to L4, greater than 20 degrees at L4-5, and greater than 25 degrees at L5-S1.

The range of motions observed in motion segments of persons with LBP illustrates the difficulty in
defining segmental instability strictly in terms of increased joint laxity. The frequent disparity between
joint laxity and the development of symptoms has been described in other joints. Snyder-Mackler et al19
studied 20 patients with anterior cruciate ligament deficiencies and found no correlation between joint
laxity and functional ability. They suggested that other factors, such as neuromuscular control, may
influence the relationship between joint laxity and symptom development. A similar phenomenon may
occur in the spine, with certain individuals unable to compensate for an excessive amount of joint laxity
and with other individuals with equal amounts of laxity able to "cope" without substantial pain and
disability. The rotational and translational movement criteria for diagnosing clinical instability have
been established to identify patients requiring surgical fixation, but these criteria may not be adequate
for detecting more subtle forms of segmental instability that can cause pain and disability.20

Definitions of segmental instability based solely on clinical findings have been proposed.21–23
Segmental instability has been defined as occurring in patients with low back problems whose clinical
status is unstable, with symptoms fluctuating between mild and severe symptoms in response to even
minor provocations.22 Paris23 defined instability as existing only when sudden aberrant motions such as
a visible slip or catch are observed during active movements of the lumbar spine or when a change in the
relative position of adjacent vertebrae is detected with palpation performed with the patient in a standing
position versus palpation performed with the patient in a prone position. The validity of these clinical
definitions has not been demonstrated. Frymoyer et al defined segmental instability as "a condition
where there is loss of spinal stiffness, such that normally tolerated external loads will result in pain,
deformity, or place neurological structures at risk."24(p224)

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A more recent theoretical premise of segmental instability using a "neutral zone" concept has been
proposed by Panjabi.25 The neutral zone concept is based on the observation that the load-displacement
curve of the typical spinal motion segment is highly nonlinear, with high flexibility for motion occurring
around the neutral position of the spine and with increased passive resistance to motion nearer to the
end-ranges of spinal motion.26 The total range of motion (ROM) of a spinal motion segment, therefore,
may be divided into 2 zones: a neutral zone and an elastic zone. The neutral zone is the initial portion of
the ROM during which spinal motion is produced against minimal internal resistance. The elastic
portion of the ROM is the portion nearer to the end-range of movement that is produced against
substantial internal resistance.25

The neutral zone is the zone of high spinal flexibility, whereas movements occurring in the elastic zone
encounter increased internal resistance to movement. An increase in the size of the neutral zone relative
to the total ROM, therefore, increases the amount of laxity present and increases the demands on the
stabilizing systems of the spine.25 In vitro studies25,27,28 suggest that an increase in the size of the
neutral zone may be a better indicator of segmental instability than an increase in total ROM. Segmental
instability, therefore, may be defined as a decrease in the capacity of the stabilizing system of the spine
to maintain the spinal neutral zones within physiological limits so that there is no neurological deficit,
no major deformity, and no incapacitating pain.25 Although further research is needed, this definition of
segmental instability may prove to be useful because it describes the quality of motion throughout the
ROM instead of relying solely on total ROM values for diagnosis. Clinical methods for quantitatively
assessing the size of the neutral zone have not been developed, but this definition, emphasizing the
quality as opposed to the quantity of motion, appears to fit the clinical observation that many patients
with suspected segmental instability have greater difficulty moving in the mid-ranges of spinal motion
than at the end-ranges. In addition, because muscle activity can affect the size of the neutral zone,29 the
influence of factors such as muscle activity and neuromuscular control can be accounted for within this
definition.

The Stabilizing System of the Spine

The stabilizing system of the spine must limit the excursion of spinal motion segments and maintain the
proper ratio of neutral to elastic zone motion.25 Panjabi30 conceptualized the stabilizing system of the
spine as consisting of 3 subsystems: (1) passive, (2) active, and (3) neural control. The functions of these
3 subsystems are interrelated, and reduced function of one subsystem may place increased demands on
the other subsystems to maintain stability.31,32

The Passive Subsystem

The passive subsystem consists primarily of the vertebral bodies, zygapophyseal joints and joint
capsules, spinal ligaments, and passive tension from the musculotendinous units.30 The passive
subsystem plays its most important stabilizing role in the elastic zone of spinal ROM (ie, near end-
range).33 The relative contributions of structures to segmental stability has been investigated by serially
cutting the structures32,34 and through mathematical modeling experiments.33,35 The posterior
ligaments of the spine (interspinous and supraspinous ligaments) along with the zygapophyseal joints
and joint capsules and the intervertebral disks are the most important stabilizing structures when the
spine moves into flexion.35,36 End-range extension is stabilized primarily by the anterior longitudinal
ligament, the anterior aspect of the annulus fibrosus, and the zygapophyseal joints.32,34 Rotational
movements of the lumbar spine are stabilized mostly by the intervertebral disks and the zygapophyseal
joints.37 Side-bending movements have not been studied extensively, but it appears that the

