Back and Spine 23 MF PDF

1 BACK AND SPINE Mary G. Flanagan, DPA, PA-C Co-Chair PA Programs Touro College PA Programs – Northeast Division Back and Spine 2  Vertebral Column  Spinal Cord and Meninges  Muscles of the Back  Medical Imaging of Back and Spine Layers of Back 3   Skin Subcutaneous tissue  ...

1 BACK AND SPINE Mary G. Flanagan, DPA, PA-C Co-Chair PA Programs Touro College PA Programs – Northeast Division Back and Spine 2  Vertebral Column  Spinal Cord and Meninges  Muscles of the Back  Medical Imaging of Back and Spine Layers of Back 3   Skin Subcutaneous tissue         Loose irregular CT, fat tissue, cutaneous nerves and vessels Deep Fascia Muscles Ligaments Vertebral column, Intervertebral discs & associated ligaments Ribs Spinal cord and meninges Segmental nerves and vessels Vertebral Column 4    Extends from cranium to coccyx Main part of axial skeleton Protects spinal cord and nerves  Supports weight of body  Posture  Locomotion Components of Vertebral Column 5  30 vertebrae 7 Cervical  12 Thoracic  5 Lumbar   5 Sacral – Fuse, form sacrum 4 Coccygeal- Fuse, form coccyx Motion 1st 25 vertebrae Get larger from head to coccyx for weight bearing BACK PAIN 6 10% population consult clinicians yearly for back pain More than 80% people have back pain in their lifetime Vertebral Column 7    Vertebrae are separated by cartilaginous DISCS Vertebra articulate at synovial Zygapophyseal joints AKA FACET joints  Control flexibility Height Vertebra contribute 75 %  Discs contribute 25%   Stability  Via discs, ligaments, muscles Curvatures of Vertebral Column 8  4 curvatures in adults spine  Cervical and Lumbar ◼ Lordosis  Thoracic and Sacral ◼ Kyphosis  Lumbosacral ◼ Formed Angle at Junction L5 & sacrum Abnormal Curvatures of Spine 9    Kyphosis  Excess thoracic kyphosis  “humpback”  > 40 degrees Lordosis  Excess lumbar lordosis  “hollow back”  Associated with weak trunk muscles Scoliosis  Lateral curvature of spine accompanied by rotation of vertebrae ◼ Most common = Idiopathic ◼ Most progressive = Neuromuscular COBB Angel to Measure Scoliosis 10   choose the most tilted vertebrae above and below the apex of the curve The angle between intersecting lines drawn perpendicular to the top of the top vertebrae and the bottom of the bottom vertebrae is the Cobb angle SCOLIOSIS 11   Posteroanterior radiograph of the spine in a patient with a thoracic spinal curve Right thoracic curve, T6-11 (most tilted vertebrae above apex of curve T6, most tilted vertebrae below apex of curve T11). The degree of curvature is 65. ALL scoliosis films should be done in the STANDING position SCOLIOSIS 12 Look at heights of scapula and hemipelvis Truncal rotation measured with scoliometer Risser Sign / Classification 13  The Risser classification is used to grade skeletal maturity based on the level of ossification and fusion of the iliac crest apophyses Magnetic resonance imaging should be obtained in patients with an onset of scoliosis: 1. Before eight years of age 2. Rapid curve progression 3. An unusual curve pattern 4. Neurologic deficit 5. Pain. 14 Scoliosis can also be DEGENERATIVE 15 ➢ Asymmetric disc degeneration ➢ Causes lateral tilt or listhesis of vertebral body ➢Can cause spinal stenosis and sciatica……neurogenic claudication Landmarks Spine on Physical Exam 16     Vertebra Prominence  Post spinous process C7 Spinous Process T1 L4-L5 disc space  Horizontal line through iliac crests “Dimples” of posterior superior iliac spines  May be absent in obesity or abnormal spinal curvatures Spine – Typical vertebrae 17 TYPICAL VERTEBRA 18  Spinous process  Transverse process  Lamina  Superior articular facet  Vertebral foramen  Pedicle  Vertebral body Structure Vertebra 19  7 processes arise from Vertebral Arch Posterior Spinous Process  2 Transverse processes  4 Articular processes ◼ 2 superior Called FACETS ◼ 2 inferior  Spinous processes allow attachment for ▪ deep back muscles ▪ Serve as LEVERS