Back Flashcards
Strongest of the cervical vertebrae
Axis (C2)
50% of flexion/extension
C1 (Atlas)
50% of rotation
C2 (Axis)
What does C7 provide an attachment for?
Nuchal ligament, supraspinous ligaments, and numerous back muscles
Where does whiplash injury usually occur?
Junction of C4 and C5, injury is mainly posterior (musculo-ligamentous).
Blow from top of the head that is usually not associated with spinal cord injury
Jefferson “burst” fracture (C1)
One of the most common cervical fractures that results from hyperextension of the head and neck, resulting in transection of the cord above C3
C2 fracture, Hangman’s fracture
A type III dens fracture is a fracture through what?
Vertebral body. Type I is a fracture of the tip, and type II is a fracture at the waist.
Congenital malformation in which the cerebellum and brain stem protrude down into the vertebral canal through the foramen magnum
Arnold-Chiari Deformity
Arnold Chiari deformity is associated with what conditions?
CSF obstruction, spina bifida, short neck and obstructive hydrocephalus
Multifactorial skeletal disease characterized by severe bone loss and disruption of the skeletal micro-architecture. Disease is painless until fracture occurs.
Osteoporosis
What type of osteoporosis is most common? Where does it occur?
Postmenopausal. Affects 30-40% of females. Occurs in thoracic spine.
At what point would you treat compression fractures with kyphoplasty?
Greater than 50% compression
Percutaneous injection of bone cement into vertebrae
Kyphoplasty
Significant kyphotic deformity from osteoporosis
“Dowager’s hump”
1/4 of the length of the spinal column; allows movement between vertebrae and absorbs some shock
intervertebral discs
Collagenous fibers embedded in mucoid substance, described as “crabmeat”
Nucleus Pulposis
Fibrocartilaginous outer cover that resists tensile and rotational forces
Anulus fibrosis
Where is the most superior and most inferior intervertebral disc?
1st disc is between C2 and C3, last disc is between L5 and S1
Weakest part of anulus fibrosis
Posterior part
Where do HNPs usually protrude to?
Posteriorly, then either right or left because strong posterior longitudinal ligament forces it in either direction. Midline protrusion is rare.
Where do 90% of HNPs occur?
L4-L5 and L5-S1
Low back pain, radicular radiation into lower extremity, sensory, motor, and reflex dysfunction.
Herniated Nuclear Pulposis
Lumbosacral pain radiating to buttocks in which radicular symptoms are not present.
Chronic Low Back Pain
Treatment of chronic low back pain?
Pain management. Non narcotic pain meds, PT, and ergonomic workplace adjustment.
Bony defect in vertebral arch (pars interarticularis) that results in an x-ray showing a “scotty dog” wearing a collar. Results from repetitive hyperextension.
Spondylolysis
Anterior movement of L5 vertebrae on sacrum
Spondylolisthesis
Lateral curvature of the spine >10 degrees, usually involving thoracic or lumbar spine. Affects females > males, especially between ages 10 and 16.
Adolescent idiopathic scoliosis.
Diagnostic evaluation of scoliosis?
Forward bending is the most sensitive test; rotation of vertebrae and rib elevation. Inequality of shoulder and pelvic height are NOT reliable
Neural tube defect that affects bone only
Spina bifida occulta
Neural tube defect in which meninges protrude out of spinal canal
Spina bifida meningocele
Meninges and spinal cord protrude
Meningomyelocele
Forms the posterior boundary of the true pelvis
Promontory of sacrum
Superior and lateral part of sacrum; formed by fused transverse processes and costal processes of first sacral vertebrae
Ala of sacrum
Where epidural anesthesia is given. Diffuses through dura and arachnoid
Sacral hiatus
Binds sacral hiatus at inferior sacral border; important landmark for locating the sacral hiatus
Sacral cornua or horn
What does the coccyx provide an attachment site for?
Coccygeus and levator ani muscles
Spinous process marks location of the end of the spinal cord
L2
Even with the horizontal line joining the highest points of the iliac crests
L4
Even with the PSIS
S2
Vertebral ligament that limits extension. Widens as it descends, maintains joint stability.
Anterior longitudinal ligament
Very strong vertebral ligament that limits flexion and narrows as it descends. Runs anterior to cord.
