요천추 인대와 경추 인대 각각의 기능 - 정리 중

[문형철]

 lumbopelvic-hip의 인대는 

전종인대, 후종인대, 황색인대, 극간인대, 극상인대, 장요인대, 천조인대, hip joint capusle가 있다

각각의 인대는 각각의 기능을 가지고 있다.

항상 어떤 구조, 기능을 탐구할때는 기능복합체(functional complex)로 파악해야 한다. 

lumbopelvic-hip

shoulder girdle

ankle-foot complex

panic bird...

The Soft Tissue Structures of the Lumbar Spine Michael McMurray.pdf

The main supporting ligaments of the lumbar spine are the anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), sacrotuberous ligament, iliolumbar ligament, and ligamentum flavum.

- 요추를 지지하는 인대는 전종인대, 후종인대, 천조인대, 장요인대, 황색인대임.

천조 인대 sacrotuberous ligament

The sacrotuberous ligament is composed of three bands: lateral, medial, and superior. The lateral band connects the ischial tuberosity and the posterior inferior iliac spine and spans the piriformis. The medial band spirals and attaches to the transverse tubercles of S3-5 and lateral margin of the lower sacrum and coccyx. The superior band runs superficial to the interosseous ligament and connects the coccyx with the posterior superior iliac spine. The function of this ligament is to prevent sacral nutation and control posterior rotation of the innominate. This ligament also serves as an attachment for the gluteus maximus muscle (Figure 1).

- 천조인대는 3 band로 구성됨. lateral, medial, and superior

-  외측 band는 좌골결절과 PIIS를 연결하고, 이상근을 가로지름. 

- 내측 band는 나선으로 감겨  S3-5번 횡돌기에 부착

- 상부 band는 interosseous ligament에서 꼬리뼈로 연결됨. 

- 천조인대의 기능은 천골의 nutation을 방지함. 

- 천조인대는 대둔근 부착부를 제공함. 

해부학 사이트네.. 

장요인대

The iliolumbar ligament consists of five bands: anterior, posterior, superior, inferior, and vertical. It connects from the tip of the L5 transverse process to the anteriomedial surface of the ilium and the inner lip of the iliac crest. 

The function of this ligament is to minimize the torque forces at the lumbosacral junction and resist forward sliding of L5 on the sacrum. Unilaterally, it will resist side bending as well as some twisting and forward bending (Figure 1).

장요인대 기능은 l5-s1 junction에서 비틀림의 힘을 최소화하고, 천골에서 요추 5번 요추체가 앞으로 밀려나가는 것을 막아줌. 

한쪽으로는 측굴을 제한하고, 약간의 회전과 전방굴곡을 막아줌. 

Additional lumbar ligaments - 장요인대

The iliolumbar ligaments ( Fig. 1 0. 1 9 ) are the most important complex of ligaments that have contact wit h the lumbar

spine but arise elsewhere. They run from different points on the L4 and L5 costal processes to the anterior aspect of the iliac crest and the ala of the ilium. The individual sections vary in their construction and are connected to the lumbar segmental ligaments and the sacroiliac ligaments ( Pool-Goudzwaard et aI., 200 1 ).

- 장요인대는 요추와 함께 연결된 가장 중요한 복잡한 인대구조임. 

- 장요인대는 요추 4, 5 횡돌기에서 장골능, 장골의 날개로 이어짐. 

- 장요인대는 요추분절인대와 천장인대를 연결함. 

The iliolumbar ligaments are also described in the anatomical literature ( Lanz and Wachsmuth, 2004a) as a continuation of the intertransverse ligaments , partially as reinforcement of the thoracolumbar fascia ( middle layer), as well as fibrotic parts of the quadratus lumborum. The position of these structures becomes apparent when the ligament is seen on an anatomical specimen. They are hidden beneath the several-centimeter-thick layer of intrinsic back muscles and lie in a tight corner between the transverse processes and the pelvis.

- 장요인대는 해부학 문헌에 "횡돌기 사이인대의 연결로 묘사됨", 특히 흉요근막 중간층을 강화할 뿐 아니라 요방형근의 섬유성 부분을 강화함. 