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intertransverse ligaments may play an important role in segmental stability for movement occurring in
the frontal plane.33

In the neutral zone of ROM, the structures of the passive subsystem may function as force transducers,
sensing changes in position and providing feedback to the neural control subsystem.30,33,38 Evidence for
this role is provided by anatomical observations of afferent nerve fibers capable of conveying
proprioceptive information in most of the structures of the passive subsystem, including the
intervertebral disks, the zygapophyseal joint capsules, and the interspinous and supraspinous
ligaments.31,38 Injury to the passive subsystem may have important implications for spinal stability.
Intervertebral disk degeneration or disruption of the posterior ligaments of the spine may increase the
size of the neutral zone, increasing the demands on the active and neural control subsystems to avoid the
development of segmental instability.25,29

The Active Subsystem

The active subsystem of the spinal stabilizing system consists of the spinal muscles and tendons. The
active and neural control subsystems are primarily responsible for spinal stability in the neutral zone,
where passive resistance to movement is minimal.30,34 In experiments performed with the musculature
removed, the lumbar spine is known to be highly unstable at very low applied loads, attesting to the
importance of muscle activity for spinal stability.39 The relative importance of different muscle groups
in providing stability for the lumbar spine has been a topic of much debate and research.40–44

Differing roles have been suggested for the deeper, unisegmental muscles and the more superficial
multisegmental muscles such as the abdominal and erector spinae muscles.40 The unisegmental muscles
of the lumbar spine, such as the intertransversarii and interspinalis muscles, are proposed to function
primarily as force transducers, providing feedback on spinal position and movements to the neural
control subsystem.30 Evidence for this role is provided by the small size of these muscles, their close
proximity to the center of rotation for spinal movements, and the high concentration of muscle spindles
located in the smaller, unisegmental muscles of the body.7,45

The larger, multisegmental muscles are responsible for producing and controlling movements of the
lumbar spine. Lifting and rotational movements have been studied most extensively because these are
tasks frequently performed by the lumbar spine. The lumbar erector spinae muscle group provides most
of the extensor force required for most lifting tasks.46 Rotation is produced primarily by the oblique
abdominal muscles.41 The oblique abdominals and the majority of the lumbar erector spinae muscle
fibers lack direct attachment to the lumbar spinal motion segments and, therefore, are unable to exert
forces directly on individual motion segments. The multifidus muscle is better suited for the purpose of
segmental control.47 This muscle originates from the spinous processes of the lumbar vertebrae and
forms a series of repeating fascicles attaching to the inferior lumbar transverse processes, the ilium, and
the sacrum. The multifidus muscle is proposed to function as a stabilizer during lifting and rotational
movements of the lumbar spine.47 Stability of the lumbar spine during movements in the frontal plane
has not been studied extensively, but the quadratus lumborum muscle has been proposed to be the
primary active stabilizer for these movements.48

The role of the abdominal muscles in spinal stability has been the topic of much debate. The abdominals
have been proposed to play an important role in generating extensor force during lifting tasks, either by
increasing intra-abdominal pressure or by creating tension in the lumbodorsal fascia.42,49 Research

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indicates that the abdominal muscles are not capable of generating substantial extensor force through
these mechanisms.43,50 The abdominal muscles are primarily flexors and rotators of the lumbar spine.41
The oblique abdominal and transversus abdominis muscles, with their more horizontal orientation, are
thought to contribute to spinal stability by creating a rigid cylinder around the spine and by increasing
the stiffness of the lumbar spine.44,51 This theory is supported by studies demonstrating continuous
activity of the transversus abdominis muscle throughout flexion and extension movements of the lumbar
spine.52

The Neural Control Subsystem

The neural control subsystem is thought to receive input from structures in the passive and active
subsystems in order to determine the specific requirements for maintaining spinal stability, then acting
through the spinal musculature to stabilize the spine.30,44,53 Dysfunction in the neural control system
may place other spinal structures at risk for injury.30 If proper functioning of the neural control system is
not restored following an injury, the potential for reinjury may be heightened.53

No evidence exists linking poor neuromuscular control with increased risk of an initial injury to the
lumbar spine. Several studies44,54–57 have shown that patients with LBP often have persistent deficits in
neuromuscular control, indicating that recovery of proper function of the neural control subsystem is not
automatic following an initial injury. Studies54–56 have demonstrated increased postural sway and
slower reaction times in patients with LBP when compared with subjects without LBP. Luoto et al54
found that improvements in reaction time correlated with reduced disability in patients undergoing
rehabilitation. These results support the hypotheses that neuromuscular control deficits often exist
following lumbar spine injury and that reduction in these deficits correlates with improvements in
functional status.

