Functional Anatomy of the Lumbar Spine

Nabil A. Ebraheim, MD,* Ali Hassan, MD,† Ming Lee, MS,‡ and Rongming Xu, MD‡

The dysfunction of the lumbar spine has a pivotal role in etiology of low back pain. A
thorough knowledge of the functional anatomy of the lumbar spine is needed to aid in
understanding the mechanisms that lead to low back pain and to provide rationale of
management. This article reviews functional anatomy of the lumbar spine involving the
bony structures, articulation, ligaments, muscles, blood supply, and neural structures.
Semin Pain Med 2:131-137 © 2004 Elsevier Inc. All rights reserved.

KEYWORDS anatomy, lumbar spine, low back pain

T he dysfunction of the lumbar spine has a pivotal role in

etiology of low back pain. A thorough knowledge of the
functional anatomy of the lumbar spine is needed to aid in
understanding of the mechanisms that cause low back pain
and to provide rationale of management. This article reviews
the functional anatomy of the lumbar spine involving the
bony structures, articulation, ligaments, muscles, blood sup-
ply, and neural structures.
Osseous Structures
There are 5 lumbar vertebrae, followed by the sacrum. Each
lumber vertebra has 2 parts, the vertebral body and neural
arch. The vertebral body lies anteriorly, and its dimensions
gradually increase from cephalad to caudal. The neural arch
lies posterior to vertebral body and consists of a pair of
pedicles emerging from the postero-lateral surface of the up-
per portion of vertebral body that joins with paired laminae,
which are located further posteriorly (Fig. 1). When viewed
from above, the superior surface of vertebral body is wider
transversely and resembles to kidney’s shape. The spinal ca-
nal is triangular, which is most distinguishable at the L5 level.
The angled lateral borders of the spinal canal are called the
lateral recesses, which constitute the bony canal of the spinal
nerve root. Pedicles are short and have a slight medial incli-
nation.
In general, the pedicle width increases gradually from L1
to L5 but the pedicle height varies between individuals (Table
*Department of Orthopaedic Surgery, Medical College of Ohio, Toledo, OH.
†Department of Anesthesiology, Medical College of Ohio, Toledo, OH.
‡Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhe-
jiang, P.R. China.
Address correspondence to Nabil A. Ebraheim, MD, Department of Ortho-
paedic Surgery, Medical College of Ohio, 3000 Arlington Avenue, To-
ledo, OH 43614.
1).1-3 The pedicle lengths measured between the dorsal and
ventral cortex of the vertebra averages between 40 and 50
mm. The medial inclination of the lumbar pedicle increases
consistently from L1 to L5. The projection point of the pedi-
cle axis is located above the midline of the transverse process
at the levels above L4. At L4, the projection point is close to
the midline of the transverse process. At L5, this point is
located inferior to the midline of the transverse process.1
The lamina is thicker and oriented in a more vertical di-
rection in the sagittal plane as compared with the cervical and
thoracic spines. The lamina may be divided into 2 portions:
the cephalic and caudal.4 The cephalic portion is arched and
has a smooth inner surface, whereas the caudal portion has a
rough inner surface, which is the site for the attachment of
the ligamentum flavum.
The portion of the lamina between the superior and infe-
rior articular processes and just below the level of the pedicle
is the isthmus or pars interarticularis, which is the common
site of stress fractures. The superior and inferior articular
facets are quite different from the cervical and thoracic re-
gions, which are orientated in the sagittal plane. In lumber
region, the superior articular surface is concave and faces
posteromedially, and the inferior articular surface is convex
and faces anterolaterally. The facet angles relative to the sag-
ittal plane ranges from 120° to 150°, with a trend of consis-
tent decrease from L1 to L5.5 From the junction of 2 lamina,
a spinous process arises posteriorly. It is almost horizontal,
quadrangular, and thickened along its posterior and inferior
borders.
Articulations and Ligaments
The articulations include the intervertebral disc anteriorly
and a pair of the facet or zygapophyseal joints posteriorly,
reinforced by ligaments. The intervertebral discs, which are

