B7.006 Spine and Back Flashcards
1
Q
structure of vertebra
A
body - anterior to spinal cord, become larger from C2 to L5
arch - creates a cranial/caudal opening that protects the spinal cord
4 articular processes
2 transverse processes
1 spinous process
2
Q
components of vertebral arch
A
2 pedicles
2 laminae
3
Q
vertebral foramen
A
helps form the vertebral canal containing the spinal cord
4
Q
intervertebral foramen
A
formed by inferior and superior vertebral notches
contains dorsal root ganglion and spinal nerves
5
Q
spinous processes
A
extend posteriorly and inferiorly
connected by:
interspinous ligaments
supraspinous ligament
6
Q
transverse process
A
originate from the junction of the pedicles and laminae
serve as site of muscle attachment
7
Q
articular facets
A
at oblique angles which vary significantly up and down the spinal column
limit rotation and flexion of adjacent vertebral bodies
add stability to column
8
Q
pars interarticularis
A
portion between the superior and inferior articular facet on each vertebra
often defective in spondylolisthesis
9
Q
key difference in cervical vertebrae
A
have a transverse foramen for the vertebral artery in C1-C6
10
Q
bump you feel on the back of your neck
A
C7 has an extra long spinous process (vertebral prominence)
11
Q
atlas
A
C1 vertebrae
has no body or spinous process, but has a posterior arch and posterior tubercle
12
Q
axis
A
C2 vertebrae
has a body and spinous process, two large superior articular facets, and one large dens process
13
Q
dens process
A
formed during embryonic development from body of the first cervical vertebra
14
Q
stabilization of atlas and axis to the skull
A
alar ligaments
cruciform ligaments
15
Q
thoracic vertebrae (12)
A
very stable
articulate with ribs
have at least one or sometimes two facets for the heads of ribs on each side of the body
long thin spinous process points inferiorly
16
Q
lumbar vertebrae (5)
A
large, kidney shaped vertebral bodies
no facets for ribs
articular processes project superior and inferior and limit rotation while permitting flexion and extension
contain an additional process of muscle attachment - mammillary process
spinout process is thicker and shorter than in the thoracic region
17
Q
function of facet joints
A
limit movement between adjacent vertebrae
18
Q
sacrum
A
5 fused vertebrae
support vertebral column
forms the posterior of bony pelvis
19
Q
intervertebral discs
A
shock absorbers in between each vertebrae
make up 1/4 height of column
allow for flexion of the vertebral bodies between each other
20
Q
intervertebral discs as a symphysis
A
fibrocartilaginous articulation between hyaline cartilage on the “end” of the bodies of vertebrae
21
Q
2 parts of the intervertebral disc
A
annulus fibrosus- concentric layers of oblique fibers
nucleus pulposus - avascular gelatinous mass, derived from notochord
22
Q
height variation throughout the day
A
1/4 of the length of the vertebral column is due to the intervertebral disks which are hydrated structures
in the morning, you are the tallest
most adults are 1 cm short by the end of the day
23
Q
location of dorsal root ganglia
A
sits in the intervertebral foramen
24
Q
how does an intervertebral disk respond to increased load?
