Spine (Neck and Back) Flashcards
How many vertebra?
Describe
7 C 12 T 5 L 5 S (fused) 4 Coccygeal (fused)
3 column theory (Denis):
○Anterior: ALL & anterior ⅔ of vertebral body/annulus
○Middle: PLL & posterior ⅓ of vertebral body/annulus
○Posterior: Pedicles, lamina, spinous process, and ligaments
describe normal spinal curves
•Spinal curves: normal curves ○Cervical lordosis ○Thoracic kyphosis ○Lumbar lordosis ○Sacral kyphosis
describe the spinal region:
cervical:
C1-C2: unique bones allow stabilization of occiput to spine and rotation of head. Motion: rotation and flexion/extension.
describe the spinal region:
thoracic
Relatively stiff due to costal articulations. Motion: rotation. Minimal flexion/extension.
Describe the spinal region:
thoracolumbar
Facet orientation transitions from semicoronal to sagittal. Segments are mobile. Most commonsiteof lower spine injuries.
describe the lumbar spinal region
Largest vertebrae. Common site for pain. Houses cauda equina. Motion: flexion/extension. Minimal rotation.
describe the sacral spinal region
no motion. center of pelvis
Which part of vertibrae?
Has articular cartilage on both superior & inferior surfaces. Articulates with intervertebral discs & gets larger distally.
body (centrum)
which part of vertibrae?
Made up of pedicles and lamina. Develops from 2 ossifications centers that fuse. Failure to fuse occurs in spina bifida. It forms the vertebral canal for the spinal cord.
arch
which part of vertebrae?
Spinous: ligament attachment site.
Transverse: rib (T-spine) and ligament attachment site.
processes
which part of vertebrae?
Vertebral: spinal cord/cauda equina.
Neural: nerve roots exit via here
foramina
Name the four muscles of the suboccipital triangle
- Rectus capitis posterior major
- Rectus capitis posterior minor
- Obliquus capitis superior
- Obliquus capitis inferior
OINA
Anterior scalene
O: C3-6 TP
I: 1st rib
N C5-C8 nerve roots
A: Laterally flexes neck and elevates 1st rib
MIddle scalene OINA
O: C2-7 TP
I: 1st rib
N: C5-8 nerve roots
A: Laterally flexes neck and elevates 1st rib
Posterior scalene OINA
O: C4-6 TP
I 2nd rib
N: C5-8 nerve roots
A: laterally flexes neck and elevates 2nd rib
Rectus capitus posterior major
OINA
part of suboccipital triangle
O: spine of axis
I inferior nuchal line
N: Suboccipital nerve
A: extend, rotate, lateral flex head
Rectus capitis posterior minor
OINA
part of suboccipital triangle O: posterior tubercle of atlas I Occipital bone N: suboccipital nerve A: extend, laterally flex
Obliquus capitis superior
OINA
part of suboccipital triangle O: Atlas transverse process I: occipital bone N: suboccipital nerve A: extend rotate, lateral flex
Obliquus capitis inferior
OINA
part of suboccipital triangle O: spine of axis I: atlas transverse process N: suboccipital nerve A extend, laterally rotate
Name the 7 superficial (extrinsic) spinal muscles
Trapezius Latissimus dorsi Levator scapulae Rhomboid minor Rhomboid major Serratus posterior superior Serratus posterior inferior
Trapezius
group?
OINA?
Superficial (extrinsic) O: Spinous process C7-T12 I: clavicle; scapula (spine, acromion) N: Thoacodorsal A: rotate scapula
Latissimus dorsi
group?
OINA?
superficial (extrinsic) O: Spinous process T6-S5 I: humerus N: Thoracodorsal A: Extend, adduct, IR arm
Levator scapulae
group?
OINA
superficial (extrinsic) O: TP C1-4 I scapula (medial) N: Dorsal scapular n, C3, C4 (dorsal rami) A: elevate scapula
Rhomboid minor
group
OINA
superficial (extrinsic) O: SP C7-T1 I: Scapula (spine) N: Dorsal Scapular N A: adduct scapula
Rhomboid major
group:
OINA:
superficial (extrinsic) O: SP T2-5 I: Scapula (medial border) N: Dorsal scapular n A: adduct scapula
Serratus posterior superior
group
OINA
superficial (extrinsic) O: SP C7-T3 I: Ribs 2-5 (upper border) N: Intercostal N (T1-4) A: Elevate ribs
Serratus posterior inferior
group:
OINA
superficial (extrinsic) O: SP T11-L3 I: Ribs 9-12 (lower border) N: intercostal n (T9-12) A: depress ribs.