for movement Structure and Function Vertebrae 20   Vary in size/ shape/ angulation from one region to another Typical Vertebra  Vertebral body ◼ Anterior ◼ Give Strength to spine ◼ Supports body weight  Vertebral Arch ◼ Posterior ◼ Formed lamina by pedicles and R and L Structure Typical Vertebrae 21  Pedicle ◼ ◼  Vertebral foramen ◼  Formed by vertebral arch and posterior surface vertebral body Vertebral (Spinal)Canal ◼  Join vertebral arch to body Project posterior to meet lamina Contains spinal cord, meninges, fat, spinal nerve roots and vessels Intravertebral foramina ◼ Spinal nerve roots pass here Because of their more HORIZONTAL facets, cervical vertebrae are less tightly interlocked than the rest . As a result, cervical vertebrae are MORE EASILY DISLOCATED than FRACTURED!! 22 XRAY C1- C2 ARTICULATION 23 ➢ Ring like C1 vertebrae creates a joint with occipital condyles ➢Flat inferior facets of C1 meet with C2 ➢Dens of C2 projects superiorly providing PIVOT for ATLAS to TURN ➢ Visible in this “Open mouth” or “water’s view” of C1-C2 articulation Regional Characteristics of Vertebrae 24 CERVICAL Regional Characteristics of Vertebrae 25 Thoracic Regional Characteristics of Vertebrae 26 LUMBAR CERVICAL VERTEBRA 27  Foramina in Transverse Processes for vertebral artery  C1-C7 = skeleton n ◼ C1 = Atlas Atypical ◼ C2 = Axis CERVICAL VERTEBRA 28  C1 - ATLAS ◼ No spinous process or body ◼ 2 lateral masses connected by anterior and posterior arches  C2 = strongest Cervical AXIS ◼ Dens projects superiorly and provides PIVOT around which the Atlas turns Cervical Vertebrae 29 Cervical rotation is predominantly a C1-C2 function. Patients with Rheumatoid Arthritis and Psoriatic Arthritis are prone to severe arthritis in the upper cervical spine leading to marked restricted rotation of the neck !! 30 C1 ATLAS 31  Transverse Ligament of Atlas  STRONGER than the DENS  Holds DENS of C2 in position  Prevents Posterior displacement of the DENS and Anterior displacement of the ATLAS ◼ Either would compromise the Spinal Cord C1-C2 articulation 32 Cervical Spine 33  Distinctive Feature  Transverse Foramen ◼ Vertebral  arteries, veins pass here TYPICAL C3-C7 Vertebrae  Large vertebral foramen ◼ Accommodate cervical spinal nerves in this region to innervate the upper limbs  C7 – Vertebra Prominens  Prominent posterior spinous process Fracture C1 – Atlas (Jefferson or Burst Fracture) 34  Burst fracture ring of C1  Up to 4 part fracture .. of both bony arches  BLOW to top of Head…...VERTICAL force    DIVING accident into Pool 1/3 are associated with Fx C2 Can be associated with injury/rupture transverse ligament Jefferson or Burst Fracture C1 35 Offset R and L lateral masses of C1 relative to C2 in this openmouth XRAY Axial CT shows fracture both anterior rings and R posterior ring Rupture Transverse ligament 36  Destabilization injury  Flexion injury    Isolated atlantoaxial dislocation OR in association with Atlas Fx Force of ~ 85kg needed to rupture this ligament If unstable, treat with Halo Atlantoaxial Subluxation 37    Softening verses rupture of the transverse ligament MORE likely to cause spinal cord compression than fractures of DENS Seen in connective tissue disorders people with Downs Syndrome have LAXITY or AGENESIS of the transverse ligament of atlas  20% 38 Cervical Subluxation Dislocations Fracture DENS of C2 39   Horizontal blow to head … OR Complication of Osteopenia Pathology Cervical Spine 40  Hangman’s Fracture   Hyperextension traumatic spondylolisthesis C2 (Hanging or whiplash) Tear Drop Fracture  Flexion  injury MVA MC may either involve an anteroinferior body fragment, or a posterior inferior fragment; ◼ Often assoc with spinal cord injury displacment of postero-inferior fragment may encroache into the canal and cause paralysis Hangman’s Fracture 41 http://www.squidoo.com/traumaxray Hyperextension causing fracture and dislocation of AXIS Flexion – Tear Drop Fracture C5 