Session 2

Question 1

Describe the gross structure and arrangement of the vertebral column LO

1. How many vertebrae are there?
2. Are all the vertebrae discrete? Which are relatively mobile and immobile
3. How do the size of the vertebrae change? Why?

Answer 1

1. 33= 7 cervical, 12 thoracic, 5 lumbar, 5 sacral & 4 coccygeal
2. No sacral & coccygeal are fused. Thoracic immobile sacral & coccygeal mobile
3. 3. Inc in size inferiorly as compression forces inc (Sacral vertebrae: fused, widened & concave anteriorly to transmit weight of the body through pelvis to legs)

Question 2

(Q. Functions of the vertebral column)

Question 3

Answer 3

Question 4

1. Movements of the lumbar spine?
2. General characteristics of vertebrae: Vertebral arch: Gives rise to 7 processes
3. Vertebral body: Usually the largest part of the vertebra – 10% ? Bone 90% ?

Answer 4

A. Flexion, extension & lateral rotation

2. • Kidney shaped vertebral body •Vertebral arch posteriorly •Vertebral foramen: for spinal cord and meninges •x1 Spinous Process •x2 Transverse Process •x2 Superior Articular Process •X2 Inferior Articular Process
3. Cortical & cancellous

Question 5

Q. Draw two vertebrae in the spine interacting with one another

Answer 5

Question 6

Q. Lamina + pedicle =

Answer 6

A. vertebral arch

Question 7

Answer 7

(Synovial joint) facet

Question 8

Q. Why is there an interlocking design?

Answer 8

A. Interlocking design
– Prevents anterior displacement of vertebrae
– Orientation determines amount of flexion & rotation permitted

Question 9

Answer 9

Question 10

Answer 10

Question 11

Q. What is the components, features & function of the Annulus fibrosus?

Answer 11

A. Outer lamellae Type 1collagen, Inner lamellae are fibro-cartilaginous (different orientations)
• Avascular and aneural
• Is the major ‘shock absorber’ (Highly resilient under compression - stronger than the vertebral body)

Question 12

Q. What is the components & features of the nucleus pulposus?

Answer 12

A. Remnant of notochord, Gelatinous, Type 2 collagen
• High osmotic pressure

• Changes in size throughout day & with age
• Centrally located in the infant
• Located more posteriorly in the adult

Question 13

Answer 13

Question 14

State how the structure of the various vertebrae & their associated ligaments help to maintain the stability of the vertebral column LO
1. What is the result of the ALL being stronger than the PLL?

2. Anterior longitudinal ligament originates from & inserts onto? How does it attach to the vertebral bodies and the intervertebral disc?

Answer 14

1. Allows more flexion compared to extension
2. • Anterior tubercle of atlas to sacrum

• United with periosteum of vertebral bodies & Mobile over intervertebral discs
• Prevents hyperextension

Question 15

Q. Posterior longitudinal ligament originates and inserts from? Function?

Answer 15

A. • Body of axis to sacral canal

• Continues superior to axis as ‘tectorial membrane’
• Relatively weak
• Prevents hyperflexion
• Position dictates where disc prolapse

Question 16

Q. Ligamentum flavum • ? in colour: elastic fibres

• Between ? of adjacent vertebrae
• Stretched during ? of the spine

Answer 16

A. Yellow, laminae, flexion

Question 17

Q. Interspinous ligaments • Relatively weak sheets of ?
• Unite ? along adjacent borders
• Well developed only in the ? region (stability in flexion)
• Fuse with ? ligaments

Answer 17

A. fibrous tissue, spinous processes, lumbar, supraspinous

Question 18

Q. Supraspinous ligaments
• Tips of adjacent ?
• Strong bands of ? fibrous tissue
• ? in extension
• ? in flexion (mechanical support for vertebral column)

Answer 18

A. spinous processes, white, Lax, Tight

Question 19

Q. Sacrum consists of 5 fused vertebrae • Articulates with ? superiorly , ilium ? , and coccyx ?

Answer 19

A. L5, laterally, Inferiorly

Question 20

Answer 20

Question 21

Q. Vertebral column in the fetus • Flexed in a single curvature • C-shaped • Concave anteriorly = ? • This curvature is known as the Primary Curvature• Primary curvature is retained throughout life in Thoracic, Sacral and Coccygeal regions

Answer 21

A. kyphosis

Question 22

Q. Vertebral column in young adult
• 4 distinct curvatures
• Sinusoidal profile – confers great flexibility and resilience
• 2 kyphoses (? flexions): thoracic and sacrococcygeal
• Kyphoses are continuations of the primary curvature of the foetus
• 2 lordoses (? flexions): cervical and lumbar
• Lordoses are secondary curvatures

Answer 22

A. anterior, posterior

Question 23

Q. Development from fetus to young adult
• The primary curvature is remodelled to add two secondary curvatures
• The cervical spine develops the first posterior concavity (cervical lordosis) when young child begins to ?
• The lumbar spine loses it’s primary kyphosis during ?
• When the child begins to ?, lumbar lordosis develop
• Lumbar lordosis is the second secondary curvature

Answer 23

A. lift its head, crawling, stand-up & walk

Question 24

Q. Centre of gravity
• Passes through vertebral column at: ?
• ‘Weak points’ of vertebral column

Answer 24

A. – C1 & C2 – C7 & T1 – T12 & L1 – L5 & S1

Question 25

Q. Physiological curvatures • Exaggeration of ? during pregnancy

Answer 25

A. lumbar lordosis

Question 26

Q. A 3 year old girl is admitted with fever, tachypnoea (rapid breathing), photophobia, neck stiffness and a non-blanching rash. Meningitis is suspected. A lumbar puncture is performed.
Q1. Suggest a suitable vertebral level at which the needle should be inserted. Explain the rationale for your choice.
Q2. State the structures through which the needle will pass, in order from the skin to the subarachnoid space.

Answer 26

A. 1. (L2/3), L3/4 or L4/5 (after the conus medullaris so only mobile spinal nerve roots not cord; least chance of neurological damage)
2. (Skin), subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural fat and veins, dura mater, arachnoid mater, (subarachnoid space)

Question 27

Describe the pathophysiology & clinical features of mechanical back pain LO

1. Is back pain common? Relieving / aggravating factors? Predisposition?
2. Describe this type of pain
3. Behavioural Modifiers for back pain

Answer 27

1. Yes, rest, exercise/ innocuous activity, overweight, unhealthy lifestyle, deconditioned core muscles
2. Intermittent
3. Mental health: Benefits, Accident, Fear/Beliefs, Job, Relationship
   Disc degeneration and ‘marginal osteophytosis’
   • Nucleus pulposus can dehydrate with age
   • Height of IV disc decreases
   • Load stresses on the IV disc alter → reactive ‘marginal osteophytosis’ adjacent to affected endplates (spondylosis deformans, senile ankylosis)
   • As disc space decreases in height, increased stress is also placed on the facet joints → osteoarthritis (innervated by meningeal branch of spinal nerve → pain)
   • Decreased size of intervertebral foramen and compression of spinal (segmental) nerves

Question 28

Q. Describe the pathophysiology and clinical features of prolapsed intervertebral discs LO

Answer 28

Q. Describe the pathophysiology and clinical features of prolapsed intervertebral discs LO
A. • Disc Degeneration: chemical changes associated with aging cause discs to dehydrate & BULGE
• Prolapse: protrusion of the nucleus pulposus with slight impingement into the spinal canal (contained)
• Extrusion: nucleus pulposus breaks through annulus fibrosus, but remains within the disc space.
• Sequestration: nucleus pulposus breaks through annulus fibrosus and separates from the main body of the disc in the spinal canal.

DICK PICS EVERY SATURDAY

Question 29

1. • Most commonly occurs at ? • Usually herniates ? , causing compression of spinal nerve roots
2. Types of Disc Prolapse:

Answer 29

1. L4/5 or L5/S1, posterolaterally
2. • Paracentral – 96%

• Far Lateral – 2%
• Canal Filling – CES – 2%

Question 30

Q. If a patient has a slipped disc at the L3/L4 level which nerve roots would be affected if there is a paracentral disc prolapse or a far lateral disc prolapse

Answer 30

A. Paracentral -> L4
Far lateral disc -> L3

Question 31

Q. What are the clinical features of prolapsed invertebral discs LO
What symptoms does a patient with disc prolapse present with?

Answer 31

A. Chronic back pain ???

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Question 32

What is the pathophysiology of sciatica? LO

1. What is sciatica?
2. Common cause?

Answer 32

1. Sciatica is compression of the nerve roots which contribute to the sciatic nerve
2. Spinal disc herniation pressing on the lumbar or sacral nerves. Other causes spondylolisthesis (vertebra slips forward over another one), spinal stenosis (narrowing of the spinal canal in the lower back), piriformis syndrome, pelvic tumours, and compression by a baby’s head during pregnancy.

Question 33

1. What ?? make up the sciatic nerve?
2. Draw the complete dermatome map

Answer 33

1. • L4 • L5 • S1 • S2 • S3
2. C4 T4 above and below the nipples

Question 34

1. Types of Sciatica is based on ?
2. • L4 Sciatica:
   • L5 Sciatica:
   • S1 Sciatica:

Answer 34

1. A. Dermatomes
2. Anterior thigh, Anterior knee medial shin

Lateral Thigh, lateral calf, dorsum of foot

Posterior Thigh, Posterior Calf, Heel, Sole of Foot

Question 35

Answer 35

Question 36

1. Clinical features of sciatica LO Common symptoms of sciatica include:
2. Natural History of Prolapsed Intervertebral Disc. Occurs in ? year olds. Natural History = 90% resolve by ?

Answer 36

1. Lower back pain, Buttock pain, Leg pain, Numbness, Tingling, Calf muscle weakness, Foot and toe muscle weakness
2. 30 to 50, 3 months

Question 37

1. Pathophysiology of Cauda Equina Syndrome LO what is cauda equina syndrome
2. Causes of CES?

Answer 37

1. Canal filling disc compressing the Lumbar and Sacral Nerve roots
2. • A. A herniation (bulging) of a spinal disk in the lumbar area that presses on the nerves - the most common cause
   • Narrowing of the spinal canal (stenosis)
   • A spinal lesion or tumour
   • A spinal infection, inflammation, haemorrhage or fracture
   • A complication from a severe lumbar spine injury such as a car crash, fall or other traumatic injury such as a stabbing
   • A birth defect such as an abnormal connection between blood vessels (arteriovenous malformation)

Question 38

1. Common in?
2. Is this condition common?
3. Clinical features
4. Need to Treat within 48 Hours of Sphincter Symptoms to be in good prognostic group otherwise?

