Session 8 The Vertebral Column

Question 0

What are the Gross Functions of the Vertebral Column?

Answer 0

Provides for:
Centre of gravity of the body: weight of the body is projected into lower limbs about a line that passes centrally through the natural curvatures of the vertebral column
Attachments for Bones: both appendicular and axial skeleton. Together with the hip bones, they bear most of the body weight.
Attachments for Trunk muscles: –> upright posture is determined by continuous low level contraction of trunk muscles to support body weight
Protection and Passage of the Spinal Cord:
Segmental Innervation of the body: (allowing segmental nerves to leave or join the cord at specified points along the continuum of the vertebral column to supply their targets).

Question 1

Describe the Vertebral Column

Answer 1

Forms the main central axis of the skeleton and forms the skeleton of the neck.
Around 70-75cm long.
Accounts for 42% of height (average UK height 165-175cm).
Made from a series of small bones joined and close to each other.
Highly flexible.
24 Discrete Vertebrae - all separable and capable of individual movement
9 Fused vertebrae - to give 2 innominate structures (sacrum - fusion of 5 fierce fad, coccyx - fusion of 4 vertebrae)

Question 2

What are the movements of the vertebral column?

Answer 2

Lateral flexion (abduction of the vertebral column)
Rotation
Flexion (I.e. Bowing)
Extension

Question 3

Describe the Vertebral Column in the Foetus

Answer 3

Lies flexed in a single curvature throughout its extent
Curvature faces anteriorly - concave anteriorly (or an anterior flexion)”
Known as the primary curvature
The primary curvature is regained throughout life in the thoracic, sacral and coccygeal parts.

Question 4

Describe the Vertebral Column in the Young Adult

Answer 4

(Viewed from the side): 4 distinct curvatures - approximate S figure.
Sinusoids profile - sinuous bends give the column resilience.
2 anterior flexions (anterior concavities)
2 posterior flex ions (posterior concavities).
Anterior concavities are continuations of the primary curvature of the foetus.
Posterior concavities are secondary curvatures.

Question 5

Describe the development of the Secondary Curvatures

Answer 5

During development from the fetus to young adult, the primary concave curvature is remodelled in parts - the C-shaped column opens up to elongate.
The cervical spine develops the first posterior concavity when a young child begins to lift its head. This becomes the first secondary curvature.
The lumbar spine also opens during crawling until the child begins to stand up and walk. A second posterior concavity then appears and becomes the second secondary curvature.

Question 6

Describe the Vertebral Column in old age

Answer 6

The secondary curvatures start to disappear.
The vertebral column seems to return to its original shape in the foetus - a fully continuous primary curvature is re-established.
The vertebral column closes up again (as if in the foetus)

Question 7

Describe the structure of a typical vertebra

Answer 7

Consists of a vertebral body (anteriorly) and a vertebral arch/neural arch (posteriorly). Between them they enclose the spinal canal/vertebral foramen/neural foramen.

Question 8

Describe the Vertebral Body

Answer 8

Usually the largest part of the vertebra and the main weight-bearing part.
Also the main site of contact between adjacent vertebrae (apart from 2 atypical bones).
Lined with hyaline cartilage.
Linked to adjacent vertebral bodies by way of intervertebral discs.
Size of body of vertebrae increases top-downwards.
Vertebral bodies and intervertebral discs inter-digitate sequentially from C2/C3 - L5/S1 intervertebral joints.

Question 9

Describe the Vertebral/Neural Arch

Answer 9

3 processes emerge from vertebral arch.
Spinous Process (n=1) - midline, posterior
Transverse Process (n=20) - found laterally, 1 on each side of midline.
The pedicle is the part of the neural arch between the vertebral body and the transverse process.
The lamina is the part of the neural arch between the transverse process and the spinous process.

Question 10

Describe the articular processes of the neural arch

Answer 10

At the junction of the lamina and the pedicle are articular facets,
1 above and 1 below on each side. (N=2)
They are found on both sides (total n=4)
They are hyaline cartilage-lined
Allow for synovial joints to be formed between neural arches of adjacent vertebrae.
They are strengthened by ligamentum flavour.
The joints formed between adjacent neural arches are synovial and prevente anterior displacement of the vertebrae. They allow for limited movements and can bear weight when uprighting.

