Spine Flashcards
Sections of the Spine ?
Cervical - C1 - C7
Thoracic - 12 bones
Lumbar - 5 - L1 - L5
Sacrum - 5 ( fused )
Coccyx - 4 (fused)
Structure of spine a vertebrae ?
2 major parts : Vertebral body and arch.
- Vertebral body - anterior part
* the weight bearing part. Vertebral bodies get larger as you go down the spine.
Adjacent bodies separated by fibrocartilaginous intervertebral disc.
- Vertebral arch - posterior aspect.
Has bony prominences - attachment for muscles/ ligaments
The vertebral body + arch - leaves a hole in the middle - forearm -
* When all the bodies and arches line up form the vertebral canal - encloses the spinal cord.
Structure of the vertebrae - different sections of the spine ?
Cervical - C1 - C7
3 FEATURES :
0 Bifid Spinous process
0 Transverse foramina
0 Triangular foramen.
(C1 - no spinous process
C7 - spinous process - may not bifurcate . )
Thoracic -
have 2 demi facets and costal facet.
Circular vertebral foramen.
Lumbar-
Kidney shaped
Vertebral bodies - very large.
Triangular foramen.
- size and orientation allow for needle access not possible in other section e.g. lumbar puncture , epidural anaesthesia administration.
Coccyx - has no veterbral arches thus no vertebral canal.
congenital abnormalities
sacralisation
lumbarisation
Abnormal morpholgy of the spine
Kyphosis - excessive thoracic curvature- hunchback defomity
lordosis - excessive lumbar curvature - sawyback deformity
scolosis - lateral curvature of spine
cervical spondylosis.- decreased size of IV foramen- narrows IV foramina - put pressure on nerves passing through
What is three column concept .
A way of describing & diagnosing spinal fractures.
0 Anterior column
- Anterior
Longitudinal
ligament
- Anterior
disc
- Anterior
half of
vertebral
body.
0 Middle column
- same as anterior just replace anterior with posterior.
0 Posterior column
- Spinous P
- Pedicels
- Lamina
- Ligamentum Flavum
- Interspinous & Supraspinous L
- Superior and inferior articulating P.
IMPORTANT - Fracture is unstable if it affect 2 adjacent columns e.g anterior & middle or middle & posterior. Also, if all three are.
Considered stable - if one affected.
exception - Bilateral pedicle fracture - Happens in posterior column, however effects the other columns (pedicles - connect
STABLE - do not cause spinal deformity or nerve problems . Can still distribute weight well.
UNSTABLE - opposite of stable.
What is a burst fracture ?
Burst fracture - Axial loading injury - disc above is pushed into the IV disc pushed into veterbral body below.
( discs crushed / compressed against each other due to pressure - causing spreading fractures )
Vertebrae break in multiple direction and can cause damage to spinal cord.
(greater the force applied , the more fragaments may be forced into spinal canal and damage the spinal cord - nerve damage - possible paralysis depending on severity
- occur usually from severe trauma - motorcycle accident , fall from height.
Typically - in the back - will complain of severe back pain - if had accident lie patient flat don’t sit them up of flex back - worsen neurological injury. Also complain of Lower limb neurological deficits
Patient may not be also wot walk after injury - if they can should still avoid to avoid further injury.
Summary - clincal presentation when trauma involved
- severe back pain
- lower limb deficits.
Types of Spinal Fractures ?
0 Burst Fracture
0 Veterbral compression fracture
0 Fracture - dislocation
management of Burst fracture ?
CT scan - evaluate extent of retro pulsed fragments - ( retro pulsed fragments
vertebral fragment which has been displaced into spinal canal - potential spinal cord injury.)
Radiological investigation - may see :
0 loss of veterbral height from lateral view - anterior portion of veterbral body compressed more than posterior.
What is a Fracture- dislocation fracture ?
Involves displacement - Vetebrae moves off adjacent veterbrae. ——> often cause serious spinal cord compression.
Occur secondary to high energy trauma ( e.g motorcycle accident.
Unstable and high risk of spinal cord injury.
- complete fracture - dislocation often result in severe neurological injury causing lower extremity weakness & decreased sensation.
- seems to usually occur in Thoracolumbar spine and usually involve all 3 columns - unstable.