Answer 38

1. 30 - 50 yr olds
2. No 2% of all prolapsed invertebral discs
3. • Bilateral Sciatica

• Perianal Numbness
• Painless Retention of Urine
• Urinary/ Faecal Incontinence

4. • Intermittent Self Catherisation • DRE • Sexual Dysfunction

Question 39

What is this image showing?

Answer 39

A. spinal canal narrows and compresses the spinal cord and nerves at the level of the lumbar vertebrae

Question 40

1. What is lumbar spinal stenosis
2. Pathophysiology
3. Common in?
4. Clinical features

Answer 40

1. Narrowing of the vertebral foramen in the lumbar region
2. Aging. It can also sometimes be caused by spinal disc herniation, osteoporosis, a tumor, or trauma. In the cervical (neck) and lumbar (low back) region it can be a congenital condition to varying degrees.
3. The elderly
4. Claudication (pain and/or cramping in the lower leg due to inadequate blood flow to the muscles. The pain usually causes the person to limp) (Pain in legs when walks • Neurogenic • Vascular)

Question 41

1. What is Pathophysiology?
2. Natural History of Lumbar Canal Stenosis
   • ?% stay the same

• ?% progressive worse
• ?% Better
• Treat those for whom the restricted waking distance affects quality of life

Answer 41

1. Venous engorgement
2. A. 70, 15, 15

Question 42

Q. What is this image showing?

Answer 42

A. Spondylolisthesis (A slip forwards of the vertebra above on the vertebra below)

Question 43

Q. Explain what these different types of spondylolisthesis are / pathologies
• Dysplastic –
• Isthmic –
• Degenerative –
• Iatrogenic –
• Pathological –​

Answer 43

A. Types of Spondylolisthesis
• Dysplastic – abnormality in the shape of the facet joints
• Isthmic – Defect in the pars interarticularis -> a fracture of the isthmus causes one vertebral body to slip forward on top of the vertebral body below it
• Degenerative – age – arthritis weakens ligaments and joints
• Iatrogenic – laminectomy procedures that result in pars fractures
• Pathological – bone or connective tissue disorders or infection, neoplasm,

Question 44

Spondylolisthesis

1. Clinical features
2. What is the pathophysiology of neurogenic claudication
3. Clinical features of lumbar spinal stenosis

Answer 44

1. Back Pain and L5 Sciatica as arch not intact no central canal stenosis,
2. Common symptom of lumbar spinal stenosis
3. discomfort, pain, numbness and weakness in the calves, buttocks, and/or thigh

Question 45

1. Describe the structure of the major joints of the vertebral column LO
2. Describe the characteristic features of lumbar vertebrae LO

Answer 45

1. Vertebral body has cartilaginous joints, joints are covered with hyaline cartilage and between them fibrocartilage discs. Joint strengthened by anterior and posterior longitudinal ligaments.
   Facet (synovial joint) strengthened by interspinous, ligamentum flavum and supraspinous
2. • Large size, cylindrical vertebral body, triangular foramen

• Lack facets for articulation with ribs
• Thin, long transverse processes
• except for L5 which are massive for the attachment of iliolumbar ligaments to connect the transverse processes to the pelvic bones

Question 46

1. The upper part of the posterior longitudinal ligament that connects C2 to the intracranial aspect of the base of the skull is termed the ?

Answer 46

1. tectorial membrane

Question 47

Q. Supraspinous ligament connects and passes along the tips of the vertebral spinous processes from the ? To ?

Answer 47

A. vertebra C7 to the sacrum

Question 48

The conus medullaris, cauda equina, filum terminale, spinal nerve roots, dorsal root ganglia, spinal nerves, and peripheral nerves LO

Answer 48

Question 49

Q. Spinal Cord:
• Extends from the ? to approx ? disc
• The distal end of the cord is the ?
• A fine filament of connective tissue (the pial part of the filum terminale) continues inferiorly from the apex of the conus medullaris
A. foramen magnum, L1/L2
B. conus medullaris

Answer 49

Question 50

Answer 50

Question 51

Q. • Spinal dura mater is separated from the bones forming the vertebral canal by an ?
• Inferiorly, the dural sac dramatically narrows at ? and forms an investing sheath for the pial part of the ? of the spinal cord
This dural part of the filum terminale attaches to the ?

Answer 51

A. - extradural space

• S2, filum terminale
• posterior surface of the coccyx

Question 52

Answer 52

Question 53

Q. Cauda Equina
• Spinal cord terminates at L1/L2 • Below the end of the spinal cord, the roots of lumbar, sacral, and coccygeal nerves pass inferiorly to reach their exit points from the vertebral canal
• This terminal cluster of roots is the cauda equina

Question 54

Identify patterns of normal and abnormal curvature in the spine LO
Q.

Answer 54

A. Kyphosis: Excessive thoracic curvature, causing a hunchback deformity.

• *Lordosis**: Excessive lumbar curvature, causing a swayback deformity.
• *Scoliosis**: A lateral curvature of the spine, usually of unknown cause.
• *Cervical Spondylosis**: A decrease in the size of the intervertebral foramina, usually due to degeneration of the joints of the spine. The smaller size of the intervertebral foramina puts pressure on the exiting nerves, causing pain.

Question 55

Q. Understand the main types of spina bifida and their clinical features LO What is Spina Bifida?

Answer 55

A. A birth defect where there is incomplete closing of the backbone and membranes around the spinal cord

Question 56

Q. What are the main types of Spina Bifida?

Answer 56

A. There are two types: spina bifida occulta and spina bifida cystica. Spina bifida cystica : meningocele and myelomeningocele.

Question 57

Q. Describe Spina Bifida occulta

Answer 57

A. Outer vertebrae is not completely closed, spinal cord does not protrude, skin at the lesion may be normal, hairy/ dimple in the skin, or a birthmark

Question 58

Q. Describe meningocele

Answer 58

A. Meninges to herniate between the vertebrae. nervous system remains undamaged. Causes of meningocele include teratoma and other tumors of the sacrococcyx and of the presacral space, and Currarino syndrome.

Question 59

Q. Describe myelomeningocele

Answer 59

A. unfused portion of the spinal column allows the spinal cord to protrude through an opening. The meningeal membranes that cover the spinal cord also protrude through the opening, forming a sac enclosing the spinal elements, such as meninges, cerebrospinal fluid, and parts of the spinal cord and nerve roots.

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Question 60

Q. What is the pars interarticularis

Answer 60

Question 61

Q. What is spondylolisthesis? How does it differ from spondylolysis?

Answer 61

A. Spondylolisthesis: slipped vertebral bone
Spondylolysis: stress fracture in The pars interarticularis of the vertebral arch.

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Question 62

1. What is neurogenic claudication?
2. What is the pathology and pathophysiology of neurogenic claudication?

Answer 62

1. Common symptom of lumbar spinal stenosis which results from compression of the spinal nerves
2. The pathophysiology is thought to be ischemia of the lumbosacral nerve roots secondary to compression from surrounding structures, hypertrophied facets, ligamentum flavum, bone spurs, scar tissue, and bulging or herniated discs.

Question 63

1. State four factors that contribute to the stability and mobility of the vertebral column.
2. Describe the movements of the vertebral column that can occur in each of the cervical, thoracic and lumbar regions. Explain what anatomical features determine the movements possible in each region.

Answer 63

1. Stability – ligaments (flavum, supraspinatous, interspinatous, posterior longitudinal ligament in flexion) (anterior longitudinal ligament in extension)
   Joints – facet and cartilaginous intervertebral joints
   Attachments of the ribs by Demi facets?
   intervertebral discs permit flexibility of the spine
   4) vertebral body - weight bearing and size increases as
   you go down the spine - promotes stability
2. Cervical:
   Thoracic:
   Lumbar:

Question 64

Q. Describe the pathophysiological processes that result in diminution of height and loss of secondary curvature of the spine in old age?​

Answer 64

A. Dehydration of the intervertebral discs leads to loss of height and Age-related postural hyperkyphosis is an exaggerated anterior curvature of the thoracic spine, sometimes referred to as Dowager’s hump or gibbous deformity. This condition impairs mobility,2,31 and increases the risk of falls33 and fractures.26 The natural history of hyperkyphosis is not firmly established. Hyperkyphosis may develop from either muscle weakness and degenerative disc disease, leading to vertebral fractures and worsening hyperkyphosis, or from initial vertebral fractures that precipitate its development.

Question 65

Q. Describe the characteristic features of cervical vertebrae, including the atypical cervical vertebrae LO (6)

Answer 65

A. • Smallest of the discrete vertebrae
• Bifid Spinous Process (except C7)
• Transverse foramen in transverse process (Foramen transversarium):
– Conduit for vertebral artery and vein (except C7)
– C7 foramen transmits the accessory? vertebral vein
• Large triangular vertebral (neural) foramen
• Body is small and broad from side to side
• Superior articular facet faces upward and backward while inferior articular facet faces downward and forward.

Question 66

Answer 66

Question 67

Answer 67

Question 68

Q. First cervical vertebra – Atlas Articulates with? What is this joint called? Action of joint? Characteristic features of Atlas?

Answer 68

A. - Occiput of skull superiorly
– atlanto- occipital joint
– 50% of Total flexion and extension e.g. “nodding”
- Axis (C2) inferiorly
– atlanto-axial joint → 50% Total rotation e.g. shaking the head
• No vertebral body (Body is fused with axis to form dens or odontoid process)
• No spinous process
• Widest cervical vertebra
• Vertebral arches are thick and strong to form a powerful lateral mass

Question 69

Describe the characteristic features of thoracic vertebrae and their articulation with the ribs LO
1. Describe the characteristic features of thoracic vertebrae LO​

2. What ligament links axis with atlas and what’s its purpose?

Answer 69

1. – The Odontoid Process or Dens
   – Rugged lateral mass
   – Large spinous process
2. The transverse ligament which is located on atlas. The transverse ligament along with dens prevents horizontal movement of axis

Question 70

Answer 70

Question 71

Q. Seventh cervical vertebra characteristic features? (3)

Answer 71

A. • Longest spinous process
• Spinous process is not bifid
• The transverse process is large, but the foramen transversarium is small and only transmits the accessory vertebral veins.