1537-5897/04/$-see front matter © 2004 Elsevier Inc. All rights reserved. 131
doi:10.1016/j.spmd.2004.08.004
132 N.A. Ebraheim et al

Figure 1 The superior, posterior, and lateral views of the lumbar vertebra.

avascular structures, are located in between adjacent verte-
bral bodies and allow flexion, extension, and lateral bending
motions. They mainly consist of a centrally located nucleus
pulposus, the annulus fibrosus encircling the nucleus pulpo-
sus, and cartilaginous end plates adjacent to the surfaces of
the vertebral bodies (Fig. 2).
The nucleus pulposus is composed mainly of mucoid ma-
terial, which contains 70% to 90% water.6 On T2-weighted
magnetic resonance imaging, the nucleus pulposus shows
hyperintensity signal (white). The percentage of the water in
the nucleus pulposus gradually decreases with aging. After
the fifth decade, the nucleus pulposus becomes less distin-
guishable from the annulus fibrosis due to the loss of water.
The loss of water could be the major factor responsible for
disc degeneration, presented by the decrease in height of the
disc.
The annulus fibrosus consists mainly the collagenous fi-
bers and looks like a laminated structure surrounding the
nucleus pulposus. The posterior portion of annulus fibrosus
is thinner as compared with its anterior portion. The fibers of
the lamellae are arranged obliquely in concentric rings that
overlap one another. The peripheral fibers of the annulus
fibrosus insert into the cartilaginous end plates and anterior
and posterior longitudinal ligaments. In the posterior portion
of the disc, the fibers run in a more vertical direction.7 A
thinner posterior annulus fibrosus and a more vertical ar-
rangement of the fibers could account for increased incidence
of posterior or posterolateral disc herniation as compared

Table 1 Anatomic Parameters of Lumbar Pedicle (Mean ⴞ SD, mm)

