Stability and Instability of the Spine

  • Roberto Izzo
  • Gianluigi Guarnieri
  • Mario Muto
Part of the New Procedures in Spinal Interventional Neuroradiology book series (NPSIN)


The spine is a complex structure formed by motion segments (MSs) which, by working together, create a mobile, elastic and resistant ensemble, able to support the head and trunk and protect the spinal cord, the nerve roots and the vertebral arteries.


  1. 1.
    White AA, Panjabi MM (1978) Clinical biomechanics of the spine. Lippincott, PhiladelphiaGoogle Scholar
  2. 2.
    Brinckmann P, Biggermann M, Hilweg D (1988) Fatigue fracture of human lumbar vertebrae. Clin Biomech 3(Suppl 1):S1–S23Google Scholar
  3. 3.
    Bogduk N (2012) Clinical and radiological anatomy of the lumbar spine, 5th edn. Churchill Livingstone Elsevier, Edinburgh, pp 61–71Google Scholar
  4. 4.
    Hansson TH, Keller TS, Spengler DM (1987) Mechanical behavior of the human lumbar spine. II. Fatigue strength during dynamic compressive loading. J Orthop Res 5:479–487CrossRefPubMedGoogle Scholar
  5. 5.
    Adams MA, McNally DS, Wagstaff J et al (1993) Abnormal stress concentration in lumbar intervertebral discs following damage to the vertebral bodies: a cause of disc failure? Eur Spine J 1:214–221CrossRefPubMedGoogle Scholar
  6. 6.
    Bogduk N (2012) Clinical and radiological anatomy of the lumbar spine, 5th edn. Churchill Livingstone Elsevier, Edinburgh, pp 173–196Google Scholar
  7. 7.
    Farfan HF, Kirkaldy-Willis WH (1981) The present status of spinal fusion in the treatment of lumbar intervertebral joint disorders. Clin Orthop 158:198–214Google Scholar
  8. 8.
    Bogduk N (1992) Sources of low back pain. In: Jayson MIV (ed) The lumbar spine and back pain. Churchill Livingstone, Edinburgh, pp 61–88Google Scholar
  9. 9.
    Bogduk N, Twomey L (1991) Clinical anatomy of the lumbar spine, 2nd edn. Churchill Livingstone, MelbourneGoogle Scholar
  10. 10.
    Ohshima H, Urban JPG (1992) The effect of lactate and pH on proteoglycan and protein synthesis rates in the intervertebral disc. Spine 17:1079–1082CrossRefPubMedGoogle Scholar
  11. 11.
    Peng B, Chen J, Kuang Z, Li D et al (2009) Diagnosis and surgical treatment of back pain originating from endplate. Eur Spine J 18:1035–1040CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Peng BG (2013) Pathophysiology, diagnosis, and treatment of discogenic low back pain. World J Orthop 4(2):42–52CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Bogduk N (2012) Clinical and radiological anatomy of the lumbar spine, 5th edn. Churchill Livingstone Elsevier, Edinburgh, pp 11–27Google Scholar
  14. 14.
    Adams MA (2004) Biomechanics of back pain. Acupunct Med 22(4):178–188CrossRefPubMedGoogle Scholar
  15. 15.
    Kuslich S, Ulstro C, Michael C (1991) The tissue origin of low back pain and sciatica. Orthop Clin North Am 22:181–187Google Scholar
  16. 16.
    Taylor JR (1990) The development and adult structure of lumbar intervertebral discs. J Man Med 5:43–47Google Scholar
  17. 17.
    Hickey DS, Hukins DWL (1980) X-ray diffraction studies of the arrangement of collagen fibres in human fetal intervertebral disc. J Anat 131:81–90PubMedPubMedCentralGoogle Scholar
  18. 18.
    McNab I (1977) Backache. Williams and Wilkins, Baltimore, pp 4–7Google Scholar
  19. 19.
    Louis R (1989) Chirurgia del rachide. Piccin, Padova, pp 67–69Google Scholar
  20. 20.
    Dunlop RB, Adams MA, Hutton WC (1984) Disc space narrowing and the lumbar facet joints. J Bone Joint Surg Br 66:706–710CrossRefPubMedGoogle Scholar
  21. 21.
    Bogduk N (2012) Clinical and radiological anatomy of the lumbar spine, 5th edn. Churchill Livingstone Elsevier, Edinburgh, pp 1–10Google Scholar
  22. 22.
    Pearcy M, Portek I, Sheperd J (1984) Three-dimensional X-ray analysis of normal movement in the lumbar spine. Spine 9:294–297CrossRefPubMedGoogle Scholar
  23. 23.