A
bulges into intervertebral foramen, can impinge on exiting and entering spinal nerves when this occurs
25
at what positions is your body putting the most load on your 3rd lumbar disc
bending over
sitting
this is why standing desks are good
26
ligamentum flavum
extends from lamina to lamina
forms the:
1. posterior boundary of the intervertebral foramen
2. posterior wall of the spinal canal
27
result of hypertrophy of ligamentum flavum
spinal cord stenosis
| most frequently in lumbar and cervical regions
28
anterior longitudinal ligament
strong, broad fibrous band running anterior to the vertebral bodies and discs from base of skull to sacrum
limit hyperextension
29
posterior longitudinal ligament
weaker than anterior
runs within the vertebral canal, just anterior to the spinal cord
helps stabilize vertebral bodies
called tectorial membrane when it reaches the base of the skull
30
causes of vertebral body (compression) fracture
osteoporosis
cancer
trauma
31
where do compression fractures occur
weight of body is largely anterior to the spinal column so compression fractures occur first within the anterior portion of the vertebral body
32
burst fractures
more severe
| can put bone fragments into the spinal canal
33
effect of compression fractures
trap spinal nerves as they pass out in the intervertebral foramen
leads to radicular pain or loss of function
34
spondylolysis
defect in pars interarticularis (in between superior and inferior facets)
bone breaks, most common at L5 inferior facets, can lead to pain and instability of the vertebra
may be unilateral or bilateral
35
who gets spondylolysis
adolescent athletes
| prevalence of LBP in 11-17 year old athletes is 30.4%
36
diagnosis of spondylolysis
breakage most frequent at the pars interarticularis or isthmus (neck)
may not be visible on plain films, but typically seen on MRI of thin slices and high resolution
37
spondylolisthesis
slipping (subluxation) of vertebra in relation to the adjacent inferior vertebra or sacrum
often secondary to spondylolysis of the L5 vertebra, allowing the vertebral column to slide forward on top of the sacrum
38
result of spondylolisthesis
dislocation/ subluxation of the vertebral body, typically anteriorly
compression of sacral spinal nerves and thus, leg pain
39
classification of spondylolisthesis
by degree of slippage, measured as percentage of the width of the vertebral body
40
when is surgery required in spondylolisthesis
generally 50-100% slippage
| grade 3-4
41
primary curvature of spine
develops in utero
| concave (anterior) curve
42
secondary curvature of the spine
occurs in cervical and lumbar regions as we learn to look around and walk
saves energy
43
kyphosis
anterior concave curvature of the vertebral column
most frequently in thoracic region
when severe, can limit lung function and cause digestive problems
>3 mil per year in US
44
lordosis
anterior convex curvature of the vertebral column
200,000 per year in US
most frequently occurs w pregnancy
45
scoliosis
lateral and/or rotational curvature of the vertebral column
most frequently initiates during adolescence and involves both thoracic and lumbar regions
3 mil per year in US
46
screening for scoliosis
having patient bend forwards looking at the height of the left and right shoulder lades
47
types of curves in scoliosis
thoracic - 90% on right side
thoracolumbar - 80% on right side
lumbar - 70% on left side
double major - right thoracic and left lumbar curves are equal in size
48
embryonic spinal cord in vertebral canal
at 8 weeks, the spinal cord fills the vertebral spinal canal and the spinal levels match the vertebral level
49
differential growth of the spinal cord
eventually, spinal cord slows its growth and the bones and ligaments continue to grow rapidly
in a full term newborn, cord terminates at L3
50
where does the cord terminate in adults
most around L1
| 99% by inferior end of L2
51
what is the spinal cord
cylindrical structure beginning in the medulla, exiting from the foramen magnum and ending at L1-2
52
how many spinal nerves
31
| made up of ventral motor roots and dorsal sensory roots
53
corresponding nerves and vertebra
in cervical level, nerve exits above corresponding vertebra (C8 exits below C7)
for thorax, lumbar, and sacral levels, nerve exits below the corresponding vertebra
54
cervical enlargement