Posterior longitudinal ligament
Vertebral ligament that connects the laminae of adjacent vertebrae. Helps straighten the vertebral column after flexion.
Ligamentum flavum “yellow ligament”
Attaches to C2-C6 and supports back of skull, formed by thickened supraspinous ligaments
Ligamentum nuchae
Muscles that work away from where you are. Ex. muscles of the forearm that work the hand.
Extrinsic muscles (superficial and intermediate)
Extrinsic superficial back muscles
"Let's discuss this rascal later sonny" Latissimus dorsi Trapezius Rhomboids (major AND minor) Levator scapulae
Superficial back muscles work on what?
The shoulder
Extrinsic intermediate back muscles
Muscles of respiration! Help move the ribs during inhale/exhale.
Serratus posterior superior (elevates the ribs)
Serratus posterior inferior
(depresses the ribs)
“some people suck”
Intrinsic Intermediate Muscles
spinotransverse group (splenius capitis, splenius cervicis). "suck cock" extends, rotates, and laterally flexes head and neck. Sacrospinalis group: Erector spinae (iliocostalis, longissimus, spinalis) "Every stretch" Extension and control of flexion (head, spine), side bending.
Extend, rotate, and laterally flexes head and neck
Intrinsic intermediate muscles. Spinotransverse group (splenius capitis and splenius cervisis)
Extension and control of flexion (head, spine), side bending
Intrinsic intermediate muscles. Erector spinae (iliocostalis, longissimus, and spinalis)
Muscles of respiration
Extrinsic intermediate muscles (Serratus posterior superior/inferior)
Muscles that act on the shoulder
Extrinsic superficial muscles Lats Trapezius Rhomboids Levator scapulae
Intrinsic deep muscles
Transversospinal group
Semispinalis, multifidus, rotatores
Short men rock
What is the arterial supply of the cervical region of the spine?
“Obviously vegans don’t care about insignificant animals”
Occipital, vertebral, deep cervical, ascending intercostal arteries
What is the arterial supply of the thoracic spine?
“Please ignore Amy”
Posterior intercostal arteries
What is the arterial supply of the lumbar spine?
“Smoking costs lives”
Subcostal arteries
Lumbar arteries
What is the arterial supply of the sacrum?
“I love little surprises”
Iliolumbar
Lateral Sacral arteries
Are there valves in the venous supply of the spinal cord?
No
Where does the internal vertebral venous plexus live? How does it relate to cancer?
Epidural space between dura mater and vertebral canal. Thought to be the route of early metastasis of carcinoma from lung, breast, or prostate to the bones or CNS.
Where does superficial lymph of the back drain to?
Axillary nodes (above iliac crest) and superficial inguinal nodes (below iliac crest)
Where does deep lymph of the back drain to?
Tend to cluster around the aorta. Deep cervical, posterior mediastinal, lateral aortic, sacral nodes
The nerve root that comes out below C7 vertebrae is what?
C8 nerve root
The nerve root that comes out below T1 vertebrae is what?
T1 nerve root
The nerve root that comes out below the axis is what?
C3 nerve root
The nerve root that comes out below L4 vertebrae is what?
L4 nerve root
How many pairs of nerves are there?
31
Intrinsic back muscles are innervated by what?
Posterior rami
Efferent (motor nerves) are in which root?
Ventral root
Afferent (sensory nerves) are in which root?
Dorsal root
What are the components of a spinal nerve?
Two major components: Somatic fibers and Visceral fibers.
Somatic: Sensory transmits exteroreceptive or proprioreceptive info from body to the cord. Motor transmits impulses to skeletal muscles.
Visceral: Sensory transmits reflex or pain sensation from membranes, glands, and vessels
Motor transmits impulses to smooth muscle and glandular tissue
What area of spinal meninges is a potential space only?
Subdural space
Where is CSF?
Subarachnoid space
What structure helps to suspend the spinal cord in the middle of the menginges?
Arachnoid trabeculae
What do the cervical enlargement and lumbosacral enlargement do?
Gray matter gets larger in both areas to work the upper extremity and lower extremities respectively.
White matter gets _____ as you go from distal to proximal
Larger
Thread of pia mater extending from the inferior spinal cord
Filum terminale
Congenital anomaly resulting from defective closure of neural tube characterized by an abnormally low conus medullaris. Thickened filum terminale, leads to conditions like scoliosis and progressive neurologic defects in legs and feet
Tetehred Cord Syndrome
Lateral disc protrusion at level L4-L5 would affect which nerve?
