anatomy block 3 BACK Flashcards
back regions -
vertebral
scapular
interscapular
surpascapular
deltoid
lateral pectoral
infrascapular
superior and inferior lumbar trialngles
sacral region
superior and inferior lumbar trialngles
two areas of herniation -
grynfeitt lesshaft
petits
buttock regions - 3
gluteal, intergluteal, anal
four curvatures of back
PRIMARY _ in utero - thoracic, sacral
both CONCAVE
SECONDARY - convex
cervical - baby lifting head
lumbar baby begin to stand
4 abnormal curvatures - lordosis?
butt sticks out - swayback - pregnant
kyphosis
kyphoscoliosis
hump
scoliosis
S shape - most common 0.5%
vertebral joints -
atlanto occiptital
Head and atlas - nodding
synovial joint
A synovial joint, also known as diarthrosis, joins bones with a fibrous joint capsule that is continuous with the periosteum of the joined bones, constitutes the outer boundary of a synovial cavity, and surrounds the bones’ articulating surfaces. The synovial cavity/joint is filled with synovial fluid.
atlanto axial -
atlas and axis - ROTATION
3 joints - synovial -
Dens - anterior Arch Atlas
1st cervical vertebra and the superior articular
facets of the 2nd cervical vertebra.
One is found between the dens (odontoid process) of the axis (2nd cervical vertebra) and the anterior arch
of the atlas (1st cervical vertebra), and two are located between the lateral masses of the
occipital condyles?
each of two rounded knobs on the occipital bone that form a joint with the first cervical vertebra.
zygapophysial joint?
facet joint
transverse foramen ?
provide a passageway by which the vertebral artery, vein and sympathetic nerves can pass.
EXC 7
transverse foramen. : a foramen in each transverse process of a cervical vertebra through which the vertebral artery and vertebral vein pass in each cervical vertebra except the seventh.
vertebral joints? - 5 taught
atlanto-occipital
atlanto axial
intervertebral sinovial -
intervertebral cartilaginous
sacral -
art with hip bones and 5th lumbar
sacrococcygeal joint (coccyx and sacrum)
atlanto axial joint ligaments? Rotates
apical (apex of odontoid to foraman magnum
alar - limits rotation
cruz - rotates
anterior/posterio longit - runs down vertebral column = all of vertebral bodies and discs
posterior within vertebral canal - along posterior surfaces of vertebral bodies from c2 to sacram
tectorial membrane
from atlanto axial to occipital - continues posterior longit lig - The tectorial membrane is the thin superior continuation of the posterior longitudinal ligament from the body of the axis. It joins the axis body to the clivus on the anterior half of the foramen magnum, and ascends as high as the spheno-occipital synchondrosis and laterally extends to the hypoglossal canal.
Ligamentum flavum ?
Connect LAMINAE of adjacent vertebrae
starting from the axis (C2) vertebra to first segment of sacrum;
-They are best seen from the interior of the vertebral canal
-Their elasticity serves to preserve the upright posture,
and to assist the vertebral column in resuming it after
flexion.; -The elastin prevents buckling of the ligament
into the spinal canal during extension, which would
cause canal compression.
intrinsic back -
three layers -
superficial (splenius m - neck)
intermediate - erector spinae m (though spine)
deep - trasnversospinales - fill spaces betwe transverse processes and spinous processes
True vs false back muscles?
The deep back muscles are a group of skeletal muscles located within the deepest part of the dorsal trunk, closest to the spine. They are sometimes referred to as the intrinsic back muscles or true back muscles as they control the movement and posture of the vertebral column.
true back m. innervated by?
dorsal rami
spondylolisthesis - spondylosis
spondylitis?
???
spondylolisthesis -
forward vert slip - usually 5th lumbar to sacrum body or L4 to L5
pain re nerves, sciatica, muscle tightnesse, shortened trunk, etc
spondylosis
degenerative osteoarthritis
spondylitis?
Inflamation of vert - if ankylosing spondylitis - rheumatoid - bones can grow together - deform, bamboo spine, limit motion -
what causes kyphosis? SHEUERMANN’s Disease
juvenile kyphosis - failure of thoracic vertebrae ant and post growing at same time.