The neural control system may play an important role in stabilizing the spine in anticipation of an
applied load. Hodges and Richardson44,57 reported that the transversus abdominis and multifidus muscle
activity consistently precedes active extremity movement in subjects without LBP. This finding suggests
that the neural control system normally anticipates the need for stabilization against the reactive forces
from limb movements. In a study of patients with LBP,44 the contraction of the transversus abdominis
muscles was delayed, possibly indicating deficient neural control. Further research is needed to clarify
the role of neural control in patients with LBP, but these preliminary findings indicate that enhancing
neural control may be an important consideration in the prevention and rehabilitation of LBP.

Diagnosing Spinal Instability

In 1944, Knuttson58 described a method for diagnosing segmental instability by taking lateral
radiographs of the lumbar spine with the patient performing a maximum active extension while standing
and a maximum active flexion while sitting. The amount of sagittal-plane translation and rotation were
then calculated from the 2 radiographs and compared with criteria defining segmental instability.
Flexion-extension radiographs have now become the standard by which segmental instability is
diagnosed.5,12,14 Variations in the exact technique used, large variability in the motion characteristics of
individuals without LBP, and high false-positive rates using the established criteria, however, have
caused many authors17,27 to question the usefulness of flexion-extension radiographs.

Friberg59 described an alternative diagnostic method in which radiographs are taken during axial

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compression while the patient supports a weight on the shoulders and then during traction while the
patient hangs from a bar. Anteroposterior translation occurring between the 2 positions was reported by
Friberg to be more accurate in detecting abnormal movement in patients suspected of having segmental
instability,59 but more recent work has questioned the accuracy of this technique.60

Other authors20 contend that a decrease in symptoms with bracing provides evidence of segmental
instability. This technique is limited by the inability of most braces to effectively immobilize the
spine,61 and data have not been reported for a large group of patients. Olerud et al62 used an external
fixation device to achieve immobilization and reported that patients experiencing relief with this
technique were more likely to achieve favorable results with spinal fusion. The invasiveness of this
technique, however, precludes its use with most patients.

Diagnosis of lumbar segmental instability may also be based on examination findings or the patient's
history. Delitto et al63 believe that confirmatory data for segmental instability include frequent
recurrences of LBP precipitated by minimal perturbations, deformity (eg, lateral shift) in prior episodes
of LBP, short-term relief from manipulation, a history of trauma, use of oral contraceptives, or an
improvement of symptoms with the use of a brace in previous episodes of LBP. Some authors23,64
contend that the presence of a "step-off" between the spinous processes of adjacent vertebrae felt with
palpation or increased mobility with passive intervertebral motion testing are indicative of instability.
The reliability of these techniques, however, has been questioned, and their validity has not been
demonstrated.65 Other authors22,23 have emphasized that aberrant motions such as the "instability catch"
occurring during active ROM testing of the motion indicate instability. The instability catch has been
described by numerous authors22,66,67 as a sudden acceleration or deceleration of movement, or a
movement occurring outside of the primary plane of motion (eg, side-bending or rotation occurring
during flexion), and is proposed to indicate segmental instability. Its presence, however, has never been
related to symptoms or abnormal movements in diagnostic imaging studies.

A diagnostic "gold standard" has not been identified for segmental instability. A criticism of current
diagnostic imaging approaches is their inability to capture segmental spinal movements in the mid-
ranges of spinal motion, where aberrant motions such as the instability catch are most likely to be
observed.68 Flexion-extension radiographs taken at the end-range of movement will capture only the
function of the passive stabilizing subsystem and fail to address the active and neural control
subsystems. Because of the importance of motor control in spinal stability, some authors20,69 believe
that electromyographic techniques may hold more promise in diagnosing segmental instability, but
clinically useful techniques have yet to be described.

Treatment of Segmental Instability

Patients with segmental instability resulting in severe disability may be considered candidates for
lumbar spinal fusion.18 The rate of lumbar spinal fusion is increasing rapidly in the United States,
despite the fact that indications for the procedure are uncertain, costs and complication rates are higher
than for other surgical procedures performed on the spine, and long-term outcomes are uncertain.70–72
Fusion for segmental instability is usually reserved for patients with severe symptoms and radiographic
evidence of excessive motion (greater than 4 mm translation or 10o of rotation) who fail to respond to a
trial of nonsurgical treatment.18

The use of braces or corsets has been recommended in the treatment of persons with segmental

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instability.63,73 Spratt et al73 reported on a treatment program consisting of patient education, extension
exercises, and bracing to prevent flexion in a group of patients with radiographic evidence of segmental
instability. The treatment program was effective in reducing pain. The design of the study, however, did
not allow for an evaluation of the efficacy of bracing alone.