42   MVA victim with resulting Quadriplegia Note: Tear drop fractures can also occur with extension injuries Extension Tear Drop Fx 43  Extension tear drop fracture  avulsion of the anteroinferior corner of the vertebral body  Extension teardrop is not considered as severe as flexion teardrop fractures. Clay-Shoveler’s fracture 44  Stable fracture through the spinous process of a vertebrae  Lower cervical or upper thoracic vertebrae  Classically  C6 or C7 Diagnosis  Plain film XRAY or CT http://www.squidoo.com/traumaxray Chance Fracture 45  Violent forward Flexion injury    Pure bony injury extending from posterior to anterior thru the spinous processes, pedicles and vertebral body Compression anterior portion vertebrae  50% are associated with intra-abdominal injury MC pancreas  Contusions duodenum  Contusions/ laceration mesentery  MC site: T12-L2 and midlumbar in PEDS  Aka (seatbelt injury) ◼ Less common with phase out of lap belts http://boneandspine.com/spine/thoracic-lumbar-spine/what-is-chance-fracture/ Holdsworth Fracture 46  UNSTABLE Fracture/Dislocation thoracolumbar junction  Flexion/rotation injury  Fracture includes:  Fracture thru vertebral body  Rupture posterior spinal ligaments  Fractures of the facet joints http://radiographics.rsna.org/content/20/3/819/F17.expansion.html Thoracic Vertebrae 47      Primary Function  Costal Facets for articulation with RIBS Limited ROM particularly flexion, extension, lateral rotation T1-T4 some features cervical T5-T8 = typical thoracic allowing some rotation and lateral flexion T9-T12 Some features Lumbar  T12 = transitional in character ◼ Subject to transitional stress ◼ MOST COMMONLY fractured vertebrae Lumbar Vertebrae      Large bodies for support Spinous processes are short thick and broad No transverse foramina or costal facets Increase weight bearing L5-S1 Common site Disc degeneration, herniation, arthritic spondylosis, spondylolisthesis Prostate cancer can metastasize 48 here via Batson's venous plexus  Also, cause of diskitis secondary to hematogenous spread of bacteria from UTI Intervertebral Discs 49   Separate adjacent vertebrae Each disc consists of an outer ring made of concentric lamella of fibrocartilage, annulus fibrosus surrounding a semifluid cushion, nucleus pulposus provides elasticity and compressibility  “shock absorbers”  Act as fulcrum for flexion and extension spinal column  NO disc between C1and C2  Function Disc with Movement 50 Examples of Disc Problems 51 Degenerative Discs Spine 52     Loss of fluid contents of disc Disruption of collagen and protein content of discs Loss of height Results in abnormal motion and surrounding bony degenerative changes Disc Herniation 53 Spondylosis Lumbar 54  Characterized by: disc degeneration  and osteophytosis  DISKITIS 55     Inflammation of the vertebral disk space often related to infection (also metastasis and post-operative) Infection can then spread to the epidural space or paraspinal soft tissues Batson’s venous plexus in the epidural space drains each segmental level and is continuous with the pelvic veins MRI with contrast = DX test of choice DISKITIS 56 https://radsource.us/discitis/ Disc degeneration on plain XRAY and MRI 57 Note vestigial disc at S1-S2 58 http://www.spineresearcher.com/MRI-page.html 59 60 61 https://www.slideshare.net/abd_ellah_nazeer/presentation1-radiologicalimaging-of-degenerative-and-inflammatory-disease-of-the-spine END OF PART 1 62 Laminectomy 63 ▪ Surgical excision of 1 or more spinous processes and their supporting laminae ▪ Provides access to vertebral canal to relieve pressure on spinal cord or nerve roots from for example: ▪ Herniated discs ▪ Bony hypertrophy (osteophyte) ▪ Tumor Spinal Stenosis Lumbar 64  Stenotic (narrow) vertebral foramen  Can be hereditary  Often due to age-related degenerative changes   Pain with standing and walking = neurogenic claudication May require surgical decompression Spinal Stenosis