Back Flashcards
what are the visceral structures that refer pain symptoms to the back?
and describe where they refer to
- Upper GI
- stomach, pancreas (refer to mid back)
- liver, gallbladder (refer to mid back AND SHOULDER) - lower GI
- large intestine, distal small intestine (refer to low back) - GU structures
- kidneys (refer to low back and costal vertebral angle to flank)
- Ureter (refer from flank to groin)
- bladder (refer to sacral)
- prostate (refer to sacral)
Referred back pain vs Intrinsic back pain (for this exam)
referred- visceral structures that may REFER symptoms to the back
intrinsic-vertebral structures that may refer pain to the back
referred mid back pain comes from:
stomach, pancreas, liver, gallbladder
referred shoulder pain comes from
liver, gallbladder
referred low back pain comes from..
large intestine and distal small intestine, kidneys
referred CVA to flank pain comes from..
kidneys
referred pain from flank to groin comes from
ureter
referred sacral pain comes from..
bladder, prostate
list the 6 vertebral structures that refer back pain
vertebrae intervertebral disc facet joints ligaments of spine muscles of spine nerve roots
list landmarks of the upper quadrant
C7, medial scapula border, inferior angle of scapula, spine of scapula, upper trap
list landmarks of lower quadrant (8)
CVA, T12, L4, Lower trap, lumbar paraspinal muscles, iliac crest, PSIS (posterior superior iliac spine), Sacrum
list and describe the two curves of the spine and their main function
absorb shock
primary curve (kyphotic)
-born with these: thoracic and sacral (T&S) “hunch over”
secondary curve (lordotic)
- cervical and lumbar (C&L)
- develop with weight bearing: cervical- when you start to hold head up/sit upright; lumbar-when you start to stand/walk
ID the movements of the spine (4)
flexion (touch toes)
extension (reach back over head)
lateral flexion (bend at waist to the side)
rotation (turn around over shoulder to crack back)
what are the TYPICAL vertebrae? what 9 structures make them typical?
C3-L5
they have body, vertebral arch, spinous process, transverse process, articular process, vertebral notches, intervertebral foramen, vertebral foramen, vertebral canal
describe the body of typical vertebrae?
T 4 and below gradually increase in size to support increasing body weight
describe spinous process of typical vertebrae
project posteriorly from junction of R/L lamina (Right and left lamina join to form this)
this is an attachment lever for spinal muscles
describe the vertebral arch of typical vertebrae
pedicles and lamina
pedicles come off the body
lamina form the posterior part of the arch
describe the transverse process of typical vertebrae
project laterally from junction of pedicles and lamina (pedicles and lamina of one side join to form this)
attachment lever for spinal muscles
what structures of the typical vertebrae are attachment levers for the spinal muscles?
transverse and spinous processes
describe the articular processes of typical vertebrae
There are superior and inferior processes
project from the junction of the pedicle and lamina (pedicle and lamina of one side forms this) –
this forms a joint [ zygapophyseal ] with the facet of adjacent articular processes between the vertebrae
describe the vertebral notches of typical vertebrae
*this is not the facet..it is the notch** that forms the intervertebral foramen with the inferior and superior ones
each vertebrae has a superior and inferior (remember that the inferior of vertebrae A sits on the superior of vertebrae B)
describe the intervertebral foramen in the typical vertebrae
formed btwn vertebrae by the vertebral notches of 2 adjacent segments (Sup and inf vertebral notches)
describe vertebral foramen in typical vertebrae
formed by the body and arch of vertebrae (vertebral arch)
describe the vertebral canal of the typical vertebrae
vertebral foramina collectively form the canal (stack them up)
what are the atypical vertebrae?
C1 atlas and C2 axis
movement of C1 and C2
atlas c1 = “yes” movement
axis c2 = “no” movement
ID landmarks of atlas (c1)
anterior arch - smaller side
anterior tubercle - forms synovial joint with dens of c2
posterior arch
posterior tubercle
transverse process-can feel them inferior to mastoid process
lateral mass
-superior facets articulate with occiput–> Flexion and Extension movement “yes” (i think these surfaces look like kidney and are closer to anterior side)
-inferior facets articulate with C2–>rotation movement “no” (i think these look more oval and again are closer to anterior side of c1
ID landmarks of axis (c2)
DENS! (odontoid procesS)
- “pivot” or axis for ROTATION between C1 and C2
- forms a small synovial joint with anterior arch of C1***
ID typical cervical vertebrae
c3-c7
body: small, rectangle like, wider side to side (i think these have unicate processes on body?)