accommodating spinal segments C4-T1 for the brachial plexus
55
lumbosacral enlargement
L1-S3 spinal segments (T11-L2 vertebral segments)
56
tethered spinal cord syndrome
neuro disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column
usually in children
57
symptoms of tethered spinal cord in children
back pain
shooting pain in the legs
weakness, numbness, or problems with muscle function in the legs
tremors or spasms in the leg muscles
changes in the way the feet look, like high arches or curled toes
loss of bladder or bowel control that gets worse
scoliosis or abnormal curve of the spine that changes or gets worse
repeated bladder infections
58
symptoms of tethered spinal cord in adolescents
bending slightly
buddha sitting with legs crossed
baby holding (or equivalent weight) at the waist level
59
diagnosis and treatment of tethered spinal cord
diagnosed by MRI
| treated surgically
60
meninges of the spinal cord
dura matter
arachnoid matter
pia matter
61
dura mater
tough, fibroelastic connective tissue sheath, free within the vertebral canal
ends at S2ish
62
what is located outside of the dura mater
fat, arteries, veins, and periosteum
| between dura mater and periosteum = extradural / epidural space which is filled with fat and venous blood vessels
63
sacral hiatus
opening at end of spinal canal
located 1.5-2 in above the top of the coccyx
allows access to epidural space
64
inside the dura mater
arachnoid mater
| denticulate ligament
65
denticulate ligament
formed of pia mater
ribbon-like structure extending laterally from the midline from each side of the spinal cord to attach to the inner surface of the dura in 21 tooth like projections
stabilizes spinal cord within the dura mater
66
arachnoid mater
separates pia from the dura by a fluid filled space, the subarachnoid space
applied directly to the inner surface of the dura, and sends arachnoid trabeculae through the subarachnoid space to the pia
contains CSF
67
pia mater
2 fused layers of loos connective tissue
| encloses network of blood vessels which supply the cord
68
subdural space
potential space (pathologic) between dura and arachnoid mater
69
end of the spinal cord
ends in the conus medullaris at L1-2
dura mater and subarachnoid space end at S2
from L2-S2 is the lumbar cisterna
70
cauda equina
within the lumbar cisterna
| spinal nerves distal to the conus medullaris
71
filum terminale internus
strand of connective tissue from the end of L2 to S2
attaches to the periosteum of the coccyx below the dural sac
upon flexion, pulls the spinal cord anteriorly
72
function of CSF
serves as mechanical and protective support for the brain
| serves as an ion sink
73
volume of CSF
120-150 mL
95 mL within brain, 35-55 mL around spinal cord
450-500 mL produced every day
74
composition of CSF
clear fluid w SG = 1.007
| pressure 70-180 mm
75
spinal tap / lumbar puncture procedure
cerebral spinal fluid is most commonly taken from the lumbar cisterna by inserting a spinal tap needle between L3/L4 or L4/L5
76
how to find L4
horizontal line across superior iliac crests generally falls between L3 and L4 (or on the L4 spinous process)
77
superficial back muscles
```
trapezius
levator scapulae
rhomboid minor
rhomboid major
latissimus dorsi
serratus posterior superior
serratus posterior inferior
serratus anterior
```
78
trapezius origin
superior nuchal line on back of head down to the T12 spinous process
79
trapezius insertion
spine of scapula
acromion
lateral 1/3 of clavicle
80
innervation of trapezius
CN XI
| C3, C4
81
action of trapezius
adduct, elevates, depresses, and rotates scapula
82
levator scapulae origin
transverse processes of C1-C4
83
levator scapulae insertion
medial border of scapula
84
levator scapula innervation
dorsal scapular nerve
| C3,C4
85
rhomboid minor origin
spines of C7-T1
86
rhomboid minor insertion
root of spine of scapula
87
rhomboid minor innervation
dorsal scapular nerve
| C5
88
levator scapulae function
elevates scapula
89
rhomboid minor function
adducts scapula
90
rhomboid major origin
spines of T2-T5
91
rhomboid major insertion
medial border of scapula
92
rhomboid major innervation
dorsal scapular nerve
| C5
93
rhomboid major action
adducts scapula
94
latissimus dorsi origin
spines of T5-T12
thoracolumbar fascia
iliac crest
ribs 9-12
95
latissimus dorsi insertion
floor of bicipital groove of humerus
96
latissimus dorsi innervation