Patient education may be an important component in the nonsurgical treatment of patients with
segmental instability. Education should focus on avoiding end-range movements of the lumbar spine to
avoid positions that may overload the passive stabilizing structures of the spine. Patients should be made
aware that lifting even light loads from a position near the end-range spinal flexion can create potentially
damaging forces in the passive stabilizing structures of the spine.35,48 Patients also should be made
aware of the importance of maintaining muscle strength and endurance, particularly in the muscles of
the lumbar spine. Fatigue can adversely affect the ability of the spinal muscles to respond to imposed
loads,74 and general strengthening programs have been shown to be effective in patients with chronic
LBP.75

The physical therapy treatment for segmental instability often focuses on exercises designed to improve
stability of the spine. Several muscle groups have been identified in the literature as potentially playing
an important role in stabilizing the spine.46,47,76–78 The lumbar erector spinae muscles are the primary
source of extension torque for lifting tasks; therefore, strengthening this muscle group has been
advocated.46,79 Callaghan et al79 studied erector spinae muscle activity and imposed loads on the
lumbar spine during a variety of exercises thought to strengthen the back extensor muscles. Exercises
performed with the patient in a quadruped position, including single-leg extension and contralateral arm
and leg extension exercises, provided sufficient challenge to the erector spinae muscles without
producing a high load on the lumbar spine.79 Active trunk extension exercises performed with the
patient in a prone position produced high levels of activity in the erector spinae muscles, but also
imposed a substantial load on the lumbar spine, which may make these exercises a contraindication in
the rehabilitation process.79

The abdominal muscles, particularly the transversus abdominis and oblique abdominals, and the
multifidus muscle have been proposed to play an important role in stabilizing the spine by co-
contracting in anticipation of an applied load.77,80 The multifidus muscle, because of its segmental
attachments to the lumbar vertebrae, may be able to provide segmental control, particularly during
lifting and rotational motions.47 Exercises targeting these muscle groups, therefore, may be desirable.
Richardson and Jull78 described an exercise program that proposes to retrain the co-contraction pattern
of the transversus abdominis and multifidus muscles. The exercise program is based on training the
patient to draw in the abdominal wall while isometrically contracting the multifidus muscle. This co-
contraction exercise is then performed in a variety of postures.78 O'Sullivan et al80 recently reported the
results of a randomized trial comparing this exercise program with a program of general exercise
(swimming, walking, gym exercises) in a group of patients with chronic LBP. The stabilization exercise
group had less pain and functional disability following a 10-week treatment program than the general
exercise group, a difference that was maintained at a 30-month follow-up.80

Exercises proposed to address the abdominal muscles in an isolated manner usually involve some type
of curl-up maneuver. McGill76,81 found that dangerously high compressive and shear forces are
imposed on the lumbar spine during both straight and bent-knee curl-up exercises. A horizontal side-
support exercise has been recommended as an alternative to curl-ups for strengthening the abdominal
muscles.76 This exercise is performed with the patient side-lying and the upper body supported by the

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elbow to create a side-bending of the spine. The patient then lifts the pelvis off the support surface to a
position in line with the shoulders, eliminating the side-bending. This exercise provides a substantial
challenge to the oblique abdominal muscles without imposing high compressive or shear loading forces
on the lumbar spine.76 In addition, the horizontal side-support exercise challenges the quadratus
lumborum muscle, which may be an important spinal stabilizer for movements occurring in the frontal
plane.48

Exercises designed to challenge the neural control subsystem also have been recommended in the
treatment of persons with segmental instability.54 Effective exercises for achieving this outcome have
not been identified. The use of unstable surfaces such as therapy balls have been recommended for this
purpose. The efficacy of such an approach has not been investigated in the rehabilitation of patients with
LBP, but similar approaches have been found to be effective in the treatment of patients with knee joint
instability secondary to rupture of the anterior cruciate ligament.82

Conclusion

The concept of lumbar segmental instability is receiving increased interest from researchers and
clinicians alike as a potential pathomechanical mechanism in patients with LBP. At present, much
controversy exists regarding the proper definition of the condition, the best diagnostic methods, and the
most efficacious treatment approaches. Further research is needed to clarify these issues.

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