SPINE COMPOSITION
The spine has three major components:
The Spinal Column (i.e., bones and discs)
Neural Elements (i.e., the spinal cord and nerve roots)
Supporting Structures (i.e., muscles and ligaments)
SPINAL ANATOMY REGIONS
REGIONS# of
VertebraeBody Area Abbreviation
Cervical 7 Neck C1 – C7
Thoracic 12 Chest T1 – T12
Lumbar 5 or 6 Low Back L1 – L5
Sacrum 5 (fused) Pelvis S1 – S5
Coccyx 3-4 Tailbone None
SPINAL ANATOMY
(Odontoid
Process)
NORMAL SPINE CURVATURES
The spine has four natural curves
That help to distribute mechanical
stress as the body moves.
Cervical and Lumbar curves are
Lordotic.
Thoracic and Sacral curves are
Kyphotic.
VERTEBRAL COLUMN FUNCTIONS
Protection
Spinal Cord and Nerve Roots
Many internal organs
Base for Attachment
Ligaments
Tendons
Muscles
Structural Support
Head, shoulders, chest
Connects head, upper and
lower body
Balance and weight distribution
Flexibility and Mobility
Flexion (forward bending)
Extension (backward bending)
Side bending (left and right)
Rotation (left and right)
Combination of above
Other
Bones produce red blood cells
Mineral storage
Fat storage
SPINAL LIGAMENTS
LIGAMENTS IN THE SPINE
Three of the more important ligaments in the spine
The Ligamentum Flavum forms a cover over the
dura mater: (a layer of tissue that protects the spinal
cord.)
This ligament connects under the facet joints to
create a small curtain over the posterior openings
between the vertebrae.
The Anterior Longitudinal Ligament attaches to the
front of each vertebra.
This ligament runs up and down the spine
(vertical or longitudinal).
The Posterior Longitudinal Ligament runs up and
down behind the spine and inside the spinal canal.
THORACIC VERTEBRAE ANATOMY
The thoracic vertebrae
increase in size from T1
through T12.
They are characterized
by small pedicles
Long spinous processes
Relatively large Neural
Foramen, (which result in
less incidence of nerve
compression).
Costal facet joints Costo-
Tranverse &
FACET JOINTS
Each vertebra has two sets of facet joints,
located at the back of the spine (posterior).
One pair faces upward (superior articular
facet) and one downward (inferior articular
facet).
There is one joint on each side (right and
left).
Facet joints are hinge–like and link vertebrae
together.
FACET JOINTS
ZYGAPOPHYSEAL (FACET) JOINTS
Facet joints are synovial joints.
Each joint is surrounded by a capsule of connective
tissue and produces synovial fluid to nourish and
lubricate the joint.
The joint surfaces are coated with cartilage allowing
joints to move or glide smoothly (articulate) against
each other.
These joints allow Flexion (bend forward), Extension
(bend backward), and Rotation (twisting motion).
The spine is made more stable due to the interlocking
nature to adjacent vertebrae.
FACET JOINTS & DISCS
FACET JOINTS ANGLE
ZYGAPOPHYSEAL JOINT
INNERVATIONEach Facet joint receive double innervations from
The Medial Branch of The Dorsal Ramus
(posterior) of the Spinal Nerve
L3
L4
L5
Ascending
Descending
MEDIAL BRANCH OF THE DORSAL RAMUS
OF THE SPINAL NERVE
One from above from the
Descending Branch of
the higher spinal segment
One from below from the
Ascending Branch of
the lower Spinal segment
Receives double innervations
from The Medial Branch
Each Facet Joint
INTERVERTEBRAL DISCS
The intervertebral discs are Fibrocartilagenous cushions serving as the spine's shock absorbing and shock distribution system, protecting the vertebrae, brain, and other structures (i.e. nerves).
The intervertebral discs make up one fourth (1/4) of the spinal column's length.
There are no discs between the Atlas (C1), Axis (C2), and Coccyx.
The discs allow for some vertebral motion, extension, flexion and rotation.
Individual disc movement is very limited however considerable motion is possible when several discs combine forces.
Discs are not vascular and therefore depend on the end plates to diffuse needed nutrients.
INTERVERTEBRAL DISCS
STRUCTURE
Discs are composed of an
Annulus Fibrosus and
a Nucleus Pulposus.
The annulus fibrosus
is a strong radial tire
like structure made up
of lamellae; concentric sheets of collagen fibers
connected to the vertebral end plates.
The sheets are orientated at various angles.
The annulus fibrosus encloses
the nucleus pulposus.
INTERVERTEBRAL DISCS
COMPOSITIONBoth the annulus fibrosus and nucleus pulposus are composed of water, collagen, and proteoglycans (PGs), the amount of fluid (water and PGs) is greatest in the nucleus pulposus.
PG molecules are important because they are hydrophilic (attract and retain water).
The nucleus pulposus contains a hydrated gel–like matter that resists compression.
The amount of water in the nucleus varies throughout the day depending on activity.
INTERVERTEBRAL DISC FLUID & O²
actual disc appearance
NEURO-ANATOMY CNS & PNS
The CNS extends to the Peripheral Nervous System (PNS), a system of nerves that branch beyond the spinal cord, brain, and brainstem.
The PNS includes the Somatic Nervous System (SNS)and the Autonomic Nervous System (ANS).
The Somatic Nervous System includes the nerves serving the musculoskeletal system and the skin.
It is Voluntary and reacts to outside stimuli affecting the body.
The Autonomic Nervous System (Sympathetic Nervous System and Parasympathetic Nervous System).
Is Involuntary, automatically seeking to maintain normal function “homeostasis”.
UPPER & LOWER MOTOR NEURONS
The nerves bundle that lie within the spinal cord
are Upper Motor Neurons (UMNs).
They carry the messages back and forth
from the brain to the spinal nerves along the
spinal tract.
