Clinical spinal anatomy for students v2
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Transcript of Clinical spinal anatomy for students v2
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Clinical spinal anatomy
Mr. Daniel Chan FRCSEd FRCSOrth
Consultant Orthopaedic Spinal Surgeon
PEOC/RD and E
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Anatomy of the SpineAnatomy of the Spine
Cervical spine7 vertebraeC1 - C7
Thoracic spine12 vertebraeT1-T12 (D1-D12)
Lumbar Spine5 vertebraeL1-L5
Sacrum & Coccyx5 fused vertebraeS1-S53-5 Coccygeal segments
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ANTERIOR COLUMN• solid column of
vertebral bodies• compression-
resistant
POSTERIOR COLUMN
• hollow column of neural canal
• tension-resistant
• Axial skeleton• Protection of neural
structures• Flexible weight bearing
column• Anterior compression
column• Posterior tension
column• Facets resist rotation
and anterior displacement
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Sagittal profile
• To maintain upright balance
• Cervical and lumbar lordosis
• Thoracic and sacral kyphosis
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00
11223344
55
66
77
upper cervical spine - Axial
lower cervical spine – Sub-Axial
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Anatomy - Osteology
• Occiput– Inion – external occipital protuberance– Transverse sinus close proximity– Occipital screws just below inion (thick)
• Typical - C3-6
• Atypical - Atlas, Axis, C7 (vertebra prominens)
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Restricts rotation of occiput on dens
Major stabiliser C1-C2
Major ligs of subaxial spine+ lig flavum + inter + supra spinous ligs
C0-C2 Joint surfaces very unstableStability via ligaments
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Steel’s Rule of Thirds1/3 Dens1/3 Cord1/3 Space
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Feel your own!
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For feeling the pulse!
Tripod = VB +2 Facets / Lateral masses
Scalenes ant + med
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Uncinate ProcessUncovertebral Joints of LuschkaLimit Lateral Translation or BendingGuide Rail for Flexion / Extension
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Anatomy - Articulations
• Arc of motion:
• Flexion/Extension 145°
• Axial rotation 180°
• Lateral flexion 90°
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Anatomy - Articulations
• 50% cervical flex / ext @ Co-C1
• 50% cervical rot @ C1-C2
• Rest motion in sub-axial spine by “coupling” action of motion segments
• Sub-axial cervical facet joint orientation unique– 45˚ sagittal– 0˚ coronal
• Permits flex / ext / lat bend / rot
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Anatomy - Neural
• 8 Cervical nerves
• 7 Vertebrae
• Dorsal root + DRG = sensory
• Ventral root = motor
• Unite = spinal nerve
• Dorsal ramus = to the back
• Ventral ramus = to the front
• Sinuvertebral nerve = to the spinal column
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Anatomy - Neural
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Starting point 1mm medial to centre of lateral mass
Starting point 1mm medial to centre of lateral mass
1mm15o
Vertebral artery anterior to entry point
Vertebral artery anterior to entry point
Pedicles small and highly variableTherefore – lateral mass screws
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Place a flat probe in the facet joint of the level to be fused to indicate the cephalad angulation of the drill or ‘K’ wire
Place a flat probe in the facet joint of the level to be fused to indicate the cephalad angulation of the drill or ‘K’ wire
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greateroccipitalnerve
vertebralartery
sub-occipitalnerve
posterioratlantooccipitalmembrane
axis
atlas
atlanto-axialjoint
spinal cord
vertebralartery
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Atlanto-axial dislocations-surgical stabilisation
Atlanto-axial dislocations-surgical stabilisation
• Magerl transarticular screw fixation• Magerl transarticular screw fixation
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Atlanto-axial dislocations-surgical stabilisation
Atlanto-axial dislocations-surgical stabilisation
• Gallie C1/2 wiring• Gallie C1/2 wiring
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Atlanto-axial dislocationSurgical stabilisation
Atlanto-axial dislocationSurgical stabilisation
• Brook Jenkins C1/2 fusion
• Brook Jenkins C1/2 fusion
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(Goel) Harm’s C1/2 fixation
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DF injury
• example
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DF injury
• Reduction of unifacet dislocation
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DF injury - redisplacement
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• Roger’s wiring
• Bohlman’s triple wiring