What the 3 Spinal fracture patterns ?
0 Flexion fracture pattern :
Compression fractures - compression causes breaking of veterbrae bone ( osteoporosis & trauma)
Axial burst fractures - high eneegy trauma - parts of vetebrae shatter - more severe than compression farctures - can cause long term neurological damage.
0 Externsion FP - veterbrae pulled apart (e.g seat belt injury - in a head on car accdient the seat belt keeps lower body in place while upper body thrust forward. )
0 Rotation
- e.g Transverse frcature - cause by extreme rotation or sideways bending.
- fracture - disloaction - vetebrae displaced - compressing spinal cord.
What is veterbral compression fracture ?
Vetebral body ins spine collaspses causing loss of height , deformity and severe pain.
CAUSES -
- Osteoporosis
Most common fracture in patients with osteoporosis - caused by falling down or trauma.
- if severe osteoporosis - fracture can be ccaused by simple daily task (e.g sneezing forcelly , liftinh heavy object - no traumatic accident)
- also effect postmenapausal women.
- People with Osteporotic VCF more likely to get a second.
- Cancer -
metastic cancers/ tumours - cancer spreads to bone and causes destruction of veterbrae. - weakening bone. - Severe trauma - healthy spine - car accidents etc.
Symptoms of VCF ?
0 Sudden onset of back pain
0 An increase of pain intensity while standing or walking
0 A decrease in pain intensity while lying on the back
0 Limited spinal mobility
0 Eventual height loss
0 Eventual deformity and disability
- Acute VCF - pain is usually well localised to midline
- Chronic VCF - progressive loss of height
- numerous VCF - causes curvature of spine (Hyperkyposis)
What is veterbral compression fracture ?
Vetebral body in spine collaspses causing loss of height , deformity and severe pain.
CAUSES -
- Osteoporosis
Most common fracture in patients with osteoporosis - caused by falling down or trauma.
- if severe osteoporosis - fracture can be ccaused by simple daily task (e.g sneezing forcelly , lifting heavy object - no traumatic accident)
- also effect postmenapausal women.
- People with Osteporotic VCF more likely to geta second.
- Cancer -
metastic cancers/ tumours - cancer spreads to bone and causes destruction of veterbrae. - weakening bone. - Severe trauma - healthy spine - car accidentss etc.
Treatment of VCF ?
Analgesics - pain relief
Physical therpay - early mobilisation - to prevent further bone loss and disability.
( may be delayed if pain not controlled )
if Osteoporosis present - treat e.g biphosphonate.
Bracing
Diagnosis -
X - ray - if osteoporotic fractures
0 Loss of vertebral height (particularly >
6 cm or more than half the height of
the vertebral body)
0 Decreased radiodensity
Loss of trabecular structure
0 Anterior wedging
What is Spondylolisthesis ?
Spondyl - condition of Vetebrae
Listhesis - slipping
Condtion - one vetebrae slides forward over the veterbrae below it.
4 grades
- Grade 1 - 0 -25 % sublaxation -
- Grdae 2 - 25 -50 % sublaxation )
- Grade 3 - 50 - 75 % sublaxation )
- Grade 4 - 75 - 100 % (sublaxation )
*Sublaxation - partial dislocation
What is Spondylolisthesis ?
CAUSES - TYPES
GRADES
Spondyl - condition of Vetebrae
Listhesis - slipping
Condtion - one vetebrae slides forward over the veterbrae below it.
4 grades
- Grade 1 - 0 -25 % sublaxation - spillage
- Grade 2 - 25 -50 % sublaxation )
- Grade 3 - 50 - 75 % sublaxation )
- Grade 4 - 75 - 100 % (sublaxation )
*Sublaxation - incomplete / partial dislocation
sub - below
laxation - to dislocate
- common in lumbar spine
CAUSES
0 Type 1 - congenital: caused by agenesis (failure / lack of development ) of superior articular facet.
0 Type 2 - isthmic: caused by a defect in the pars interarticularis( part of vetebrae inbetween inferior and superior artcular process )- causes (spondylolysis)
0 Type 3 - degenerative: caused by articular degeneration( degeneration of articular cartlage ) as occurs in conjunction with osteoarthritis.