- 장요인대는 몇센치미터의 두깨를 가진 척추 등 내재근 아래에 숨겨져 있고 골반과 횡돌기 사이에 단단한 구석에 자리함, 

Individual fibers run along the frontal plane and restrict lateral flexion and rotation at L4-S1. The fibers are also arranged in a variety of ways in the sagittal plane ( Figs. 1 0. 1 9 and 1 0.20), limiting flexion and extension (Yamamoto et aI., 1 990) and helping to prevent the lowermost free vertebra from gliding anteriorly ( Bogduk, 2000). Muscle activity can most likely assist the deep lumbar stability to a large extent by placing these ligaments under tension.

- 장요인대 각각의 섬유들은 전두면을 따라 연결되고, 요추 4, 5, 천골 1번에서 측굴과 회전을 제한함. 

- 장요인대는 시상면에서 다양한 방식으로 배열되어 굴곡과 힌전을 제한하고 하부요추가 전방으로 미끄러지는 것을 막아줌. 

- 장요인대가 장력하에 놓여짐에 의해서 근육 활성이 심부 요추안정성을 상당범위까지 도울 수 있음. 

How Does this Affect Palpation?

장요인대의 촉진

The iliolumbar ligaments help to control lateral flexion and rotation, especially at L5-S1 . This action must be considered when palpating during movement. Some textbooks (Chaitow, 2001 ) recommend palpating these ligaments for diagnostic purposes. Readers should form their own opinion as to whether diagnostically conclusive palpation through the thoracolumbar fascia and the erector spinae, 5-7 cm deep, is possible.

- 장요인대는 요추 5-천추1번사이의 측굴과 회전을 조절하는 것을 도움. 이러한 작용은 움직임 동안 반드시 고려되어야 함. 

- 어떤 책은 장요인대의 촉진을 진단목적으로 시행해야 한다고 조언함. 

- 독자는 반드시 진단에 결정적인 촉진부터 흉요근막과 척추기립근 5-7cm깊이까지 자신만의 의견을 만들어야 함. 

황색인대

The ligamentum flavum, otherwise known as the yellow ligament, is a short and thick ligament which connects the laminae of  consecutive vertebrae. Its function is to prevent flexion, as well as pre-stress the disc for functional activities. It is known as the yellow ligament because it is comprised of 80% elastin and 20% collagen which gives it a yellowish hue and makes it more elastic than other ligaments in the body. This is important functionally so that during backward bending the ligament does not buckle and put pressure on the spinal cord (Figure 1).

황색인대의 기능은 요추의 굴곡을 막아주고, 요추분절의 기능적 활성을 위해 전부하를 제공함. 

황색인대는 기능적으로 중요함. 특히 허리를 뒤로 신전할때 황색인대는 찌그러지지 않기때문에 척수에 압력을 가하지 않음. 

The ligamenta flava (singular, ligamentum flavum, Latin for yellow ligament) are ligaments of the spine. They connect the laminae of adjacent vertebrae, all the way from the second vertebra, axis, to the first segment of the sacrum. They are best seen from the interior of the vertebral canal; when looked at from the outer surface they appear short, being overlapped by the lamina of the vertebral arch. Each ligament consists of two lateral portions which commence one on either side of the roots of the articular processes, and extend backward to the point where the laminae meet to form the spinous process; the posterior margins of the two portions are in contact and to a certain extent united, slight intervals being left for the passage of small vessels. Each consists of yellow elastic tissue, the fibers of which, almost perpendicular in direction, are attached to the anterior surface of the lamina above, some distance from its inferior margin, and to the posterior surface and upper margin of the lamina below. In the neck region the ligaments are thin, but broad and long; they are thicker in the thoracic region, and thickest in the lumbar region. Their marked elasticity serves to preserve the upright posture, and to assist the vertebral column in resuming it after flexion. The elastin prevents buckling of the ligament into the spinal canal during extension, which would cause canal compression. Hypertrophy of this ligament may cause spinal stenosis because it lies in the posterior portion of the vertebral canal.