Lumbar 65 NORMAL Spondylolysis – Pars Defect 66 Oblique projection radiograph shows the presence of bilateral pars defects (arrows), with an appearance resembling a Scottie dog with a collar. (The collar is the pars defect.) MC location L5S1 Spondylolisthesis – “slipped disc” 67 ▪ Forward displacement of ▪ vertebral body Etiology ▪ Congenital (dysplastic) ▪ Spondylolytic (isthmic) ▪ Most common ▪ Degenerative ▪ Traumatic / Activity ▪ Gymnastics, rowing, tennis, wrestling, football, weightlifting ▪ Pathologic ▪ Iatrogenic (post-op) Spondylolisthesis 68  Graded 1 To 5  depending on mm of translation in alignment  Stable vs Unstable  More than 4 mm change of translation with flexion/extension demonstrates instability Flexion Extension 69 Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 39102 Common Congenital Spinal Deformity 70 Spina Bifida Occulta ▪ The neural arches usually L5 and/or S1 fail to fuse. ▪ Often asymptomatic Spinal Bifida Cystica ▪ More serious ▪ Complete failure of vertebral arch to develop ▪ Herniation of meninges and/or neural tissue Neural Tube Defects in Utero = Defective closure of the neural tube during 4th week of embryonic development Spina Bifida Occulta 71 Sacrum 72       Large, triagular, wedge-shaped Vertebra usually fused Provides strength and stability to pelvis Supports vertebral column and forms posterior part of bony pelvis Sacral canal = continuation vertebral canal in sacrum  Contains cauda equina AKA “horse tail” 4 pairs of sacral foramina for exiting sacral spinal nerves Coccyx 73  Small triangular bone \\   Formed by fusion of 4 rudimentary coccygeal vertebrae Provides attachment for gluteus maximus, coccygeus muscles and others Coccygeal Injury 74   Contusion Fracture  Dislocation rare  Surgery limited to severe cases unresponsive to conservative treatment Tailbone serves as an excellent flexible anchor for the spinal cord and the outer layer of the meninges, therefor terrible pain when injured ! Key Points: Chief Regional Characteristics of VERTEBRAE 75  Transverse foramina of Cervical vertebrae  Costal facets of Thoracic vertebrae  Absence of Transverse foramina and costal facets of Lumbar vertebra  Fusion of adjacent sacral vertebrae  Rudimentary nature of coccygeal vertebrae Joints of Vertebral Column 76  Joints Vertebral Bodies  Symphyses = 2º cartilagenous jnts  Joints of Vertebral Arches  Craniovertebral Joints  Atlantoaxial and Atlanto-occipital  Uncovertebral joints  Costovertebral joints  Sacroiliac Joints Uncovertebral “Joints” (of Luschka) 77  Located C3-C7  Synovial-like joint   Located posterolateral margins of IV discs – circles in blue Frequent sites SPUR formation causing neck pain Joints of Vertebral Column 78  Joints of Vertebral Arches AKA zygopophyseal joints AKA FACET JOINTS  Plane synovial joints with capsule & nerve endings  Permit gliding movements  Can encroach upon adjacent spinal nerves with degenerative changes causing dermatomal pain and muscle spasms Ligaments of Vertebral Column 79  Accessory Ligaments of IV Joints Ligamenta flava extend vertically from lamina above to below ◼ Arrest abrupt flexion ◼ Preserve normal spinal curvature  Interspinous ligaments, supraspinous ligaments and nuchal ligament  Anterior longitudinal ligament (ALL) and Posterior longitudinal ligament (PLL)  http://www.radiologyassistant.nl/en/p4bb9e3b74b6a0/spine-lumbar-disc-herniation.html 80 http://www.radiologyassistant.nl/en/p4bb9e3b74b6a0/spine-lumbar-disc-herniation.html Joints and Ligaments Vertebral Column 81 82 Movements of Vertebral Column 83  Flexion  Extension  Lateral Bending  Lateral Rotation Principal Muscles in NECK ROM 84 Extension via splenius capitus, multifidus, longissimus capitus, semispinalis capitus and trapezius Rotation via rotatores, splenius cervicis, semispinalis capitus and cervicis Principal Muscles in Thoracolumbar ROM 85 Lateral Flexion Rotation Arterial Blood supply of Vertebrae 86   Segmental