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Question 72

Answer 72

Question 73

What is the Nuchal ligament? Attached to? Function?

Answer 73

Q. • Thickening of the Supraspinous Ligament
• Attached to:
– External occipital protruberance
– Spinous processes of all cervical vertebrae
– Spinous process of C7
• Function:
- Maintains secondary curvature of cervical spine
- Helps the cervical spine support the head
- Major site of attachment of neck and trunk muscles (e.g. Trapezius, Rhomboids)

Question 74

Q. Characteristic features of thoracic vertebrae? (4)

Answer 74

A. • Demi-facets (T2-T8); whole facets T1, T9-10 (we T11, T12?)
• Costal facets on transverse processes for articulation with tubercle of rib (except T11 & T12)
• Vertebral foramen is small & circular
Articular processes face posterolaterally (superior) and anteromedially (inferior) – permits rotation, limits flexion

​

Question 75

Q. Give a general overview of the anterior, posterior and central parts of the spinal cord functions?​

Answer 75

A. Anterior Cord – Sensory and Motor Light Touch, Pinprick and Pain
Posterior Cord (Dorsal Columns)– Vibration and Proprioception
More central tracts move the arms and more lateral tracts move the legs

Question 76

Q. Explain the myotomes of the arm

Answer 76

Question 77

Q. What is a neural level? LO

Answer 77

A. Last functioning level Remember level of the nipples is the junction between C4 and T4

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Question 78

Identify the features of the spinal column on Plain X-rays and MR images LO
Q. In the cervical spine The nerve roots exit?. Nerve Roots in cervical spine exit ? their vertebral body until the ? junction. Draw a diagram.

Answer 78

A. more horizontally, above, C7/T1

Question 79

Answer 79

A. Inferior surface of mandible in line with C1
Know which is C7 as it does not connect with the head of the ribs

Question 80

Answer 80

Question 81

Answer 81

Question 82

Q. What is this image showing?

Answer 82

Cervical spondylosis

Question 83

Q. What is Cervical spondylosis?​

Answer 83

A. (Age related neck pain due to) Degenerative osteoarthritis of intervertebral joints in cervical spine
Disc loses water, losses pressure then losses height, pressure change across the disc then get these osteophytes can happen at the front and back (circumferentially) of the neck sindesmophytes), as there is a reduction in height the facet joints then become arthritic
Develop on the side nerve root problems
Posteriorly cord root problems
• Pressure on nerve roots leads to radiculopathy:
– Dermatomal sensory symptoms: paraesthesia, pain – Myotomal motor weakness
• Pressure on the cord leads to myelopathy (less common):
– Global weakness – Gait dysfunction – Loss of balance – Loss of bladder and bowel control

Question 84

Q. What is this image showing? Describe the fracture & the common mechanism by which it is sustained

Answer 84

A. Hangman’s fracture
– Hyperextension of head on neck
– Axis fractures through the pars interarticularis
– Unstable fracture
– Forward displacement of C1 & body of C2 on C3

Question 85

Q. What are these two images showing? Describe the fracture & common mechanism of how it is sustained

​

Answer 85

A. Peg fracture (PEGS get hit on the back by the wind)
Transverse fracture through the dens
– Blow to back of head e.g. falling against a wall when balance is compromised
– ‘Open mouth’ AP X-ray = ‘peg view’ or MRI cervical spine

Question 86

Q. What is this an image of? Describe the fracture? Common mechanism?

Answer 86

A. Fractures of the atlas: Jefferson’s fracture : burst fracture
• Describe: Fracture of anterior & posterior arches of atlas
• Mechanism: Axial load e.g. diving into shallow water, impact against the roof of a vehicle, falls from playground equipment
• Typically causes pain but no neurological signs
• May damage arteries at base of skull with secondary neurological sequelae e.g. ataxia (disorders that affect co-ordination, balance and speech), Horner’s syndrome

Question 87

Q. What is whiplash​

Answer 87

A. A low energy RTA that results in neck pain/dizziness/headache but no identifiable structural injury
High mobility low stability

Question 88

Q. What movements occur in the neck during whiplash (Indiana Jones whip)
Hyperextension then hyperflexion

Question 89

Understand common clinical conditions: cervical myelopathy, cervical disc prolapse and cord compression LO
Q. Identify where the disc has prolapsed

Answer 89

Question 90

Describe the clinical effects of spinal cord transection at various neural levels, utilising your knowledge of the dermatomes and myotomes of the upper and lower limb.
Conversely, be able to localise lesions to a neural level based on the residual sensory and motor function of the trunk and limbs LO
Q. What will a patient complain of with left sided prolapse C5/C6 disc? Which nerve is affected?

Answer 90

A. C6
Pain: Biceps into thumb and index finger
Motor weakness: Biceps and wrist extension
Sensory: Numbness/ P&Ns Thumb and Index finger

Question 91

Q. C7/T1 Prolapsed intervertebral disc. Which Nerve Root is affected? Location of pain, motor weakness and sensory?
C8
Pain: Down to Little and Ring Fingers
Motor weakness: Long Finger Flexors
Sensory: Numbness/ P&Ns Little and Ring fingers

Question 92

Q. What is Cervical myelopathy

Answer 92

A. Compression of the spinal cord

Question 93

Q. What is Cervical myelopathy

Answer 93

A. Compression of the spinal cord

Question 94

Q. Anatomy changes in cervical myelopathy?​

Answer 94

A. Osteoarthritis of the cervical spine
Osteophytes
Thickening Ligamentum Flavum
Signal Change in the Spinal Cord

Question 95

Q. Anatomy changes in cervical myelopathy?

Answer 95

A. Osteoarthritis of the cervical spine
Osteophytes
Thickening Ligamentum Flavum
Signal Change in the Spinal Cord

Question 96

Q. Identify where the compression is occurring in the spine

Answer 96

Question 97

Q. What will a patient complain of with a cervical myelopathy at C3/4? Location of : Pain Motor weakness Sensory. Which nerve would be affected if this was just a disc herniation

Answer 97

A. Pain: Neck Pain
Motor weakness: Shoulder Abduction
Sensory: Numbness/ P&Ns from shoulder down and feet

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Question 98

Q. What will a patient complain of with a cervical myelopathy at C5/6?

Answer 98

A. Pain: Neck Pain (arthritis)
Motor weakness: Elbow Flexion, Wrist Movements and finger movements
Sensory: Numbness/ P&Ns from elbows down and feet

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Question 99

Q. Thoracic Cord Compression Anatomy change?

Answer 99

A. Fracture of the vertebra giving bony fragments in the canal or tumour developing in the canal compressing the spinal cord

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Question 100

Q. Location of : Pain, Motor weakness & Sensory

Answer 100

A. Pain: Thoracic Pain
Motor weakness: Weakness of all muscles in the legs
Sensory: Numbness/ P&Ns from umbilicus down
Loss of Sphincter Control

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Question 101

Q. If the tumour was at T5 how would the presentation change? Location of : Pain, Motor weakness & Sensory

Question 102

Q. What will a patient complain of with a cervical myelopathy at C3/4? Location of : Pain Motor weakness Sensory. Which nerve would be affected if this was just a disc herniation

Answer 102

A. Pain: Neck Pain
Motor weakness: Shoulder Abduction
Sensory: Numbness/ P&Ns from shoulder down and feet

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Question 103

Q. What will a patient complain of with a cervical myelopathy at C5/6?

Answer 103

A. Pain: Neck Pain (arthritis)
Motor weakness: Elbow Flexion, Wrist Movements and finger movements
Sensory: Numbness/ P&Ns from elbows down and feet

Question 104

Q. Thoracic Cord Compression Anatomy change?

Answer 104

A. Fracture of the vertebra giving bony fragments in the canal or tumour developing in the canal compressing the spinal cord

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Question 105

Q. Location of : Pain, Motor weakness & Sensory

Answer 105

A. Pain: Thoracic Pain
Motor weakness: Weakness of all muscles in the legs
Sensory: Numbness/ P&Ns from umbilicus down
Loss of Sphincter Control

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Question 106

Q. If the tumour was at T5 how would the presentation change? Location of : Pain, Motor weakness & Sensory

Answer 106

A. Pain: High Thoracic Pain
Motor weakness: Weakness of all muscles in the legs and INTERCOSTALS
Sensory: Numbness/ P&Ns just below the nipples
Loss of Sphincter Control

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Question 107

Question 108

Answer 108

Question 109

Answer 109

Question 110

Answer 110

Question 111

Q. What anatomical feature of the cervical vertebrae is protective against spinal cord injury in whiplash injury?

Answer 111

A. Vertebral foramen
Less likely to impinge on the spinal cord

Question 112

Q. What is this an image of?

​

Answer 112

A. Hangman’s fracture

Question 113

Draw a line showing where the fracture occurs in a hangman’s fracture

Answer 113

Question 114

This is an unstable fracture and hence the bones are likely to displace, as per the X-ray below (figure 9.9). Indicate the site of the fracture with an accurately positioned arrow. Between which two vertebrae has this displacement occurred?

Answer 114

Question 115

Q. Draw the complete dermatome map

Answer 115

Question 116

Q. State the function of the myotomes from C1 to S4
A.

Question 117

Q. The following case study was provided for you in week 3 of the MSK course. Please work through it with the CTFs in your groupwork session to ensure that you understand it:
A 26 year old rugby player sustains a cervical fracture during a scrum, with impingement of the bony fragments onto his spinal cord. On examination of his upper limbs, elbow flexion and shoulder abduction are intact bilaterally but supination is lost. He has no active elbow extension, wrist extension or wrist flexion and no active movement of his fingers. Function of the muscles in the torso and trunk as well as the legs is lost.
What is the most likely neural level of his injury?
(a) C3
(b) C5
(c) C7 (d) C8
(e) T1

Answer 117

A. (b)

Question 118

Q. Features Specific to Atypical Cervical Vertebrae ( clue 3 for C1, 2 for C2 and 1 for C7)

Question 119

Q. What structure passes through the foramen transversarium in the transverse processes of the cervical vertebrae?

Answer 119

A. Vertebral artery and vein accept C7 were only the accessory vertebral vein passes through

Question 120

Identify key osteological features of the skull and cervical spine and relate this to their radiographic appearance and their surface anatomy LO
1. Between each vertebrae is an intervertebral disc except between ?