0 Type 4 - traumatic: caused by fracture, dislocation, or other injury
0 Type 5 - pathologic: caused by infection, cancer, or other bony abnormalities
- TYPE 1 AND 2 most common
Treatment of Spondylolisthesis ?
Physical therapy
Lumbar stabilisation.
plain x ray.
What is Whiplash ?
Head forcibly hyperextended - occurs car collsion -head rest poorly positioned.
Usually effects soft tissue - soft tissue injury.
Severe whiplash can cause fractures.
Hyperextended - anterior longitudinal ligament
( head is moved backwards - angle btween chest and head increases - neck extended )
( if head was hyperflexed - nuchal ligament - extends from external occipital protubernace to spinous P of C7, - Supraspinous ligament takes over - nuchal and supraspinous L are continous )
most likely damaged )
( head moves forward - angle btw head and chest decrease - length of neck decreases.
What is Spinal herniation ?
What is it ? , causes ? , Stages - brief ?
Nucleus Pulpsus herniates through weakness/ tear in Annulus Fibrosus. NP displaced posterolaterally /posteriorly into extradural space.
0 Nucleus Pulposus ( NP) - inner core of the veterbral disc.
0 Annulus Fibrosus surrounds - tough exterior of the inveterbral disc - surrounds NP
0 Endplate - the interface btw the IV disc & veterbrae.
CAUSES
0 violent Hyperflexion + Annulus Fibrosus degeneration - disc rupture -
disc compressed anteriorly , posterior section of disc is stretched , NP squeezed posteriorly towards thin part of Annulus Fibrosus.( herniation will occur if if AF degenerated )
4 stages 0 Degenerating disc 0 Protrusion 0 Extrusion 0 Sequestration.
Stages of Herniation - spine ?
0 Disc degeneration - AF damaged / weak / torn due injury - NP unable to retain as much fluid so decreased thickness of disc.
0 Protrusion - Nuclues Pulposus impinges ( encoarches/ obtrude into ) Annular Fibrosus - Posterior Longitundinal ligament remains intact.
0 Extrusion - NP emerges through AF. PLL intact. ( still within disc )
0 Sequestration - PLL is disrupted + portion of NP protuded into epidural space.
- (Epidural speace - btw dura matter and veterbral wall )
Consquences of Spinal herniation ?
symptoms depend on dermatome effected
Most herniation happen in lumbar region - as age herniation can occur at higher levels - as degradation occurs
0 Compression of nerve in the interveterbral foramen.
0 Radiculopathy - compression of nerve route causes pain + weakness of muscles in the myotome it supplies.
SYMPTOMS - pain ,weakness ,
numbness & tingling ( Paraesthesia -
pins and needles ) , anaesthesia -
loss of sensation .
0 Referred pain - pain felt in the dermatome which is supplied by the compressed nerve route.
0 Localised acute pain where disc is herniated - pain caused by pressure on ligaments & AF & inflammation ( due to ruptured NP causing chemical irritation)
What are myotomes ?
important ones ?
Myotome - group of muscles innervated by a single nerve route
C4: shoulder shrugs C5: shoulder abduction and external rotation; elbow flexion C6: wrist extension C7: elbow extension and wrist flexion C8: thumb extension and finger flexion T1: finger abduction L2: hip flexion L3: knee extension L4: ankle dorsiflexion L5: big toe extension S1: ankle plantarflexion S4: bladder and rectum motor supply
What is Sciatica ?
Sciatica - Pain down the sciatic nerve
can be refererred to Lumbar radiculpathy - nerve root compression causing pain , tingling & numbness , irritation in lumbarsacral spine,
SYMPTOMS
Extend from buttocks —-> back of thigh ——-> outer calf ——-> sometimes to foot and toes.
( sciatic nerve - L4 -S3 - innervates muscles of posterior thigh , hamstring portion , indirectly innervates all muscles of leg and foot )
CAUSES
0 Herniated IV disc - 90 % of time
0 spondylolithesis
0 spinal stenosis
Treatment
0 Urgent referral symtoms
- signs of Cauda equina syndrome
- Spinal fracture
- cancer
- signs of infection
offer analegesia - manage low back pain
Group excercise , physiotherapy
- stop opiods , gabapentinoids , benxodiazepines , corticosteriods , antiepileptics .