Question 11

Describe the elaborations of the Vertebral/Neural Arch

Answer 11

Each pedicle has 2 notches that reduce its height called vertebral notches. (Superior and inferior).
Superior and inferior vertebral notches on each side of adjacent vertebrae form an intervertebral foramen which segmental nerves pass from cord to periphery through. The dorsal root ganglia is found here.

Question 12

Describe the Intervertebral Discs

Answer 12

Forms the joint between vertebral Jodie’s.
Secondary cartilaginous joints hence known as symphoses.
Presence is responsible for the flexibility of the vertebral column.
Acts as a shock absorber, dampening impact shocks to the skull.
Not all the same size - increase in size from superior to inferior.
Wedge-shaped in lumbar and thoracic levels; thickest anteriorly and thinnest posteriorly in the lumbar and thoracic levels.
Wedge-shaped of the IVD accounts for secondary curvature of the spine.
High water content that keeps it turgid and forms its bulk. May shrink in size with age. This shrinkage may account for reduction in height with age (accept with caution).
Consists of 2 regions - a central region and a peripheral region.
The discs permit tilting movements between adjacent vertebrae.

Question 13

Describe the Peripheral Region of the Intervertebral Disc

Answer 13

The annulus fibrosis has a highly complex design, made from a series of annular bands with varying orientations.
Outer bands are collagenous and inner bands are fibro-cartilaginous,
Very resilient and stronger than the vertebral body.
It is the real shock absorber.
It is attached to the cartilaginous plates covering the bodies of the vertebrae.

Question 14

Describe the Central Region of the Intervertebral Disc

Answer 14

The nucleus pulposus is jelly-like, mucoid and has high osmotic pressure - acts as a water reservoir for the disc.
Changes in size and thickness throughout the day depending on water distribution within the disc. Also changes in size with age and is surrounded entirely by annulus fibrosus.
Centrally located in the infant but can be found posteriorly in the adult.

Question 15

Describe the Degeneragion of Nucleus Pulposus

Answer 15

It can dehydrate with age - height of the IV dis then decreases.
When this happens, load stresses on the IV disc alter, leading to reactive marginal osteophytosis (outgrowth of bone tissue) adjacent to the affected end plates.
As the disc space decreases in height, increased stress is also placed on the facet joints. This can lead to osteoarthritis on the facet joints - can lead to osteoarthritis of the facets at the same level.
Decreasing disc height can also lead to congestion in the intervertebral foramen and compression of segmental nerves.

Question 16

Describe Degenerative Annular Disease

Answer 16

Degeneration of the annulus fibrosus leads to marginal osteophytosis at the endplates.
Progressive Degeneragion of the annulus leads to increasing osteophytosis at tithe disc space margins - then height of disc space is largely preserved,
Usually seen in thoracolumbar spine of persons over 50 years of age.
In literature, this entity had been termed “spondylosis deformans” or “senile ankylosis” with increasing age.

Question 17

Does degenerative disc disease actually refer to?

Answer 17

Umbrella term is often used to refer to degeneration of one or both components of the discs - in practice, degeneration annulus and the nucleus pulposus occur concurrently. It usually doesn’t make a lot of difference to the referring clinician which component of the disc has degenerated.

Question 18

What is a Herniated Intervertebral Disc?

Answer 18

The nucleus pulposus can herniate through annulus fibrosus if there is degeneration. Occurs most commonly posterolaterally.
Results in compression of spinal segmental nerves (pain).
Posterior herniation may compress the spinal cord (leading to complete paralysis).

Question 19

What are the two major ligaments which run along the longitudinal axis of the vertebral column?

Answer 19

All vertebra and intervertebral discs are strapped together by two major ligaments which run along the longitudinal axis of the vertebral column.
One occurs anteriorly to the vertebral column and is known as the Anterior Longitudinal Ligament.
The other occurs posteriorly and is known as the Posterior Longitudinal Ligament.
NB: there are other additional ligaments that support the integrity of the vertebral column but these will be considered in detail only in Phase II.