2. Why is the vertebral foramen in the cervical vertebrae much larger?
3. The vertebral foramen through which the spinal cord runs get ? the more caudal it goes as more and more nerves leave the spinal cord to innervate various structures.

Answer 120

1. C1/C2; C1 has no vertebral body
2. To accommodate the thicker cervical spinal cord
3. smaller

Question 121

1. What two joints does the atlas form? Which vertebrae is stronger the atlas or axis? What ligament is attached to the atlas
2. Are the cervical vertebrae most likely to dislocate or fracture? Why?
3. Slight dislocation would not damage the spinal cord because?

Answer 121

1. Atlanto-occipital joint, atlanto-axial joint, axis, transverse ligament
2. articular surfaces of the cervical vertebrae are more horizontally orientated than in other vertebrae, thus force to dislocate is less fracture
3. The vertebral foramen is large

Question 122

Describe the major types of injury that can involve the skull and cervical spine & the potential consequences of such injuries. LO
Q. The most common sites of cervical spine injuries are at ?. The most severe injuries occur in the upper part of the spine, C1- C4, where damage can lead to ?

Answer 122

A. C2, C6 and C7
Quadriplegia (paralysis of all four limbs) and cessation of respiratory movements

Question 123

Q. What are hyperextension injuries associated with?

Answer 123

A. Hyperextension injuries of the neck (e.g. associated with a rear-end vehicle collision) more commonly affect the upper cervical spine. Such injuries can result in vertebral fracture and disc prolapse, cervical spinous process or odontoid process fracture . Tearing of the anterior longitudinal ligament or kinking of the posterior longitudinal ligament (in the degenerative spine) can also occur. Car seat head rests act to minimise the range of hyperextension that can occur

Question 124

Q. What are hyperflexion injuries associated with?

Answer 124

A. Hyperflexion injuries of the cervical region e.g. during a head-on collision tend to involve the lower part of the cervical spine. Such injuries can lead to a number of complications such as crush fractures of the vertebral body or rupture of the supraspinous ligament making the bony spine unstable. Rupture of the lower cervical intervertebral discs (e.g. C5/C6 and C6/C7) can also occur, which may cause compression of spinal nerve roots C6 and C7.

Question 125

1. Any patient with a significant mechanism for neck injury should have?
2. What regulations must we follow for the spine to be cleared
3. What happens if after clinical examination the spine is not cleared

Answer 125

1. full in-line spinal immobilised
2. Canadian C spine rules
3. Radiological examination e.g. plain radiography (3 views) and/or a CT

Question 126

Q. Describe the pathophysiology of two degenerative spine diseases that cause the intervertebral foramen to narrow

Answer 126

A.1. The facet/zygapophyseal joint can be affected by osteoarthritis affecting the nearby intervertebral foramina
2. Degeneration of the intervertebral discs
= pain along the distribution of the dermatome relating to the spinal nerve +/- muscle weakness in the muscles derived from the associ ated myotome.

Question 127

Q. The cranium is the skeleton of the head. A series of bones form its two parts, the neurocranium and viscerocranium. The neurocranium is the bony case of the brain and its membranous coverings, the cranial meninges. It also contains proximal parts of the cranial nerves and the vasculature of the brain. The neuro- cranium in adults is formed by a series of eight bones: four singular bones centered on the midline (frontal, ethmoidal, sphenoidal, and occipital) and two sets of bones occurring as bilateral pairs (temporal and parietal)

Question 128

Q. Most bones of the calvaria consist of ?

Answer 128

A. internal and external tables of compact bone, separated by diploë

Question 129

Q. The diploë is cancellous bone containing red bone marrow during life, through which run canals formed by diploic veins. The diploë in a dried calvaria is not red because the protein was removed during preparation of the cranium. The internal table of bone is thinner than the external table, and in some areas there is only a thin plate of compact bone With no diploë.
The bony substance of the cranium is unequally distributed. Relatively thin (but mostly curved) flat bones provide the necessary strength to maintain cavities and protect their contents.

Question 130

Q. How are the bones of the calvaria arranged?​

Answer 130

A. Tri-laminar arrangement confers protective strength without adding significant weight

Question 131

Q. Intersections between bones of the skull are called? How are they designed and why?

Answer 131

Sutures these are fibrous joints (saggital, coronal and lambdoid), serrated preventing slippage and movement

Question 132

Answer 132

Question 133

Q. Growth at sutures stops around ?
• Then gradually obliterated from inside -> outside

Answer 133

A. puberty

Question 134

Q. Stages of Intramembranous Ossification

Answer 134

A. A small cluster of mesenchymal stem cells (MSCs) form a tight cluster of cells (a nidus).
The MSCs become osteoprogenitor cells (each developing more Golgi apparatus and rough endoplasmic reticulum).
The osteoprogenitor cells become osteoblasts and lay down an extracellular matrix containing Type I collagen (osteoid).
The osteoid mineralises to form rudimentary bone tissue spicules, which are surrounded by osteoblasts, and contain osteocytes.
The spicules join to form trabeculae, which merge to form woven bone, which is finally replaced by the lamellae of mature compact bone.

Question 135

Q. Outline the major differences between the fetal/infant and adult skull LO

Answer 135

A. Fetal skulls have fontanelles

Question 136

Q. What are fontanelles?

Answer 136

A. Large areas of unossified membranous gaps between flat bones of calvaria

Question 137

1. Important because ?
2. Fontanelles fuse in early infancy give the aprox time when the anterior and posterior fontanelles fuse? What is the condition called where the fontanelles and sutures fuse early?

Answer 137

1. Allow for alteration of the skull size and shape during childbirth
   • Permit growth of infant brain

A. • Anterior ~18 months- 2 years
• Posterior ~1-3 months
• craniosyntosis (rare condition) baby develops or is born with an abnormally shaped skull. It happens when one or more of the infant’s cranial sutures fuses too early

Question 138

Q. What is the clinical importance of the Anterior Fontanelle

Answer 138

A. Clinically Useful when Examining Newborns and Infants
• Slightly convex shape in a healthy baby
• Inspection and gentle palpation of anterior fontanelle can be used to assess intracranial pressure and state of hydration

Question 139

Q. What other key differences are there?

Answer 139

A. - calvaria are smooth and unilaminar; no diploë is present.

• The frontal and parietal eminences are especially prominent
• The cranium of a newborn infant is disproportionately large compared to other parts of the skeleton;
• Infant: the facial skeleton forms 1/8 of the cranium / adult: the facial skeleton forms 1/3of the cranium
• frontal suture
• intermaxillary suture and mandibular symphysis
• no mastoid and styloid processes

Question 140

Describe the major types of injury that can involve the skull LO
Q. Can you have intracranial injury without a skull fracture? Why does the resistance to a fracture vary in different parts of the skull? When we say intracranial injury what is actually at risk of being injured?

Answer 140

A.- Yes
– Thickness of cranial bones varies, resistance to fracture therefore varies
- Main concern is risk of intracranial injury (i.e. injury to brain, blood vessels, cranial nerves)
• CT scanning should be performed in all patients with known or suspected skull fractures to identify any intracranial injuries

​

Question 141

Q. State and explain the two main fracture types

Answer 141

A. – Linear: pass full thickness of skull, fairly straight, involve no bone displacement
– Depressed: fragment is displaced inwards towards the brain (hard blow, thin area

​

Question 142

Q. What do you call fractures involving the cranial base (Middle meningeal artery (anterior branch)) =
– Associated with cranial nerve injuries
– Prone to causing cerebrospinal fluid leaks
– Additional, specific clinical signs indicate their presence

Answer 142

A. basilar skull fractures

Question 143

Q. Clinical signs of basilar skull fractures

Answer 143

A. Stain on CSF on the pillow (breakage in the meninges) , Battle’s sign – bruising of the mastoid process of the temporal bone, Raccoon eyes – bruising around the eyes, i.e. “black eyes”

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Question 144

Q. What is the pterion and state its clinical relevance

Answer 144

A. - Thinnest area of skull: relatively easy to fracture

• Blows to the side of the head
• Middle meningeal artery (anterior branch)
• Intracranial haemorrhage (extradural)

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Question 145

Q. What other facial injuries/ fractures are common?

Answer 145

A. Fractures: - nasal - zygomatic bone & arch - mandible
Injury: supra ciliary

Question 146

Identify key osteological features of the skull and cervical spine & relate this to their radiographic appearance and their surface anatomy LO

Answer 146

Question 148

Answer 148

Question 149

Describe the arrangement of pia, arachnoid and dura mater in relation to the brain and skull, and the location of CSF and blood vessels between these layers LO

Answer 149

Question 150

Answer 150

Question 151

Answer 151

Question 152

Describe the arrangement of pia, arachnoid and dura mater in relation to the brain and skull, and the location of CSF and blood vessels between these layers LO
Q. The meninges are composed of three membranous connective tissue layers:

Answer 152

A. – Dura: tough fibrous membrane
(Potential space)
– Arachnoid: soft translucent membrane
(Potential space)
– Pia: microscopically thin, delicate closely adherent to surface of brain (cannot peal pia)

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Question 153

Q. Where is the location of the CSF?

Answer 153

A. Subarachnoid

Question 154

1. Function of CSF? What is CSF?
2. CSF is formed by?

Answer 154

1. This fluid-filled space helps maintain the balance of extracellular fluid in the brain. CSF is a clear liquid similar to blood in constitution; it provides nutrients but has less protein and a different ion concentration.
2. choroid plexuses of the four ventricles of the brain.

Question 155

1. Dura consists of two layers
2. For most part two layers closely adhered but areas where they separate. Separation of two layers forms?