Potts Tuberculosis Disease?
tuberculosis of spine - often cause kyphosis, usually in thoracic portion
soft/collapse of vert
Spina Bifida? - various types - less severe to severe
defective closure of verebral arch - folic acid - various types, from not serious to severe
baby should be delivered via C section
parts of vertabrae?
body - takes weight
arch - paired pedicles laterally and paired laminae posteriorly
laminae
pedicles
foramen
processes of vertebral arch?
spinous - projects post
bifid cerv
spine like in thorac
oblong lumbar
transverse - lateral projection to ribs 1 - 10 in thoracic region
have formina in cervical region (for 2x arteries, vein)
articular (facets)
two superior, two inferior
form plane synovial joints above and below
mamillary - tubercles on superior articular processes of lumbar
accessory - project backward from based of transverse process and off of mamillary process of lumbar
Foramina?
vertebral - passage of vertebral canal
intervertebral - between inferior and superior surfaces of pedicles - transmit SPINAL nerves and accompanying vessels as exit canal
transverse - at cervical vert except c7
transmit vert artery, veins, and autonomic nerves
Klippel-Feil syndrome - SHORT NECK
congenital defense - short neck, missing cervical vert or fused -
limited motion, low hairline
Whiplash? ? anterior or posterior lig usually out?
often c4-c5
intervertebral discs? where not found?
between atlas and axis
what made of?
nucleus pulposus w/ surrounding annulus fibrosus
cartilaginous joint
1/4 of length of column
shock absorber
avascular but for perifery - adj blood vessels supply
Nucleus pulposus?
remnant of notochord -
reticular and collag fibers in mucoid
may herniate thru annulus fibrosus - impinging nerve
shock absorber
annulus fibrosus?
concentric layers of fibrous tissue and fibrocartilage -
binds vert column together - retains nucleus , permits limited movement, shock abosorber
herniated (slipped) disc?
protusion of nucleus pulposus into foramen or canal - compressing spinal nerve root
often occur where posterior longit ligmanet not reinforce -
often lumbar region
hernia at L4-L5 - most likely damage 5th lumbar nerve root, not 4th, re oblique descending nerve roots
sciatica?
lower back/hip radiating pain in butt, lower limb - most common cause herniated lower disc - compressting/irritating roots
upper vert characterisitics?
C1 - supports head, nod, , atlas - no body, no spine -
c2 - DENS allows head pivot - supported by various other lig - alar, cruciform, apical, and tectorical membrane
Hangman’s fracture ?
cruciform lig torn - spinal column crushed. also see in car accidents.
c 3 - 6 normal (with transverse foramen ) with bifed process - but what about c7?
vertebra prominens - long spinous process - not bifid
visible protrusion -
numerous attachements here -
lig nuchae, supraspinous lig, etc.
Thoracic vert?
Lumbar?
line up with ribs - like puzzle pieces - connecting up and down
ID by large bodies - 5th largest - weight? -
have mamillary and accessory processes
sacrum?
5 fused sacral verts - four pairs of foramina -
ventral and dorsal rami exit
stabilizes pelvis -
Promonitory, ala, medianl sacral crest, sacral hiatus, and horn
Coccyx?
wedge shapped, four coccy vert
coccygeus and levator ani muscles attach
lIgaments of vert?
anterior longit - from skull to sacrum, anterior surface of vert bodies and interertebral disks -
narrowest at top, widents supports annulus firbrosus anteriorilty
limits extension
POSTERIO - narrows at descends - in canal, limits flexion
lig Flavum?
connects laminae of two adj vert and maintain posture
lig nuchae (back of neck?) and others?
triangular septum betwe muscles
c7 - occipital protuberance and crest
also attach to posterior tubercle of atlast and spinouse processes of other cervical vert
there are some other ligs too - interspinous, intertrasnverse, supraspinouse
vertebral venous system?