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Posterior stabilisation
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Lateral mass fixation
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•12 Vertebrae, Smaller than Lumbar12 Vertebrae, Smaller than Lumbar
•Facets Frontally Orientated in A-P ViewFacets Frontally Orientated in A-P View
•Spinous Processes Longer, Distally OrientatedSpinous Processes Longer, Distally Orientated
•Transition at Thoracolumbar Junction T9-12Transition at Thoracolumbar Junction T9-12
Thoracic Anatomy
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Anatomy – general considerations
•transverse processes short transverse processes short but thick, but thick, orientated postero-laterally, orientated postero-laterally, articulate with ribs articulate with ribs
•Pedicles smallerPedicles smaller
•Spinal Canal smaller Spinal Canal smaller diameterdiameter
•Ribs articulate with Ribs articulate with vertebral bodiesvertebral bodies
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Anatomy – body and pediclesAnatomy – body and pedicles•Left side flattened Left side flattened due to aortadue to aorta
•Heart shapedHeart shaped
•Pedicles smallest Pedicles smallest at T3-6 (3-4mm)at T3-6 (3-4mm)
•Centre projects Centre projects intersection 1-2mm intersection 1-2mm medial to lateral medial to lateral lamina with parallel lamina with parallel line superior 1/3 tp.line superior 1/3 tp.
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Anatomy -costovertebral joints and ribsAnatomy -costovertebral joints and ribs
•11stst, 11, 11thth and 12 and 12thth ribs ribs soleley with named soleley with named vertebravertebra
•2-10 with rostral 2-10 with rostral neighbourneighbour
•Articulate with anterior Articulate with anterior tptp
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Structures anterior to thoracic spine
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Tomita Procedure
• 55/M(AM)• Back pain+
paraparesis• T7 Mets• Tokuhashi Score-12• Hypernephroma
primary
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Tomita procedure (Spine 1997; 22: 324-333)
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3 months
28 monthsNo recurrence
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Lumbar SpineLumbar Spine• L1 to L4 ‘Typical’ Lumbar
Vertebrae
- wide strong kidney shaped bodies with parallel endplates;
- a wide posterior arch fusing to form a horizontally projecting spinous process
- Superior facets face posteromedially, Inferior facets face anterolaterally and therefore allow flexion/extension but limit rotation
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Ligamentumflavum
Interspinous ligament
Anteriorlongitudinal ligament
Posterior longitudinalligament
Intervertebraldisc
Supraspinousligament
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Pars interarticularisPars interarticularisSpondylolysis: The Scotty Dog Spondylolysis: The Scotty Dog Spondylolytic spondylolisthesisSpondylolytic spondylolisthesis
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• NUCLEUS PULPOSUS– GAGS. Hydrated
Aggrecans– Hydrostatic
structure
• ANNULUS FIBROSUS– fibrocartilagenous
structure with different “mesh-type” layers
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L4
L5
Cauda equina and Nerves rootsCauda equina and Nerves roots
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Degenerative
• Disc herniations
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Anatomy• Thoracolumbar fascia
• Cluneal nerves
• Sacrospinalis– Iliocostalis– Longissimus– Spinalis
• multifidus• rotators• intertransversarii
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Anatomy
• crest on pars
• crest on TP
• converge on superior facet
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Sacral anatomy
• lateral sacral crest
• junction with superior facet
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Sacral anatomy• converge to
promontary
• diverge to ala
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Plan screw trajectory
MRI Plain X rays
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Anterior relations
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Cross section anatomy - L4 L5
• root medial and inferior to pedicle
• great vessels anterior
L4 L5
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Cross section anatomy - S1
• “bare” area
• L5 root
S1
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L4/5 exposure L5S1 exposure
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May the force be with you
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Clinical Instability
The loss of the ability of the spine under physiological loads to maintain its pattern of displacement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating pain
Clinical Instability
The loss of the ability of the spine under physiological loads to maintain its pattern of displacement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating pain
White and Panjabi Clin Orthopaedics 1975