Zindrick3 Panjabik2 Ebraheim15
PH PW PH PW PH PW
L1 15.4 ⴞ 2.8 8.7 ⴞ 2.3 15.9 ⴞ 0.8 8.6 ⴞ 0.9 14.1 ⴞ 1.3 7.5 ⴞ 1.5
L2 15.0 ⴞ 1.5 8.9 ⴞ 2.2 14.9 ⴞ 0.5 8.3 ⴞ 0.7 14.0 ⴞ 1.2 8.2 ⴞ 1.3
L3 14.9 ⴞ 2.4 10.3 ⴞ 2.6 14.4 ⴞ 0.6 10.2 ⴞ 0.6 13.9 ⴞ 1.4 9.8 ⴞ 1.1
L4 14.8 ⴞ 2.1 12.9 ⴞ 2.1 15.5 ⴞ 0.5 14.1 ⴞ 0.3 12.8 ⴞ 1.7 12.7 ⴞ 1.9
L5 14.0 ⴞ 2.3 18.0 ⴞ 4.1 19.6 ⴞ 0.9 18.6 ⴞ 1.0 11.4 ⴞ 1.4 18.0 ⴞ 2.4
PH, pedicle height; PW, pedicle width.
Functional anatomy of the lumbar spine
Figure 2 The sagittal and transverse sections of the lumbar disc.
with anterior herniation. Disc herniations are commonly seen
in the lumbar spines at the levels of L4 to 5 and L5 to S1. The
cartilaginous end plate that is located between the vertebral
body and disc, functions as a growth plate and transfuses
nutrients from the vertebral body to the disc.
Facet Joints
Facet joint (zygapophyseal or synovial joint) consists of the
adjacent inferior and superior articular processes and the
articular capsule. The articular surfaces are covered by hya-
line cartilage, which allows sliding motion occurring in the
posterior arch of the spinal column. The articular capsules
are thin, and have an inner synovial and an outer fibrous
membrane. They are attached peripheral to the articular sur-
faces of the facet joints. In the lumbar region narrowing of the
joint space, thinning of articular cartilage, and hypertrophy
of the subarticular cortical bone are the frequently observed
changes due to aging process.8
Ligaments
There are several ligaments that play an important role in
stabilization of the spines as one unit. These include the
anterior and posterior longitudinal ligaments, ligamentum
flava or yellow ligaments, supraspinous and interspinous lig-
aments (Fig. 3).
The anterior longitudinal ligament is a strong band that
attaches to the whole anterior aspect of the vertebral bodies
and intervertebral discs from the skull down to the upper
133
part of sacrum. It is thicker anteromedially and thinner lat-
erally. Its most superficial fibers are the longest and extend
over 3 to 4 vertebrae. Its deepest fibers extend over 2 verte-
brae and are firmly attached to the inferior margin of the one
vertebra and to the superior margin of the next. Limitation of
extension of the spinal column is the main function of the
anterior longitudinal ligament.
Opposing the anterior longitudinal ligament, the posterior
longitudinal ligament attaches to the posterior aspect of the
vertebral bodies and discs, from the occipital bone to the
sacrum. It is broad and uniform in the cervical region, but in
the thoracic and lumber regions it is narrow over the middle
of the vertebrae and broad over the discs. In the region of the
intervertebral foramen, the posterior longitudinal ligament
extends laterally and fuses with the lateral extensions of the
anterior longitudinal ligament. Similar to the anterior longi-
tudinal ligament, the superficial fibers of the posterior longi-
tudinal ligament extend over 3 to 4 vertebrae, and the deeper
fibers bridge merely the adjacent vertebrae. The role of the
posterior longitudinal ligament is to stabilize the spinal col-
umn during flexion.
The ligamentum flava are present in between the laminae
of adjacent vertebrae and fuse with each other in the midline.
They are mainly composed of the yellow elastic fibers, which
run in vertical direction. The attachments of the ligamentum
flavum extend from the lower portion of the anterior surface
of the upper laminae to the upper portion of the posterior
surface of the lower laminae, covering whole interlaminar
134
Figure 3 The sagittal section and anterior view of the lumbar ligaments.
space.9,10 Laterally, the ligamentum flavum fuses with the
capsule of the facet joint. The ligamentum flavum is very
thick in the lumbar spine. The lumbar ligamentum flavum
has 2 layers, 1 superficial and another that is deeper.11 Hy-
pertrophy or thickening of the ligamentum flavum in the
lumbar spine is one of the common causes of spinal steno-
sis.12
The interspinous and supraspinous ligaments are the
posterior ligaments of the spinal column, which connect
the spinous processes with each other. The interspinous
ligament is thin and extends from the lower border of one
spinous process to the upper border of the next. The su-
praspinous ligament is stronger and extends over spinous
processes from the occipital bone to the sacrum. The in-
tertransverse ligaments are membranous structures lo-
cated between the transverse processes, typically in the
lumbar region. The lumbar nerves lateral to the interver-
tebral foramina lie directly underneath the intertransverse
ligaments.13
Neural Structures
The spinal cord ends between the disc levels of T12 to L1 and
L2 to 3. The distal part of spinal cord forms a cone like
structure called as conus medullaris, and is followed by a
bundle of nerve roots termed the cauda equina (Fig. 4). The
lumbar enlargement of the spinal cord is located between the
L1 and S3 segments that gives rise to large nerves supplying
the lower extremities.
N.A. Ebraheim et al
The cauda equina is arranged in a consistent pattern
when seen in cross-sectional plane.14 At L4 to 5 level, the
L5 nerve is situated in the anterolateral corner of the dural
sac, followed by the S1 and S2 to 5 nerves posteriorly. At
L5-S1 level, the S1 nerve is situated in the anterolateral
corner of the dural sac, followed by the S2 to 3 and S4
nerves posteriorly.
The spinal cord is covered by three meninges, the dura
mater, arachnoid, and pia mater. The dura mater is the out-
ermost layer of the spinal meninges and is composed of
dense, fibrous connective tissue. The space between the spi-
nal canal and the dura matter is called the epidural space, and
contains fat, loose connective tissue, and venous plexus,
which function as padding around the spinal cord. The mid-
dle layer of the spinal meninges is the arachnoid, which con-
sists of delicate connective tissue. There is a small space be-
tween the dural matter and arachnoid, termed the subdural
space. The subdural space contains serous fluid. The inner
thin transparent layer of the spinal meninges is the pia mat-
ter, which contains numerous nutrient vessels. The pia mat-
ter adheres closely to the surface of the spinal cord, and
extends laterally to the dura matter between the ventral and
dorsal nerve roots on either side.
The lateral extensions of the pia matter are called the den-
tate ligaments, which serve to protect the spinal cord from
injury during movement of the spinal column. The space
between the arachnoid and pia matter is called the subarach-
noid space, which contains the cerebrospinal fluid.
Functional anatomy of the lumbar spine 135