vertebral foramen-triangular, large (largest of C, T, L)
transverse foramen: c1-c6 where vertebral artery ascends (i think these are in the transverse processes, no facets, more anterior) not c 7 (they are more on the body sides then T,L)
spinous process: BIFID C3-C5 .. C7 is most prominent
ID typical thoracic vertebrae
body: heart shaped, has costal facets
vertebral foramen: circular, smallest of C, T, L
transverse process:long, T1-10 have facets for articulating with ribs [called transverse costal facets–not on T 11 or T12] (these extend more off tip of heart/body)
spinous process: long, extends inferior to segment below (longest of C, T, L)
Upper T’s transition from C spine
Mid T’s thoracic vertebrae characteristics
Lower T’s begin to transition to L spine
ID typical lumbar vertebrae
body: kidney shaped
vertebral foramen: triangular, larger then T and smaller then C (middle C and T)
spinous process: sturdy, “hatchet” shape
accessory process: located at the base of the transverse process
mamillary process: located on superior articular process
transverse process: thing and tapered, no facets
compare typical C, T, L vertebrae
C T L
Body: rectangle , heart with costal facets, kidney
vert. foramen: triangle largest, circular smallest, triangle middle
trans. foramen: c1-6 no facets, - , -
transverse process: - , long and trans. costal facets on t1-10, thin
accessory process: -, -, +
mammillary process: -, -, +
spinous process: bifid c3-5 , long extend inferior, sturdy/hatchet
ID landmarks of sacrum (and describe)
- apex (inferior portion)
- base (superior portion)
- promontory (prominent anterior edge of 1st vertebrae of sacrum)
- ala (superior/lateral portion of sacrum “wings”)
- median sacral crest (midline, formed by Fused spinal processes*)
- sacral hiatus (formed because lamina of s5 did not fuse - this is opening to sacral canal)
- sacral cornu/horns (formed by pedicles of s5
- sacral canal (contain the nerve roots of cauda equina ** )
describe landmarks of coccyx
webshapped bone of 4 fused coccygeal vertebrae
these provide attachment for pelvic muscles
Lordosis
excessive lordosis in lumbar region (anterior curve)
caused by: orthopedic anomalies, postural habits, pregnancy
kyphosis
excessive kyphosis in T spine (posterior curve)
caused by: compression fracture, postural habits, pathology
scoliosis– this might be in the blue boxes if it is skim it!!
**Lateral deviation with Rotary component**
curve is named for convexity
school screenings to id potential curves-> key factors are progression and severity
tx depends on progression and severity and ranges from:
- observation
- bracing
- surgical intervention
what are the 5 joints of the vertebrae
- facet joints (zygapophyseal)
- intervertebral disc
- uncovertebral (joints of Luschka)
- atlanto-axial joint
- Atlanto-occipital joint
describe the facet/zygapophyseal joint structure
- synovial joint
- btwn superior and inferior facets of articular process (the inferior articular process of vertebrae a joins with the superior of vertebrae b to form the joint)
- orientation varies in each region to enhance and limit movement depending on the motion
- has some of the weight bearing function in C and L regions
- clinical: 1. prone to degenerative changes: limits mobility and movement and can cause pain (i think of arthritis, or stiffness in lower back/neck)
2. excessive bone spurs (bony growth) can cause stenosis of IVF (this can cause impaction to the nerve root that comes out of the IVF = pain)
describe the intervertebral joint structure (3 main parts)
A. DISC -absorbs shock and influences motion
- made of water, collagen fibers, proteoglycans (fluid is key to function)
- ends up being 1/4th of the spine length
- *THERE IS NO DISC BTWN OCCIPUT AND C1**
- *THERE IS NO DISC BTWN C1 AND C2**
- no innervation*
B. Annulus Fibrosus (outer layer)
- concentric layers made of collagen fivers that change direction with each layer “crosswoven effect”
- anchor the disc to the bone or the cartilaginous end plate (sits on the body of the next vertebrae)
- the outermost layer blends with the ALL and PLL
- outer layers are innervated = source of pain!!**
C. Nucleus Pulposus (center)
- proteoglycans attract water here
- made of FINE, LOOSE, RANDOM arrangement of collagen fibers
- aging: decreased proteoglycan content = decreased water to the nucleus = decreased disc height (so possibly less absorption and motion? -my thought)
D. clinical:
- Fissures- cause discogenic (lumbar) pain
- Herniation -can compress nerve roots which can cause Radicular pain (myoome, dermatome patterns) (following nerve root etc)
- Degenerative Changes-aging causes loss of disc height
describe uncovertebral / joint of Luschka structure