What is lumbar puncture ?
Lumbar puncture / spinal tap
Aim - sample CSF in subarachnoid space ( between arachnoid and pia mater )
Thin needle - inserted either btw L3 -L4 or L4 - L5
BELOW L2 - TO AVOID PUNCTURING SPINAL CORD
Contraindication of Lumbar puncture ?
0 Raised Intercranial pressure
- reduced or flucuating GCS - below 9 or drop of more three three
- uequal , dilated , or poorly responsive pupils
- papilloedema
- relative bradycardia and hypertension
- focal neurological signs
- abnormal posture or posturing
etc.
Shock
0 Convulsions - need to stabilise
0 coagulation abnormalities
- Blood outside normal
- on
anticoagulant therapy
- platelet count below 100×109/litre
0 superficial infection at the lumbar puncture site
0 respiratory insufficiency (high risk of precipitating respiratory failure in the presence of respiratory insufficiency)
0extensive / spreading Pupura - blood spots /skin haemorrages - reddish- purple coloured
(blood vessels burst & pooled under skin ) - a sign of blood clotting disorder but can be benign.
Indications of Lumbar puncture ?
Diagnostic & therapetic
0 Cerebrospinal fluid analysis (i.e. meningitis,
- suspicion of Meningitis
0 multiple sclerosis,
0 subarachnoid haemorrhage)
0 Spinal epidural (i.e. during labour)
0 Spinal medications (i.e. analgesia, chemotherapy, antibiotics)
0 Fluid removal (i.e. to reduce intracranial pressure)
Leg pain
nerve or blood vessel pain
when you bend forwards - makes it work , more relief when you bend spine
vessel pain - ischemic -worse with physical activity/ n excretion - oxygen demand increased.
What is ankylosing spondylitis ?- adults
Character
Risk factors
Diagnosis
Ankylosing spondylitis - form of ongoing joint inflammation (chronic inflammatory arthritis) that primarily affects thespine.
CHARACTER
Primarily affects sacroiliac joints and axial spine.
- back pain and stiffness .
- Vertabrae fusion over time, back movement gradually becomes limited.
- progressive bony fusion is called ankylosis.
-inflammatory back pain (Inflammatory back pain is the hallmark clinical feature. This is defined as back pain that is of insidious (gradual & cumulative) onset, is worse in the morning, and improves with exercise.)
iritis/uveitis - extra- articular inflammation can cause this
RISK FACTORS
enthesitis (Inflammation of joint)
presentation in late teens and early 20s
DIAGNOSIS
O pelvic x ray ( includes lower spine) - Sacrolitis present - bamboo spine (fusion)
Possible ones - spine x tay Cervical Lumbar Thoracic
-MRI
HLA-B27 is present in about 90% of patients who have AS.[32
male sex
positive family history of AS
Treatmemt of ankylosing spondylitis?
ADULTS - PAIN OR STIFFNESS
1ST LINE
NSAIDS + non pharmacological intervention ( supervisee physiotherapy)
Adjunct - analgesics ( 1st - para , 2nd codeine)
If peripheral joint involved( joint other than spine )
PLUS - methotrexate or sulfasalazine
If local intra articular involvement
PLUS - intra- articular corticosteroids.
ADULT - Without pain and/or stiffness
Patients with a diagnosis of AS but without spinal pain and/or stiffness should be reviewed to confirm a definite diagnosis of AS.
REFACTORY TO 2 NSAIDS
1ST LINE
Tumour necrosis factor alpha inhibitor + physiotherapy
-etanercept
OR
infliximab
Golimumab
Cetrolizumab
OR
adalimumab
2ND LINE
0 another TNF alpha inhibitor + physiotherapy or interleukin 17 inhibitor e.g.
secukinumab
ixekizumab
All lines of treatment NSAIDS use should be continued .
What is ankylosing spondylitis ? - child
Oligoathritis (1-5 joints)
1st line
0 NSAIDS + Non pharmacological intervention
Plus- intra articular corticosteroids
Polyathritis (more than 5)
0 Sulfasalazine + non pharmacological intervention
Enthesitis and/or peripheral athritis.
0 Tumour necrosis factor alpha inhibitor + non pharmacological intervention
-etanercept
OR
infliximab
OR
adalimumab
