The anatomy of the middle layer of lumbar fascia (MLF) is of biomechanical interest and potential clinical relevance, yet
it has been inconsistently described. Avulsion fractures of the lumbar transverse processes (LxTP’s) are traditionally attributed
to traction from psoas major or quadratus lumborum (QL), rather than transversus abdominis (TrA) acting via the MLF. This
attachment is also absent from many biomechanical models of segmental control. The aims of this study were to document: (1)
the morphology and attachments of the MLF and (2) the attachments of psoas and QL to the LxTP’s. Eighteen embalmed cadavers
were dissected, measuring the thickness, fibre angle and width of the MLF and documenting the attachments of MLF, psoas and
QL. The MLF was thicker at the level of the LxTP’s than between them (mean 0.62: 0.40 mm). Psoas attached to the anteromedial
surface of each process and QL and TrA to its lateral border; QL at its upper and lower corners and TrA (via the MLF) to its
tip. In three cadavers, tension applied to the MLF fractured a transverse process. The MLF has a substantial and thickened
attachment to the tips of the LxTP’s which supports the involvement of TrA in lumbar segmental control and/ or avulsion fracture
of the LxTP’s.
Keywords Lumbar fascia - Anatomy - Transverse process - Transversus abdominis - Psoas - Quadratus lumborum