MRI evaluation of lumbar spine flexion and extension in asymptomatic individuals

Flexion and extension movements or positions have been advocated in the treatment of various forms of low back dysfunction due to the potential pain relieving effects attributed to displacements of the intervertebral disc (IVD). Objective in vivo determination of the segmental behaviour of the disc to contrasting positions has until recently been difficult. Magnetic resonance imaging (MRI) was used in this study to evaluate the influence of sagittal plane positions on lumbar IVD height and nucleus displacement in a small asymptomatic population.T2-weighted sagittal plane images from L1 to S1 were obtained from 10 subjects (mean age: 30+/-5 years) positioned supine in lumbar flexion, followed by extension. Changes in disc height and localization of nucleus position (determined by peak MRI signal intensity) between the two positions were calculated. Discs were classified for degenerative changes using a semi-quantitative grading scale. The mean range of lumbar sagittal movement achieved in the MRI was 44 degrees (range: 22-77 degrees ). Between flexion and extension, a significant increase in measured anterior disc height of 1.1 mm (P<0.0001) and anterior displacement of the nucleus of 6.7% (P<0.0001) was observed. Despite the anterior displacement of the nucleus in extension observed in the pooled analysis, 30% of discs did not follow this trend. Nucleus degeneration was observed in at least one disc in nine subjects and in 26% of all discs examined. Lumbar spine position was found to be associated with small measured changes in anterior disc height and nucleus position, however, this response was variable within and between individuals. The theoretical concept of a stereotypical effect of spinal position on the lumbar IVD is challenged by these initial data. Since the health of the disc is often unknown in clinical practice, manual therapy treatment for lumbar spine pain should be based on the symptomatic response to movement and position rather than biomechanical theory.