Lecture 4: Part 3 (Vertebral Ligaments and Herniation)

Question 1

Vertebral Ligaments:

• ​Unite individual _______ into one ________
• Allow for _________ for ________

Answer 1

Vertebral Ligaments:

• ​Unite individual vertebra into one vertebral column
• Allow for flexibility for movement

Question 2

Supraspinous ligament

• Goes from one ______ to ______
• runs from ______ (vertebral level) to ______, connecting to the _______

Answer 2

Supraspinous ligament

• Goes from one spinous process to the next
• runs from C7 (vertebral level) to the mid-lumbar spine, connecting to the tips of spinous processes

Question 3

Nuchal Ligament (ligamentum nuchae)

• a continuation of the _______
• runs from _____ to ______
• large, ____ shaped extension of ______ tissue that is very tight with _____

Answer 3

Nuchal Ligament (ligamentum nuchae)

• a continuation of the supraspinous ligament
  
  • ​the supraspinous ligament changes to the nuchal ligament from C7 up to the occipital protruberance
• runs from the external occipital protruberance and atlas to the spinous processes of cervical vertebrae, ending at C7
• large, fan-shaped extension of dense irregular connective tissue that is very tight with collagen

Question 4

Interspinous Ligament

• runs between ______ of adjacent vertebrae
• exists in _____ regions of the spinal column

Answer 4

• runs between spinous processes of adjacent vertebrae
• exists in all regions of the spinal column

Question 5

Intertransverse Ligaments

• runs between ______ of adjacent cervical, thoracic, and lumbar vertebra
• made of ______ tissue

Answer 5

Intertransverse Ligaments

• runs between transverse processes of adjacent cervical, thoracic, and lumbar vertebra
• made of dense irregular connective tissue

Question 6

ligamentum flavum

• L. flavum means ______
• has a lot of _____
  
  • allows you to (3)
• attaches to _____ of adjacent vertebrae
• forms the _____ wall of the spinal cord

Answer 6

ligamentum flavum

• L. flavum means yellow or blonde
• has a lot of elastic fibers
  
  • allows you to:
    
    • bend or move
    • maintain changes in gravity
    • move your neck
• attaches to lamina of adjacent vertebrae
• forms the posterior wall of the spinal cord

Question 7

Posterior Longitudinal Ligament

• between _____
• attaches to the posterior surface of _____ and _____, running continuously from ____ vertebral level to the _____
• forms the ______ surface of the spinal cord
• the _______ sits on top of the PLL

Answer 7

Posterior Longitudinal Ligament

• between vertebral bodies
• attaches to the posterior surface of vertebral bodies and IV discs, running continuously from C2 vertebral level to the sacrum
• forms the anterior surface of the spinal cord
• the spinal cord (completely wrapped in it’s meninges) sits on top of the PLL

Question 8

Anterior Longitudinal Ligament

• between ______
• attached to anterior surface of ______ and ______
• runs continuously from ______ to ______
• anterior longitudinal ligament is in contact with what surface?

Answer 8

Anterior Longitudinal Ligament

• between vertebral bodies
• attached to anterior surface of vertebral bodies and IV discs
• runs continuously from occipital bone to sacrum
• anterior longitudinal ligament is in contact with the body (i.e. in contact with abdominal aorta)

Question 9

why is the red section relevation? what is going on?

Answer 9

• in this view, we have cut the pedicles and removed the entire lamina and spinous process - as if you are lying in this space and have lost your ceiling (the vertebral arch)
• we have also cut through several ligaments
• this is important because these ligaments need to be punctured in this way if we want to gain access to the spinal column (like during a lumbar puncture)

Question 10

Label Ligaments 1-7

Answer 10

Ligaments of the lower cervical spine

• (a) Lateral view, (b) sagittal section, (c) cranial view*
  1) Anterior longitudinal ligament
  2) Inter-transversal ligament
  3) Joint capsule (of zygopothosial joint)
  4) Ligamentum flavum
  5) Inter-spinous ligament
  6) Supra-spinous ligament
  7) Posterior longitudinal ligament

Question 11

Label vertebral ligaments 1-5

Answer 11

Spinal ligaments

(1) Anterior longitudinal ligament (ALL)
(2) Posterior longitudinal ligament (PLL)
(3) Ligamentum Flavum
(4) Interspinous ligament
(5) Supraspinous ligament
* (3), (4), and (5) are in continuity in the horizontal plane but they are not in continuity in the vertical plane as (1), (2), and (5)*

Question 12

Lumbar Puncture:

• done from what approach?
• what position is patient in and why?

Answer 12

Lumbar Puncture:

• done from what approach?
  
  • done from posterior approach​
• what position is patient in and why?
  
  • ​patient is placed back into primary curvature we had as a fetus (kyphosis)
  • this is done because we need to stretch the ligamentum flavum to allow a gap to occur so we can access the CSF bathing the cauda equina

Question 13

Lumbar Puncture:

• where do we insert the needle and why?
• what is the surface landmark we use as reference?

Answer 13

Lumbar Puncture:

• where do we insert the needle and why?
  
  • ​want to insert around L4-L5
  • This is below the conus medullaris, where the cauda equina lie
    
    • essentially, we want to insert the needle below the conus medullaris, which is at L1-L2
• what is the surface landmark we use as reference?
  
  • ​posterior superior iliac spine - creates dimples just superior to the pant line
    
    • we want to go above this at L4-L5

*we do not have to worry about sucking up a rootlet from the cauda equina because the vacuum created in a lumbar puncture pushes all those little spinal nerves to the side and allows you to get a clean draw

Question 14

Lumbar puncture:

• what angle do you insert the needle? why?