The Spinal Nerves that branch out from the
spinal cord to the other parts of the body are
Lower Motor Neurons (LMNs).
These Spinal Nerves exit and enter at each
vertebral level and communicate with specific
areas of the body.
DERMATOMES
Relationship
between the spinal
nerves & skin
sensation.
Each of the spinal
nerves root
provides sensation
to a predictable
area of skin
although, there is a
great deal of
overlapping
MYOTOMES
Myotome - Relationship between the Spinal Nerves & Muscles.Each muscle in the body is supplied by a particular level or segment of the spinal cord and by its corresponding spinal nerve with some overlapping.
C3,4 and 5 - diaphragm
C5 the shoulder muscles and muscle to bend elbow .
C6 bending the wrist back.
C7 straightening the elbow.
C8 bends the fingers.
T1 spreads the fingers.
T1 –T12 supplies the chest wall & abdominal muscles.
L2 bends the hip.
L3 straightens the knee.
L4 pulls the foot up.
L5 wiggles the toes.
S1 pulls the foot down.
S3,4 and 5 bladder, bowel, sex organs, anus and other pelvic muscles.
SPINAL CORD NEURO-ANATOMY
The Central Nervous System is composed
of the Brain and Spinal Cord.
The Spinal Cord, originates immediately
below the Brain Stem, and extends to the
last Thoracic (T12) or first lumbar vertebra
(L1)
Beyond L1 the spinal cord becomes the
Cauda Equina
SPINAL CORD ANATOMY
CONUS MEDULLARIS & CAUDA
EQUINA Just below the first Lumbar (L1) vertebra the spinal cord ends at the Conus Medullaris, and the Filum Terminale extends down like a fibrous tract to the level of S2
From the conus medullaris,
the spinal nerves extend in a
group resembling a horse’s
tail, known as the Cauda
Equina extending to the
coccyx.
These nerves are suspended
“Floating” in CSF.
CAUDA EQUINA ANATOMY
CERVICAL SPINE BONE ANATOMY
NORMAL CERVICAL SPINE X RAYS
ATLANTO-OCCIPITAL & ATLANTO-ODONTOID
CERVICAL SPINAL STENOSIS
Cervical spinal stenosis may cause symptoms
in the shoulders, arms, and legs; hand
clumsiness and gait and balance disturbances
can also occur.
In some patients the pain starts in the legs and
moves upward to the buttocks; in other patients
the pain begins higher in the body and moves
downward.
This is referred to as a “sensory march”.
CERVICAL RADICULITIS HNP
Herniated disks and nerve canal stenosis in the neck most commonly affect the:
C5 root causing shoulder pain
C6 root causing thumb and second digit pain
C7 root causing pain into the middle finger
Other cervical dermatomes are only rarely affected by degenerative disease in the neck.
CERVICAL DERMATOMES
CERVICAL SPINAL
MYOTOMESMyotomes: Muscular innervations
C1: Head and neck
C2: Head and neck
C3: Diaphragm
C4: Upper body muscles (e.g. Deltoids,
Biceps)
C5: Wrist extensors
C6: Wrist extensors
C7: Triceps
C8: Hands
TORTICOLLISTorticollis
(from the Latin torti, meaning twisted and collis, meaning neck)
Torticollis / Stiff Neck / Wryneck / Cervical Dystonia
TypesCongenital / Inherited
Acquired / Acute, Spasmodic
Refers to the neck in a twisted or bent position, manifests in involuntary contractions of the neck muscles, leading to abnormal postures and movements of the head.
Dx: Clinical
Tx:Overlaying Cause
PT stretching exercises
Muscle Relaxants/NSAIDs
Botox
Surgical elongation
CERVICAL SPINE INJURY
Injury or mild trauma to the cervical spine
can cause a serious or life-threatening
medical emergency [e.g. spinal cord injury
(SCI) or fracture].
Sx: Pain, numbness, weakness, and
tingling are symptoms that may develop
when one or more spinal nerves are
injured, irritated, or stretched.
The cervical nerves control many bodily
functions and sensory activities.
CERVICAL SPINE INJURIES
Cervical spine injury:
Most often, a spine injury results from a
collision, and there may be assoc head injury.
The head and neck must be immobilized
immediately, and ease of breathing and LOC
must be ascertained.
If spine injury is suspected, it is wise to be
extremely cautious until a proper Dx is made.
This is the best way to prevent conversion of
a repairable injury to a catastrophic one
WHIPLASH
WHIPLASHWhiplash" is a nonmedical term to describe a flexion-hyperextension injury to the neck resulting from an indirect force, typically a rear-end automobile collision.
This injury is caused by the successive flexing and sudden and excessive stretching by hyperextension of the neck.
This combination may cause a cervical sprain in the flexing stage and, above all, an injury in the facetary joints in the spine during the stretching phase.
The diagnosis of whiplash is often one of exclusion.
Most are Sprain/Strain injuries to the so called soft tissues such as the IV disks, muscles and ligaments, and cannot be seen on standard X-rays.
WHIPLASH
NECK SPRAIN/STRAINStretch or tear resulting from a sudden movement that causes the neck to extend to an extreme positionThis pain can result from a ligament sprain or musclestrain.motor vehicle accidents (MVA), hard falls in a contact sport or around the houseTx:
NSAIDS, Muscle relaxers,NarcoticsSoft collar or not??
SPRAIN & STRAINSprains and strains are 2 different types of
injuries, common to the musculoskeletal
system, that may occur concomitantly.
What is a Sprain?
A sprain is an injury involving the stretching or
tearing of a Ligament (tissue that connects bone
to bone) or a joint capsule. Sprains occur when a
joint is forced beyond its normal range of motion,
Symptoms may include pain, inflammation,
tumescence, even ecchymosis, and in some
cases, inability to move a limb (arm, leg, foot).
STRAINWhat is a strain?Strains are injuries that involve the stretching or tearing of a Musculo-Tendinous (where the muscle is becoming a tendon) structure. Strains take place when a muscle is stretched and suddenly contracts. This type of injury is frequently seen in runners who strain their hamstrings, while the leg is in full stride.
Acute strain symptoms may include pain, tumescence, ecchymosis, muscle spasm, loss of strength, and limited range of motion.
Chronic (long-lasting) strains are injuries that gradually build up from overuse or repetitive stress, resulting in tendinitis (inflammation of a tendon). For example, a tennis player may get tendinitis in his or her shoulder as the result of constant stress from repeated serves.
SPRAIN & STRAIN GRADING & TX
Severity of sprains and strains
Grade I (mild) sprain or strain involves some stretching or
minor tearing of a ligament or muscle.
Grade II (moderate) sprain or strain is a ligament or muscle
that is partially torn but still intact.
Grade III (severe) sprain or strain means that the ligament or
muscle is completely torn, resulting in joint instability.
TREATMENT:
Grade I injuries usually heal quickly with rest, ice,
compression, and elevation (RICE). Therapeutic exercise can
also help restore strength and flexibility.
Grade II injuries are treated similarly but may require
immobilization of the injured area to permit healing.
Grade III sprains and strains usually require immobilization and
possibly surgery to restore function.
SPINAL FX’S &
SPINAL CORD INJURIESVarious fractures, dislocations, blunt and
penetrating injury patterns, and disk herniations
may lead to SCI or nerve root impingement
syndromes.Bony injury may exist without actual SCI or nerve root
trauma.
Vertebral fractures may have
localized pain on palpation of the injured spine, muscle
spasms, splinting, and resistance to movement.
Palpable crepitus, deformity, and step-off may also be
present on examination of the midline.
SCI EXAMINATIONSevere spinal cord injury
DTR’s usually absent below level of lesion
Sensory level to pinprick may be found on chest
High cervical lesions (C3-C5) affect all arm muscles and ventilation
Midcervical lesions affect extension but not flexion at elbow
Low cervical lesions affect hand muscle function but may preserve elbow flexion and extension
Thoracic lesions result in paraplegia
PARTIAL SPINAL CORD INJURY
May be seen with acute neck
hyperextension
Typically get central spinal cord
syndrome or anterior spinal artery
syndrome
with bilateral arm weakness and normal
leg strength
NERVE ROOTS INJURIES
Injury to the nerve roots produces an
ipsilateral lower motor neuron
lesion and a radiculopathy that
may result in decreased deep
tendon reflexes
weakness
sensory loss in that nerve
distribution.
SCI DIFFERENTIAL DIAGNOSIS
The history is useful in defining the mechanism of SCI
thus allowing the clinician to anticipate specific potential injury patterns.
The physical examination should focus on
complete palpation of the spine,
testing the symmetry of reflexes,
motor strength,
pain sensation, and
light touch and
proprioception in each extremity.
IMAGINGPortable X-ray of C-spine
Lateral must include all 7 vertebra & top of T1
Extension and flexion radiographs if plain X-rays normal and pt still has midline tenderness
Check for cervical spine stability in patient with neck pain
CAT scanSubluxation or fractures
Neuro abnormality present
MRI Readily demonstrates spinal cord hemorrhage or contusion, herniation
Images bone poorly
IMAGINGRectal tone, perianal sensation and wink, should be assessed.
Plain film radiography of the traumatized portion of the spine
is required when the following are present:
(a) midline pain or bony tenderness, crepitus, or step-off;
(b) neurologic deficit;
(c) presence of distracting injuries;
(d) altered mental status (including intoxication);
(e) complaint of paresthesias or numbness
Cervical spine radiographs require 3 views:
an anteroposterior view, a lateral view, and an odontoid
view (open mouth)
IMAGING
A computed tomography (CT) scan with or without myelography
or a magnetic resonance imaging (MRI) scan may be required
to further evaluate the extent of the spinal injury.
Once a bony abnormality is identified, a key component of the
differential is the degree of stability associated with that
particular type of injury.
Fractures of the odontoid with rupture of the transverse atlantal
ligament are extremely unstable.
CERVICAL FX
A Jefferson fracture is a C1 ATLAS axial load compression fracture of the anterior and posterior arches of and is an unstable fracture.
A Hangman’s fracture is a C2 AXIS unstable fracture of the pedicles of the posterior arch, caused by extension and distraction injury.
Extension “teardrop” avulsion fractures are unstable fractures where the anterior longitudinal ligament avulses the anterior-inferior corner of the vertebral body.
JEFFERSON FX (ATLAS)
Anteroposterior tomogram at the craniocervical junction demonstrates lateral mass of C1 (arrows) lying lateral to the lateral masses of C2 (arrowheads) on both the left and right sides as a result of spread of the ring of C1.
HANGMAN’S FX (AXIS)
Lateral radiograph reveals markedly increased prevertebral swelling (two short arrows) associated with the fracture at the posterior aspect of C2 pedicles (medium arrow). Displacement is obvious by following the posterior spinal line (long arrow).
Teardrop fractureODONTOID BASE AVULSION
CLASSIFICATION OF ODONTOID FX’S
C5-C6 FX DISLOCATION
LUMBAR SPINE ANATOMY
The lumbar vertebrae graduate in size from L1 through L5.
Most people have five lumbar vertebrae although it is not unusual to have six
These vertebrae bear much of the body's weight and related biomechanical stress.
The pedicles are longer and wider than those in the thoracic spine.
The spinous processes are horizontal and more squared in shape.
The intervertebral foramen (neural passageways) are relatively large but nerve root compression is more common than in the thoracic spine.
LUMBOSACRAL HYPER LORDOSIS
SCIATICA: SCIATIC NERVE
COMPRESSION
Sciatic nerve fibers begin at the 4th and
5th lumbar vertebra (L4, L5) and the first
few segments of the sacrum.
The nerve passes through the sciatic
foramen just below the Piriformis muscle
(rotates the thigh laterally), to the back of
the hip (extension) and to the lower part of
the Gluteus Maximus (thigh extension).
SCIATICA: SCIATIC NERVE
COMPRESSIONThe sciatic nerve is the longest and largest nerve in the body measuring three-quarters of an inch in diameter.
The sciatic nerve originates in the sacral plexus; a network of nerves in the lumbosacral spine.
The lumbosacral spine refers to the lumbar spine and the sacrum combined.
The sciatic nerve and its branches enable motor and sensory functions in the thigh, knee, calf, ankle, foot and toes.
SCIATIC NERVE
SCIATICA: SCIATIC NERVE
COMPRESSIONIf the sciatic nerve is injured or becomes inflamed, it causes symptoms called sciatica.
Sciatica can cause intense pain along any part of the sciatica nerve pathway - from the buttocks to the toes.
If the nerve is compressed, caused by conditions such as:
bulging or herniated disc, DJD, spinal stenosis, Isthmic Spondylolisthesis or tumor (rare),
symptoms may include a loss of reflexes, weakness and numbness besides severe pain.
Sciatic nerve pain can make everyday activities such as walking, sitting and standing difficult.
SCIATIC NERVE
PIRIFORMIS MUSCLE
The piriformis is
a small muscle
located deep
within the hip and
buttocks region,
that connects the
sacrum to the
major trochanter
of the femur &
aids in external
rotation of the hip
joint.
PIRIFORMIS SYNDROME CAUSES
“The Fat wallet syndrome” or “deep buttock syndrome”
Overload (or training errors)
Exercising on hard surfaces, like concrete; on uneven ground
Beginning an exercise program after a long lay-off period
Increasing exercise intensity or duration too quickly
Exercising in worn out or ill fitting shoes
Sitting for long periods of time, driving, fat wallet in back pocket
Biomechanical Inefficiencies
Poor running or walking mechanics;
Tight, stiff muscles in the lower back, hips and buttocks;
Running or walking with your toes pointed out.
PIRIFORMIS SYNDROMEWhen this muscle becomes tight or spasms, and irritates the sciatic nerve.
S&S:
Sciatic type Pain deep in the buttocks region or referred pain in the lower back and thigh.
Weakness, stiffness and a general restriction of movement
Even tingling and numbness in the legs can be experienced.
Dx
Physical exam
MRI
Tx
RICE
Stretching
Nsaids
Botox
Steroid injection (block)
Surgical elongation or section
SCIATICA: SCIATIC NERVE
COMPRESSION
Sciatic nerve fibers begin at the 4th and
5th lumbar vertebra (L4, L5) and the first
few segments of the sacrum.
The nerve passes through the sciatic
foramen just below the Piriformis muscle
(rotates the thigh laterally), to the back of
the hip (extension) and to the lower part of
the Gluteus Maximus (thigh extension).
SCIATICA
Sciatica is the Sciatic nerve swelling or
irritation frequently due to a lumbar disc
pressing on a nerve root as it exits the
intervertebral foramen in the lumbar spine.
The sciatic nerve then runs vertically downward
into the back of the thigh, behind the knee
branching into the hamstring muscles, calf and
further downward to the feet.
Rarely is sciatic nerve damage permanent and
paralysis is seldom a danger as the spinal cord
ends before the first lumbar vertebra.
TESTING LUMBAR ROOTS
STRAIGHT LEG RAISING (SLR) TEST
Patient in supine position. On the tested leg keep the knee fully extended with one hand. Ask the patient to relax.
With the other hand cupped under the heel, slowly raise the straight limb, ask the patient, "If this bothers, and to let you know, when to stop." Positive if symptoms elicited.
Check for any movement of the pelvis before complaints. True sciatic tension elicit complaints before the hamstrings are stretched enough to move the pelvis.
Estimate the degree of leg elevation that elicits complaint from the patient.
Determine the most distal area of discomfort: back, hip, thigh, knee, or below the knee.
LASEGUE MANEUVER
While holding the leg
at the limit of straight
leg raising, dorsiflex
the ankle.
Positive if aggravates Sciatic Pain at 30 to 70
degrees.
Internal rotation of the limb can also increase
the tension on the sciatic nerve roots.
BECHTEREW’S TEST
Bechterew's Test or seated straight-leg
raising
With the patient sitting on a table, both hip and
knees flexed at 90 degrees, slowly extend the
knee as if evaluating
the patella or bottom
of the foot.
Positive if symptoms
elicited
ELY’S SIGN & HEEL TO BUTTOCK
TESTEly’s Sign: Prone position on the table. The examiner flexes the leg upon the thigh, to ipsilateral buttock. Positive when the pelvis rises from the table.
Significance: Rectus femoris and/or lateral thigh fascia contracture.
Ely’s “heel to buttock” Test
This is a two-stage test, patient prone on the table.
In The First Stage the knee is flexed approximating the heel to the opposite buttock,
Significance: 1. In any significant hip lesion it will be impossible to do the test normally.
In The Second Stage, from this position the thigh is hyperextended.Significance:
2. In the irritation of the iliopsoas muscle or its sheath it will be impossible to extend the thigh to any normal degree.
3. Inflammation of the lumbar nerve roots will be aggravated eliciting femoral radicular pain.
4. Lumbar nerve root adhesions will be stretched with the production of upper lumbar discomfort.
PATRICK’S FABER TEST
Patrick’s test: FABER (Flexion ABduction External Rotation)
Patient supine. The knee is flexed on the
affected side and the external malleolus placed
over the patella of the opposite leg to make a
figure 4. Pressure on the flexed knee.
In a healthy individual or in one with sciatica,
pain is not elicited.
Test for the hip or sacroiliac Joint disorders
Positive causes pain
KEMP’S TEST
Kemp’s Test is performed with the patient standing or sitting.
Standing: The examiner, stands behind the patient, one hand anchors the pelvis and sacrum and the other grasps the opposite shoulder and firmly forced obliquely backward, downward and medialward. forcing the lower spine on the opposite side in a combined position of rotation, lateral bending and extension
Sitting: The examiner stands in front of the patient who is sitting with arms folded across the body and legs dangling over the examining table. One hand stabilizing the pelvis by firmly pressing on the thigh, the other hand pushes the homolateral shoulder obliquely backwards.
Positive: Pain radiating into the lower extremity corresponding dermatome
It has different interpretations.
Significance: Disk protrusion, the nuclear material may lie in a Medial, Lateral or Inferior position relative to the nerve root.
In disk Medial to the Nerve Root, will be positive when leaning away from the side of the lower extremity dermatome pain and mildly positive when leaning into the side of pain.
In disk Lateral to the Nerve Root, the relief position of the patient will be away from the side of the pain and negative when leaning away.
In disk Inferior to the Nerve Root, the patient resists bending to either side and prefers to stay in a strict flexed attitude of the lumbar spine.
Local pain in the low back does not constitute a positive Kemp’s test, is indicative of posterior articular facetogenic pain.
SCIATICA VS. PIRIFORMIS
SYNDROMEPiriformis Syndrome is caused by an entrapment (pinching) of the sciatic nerve as it exits the Greater Sciatic notch in the gluteal region
The second common site of entrapment is when the sciatic nerve actually pierces the piriformis muscle itself.
This can occur in about 1% to 10% of all humans.
In this case myospasm and or contraction of the piriformis muscle itself can lead to pain along the sciatic nerve
This particular syndrome can often mimic sciatica.
SPINAL STENOSIS
Spinal stenosis is a narrowing of the spinal
canal, which places pressure on the spinal cord
As people age, the ligaments of the spine can
thicken and harden (calcification).
Bones and joints may also enlarge, and bone
spurs (osteophytes) may form.
Bulging or herniated discs are also common.
SPINAL STENOSIS
The narrowing of the spinal canal itself does not usually cause any symptoms.
It is when inflammation of the nerves occurs at the level of increased pressure that patients begin to experience problems.
When these conditions occur in the spinal area, they can cause the spinal canal to narrow, creating pressure on the spinal nerve
LUMBAR SPINAL STENOSIS
Patients with lumbar spinal stenosis may feel
pain, weakness, or numbness in the legs,
calves or buttocks.
In the lumbar spine, symptoms often increase
when walking short distances and decrease
when the patient sits, bends forward or lies
down.
SPINAL STENOSIS
The pain may radiate like
sciatica, may be a cramping
or constant.
Severe cases of stenosis can
also cause bladder and
bowel problems, but this
rarely occurs.
Also paraplegia or significant
loss of function also rarely, if
ever, occurs.
NEURAL FORAMEN & SPINAL
STENOSIS
MRI LUMBAR SPINAL CANAL
STENOSISMultifactorial Spinal Stenosis
Color enhanced sagittal ( from
the side ) T2 weighted MRI
image of the lumbar spine shows
severe degenerative changes
severe multilevel spinal canal
stenosis secondary to
a combination of multilevel disc
herniations and
severe degenerative changes
of the facet joints and
thickening of the ligamentum
flavum.
SPINAL STENOSISTx:
NSAIDs
Corticosteroid injections (epidural steroids) can help reduce swelling and treat acute pain that radiates to the hips or down the leg.
This pain relief may only be temporary and patients are usually not advised to get more than 3 injections per 6-month period.
Rest or restricted activity (this may vary depending on extent of nerve involvement).
Physical therapy and/or prescribed exercises to help stabilize the spine, build endurance and increase flexibility.
SurgicalDiscectomy, Decompression laminectomy, etc.
SPONDYLOLYSISIn spondylolysis, there is a defect in the pars
interarticularis
(which literally means the "piece between the
articulations").
So spondylolysis means a defect in the thin
isthmus of bone connecting the superior and
inferior facets, and could be unilateral or
bilateral
Although the defect can be found at any level,
the Most Common vertebra involved is L5.
SPONDYLOLYSIS
In cases of bilateral spondylolysis, the posterior
articulations can no longer provide the posterior
stability, and anterior slipping of the L5 vertebra
over the sacrum could result.
This slip is called Spondylolisthesis.
Spondylolysis is the MCC of spondylolisthesis
SCOTTY DOG SIGNA B
SPONDYLOLISTHESIS
SPONDYLOLISTHESISMay be congenital (present at birth) or develop during childhood or later in life.
Type I: Congenital spondylolisthesis
Type II: Isthmic spondylolisthesis
Type III: Degenerative spondylolisthesis
Type IV: Traumatic spondylolisthesis
Type V: Pathologic spondylolisthesis
The disorder may result from the physical stresses to the spine from carrying heavy things, weightlifting, football, gymnastics, trauma, and general wear and tear.
As the vertebral components degenerate the spine's integrity is compromised.
SPONDYLOLISTHESIS S&SSpondylolisthesis occurs when one vertebra slips forward in relation to an adjacent vertebra, usually in the lumbar spine.
The symptoms that accompany a spondylolisthesis include
pain in the low back, thighs, and/or legs, muscle spasms, weakness, and/or tight hamstring muscles.
Some people are symptom free and find the disorder exists when revealed on an x-ray.
In advanced cases, the patient may appearswayback with a protruding abdomen,
exhibit a shortened torso,
and present with a waddling gait.
SPONDYLOLISTHESISThe Meyerding
Grading System
Grade I: 1-24%
Grade II: 25-49%
Grade III: 50-74%
Grade IV: 75%-99%
Grade V: Complete
slip (100%), known
as Spondyloptosis
SPONDYLOLISTHESIS TXNon Operative
Short-term bed rest
Activity restriction
Over-the-counter or Rx pain medication
Anti-inflammatory medication
Muscle relaxants
Steroid injections (i.e. epidural steroid injection)
Physical therapy
Bracing
Surgery
FOOT DROP
Foot Drop is an abnormal neuromuscular
(nerve and muscle) disorder that affects the
patient's ability to raise their foot at the ankle.
Drop foot is further characterized by an
inability to dorsiflex or move the foot at the
ankle inward or outward.
Pain, weakness, and numbness may
accompany loss of function.
DROP FOOTWalking becomes a challenge due to the patient's inability to control the foot at the ankle.
The foot may appear floppy and the patient may drag the foot and toes while walking.
Patients with foot drop usually exhibit an exaggerated or high-stepping walk called Steppage Gait or Foot drop Gait.
CAUSES OF FOOT DROPThe peroneal nerve is susceptible to different types of injury, including nerve compression from
Lumbar disc herniation (e.g. L4, L5, S1), trauma to the sciatic nerve, spondylolisthesis, spinal stenosis, spinal cord injury, bone fractures (leg, vertebrae), stroke, tumor, diabetes, lacerations, gunshot wounds, or crush-type injuries, hip or knee replacement surgery
Drop foot is found in some patients with Amyotrophic Lateral Sclerosis (ALS)Multiple Sclerosis (MS)Parkinson's Disease
HERNIATED DISC (HNP)
Herniation of the nucleus pulposus (HNP)
occurs when the nucleus pulposus breaks
through the annulus fibrosus of an intervertebral
disc.
A herniated disc occurs most often in the
lumbar region of the spine Most Commonly at
the L4-L5 and L5-S1 levels
This is due to the ample ROM of the lumbar
spine carrying most of the body's weight.
HERNIATED DISC
People between the ages of 30-50 appear to be
vulnerable because the elasticity and water
content of the nucleus decreases with age.
Lost of muscular conditioning
Overweight
The progression to an actual HNP varies from
slow to sudden onset of symptoms
DISC HERNIATION
Pain resulting from herniation may be
discogenic or combined with a radiculopathy.
caused by nerve compression
The deficit may include sensory changes (i.e.
tingling, numbness) and/or motor changes (i.e.
weakness, reflex loss).
HERNIATED DISC
There are four stages:
(1) disc protrusion
(2) prolapsed disc
(3) disc extrusion
(4) sequestered disc.
Stages 1 and 2 are referred to as incomplete
where 3 and 4 are complete herniations.
INTERVERTEBRAL
DISC LESIONS
HERNIATED DISCDx
The spine is examined with the patient laying down, sitting and standing.
Due to muscle spasm, a loss of normal spinal curvature may be noted.
Radicular pain may increase when pressure is applied to the affected spinal level.
A Lasegue test, also known as Straight-leg Raise Test, is performed.
The patient lies down, the knee is extended, and the hip is flexed.
If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots are inflamed.
If the contralateral SLR also produces pain, it is more likely to be from a herniated disc
HERNIATED DISC
Other neurological tests are performed to
determine loss of sensation and/or motor
function.
Abnormal reflexes are noted; changes may indicate
the location of the herniation.
Radiographs are helpful, but the MRI is the
best method for confirmation of DX of
HNP and evaluation
CAUDA EQUINA SYNDROME
HNPThe cauda equina syndrome is less of
a spinal cord lesion than it is a peripheral nerve
injury, and it presents with
variable motor and
sensory loss in the
lower extremities,
sciatica,
bowel or bladder
dysfunction,
and “saddle anesthesia.”
CAUDA EQUINA SYNDROME
May occurs from a central disc herniation, injury
or neoplasms, and is a serious condition
requiring emergency treatment and immediate
surgical intervention.
The symptoms include Bilateral leg pain
Loss of perianal sensation (anus) “Saddle
anesthesia”
Paralysis of the urinary bladder & urinary retention
Weakness of the anal sphincter (incontinence)
Increasing trunk weakness
CAUDA EQUINA SYNDROME
However, increasing trunk or leg weakness, or
bladder and/or bowel incontinence is an
indication of Cauda Equina Syndrome, a
serious disorder requiring emergency
treatment.
INJURIES TO
CONUS MEDULLARIS & CAUDA EQUINAVery important to distinguish injuries in the spinal cord from those to the conus medullaris or to the cauda equina.
A Spinal Cord Injury with preservation of segments below the level of injury usually produces an upper motor neuron (UMN) type of injury or Spastic Paralysis.
The intrinsic reflexes are now uninhibited and become hyperreflexic and lead to increased muscle tone, spasms, and spasticity.
A Conus Medullaris Injury, without preservation of spinal cord segments below the lesion, or a Cauda Equina Injury produces a lower motor neuron (LMN) type of injury or Flaccid Paralysis.
With this type of injury, the stimuli cannot reach the spinal cord; therefore, the reflexes and muscle tone remain decreased or absent (flaccid).
CAUDA EQUINA SYNDROME
SCOLIOSISScoliosis: any lateral curvature of the spine.
MC spinal deformity evaluated
In scoliosis, the spine curves to the side when viewed from the front, and each vertebra also twists on the next one in a corkscrew fashion.
Girls : Boys = 2 : 1
Usually > 10 y/o
SCOLIOSIS PHYSICAL
EXAMStanding position: From behind the patient
Evaluation of truncal alignment, overall balance and torso displacement.
Asymmetry of the shoulder height, skin folds, buttock crease level of the iliac crest, shifting of the thoracic cage, prominence of the anterior chest.
A plumb line from the occiput should line up with the gluteal cleft. In a compensated double major curves, the alignment may be normal.
Symmetry of Shoulder Girdle: neck shoulder angle distortion is due to trapezius asymmetry from cervical or high thoracic curves.
Adam’s sign: When bending over will have no straightening of the curve, “positive” .Straightening of the curve a “negative” result.
SCOLIOSIS PHYSICAL EXAMAssessment of specific curves:
Types of curves, i.e., left vs. right, C-T-L or combination.
Flexibility vs. rigidity can be assessed by side bending or head
distraction.
Degree of rotation is assessed in the bent position by noting
prominences in the thoracic and lumbar areas
Pelvic obliquity and stability: Obliquity can be non-structural due to
habits or structural due to leg length discrepancy or contracture of
muscle groups.
Neurologic examination, reflexes, sensation, motor, Isolated
decreased vibratory sensation is frequent in idiopathic scoliosis and
does not warrant further work up.
Forward Bending test to asses for
“Rib Hump” and asymmetry.
Scoliometer readings >5 ̊ difference
between Dorsal & Lumbar is positive.
SCOLIOSIS ETIOLOGYIn most cases (85%), the cause of scoliosis is idiopathic.
The other 15% of cases fall into 2 groups:
Nonstructural (functional): a temporary condition when the spine is otherwise normal.
The curvature occurs as the result of another problem.
Examples include 1 leg being shorter than another, from muscle spasms or from appendicitis.
Structural: the spine is not normalThe curvature is caused by another disease process such as a Birth Defect, Muscular Dystrophy, Metabolic Diseases, neoplasm, Connective Tissue Disorders, or Marfan Syndrome.
IDIOPATHIC SCOLIOSIS
Occurs at three separate time periods with different characteristic deformities and prognosis.
Infantile: Birth and 3 years of age. Usually in the first year of life. More common in boys particularly from England. Left thoracic curve MC, and often resolves spontaneously. Few patients require bracing or surgery.
Juvenile: 4-10 years of age. Equal for boys and girls. Most right thoracic curves that are progressive in nature and need close follow up.
Adolescent: Usually Dx at the age of 10. Most are right thoracic and thoracolumbar curves with a strong tendency to progress during adolescent growth spurt. Extremely active, athletic teenage girls with delayed menses are most of risk for curve progression.
SCOLIOSIS CLASSIFICATIONScoliosis: any lateral curvature of the spine.
May be described as: Right or Left (Dextro or Levo)by the side of convexity.
Cervical, Cervicothoracic, Thoracic, Thoracolumbar, Lumbar.
Single vs. Compound: single deviation & compound has both right and left spinal deviations.
Primary vs. Secondary: primary is the initial curve & secondary a compensatory curve in the other direction.
Major vs. Minor: major is the greatest curve & minor is a “compensatory” small curve(s) in the other direction above and below the major curve.
Structural vs. Nonstructural: Nonstructural curve gets corrected with lateral bending. In structural scoliosis, the curve remains despite side bending.
SCOLIOSIS
SCOLIOSIS EVALUATION
standing posteroanterior radiographs of the full spine to assess curvature with the Cobb method. The most tilted vertebral bodies above and below the apex of the spinal curve are used to create intersecting lines that give the curve degree.
This definition is controversial, and patients do not exhibit clinically significant respiratory symptoms with idiopathic scoliosis until their curves are 60 to 100 degrees.
No difference in prevalence of back pain or mortality between patients with untreated adolescent idiopathic scoliosis and the general population.
SCOILIOSIS COBB METHOD
Cobb method is used to measure
the degree of scoliosis on the posteroanterior radiograph. In addition to curvature degree, physicians should describe curves as “right” or “left” based on their curve convexity.
X Rays every 6 months in Long-term
management of scoliosis poses
no radiation related risks to patients
MRI should be done for onset of scoliosis
before eight years of age,
rapid curve progression of more than 1 degree per month,
an unusual curve pattern such as
left thoracic curve,
neurologic deficit, or
pain.
RISSER STAGING FOR SKELETAL
MATURITYOssification of the iliac apophysis begins at the Anterior Superior Iliac Spine (ASIS) and progresses posteromedially.
The iliac crest is divided into quadrants, and the stage of maturity is designated as the number of ossified quadrants. Risser grades 0 to 5 from no ossification to complete fusion
Ex: 50 percent ossified 2 quadrants is a Risser grade 2.
All quadrants ossified and the apophysis is fused to the iliac
crest, is a Risser grade 5.
The lower Risser degree at time
of Dx the Higher probability of
progression up to 75% from 10 to 16
years of age, (depending on degrees
of curvature).
Triradiate cartilage (acetabular)
open = skeletal immaturity
SCOLIOSIS TX
Tx:
10-* curve = f/u in 6 mo re-eval
Forward bending, and Scoliometer test
15-20* curve = serial XR’s Q 3-4 mo
Or 6-8 mo for smaller curves or older pt’s
>20* curve = ortho referral for possible bracing or
surgery
Depending on degree and age of pt
SCOLIOSIS CONSERVATIVE
TXMilwaukee brace for thoracic curves and TLSO for lumbar or thoracolumbar curves. Braces 20-22 hours per day and taken off for hygiene and strengthening exercises.
No bracing needed for curves < 20 degrees.
20-29 degrees bracing with 2 or more years of growth remain or evidence of progression.
30-39 degrees should be braced at the first visit if growth remain.
No bracing needed for patients with Risser 4 or 5.
Patients F/U monthly basis for brace adjustment & X-ray taken every 6 months.
Weaning off brace: children more mature and curve holds its position, the child is allow more time out of the brace.
The weaning period takes about 2-3 years until the age of 15 in girls and 16 ½ in boys.
SCOLIOSIS SURGICAL TXIndications:
Adolescents with curve more than 45 degrees.
Relentless curve progression
Major curve progression in spite of bracing
Inability to wean the patient from the brace
Significant thoracic and lumbar pain
Progressive loss of pulmonary function.
Emotional or psychological inability to accept the brace.
Severe cosmetic changes in the shoulder and trunk.
KYPHOSIS
Increased convex curvature of thoracic spine (Round back)
(Pott’s disease)- TB of spine causes progressive Kyphoscoliosis
Idiopathic (Scheuermann’s) defined as:anterior wedging of 5° or more in at least 3 adjacent vertebral bodies
Often associated c respiratory distress
Tx:45-60* curve = observed 3-4 mo c PT
>60* curve or persistent pain = bracepossible surgery
SCHEUERMANN’S DISEASE
ANKYLOSING SPONDYLITISAnkylosing Spondylitis (Marie-Strumpell Disease)
(AS) is a systemic condition, a chronic, multisystem
inflammatory disorder in which the joints and ligaments of
the back become inflamed and eventually fuse.
Inflammation & progressive fusion of vertebrae occurs
The sacroiliac (SI) joints and the axial skeleton are
especially affected.
AS characterized as a seronegative spondyloarthropathy
The disorder often is found in association with other
seronegative spondyloarthropathies including
reactive arthritis, psoriasis, juvenile chronic arthritis,
ulcerative colitis, and Crohn’s disease.
ANKYLOSING SPONDYLITIS
The etiology is not understood completely;
however, a strong genetic predisposition exists.
A direct relationship between AS and the major
histocompatability human leukocyte antigen
(HLA)-B27 has been established
Involvement of the sacroiliac (SI) joints is
required to establish the diagnosis
ANKYLOSING SPONDYLITISProgressive Limited ROM
Extra-articular manifestations:
Eyes, Iriitis or anterior uveitis
Cardiac, kidneys, & interstitial lung ds
Labs:
ESR, HLA-B27
XR:
“Bamboo spine”
Osteopenia
Tx:
NSAIDS, PT
Tx underlying conditions
Surgery rare
“Bamboo Spine”
THORACO-LUMBAR SPINE FRACTURES
A compression fracture is a condition in which a vertebra is crushed mainly in the front part of the body, causing a wedge shape. If a vertebra is crushed in all directions, the condition is called a burst fracture.
Burst fractures are much more severe than compression fractures. The bones spread out in all directions and may damage the spinal cord.
This damage can cause paralysis or injury to the nerves, causing sensorial or muscular deficiencies.15-20% of thoraco-lumbar fractures present with a neurologic deficitTx:
Hyperextension braceKyphoplasty (surgery)
VERTEBRAL COMPRESSION
FRACTURES
Wedge Fracture Burst Fracture
CHANCE FRACTURE
With flexion-distraction mechanisms such as
those observed in passengers restrained with
lap seatbelts,
a progression of injury from the posterior
column of the thoraco-lumbar spine is observed
anteriorly.
The diagnosis can be made on good quality
radiographs obtained in 2 planes
(anteroposterior [AP] and lateral).
CHANCE FRACTURE
Chance fracture represents a pure bony injury
extending from posterior to anterior through the
spinous process, pedicles, and vertebral body,
respectively.
This fracture most commonly is found in the
upper lumbar spine, but it may be observed in
the midlumbar region in children.
CHANCE FRACTURE
Prompt recognition followed by appropriate reduction and immobilization usually results in a good clinical outcome.
Always exclude associated injuries (i.e.., intra-abdominal trauma) at the time of presentation, as these are observed in up to 50% of cases
CHANCE
FRACTURE
CLINICAL NOTES SCI
Closed Spinal Cord Injuries (SCIs) should be treated with high-dose steroid
Removal of the patient from the long spine board within 2 h, with full spine precautions, is recommended
to prevent skin breakdown and pressure sores.
Stable patients may be further imaged with specific spinal radiographs, CT scans, or MRI.
CLINICAL NOTESBlood tests: Are not used generally in diagnosing the cause of back pain.
To R/O infection, inflammation, a tumor, or bone destructive processes, metabolic diseases or rheumatic conditions.
Most commonly used include:
Complete blood count (CBC)
Erythrocyte Sedimentation Rate (Sed Rate),
Alkaline Phosphatase
C-Reactive Protein (CRP)
HLA-B27
Uric Acid
Vit D 25 hydroxy
CLINICAL NOTES CSI
MANAGEMENTNeurosurgical or orthopedic consultation is required
for clinically significant spinal fractures or SCI.
Any patient with an unstable spine, nerve root
compression, uncontrollable pain, or intestinal ileus
should be admitted to the hospital.
Patients with significant vertebral or spinal cord
trauma should be managed at a regional trauma or
spinal cord injury center.
PEARL
Non-Traumatic Low back pain in >55 y/o
suspect AAA
INJECTIONS AS TREATMENT FOR BACK PAIN
When oral medications and other nonsurgical treatments fail to relieve
chronic back pain, injections may be useful for pain relief.
Trigger point injections: An anesthetic is injected into specific areas that
are painful when the doctor applies pressure to them. An steroid medication
can be added to the injection. Some people claim that this provides no more
relief than “dry needling”.
Prolotherapy: Is an injection of a sugar solution or other irritating substance
into trigger points to elicit a local inflammatory response that promotes
healing. Used mostly by Homeopathic doctors
Nerve root blocks: The injection contains a steroid medication or/and
anesthetic and is administered to the affected part of the nerve.
Facet joint injections: the injection of anesthetics or steroid medications
into facet joints is sometimes a way to relieve pain.
Epidural blocks: A steroid medication, anesthetic or a mix of both are
administered to the epidural space.
OTHER SPINAL DISORDERS
Other Spinal Disorders
Arthritis (DJD, Rheumatoid)
Spinal Tumors
Diseases of the Spine
Infectious, Osteomyelitis, Osteoporosis