thoracodorsal nerve
97
latissimus dorsi action
adducts, extends, and rotates arm medially
98
serratus posterior superior origin
ligamentum nuchae
supraspinous ligament
spines of C7-T3
99
serratus posterior superior insertion
upper border of ribs 2-5
100
serratus posterior superior innervation
first 4 intercostal nerves
101
serratus posterior superior action
elevates ribs
102
serratus posterior inferior origin
supraspinous ligament
| T-11-L3
103
serratus posterior inferior insertion
lower border of and spines of ribs 9-12
104
serratus posterior inferior innervation
last 4 intercostal nerves
105
serratus posterior inferior action
depresses ribs
106
serratus anterior origin
outer surface of ribs 1-8
107
serratus anterior insertion
medial border of scapula
108
serratus anterior innervation
long thoracic nerve
109
serratus anterior action
abducts and protracts scapula
110
triangle of auscultation
by the trapezius, lat dorsi, and medial border of the scapula
111
ddx of back pain
```
intervertebral disc rupture / herniation
nerve inflammation or compression
degenerative changes in the vertebral facet joints
metabolic bone disease
abdominal aortic aneurysm
metastatic cancer
myofascial disorders
back strain and sprain
```
112
characterize the intermediate layer of deep back muscles
called the erector spinae group
| contained within a common connective tissue sheath (thoracolumbar fascia)
113
what muscles are included in the intermediate layer of deep back muscles
iliocostalis (most lateral)
longissimus
spinalis (most medial)
I love spaghetti (lateral > medial)
114
deep layer of back muscles
collectively called transversospinalis
semispinalis
multifidus
rotatores
115
semispinalis
most superficial of deep back muscles
runs next to spinalis portion of erector spinae
arise from transverse processes of C4-T12 and insert onto spinous processes 4-6 segments superiorly
116
multifidus
deeper than semispinalis
arise from sacrum and ilium inferiorly or transverse processes more cranially
insert into spinous processes 2-4 segments superiorly
117
rotatores
deepest and smallest of the deep back muscles
| arise from transverse processes and insert into spinous process 1 or 2 segments superiorly
118
back sprain
damage to back ligaments which connect vertebrae
| less common than back strain
119
back strain
muscular problem
microscopic tears to the muscle fibers, typically due to overuse
"weekend warrior"
120
symptoms of back strain/sprain
may cause protective reflex tonic muscle contraction (tight back) to guard and protect the back from excessive movement and further damage
121
muscle guarding
protective response in muscle that results from pain or fear of movement
semi-contracted or stimulate state which may produce muscle pain and fatigue
122
treatment of muscle guarding
induced relaxation by using biofeedback to reduce EMG activity
123
injuries that can produce muscle guarding
damage to vertebrae or ligaments that connect vertebrae
| damage to back muscle
124
muscles surrounding spine at L4 level
psoas
transversospinalis group
erector spinae group
this is why do you do sit ups to strengthen your back as well as back muscle exercises
125
blood supply to the spinal cord
medullary arteries reach the anterior or posterior spinal arteries of the spinal cord
radicular arteries supply non-spinal cord structures (vertebrae)
126
artery of Adamkiewicz
great medullar artery which provides major blood supply to the lumbar and sacral cord
127
origin of artery of Adamkiewicz
in 75% of people, the left side of the aorta between the T8 and L1 vertebral segments
128
damage to the artery of Adamkiewicz
can result in anterior spinal artery syndrome, with urinary and fecal/anal incontinence and impaired motor function of the legs
sensory function is often preserved to a degree
129
importance of identifying artery of Adamkiewicz
when surgically treating an AAA to prevent damage which would result in insufficient blood to the spinal cord
130
Batson's venous plexus
network of valve-less veins that connect from deep pelvic veins, thoracic veins, and head and neck veins to the internal vertebral venous plexus
epidural veins
thought to allow the spread of some metastatic cancers to the vertebral column and brain
131
communications of batson's venous plexus
scalp, skull, and face
thoracoabdominal wall