Internal and external vert
no valves
internal - epidural space
more in book not included here.
soft tissues of back - triangles and fascis?
triangle of ausculatation - where breathing can be heard on back-
lumbar triangle (of PETIT) - abdominal hernias
Thoracoumbar fascias (lumbodorsal fascia)
The thoracolumbar fascia (lumbodorsal fascia) is a deep investing membrane which covers the deep muscles of the back of the trunk. in the cervical region, it passes in front of the Serratus posterior superior and is continuous with a similar investing layer on the back of the neck—the nuchal fascia.
superficial - extrinsic muscles?
trapezius
stabilize and move the scapula. The upper fibers can elevate and upwardly rotate the scapula and extend the neck. The middle fibers adduct (retract) the scapula
levator scapulae
When the spine is fixed, levator scapulae elevates the scapula and rotates its inferior angle medially. It often works in combination with other muscles like the rhomboids and pectoralis minor to rotate down
rhomboid - minor, major
A rhomboid muscle strain or spasm is usually caused by overuse of the shoulder and arm, especially during repetitive overhead activities like serving a tennis ball or reaching to put objects on a high shelf.
latissimus dorsi
Latissimus dorsi works collaboratively with the teres major and pectoralis major to perform actions of the upper extremity. Together, these muscles will work to adduct, medially rotate and extend the arm at the glenohumeral joint
serratus posterior - superior, inferior
What are true back muscles?
The deep back muscles are a group of skeletal muscles located within the deepest part of the dorsal trunk, closest to the spine. They are sometimes referred to as the intrinsic back muscles or true back muscles as they control the movement and posture of the vertebral column.
Deep Intrinsic muscles?
SUPERFICIAL LAYER - spinotransverse
splenius capitis and cervicis
_ extend, rotate, flex head -
dorsal rami of cervical spinal nerves
INTERMEDIATE LAYER
extend rotate and flex vert column and head -
dorsal rami of spinal nerves
DEEP LAYER -
extend, roate head, neck , trunk -
dorsal rami of spinal nerves
subocciptal area? suboccipital triangle?
contains vertebral artery and suboccipital nerve and vessels
suboccipital nerve?
from dorsal ramus of c1 - betwe vert artery and posterior arch of atlas below
Dermatomes
neurons are pseudounipolar - reside in single dorsal root ganglion - assoc with specific spinal cord level
region of skin innervated by somatic sensory nerve axons
what type of cartilage gives tensile strength to intervert disc?
fibrous - type 1 collagen
spina bifida oculta?
mildest form, might not even know it - hair grows over - or dimple or birthmark
sensory receptors of skin come from where?
Posterior dorsal (primary) rami
whiplash- what ligament is often damages?
anterior longitudinal - it gives protection, but can’t always win.
ALS lou gehrig’s disease - degenerating motor neurons in voluntary muscles - where see this in cell bodies of neurons?
Anterior (ventral) grey horn of spinal column
Lateral grey - sympathetic
Boundaries of ausculation triangle _ to hear breathing?
Trapezius, scapula, latissimas dorsi
paraplegia vs quad?
if spinal cord transected at T9 - patient will be paraplegic - incontinence, etc - from neck down give you quad / T9 was just a test Q and not a significant location-
rhizotomy?
operation several problematic nerves - to relieve pain, spasm, etc - pain in left forearm - relieve pain via posterior dorsal primary rami - - where afferent info arrives
scapular winging? what nerve?
long throracic - nerve is superficial on lateral thoracic wall, superficial to serratus anterior - not in a muscle - easy to damage,
takes weeks to develop - because trapezium muscle must stretch
deltoid problem? axillary n
medial rotation of arm? thoracodorsal n
weak elevating, retracting scapula? dorsal scap n
weak extend, rotate head? suocciptital n
older person, loss of leg sensation, xray shows spurs narrowing iv foramina at t12 - L3
what likely to be impinged
spinal ganglia
primary rami are not in IF foramina,
headless scottie dog injury ?
spondylolisis
Most believe it is due to a genetic weakness of the pars interarticularis. Both spondylolysis and spondylolisthesis can be present at birth or occur through injury. Repeated stress fractures caused by hyperextension of the back (as in gymnastics and football) and traumatic fractures are also causes.