Figure 5 Blood supply of the spinal cord.

the lower abdominal wall and part of the lower extremity.

The femoral nerve is the largest branch from the lumbar
plexus, which passes under the inguinal ligament to supply
the flexor muscles of hip and extensor muscles of knee.

Figure 4 The posterior view of spinal cord.

The Spinal Nerves

The spinal nerves consist of ventral and dorsal roots that
leave and enter the spinal cord, respectively. The ventral
roots contain axons of motor neurons from the anterior gray
horn of the spinal cord. The dorsal roots contain sensory
axons that arise from the sensory cell bodies contained in
ganglia, which are the enlargement of the dorsal roots. There
are 11 pairs of spinal nerves in the lumbar region, including
5 lumbar, 5 sacral, and 1 coccygeal. The spinal nerves emerge
below the corresponding vertebrae in the lumbosacral re-
gion. The spinal nerves exiting from the spinal canal are close
to the medio-inferior border of the upper pedicle and lie in
the upper portion of the intervertebral foramina in the lum-
bar spine.15,16 Most ganglia of the lumbar spinal nerves lie
within the intervertebral foramen.17,18
After exiting from the intervertebral foramina, each spinal
nerve divides into a small dorsal ramus and a large ventral
ramus. The dorsal rami courses posteriorly to supply the
spinal ligaments, muscles and skin of the back. The ventral
rami are longer, and run in infero-lateral direction in the
lumbar region to form the lumbar, and sacral plexuses. These
plexuses give rise to nerves supplying the muscles, joints, and
skin of the upper and lower extremities.
The lumbar plexus consists of the ventral rami of L1, L2,
L3, and L4 nerves. The lumbar plexus courses in the infero-
lateral direction, passes posterior to the psoas major muscle
and anterior to the quadratus lumborum muscle. It supplies Figure 6 The superficial layer of the posterior muscles of spine.
136
Figure 7 The intermediate (right) and deep (left) layers of the posterior muscles of spine.
The sacral plexus consists of the ventral rami of L4, L5, and S1
through S4 nerves. Within the pelvis, the sacral plexus gives its
peripheral nerves to supply the buttocks, perineum, and lower
extremities. The largest branch from the sacral plexus is the
sciatic nerve, which leaves the pelvis through the greater sciatic
notch and supplies entire leg and foot. The main branches from
the sciatic nerve are the common peroneal nerve and the tibial
nerve. The common peroneal nerve further branches into the
superficial and deep peroneal nerves.
Blood Supply
The blood supply of the lumbar spine and spinal cord comes
mainly from the segmental arteries that originate from the
intercostal and lumbar arteries. Each of the segmental arteries
gives off a spinal branch supplying the vertebrae, spinal cord
and cauda equina. The spinal branch enters the spinal canal
through the intervertebral foramen and anastomoses with the
N.A. Ebraheim et al
spinal arteries above and below. The fifth lumbar vertebra
and sacrum receive their blood supply from the fourth lum-
bar artery, the iliolumbar arteries, and the middle and lateral
sacral arteries. The main blood supply of the spinal cord is by
a single anterior spinal artery, paired posterior spinal arteries
and several radicular (medullary) arteries (Fig. 5).
The number of the medullary arteries varies from the cer-
vical to lumbar region because only a few segmental arteries
branch off the medullary arteries to join with the anterior
spinal artery.19 There are usually one to three medullary ar-
teries in lower thoracic and lumbosacral cord regions.20
The most caudal medullary artery is the largest with a mean
diameter of 0.9 mm and also called Adamkiewicz’s artery. It
usually originates from the lower intercostal or upper lumbar
artery.21 The medullary arteries provide vital contributions to
blood supply of the anterior spinal artery. The risk of ischemic
injury to spinal cord greatly increases if the anterior spinal artery
