Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

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Understanding Back Pain:

Basics of Spine

Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India www.agrasenortho.com drsandeep123@gmail.com 09960122234

Spinal Anatomy

● Spine three major components: !– Spinal column (i.e.,

bones and discs) – neural elements (i.e.,

the spinal cord and nerve roots)

– supporting structures (i.e., muscles and ligaments)

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

!• 33 vertebrae !• 23 intervertebral disks!!

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!• Primary curves!• Secondary curves

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OSTEOLOGY

Sagittal Plane CurvesCervical Lordosis 20°-

40°

Sacral Kyphosis

Lumbar Lordosis 30°- 50°

Thoracic Kyphosis 20°- 40°

• Protection of – spinal cord and nerve roots

Functions of the Spine

– internal organs

Spinal Nerve Topography

31 pairs of spinal nerves • 8 cervical • 12 thoracic • 5 lumbar • 6 sacrococcygeal

Spinal NervesSpinal cord

Epidural space

Dura mater and Arachnoid layers

Subarachnoid space

Dorsal root

Ventral root

Dorsal root ganglion

Peripheral nerve

Spinal Nerve Structures

Spinal Cord

Foramen magnum

• Extends from foramen magnum to L1

• Terminates at the conus medularis

• The cauda equina begins below L1

• Filum terminale extends from conus medularis to the coccyx

Conus medularis

Cauda equina

● Beyond L1 the spinal cord becomes the Cauda Equina

● Beyond L1 the spinal cord becomes the Cauda Equina

Batson’s Plexus

Because of the azygos system, patient positioning is very important in posterior lumbar spine surgery.

Patient’s abdomen should always hang free and without abdominal pressure. An increase in pressure will diminish flow through the azygos system and the vena cava. This results in an increase of venous flow into Batson’s plexus with a corresponding increase of blood loss.

Batson’s plexus

Azygos system also communicates with a valveless venous network known as BATSON’S PLEXUS. When the vena cava is partially or totally occluded, Batson’s plexus provides an alternate route for blood return to the heart.

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

Autonomic Nervous System

SYMPATHETIC NERVOUS SYSTEM: !Injury to the sympathetic nerve chain in the

lumbar spine may result in genitourinary problems for the patient.

!!Each sympathetic ganglion has fibers that

join to the adjacent spinal nerve. !!! PARASYMPATHETIC NERVOUS SYSTEM has

ganglia located close to the organs they control.

• Flexibility of motion in six degrees of freedom

Functions of the Spine

Left and Right Side Bending

Flexion and Extension Left and Right Rotation

• Structural support and balance for upright posture

The spine is the axle bearing the load of the head, shoulders and thorax. The upper body weight is then distributed to the lower extremities through the sacrum and pelvis.

This reduces the amount of work required by the spinal muscles and can eliminate muscle fatigue and back pain.

Functions of the Spine

• Line of gravity

Auricle of the ear

Odontoid

Body of C7

Anterior to thoracic spine

Posterior to L3

Mid femoral heads

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

Intervertebral Disks: !• Collagen fibers of anulus fibrosus are

arranged in sheets: lamellae

• Concentric rings surrounding nucleus

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● No discs between the Atlas (C1), Axis (C2), sacrum and Coccyx.

● Discs are not vascular and therefore depend on the end plates to diffuse needed nutrients

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

!!1. Interbody Joints!• Capable of translations and tilts in all directions!!!!!!!2. Zygapophyseal articulation!• True synovial joints!• Fibroadipose meniscoid structures

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ARTICULATIONS

Vertebral StructuresSuperior Articular Process

Inferior Articular Process

Zygapophyseal Joint

(Facet Joint)

Pars

Basic Vertebral Structures

Cervical Thoracic Lumbar

MRI

The Atlas (C1)

Transverse Process

Transverse Foramen

Anterior Tubercle

Articular Facet for Dens

Lateral Mass

LaminaPosterior Tubercle

Superior Articular

Facet

Superior View

The Axis (C2)

Odontoid Process (Dens)

Body

Transverse Process

Inferior Articular

Facet

Superior Articular

Facet

Anterior View Posterior View

Lateral Mass

Spinous Process

Lower Cervical Vertebrae C3 - C7

Transverse ProcessBodySulcus for

Spinal Nerve

Lateral Mass

Lamina

Pedicle

Superior Articular Facet

Vertebral Foramen

Bifid Spinous Process

Transverse Foramen

Axial View

Thoracic Vertebrae, T1-T12• Body - heart shaped when

viewed superiorly.