Name the 3 deep (intrinsic) layers of the back
Superficial layer: (spinotransverse group) Intermediate layer (sacrospinalis group (erector spinae) Deep layer (thransversospinalis group)
Semispinalis capitis
group:
OINA:
Group: deep layers - transversospinalis group O: TP T1-6 I: Nuchal ridge N: Dorsal primary rami A: extends head
Semispinalis (C&T)
group:
OINA:
Deep layer (transversospinalis group) O: TP I: Spinous process N: Dorsal primary rami A: Extend, rotate to opposite side
Multifidus (C2-S4)
group:
OINA:
deep layers: transversospinalis group O: TP I: Spinous process N: dorsal primary rami A: flex laterally, rotate opposite
Rotatores
group:
OINA:
deep layers: transversospinalis O: TP I: SP + 1 N: dorsal primary rami A: rotate superior vertebrae opposite
Levator costarum
group:
OINA:
deep (intrinsic) deep layers: transversospinalis O: TP I: Brevis: rib - 1; longus rib - 2 N: Dorsal primary rami A: elevate rib during inspiration
Interspinales
Group:
OINA:
deep (intrinsic) deep layers: transversospinalis O: SP I: SP + 1 N: Dorsal primary rami A: extend column
Intertransversari
Group:
OINA:
deep (intrinsic) deep layers - transversospinalis O: TP I: TP+1 N: Dorsal primary rami A: Laterally flex column
Splenius capitis, splenius cervicis
group?
OINA:
deep (intrinsic)
Superficial layer - spinotransverse group
(thoracis, cervicis, and capitus)
O: Ligamentum nuchae; spinous process T1-6
I: Mastoid & nuchal line; TP C1-4
N: dorsal rami of inferior cervical nerves
A: both: laterally flex and rotate neck to same side.
Iliocostalis, longissiumus
group:
OINA:
deep (intrinsic)
intermediate layer - sacrospinalis group (erector spinae)
(thoracis, cervicis, capitus)
O: Common origin: sacrum, iliac crest, and lumbar spinous process
I: Ribs; T&C spinous process, mastoid process
N: Dorsal rami of spinal nerves
A: Laterally flex, extend, and rotate head (to same side) and vertebral column
Spinalis
group:
OINA
deep (intrinsic)
intermediate layer - sacrospinalis group (erector spinae)
(thoracis, cervicis, capitus)
O: sacrum, iliac crest, and lumbar process
I: T spine - spinous process
N: dorsal rami of spinal nerves
A: laterally flex, extend, and rotate head (to same side) and vertebral column)
Back pain per age likely etiology: Young: Middle Age: Elderly:
Young: disc injuries, spondylolisthesis
Middle age: Sprain/strain, nucleus pulposis/disc (HNP), degenerative disc disease (DDD)
Elderly: spinal stenosis, herniated disc, DDD, spondylosis
Character of pain
What etiology?
1. Radiating (shooting)
2. Diffuse, dull, non radiating
- Radiculopathy (herniated nucleus pulposis HNP)
2. Cervical or lumbar strain
Location of pain:
Etiology:
- Unilateral vs bilateral
- Neck
- Arms (+/- radiating)
- Lower back
- Legs (+/- radiating)
- Unilateral - herniated nucleus pulposis;
Bilateral: systemic or metabolic disease, space-occupying lesion - cervical spondylosis (+/- myelopathy), neck sprain or muscle strain
- cervical spondylosis, (+/- myelopathy), HNP
- DDD, back sprain/muscle strain, spondylolisthesis
- Herniated nucleus pulposis, spinal stenosis
Occurrence of pain:
Night pain:
With Activity:
infection or tumor
usually mechanical etiology
Alleviation of pain (name etiology)
- with arms elevated:
- sit down
- herniated cervical disc (HNP)
2. spinal stenosis (stenosis relieved)
Exacerbation of pain (name etiology)
1. back extension
- spinal stenosis (going down stairs), DJD/facet hypertrophy
Trauma (name etiology of back pain)
MVA seatbelt:
cervical strain (whiplash), cervical fractures, ligamentous injury
Activity that causes pain:
sports: stretchinginjury:
burner/stinger - esp in football, fractures
Neurologic symptoms
- pain, numbness tingling:
- spasticity, clumsiness:
- bowel/bladder symptoms
- radiculopathy, neuropathy, cauda equina syndrome
- myelopathy
- cauda equina syndrome
which test?
hyperextension and flexion of neck ipsilateral to the side of the lesion causing radicular pain in neck and down affected arm
spurling maneuver
Which test?
passively flex hip, stop when pain occurs. Lower leg until pain resolves, then dorsiflex the foot
straight leg raise (Lasegue’s Test)
Which test?