황색인대

In young people, the ligamenta flava ( Fig. 1 0. 1 8) are mainly made of elastic fibers. They extend between the laminae of the vertebral arch and line the posterior side of the vertebral canal. These ligaments are under tension even in an upright posture. When the trunk is flexed, these ligaments are placed under increasing tension, save energy, and help the vertebral column to return to an upright posture, therefore reducing the required muscle power. 

- 젊은 사람에서, 황색인대는 주로 탄력섬유로 구성. 

- 황색인대는 척추아치와 척추 canal의 후면사이 라미나를 연결하여 이어짐. 

- 황색인대는 서있는 자세에서 장력하에 놓임. 

- 몸통을 굴곡할때, 황색인대는 증가된 장력하에 놓여지고, 에너지를 비축하고 척주가 선자세로 되돌아갈수 있도록 도와줌. 

전종인대, 후종인대

Both longitudinal ligamentous columns accompany the entire vertebral column: the anterior and the posterior longitudinal ligaments. These ligaments are also part of the basic ligamentous structures found in a segment (Fig. 10. 1 7 ).

- 두개의 종인대로 척주를 앞뒤에서 둘러쌈 : 전종인대와 후종인대

전종인대

The anterior longitudinal ligament (ALL) lies on the front of the spine and attaches segmentally to the vertebral bodies. The function of this ligament is to prevent extension of the spine (Figure 2).

- 전종인대 기능은 척추의 신전을 방지함. 

The anterior longitudinal ligament is a ligament that runs down the anterior surface of the spine. It traverses all of the vertebral bodies and intervertebral discs. The ligament is thick and slightly more narrow over the vertebral bodies and thinner but slightly wider over the intervertebral discs which is much less pronounced than that seen in the posterior longitudinal ligament. The ligament actually has three layers: superficial, intermediate and deep. The superficial layer traverses 3 – 4 vertebrae, the intermediate layer covers 2 – 3 and the deep layer is only between individual vertebrae.  

- 전종인대는 3개의 층을 가짐. The superficial layer traverses 3 – 4 vertebrae, the intermediate layer covers 2 – 3 and the deep layer is only between individual vertebrae.  

전종인대

The anterior longitudinal ligament (ALL) is found anterior to the foramen magnum and extends down to the sacrum

where it attaches inseparably onto the periostium. lt becomes increasingly wider more inferiorly. Superficial layers skip over four to five vertebrae. Deeper layers connect two neighboring vertebrae ( Bogduk, 2000). All sections of the ligament are attached to the middle of the vertebral body and are not firmly connected to the intervertebral disk's anulus fibrosus. This ligament helps to restrict lumbar extension and prevent an increase in lordosis. 

- 전종인대는  foramen magnum 앞쪽에서 천골까지 이어진 구조로, 골막과 떨어질수 없이 붙어 있음.

- 아래쪽으로 내려갈수록 넓어짐. 

- 천층부는 4-5번째 척추를 skip over. 심층부는 두개의 이웃한 척추를 연결함.

- 전종인대의 전부분은 척추의 중앙에 부착하고, 추간판 섬유륜을 단단하게 연결하고 있지 않음. 

- 전종인대는 요추신전을 제한하고 요추전만이 증가하는 것을 막아줌. 

후종인대

The posterior longitudinal ligament (PLL) is a narrow band that attaches segmentally to the back of the vertebral bodies. It widens over the discs and is narrower over the vertebral bodies. The function of this ligament is to resist flexion (Figure 3).

- 후종인대는 굴곡에 저항함. 

The posterior longitudinal ligament is situated within the vertebral canal, and extends along the posterior surfaces of the bodies of the vertebræ, from the body of the axis, where it is continuous with the membrana tectoria, to the sacrum.

It is broader above than below, and thicker in the thoracic than in the cervical and lumbar regions. The ligament is more narrow at the vertebral bodies and wider at the intervertebral disc space which is more pronounced than the anterior longitudinal ligament. This is significant in understanding certain pathological conditions of the spine such as the typical location for a spinal disc herniation.

In the situation of the intervertebral fibrocartilages and contiguous margins of the vertebræ, where the ligament is more intimately adherent, it is broad, and in the thoracic and lumbar regions presents a series of dentations with intervening concave margins; but it is narrow and thick over the centers of the bodies, from which it is separated by the basivertebral veins.