• Vertebral foramen - round

• Pedicles - small in diameter

• Spinous processes - long and projected downwards

Lumbar Vertebrae, L1-L5• Body - L1 to L5 progressive

increase in mass• Pedicles - longer and wider than

thoracic; oval shaped

• Spinous processes - horizontal, square shaped

• Transverse processes - smaller than in thoracic region

• Intervertebral foramen - large, but with increased incidence of nerve root compression

The Sacrum

Sacral Horns

Sacral Ala

PediclesDorsal

Foramina

Sacral Hiatus

CoccyxPosterior View

Inverted triangle shape

The Sacrum

CoccyxLateral View

Sacral Promontory

Sacral Tilt

30°-60°

Sacral Canal

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3

4

5

Sacral Hiatus

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

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Lumbosacral articulation:!• 5th lumbar vertebra and 1st sacral segment. !• 1st sacral segment is inclined slightly anteriorly and

inferiorly, forms an angle with horizontal: lumbosacral angle

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

• Increase in angle : increase in lumbar lordosis !• Increase shearing stress at lumbosacral joint

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

❖ Anterior longitudinal ligament

is strong and well developed in this region !

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❖Posterior Longitudinal Ligament is only a thin ribbon in lumbar region, whereas ligamentum flavum is thickened here

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

• Flexion generates compression forces on anterior side of disc tending to migrate nucleus pulposus posteriorly!!

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• Limited by tension in posterior annulus fibrosus and posterior ligament system

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

• Increase in lumbar lordosis!

• Posterior tilting , gliding of superior vertebra!

• Lumbar extension reduces the diameter of ! intervertebral foramina

Lumbar Extension:

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

• Fewer ligaments checks extension!!• During lumbar extension nucleus pulposus displaces anteriorly

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

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Lumbo-pelvic rhythm:!!• The kinematic relationship between! lumbar spine ! and ! hip joints ! during sagittal plane movements

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

• Bending forward- lumbar flexion (40⁰) followed by ! anterior tilting of pelvis at hip joint (70⁰)!!• Return to erect- posterior tilting at pelvis at hips followed ! by extension of lumbar spine

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

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PARS INTERARTICULARIS FRACTURES:!• Region between superior and inferior articular facets!• Weakest bony portion of vertebral neural arch

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

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Spondylolysis Spondylolisthesis

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

• Common at L5-S1 and L4-L5

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

INTERVERTEBRAL DISC PROLAPSE:!• Common site: L4-L5 & C5-C6!

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

LUMBAR CANAL STENOSIS:!• Narrowing of lumbar canal!• Congenital OR Acquired

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

'Red Flags' in the Medical History: Potentially Serious Conditions That May Present as Low Back Pain

Fracture • Major trauma (motor vehicle accident, fall from height)

• Minor trauma or strenuous lifting in an older or osteoporotic patient

Tumor or infection • Age >50 years or <20 years

• History of cancer • Constitutional symptoms (fever, chills, unexplained weight loss) • Recent bacterial infection • Intravenous drug use • Immunosuppression (corticosteroid use, transplant recipient, HIV infection) • Pain worse at night or in the supine position

Cauda equina syndrome • Saddle anesthesia

• Recent onset of bladder dysfunction • Severe or progressive neurologic deficit in lower extremity

'Red Flags' in the Medical History: Potentially Serious Conditions That May Present as Low Back Pain

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

Lumbar Puncture

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

Epidural anesthesia

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Humor And Laughter Are Important!!

Humor in our daily lives is an essential ingredient!

of happiness. So, learn to look on the funny! side of things. Even serious situations.

Have you had a good laugh today? !If you haven't, then please do - don't!

let the day go to waste! Laughter! melts the distances between people.

THANK YOU

There is only one difference between Dream & Aim.

 Dreams require effortless Sleep &  Aim (Ambition In Mind)  requires

sleepless efforts.  Sleep for Dreams & Wake up for

Aims.

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