    Boden SD, Riew DK, Yamaguchi K et al (1996) Orientation of the lumbar facet joints: association with degenerative disc disease. J Bone Joint Surg Am 78-A:403–411CrossRefGoogle Scholar
  24. 24.
    Fujiwara A, Lim TH, An HS et al (2000) The effect of disc degeneration and facet joint osteoarthritis on the segmental flexibility of the lumbar spine. Spine 25(23):3036–3044CrossRefPubMedGoogle Scholar
  25. 25.
    Shah JS (1980) Structure, morphology and mechanics of the lumbar spine. In: Jayson MIV (ed) The lumbar spine and backache, 2nd edn. Pitman, London, pp 359–405Google Scholar
  26. 26.
    Bogduk N (2012) Clinical and radiological anatomy of the lumbar spine, 5th edn. Churchill Livingstone Elsevier, Edinburgh, pp 207–215Google Scholar
  27. 27.
    Panjabi MM (1992) The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord 5:390–397CrossRefPubMedGoogle Scholar
  28. 28.
    Kirkaldy-Willis WH (1985) Presidential symposium on instability of the lumbar spine. Introduction. Spine 10:254CrossRefGoogle Scholar
  29. 29.
    White AA, Panjabi MM (1990) Clinical biomechanics of the spine, 2nd edn. JB Lippincott, PhiladelphiaGoogle Scholar
  30. 30.
    Larson SJ (1993) Vertebral injury and instability. In: Holtzman RMN (ed) Spinal instability. Springer, New YorkGoogle Scholar
  31. 31.
    Panjabi MM (1992) The stabilizing system of the spine. Part I. Function, dysfunction, adaptation and enhancement. J Spinal Disord 5:383–389CrossRefPubMedGoogle Scholar
  32. 32.
    Pope MH, Panjabi M (1985) Biomechanical definitions of spinal instability. Spine 10:255–256CrossRefPubMedGoogle Scholar
  33. 33.
    Akkerveeken PE, O’Brien JP, Parl WM (1979) Experimentally induced hypermobility in the lumbar spine: a pathologic and radiologic study of the posterior ligament and annulus fibrosus. Spine 4:236–241CrossRefPubMedGoogle Scholar
  34. 34.
    Abumi K, Panjabi MM, Kramer KM et al (1990) Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine 15:1142–1147CrossRefPubMedGoogle Scholar
  35. 35.
    Panjabi MM (2003) Clinical spinal instability and low back pain. J Electromyogr Kinesiol 13:371–379CrossRefPubMedGoogle Scholar
  36. 36.
    Panjabi MM (2006) A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J 15:668–676CrossRefPubMedGoogle Scholar
  37. 37.
    Weiler PJ, King GJ, Gertzbein SD (1990) Analysis of sagittal plane instability of the lumbar spine in vivo. Spine 15:1300–1306CrossRefPubMedGoogle Scholar
  38. 38.
    Scarfo’ GB (2002) Towards a functional definition of lumbar vertebral instability. Riv Neuroradiol 15:163–180CrossRefGoogle Scholar
  39. 39.
    Harris R, Mcnab I (1954) Structural changes in the lumbar intervertebral discs their relationship to low back pain and sciatica. J Bone Joint Surg 36B:304–321CrossRefGoogle Scholar
  40. 40.
    Harmon P (1964) Indications for spinal fusion in lumbar diskopathy, instability and arthrosis indications for spinal fusion in lumbar diskopathy, instability and arthrosis. I. Anatomic and functional pathology and review of literature. Clin Orthop Relat Res 34:73–91PubMedGoogle Scholar
  41. 41.
    Kirkaldy-Willis WH, Farfan HF (1982) Instability of the lumbar spine. Clin Orthop Relat Res 165:110–123Google Scholar
  42. 42.
    Jinkins JR (2004) Acquired degenerative changes of the intervertebral segments at and suprajacent to the lumbosacral junction. A radioanatomic analysis of the nondiscal structures of the spinal column and perispinal soft tissues. Eur J Radiol 50(2):134–158CrossRefPubMedGoogle Scholar
  43. 43.
    O’Sullivan BP (2000) Lumbar segmental instability: clinical presentation and specific stabilizing exercise management. Man Ther 5:2–12CrossRefPubMedGoogle Scholar
  44. 44.
    Park AL (2008) Instability: clinical manifestations and assessment. In: Slipman CW, Derby R, Simeone FA, Mayer TG (eds) Interventional spine an algorithmic approach. Saunders, Philadelphia, pp 1109–1119Google Scholar
  45. 45.