Answer 155

1. – Periosteal = endosteum lining inner bones of skull
   – Meningeal = layer adjacent to arachnoid
2. – Dural folds

– Dural venous sinuses (spaces which become venous channels)

Question 156

1. The dura mater, a thick, dense, bilaminar membrane. It is adherent to the internal table of the calvaria. The two layers of the cranial dura are an ?, formed by the ? covering the internal surface of the calvaria, and an ? layer, a strong fibrous membrane that is continuous at the foramen magnum with the ? covering the spinal cord
2. The external periosteal layer of the dura adheres to the internal surface of the cranium; its attachment is tenacious along the suture lines and in the cranial base. The external periosteal layer is continuous at the cranial foramina with the periosteum on the external surface of the calvaria. How does the dural layer differ in the spinal cord?

Answer 156

1. external periosteal layer, periosteum, internal meningeal, spinal dura,
2. outer layer is not continuous with the dura mater of the spinal cord, which consists of only a meningeal layer

Question 157

Answer 157

Question 158

Answer 158

Question 159

Q. The internal meningeal layer of dura mater is a sustentacular (supporting) layer that reflects away from the external periosteal layer of dura to form dural infoldings (reflections). The dural infoldings divide the cranial cavity into compartments, forming partial partitions (dural septa) between certain parts of the brain and providing support for other parts. The dural infoldings include the:

Answer 159

A. • Falx cerebri (cerebral falx)
• Tentorium cerebelli (cerebellar tentorium)
• Falx cerebelli (cerebellar falx)
• Diaphragma sellae (sellar diaphragm)

Question 160

1. Function of dural folds
2. The falx cerebri, the largest dural infolding, lies in the longitudinal cerebral fissure that separates? State it’s attachments.
3. The falx cerebri attaches in the median plane to the internal surface of the calvaria, and extends from ? To?

Answer 160

1. Stabilise the Brain and act as Rigid Dividers
2. the right and the left cerebral hemispheres
3. frontal crest of the frontal bone and crista galli of the ethmoid bone anteriorly
   Internal occipital protuberance posteriorly
   Ends by becoming continuous with the tentorium cerebelli

Question 161

Q. The tentorium cerebelli, the second largest dural infolding, is a wide crescentic septum that separates? Attachments?

Answer 161

A. occipital lobes & cerebellum
The tentorium cerebelli attaches rostrally to the clinoid processes of the sphenoid, rostrolaterally to the petrous part of the temporal bone, and posterolaterally to the internal surface of the occipital bone and part of the parietal bone.

​

Question 162

Q. The falx cerebri attaches to the tentorium cerebelli and holds it up, giving it a tent-like appearance. The tentorium cerebelli divides the cranial cavity into ? The concave anteromedial border of the tentorium cerebelli is free, producing a gap called the ? Purpose? ​

Answer 162

A. - supratentorial and infratentorial compartments. The supratentorial compartment is divided into right and left halves by the falx cerebri,
tentorial notch, through which the brainstem (midbrain, pons, and medulla oblongata) extends from the posterior into the middle cranial fossa.

Question 163

Describe the reflections of the dura mater and the formation of the venous sinuses, including their connection with the internal jugular vein and cerebral veins LO
1. DURAL VENOUS SINUSES what are they?

2. What drains into these sinuses and what do the sinuses drain into?

Answer 163

1. endothelium-lined spaces between the periosteal and the meningeal layers of the dura. They form where the dural septa attach along the free edge of the falx cerebri and in relation to formations of the cranial floor
2. Large veins from the surface of the brain empty into these sinuses and most of the blood from the brain ultimately drains through them into the IJVs.

Question 164

Q. What is the sinus that lies in the convex attached border of the falx cerebri. Where does it begin and finish? How does it receive deoxygenated blood?

Answer 164

A.- The superior sagittal sinus

• It begins at the crista galli and ends near the internal occipital protuberance at the confluence of sinuses, a meeting place of the superior sagittal, straight, occipital, and transverse sinuses.
• The superior sagittal sinus receives the superior cerebral veins and communicates on each side through slit-like openings with the lateral venous lacunae, lateral expansions of the superior sagittal sinus.

Question 165

Q. What are arachnoid granulations and their function?​

Answer 165

A. Arachnoid granulations are tufted prolongations of the arachnoid that protrude through the meningeal layer of the dura mater into the dural venous sinuses. Transport of CSF from the subarachnoid space to the venous system.

Question 166

Q. How is the inferior saggital sinus formed?

Answer 166

A. The inferior sagittal sinus is much smaller than the superior sagittal sinus. It runs in the inferior concave free border of the falx cerebri and ends in the straight sinus. The straight sinus is formed by the union of the inferior sagittal sinus with the great cerebral vein. It runs inferoposteriorly along the line of attachment of the falx
cerebri to the tentorium cerebelli, where it joins the confluence of sinuses.

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Question 168

Answer 168

Question 169

Answer 169

Question 170

Answer 170

Question 171

Q. The transverse sinuses pass laterally from the confluence of sinuses, forming a groove in the occipital bones and the posteroinferior angles of the parietal bones. The transverse sinuses course along the posterolateral attached margins of the tentorium cerebelli and then become the sigmoid sinuses as they approach the posterior aspect of the petrous temporal bones. Blood received by the confluence of sinuses is drained by the ?, but rarely equally. Usually the ? is dominant (larger).

Answer 171

A. transverse sinuses, left sinus

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Question 172

Answer 172

Question 173

Answer 173

Question 174

Q. What connects the dural venous sinuses with veins outside the cranium? Describe its structure and the consequences of is structure.

Answer 174

A. -Emissary veins
-Valveless and blood may flow in both directions, but is usually away from the brain

Question 175

Q. A frontal emissary vein is present in children and some adults. What dural sinus and extracranial veins does it connect?

Answer 175

A. It passes through the foramen cecum of the cranium, connecting the superior sagittal sinus with veins of the frontal sinus and nasal cavities. A parietal emissary vein, which may be paired bilaterally, passes through the parietal foramen in the calvaria, connecting the superior sagittal sinus with the veins external to it, particularly those in the scalp

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Question 176

Q. A mastoid emissary vein passes through the mastoid foramen. What dural sinus and extracranial vein does it connect?

Answer 176

A. Connects each sigmoid sinus with the occipital/posterior auricular vein. A posterior condylar emissary vein may also be present, passing through the condylar canal, connecting the sigmoid sinus with the suboccipital venous plexus.

Question 177

Q. What is the largest artery of the dura? What is it a branch of? How does it enter the cranial cavity?

Answer 177

A. - Middle meningeal artery

• Maxillary artery
• middle cranial fossa through the foramen spinosum
• runs laterally in the fossa, and turns superoanteriorly on the greater wing of the sphenoid, where it divides into anterior and posterior branches. The anterior branch of the middle meningeal artery runs superiorly to the pterion and then curves posteriorly to ascend toward the vertex of the cranium. The posterior branch of the middle meningeal artery runs posterosuperiorly and ramifies (breaks up into distributing branches) over the posterior aspect of the cranium. Small areas of dura are supplied by other arteries: meningeal branches of the ophthalmic arteries, branches of the occipital arteries, & small branches of the vertebral arteries.

Question 178

Q. The middle meningeal veins accompany the middle meningeal artery, leave the cranial cavity through the ?, and drain into the pterygoid venous plexus.

Answer 178

A. foramen spinosum or foramen ovale

Question 179

Q. The arachnoid mater and pia mater (leptomeninges) develop from a single layer of mesenchyme surrounding the embryonic brain, becoming the parietal part (arachnoid) and visceral part (pia) of the leptomeninx. The derivation of the arachnoid–pia from a single embryonic layer is indicated in the adult by?

Answer 179

A. Arachnoid trabeculae passing between the arachnoid and the pia
The trabeculae are composed of flattened, irregularly shaped fibroblasts that bridge the sub- arachnoid space. The arachnoid and pia are in continuity immediately proximal to the exit of each cranial nerve from the dura mater. The arachnoid mater contains fibroblasts, collagen fibers, and some elastic fibers. Although thin, the arachnoid is thick enough to be manipulated with forceps. The avascular arachnoid, although closely applied to the meningeal layer of the dura, is not attached to the dura; it is held against the inner surface of the dura by the pressure of the CSF.

​

Question 180

Q. Features of the pia?

Answer 180

A. - even thinner membrane

• vascularized
• shiny appearance
• follows contours of brain

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Question 181

Q. Which of the three meningeal spaces are present in pathology and which is a real space?​

Answer 181

A. • The dura–cranial interface (extradural or epidural “space”) is not a natural space between the cranium and the external periosteal layer of the dura because the dura is attached to the bones. It becomes a space only pathologically—for example, when blood from torn meningeal vessels pushes the periosteum away from the cranium. The potential or pathological cranial epidural space is not continuous with the spinal epidural space (a natural space occupied by epidural fat and a venous plexus) because the former is external to the periosteumlining the cranium and the latter is internal to the periosteum covering the vertebrae.
• The dura–arachnoid junction or interface (“subdural space”) is likewise not a natural space between the dura and the arachnoid. A space may develop in the dural border cell layer as the result of trauma, such as after a blow to the head.
• The subarachnoid space, between the arachnoid and the pia, is a real space that contains CSF, trabecular cells, arteries, and veins.