This ligament is composed of smooth, shining, longitudinal fibers, denser and more compact than those of the anterior ligament, and consists of superficial layers occupying the interval between three or four vertebræ, and deeper layers which extend between adjacent vertebræ.It functions to prevent hyperflexion of the vertebral column.

후종인대

The posterior longitudinal ligament ( PLL) is also made up of two layers. The superficial layer runs in a longitudinal direction and is thin. The deep layer runs in a transverse direction and is wider. It connects to the anulus fibrosus, reinforcing the disk. This ligament passes from the occiput to the coccyx, just like the anterior longitudinal ligament. 

- 후종인대는 두개의 층으로 구성됨. 천층은 수직방향으로 내려가고 얇음. 심층은 횡방향으로 이어지고, 넓음. 

- 후종인대는 섬유륜을 연결하고, 추간판을 강화함. 후종인대는 후두에서 꼬리뼈를 연결함. 

The ligament has special nomenclature in its upper cervical section and at the lumbosacral junction. In comparison to the ALL, the PLL possesses a high number of nociceptors and acts as an "alarm bell" for certain pathological conditions in the intervertebral disk.

- 전종인대와 비교하여, 후종인대는 많은 통각수용기를 가지고 있어서 추간판에서 병리적 조건을 알려주는 "알람 벨" 역할을 함. 

극상인대, 극간인대

논문참조) The mechanical function of the interspinous and supraspinous ligaments has been examined by simulating, on excised specimens, the deformation caused during forward flexion of the spine in real life. The load extension curves showed that during the first half of flexion the ligaments carried very little load but towards the end of the range of flexion they resisted up to 134N. When the supraspinous ligament was sectioned the interspinous ligament alone resisted 75% of this load. Testing at high strain rates showed an increase in load-carrying capacity of up to 30%. The maximum extension moment that can be produced by these ligaments was calculated to be approximately 7 Nm, or 5% of the moment the back muscles can produce across any intervertebral joint. Hence, during active lifting, these ligaments in isolation provide little mechanical assistance.

극간인대

The interspinal ligaments (interspinous ligaments) are thin and membranous ligaments, that connect adjoining spinous processes of the vertebra in the spine.^[1][2][3] They extend from the root to the apex of each spinous process. They meet the ligamenta flava in front and blend with the supraspinal ligament behind.^[2]

The ligaments are narrow and elongated in the thoracic region, broader, thicker, and quadrilateral in form in the lumbar region, and only slightly developed in the neck.^[1] In the neck they are often considered part of the nuchal ligament.^[2]

The function of the interspinal ligaments is to limit flexion of the spine.^[2]

극간인대

The interspinous ligaments ( Fig. 1 0. 1 8 ) stretch between the spinous processes of two neighboring vertebrae.

The literature describes the alignment of the fibers quite differently. The details vary from a vertical alignment, via the anterosuperior course of fibers (Netter, 2004), to the posterosuperior course of fibers ( Bogduk, 2000), demonstrating the need for clarification in descriptive anatomy. All authors agree that these ligaments limit flexion and rotation.

- 극간인대는 두개의 이웃하는 척주의 극돌기 사이에 뻗어 있음. 문헌은 극간인대의 섬유배열이 완전히 다르다고 기술함.

- 극간인대는 수직배열, 전상배열, 후상배열 섬유로 다양함. 

- 모든 저자는 극간인대가 굴곡과 회전을 제한한다고 동의함. 

극상인대

The supraspinous ligament connects the tips of the spinous processes from the seventh cervical vertebra to the sacrum. Above the seventh cervical vertebrae, the supraspinous ligament is continuous with the ligamentum nuchae.^[1] :45Between the spinous processes it is continuous with the interspinal ligaments. It is thicker and broader in the lumbar than in the thoracic region, and intimately blended, in both situations, with the neighboring fascia. The most superficial fibers of this ligament extend over three or four vertebræ; those more deeply seated pass between two or three vertebræ while the deepest connect the spinous processes of neighboring vertebræ. The supraspinous ligament helps maintain the upright position of the head.^[1]

극상인대

The supraspinous ligament ( Fig. 1 0. 1 8) is found superficial to the spinous processes and is basically the only ligament that can be palpated in the lumbar spine. This structure should not be seen as a ligament. Rather, it should be viewed as a doubling of the thoracolumbar fascia. Vleeming recently commented on this (personal communication ): "The supraspinous ligament is really an anatomical specimen artifact."