    Posner I, White AA, Edwards WI et al (1982) A biomechanical analysis of the clinical stability of the lumbar and lumbosacral spine. Spine 7:374–389CrossRefPubMedGoogle Scholar
  46. 46.
    Boden SD, Wiesel SW (1990) Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly? Spine 15:571–576CrossRefPubMedGoogle Scholar
  47. 47.
    Hayes MA, Howard TC, Gruel CR et al (1989) Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine 14:327–331CrossRefPubMedGoogle Scholar
  48. 48.
    Lowe RW, Hayes TD, Kaye J et al (1976) Standing roentgenograms in spondylolisthesis. Clin Orthop 117:80–84Google Scholar
  49. 49.
    Pearcy M, Shepherd J (1985) Is there instability in spondylolisthesis? Spine 10:175–177CrossRefPubMedGoogle Scholar
  50. 50.
    Axelsson P, Johnsson R, Stromqvist B (2000) Is there increased intervertebral mobility in isthmic adult spondylolisthesis? A matched comparative study using roentgen stereophotogrammetry. Spine 25:1701–1703CrossRefPubMedGoogle Scholar
  51. 51.
    Matsunaga S, Ijiri K, Hayashi K (2000) Nonsurgically managed patients with degenerative spondylolisthesis: a 10- to 18-year follow-up study. J Neurosurg 93:194–198CrossRefPubMedGoogle Scholar
  52. 52.
    Alyas F, Connell D, Saifuddin A (2008) Upright positional MRI of the lumbar spine. Clin Radiol 63:1035–1048CrossRefPubMedGoogle Scholar
  53. 53.
    Weishaupt D, Schmid MR, Zanetti M (2000) Positional MR imaging of the lumbar spine: does it demonstrated nerve root compromise not visible a conventional MR imaging? Radiology 215:247–253CrossRefPubMedGoogle Scholar
  54. 54.
    McGregor AH, Anderton L, Gedroyc WM et al (2002) The use of interventional open MRI to assess the kinematics of the lumbar spine in patients with spondylolisthesis. Spine 27(14):1582–1586CrossRefPubMedGoogle Scholar
  55. 55.
    Niggemann P, Kuchta J, Beyer HK et al (2010) Spondylolysis and spondylolisthesis prevalence of different forms of instability and clinical implications. Spine 20:1–6Google Scholar
  56. 56.
    Murata M, Morio Y, Kuranobu K (1994) Lumbar disc de generation and segmental instability: a comparison of magnetic resonance images and plain radiographs of patients with low back pain. Arch Orthop Trauma Surg 113:297–301CrossRefPubMedGoogle Scholar
  57. 57.
    Cartolari R (1997) Functional evaluation of the lumbar spine with axial-loaded computer tomography and cine ALCT. Riv Neuroradiol 10:569–584CrossRefGoogle Scholar
  58. 58.
    Matsunaga S, Sakou T, Morizono Y et al (1990) Natural history of degenerative spondylolisthesis: pathogenesis and natural course of the slippage. Spine 15:1204–1210CrossRefPubMedGoogle Scholar
  59. 59.
    Hioki A, Miyamoto K, Sakai H et al (2010) Lumbar axial loading device alters lumbar sagittal alignment differently from upright standing position: a computed tomography study. Spine 35(9):995–1001CrossRefPubMedGoogle Scholar
  60. 60.
    Mulholland RC (2008) The myth of lumbar instability: the importance of abnormal loading as a cause of low back pain. Eur Spine J 17:619–625CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    McAfee P (1999) Interbody fusion cages in reconstructive operations on the spine. J Bone Joint Surg Am 83A:294–297Google Scholar
  62. 62.
    Schmoelz W, Huber JF, Nydegger T, Claes L, Wilke HJ (2006) Influence of a dynamic stabilisation system on load bearing of a bridged disc: an in vitro study of intradiscal pressure. Eur Spine J 15(8):1276–1285CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Benzel EC (2003) Biomechanics of the spine. Thieme-Verlag, Stuttgart, pp 10–100Google Scholar
  64. 64.
    Bucholz RW, Gill K (1986) Classification of injuries to the thoracolumbar spine. Orthop Clin North Am 17:67–83PubMedPubMedCentralGoogle Scholar
  65. 65.
    Whitesides TE (1977) Traumatic kyphosis of the thoracolumbar spine. Clin Orthop 128:78–92Google Scholar
  66. 66.