Question 182

Answer 182

Question 183

Answer 183

Question 184

Describe the likely origin of bleeding in extradural and subdural haemorrhages & relate your understanding of meningeal anatomy to the radiographic appearance of extra- and sub-dural haemorrhages LO
Q. Extradural/epidural hemorrhage is arterial in origin. Blood from torn branches of a middle meningeal artery collects between the external periosteal layer of the dura and the calvaria. The extravasated blood strips the dura from the cranium. Usually this follows a hard blow to the head, and forms an extradural or epidural hematoma. Typically, a brief concussion (loss of consciousness) occurs, followed by a lucid interval of some hours. Later, drowsiness and coma (profound unconsciousness) occur. Compression of the brain occurs as the blood mass increases, necessitating evacuation of the blood and occlusion of the bleeding vessels.
A dural border hematoma is classically called a subdural`hematoma; however, this term is a misnomer because there is no naturally occurring space at the duraarachnoid junction. Hematomas at this junction are usually caused by extravasated blood that splits open the dural border cell layer. The blood does not collect within a preexisting space, but rather creates a space at the dura-arachnoid junction. Dural border hemorrhage usually follows a blow to the head that jerks the brain inside the cranium and injures it. The precipitating trauma may be trivial or forgotten. Dural border hemorrhage is typically venous in origin and commonly results from tearing a BRIDGING VEINS which drain into the superior cerebral vein as it enters the superior sagittal sinus. Usually in older people veins more stretched due to weakened CT more likely to rupture.
(Subarachnoid hemorrhage is an extravasation of blood, usually arterial, into the subarachnoid space. Most subarachnoid hemorrhages result from rupture of a saccular aneurysm (sac-like dilation on the side of an artery), such as an aneurysm of the internal carotid artery. Some subarachnoid hemorrhages are associated with head trauma involving cranial fractures and cerebral lacer- ations. Bleeding into the subarachnoid space results in meningeal irritation, severe headache, stiff neck, and often loss of consciousness)

Question 185

Answer 185

Question 186

Answer 186

A. Cephalohaematoma (A) (Sub-periosteal) or Subgaleal (B) (Sub-aponeurotic)

Question 187

Q. What is this image showing A or B

Answer 187

A. Bleed between the periosteum and the bone cannot pass between the suture lines Cannot pass to the intracranium wouldn’t

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Question 188

Q. What is this image showing? Describe this bleed.

Answer 188

A. Extradural Haemorrhage
Arterial Bleed
Bleeding between the bone and outermost layer of dura
Periosteal dura
Split away layer of periosteal dura
Blood cannot travel beyond suture lines as periosteum is continuous with the sutures
Arteria; bleed middle meningeal artery

Question 189

Q. What is this image showing? Describe the bleed. Draw a diagram to explain your answer.

Answer 189

A. Bridge between the arachnoid layer and the dura layer
If there is a bleed it is a venous blood
In elderly people simple stumble can rattle the brain and shear veins and cause sub Dural heamarrhadge banana shape
What will limit the blood the falx cerebri as fold in the midline is stopping its spread can spread down one half

Question 190

Answer 190

Question 191

Q. What is this scan showing? Type of bleed? Common pathological cause? How to diagnose?

Answer 191

A. -Subarachnoid Haemorrhage
-Arterial bleed
• Secondary to trauma or spontaneous rupture of blood vessel e.g. aneurysm
– Usually a branch of ‘Circle of Willis’ (the arterial circuit responsible for supplying brain structures)
• Blood leaks into subarachnoid space, mixing with CSF
– Sudden, often fatal
• CT imaging of head
– 93% picked up if within 24 hours; 100% if within 6 hours
– Lumbar puncture-if CT inconclusive: sample CSF to identify presence of blood (haemoglobin degradation products)

Question 192

1. Intracranial haemorrhage, bleeding does not have to occur between the meningeal layers. Where else can it occur?
2. What type of necrosis would’ve occur?

Answer 192

A. Bleeding can also occur within the brain tissue itself (e.g. contusions (region of injured tissue or skin in which blood capillaries have been ruptured; a bruise) tearing of white matter)

– Intracerebral haemorrhage

2. Liquefactive

Question 193

Q. How does bleeding cause injury if it is intracranial?

Answer 193

A. Addition of ‘volume’ to an already fixed space (the skull) leads to rise in pressure and damage to brain tissue, brainstem and other important structures e.g. cranial nerves

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Question 194

Answer 194

Question 195

Answer 195

Question 196

Q. Dural Folds help to Stabilise the Brain and act as Rigid Dividers but a rise in pressure inside the skull e.g. secondary to a bleed can lead to?

Answer 196

A.compression and displacement of brain against rigid dural folds and/or through foramen magnum = Herniation -> neurological signs squish nervous tissue

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Question 197

Answer 197

Question 198

Q. Dural Venous Sinuses Venous blood filled spaces created by?
• Major dural venous sinuses lie at the margins of borders of falx cerebri and tentorium
cerebelli and on cranial floor e.g. cavernous sinus
• Venous blood from ? drain to the sinuses
• Eventually dural venous sinuses drain into ?

Answer 198

A. -Separation of meningeal from periosteal layer of dura

• brain (in cerebral veins)
• internal jugular vein (jugular foramen)

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Question 199

Q. Dural Venous Sinuses Venous blood filled spaces created by?
• Major dural venous sinuses lie at the margins of borders of falx cerebri and tentorium
cerebelli and on cranial floor e.g. cavernous sinus
• Venous blood from ? drain to the sinuses
• Eventually dural venous sinuses drain into ?​

Answer 199

A. -Separation of meningeal from periosteal layer of dura

• brain (in cerebral veins)
• internal jugular vein (jugular foramen)

Question 200

Answer 200

Question 201

Answer 201

Question 202

Answer 202

Question 203

Q. Identify on the skulls (and label) the only moveable joint in the skull.​

Answer 203

A. Tempooromandibular

Question 204

Answer 204

Question 205

Q. Identify the bony structures on the following normal plain radiographic image of the skull. Note that in x-rays the structures overlap and make the osteology more difficult to distinguish!

Answer 205

A. A- frontal sinus
B- zygoma
C- zygomatic arch
D- mandible
E-coranoid
F- angle of mandible
G- Dens
H- foramen magnum?
I- maxillary sinus
J-

Question 206

Q. Why do you think CT imaging, rather than a skull x-ray, is the preferred modality when investigating patients with head injuries and/or suspected skull fractures?
A. In clinical practice, plain (skull) x-rays (SXR) should not be performed either in addition or instead of a CT in patients with serious head injuries (or suspected skull fractures). The first line imaging of choice would be a CT scan. Facial x-rays, are often used when bony injuries are suspected in facial injuries, (e.g. fracture of zygomatic arch). However, in any significant injury involving part of the face/head consideration must always be given for any potential associated injuries to the brain, and/or cervical spine.

Question 207

1. What is the cranium?
2. The cranium is formed by bones which can be grouped into two parts?

Answer 207

1. Skeleton of the head
2. Neurocranium (n for neck higher up) & viscerocranium (v for vagina which is lower down)

Question 208

1. What is the neurocranium?
2. How many bones make up the neurocranium and name them

Answer 208

1. Bony brain case + cranial meninges
2. Eight bones:
   4 singular bones centered on the midline (frontal, ethmoidal, sphenoidal, & occipital)
   2 x bilateral pairs (temporal & parietal)

Question 209

1. The neurocranium has a dome-like roof, the ? (skullcap), and a floor or ? (basicranium).
2. The bones making the calvaria are? The bones contributing to the cranial base are? How are they formed?

Answer 209

1. calvaria, cranial base
2. primarily flat bones (frontal, parietal, and occipital) formed by intramembranous ossification of head mesenchyme from the neural crest.
   Primarily irregular bones with substantial flat portions (sphenoidal & temporal) formed by endochondral ossification of cartilage (chondrocranium) or from more than one type of ossification.

Question 210

1. The ? bone is an irregular bone that makes a relatively minor midline contribution to the neurocranium but is primarily part of the viscerocranium
2. Most calvarial bones are united by fibrous interlocking sutures; however, during childhood, some bones (sphenoid and occipital) are united by hyaline cartilage (synchondroses).
3. The spinal cord is continuous with the brain through the foramen magnum, a large opening in the cranial base. The viscerocranium (facial skeleton) comprises the facial bones that mainly develop in the mesenchyme of the embryonic pharyngeal arches (Moore and Persaud, 2008). The visce- rocranium forms the anterior part of the cranium and consists of the bones surrounding the mouth (upper and lower jaws), nose/nasal cavity, and most of the orbits (eye sockets or orbital cavities)

Question 211

Q. How are calvarial bones United?

Answer 211

A. fibrous interlocking sutures; however, during childhood, some bones (sphenoid and occipital) are united by hyaline cartilage (synchondroses)

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Question 212

Q. The viscerocranium forms the anterior part of the cranium and consists of the bones surrounding the mouth (upper and lower jaws), nose/nasal cavity, and most of the orbits (eye sockets or orbital cavities)

Question 213

Q. The viscerocranium consists of 15 irregular bones:

Answer 213

A. 3 singular bones centered on or lying in the midline (mandible, ethmoid, and vomer) & 6 bones occurring as bilateral pairs (maxillae; inferior nasal conchae; and zygomatic, palatine, nasal, and lacrimal bones).

Question 214

Q. The maxillae and mandible house the teeth—that is, they provide the sockets and supporting bone for the maxillary and mandibular teeth. The maxillae contribute the greatest part of the upper facial skeleton, forming the skeleton of the upper jaw, which is fixed to the cranial base. The mandible forms the skeleton of the lower jaw, which is movable because it articulates with the cranial base at the ?

Answer 214

A. temporomandibular joints

Question 215

Q. What are pneumatized bones?

Answer 215

A. Several bones of the cranium (frontal, temporal, sphenoid, and ethmoid bones) are pneumatized bones, which contain air spaces (air cells or large sinuses), presumably to decrease their weight. The total volume of the air spaces in these bones increases with age.

Question 216

Q. The frontal bone, specifically its squamous (flat) part, forms the skeleton of the forehead, articulating inferiorly with the? In some adults a metopic suture, a persistent frontal suture or remnant of it, is visible in the midline of the glabella, the smooth, slightly depressed area between the superciliary arches. The frontal suture divides the frontal bones of the fetal cranium.

Answer 216

A. nasal and zygomatic bones,

Question 217

Answer 217

Question 218

Answer 218

Question 219

Answer 219

Question 220

Answer 220

Question 221

Answer 221

Metopic suture, frontal bome

Question 222

Q. The intersection of the frontal and the nasal bones is the ?, which in most people is related to a distinctly depressed area (bridge of nose). The frontal bone also articulates with the lacrimal, ethmoid, and sphenoids; a horizontal portion of bone (orbital part) forms both the roof of the orbit and part of the floor of the anterior part of the cranial cavity

Answer 222

A. nasion

Question 223

Q. The frontal bone also articulates with the ?; a horizontal portion of bone (orbital part) forms both the roof of the orbit and part of the floor of the anterior part of the cranial cavity

Answer 223

A. lacrimal, ethmoid, and sphenoids

Question 224

Q. How can infections track from the neck to thorax​

Answer 224

A. Buccopharyngeal fascia

Question 225

Q. Label the diagrams

Answer 225

Question 226

Q. Osteological features:
• Shallow depressions or hollows (?)
• Bony tunnel (?)
• Holes
• Round-ish = ? • Narrow slit = ?​

Answer 226

A. fossae, canal, foramina, fissures

Question 227

Q. Neurocranium (8 bones)
– Encase and protect brain
– Calvaria (“skull cap” or “vault”), cranial floor (base) and cranial cavity
– ‘Vault’ bones begin as membranes (? ossification): floor/base begin as cartilage (? ossification)
Viscerocranium (14 bones)
– Facial skeleton and the jaw
– Surrounds oral cavity, pharynx and upper respiratory passages
– Bones begin as membranes or cartilage and ossify
– Structures (most) develop from the pharyngeal arches (1&2)

Answer 227

A. intramembranous, endochondrial

Question 228

Q. The supra-orbital margin of the frontal bone, the angular boundary between the squamous and the orbital parts, has a ? in some crania for passage of the ? Just superior to the supra-orbital margin is a ridge, the ?, that extends laterally on each side from the glabella. The prominence of this ridge, deep to the eyebrows, is generally greater in males.

