The iliolumbar ligament: its influence on stability of the sacroiliac joint
Introduction
In the majority of cases low back pain (LBP) manifests itself in the lower lumbar region, with pain radiating to the iliac crest, into the buttocks or even the leg. Therefore, most studies on the etiology of LBP focus on the mechanical behaviour of the lumbosacral area and specifically on the intervertebral discs (Adams and Hutton, 1982; Nachemson, 1981; Keller et al., 1990; Brinckman, 1986). However, modern imaging techniques have shown that spinal abnormalities such as disk herniation are common in persons without back pain (Riihimaki, 1991). Furthermore, in the majority of LBP patients, only rarely a specific cause can be identified (Waddell, 1987). For these LBP patients the expression non specific LBP is used (Waddell, 1987).
Recently, several anatomical, biomechanical and neurophysiological studies on the lumbopelvic region have supported the view that loss of stability of the sacroiliac joints (SIJ) can be crucial in the aetiology of non specific LBP (Vleeming et al., 1996; Richardson et al., 2002; Pool-Goudzwaard et al., 1998). Main conclusions from these studies are: (a) in all loading conditions muscle forces are necessary for lumbosacral stability (Snijders et al., 1997, Snijders et al., 1993a, Snijders et al., 1993b); (b) mechanoreceptors in the massive ligamentous system of the lumbosacral area are important for the activation of muscles for posture control (Richardson et al., 2002; Indahl et al., 1999; Hides et al., 1994; Jull and Richardson, 1999; Richardson and Jull, 1995) and (c) ligaments that restrict the range of motion of the SIJ play an important role in the stability of the SIJ (Vleeming et al., 1996; Wingerden et al., 1993; Vleeming et al., 1989).
Stability can be interpreted in multiple ways. In this study we define stability as the ability of a joint to bear loading without uncontrolled displacements. Stability depends on the relative positions of the respective bones: in certain positions the joint can bear loading, in others it cannot. Uncontrolled displacements will allow the joint to adopt positions in which the joint cannot bear loading. Ligaments contribute to stability by controlling the relative positions of the joint, restricting the mobility of the joint to those positions in which the joint can bear loading. Hence, the ligaments contribute to stability by restriction of mobility.
To assess the contribution of the ligamentous system to stability of the SIJ, all relevant ligaments in the lumbosacral area have to be taken into consideration. Surprisingly, the function of one of the major ligaments in this region, the iliolumbar ligament (IL), is poorly understood. Several authors describe its influence on flexion–extension, lateroflexion in the L5-S1 facet joint and torsional stability of the L5-S1 facet joint (Yamamoto et al., 1990; Leong et al., 1987; Yamamoto et al., 1989; Chow et al., 1989). However, no study exists in relation to the mechanics of the SIJ. This is remarkable since the IL actually crosses the SIJ (Pool-Goudzwaard et al., 2001).
Knowledge of the function of the IL is of special interest since the assumption has been made that the IL is the primary cause of many cases of LBP (Sims and Moorman, 1996; Naeim et al., 1982; Broudeur et al., 1982; Broadhurst, 1989).
In the present study we analyse whether the IL is able to contribute to SIJ stability by restricting SIJ mobility.
Section snippets
Methods
In this study we consider an increase of SIJ mobility after sectioning the IL, as evidence that the IL is able to restrict SIJ mobility. To test the SIJ mobility we applied different moments of force to the SIJ and measured the amount of rotation in the sagittal plane. The relation between SIJ rotation and load is shown in Fig. 1 (thick S-curve). After sectioning of the IL the same moments of force have been applied to the SIJ. We hypothesize that section of the IL results in a steeper S-curve,
Results
Comparing the data of the intact specimens with those after a total cut of both ILs, the paired t-test showed a significantly steeper slope (P=0.021) of the load deformation curves after the total cut (Table 1). The mean increase of the normalised values in specimens with the IL totally cut was 28.1%. Also after transection of exclusively the ventral bands of the ILs, the paired samples t-test showed a significantly steeper slope (P=0.002) (Table 1). Transection of both dorsal bands as well as
Discussion
A significant increase of SIJ mobility in the sagittal plane occurs after a total cut of both ILs, as shown by the significantly steeper slope of the load deformation curves. This increase in SIJ mobility was not due to changes over time since four subsequent tests in intact specimens without transection did not show significant changes. Obviously, the IL restricts SIJ mobility in the sagittal plane (nutation and counternutation). This finding does expand the biomechanical functions of the IL
Conclusions
Based on this study we conclude the following:
- 1.
the ILs restrict sagittal SIJ mobility,
- 2.
especially the ventral band of the IL contributes to this restriction,
- 3.
no important role restricting sagittal SI joint mobility could be attributed to the sacroiliac part and the dorsal band of the IL.
Acknowledgements
The authors would like to thank the “Vereniging Trustfonds Erasmus Universiteit” for their financial support. The authors would like to thank J. Velkers and C. Entius for their effort, and J. Twisk for his advice.
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