5th lumbar nerve
Lateral extensions of pia mater consisting of 21 pairs of toothpick-like processes that helps hold the spinal cord in position in the subarachnoid space
Denticulate ligaments
Where is a lumbar puncture usually performed?
Between L3/L4 or L4/L5 spinous processes. Usually go through midline
What does a lumbar puncture have to go through to reach CSF?
Skin, fascia, ligaments, dura, and arachnoid
What is characteristic of nerve compression resulting in paresthesias, atrophy, reflex loss and sometimes autonomic instability?
Radiculopathy
Nerve root affecting area of the nipples
T4
Nerve root affecting area of the umbilicus
T10
Nerve root affecting perianal sensation
S4,S5
Nerve root affecting genitalia
S2,S3
Referred neurogenic dysfunction in the leg that is motor, sensory, or reflex. Most commonly involves irritation of L5 or S1, Begins as abrupt back pain which decreases as leg pain begins, and then that dominates. Discomfort exaggerated by coughing or sneezing. Pt will not be able to find a comfortable position.
Lumbar Radiculopathy
What is the most common cause of lumbar radiculopathy?
Herniated nucleus pulposis. Can also be from chemical irritation.
What level of herniation is characterized by pain in lower back, hip, posterolateral thigh and anterior leg. Numbness in anteriomedial thigh and knee, weakness and atrophy in quads, and knee jerk is diminished?
L3-L4 disc, L4 nerve root
What level of herniation is characterized by pain above the SI joint, hip, lateral thigh and leg. Numbness in lateral leg and first 3 toes. Weakness with dorsiflexion, foot drop may occur. Posterior tibial reflex is diminished.
L4-L5 disc, L5 nerve root
What level of herniation is characterized by pain over the SI joint, hip, posteriolateral thigh, and leg to heel. Numbness in back of calf, weakness with plantar flexion. Atrophy of gastrocnemius and soleus. Ankle jerk diminished.
L5-S1 disc, S1 nerve root.
If someone can no longer adduct their thigh, what nerve segments are affected?
L2, L3
If someone can no longer extend their knee (aka no longer can stand or walk, either) what nerve segments are affected?
L3, L4 (quad)
If someone cannot dorsiflex their ankle, what nerve root is affected?
L4, L5 (tibialis anterior)
If someone cannot extend their great toe, what nerve root is affected?
L5, S1 (extensor hallucis longus)
If someone cannot perform ankle plantar flexion, what nerve root is affected?
S1, S2 (gastroc, soleus)
If someone can no longer control anal contraction, what nerve root is affected?
S2,3,4 (sphincter ani externus)
On PE, you find weak quads, numbness across the knee, thigh pain, and asymmetrical knee reflex.
L4 nerve root (5% of disc ruptures)
On PE, you find weakness in the great toe extensors, numbness on the top of the foot and first web space with lateral calf pain.
L5 nerve root
On PE, you find weakness of the plantar flexors, numbness of back of calf to sole of foot, and no Achilles reflex
S1 nerve root
What imaging study should you use to show herniated disc?
MRI (x ray won’t show squat)
Treatment of lumbar radiculopathy
Nonsurgical: NSAIDS, epidural steroid injections, time (most improve in 6 weeks)
Surgical: Indicated by severe neurologic deficit/pain or cauda equina syndrome. Mini-open discectomy
Saddle anasthesia, loss of bladder and bowel function
Cauda equina syndrome (surgical emergency)
Sacralization of L5 or Lumbarization of S1
Lumbosacral transitional vertebrae
Narrowing of the spinal canal that causes pressure on the nerve roots. Tends to be bilateral and has an insidious onset. LBP and leg symptoms worsened by extension of the spine (neurogenic claudication) but relieved by sitting or bending forward.
Spinal stenosis
On PE, diminished knee/ankle reflex, weakness in toe or heel walking, and abnormal pinprick and temperature sensation. No hard neurologic findings.
Spinal Stenosis
Treatment of Spinal Stenosis
NSAIDS, PT, epidural steroid injections. Surgery if conservative tx fails which is a decompressive laminectomy.