    Tran NT, Watson NA, Tencer AF et al (1984) Mechanism of the burst fracture in the thoracolumbar spine. Spine 20:1988–1995Google Scholar
  67. 67.
    Holdsworth FW (1963) Fracture, dislocation and fracture-dislocation of the spine. J Bone Joint Surg Br 45B:6–20CrossRefGoogle Scholar
  68. 68.
    Denis F (1983) The three columns spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8:817–831CrossRefPubMedGoogle Scholar
  69. 69.
    Denis F (1984) Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop 189:65–76Google Scholar
  70. 70.
    Magerl F, Aebi M, Gertzbein SD et al (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184–201CrossRefPubMedGoogle Scholar
  71. 71.
    Leferink VJM, Veldhuis EFM, Zimmerman KW et al (2002) Classificational problems in ligamentary distraction type vertebral fractures: 30% of all B-type fractures are initially unrecognised. Eur Spine J 11:246–250CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Lee HM, Kim HS, Kim DJ et al (2000) Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine 25(16):2079–2084CrossRefPubMedGoogle Scholar
  73. 73.
    Starr JK, Hanley EN (1991) Junctional burst fractures. Spine 17:551–557CrossRefGoogle Scholar
  74. 74.
    Sliker CW, Mirvis S, Shanmuganathan K et al (2005) Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. Radiology 234(3):733–739CrossRefPubMedGoogle Scholar
  75. 75.
    Williams RL, Hardman JA et al (1998) MR imaging of suspected acute spinal instability. Injury 29:109–113CrossRefPubMedGoogle Scholar
  76. 76.
    Kirschner J, Seupaul RA (2012) Does computed tomography rule out clinically significant cervical spine injuries in patients with obtunded or intubated blunt trauma? Ann Emerg Med 60(6):737–738CrossRefPubMedGoogle Scholar
  77. 77.
    Fine PR, Kuhlemeier KV, De Vivo MJ et al (1979) Spinal cord injury: an epidemiologic perspective. Paraplegia 17:237–250PubMedGoogle Scholar
  78. 78.
    Knopp R, Parker J, Tashjian J et al (2001) Defining radiographic criteria for flexion-extension studies of the cervical spine. Ann Emerg Med 38:31–35CrossRefPubMedGoogle Scholar
  79. 79.
    Morris C, McCoy É (2004) Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening. Anaesthesia 59(5):464–482CrossRefPubMedGoogle Scholar
  80. 80.
    Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM et al (2005) Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi–detector row CT findings are normal? Radiology 237(1):106–113CrossRefPubMedGoogle Scholar
  81. 81.
    Panczykowski DM, Tomycz ND, Okonkwo DO (2011) Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J Neurosurg 115(3):541–549CrossRefPubMedGoogle Scholar
  82. 82.
    Chang W, Alexander MT, Mirvis SE (2009) Diagnostic determinants of craniocervical distraction injury in adults. Am J Roentgenol 192(1):52–58CrossRefGoogle Scholar
  83. 83.
    Rojas CA, Bertozzi JC, Martinez CR, Whitlow J et al (2007) Reassessment of the craniocervical junction: normal values on CT. Am J Neuroradiol 28(9):1819–1823CrossRefPubMedGoogle Scholar
  84. 84.
    Vaccaro AR, Hulbert RJ, Patel AA et al (2007) The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine 32(21):2365–2374CrossRefPubMedGoogle Scholar
  85. 85.
    Petersilge CA, Emery SE (1996) Thoracolumbar burst fracture: evaluating stability. Semin Ultrasound CT MR 17(2):105–113CrossRefPubMedGoogle Scholar
  86. 86.
    Van der Roer N, de Lange ES, Bakker FC et al (2005) Management of traumatic thoracolumbar fractures: a systematic review of the literature. Eur Spine J 14:527–534CrossRefPubMedPubMedCentralGoogle Scholar
  87. 87.
    Knop C, Bastian L, Lange U et al (2002) Complications in surgical treatment of thoracolumbar injuries. Eur Spine J 11(3):214–226CrossRefPubMedPubMedCentralGoogle Scholar
  88. 88.
    McCormack T, Karaikovic E, Gaines RW (1994) The load sharing classification of spine fractures. Spine 19(15):1741–1744CrossRefPubMedGoogle Scholar
  89. 89.
    Oner C, van der Rijt RR, Ramos LMP et al (1998) Changes in the disc space after fractures of thoracolumbar spine. J Bone Joint Surg Br 80:833–839CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Neuroradiology DepartmentAntonio Cardarelli HospitalNaplesItaly

Personalised recommendations