- formed by uncinate process of c3-c7 (uncinate process are on the body of cervical vertebrae)
- called “pseudo” joint because it has cartilage and a capsule which make it look like a synovial joint
- clinical: prone to degenerative changes - bone spur formation
describe atlanto-axial joint structure
- facet of c1 and facet of c2 form this joint
- ALSO: c2 dens forms joint with anterior arch of C1 = rotation of head and neck “no”
describe the atlanto - occipital joint structure
- this is a synovial joint between the superior facet of c1 and the occipital condyles
- “yes” flexion and extension movement of head and neck
list 5 ligaments of the vertebral column
- anterior longitudinal ligament (ALL)
- posterior longitudinal ligament (PLL)
- Ligamentum flavum
- Interspinous ligaments
- Supraspinous ligaments
list the ligament continuation of each ligament of vertebral column
- anterior longitudinal ligament (ALL)-anterior atlanto-occipital membrane
- posterior longitudinal ligament (PLL)-tectorial memebrane
- Ligamentum flavum-posterior atlanto -occipital membrane
- Interspinous ligaments-none
- Supraspinous ligaments -nuchal ligament
list the ligaments that are unique to the cervical spine
- anterior atlanto -occipital membrane
- tectorial membrane
- posterior atlanto-occipital membrane
- nuchal ligament
- cruciate ligament
- alar ligament
- apical ligament
describe the 5 ligaments of vertebral column
- anterior longitudinal ligament (ALL)-c2-sacrum; anterior vertebral column (front of v.body)
- posterior longitudinal ligament (PLL)-c2-sacrum; posterior vertebral column (back of v.body)
- Ligamentum flavum-connects the lamina between each vertebrae; high ELASTIN content; elasticity assist with restoring neutral position after flexion of spine; forms the posterior wall of vertebral canal (so the anterior wall of this canal is the PLL, then we see the spinal cord, then the posterior wall is the ligamentum flavum -this is on the vertebral arch side)
- Interspinous ligaments-connects the adjacent spinous processes by attaching along the inferior and superior portion of the SP (inbetween each of them)
- Supraspinous ligaments -c7-sacrum connects adjacent spinous processes c7-sacrum (this is the thin line over the tip of each SP)
describe the 7 ligaments that are unique to the cervical spine
- anterior atlanto -occipital membrane-continuation of ALL; connects ARCHES of C1 to OCCIPUT (edges of foramen magnum)
- tectorial membrane-continuation of PLL; C2-foramen magnum
- posterior atlanto-occipital membrane- continuation of ligamentum flavum; connect ARCHES of C1to the OCCIPUT (edges of foramen magnum)
- nuchal ligament-continuation of the supraspinous ligament; EOP to C7; connections EOP, posterior tubercle of C1 and SPs of C2-7; acts as a septum separating muscles of R/L posterior neck (this starts at c7 and gets wider as it ascends making a triangle with c2 and eop, also hits each sp of c2-7)
- cruciate ligament-stabilizes the dens against the anterior arch of C1 (posterior to the dens) THREE sections: 1. transverse band 2. superior band which connects occiput to dens 3. inferior band which connects the body of c2 to the dens
- alar ligament-limits excessive rotation!! extends from sides of the dens to lateral margin of foramen magnum (this is on the anterior side of the dens i think and the bands go up/lateral into wall of foramen magnum)
- apical ligament -apex of the dens to the foramen magnum (i think this is anterior to dens, and is kind of hidden by the superior band which is posterior to dens)
list organizational hierarchy of the back muscles
- superficial layer of the back
- middle layer of the back
- deep layer of the back
a. superficial layer of the deep back muscles
b. middle layer of the deep back muscles
c. deep layer of the deep back muscles
list the muscles that form the sperficial layer of the back
trapezius
latissimus dorsi
rhomboid major/minor
levator scapula
list muscles that form the intermediate layer of the back
serratus posterior superior
– are deep to rhomboid and go in same direction to DDX them
serratus posterior inferior
list muscles in the deep layer of back
superficial deep: splenius capitis/cervicis
intermediate deep: erector spinae
deep layer of deep: semipinalis, multifidi, rotators
trap
attachment innervation action
spinous process of cervical and transverse -> scapula/clavical
CN11
1. upper trap= up elevation and up rotation of scapula
2. middle trap = retraction of scapula-squeeze blades together
3. lower trap - depression and up rotation of scapula
latissimus dorsi
attachment innervation and action
floor of bicipital groove of humerous-> fascia on spine
thoracodorsal nerve (?do we need to know this?)