azygous, pulmonary, and caval venous systems
pelvic, prostatic, and sacral veins
132
lifetime risk of disc herniation
2-4%
| more common in males
133
epidemiology of disc herniation
most frequently occurs during middle ages
- younger individuals may not be strong enough to lift weight sufficient to cause herniation
- as individuals age the nucleus pulposus tends to dry out and herniate less frequently
134
what spinal nerves are at risk during herniation
spinal nerve BELOW level of herniation
| *disk herniation usually occurs in either cervical or lumbar regions*
135
L4 herniation symptoms
rare
pain: lower back, hip, posterolateral thigh, anterior leg
numbness: anteromedial thigh, knee
weakness: quad
atrophy: quad
reflexes: knee jerk
136
L5 herniation symptoms
pain: SI joint, lateral thigh and leg
numbness: lateral leg, web of great toe
weakness: dorsiflexion
atrophy: minor
reflexes: none
137
S1 herniation symptoms
common
pain: SI joint, hip, posterolateral thigh and leg to heel
numbness: back of calf, lateral heel, foot and toe
weakness: plantarflexion
atrophy: gastroc and soleus
reflexes: ankle jerk
138
function of sacral hiatus
used to gain access to caudal epidural space
injection of steroid into the fat and venous blood within the sacral canal
used for birthing pain relief
139
C5
lat deltoid
140
C6
thumb
141
C7
middle finger
142
C8
little finger
143
L1
inguinal ligament
144
L4
knee cap (patella)
medial malleolus
side of big toe
145
L5
lateral knee
| top and sole of foot
146
S1
lateral malleolus
| back of thigh
147
S2,3,4
external genitalia and perineum
148
C2-3
upper neck
149
C5
clavicle
150
T4
nipple
151
T7
xiphoid
152
T10
umbilicus
153
hip movement
flexion: L2,3
extension: L4,5
154
knee movement
extension: L3,4
flexion: L5,S1
155
ankle flex/extend movement
dorsiflexion: L4,5
plantarflexion: S1,2
156
ankle inversion/eversion movement
inversion: L4
eversion: L5,S1
157
3 most common nerve roots damages in disc herniation
C7
L5
S1
158
myotome of C7
tricep
| extension of forearm
159
myotome of L5
extensor hallicus longus
| dorsiflexion of great toe
160
myotome of S1
gastrocnemius
| plantarflexion
161
ankylosing spondylitis
chronic inflammatory disease of the axial skeleton
manifested by back pain and progressive stiffness of the spine
inflammation around the enthesis (site of ligament insertion onto bone)
162
epidemiology of ankylosing spondylitis
peak onset in 20s
prevalence 0-1.4% depending upon ethnic group
HL-B27 association
163
ankylosis
fibrous or bony bridging of oint
164
other sponyloarthropathies
reactive arthritis
psoriatic arthritis
juvenile spondyloarthropathy
IBD associated arthropathy
165
diagnosis of ankylosing spondylitis
suggestive clinical features and evidence of sacroiliitis by radiological imaging
166
characteristics of identifying inflammatory back pain
```
onset before 40
insidious
persistence for 3 months
morning stiffness
improvement with exercise
```
167
chest expansion
measured at 4th intercostal space
should be >5cm
less than 2.5 cm is abnormal
168
causes of cauda equina syndrome
severe / massive ruptured disc in the lumbar area (most common)
narrowing of spinal canal
spinal lesion or tumor
spinal infection, inflammation, hemorrhage, or fracture
complication from a severe lumbar spine injury
AV malformation
169
symptoms of cauda equina syndrome
```
occur suddenly
severe low back pain
pain, numbness, or weakness in legs that causes stumbling or trouble arising from a chair
loss of or altered sensation in legs, butt, inner thighs, external genitalia, back of legs, feet
bladder/bowel dysfunction
sexual dysfunction
absent Achilles reflex
absent anal reflex
```
170
diagnosis of cauda equina syndrome
MRI or CT
171
treatment of cauda equina syndrome
usually surgical
| often laminectomy
172
epidemiology of spinal canal stenosis
common, gradual onset
8% of people
occurs in people > 50
males and females equally
173
symptoms of spinal canal stenosis
pain, numbness, weakness in the legs and arms
gradual in onset
improve with bending forwards
174
classification of spinal canal stenosis
cervical, thoracic, lumbar
| lumbar most common followed by cervical
175
causes of spinal canal stenosis
```
ligamentum flavum hypertrophy
facet joint hypertrophy
disk bulging
posterior longitudinal ligament thickening
RA
spinal tumors
trauma
Paget's
scoliosis
spondylolisthesis
achondroplasia
```