Answer 14

Lumbar puncture:

• what angle do you insert the needle? why?
  
  • If you go slightly oblique (paramedial): you can ignore the supraspinous ligament and intraspinous ligament and begin your approach by going through the ligamentum flavum → epidural space → dura mater (will feel a pop or release) → subdural space → arachnoid mater → subarachnoid space (CSF)

Question 15

Lumbar puncture

• Involves extraction of ______ from _______
• layers you go through (10)

Answer 15

Lumbar puncture

• Involves extraction of CSF from lumbar cistern (subarachnoid space)
• layers you go through (10):
  
  1. skin
  2. superficial fascia
  3. supraspinous ligament -*can ignore if you go paramedian aproach
  4. interspinous ligament -*can ignore if you go paramedian approach
  5. ligamentum flavum
  6. epidural space
  7. dura matter
  8. subdural space - *potential space between dura and arachnoid that is only present if pathology
  9. arachnoid matter
  10. subarachnoid space (with CSF)

Question 16

Anulus Fibrosis:

• surround what structure?
• made of what type of tissue?
  
  • organization forms what?
• posteriorly it is ______
• with age becomes _____ and develops _____
• vascular or avascular?

Answer 16

Anulus Fibrosis:

• prominant dense irregular connective tissue around intervertebral discs
• fibrocartilage rings (anuli)
• posteriorly it is thinner
• with age becomes thicker and develops fissures
• vascularized

Question 17

Nucleus Pulposus

• aka ______
• _____ : _____ (tissue type)
• made of 70%-90% _____
  
  • how is this content affected by age?
• vascular or avascular?

Answer 17

Nucleus Pulposus

• aka “middle of jelly donut”
• mucoid : collagen
• made of 70%-90% water
  
  • water content decreases with increasing age
• avascular

Question 18

Intervertebral Foramen

• lateral space between the _____ of adjacent vertebra, from which ______ emerge

Answer 18

Intervertebral Foramen

• lateral space between the pedicles of adjacent vertebra, from which spinal nerves and their vessels emerge

Question 19

Disc Herniation:

• Protrusion of _____ into, or through, ______
• Usually _____ (direction) because of
  
  • Reason #1:
  • Reason #2:__​

Answer 19

Disc Herniation:

• Protrusion of gelatinous nucleus pulposus into, or through, anulus fibrosus
• Usually posterolateral because:

1. anulus fibrosis is thinner posteriorly
2. annulus fibrosis is not well supported by posterior longitudinal ligament (ALL is much thicker and broader than PLL)

• ​​​-does not herniate directly posterior because of PLL*
• -rarely does it herniate anteriorly because of thickness of the annulus fibrosis*
• -can also herniate completely lateral (and can encroach on space of intervertebral foramen)*

​

Question 20

Spinal Nerves:

• Spinal nerves are named according to the vertebra to which they are related to as they ______ (at the ______ )
  
  • How many cervical spinal nerves and cervical vertebrae are there?
• First 7 cervical spinal nerves exit ______ vertebrae for which they are named
• C8 spinal nerve exits ______, between _____ and _____
• Therefore thoracic spinal nerves & lower exit ______ vertebra for which they are named

Answer 20

• Spinal nerves are named according to the vertebra to which they are related to as they exit (at the intervertebral foramen)
  
  • ​recall that there are 8 cervical spinal nerves but only 7 cervical vertebrae - because C1 comes out above C1’s exit (between the occipit and C1)
• First 7 cervical spinal nerves exit ABOVE vertebrae for which they are named
• C8 spinal nerve exits through intervertebral foramen between C7 and T1
• Therefore thoracic spinal nerves & lower exit BELOW vertebra for which they are named

Question 21

what does the white arrow show?

Answer 21

white arrow shows = posterio-lateral disc herniation

Question 22

• Posteriolateral disc herniation will damage what nerve?
• Lateral disc herniation will damage what nerve?

Answer 22

• Posteriolateral disc herniation will damage the exiting nerve (larger #) because of it’s direction (can also damage the top nerve, but less likely)
  
  • Ex: L2-L3 posteriorlateral disc herniation will damage L3 nerve
• If purely lateral disc herniation - will most likely damage the one above

Question 23

Disc Herniation in Cervical Region:

• C3-C4 posteriorlateral disc herniation will cause damage to ______
• why? (rule that supports it)

Answer 23

Disc Herniation in Cervical Region:

• C3-C4 posteriorlateral disc herniation will cause damage to C4 nerve (larger #)
• answer is the same (greater #) but rule is different; rule because we have 8 cervical nerves and only 7 cervical vertebrae

Question 24

Disc Herniation: Lumbar Region

• L3-L4 posterior lateral disc herniation will cause damage to _____
• why? (rule that supports this)

Answer 24

Disc Herniation: Lumbar Region

• L3-L4 posterior lateral disc herniation will cause damage to: L4 nerve (greater #)
• answer is the same (greater #) but reason why is different; reason is because the cauda equina and the fact that we have such a large spanse of bone in the lumbar region

Question 25

Which curvatures of the veretebral column are maintained in the adult?

• Cervical lordosis & lumbar lordosis
• Cervical lordosis & sacral kyphosis
• Cervical lordosis and sacral lordosis
• Thoracic kyphosis & lumbar lordosis
• Thoracic kyphosis & sacral kyphosis

Answer 25

Which curvatures of the veretebral column are maintained in the adult?

• Cervical lordosis & lumbar lordosis
• Cervical lordosis & sacral kyphosis
• Cervical lordosis and sacral lordosis
• Thoracic kyphosis & lumbar lordosis
• Thoracic kyphosis & sacral kyphosis