Answer 228

A. supra-orbital foramen or notch, supra-orbital nerve and vessels, superciliary arch

Question 229

Q. The maxillae form the upper jaw; their ? include the tooth sockets (alveoli) and constitute the supporting bone for the maxillary teeth. The two maxillae are united at the ? in the median plane. The maxillae surround most of the piriform aperture and form the infra-orbital margins ?. They have a broad. Connection with the zygomatic bones laterally and an ? inferior to each orbit for passage of the ?

Answer 229

A. alveolar processes, intermaxillary suture, medially, infra- orbital foramen, infra-orbital nerve and vessels,

Question 230

Q. The mandible is a U-shaped bone with an ? that supports the mandibular teeth. It consists of a horizontal part, the ?, and a vertical part, the ? Inferior to the second premolar teeth are the ? for the ? The ? , forming the prominence of the chin, is a triangular bony elevation inferior to the mandibular symphysis the osseous union where the halves of the infantile mandible fuse.

Answer 230

A. alveolar process, body, ramus, mental foramina, mental nerves and vessels, mental protuberance, (also a MANDIBULAR FORAMEN LO)

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Question 231

Q. The lateral aspect of the cranium is formed by both the neurocranium and the viscerocranium. The main features of the neurocranial part are the ? The main features of the viscerocranial part are the infratemporal fossa, zygomatic arch, and lateral aspects of the maxilla and mandible. The temporal fossa is bounded by?​

Answer 231

A. temporal fossa, the external acoustic meatus opening, and the mastoid process of the temporal bone, Superiorly and posteriorly by the superior and inferior temporal lines, anteriorly by the frontal and zygomatic bones, and inferiorly by the zygomatic arch. The superior border of this arch corresponds to the inferior limit of the cerebral hemisphere of the brain.

Question 232

Q. The zygomatic arch is formed by the union of the ?

Answer 232

A. Temporal process of the zygomatic bone and the zygomatic process of the temporal bone.

Question 233

Q. Which sutures of bone form the pterion

Answer 233

A. Frontal, parietal, sphenoid (greater wing), and temporal bones. Less commonly, the frontal and temporal bones articulate; sometimes all four bones meet at a point.

Question 234

Q. The external acoustic opening (pore) is the entrance to the external acoustic meatus (canal), which leads to the tympanic membrane (eardrum). The ? of the temporal bone is posteroinferior to the external acoustic opening. Anteromedial to the mastoid process is the ? of the temporal bone, a slender needle-like, pointed projection. The infratemporal fossa is an irregular space inferior and deep to the zygomatic arch and the mandible and posterior to the maxilla.​

Answer 234

A. mastoid process, styloid process,

Question 235

Answer 235

Question 236

Answer 236

Question 237

Q. The external occipital crest descends from the protuberance toward the foramen magnum, the large opening in the basal part of the occipital bone. The superior nuchal line, marking the superior limit of the neck, extends laterally from each side of the protuberance; the inferior nuchal line is less distinct. In the centre of the occiput, lambda indicates the junction of the sagittal and the lambdoid sutures. Lambda can sometimes be felt as a depression. One or more sutural bones (accessory bones) may be located at lambda or near the mastoid process.

Question 238

Q. Name the three sutures, what bones they separate and what we call there intersections.​

Answer 238

A. Coronal, sagittal and lambdoid. Coronal separates the temporal and parietal bones. Sagittal separates the parietal bones. Lambdoid separates the parietal & temporal bones from the occipital bone. Bregma is formed by the coronal and sagittal suture. Lambda is formed by the sagittal and lambdoid suture.

Question 239

Q. What is the cranial base? (basicranium)

Answer 239

A. inferior portion of the neurocranium (floor of the cranial cavity) and viscerocranium minus the mandible

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Question 240

Q. The external surface of the cranial base features the alveolar arch of the ? The palatine processes of the maxillae; and the palatine, sphenoid, vomer, temporal, and occipital bones. The hard palate (bony palate) is formed by the palatal processes of the ? The free posterior border of the hard palate projects posteriorly in the median plane as the posterior nasal spine. ​

Answer 240

A. maxillae, maxillae anteriorly and the horizontal plates of the palatine bones posteriorly

Question 241

Q. Wedged between the frontal, temporal, and occipital bones is the sphenoid, an irregular unpaired bone that consists of a body and three pairs of processes: ? The greater and lesser wings of the sphenoid spread laterally from the lateral aspects of the body of the bone.

Answer 241

A. greater wings, lesser wings, and pterygoid processes

Question 242

1. The pterygoid processes, consists of:
2. The groove for the cartilaginous part of the pharyngotympanic (auditory) tube lies medial to the spine of the sphenoid, inferior to the junction of the greater wing of the sphenoid and the petrous (L. rock-like) part of the temporal bone (Fig. 7.9B). Depressions in the squamous (L. flat) part of the temporal bone, called the mandibular fossae, accommodate the mandibular condyles when the mouth is closed. The cranial base is formed posteriorly by the occipital bone, which articulates with the sphenoid anteriorly. The four parts of the occipital bone are arranged around the foramen magnum, the most conspicuous feature of the cranial base. On the lateral parts of the occipital bone are two large protuberances, the occipital condyles, by which the cranium articulates with the vertebral column.

Answer 242

1. lateral and medial pterygoid plates, extend inferiorly on each side of the sphenoid from the junction of the body and greater wings.

Question 243

Q. What major structures pass through the foramen magnum?

Answer 243

A. Spinal cord (becomes continuous with the medulla oblongata of the brain), the meninges (coverings) of the brain and spinal cord, the vertebral arteries, the anterior and posterior spinal arteries, and the spinal accessory nerve (CN XI)

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Question 244

Q. How does the cranium articulate with the vertebral column?

Answer 244

A. By the occipital condyle

Question 245

Q. The large opening between the occipital bone and the petrous part of the temporal bone is the jugular foramen, what passes through?
The entrance to the carotid canal for the internal carotid artery is just anterior to the jugular foramen. The mastoid processes provide for muscle attachments.
The stylomastoid foramen, transmitting the facial nerve (CN VII) and stylomastoid artery, lies posterior to the base of the styloid process.

Answer 245

A. internal jugular vein (IJV) and several cranial nerves (CN IX–CN XI)

Question 246

Answer 246

Question 247

Answer 247

Question 248

Q. Describe the structure of the accessory nerve and its anatomical route

Answer 248

A. Spinal Part

• arises from neurones of the upper spinal cord, specifically C1-C5/C6 spinal nerve roots.
• enter the cranial cavity via the foramen magnum
• traverses the posterior cranial fossa to reach the jugular foramen
• It briefly meets the cranial portion of the accessory nerve, before exiting the skull (along with the glossopharyngeal and vagus nerves).
• idescends along the internal carotid artery to reach the sternocleidomastoid muscle, which it innervates. It then moves across the posterior triangle of the neck to supply motor fibres to the trapezius.

Question 249

Q. Describe the origin and anatomical route of the cranial part of the accessory nerve ​

Answer 249

A. Cranial Part

• lateral aspect of the medulla oblongata
• leaves via jugular foramen, where it briefly contacts the spinal part of the accessory nerve.
• Immediately after leaving the skull, cranial part combines with the vagus nerve (CN X) at the inferior ganglion of vagus nerve (a ganglion is a collection of nerve cell bodies). The fibres from the cranial part are then distributed through the vagus nerve. For this reason, the cranial part of the accessory nerve is considered as part of the vagus nerve.

Question 250

Q. Anterior cranial fossa, is the ? of the three cranial fossae. The fossa is formed by ?

Answer 250

A. 1. shallowest
2. The frontal bone anteriorly, the ethmoid bone in the middle, and the body and lesser wings of the sphenoid posteriorly

Question 251

Q. The greater part of the fossa is formed by the orbital parts of the frontal bone, which support the frontal lobes of the brain and form the roofs of the orbits. This surface shows sinuous impressions (brain markings) of the ? of the frontal lobes.

Answer 251

A. orbital gyri (ridges)

Question 252

Q. The frontal crest is a median bony extension of the frontal bone. At its base is the ?

Answer 252

A. foramen cecum of the frontal bone, which gives passage to vessels during feta development but is insignificant postnatally.

Question 253

Q. What is posterior to the foramen caecum?

Answer 253

A. The crista galli
On each side of this ridge is the sieve-like cribriform plate of the ethmoid. Its numerous tiny foramina transmit the olfactory nerves (CN I) from the olfactory areas of the nasal cavities to the olfactory bulbs of the brain, which lie on this plate.

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Question 254

Q. Middle cranial fossa
The butterfly-shaped middle cranial fossa has a central part composed of the ? on the body of the sphenoid and large, depressed lateral parts on each side. The middle cranial fossa is ? to the anterior cranial fossa, separated from it by the sharp sphenoidal crests laterally and the sphenoidal limbus centrally. The sphenoidal crests are formed mostly by the sharp posterior borders of the lesser wings of the sphenoid bones, which overhang the lateral parts of the fossae anteriorly. The sphenoidal crests end medially in two sharp bony projections, the anterior clinoid processes.

Answer 254

A. sella turcica, posteroinferior

Question 255

Answer 255

Question 256

Q. The sella turcica is surrounded by the anterior and posterior clinoid processes which is composed of:

Answer 256

A. 1. The tuberculum sellae (horn of saddle): a variable slight to prominent median elevation forming the posterior boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.