is compromised by osteophytes, disc herniation or fracture, or if
Functional anatomy of the lumbar spine
medullary artery gets injured. The radicular arteries may also
provide blood supply to the cauda equina.22,23
Veins surrounding the spinal cord include an anterior in-
ternal vertebral venous plexus and a posterior internal verte-
bral venous plexus, which are valveless venous structures in
the epidural space. The anterior internal venous plexus con-
sists mainly of two longitudinal veins located between the
pedicles and the posterior longitudinal ligament. These veins
anastomose with each other and also with the basivertebral
sinus that drains blood from the vertebral body. The poste-
rior internal venous plexus is lesser dense, and anastomoses
with the anterior internal venous plexus. Blood from the
internal venous plexus is drained through the intervertebral
foramen into the segmental veins.
Muscle Distribution
The muscles surrounding the lumbar spine are divided into
three groups: posterior, lateral, and anterior, depending on
their location. The posterior muscles of the lumbar spine
generally consist of superficial, intermediate and deep layers.
The superficial layer is the thoracolumbar fascia, which is
thick and strong, and may play an important role in rotation
of the trunk and stabilization of the lower back (Fig. 6).24
The intermediate layer of the muscles in the lumbar region
is made by serratus posterior inferior, which origins from the
spinous processes of the cervicothoracic and thoracolumbar
spine and inserts into the ribs. The deep layer of the posterior
muscles consists of the erector spinae muscles, which are
vertically oriented muscle bundles from the iliosacrolumbar
region up to the cervical region (Fig. 7).
There are 3 distinct columns of the erector spinae muscles
under the thoracolumbar fascia in the lumbar region: iliocostalis
laterally, longissimus centrally, and spinalis medially. The ilio-
costalis is divided into the iliocostalis lumborum, iliocostalis
thoracis, and iliocostalis cervicis based on its distribution. It
originates from the posterior iliac crest and gives muscle slips to
the ribs and the transverse processes of the lower cervical spine.
The longissimus is the largest muscle of the erector spinae,
and is also divided into 3 portions: longissimus thoracis,
longissimus cervicis, and longissimus capitis. It originates
from the posterior surface of the sacrum and gives muscle
slips to the transverse processes of the thoracic and cervical
spine and the mastoid process.
The spinalis is the smallest of all the erector spinae, and has
three portions: spinalis thoracic, spinalis cervicis, and spina-
lis capitis. The spinalis originates from the spinous processes
of the upper lumbar spine and gives muscle slips to the spi-
nous processes above.
Under the erector spinae muscle, there are several short
muscles called the semispinalis, multifidi, and rotators.
These muscles course in an oblique direction between the
spinous processes and the transverse processes of the spine.
Most of the posterior muscles of the spine are supplied by the
dorsal rami of the spinal nerves and the dorsal branches of
segmental arteries. Their function includes extension, lateral
bending, and rotation of the spine.
The lateral or anterolateral muscles in the lumbar region in-
137
clude, the iliopsoas major and quadratus lumborum. The psoas
major originates from the anterolateral aspect of the vertebral
bodies and discs, from the anterior aspect of the transverse pro-
cesses of entire lumbar spine, and inserts onto the lesser tro-
chanter of the femur. The quadratus lumborum is a rectangular
muscle that originates from the L5 transverse process and iliac
crest, and inserts onto the transverse processes above and the
twelfth rib. The anterior and lateral muscles of lumber spine are
innervated by the ventral rami of the spinal nerves. Most of them
contribute to flexion and rotation of the lumbar spine.
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