arteries supply vertebral bodies Spinal branches enter through IV foramen   Supply bones, periosteum, ligaments and meninges Segmental medullary arteries  Supply spinal nerve roots and spinal cord Venous drainage of vertebral column 87   Parallels arterial supply Enters external and internal vertebral venous plexuses    Internal venous plexus surrounds the dura matter Large tortuous basivertebral veins form within the vertebral bodies Intervertebral veins  Accompany spinal nerves thru the IV foramina Nerves of Vertebral Column 88    Medial branches adjacent posterior rami of zygoapophyseal (facet) joints (recurrent) meningeal branches of the spinal nerves Branches supply Periosteum  Ligamenta flavum  Anuli fibrosis and IV discs  PLL and dura matter  Origin of Back Pain 89  Fibroskeletal structures  Periosteum, ligaments and anuli fibrosi  Meninges and coverings spinal cord  Synovial joints  Capsule of zygoapophyseal joints  Muscles : Intrinsic muscles of Back  Nervous tissue  Spinal nerves and / or nerve roots Contents of Vertebral Canal 90  Spinal Cord  Spinal Nerve Roots  Spinal Meninges and Cerebrospinal Fluid  Dura, Arachnoid and Pia Matter Spinal Cord 91     42-45cm long in adults Extends from foramen magnum in occiput to L1-L2 Protected by vertebrae and surrounding ligaments and muscles Enlarged in Cervical (C4-T1) and Lumbar (L1-S1) region for LIMB innervation Spinal Cord 92  Conus Medullaris  tapered termination of the spinal cord proper located at L1  Filum Terminale  continuation of the pia mater inferior to the conus medullaris. It descends all the way to the coccyx, anchoring the spinal cord Spinal Nerve Roots 93    First pair of spinal nerves emerges between the atlas and the skull C1 to 7 nerve roots leave the vertebral canal above the correspondingly numbered vertebrae C8 emerges below the C7 vertebra, and all the remaining spinal nerves leave inferior to the corresponding vertebrae SPINAL CORD AND SPINAL NERVES   Spinal nerves exit vertebral column thru intervertebral foramen Form 2 nerve roots  Anterior (ventral) ◼ Motor  (efferent) Posterior (dorsal) ◼ Sensory  Anterior and posterior roots unite to form MIXED spinal nerves  94 (afferent) Carries motor and sensory fibers Spinal Nerve Roots 95   Loose bundle spinal nerves arise below cord in lumbar region  Resemble a horses tail = cauda equina Termination spinal dural sac at S2 Laminectomy on the right-hand side Meninges and CSF 96  Meninges include the Dura mater, Arachnoid mater and Pia mater  Surround, protect and support the spinal cord and nerve roots including the cauda equina  Contain CSF in which these structures are suspended Meninges and CSF 97  Dura Mater  Outermost,  tough covering Arachnoid Mater  Delicate lining of dural sac and dural nerve roots  Encloses CSF filled subarachnoid space  Pierced during lumbar spinal puncture Meninges and CSF 98  Subarachnoid Space  Contains CSF  Below L2 it contains the cauda equina  Pia Mater  Innermost covering spinal cord  Continues as the filum terminale inferior to the conus medullaris Sagittal Section through the Spinal Cord 99 1. 2. 3. 4. 5. 6. Intervertebral disc Vertebral body Dura mater Extradural or epidural space Spinal cord Subarachnoid space Spinal Procedures 100  Lumbar Puncture Extraction of CSF from Lumbar cistern  Needle inserted between L3-L4   Spinal Block   Anesthetic into CSF Epidural Block Anesthetic into epidural space  Used in childbirth…  Spinal Cord Injuries  Spinal cord shock  From injury or disc herniation or spondylosis resulting in spinal stenosis  Injury C1-C3  No Function below head  Requires ventilation  C4-C5  Quadriplegic function  C6-8  Some  UE motion  May be able to self feed or propel a wheelchair Associated with paralysis below the level of the lesion  101 with respiratory T1-T9  paraplegic Back Muscles and Function 102   Superficial back muscles control upper limb movements as well as aid in respiration. They mostly receive