ankylosing spondylitis?
arthritis of spine
medullary cone?
where spinal cord ends - lumbar puncture below.
fall - lands on feet?
burst injury
exercising, posterolateral herniation of c5 -6 - where does hernia impinge?
c6 spinal nerve root - NOT posterior rami (outside cord)
N+ 1 - C6
in cervical area - nerves come out above. 8 pairs of nerves, 7 vert,
In lumbar formular works too even tho nerves come below bec of acute angle.
most common hernias at C4 c5 and L4-5
car accident - head hits with rotation - steering wheel -
Steele’s Rule of 1/3s
Dens axis (odontoid fracture) type II most common - 60%
Steele’s rule of 1/3s -
Steel’s rule of thirds states that the area inside the atlas is equally occupied in thirds by the dens, spinal cord, and space. … This accounts for the low incidence of spinal cord injuries associated with C1 and C2 fractures,
car accident, torn posterior primary rami of c1 -6 - what muscles paralyzed?
splenius capitus- neck muscles
elder, 4th, 5th finger tingle, worse when look up, degenerating cervical vert ?
in this xray - cervical spinal stenosis
typically seen in elders, disc degeneration, may lack CSF
gymnast pulling straight up, as in doing a chin up, what muscle?
Lats
shingles, here see band across near umbilical - what ganglion affected
T10 - umbilicus -
shingles most often affects sensory ganglion - not autonomic.
here shingles appears in the dermatome
Lseque’s sign? Positive straight leg raising sign?
patient lies down, flex hip by raising staightened leg increases pain in back with raidation down left leg. do leg on side of pain - if do other side, won’t work.
clothes line injury on ATV -
“hangman’s fracture”
Traumatic spondilolisis in c2, - means dfect in pars interarticularis
The pars interarticularis means the “part between the articulations” and is the bony bridge that joins these two upper and lower facets
spondilolisthesis - anterior displacement of vert in relation to vert below
jefferson burst fracture of c1?
often occurs when hit on top of head with something heavy - fractures anterior and /or posterior arches of atlas
Den’s fracture?
will likely have at least slight rotation with excessive extension and/or flexion
atlanto-axial subluxation - ?
possible death - quadriplegia, - losing integrity of transverse ligament of atlas, which holds dens in place - compresses cervical spinal cord, frequent in downs
What causes a hangman’s fracture?
spondilolisis in c2
head is snapped up and back with great force, which is known as a hyperextension injury. The most common causes of this injury are falls and car accidents. Some sports injuries or collisions can also cause this fracture.
epidural anasthesia? ligamentum flavum?
One of a series of bands of elastic tissue that runs between the lamina from the axis to the sacrum, the ligamentum flavum connects the laminae and fuses with the facet joint capsules. These bands serve as a covering over the spinal canal.
Epidural Placement layers?
The needle must pass through five distinct tissue layers: Skin, subcutaneous fat, supraspinous ligament, interspinous ligament, and ligamentum flavum. The epidural space is then encountered and the clinician must stop the advancement of the needle before it penetrates the dural sheath
Will often hear POP.
Spina bifida Memingomyelocele?
most common form of SB cystica, unfused portion of vert column allows meninges and spinal cord to protrude
may result in paralysis and losso f sensation below level of spinal cord defect
cystica has to do with cyst like SAC -
elevated AFP in amniotic fluid?
strongly asso w/ severe spina bifida -
piano moving injury - left L3 spinal nerve compressed - which is most likely cause of condition?
L3 and L4 pedicles compressed together
Note PEDICLES are compressed - tricky Q re laminae, spinous process - it is the pedicles squishing nerve
Adolescent idiopathic Scoliosis onset age?
10 - 18 years - no known cause, if deviation less thatn 20 degrees no treatment requird
posterolateral herniation L4-5 what nerves may be impinged?
spinal nerves - disrupts posterior longitudinal lig and extends into vert canal -
90 % of injuries at L4-5, or L5 - s1.