“hand cuff” - extend, adduct, medial rotation of arm
rhomboid major / minor
attachment, innervation, action
thoracic spine ->scapula
dorsal scapular nerve
retraction and elevate scapula (retraction = squeeze blades together)
levator scapula
attachment
innervation
action
cervical transverse process-> scapula
dorsal scapular nerve
1. scapula movement = elevate and down adduct rotation of scapula (bring arm down)
2. neck movement= bend and rotate to same side (ipsilateral flexion)
serratus posterior sup/inf action
elevate / depress rib
describe the muscles of the deep back
1.superficial: splenius capitis/cervicis - unilateral contraction (flexion and rotation)
2. intermediate: erector spinae- (3) bilateral extension and flexion (eccentric contraction -so we dont just fall when you lean forward)
a. iliocostalis (outermost)
b. longissimus (middle)
spinalis (innermost)
- deep: (3) unilateral contralateral rotation of spine (rotate spine to opposite side**)
a. semispinalis -(top of spine jump up 4-6)
b. multifidi-(bottom of spine jump up 3-4)
c. rotators-(mid spine jump up 1-2 segments)
ddx splenius capitis vs the deep back muscles of the deep muscles -action
splenius capitis rotates spine to same side
deep rotate spine to opposite side***
list the suboccipital region muscles
rectus capitis posterior major
rectus capitis posterior minor
obliquus capitis inferior
obliquus capitis superior
what are the borders of the suboccipital triangle and what is in it?
rectus capitis posterior major*
obliquus capitis inferior and superior
vertebral artery and the suboccipital nerve C1
what are the spinal cord landmarks?
2 enlargements (L1-S2 and C3-T1) Conus medullaris (tapered end of spinal cord) cauda equina (bundle of spinal nerves) dentate ligaments (pia matter that has 21 attachments on either side of body connecting to arachnoid and dura matter) spinal root nerve a. dorsal nerve root b. ventral nerve root c. anterior rami d. posterior rami
list and describe layers of meninges
- dura layer
a. filum terminale - part of dura extending off dural sac
b. epidural block- around the spinal cord, injects into dura - arachnoid layer
a. subarachnoid space- contains CSF
b. lumbar puncture- to get csf go into subarachnoid space in the LUMBAR CISTERN site - Pia layer
a. dentate ligaments - attach to arachnoid at 21 sites per side of each v. body
b. pia filament - tail? of the pia
where does lumbar puncture go into?
where does epidural go?
lumbar cistern of subarachnoid space
dural layer
list and describe the 3 types of spina bifida
a. spina bifida occulta- failure of vertebral arch to fuse, bony defect
b. meningocele- meninges protrude thru bony defect of vertebral arch (looks like a bubble)
c. myelomeninocele- spinal cord and meninges protrude defect of vertebral arch (spinal cord and meninges go into the bubble)
describe blood supply of the spinal cord
- anterior spinal artery (this is anterior middle running up/down the spinal cord)
a. anterior segmental medullary artery (dumps into the anterior spinal artery .. comes up the side of the spinal cord and crosses to the anterior artery)
b. anterior radicular spinal artery (these really only supply blood to the nerve root so the ventral root of the spinal cord, doesnt dump in to the anterior spinal artery) -smallest of the three! - posterior spinal arteries (2 on the posterior side)
a. posterior segmental medullary artery
b. posterior radicular artery (goes to the dorsal root of spinal cord)
landmarks of lumbar ap radiography
spinous processes
pedicles
vertebral bodies
landmarks of lumbar lateral radiography
vertebral bodies
IVF
spinous processes
landmarks of lumbar oblique radiography
spondylolisthesis – pars defect
“scotty dog” sign
(this is usually 5th lumbar v. and it is a fracture that breaks the “neck” causing displacement of the vertebrae body forward and the tail part arching back more )