their nerve supply from the ventral rami of cervical nerves Deep or true back muscles specifically act on the vertebral column, producing its movements and maintaining posture. They are innervated by dorsal rami of spinal nerves. The fascia covering them constitutes the thoracolumbar fascia Superficial Landmarks back 103 Superficial Muscles Back 104 Arteries and Nerves That Supply the Superficial Layer of Muscles of the Back 105 Intermediate Muscles 106  Two muscles that act on the ribs and are related to the thorax in function  serratus posterior superior  serratus posterior inferior Deep Intrinsic Neck Muscles 107   Semispinalis capitis Splenius cervicis Deep (Intrinsic) Back Muscles 108  Erector spinae  iliocostalis (1)  longissimus (2)  spinalis (3)  Splenius  capitis  cervicis The erector spinae group of muscles are the strongest muscles in the back and take on most of the work Deep (Intrinsic) Back Muscles 109 The erector spinae are responsible for keeping the body in the ERECT position during the waking hours, whether sitting or standing The ERECTOR SPINAE group of muscles are the strongest muscles in the back and take on most of the work Erector spinae support erect posture Deepest Back Muscles 110   Much smaller than the ones making up the erector spinae will cross only 1, 2 or 3 vertebrae as they pass from their origins to their insertions.  multifidus muscles  rotators  interspinous  intertransverse Superficial nerves Back 111 The Suboccipital triangle    112 Most of the semispinalis capitis has been removed Note the greater occipital nerve emerging at the lower border of the inferior oblique muscle The vertebral artery and the suboccipital nerve are seen in the triangle. The Suboccipital triangle 113 Medical Imaging of Vertebral Column 114  Plain XRAY  Myelography  Computered Tomography  Magnetic resonance Imaging XRAY of Lumbar Spine PA/LAT 115 Plain XRAY 116   Requires AP, Lateral +/oblique views Can demonstrate demineralization which may represent osteopenia or osteoporosis  Confirmed by Bone Density and T scores Computed Tomography 117   Differentiates white and grey matter of brain and spinal cord Excellent to identify bony fractures Magnetic Resonance Imaging (MRI) 118     NO XRAY Good images soft tissue, spinal cord and CSF Procedure of CHOICE for disc herniations Shows degree of disc degeneration MRI T2 Axial images Cervical 119 MRI T1 & T2 sagittal Lumbar 120 Spinal cord ends here Disc Degeneration and signal suggestive of herniation 121 1. Which of the following anatomical structures provides stability to the vertebral column? A. B. C. D. 122 Zygoapophyseal joints Vertebral body Spinal ligaments Transverse foramina 2. A 12-year-old boy is involved in a motor vehicle accident and sustains a forward flexion injury resulting in a fracture of T12 vertebral body. He was using a lap seat belt. Further evaluation and work up shows intraabdominal injury. Which of the following spinal fractures most likely? A. B. C. D. 123 Tear drop Clay-Shoveler's Burst fracture Chance fracture 3. A 31-year-old man comes to the clinic for pain in the right heel and lower back. He had a history of a 6-foot fall from a ladder landing on his feet. Radiographs are performed and there is a fracture of the calcaneus and the spine. Which of the spinal vertebral bodies is most likely fractured? A. B. C. D. 124 T11 T12 L1 L2 4. A 62-year-old woman is seen at the pain management clinic. She has a history of lower back pain and is diagnosed with severe degenerative disease in the facet joints. Which of the following nerves is the likely cause of her pain? A. B. C. D. 125 Cauda equina Recurrent meningeal Medial branch posterior rami Lateral branch anterior rami 5. Which of the following anatomical structures is a continuation of the pia mater inferiorly and descends to the coccyx, anchoring the spinal cord? A. B. C. D. 126 Cauda equina Arachnoid mater Conus medullaris Filum terminale