Remember N+1 - # disc + 1 = # of spinal route contacted
Here L5 - S1 - impinges S1
burst injury at L1, plus medullary cone injury with bone fractures - what spinal cord seg would most likely be injured?
choices - T7, T9, T11, L2, S2
S2.
Petit’s Inferior lumbar triangle
and grynfeltt lesshaft superior lumbar triangle?
iliac crest interiorily, lats, ext abdominal oblique (above butt cheek to the lateral side
GrYN - (superior lumbar)
Petit’s Inferior lumbar triangle
and grynfeltt lesshaft superior lumbar triangle?
two sites for hernias
iliac crest interiorily, lats, ext abdominal oblique (above butt cheek to the lateral side - floor internal abdominal oblique
GrYN - (superior lumbar) - 12th rib superiorly, internatl abd oblique, quadratus lumborum roof external abdominal - floor transversalis fascia
arterial supply of back?
Spinal cord is supplied by branches of the: major cervical and segmental arteries:
Vertebral and ascending cervical arteries in the neck (from subclavian arteries).
Posterior intercostal arteries (from thoracic aorta) in the thoracic region.
Subcostal and lumbar (from abdominal aorta) arteries in the abdomen.
Iliolumbar and lateral (from internal iliac arteries) and medial sacral arteries in the pelvis.
blood supply to vertebral column?
The main blood supply to the spinal cord is via the single anterior spinal artery (ASA) and the two posterior spinal arteries (PSA). The anterior spinal artery is formed by the vertebral arteries which originate from the first part of the subclavian artery.
venous drainage of the back?
Spinal veins form venous plexuses along the vertebral column both inside and outside the vertebral canal (internal vertebral venous plexus and external vertebral venous plexus).
These plexuses communicate through the intervertebral foramina.
Basivertebral veins form within the vertebral bodies and drain into the anterior external and the anterior internal vertebral venous plexuses.
major connecting veins in back?
Superior vena cava in the cervical region; Azygos venous system in the thoracic region; Inferior vena cava in the lumbar and sacral regions
Intervertebral veins receive veins from the spinal cord (radicular/medullary segmental veins; anterior and posterior spinal veins) and vertebral venous plexuses as they accompany the spinal nerves through the intervertebral foramina to drain into the vertebral veins of the neck and segmental (intercostal, lumbar, and sacral) veins of the trunk.
Lymph drainage in back?
The deep lymph vessels follow the veins and drain into the deep cervical, posterior mediastinal, lateral aortic, and sacral nodes.
The lymph vessels from the skin of the neck drain into the lymph nodes of the neck
Those from the trunk above the iliac crests drain into the axillary nodes
Those from below the level of the iliac crests drain into the superficial inguinal nodes
nerve supply of back?
The skin and muscles of the back are supplied in a segmental manner by the posterior (dorsal) rami of the 31 pairs of spinal nerves
The posterior rami of the first, sixth, seventh, and eighth cervical nerves and the fourth and fifth lumbar nerves supply the deep muscles of the back and do not supply the skin
The posterior ramus of the second cervical nerve (the greater occipital nerve) ascends over the back of the head and supplies the skin of the scalp
The zygapophysial joints are innervated by articular branches of the posterior rami
The vertebral column is innervated by recurrent meningeal branches of the spinal nerves arising before division of spinal nerve into anterior and posterior rami, or from the anterior ramus immediately after its formation.
lumbar puncture?
The patient is made to lie on the side with the back and hips flexed (knee-chest position).
Flexion of the vertebral column facilitates insertion of the needle by spreading apart the vertebral laminae and spinous processes, stretching the ligamenta flava.
Lumbar puncture needle is inserted in the midline between the spinous processes of the L3 and L4 (or L4 and L5) vertebrae. At these levels, there is no danger of damaging the spinal cord.
After passing 4–6 cm in adults (more in obese persons), the needle “pops” through the ligamentun flavum, then punctures the dura and arachnoid and enters the subarachnoid space.
Normally, CSF escapes at the rate of approximately one drop per second. If intracranial pressure is high, CSF flows out or escapes as a jet.
two methods of spinal anasthesia?