2. The hypophysial fossa (pituitary fossa): a median depression (seat of saddle) in the body of the sphenoid that accommodates the pituitary gland (L. hypophysis).
3. The dorsum sellae (back of saddle): a square plate of bone projecting superiorly from the body of the sphenoid. It forms the posterior boundary of the sella turcica, and its prominent superolateral angles make up the posterior clinoid processes.

Question 257

Q. On each side of the body of the sphenoid, a crescent of four foramina perforate the roots of the cerebral surfaces of the greater wings of the sphenoids:

Answer 257

A. 1. Superior orbital fissure: Located between the greater and the lesser wings, it opens anteriorly into the orbit

2. Foramen rotundum (round foramen): Located posterior to the medial end of the superior orbital fissure, it runs a horizontal course to an opening on the anterior aspect of the root of the greater wing of the sphenoid into a bony formation between the sphenoid, the maxilla, & the palatine bones, the pterygopalatine fossa.
3. Foramen ovale (oval foramen): A large foramen posterolateral to the foramen rotundum, it opens inferiorly into the infratemporal fossa
4. Foramen spinosum (spinous foramen): Located posterolateral to the foramen ovale, it also opens into the infratemporal fossa in relationship to the spine of the sphenoid.

Question 258

Q. The foramen lacerum is not part of the crescent of foramina. This ragged foramen lies posterolateral to the hypophysial fossa and is an artifact of a dried cranium. In life, it is closed by a cartilage plate. Only some meningeal arterial branches and small veins are transmitted vertically through the cartilage, completely traversing this foramen. The internal carotid artery and its accompanying sympathetic and venous plexuses pass across the superior aspect of the cartilage (i.e., pass over the foramen), and some nerves traverse it horizontally, passing to a foramen in its anterior boundary. Extending posteriorly and laterally from the foramen lacerum is a narrow groove for the greater petrosal nerve on the anterosuperior surface of the petrous part of the temporal bone. There is also a small groove for the lesser petrosal nerve.

Question 259

Q. POSTERIOR CRANIAL FOSSA 1. How does the posterior cranial fossa differ to the other fossa?
2. What does it contain?
3. The posterior cranial fossa is formed mostly by the ?
4. What is posterior to the dorsum sellae ? (Clue: anterior to the foramen magnum)
Broad grooves show the horizontal course of the transverse sinus and the S-shaped sigmoid sinus. At the base of the petrous ridge of the temporal bone is the jugular foramen, which transmits several cranial nerves in addition to the sigmoid sinus that exits the cranium as the internal jugular vein (IJV). Anterosuperior to the jugular foramen is the internal acoustic meatus for the facial and vestibulocochlear nerves (CN VIII) and the labyrinthine artery. The hypoglossal canal for the hypoglossal nerve (CN XII) is superior to the anterolateral margin of the foramen magnum.

Answer 259

A. 1. the largest and deepest

2. cerebellum, pons, and medulla oblongata
3. occipital bone, but the dorsum sellae of the sphenoid marks its anterior boundary centrally and the petrous and mastoid parts of the temporal bones contribute its anterolateral “walls.”
4. clivus, in the centre of the anterior part of the fossa leading to the foramen magnum. Posterior to this large opening, the posterior cranial fossa is partly divided by the internal occipital crest into bilateral large concave impressions, the cerebellar fossae. The internal occipital crest ends in the internal occipital protuberance formed in relationship to the confluence of the sinuses, a merging of dural venous sinuses.

Question 260

Answer 260

Question 261

Q. Also on the diagram above draw the boundaries of the three fossa

Answer 261

Question 262

Describe the likely origin of bleeding in extradural and subdural haemorrhages & relate your understanding of meningeal anatomy to the radiographic appearance of extra- and sub-dural haemorrhages LO

1. Is a EDH arteriole or venous blood?
2. What is the most likely cause of this bleed? I.e. which artery has been ruptured?
3. Which layers is the haemorrhage between?
4. Describe what a EDH haemorrhage looks like on an x-ray
5. Why?

Answer 262

1. Arteriole
2. Pterion trauma and middle meningeal artery
3. periosteal layer of the dura mater and the bone
4. Convex lens
5. Periosteal layer is continuous with the sutures

Question 263

1. Is a subdural haemorrhage venous or arteriole?
2. What veins are rupturing?
3. Cause?
4. How does it looks on a radiograph? And why?
5. If significant force is transmitted to the skull base through the vertebral column, fractures can occur through the ? This is called?
6. What signs would a patient have if they have a basilar skull fracture?
7. Explain why you get all these symptoms

Answer 263

1. Venous
2. Bridging veins
3. Fall of elderly person veins stretched more due to weak CT more likely to rupture
4. Banana shaped, spreads. Prevented by the falx cerebri.
5. cranial floor ( basilar skull fracture)
6. BATTLE’S SIGN – brusing over the mastoid process
   RACCOON EYES- - bring around both eyes
   HAEMOTYMPANUM – blood behind the eardrum
   CSF RHINORRHEA- CSF leak from nose
   CSF OTORRHEA – CSF leak from ear
   ROB the RACCOON
7. BATTLES SIGN - blood from skull fracture seeps into the soft tissue around the eyes, anterior fossa fractures then the periosteal dura ruptures continuous with bone, sinuses bleed into loose connective tissue
   CSF Rhinorrhea - ruptures arachnoid layer
   CSF otorrheao – how doe it end up in the ear??

Question 264

Q. What are theses images showing?

Answer 264

A. Top: Cephalohaematoma (Sub-periosteal) limited by suture lines
Bottom: Subgaleal (Sub-aponeurotic)

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Question 265

Q. Causes of the top picture:
Causes of the bottom picture:

Question 266

Answer 266

Question 267

Q. A 25-year-old falls from a 12 foot wall landing onto his head. He feels a crack then immediate pain in his neck but remains conscious. The ambulance is called and paramedics immobilise him on-scene before transferring his to the nearest Emergency Department. On initial examination his GCS is 15/15 and he is cardiovascularly stable. There is no evidence of neurological deficit on examination, but examination of the C-spine identifies point tenderness on palpating the top of his cervical spine. No other injuries or areas of tenderness are noted on initial examination.
Which cervical vertebrae is most likely to fracture as a result of this mechanism of injury? Describe this fracture.
A.

Answer 267

Question 268

Q. On the following normal lateral and anterior radiographic views of the C-spine label the osteological features visible

Answer 268

Question 269

Answer 269

Question 270

Q. How might an anterior view of C1 and C2 be obtained?

Answer 270

A. •Request an odontoid or peg view (open mouth view)
•This view is taken in the anterior-posterior direction but with the patient opening their mouth
•When cervical spine x-rays are requested three views are usually obtained: lateral, anterio-posterior (AP) and odontoid or peg view

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Question 271

Q. A young mother brings her newborn to the GP concerned that he has ‘holes in his head’. She said that she noticed while washing his hair and running her hand over his scalp that there appear to be two “soft spots” at the front and back of his head. The GP examines the newborn and reassures the mother than these ‘soft spots’ are the baby’s fontanelles.
What are the fontanelles and why is their presence important in the fetal/infant skull.

Answer 271

A. A SPACE BETWEEN BONES OF THE SKULL WHERE OSSIFICATION IS NOT COMPLETE
•The calvaria (of the neurocranium) is formed by the ossification of membranous forms of 7 bones: paired frontal, parietal and temporal bones and a single occipital bones.
•Sutures, which are soft but tough membranous connections, lie in the junctions where there is incomplete fusion of the bones.
•At certain points in the skull, these membranous areas between the bones are particularly large- these are called fontanelles.
•The anterior fontanelle, which is the largest, is found at the junction between parietal and frontal bones, and the posterior fontanelle between the parietal and occipital bones.
•There are actually 6 fontanelles in total in the newborn (but you do not need to know all of these)!

Question 272

Q. What are the fontanelles and why is their presence important in the fetal/infant skull

Answer 272

A. • Given the skull bones are not joined together firmly at birth the sutures & fontanelles allow the skull to change shape or mould thus assisting fetal delivery through the birth canal.
• A degree of movement between the bones of the calvaria is also important after birth to allow growth of the brain and skull during early infant life.
• The fontanelles fuse during early infancy and, as we get older (30- 40 years +), the sutures between the calvarial bones begin to ossify, obliterating from the internal surface outwards.

Question 273

Q. At what age do the anterior and posterior fontanelles fuse?

Answer 273

Question 274

Q. Describe the process that leads to the fusion of the fontanelles (4)

Answer 274

A. • The bones of the calvaria (e.g. frontal, squamous portion of temporal bone, parietal, occipital) grow via intramembranous ossification and eventually close the fontanelles.
• The process of intramembranous ossification involves replacement of connective tissue (mesenchymal stem cells) with bone.
• Cartilage is not present during this process.
• The majority of bones in the rest of the body, including those forming the base of the skull (e.g. sphenoid, ethmoid) grow via endochondral ossification, where bone is replacing an existing cartilaginous model.

Question 275

Q. How might the presence of the fontanelles be helpful when assessing an unwell newborn or infant?​

Answer 275

A. • A sunken fontanelle can give an indication of hydration status (i.e. dehydration).
• A tense/bulging fontanelle can be seen if there is raised intra-cranial pressure; infections such as meningitis can also cause a bulging fontanelle.
• The fontanelles can also provide a “window” for imaging the brain using ultrasound (very safe form of imaging but cannot penetrate bone). Ultrasound cannot be used for evaluating the brain in adults as the fontanelles are absent.
• Note that fontanelles may appear to bulge slightly when a newborn/infant is crying or when lying flat and this is entirely normal. The ‘bulging’ returns to normal when the newborn/infant is calm and in a head-up position.

Question 276

Q. In addition to the presence of the fontanelles, what other features are different in the fetal skull compared with the adult skull.​

Answer 276

A. Fetal skull vs Adult Skull
• Disproportionately large calvaria relative to the face in fetal skull; in adult skull facial skeleton forms 1/3 of cranium whereas infant skull it forms 1/8
• Small, underdeveloped maxilla, mandible and paranasal sinuses (air filled spaces within bones of skull; some of which are actually absent at birth) in fetal skull
• Absence of erupted teeth in fetal skull
• Small nasal cavities in fetal skull
• Absence of mastoid and styloid process in fetal skull

Think of JUGHEADS DAD FB as an alien baby!!