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