Page 8 P H Y S I O T H E R A P Y June, 1970 for surgery because conservative treatment will give satis­ factory results in more than half the patients. Indications for fusion are therefore clinical rather than radiological as studies have shown the similarity o f symptomatology no matter what the pathology. In a proportion o f cases therefore where there is persistant long standing low back pain that fails to respond to conservative measures and when the degree o f degeneration warrants it, fusion is indicated. CONCLUSIONS The problem o f low backache in the elderly female is thus seen to be a bewildering and difficult subject. An attempt has been made to explain the various causes o f low backache and to simplify the problem by classifying the various possible causes into a group o f clinical syndromes. Each group is described separately and the methods of examination, diagnosis and treatment are discussed. It is important to make a full assessment o f the individual patient including her mental makeup, her environment, and the physical lesion. A N A T O M I C A L FEATURES OF THE L U M B O S A C R A L SPINE By R. TREVOR-JONES An interesting collection o f abnormal lumbar vertebrae and sacra are housed in the Department o f Anatomy, Medical School, University o f Cape Town. This material inspired me to investigate the musculo-skeletal anatomy, as seen in the dissecting room, in an attempt to explain certain aspects o f backache. Clinical records o f the subjects dissected were too brief for any correlation o f findings and'symptoms. The lumbo-dorsal fascia varies in thickness and over the sacrum blends with the fascial origin o f the erector spinae muscle. From the erector spinae aponeurosis inter-muscular septa pass forwards to separate Multifidus completely from the sacro spinalis group o f muscles. . Multifidus arises from the dorsum o f the sacrum, the posterior medial edge o f the iliac crest between-posterior superior and posterior inferior iliac spines, the deep surface o f the combined lumbo-dorsal and erector spinae fascia and the medial surface o f the intermuscular septum which separates it from Longissimus. The intermuscular septum, in its upwards extension is attached to the inferior aspect of the mammillary processes while Multifidus arises from the superior aspect as well as the inter articular joint capsules. Careful dissection reveals that Multifidus can be separated into sagittal lamellae arranged segmentally although the muscle looks like a solid wedge. That portion medial to the posterior inferior iliac spine passes to the sacrum and lower four lumbar vertebrae while the portion from the posterior superior iliac spine passes to first lumbar and twelfth thoracic vertebrae. Longissimus and Iliocostalis have a common origin just lateral to the posterior superior iliac spine, from the erector spine, from the erector spinae fascia and from the lateral surface o f the intermuscular septum separating it from Multifidus. It can be divided into coronally placed musculo- tendonous lamellae passing to the accessory tubercles and adjacent laminae o f the lumbar vertebrae. Ilio-costalis is separated from Longissimus by a neuro­ vascular plane and an intermuscular septum. This muscle also can be separated into coronally placed lamellae passing to the transverse processes o f the lumbar vertebrae. The outer portions o f these lamella are formed into encircling loops which, with the erector spinae fascia and lumbar fascia firmly enclose the back muscles in the lumbo-sacral region. This segmental pattern is found in foetuses. Multifidus then has sacral segments. A six piece foetal sacrum was associated with incomplete muscle segmentation. This lack o f muscle differentiation was also found in an adult cadaver with a sacralisation o f the fifth lumbar vertebra on the left side. The muscle anomaly however occurred on the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1970 R H Y S I O.T.H E R A P Y Page 9 right side. In this case too, it was noted that the descending branch o f the fourth lumbar nerve was stretched and angulated over the enlarged transverse process o f the fifth lumbar vertebra. In partial sacralisations then it would appear that back­ ache could be due to either the pain o f the pseudarthrosis or direct nerve involvement. Disc degeneration has been adequately described by other workers. However, other soft tissue features were noted. In fat subjects, intermuscular deposits o f fat are found between the muscle segments, around the apophyseal joints and large extra articular deposits on the posterior aspects of the superior articular bearing facets o f the sacrum, the fifth and fourth lumbar vertebrae (an accumulation o f fat in front o f the sacrum, on superior and inferior surfaces o f the pelvic diaphragm could be o f gynaecological importance). Degenerations o f the interspinous ligaments were fre­ quently noted. These are frequently associated with joint like cavities between closely approximated spinous proces­ ses. The apophyseal joints vary considerably in shape, size and inclination. The articular facets are seldom symmetrical and even in fresh specimens do not articulate accurately. Asymmetry o f articular facets is often associated with osteo- arthritic changes o f vertebral bodies and apophyseal joints. The apophyseal joint capsules are usually thickened inferiorly and extend backwards to blend with the inter­ spinous ligaments. A- meniscoidal intra-articular synovial fringe encompasses the periphery o f the intra-articular facets. In osteoarthritis o f the apophyseal joints this synovial fringe enlarges so that in severely affected joints it extends as a ragged curtain across the joint. Nipping of this fringe could possibly account for sudden spasms o f backache. Enlargement o f the intra- and extra- vertebral venous plexuses is often found at osteo-arthritic levels o f the vertebral column as a whole. This may well be related to diminished intervertebral movement. The intervertebral foramen transmits the nerve root, two small arteries and three or more venous connections between intra- and extra- vertebral venous plexuses. Its boundaries consist of inter­ vertebral disc and adjacent vertebral bodies anteriorly, the superior vertebral notch inferiorly, the larger inferior verte­ bral notch superiorly and the ligamentum flavum covering the apophyseal joint posteriorly. Loose connective tissue and fat surrounds the nerves, arteries and veins. Intervertebral movement affects the size and shape o f the intervertebral foramen. In flexion all diameters o f the foramen are increased while extension caused a diminution o f these diameters. Intervertebral movement obviously subjects the emerging veins to alterations o f shape and pressure and conceivably causes a pumping effect assisting venous refum. These features suggest that adequate intervertebral move­ ment is essential for a pain free back. Clinical experience shows that backache is most frequent among office workers, housewives and the less active individuals. In contrast the African population is generally free o f backache and in fact only suffer from backache when “Westernised”. SUGG ESTED R E A D IN G FOR ANTE-AND POSTNATAL TEACHING By ROSEMARY HARTE, M .C S.P. , There are so many books available relating to the subject h 1 somet*mes at a loss to know which will be most nelpful Many I have read, and there must be as many again not readily available in this country with which I am un- J 1!aJ\^'or *he purpose o f clarity I have grouped books thp k j ve most meaningful' in my own work into ne Droad categories o f Teaching, Womanhood, Obstetrics, exercises, Relaxation and General. anrl if !° •*3e remembered that we are teaching the laywoman acrncc Slmply t.reat*ng her. Depending on our ability to put H e re in r ° r subJect follows the measure o f our success, n lies an answer why so many o f our ranks succeed in their work and so many, equally knowledgeable, somehow fail. I am sure that a good book on the technique o f teaching is invaluable. There are many on the market and I offer: The Art o f Teaching by Gilbert Highet (University Paper­ backs), Working With Groups by Josephine Klein (Hut­ chinson University Library). More specifically: An Approach to Antenatal Teaching by Sheila Kitzinger (National Child­ birth Trust). A highly commendable booklet. The approach is largely psychological, an aspect insufficiently stressed in physiotherapy training. Methods o f teaching are sound and well explained, and there is an excellent bibliography at the back for those wishing further reading, under specified headings. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )