Spine Biomechanics PDF

SPINE BIOMECHANICS Öğretim Elemanı: Dr. Öğr. Üyesi Berrak Varhan E-mail: [email protected] Bölüm: Fizyoterapi ve Rehabilitasyon  CONTENTS Features of the spine Biomechanics and pathomechanics of the cervical spine Biomechanics and pathomechanics of the thoracic spi...

SPINE BIOMECHANICS Öğretim Elemanı: Dr. Öğr. Üyesi Berrak Varhan E-mail: [email protected] Bölüm: Fizyoterapi ve Rehabilitasyon  CONTENTS Features of the spine Biomechanics and pathomechanics of the cervical spine Biomechanics and pathomechanics of the thoracic spine Biomechanics and pathomechanics of the lumbar spine  Structures of the Spine Support base The connection between the lower and upper extremities Protection of the spinal cord Stability Mobility  Regions of the vertebra Cervical Thoracic Lumbar Sacral Coxygeal 33 bones 23 discs  Curvatures Visible from Lateral C-shaped curvatures at birth Lordotic 4 different curves in adulthood Kyphotic Lordotic Semi Kyphotic Spinal Curvatures There are 4 curves in the sagittal plane 1-) Cervical curve: It extends from the 1st cervical vertebra to the 2nd thoracic vertebra. Its opening faces backwards, that is, it is a lordotic curve. 2-) Thoracic curve: It extends from the 2nd thoracic vertebra to the 12th thoracic vertebra, and its opening faces forward, it is a kyphotic curve. 3-) Lumbal curve: It continues from the 12th thoracic vertebrae to the lumbo-sacral joint, and its opening faces back, it is a lordotic curve. 4-) Pelvic curve: It extends from the lumbo-sacral joint to the tip of the coccyx. It is semi-kyphotic.  Spinal Movement Spinal movement is a combination of intervertebral discs and facet joints. Intrinsic Balance If we separate the back column from the front column, there is a 14% reduction in the height of the back column. This is because there is a tension in the ligaments located between the arch and the apophyseal protrusions of the archs (supraspinous, interspinous, and Liga. Flavum).  This tension decreases when the posterior column is separated from the anterior. The implication is that; The tension stresses of the ligaments ensure the tight connection of the vertebrae to each other and create continuity in the spine. In the normal spine, all intersegmental and intrasegmental ligaments are under tension.  Another factor in maintaining intrinsic balance is the intervertebral discs. Body weight leads to the flattening of the intervertebral disc, that is, it undergoes compression. The discs absorb all kinds of pressure stresses that feel like an elastic cushion that settles between the vertebral corpuscles.  ‘The intrinsic equilibrium of the columna vertebralia is caused by the combination of elastic tension resistance of the ligaments and elastic pressure resistance of the disc.' Together, the ligaments and discs create a system where: Ligaments control excessive movement (tension resistance). Discs manage compressive forces (pressure resistance). This balance ensures that the spine is both flexible and stable, capable of adapting to different loads and movements without compromising its structural integrity. In essence, the spine's equilibrium is a result of this harmonious interaction, enabling it to function effectively under the varying physical demands of daily life. Intervertebral Joints  Intervertebral Disc The intervertebral disc constitutes 20-30% of the inter-articular height and changes the thickness of the cervical region by 3 mm, the thickness of the thoracic region by 5 mm and the thickness of the lumbar region by 9 mm. Structure of the Disk The Nucleus Pulposus (NP) is located in the center, except for the lumbar region. In the Lumbar region, it is located posteriorly. Gelatinous mass is a liquid structure rich in proteoglycan (PG) and glycoaminoglucose (GAG) molecules. During the increase in load, the hydration of the disk decreases. This is a reason for the mechanical function. Structure of the Disk 80-90% of its structure is water. It begins to decrease with age. In height reductions of 15-25 mm in the spine, the density of the disc decreases by 20% per day. But this condition is reversible. It acts as a hydrostatic unit, ensuring uniform distribution throughout the pressure coming into the disc. Structure of the Disk The pressure stresses coming to the disc are converted into tension stress in Annulus Fibrosis. This ensures the support of the spine and stability. Weight transfer and movement guidance. Diffusion of avascular nutrition in the End-Plate.  Annulus Fibrosus It is thick in the anterior. It becomes innervable from the synovertebral nerve. 1/3 of its outermost section is connected to the Sharpie fibers of the vertebra. 2/3 of the outer part is connected to the end-plate.  Disc Pathologies - Herniation At the most C5-6, C6-7, L4-5 ve L5-S1 Disc herniation Disc protrusion or bulging In Annulus Laterally localized Diffusion in posterior – Extrusion-migration  Longitudinal Ligaments Anterior longitudinal Supraspinous Posterior longitudinal Ligamentum flavum (elastic) PLL diverts herniation posteriolaterally  Facet Joint Between the superior (concave) and inferior (convex) faces. Transfers and movement in the frontal plane  Facet Joint Capsule Limited movements It is strong in the thoracolumbar and cervicothoracic regions, especially in places of change of the spinning.  Intervertebral Foramina Nerve outlet It depends on its width, disc height and pedicle shape. Osteophytes, ligament hypertrophy and a decrease in disc height with age lead to lateral stenosis. It decreases by 20% in extension and increases by 24% in flexion.  Spinal Stability Columna vertebralis is capable of reacting to forces coming from different directions at the same time. With degeneration, instability increases. Restructuring is tried to be achieved with fibrous tissue and/or osteophyte changes. In response to instability, the body attempts to compensate by restructuring the affected areas. This compensation can occur in two main ways: 1. Fibrous tissue formation: Ligaments, tendons, or joint capsules may thicken as the body tries to stabilize the region through scar tissue or fibrosis. However, this may also limit the spine's flexibility. 2. Osteophyte (bone spur) formation: Bone growths can develop around the joints and vertebral edges as part of the body's effort to stabilize the spine. These osteophytes aim to reduce abnormal movement but can also lead to complications like nerve compression or further joint stiffness. This degenerative process, while protective in intent, often contributes to conditions such as osteoarthritis, spinal stenosis, or spondylosis, which may cause pain, limited mobility, or neurological symptoms over time.  Segmental Loads Axial compression Bending Torsion Shear  Axial Compression It occurs as a result of reactions of ligaments to gravity, ground reaction forces, muscle contraction tensile forces. Interdisk loads range from 294 N to 3332 N. (1 kg – 9.81 N) The anterior segment can lift more loads, overflows are more frequent posteriorly!!  Axial Compression Compression in the disc causes tension in the annulus, angular changes in the fibers, and stability increases. Wear on the disc increases with increased strength and aging.  Bending It is a combination of compression, shear and tension forces that occur in the segment during movement. During bending flexion, the posterior annuluus resists, while the anterior compressive forces on the posterior longitudinal ligament, capsule and anterior segments cause displacement (protrusion) of the disc.  Bending For extension, a tension load occurs in the joint and anterior longitudinal ligament by posterior compressive forces applied to the anterior segment.  Torsion It is formed by axial rotation and the combination of several movements. Stiffness may occur in some movements due to joint compression; flexion increases torsional hardness in L3-4  Shear The force exerted by opposing forces on the same point. As a result of complex movements, the load on the discs increases, in particular. If there is wear on the disc, an injury occurs.  Flexion The superior vertebrae tilt anterior tilt and move forward (anterior gliding) The intervertebral foramina expands, the nucleus pulposus shifts posteriorly, and compression force is formed in the anterior. The tension force is on the posterior annulus, flavum, capsule and posterior longitudinal ligament.  Extension The superior vertebrae tilt and shift posteriorly. Intervertebral foramina narrows. The nucleus pulposus moves in the anterior direction.  Lateral Flexion-Rotation The superior vertebrae are displaced towards the inferior. The concavity in the direction of movement becomes convexity in the opposite direction. Tension force on convex side, compression force on concave side!! KINESIOLOGY OF THE CERVICAL REGION  CERVICAL SPINE The cervical spine is a stable column consisting of 7 vertebrae between the head and thorax, allowing flexion, extension, and rotational movements. Vertebrae 1 and 2 in the cervical region differ structurally from other vertebrae. The 7th cervical vertebra also has a morphological difference because it is the transition vertebra between the cervical and thoracic region.  CERVICAL SPINE Cervical vertebrae can be distinguished from thoracic and lumbar vertebrae by the presence of a foramen (foramen transversarium) in transverse processes. Through this foramen passes the vertebral artery, venous plexus, and sympathetic plexus, except for vertebrae 7. Processus spinous is short except for the 7th cervical vertebrae. 40  CERVICAL SPINE The first and second cervical vertebrae have a structure that will perform rotation functions in addition to flexion and extension. The lower cervical vertebrae are normally in the lordotic alignment, the upper cervical vertebrae are more stable, and the spinal canal is narrower. Since the canal is narrow and there is little room left for the spinal cord, there are more spinal cord injuries in injuries in this area.  ATLAS The first cervical vertebra is called " Atlas ". It is not a vertebral corpus and has no real spinous process. The task of carrying weight instead of the body is undertaken by structures called lateral mass. On the lower and upper surfaces of the lateral mass, there are articular faces. The upper joint surface joins with the occipital condyles and the lower joint surface with the second cervical vertebra.  AXIS The second cervical vertebra is called the "Axis". It shows all the features of other cervical vertebrae. However, its most distinctive feature is that it is a protrusion extending upwards from its object. This protrusion is called " Dens (processus odontoideus) ".  C7 Vertebral prominens (C7) is the vertebra with the longest spinous process. The spinous process is quite thick and extends horizontally. Here the ligamentum nuchae and the deep and superficial muscles of the back are attached. Transverse processes are quite extensive.  SPINE LIGAMENTS Ligaments have important roles in the structural stability of the vertebral column. The main tasks of the ligaments are to prevent excessive movements, to ensure the distribution of pressure in the load-bearing formations, and to transmit information about movement and posture to the central nervous system through joint capsules  SPINE LIGAMENTS 1. External craniocervical ligaments Internal craniocervical ligaments Vertebral ligaments  EXTERNAL CRANIOCERVICAL LIGAMENTS They are the ligaments that connect the cranium to the atlas and axis. These ligaments are tied in a very loose structure so that the skull movements can be performed comfortably.  EXTERNAL CRANIOCERVICAL LIGAMENTS 1. Anterior atlanto-occipital membrane Posterior atlanto-occipital membrane Joint capsule Anterior longitudinal ligament Ligamentum nuchae  ANTERIOR ATLANTO-OCCIPITAL MEMBRANE It runs between the upper edge of the anterior arch of the atlas and the anterior edge of the foramen magnum. It is wide, thick, and fibroelastic. The anterior atlantooccipital membrane is strengthened with the participation of the anterior longitudinal ligament in the midline. 52  POSTERIOR ATLANTO-OCCIPITAL MEMBRANE It is wider but thinner than the anterior atlantooccipital membrane. It lies between the upper edge of the posterior arch of the atlas and the posterior edge of the foramen magnum.  JOINT CAPSULE It surrounds the upper articular faces of the atlas with the condyles of the occipital bone. It is quite loose, allowing for a nodding movement. The capsule is thin in the middle and thick on the sides. The thickening on the sides is called the lateral atlantooccipital ligament and limits excessive lateral flexion of the head.  ANTERIOR LONGITUDINAL LIGAMENT Extends from the base of the head to the sacrum. The upper part of this ligament strengthens the anterior atlanto-occipital membrane in the midline.  LIGAMENTUM NUCHAE It is a fibroelastic membrane that extends between the protuberensia occipitalis externus of the occipital bone and the posterior tubercle and spinous process of the atlas. It provides an adhesion site for the muscles (Trapezius muscle, constrictor muscles of the pharynx) by forming a septum in the midline. 57 58  INTERNAL CRANOCERVICAL LIGAMENTS These ligaments are located on the posterior face of the vertebral bodies. It contributes to the strengthening of the craniocervical region and prevents excessive movement.  INTERNAL CRANIOCERVICAL LIGAMENTS 1. Tectorial membrane Transverse ligaments of the atlas Apical ligament Alar ligament 2. Ligamentum accessorium  TECTORIAL MEMBRANE It is located in the vertebral canal. This membrane is an upward continuation of the posterior longitudinal ligament. From the posterior side of the corpus of the axis, the foramen extends to the anterior and anterolateral edges of the magnum.  62 Above it mixes with the dura mater The tectorial membrane covers the ligaments and dens in this region, acting as an additional protector at the junction site of the medulla spinalis and the medulla oblongata.  ATLASIN TRANSVERSE PORTS It is on the back of the dens.  APICAL LIGAMENT From the densin apex to the central part of the foramen magnum anterior. Prevents excessive flexion of the head.  ALAR LIGAMENT Dens extends from the superlateral to the upper and lateral. It controls excessive rotation in the Atlanto-occipital joint.  LIGAMENTUM ACCESSORIUM From the base of the dens to the Massa lateral of the atlas. It is located close to the adhesion sites of the transverse ligament. It controls excessive rotations in the atlantoaxial joint.  VERTEBRAL LIGAMENTS 1. Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flava Supraspinal ligament Interspinous ligament Interverse ligament  ANTERIOR LONGITUDINAL LIGAMENT It is a ligament that extends between the tuberculum anterioru and the sacrum of the atlas, in the form of a band, expanding as you go down from above. During its course, it firmly adheres to the anterior edge of the vertebral corpus and the intervertebral disc. It consists of superficial and deep fibers. This ligament prevents hyperextension of the columna vertebralis. 69  POSTERIOR LONGITUDINAL LIGAMENT Behind the vertebral corpus, the canalis lies within the vertebralis, between the axis and the sacrum. The posterior longitudinal ligament continues with the tectorial membrane in the upper part. Prevents hyperflexion of columna vertebralis.  LİGAMENTUM FLAVA It lies between two neighboring vertebral lamina. It extends between the antero-inferior edge of the upper vertebral lamina and the postero-superior edge of the lower vertebral laminate. 72  SUPRASPINAL LIGAMENT It extends between the C7 and the sacrum between the spinous processes. It continues with the ligamentum nuchae above, with the interspinal ligaments in the front. 74  INTERSPINOUS LIGAMENT They are the ligaments that fill the space between the spinous processes of the two vertebrae facing each other.  INTERTRANSVERSE LIGAMENT Two neighboring transverses fill the process gap.  JOINTS Atlanto–occipital joint (articularis atlantooccipitale) Atlanto-axial joint (articularis atlanto–axialis)  Atlanto–occipital joint (articularis atlantooccipitale) It is the joint between the Massa lateralis of the atlas and the condyles of the occipital bone. The articular face in the Atlas is divided into concave and sometimes two articular faces. These two bone joint capsules are joined by the anterior and posterior atlantooccipital membrane. Flexion and extension movements of the head take place around this joint.  Atlanto-axial joint (articularis atlanto–axialis) It is divided into two as lateral and medial formed between the atlas and the axis. The joint on the medial side is a pivotal type joint that forms between the archus anterioru of the Atlas and the axis dens. The joint on the lateral side is a plana-type joint that forms between the atlas and the objects of the axis. Rotation of the head occurs in this joint.  MUSCLES OF THE CERVICAL REGION Muscles are hypersensitive structures that react to all parts of the motor system. Not only are the movements produced by the muscles per se, but the spinal muscles have very important tasks, such as controlling and stabilizing the spine.  MUSCLES OF THE CERVICAL REGION Biomechanical abnormalities in any part of the spine can cause a secondary dysfunction anywhere.  FUNCTIONS Creating or accelerating movement with concentric contractions Slowing down movement or providing stability with isometric or eccentric contractions Applying force to structures that allow to absorb and transfer of the applied force, such as intervertebral discs and articular cartilage  Provide shock-absorbing properties To provide afferent proprioceptive feedback to the central nervous system for coordination and regulation of muscle function.  POSTERIOR NECK MUSCLES Superficial group (trapezoidal and levator scapula muscles) Middle group (splenius capitis and splenius cervic muscles) Deep group (erector spina muscles)  MUSCLES OF THE ANTEROLATERAL REGION Platysma Sternocleidomastoid Hyoid muscles Scalen muscles Longus coli and longus capitis muscles  MUSCLES OF THE CERVICAL REGION The majority of posterior muscles provide head and neck extension. Anterolateral cervical neck muscles provide head and neck flexion, lateral flexion and rotation.  MUSCLES OF THE CERVICAL REGION Contraction of the posterior cervical muscles increases normal cervical lordosis, thereby increasing the tendency to bend the spine. The neck of the anterior deep cervical muscles, especially the middle cervical segment, provides an important function in postural and segmental control by hardening and stabilizing.  MUSCLES OF THE CERVICAL REGION While deep muscles such as longus capitis and longus colli show less but continuous tonic activity besides supporting posture, superficial neck muscles such as sternocleidomastoid (SCM) have a great function in the formation of torque  MUSCLES OF THE CERVICAL REGION Neck muscles contain a higher proportion (80%) of afferent fibrils than most other striated muscles. This makes the neck muscles more sensitive.  MUSCLES OF THE CERVICAL REGION Disorders in the function of the limbic system, as in the case of anxiety, primarily affect these muscles and they undergo spasms. This can cause a variety of symptoms not only in the neck but also in the face and head.  VERTEBRAL BIOMECHANICS The spine is a flexible but stable column. Although it has a flat and symmetrical appearance in the coronal plane, there are 4 natural curvatures in the sagittal plane.  93 These are lordosis in the cervical and lumbal region, and kyphosis posture in the thoracic and sacral region. These natural curvature play an important role in spinal biomechanics.  Due to natural curvatures, axial loads affect each of the existing regions differently. They try to create an extension deformity in the cervical and lumbar vertebrae.  95 Due to these unique aspects of spinal anatomy and geometry, burst fractures occur mostly in the cervical and lumbar region, while compression fractures occur more in the thoracic vertebrae.  THE THREE MAIN FUNCTIONS OF THE CERVICAL SPINE 1. Providing support to the head and ensuring its stability provide the width of movement of the head with vertebral facet joints, To provide a sheltered passageway for the vertebral artery and spinal cord.  CERVICAL SPINE Identification of spinal movements is clinically very important. Passive elements that provide qualitative and quantitative movements of the cervical vertebra; The facet joint, disc, ligaments, and bone are the structure, while the active elements are the muscles.  98 Rotational abnormalities at one or more levels lead to changes in the range of motion, neutral zone, patterns of connectedness, and axis of sudden rotation.  CERVICAL SPINE The cervical vertebrae are the most mobile part of the spine. While the Atlanto-occipital joint plays an important role in the flexion and extension of the cranium, its role in the axial rotation is very small.  CERVICAL SPINE The mean flexion-extension range of motion in the atlanto-occipital joint is 25°. In contrast, the atlantoaxial complex (C1-C2) is very effective in axial rotation and has an average range of motion of 43°.  CERVICAL SPINE After the atlas (C2–C7), the movements of the cervical vertebrae are similar in all directions. But the main movement is flexion and extension.  102 Each segment of the middle and lower cervical vertebrae flexes from 10° to 20°. The largest flexion-extension movement is between C5 and C6.  CERVICAL SPINE Approximately 50–60% of the axial rotation of the cervical spine is between C1-C2. The remaining amount of axial rotation was distributed between the middle and lower cervical segments. The greatest flexion/extension movement is between C5 and C6.  SPINE MOVEMENTS Although the vertebrae can do flexion, extension, lateral flexion, and rotation movements, the most important thing is that the vertebral column can flex completely. During this movement, the intervertebral ligaments are compressed in front, the joint surfaces slide apart, the upper vertebra slides forward and upwards on the lower vertebra.  SPINE MOVEMENTS In flexion, the anterior longitudinal ligament is relaxed, and the posterior longitudinal ligament, ligamentum flavum, interspinous and supraspinous ligaments are stretched. In the case of limited extension, the disc is compressed in the back, and the articular process below slides back and down, limiting the movement of the lamina and spinous protrusions.  SPINE MOVEMENTS The anterior longitudinal ligament is stretched. Lateral flexion is usually accompanied by rotation. On the convex side, the facet joint slides, on the concave side it overlaps.  CERVICAL STABILITY Anterior longitudinal ligament, annulus fibrosus, posterior longitudinal ligament, apophyseal anular ligament, ligamentum flavum, inter and intra supraspinous ligaments The most basic element is the transverse ligament  CERVICAL STABILITY The anterior vertebral column is a static unit and aims to carry weight, while the intervertebral disc takes on the task of alleviating shocks. Posterior column structures are dynamic units and provide the direction and continuity of movement.  109 Cervical stability is achieved by the combination of front group structures with a rear group element or a front group element with robust rear group structures. THORACIC REGION KINESIOLOGY  Functions of the Thoracic Spine The connection place of the costa Minimal movement in this area Load carrying  Thoracic Spine Body T1 is similar to C7. The vertebral body is normal, but the disc dimensions are at the highest level. This reduces strain forces and reduces possible disc injuries. As you descend to the lower segments, the compression forces increase.  Thoracic Vertebrae Flexibility is low due to Costa articulations, disc size and spinous processes. The facet joints are more sagittal in T9-12.  Highlights The spinal canal is narrow. The cervical and lumbar are less mobile than in the region. It is the most common site of cancer metastases. It is the least common place of diseases of the musculoskeletal system. Thoracic Ligaments  Movements Flexion; 30-40 degrees. The posterior longitudinal ligament is limited by the tension on the ligament flavum and capsule. Extension; 20-25 degrees; It is limited by bone structures and tension on the anterior longitudinal ligament and abdominals. Rotation; 30 degrees; it is limited by costas. Lateral flexion; 25 degrees; the facet joint and ribs are limited LUMBAL REGION KINESIOLOGY  Lumbar Vertebra It is the most load-bearing part of the skeletal system. Their movements are on the sagittal plane. It has the largest corpus, disc, and laminates. Pedicules are short and thin; load-bearing. The most flexion-extension is between L5 and S1. Weight Transfer The L3 disc of a 70 kg person is loaded with approximately 70 kg in a standing upright position. The body part above L3 is half the size of the body. The weight is 2 times that of this body part.  When bend forward, the load increases 2 times. If the same person takes something by bending forward from the ground, it is 2 times the load of the other. Sitting and Standing It is the loose and unsupported sitting position that puts the most strain on the waist. The pelvis tilts backward in this position, and the body flexes somewhat forward.  Therefore, the gravity line of the upper part of the body passes well ahead of the center of movement. As the distance between the center of motion and the gravity line increases, it creates a rotational moment and the load on the waist increases.  In the upright sitting position, the lumbal curve increases slightly compared to the loose sitting posture without support, that is, the load on the waist is less in terms of approaching normal.  In a loose standing position, lumbar lordosis should be normal. Therefore, the distance between the gravity line and the center of movement is less, and within these 3 positions, the waist is put on the waist in a loose standing position. Supported sitting posture: It is the position with the least load on the waist in the seating forms. Because part of the weight of the upper body is carried by the back of the seat. A backward angle of the backrest or any lumbar support further reduces the load on the waist.  Supine position: When the legs are in a straight position, the load on the waist increases. If flexion is brought with hip and knee support, the load on the waist decreases. In the prone position: More load is placed on the lumbal region, it is subjected to high stress. If a pillow is placed under the abdomen in the prone position, the stress on the waist (riding on the discs) is reduced. Depending on the patient's lordosis or comfort, the pillow is placed thin or thick at the waist. PATHOMECHANICS OF THE CERVICAL REGION  CERVICAL INSTABILITY Ligamentous injury and damage to bone structure after trauma are the main causes of cervical instability. Ligaments have great importance in spinal stability. The effectiveness of a ligament depends not only on its strength but also on the length of the moment arm in which it functions.  CERVICAL INSTABILITY Ligamentous injury is a fairly serious condition, with mild damage the ligaments can heal, while in tears there is no healing. On the other hand, the most important event in the healing and fusion process in bone damage is the extreme arrival and immobility of fracture fragments.  CERVICAL FLATTENING The main important point is paravertebral muscle spasm. Muscle spasm may be the result of disc herniation or may develop as a result of emotional tension, trauma, infection and incorrect positioning (sitting in front of the computer). https://www.youtube.com/watch?v=8pm83sYZ dmM  WHİPLASH INJURY This type of neck injury is usually a hyperextension injury but can also occur with sudden hyperflexion and sideways tilting of the cervical spine. It often occurs after automobile accidents. The forward movement of the cervical spine during sudden acceleration or deceleration is restricted by contact of the jaw with the chest wall.  WHİPLASH INJURY In the case of side-bends, the contact of the head to the shoulders ends the movement. These movements remain within the physiological range of motion of the cervical spine. However, in the backward movement of the head, there is no natural obstacle to limit the extension of the cervical spine until the occiput touches the back.  WHİPLASH INJURY This range of motion is not within the physiological range of motion of the cervical spine. As a result, various degrees of injury occurs in soft tissue elements such as muscles and ligaments, intervertebral disc, bone structure, and facet joints.  CERVICAL SPONDYLOSIS AND CERVICAL DISC HERNIATION Cervical spondylosis describes degeneration, osteophyte formation, and intervertebral disc disorders occurring in the cervical spine. Since cervical discopathy leads to neural compression, the patient often complains of pain that starts in the neck and spreads to the shoulder and arm.  CERVICAL SPONDYLOSIS AND CERVICAL DISC HERNIATION The pain is often in the form of a knife stab, burning or whining, and is more severe in the limb than in the neck, and sometimes only limb pain is found.  CERVICAL SPONDYLOSIS AND CERVICAL DISC HERNIATION Long-term neural compression causes sensory loss (hypoesthesia or anesthesia), loss of reflexes, or motor loss (weakness or atrophy). In acute disc protrusion after trauma or sudden movement, the pain is more severe, the spread to the arm is pronounced, and it may take time for neurological deficits to appear. THORACIC AND LUMBAL REGION PATHOMECHANICS  Inflammation Structural pathologies affecting the bones Tropism (asymmetry) Sacralization Lumbalization Articular pathologies Disc herniation Thoracic outlet syndrome Spondylolisthesis-spondylosis  Scheuermann’s Juvenile Kyphosis It is a growth age disease characterized by an increase in dorsal kyphosis and an increase in lumbal lordosis that occurs in the juvenile period. Around the age of 11 and 12, X-ray findings are given. Clinical signs are seen around the age of 13 to 17 years.  Scheuermann’s Juvenile Kyphossis The postural defect can be corrected from the onset of the disease, but after 6 to 9 months, kyphosis becomes fixed. More often in the anterior parts of the corpus vertebrae, wedging begins, and in the posterior part, disproportionate growth begins. More static stresses mount in the wedged areas. This zone leads to the inhibition of growth plates. Scheuermann’s Juvenile Kyphossis In the posterior, intermittent stress leads to faster growth of the back, and kyphosis develops violently. In rapidly developing cases, cord lesions are encountered, often accompanied by scoliosis, and kyphoscoliosis is seen in a group of 30-40% of cases.  Transverse Process Syndrome It is more common in men. The single or double-sided transverse protrusions of L5 are longer than normal. If it is unilateral, then lateral flexion increases towards the long protruding side. The iliolumbar ligament is stretched to the side where the transverse process is long and pain appears. If it is double-sided, lateral flexion in both directions is restricted. The compression of the iliolumbar ligament between the transverse protrusion and the crista reveals pain in this movement.  Tropism It is the plane change of L5-S1. The L5-S1 articular facet is in the frontal plane, but all lumbal region facets are in the sagittal plane. The unilateral or bilateral redirection of the articular facets of the L5-S1 vertebra is called tropism. One is directed to the normal plane and the other to the right. 2-sided becomes rare. There is a limitation in lateral and rotational movements in the lower back, and severe pain occurs.  Sacralization 5 Lumbal vertebrae 1. It is the characteristic of the sacral vertebra. Sacralization can be in a complete block, meaning it may have undergone complete fusion with L5 crista. It can also be single- or double-sided. In cases where there is a complete block, the movement in the L5-S1 articular facet is completely eliminated. Since there is no movement in this region, the movement shifts to the L4-L5 segment, where early degeneration is observed.  Sacralization If it is not a complete block but shows an articular structure, the movement of this region is not completely restricted. In lateral movements, compression stress occurs on the flexed side and tension stress occurs on the opposite side. As a result, degeneration occurs in the joints.  Lumbalization It is the fact that the S1 takes the character L5 (long waist back). The only symptom is that it leads to facet and disc degeneration due to increased mobility of this area.  Spondylolysis There is a separation of the intervertebral joint elements. It reduces intradiscal pressure and the disc narrows. Reduced intradiscal pressure leads to the narrowing of the intervertebral foramina, while the event continues, the disc loses water, and the elastic fibers of the annulus turn into fibrous tissue. As a result of this condition, many pathological phenomena occur.  Lomber Spondylosis Intervertebral disc, corpus, intervertabral foramen, facet joints, lamina and ligaments are called degenerative changes.  Spondylolystesis It is the sliding of one vertebra forward and backward over the other. There is a shift of 5% to the back and 95% to the front. It is noted that there are three main causes of this pathology; Defect of facets: can be congenital or later. Defect of the peduncle or neural arch: It can be congenital or later. Structural insufficiency of bone: The lumbal vertebrae are most affected.  Spondylolystesis In the second place, the 4th lumbal vertebra and the third place, the 3rd lumbal vertebra is affected. Several vertebrae may be affected, usually the 4th and 5th lumbal segments are affected. This pathology can also be observed in the cervical region. In the cervical region, the defect is in the pedicle. CONGENITAL MUSCULAR TORTİCOLLİS It develops as a result of unilateral contracture of the SCM muscle. It is an asymmetrical deformity of the head and neck. The head tilted to the side where the muscle was shortened, and the jaw rotated to the opposite side. OXIPITALİZATION It is the congenital absence of the atlantooccipital joint. There is no yes-no movement with the head. CLIPPER-FEIL SYNDROME It occurs at the fusion of the anterior and posterior elements of two or more cervical vertebrae. Its other name is the block vertebrae. Due to fusion, the intervertebral discs disappear, and the spinous protrusions merge into a block.  There are 3 main symptoms 1. Short neck Scalp below its normal location Limitation of neck movements Mechanical Low Back Pain CHANGE IN LUMBOSACRAL ANGLE - 5. With the long axis of the lumbal vertebrae 1. Between the long axis of the sacral vertebra is formed an angle of 135 degrees, the span of which faces back. - This angle gives the waist its normal lordosis. Changes in this angle bring about 2 clinical events in the waist.  Elevation of the angle above 135 degrees: - Causes loss of lumbal lordosis (flat waist). - Causes the intensity of the compression to increase. - This severity, which is borne by vertebrae and discs, causes pain. Dropping the angle below 135 degrees As it narrows, the trunk is pushed back. It leads to increased lordosis. The abdomen stands out. If the angle goes down to around 90-100 degrees, it greatly increases the stress of fragmentation on the intervertebral disc and causes the vertebrae to rupture, the formation of degenerative arthritis. SACRAL ANGLE - The 30-degree angle between the plane passing through the upper face of S1 and the horizontal plane in a standing upright position is called the sacral angle. - If this angle decreases, lordosis improves, if there is an increase, hyper lordosis is observed.  Cause of Pain: It is mechanical straining of ligaments, muscles, capsules of facet joints, periosteum of vertebral corpuses, spinal cord membranes, and pain-sensitive parts in the structures of blood vessels, such as stretching, and pressure.  Lumbal Disc Lesions The clinical picture that occurs when one or more components of the disc in the intervertebral space are displaced posteriorly or posteriorly and compresses the nerve points is defined as disc hernia.  Lumbal Disc Lesions The severity of pain depends on the location, amount, and pressure effect of the herniation. Lateral and posterolateral disc herniations cause unilateral sciatalgia by compressing the nerve root on the same side. Bilateral sciatalgia is rarer. It depends on central or bilateral herniation. The appearance of pain-related symptoms is determined by the way the disc is torn. In annulus fibrosis fibers that lose their durability, circumferential tears first occur.  Lumbal Disc Lesions These tears increase especially with rotational movements. The fibers most stretched in rotation are those close to the nucleus. For this, the first tears start from the center. Radial tears occur with the union of circular ruptures. Since the disc has no innervation and no blood vessels, these changes proceed silently and the repair process is quite slow.  Lumbal Disc Lesions As long as the nucleus is mobile, there may be herniation into radial tears. Degenerative changes are most often in the dysfunction phase or at the beginning of the instability phase. In the dysfunction phase, the nucleus enters the multiple annular tears and there is an all-round overflow in the disc, which is called the annular bulging. Although the nucleus broke into the rupture and pushed the annulus outwards, a few external fibers of the annulus are still intact. Circular bulging is not herniation.  Lumbal Disc Lesions Pathologically, the herniation of the nucleus pulpous has three forms (protrusion, extrusion, and sequestrated disc). Localized disc bulging is called PROTRUSION, there are no problems with the posterior longitudinal ligament. EXTRUSION: It is the complete rupture of the annulus and its exit into the nucleus canal, and the posterior longitudinal ligament is ruptured. If the herniated material breaks off and remains free in the epidural area, it is called a SEQUESTRATION DISC or free fragment, where the posterior longitudinal ligament is ruptured.