Spinal anesthesia - An anesthetic agent is injected into the subarachnoid space. A needle is introduced at the L3–L4 vertebral level. This produces complete anesthesia inferior to approximately the waist level.
Epidural anesthesia (Blocks) An anesthetic agent is injected into the epidural space in the sacral canal, or using the position for lumbar spinal puncture. Within the sacral canal, the anesthesia bathes the S2–S4 spinal nerve roots, including the pain fibers from pelvic organs and and the afferent fibers from the pudendal nerve (perineum).
Both of techniques may be used in case of anesthesia for childbirth
embyronic epimere?
deep back muscles - epimere develops dorsally, hypomere develops?
each somite becomes myotome, dermatome, schleretome
sensory receptors of skin come from what rami?
posterior (Dorsal) primary rami - little vessel outside of spinal column, branching off of main looking branch (anterior primary rami)
elder, gibbus deformity in back? hurts to walk around, curviture of thoracic area?
kyphosis
crush fracture in vertebrae typically involves what part of vert?
vertebral bodies
what does ligamentum flavum connect
lamina of two adjacent vert
medial dorsal scapula injury retracting laterally - what nerve?
dorsal scapula innervates rhomboids
herpes zoster in what part of nervouse system?
dorsal root ganglia of sensory nerves
latisimus dorsi innervated by
thoracodorsal nerve - one of three major muscles that adducts and medially rotates humerus
spinal accessory innervates traps
dorsal scapular innervates scapula
in cervical region, what lig helps protect vert from direct compression
posterior longitudinal
raynaud’s disease - nerve operation?
operate on sympathetics - lower cervical, upper thoracic -
bony growths in cervical spine c 2, c3 - what may they impact
phrenic c3 -5 - diaphragm
shoulder droop?
spinal accessory nerve - CN XI
transverse ligament of axis?
CRITICAL if torn - holds dens in place - quadriplegic danger
neck flexion?
could be sternoicleidomastoid muscle
key ligament in c 1, c2?
cruciform - stabilizes c1/2 - attaches to pedicles and helps anchor dens in situ
and transverse also key -
reflexes
S1-S2 — “buckle my shoe” (Achilles reflex)
L2-L4 — “kick the door” (patellar reflex)
C5-C6 — “pick up sticks” (biceps reflex)
C7-C8 — “lay them straight” (triceps reflex)
Other reflexes include:
L1-L2 — “testicles move” (cremaster reflex)
S3-S4 — “winks galore” (anal wink reflex)
cervical rib? 7th
extra rib- 1/500
A cervical rib in humans is an extra rib which arises from the seventh cervical vertebra. Their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.2% (1 in 500 people) to 0.5% of the population
What are the symptoms of cervical rib?
pain in your neck and shoulder, which spreads into your arm – this may be constant or come and go. temporary loss of feeling, weakness or tingling in the affected arm and fingers. temporary inability to carry out fine hand movements – such as doing up buttons.
Where is the cervical rib?
Cervical rib: A cervical rib is an extra rib that grows from the cervical spine — the neck part of the spine. Between 1 and 3 percent of the population has a cervical rib, which may grow on one side or both, and may reach down to attach to the first rib or may not be fully formed
Scalene triangle?
Cervical ribs lie in the plane of the middle scalene muscle and make the scalene triangle narrower than in normal individuals. Most people with cervical ribs are asymptomatic, but an increased prevalence of cervical ribs has been noted in patients with TOS (4,11,12)
The scalene triangle (also known as the interscalene triangle) is located laterally at the root of the neck and is the space through which the roots and trunks of the brachial plexus and the third part of the subclavian artery exit the neck.
erb palsy?
baby delivery- c5-6, upper trunk of brachial plexus
OK gesture?
generated by ulnar nerve when trying to make a fist - can’t moves 4 and 5
accessory nerve?
trapezius - arm ABD probl >90
pitching injury?
infraspinatous muscle - innervated by suprascapular
erb’s palsy - ERB gets DIBS on tips
deltoid, infraspinous, brachaei -
3 nerves damaged if humerus breaks?
follow the ARM - axillary, radial, median