- 극상인대는 극돌기의 천층에서 발견됨. 그것은 요추에서 촉진할수 있음. 

- 극상인대 구조는 인대로 보아서는 안됨. 흉오근막의 두층으로 보아야 함. 

- The supraspinous ligament is really an anatomical specimen artifact...

The following relationships are currently being discussed:  이어지는 관계가 논의됨. 

• The superficial layers of this fascia meet at the midline.

• The connecting line is reinforced with ligament like structures.

• A  section is attached to the periostium of the spinous processes.

• The other section is found in the interspinous space, forms the interspinous ligaments, and even extends into the ligamenta flava deep inside the movement segment.

How Does this Affect Palpation?

As already described, it is very difficult to palpate the posterior  aspect of the spinous processes due to their irregular contours and undulating shape. The presence of the supraspinous ligament makes it even more difficult to feel the interspinous space when searching for the boundaries to the neighboring vertebra using palpation. The supraspinous ligament is absent between L5 and S1 ( Heylings, 1978, in Bogduk, 2000). This may contribute to the fact that the lower edge of L5 can be palpated well (see the section "Local Bony Palpat ion" below, p. 260).

- 앞에서 언급한 바와 같이 요추극돌기는 불규칙한 윤곽이고, 물결치는 공간때문에 촉진이 매우 어려움. 

- 극상인대의 존재는 극간인대 공간을 느끼게 하는데 어렵게 함. 

- 극상인대는 요추 5번과 천추 1번사이에는 없음. 

- 이는 요추 5번 아래 가장자리는 잘 촉진할 수 있다는 것을 의미함. 

경추의 인대

1. ligementum nuchae 항인대

This long ligament extends from the C7 spinous process to the occipital protuberance and assumes the role of the supraspinous ligament (Fig. 1 2.20). It has deep laminar and superficial funicular (ligamentlike) sections and connects

the occiput directly with the C5-C7 spinous processes. The laminar section is a thin partition (septum) made of elastic fibers. The funicular, thin, superficial section is shaped like a ligament. It is formed by the following muscles as they merge to form an aponeurosis:

• Trapezius.

• Splenius capitis.

• Serratus posterior superior.

• Rhomboid minor.

- 항인대는 경추7번 극돌기에서 후두골융기까지 이어진 긴 인대로 극상인대 역할을 수행함. 

- 항인대는 deep laminar와 superficial funicular section 을 가지고 C5-7번 극돌기와 함께 후두부로 이어짐. 

- laminar section은 탄력섬유의 얇은 부분으로 만들어짐. 

- funicular section은 얇고 전층에 있고, 인대형태임. 아래근육에 의해서 형성되고 건막을 만듬. 

It can be palpated during extensive cervical flexion. The ligamentum nuchae pulls the head back slightly when the

cervical spine is maximally flexed, preventing the upper cervical joints from moving into their maximal end position. This presumably helps to protect the spinal cord. It is also placed under tension when the head is retracted and pulls the more inferior vertebra posteriorly so that real extension is produced.

- 항인대는 극단적인 경추굴곡동안 촉진할 수 있음. 

- 항인대는 경추 완전굴곡시 항인대는 머리를 뒤로 약간 당겨, 상부경추관절이 과도하게 움직여지는 것을 막아줌. 

- 이것은 척수를 보호하기 위함. 또한 머리가 제한될때 그리고 척추가 아래로 당겨질때 긴장상태에 놓여짐.  

2. 환추의 횡인대 transverse ligament

This ligament forms the transverse part of a cross-shaped ligament ( Fig. 1 2.21 ). It originates from the inner side of

the lateral mass of the atlas and is 2 cm long. It is approximately 2 mm thick in the middle and approximately 1 cm

in height. It is made of very taut connective tissue and is very firm. 