Question 20

Describe the Anterior Longitudinal Ligament

Answer 20

Much stronger than Posterior equivalent,
Prevents excessive extension of the vertebral column. (Excessive flexion is prevented by all of the other ligaments).
Flat band that broadens as it passes downward.
Extends from anterior tubercle of the atlas to the front of the upper part of the sacrum, firmly united to the periosteum of the vertebral bodies. It is free over the intervertebral discs.

Question 21

Describe the Posterior Longitudinal Ligament

Answer 21

Extends from the back of the vertebral body of the axis to the canal of the sacrum,
It is continued above the body of the axis as the membrane tectoria.
Gradually narrows as it passes downwards.
It has serrated margins.
The serrations are broader over the intervertebral discs to which they are firmly unitedl
The ligament narrows over vertebral bodies. The ligament is separated from the vertebral bodies by the emerging basivertebral veins.

Question 22

What is the Ligamentum Flava of the Vertebral Ligament?

Answer 22

Yellow in colour due to high content of elastic fibres.
They join laminae of adjacent vertebrae and are attached to the front of the upper lamina and to the back of the lower lamina.
They are stretched by flexion of the spine (leaning forwards).

Question 23

What is the Supraspinous Ligament?

Answer 23

Joins the tips of adjacent spinous processes.
They are string bands of white fibrous tissue.
They are lax in the extended spine.
Full flexion effectively prevents erector spinal muscles from extending the spine so during flexion of the vertebral column, the Supraspinous ligament is drawn taut to mechanically support the vertebral column.

Question 24

What is the Interspinous Ligament?

Answer 24

Relatively weak sheets of fibrous tissue.
They unite spinous processes along their adjacent borders.
They are well-developed only in the lumbar region.
They fuse with Supraspinous ligaments.

Question 25

What is the Ligament Nuchae/Nuchal Ligament?

Answer 25

Highly elastic
Proximal attachment - occipital protuberance at the back of skull
Distal attachment: thoracic spinal ligaments - Interspinous and Supraspinous.
Intermediate attachments - spinal processes of all cervical vertebrae.
Functions: maintains the secondary curvature of the cervical spine, helps the cervical spine support the head, acts as as a major site of attachment of head and trunk muscles e.g. Trapezius

Question 26

What are the distinguishing, morphological features of Cervical Vertebrae?

Answer 26

Smallest of the discrete vertebrae
Bifid spinous process.
Oval transverse foramen in the transverse process.
Vertebral artery passes through all the cervical foramen apart for C7.
The smaller accessory vertebral veins go through the C7 foramen.
Large vertebral (or neural) foramen.
Broken neck may be sub-clinical (asymptomatic?) because of the large vertebral foramen.

Question 27

What are the distinguishing, morphological features of Thoracic Vertebrae?

Answer 27

Intermediate in size, increasing in size from above to downwards.
Facets on the sides of the body - Demi-facets for articulating with hrsc ov fun.
Facets (articular processes) on the transverse processes (except T11 and T12) - Coastal facets for articulations with tubercle of rib.
Vertebral foramen is small and circular.
No transverse foramen.

Question 28

What are the distinguishing, morphological features of Lumbar Vertebrae?

Answer 28

Large bodies
Their articular processes are approximate to the Sagittal plane and hence permit a large degree of flexion and extension but little rotation.
Largest of the discrete vertebrae.
Lack of foramina on the transverse processes.
Lack coastal facets on the side of the body.
Vertebral foramina are triangular and small.

Question 29

Describe the Atlas Vertebrae

Answer 29

Articulates with the skull above (Atlanto-occipital joint) - permits flexion and extension of the head.
Articulates with axis below (Atlanto-axial joint) - permits rotation of the head by allowing rotation between the atlas and axis.
Lacks a distinct body - body is fused sigh that of the axis to form the Dens or Odontoid process.
Lacks a spinous process
Widest cervical vertebra.

Question 30

Describe the Axis Vertebrae

Answer 30

C2; Strongest cervical vertebral. 
Characterised by three main features:
The Odontoid Process/Dens
Rugged lateral mass
Large spinous process
Dens prevents horizontal displacement of axis
It is fractured and dislocated in hanging to give hangman's fracture.
Allows pivotal movement.

Question 31

What injuries are the cervical spine and lumbar spine susceptible to?