- 환추의 횡인대는 환추의 외측 mass 양측을 잇는 인대로 2cm 길이. 대략 2mm두깨. 1cm높이의  매우 단단한 결합조직

In the past, anatomists have performed studies demonstrating that this ligament has a tensile strength of approximately 130 kg ( M acalister, 1 893 in Lanz and Wachsmuth, 1 979). It is covered by thin hyaline cartilage on its anterior side and forms part of the median atlantoaxial joints with the dens.

- 횡인대는 대략 130킬로그램의 장력부하를 견딤. 

- 횡인대는 dens에서 환축추관절의 일부의 전면부 초자연골부위를 덮고 있음. 

It is found on the posterior aspect of the dens in a circular depression beneath the tip (similar to a scarf wrapped around the neck). The dens is therefore positioned in an osteofibrotic funnel that tapers downward. Even massive tensile forces ( up to 40-50 kg) are not able to separate C1 from C2 when the ligament is intact. This means that it is impossible to apply traction therapeutically at this joint.

- 횡인대는 dens의 후면부에 있어 neck의 후면부를 스카프로 둘러싼것과 비슷함. 

- dens는 그래서 osteofibrotic funnel에 위치함. 

- 횡인대가 정상일때, 심지어 40-50킬로그램의 강력한 장력이 C1-2를 분리시키지 못함. 이것은 C1-2에서 견인치료효과는 불가능하다는 것을 의미함. 

The main function of the ligament is to keep the dens away from the dural sac (with the spinal cord).Physical therapists are familiar with several tests assessing the stability of this important ligament. The ligament also controls the biomechanics between the atlas and axis during flexion and extension and stabilizes the atlantoaxial joints by approximating the joint surfaces with the strength of its tissues.

- 횡인대의 주요기능은 Dural sac(척수)으로부터 dens가 떨어져 있도록 하는 것임. 

- 물리치료사는 이 중요한 인대의 안정성 평가에 익숙해야 함. 

- 횡인대는 또한 굴곡, 신전동안 환추와 축추의 생체역학기능을 조절하고, 환축추관절을 안정화시킴. 

3. alar ligament 익상인대

The four alar ligaments are also very firm (stiff and rigid) and are mostly comprised of type I collagen. The ligamental

columns are divided into two groups ( Fig. 1 2.22):  

- 4개의 익상인대는 매우 단단하고 Type 1 collagen으로 구성됨. occipital section과 atals section 2개 그룹으로 나뉘어짐. 

Alar ligaments, occipital sections. 

These sections directly connect the posterior upper side of the dens with the occiput. They are 11 -13 mm long, 3.5-6 mm thick, and approximately 8 mm wide. These sections transfer lateral flexion of the head directly onto C2.

- 익상인대 occipital section

- 이것은 dens의 윗부분에서 후두부와 직접 연결하는 인대. 

- 11-13mm 길이, 3.5-6mm 두깨, 대략 8mm 넓이임. 

- 익상인대 occipital section은 C2에서 두부의 외측굴힘을 전달함. 

• Alar ligaments, atlas sections. 

These are found at the level of the transverse ligament of the atlas. They connect the side of the dens with the anterior arch and are therefore only approximately 3 mm long.

- 익상인대 Atlas section

- 환추의 횡인대부위에서 발견됨. 그것은 dens의 앞쪽 아치에서 연결하고 대랴 3mm길이임. 

Their functions include moving the dens during cervical flexion and extension, limiting the atlantoaxial rotation, and passing lateral flexion of the head onto the axis by rotating C2. The alar ligaments therefore control the central biomechanics in the upper cervical region.

- 익상인대는 경추굴곡신전동안 움직임을 포함하고, 회전을 제한함.

- 익상인대는 상부경추부위에서 중심의 생체역학적 기능을 가짐. 

[문형철]

The ligament has special nomenclature in its upper cervical section and at the lumbosacral junction. In comparison to the ALL, the PLL possesses a high number of nociceptors and acts as an "alarm bell" for certain pathological conditions in the intervertebral disk.

- 전종인대와 비교하여, 후종인대는 많은 통각수용기를 가지고 있어서 추간판에서 병리적 조건을 알려주는 "알람 벨" 역할을 함.