Answer 31

Cervical spine:
Whiplash injuries in RTA
Sports injuries - rugby scrum, rugby high tackles, American football (blocking hits)

Lumbar spine:
Susceptible to herniation of L4/L5 or L5/S1 intervertebral discs.

Question 32

Give some natural problems of the IVD

Answer 32

Degenerated disc (+/- osteophyte formation)
Bulging disc
Herniated disc
Thinning disc

Question 33

Describe Prolapsed ‘Slipped’ Discs

Answer 33

Under normal conditions, the tension within the disc is maintained by IMBIBITION (displacement of fluid by another immiscible fluid) at a cellular level (absorption of fluid into the cellular matrix during spinal movement).
If this mechanism fails then tension within the disc falls and the annulus fibrosus is subjected to increased strength. With increasing degeneration of the annulus fibrosus, the disc softens permitting herniation. The prolapsed material usually protrudes posterolaterally and causes pressure on the associated spinal nerve. Intervertebral discs account for about 20% of the length of the vertebral column.
Failure of imbibition after middle age can therefore lead to significant loss of height.

Question 34

Describe how joins of the vertebral column are subjective to arthritic change

Answer 34

RA particularly affects the Atlanto-axial joint because of the complex arrangement of the synovium around the transverse ligament of this joint.
Stretching of the transverse ligament permits the head and atlas to slip forwards leading to the Odontoid process compressing the cervical cord.

Question 35

What is Kyphosis?

Answer 35

Excessive thoracic kyphosis, known colloquially as hunchback, is characterised by an abnormal increase in the thoracic curvature - the vertebral column curves posteriorly.

Question 36

What could Kyphosis be due to?

Answer 36

This abnormality can arise from erosion due to osteoporosis of the anterior part of one or more vertebrae e.g. Osteoporosis.
Osteoporosis especially affects the horizontal trabecular of the trabecular bone of the vertebral body. The remaining unsupported vertical trabecular are less able to resist compression and sustain compression fractures. Progressive erosion and collapse of vertebrae also result in an overall loss of height.
The excessive kyphosis leads to an increase in the AP diameter of the thorax and significant reduction in dynamic pulmonary capacity.

Question 37

What is Lordosis?

Answer 37

Excessive lumbar lordosis is known as hollow back, characterised by an anterior tilting of the pelvis (the upper sacrum is flexed or rotated antero-inferiorly) with increased extension of the lumbar vertebrae, producing an abnormal increase in the lumbar kyphosis.
This abnormal extension deformity is often associated with widened trunk musculature especially the anterolateral abdominal muscles.

Question 38

What could cause Lordosis?

Answer 38

To compensate for alterations to their abnormal line of gravity, women develop a temporary excessive lumbar lordosis during late pregnancy.
This lordotic curvature may cause lower back pain but the discomfort normally disappears soon after childbirth.
Obesity in both sexes can also cause lumbar lordosis and lower back pain because of the increased weight of the abdominal contents anterior to the normal line of gravity.
Loss of weight and exercise of the anterolateral abdominal muscles facilitate correction of this type of excessive lordosis.

Question 39

What is Scoliosis?

Answer 39

Characterised by an abnormal lateral curvature that is accompanied by rotation of the vertebrae.
The spinous processes turn toward the cavity of the abdominal curvature and when the individual bends over, the ribs rotate posteriorly (protrude) on the side of the increased convex its.
Approximately 80% of all structural scoliosis is idiopathic occurring without other associated health conditions or an identifiable cause.
Idiopathic scoliosis first develops in girls between the ages of 10 and 14 and in boys between the ages of 12 and15.
It is most common and severe among females.

Question 40

Why so herniations of the nucleus pulposus usually extend posterolaterally?

Answer 40

This is where the annulus fibrosus is relatively thin and does not receive support from either the posterior or anterior longitudinal ligaments.
The localised back pain of a herniated disc - usually acute - results from pressure on the longitudinal ligaments and periphery of the annulus fibrosus and from local inflammation caused by chemical irritation by substances from the ruptured nucleus pulposus.
Chronic pain resulting from compression of the spinal nerve roots by the herniated disc is usually referred pain, perceiving as coming from the area (dermatome) supplied by that nerve. Because IV discs are largest in the lumbar and lumbo-sacral regions where movements are consequently greater, posterolateral herniations of the nucleus pulposus are most common here.