Estimation of rib hump and evaluation of curve unwinding as patient turns trunk from side to side
Forward bending test
Segmental innervation of lower leg movements:
Hip flexion:
Hip extension:
Knee extension:
Knee flexion:
Dorsiflexion
Plantar flexion
Inversion
Eversion
Hip flexion: L2/3
Hip extension: L5/S1
Knee extension: L3/4
Knee flexion: L5/S1
Dorsiflexion: L4/5
Plantar flexion: S1/2
Inversion: L4/5
Eversion: L5/S1
Name Motor, Refex, and sensory:
C5 C6 C7 C8 L4 L5 S1
C5: Deltoid, biceps brachii, shoulder
C6: biceps brachii, brachioradialis, Thumb
C7: Triceps brachii, Triceps brachii, Middle two fingers
C8: Interossei, none, lateral two fingers
L4: Quadriceps/dorsiflexion; patella tendon; medial calf/ankle
L5: Extensor halluces longus, none (hamstrings?), Dorsal foot and 1st web space
S1: Plantarflexion/Gastroc; Achilles tendon; plantar and lateral foot
Waddells signs:
Presence indicates nonorganic pathology
- exaggerated response/overreaction
- pain to light touch
- nonanatomic pain localization
- negative flip sign with positive straight leg test
Ortiz:
•Signs (DO ReST) Comments
•Distraction: Presentation of severe radicular pain with the supine straight leg raising tes tbut no pain in the seated straight leg raising test. Both should be positive.
•Overreaction: Inappropriate, disproportionate reactions to a request. This may manifest with exaggerated verbalizations, facial expressions, tremors, or collapsing.
•Regionalization: Motor or sensory abnormalities without anatomic basis such as in a stocking glove distribution, give-way weakness or cog-wheel type of rigidity.
•Simulation: Leg or lumbar pain with a light axial load on the skull. Or a presentation of lumbar pain with simultaneous pelvis and shoulder rotation in unison.
•Tenderness: Exaggerated sensitivity or dramatic reproduction of pain with light touch of the soft tissue or with skin-rolling.
•Bowstring Test
Raise leg, flex knee, popliteal press
radicular pain with popliteal pressure indicates sciatic nerve cause
•Femoral Nerve Stretch Test (Reverse SLR Test or Ely’s Test)
a test to determine if a patient has shortening of the rectus femoris muscle. The patient is
positioned prone. The examiner passively flexes the knee of the test extremity. If the ipsilateral buttock
rises off the plinthe the test is positive.
•Hoffmann’s Sign
positive Hoffmann’s reflex reflects presence of an upper motor neuron lesion from spinal cord compression;
- is elicited by flipping either the volar or dorsal surfaces of the middle finger and observing the reflex contraction of the thumb and index finger;
- this sign is evidence by upper motor neuron disease because here should normally be no reaction;
- positioning the neck in extension (sometimes flexion) may worsen the reflex;
•FABERE (Patrick’s Test)
a test designed to alert the examiner to the possibility of hip pathology or SI jointdysfunction. The examiner places the test limb in flexion, abduction and external rotation so that the footof the test limb rests on the patients opposite knee. The examiner then passively presses the test limbtoward the table while applying stabilizing counter pressure on the opposite ilium. The test is positive ifthere is noted pain in the back or the tested limb or if the tested limb remains in a plane above theopposite limb. This may indicate tightness of the hip flexors, adductors or joint capsule of the hip.
•Gaenslen Test
The patient lie supine on a treatment table. With one leg hanging over the side of the
table in hyperextension the other knee is drawn to the chest by the patient. The clinician may aid the
patient in moving the hip into hyperextension with gentle pressure. A positive test is indicated by pain in
the ipsilateral sacroiliac joint. Which may be due to an Ipsilateral joint lesion, hip pathology, or an L4
nerve.
•Iliac Compression Test
Also called Erichsen’s test. The examiner presses the iliac
crests together. If pain is felt over the joint the reaction is
regarded as evidence of an intra-articular sacroiliac lesion.Forcible separation of the iliac crests is more likely to cause pain by stretching the anterior sacroillac ligaments when the sacroiliac joint is affected
Thoracolumbar fractures:
Mechanism (2)
_____ is most common site of fx/injury
What is the three column theory?
MVA or fall (lap belt can be fulcrum to cause flexion distraction fracture)
Thoracolumbar junction most common site
Denis 3 column theory
This model is used to predict the soft tissue injury from bone injury. Spinal stability is dependent on at least two intact columns. When two of the three columns are disrupted, it will allow abnormal segmental motion, i.e. instability.
So a simple anterior wedge fracture or just sprain of the posterior ligaments is a stable injury.
However a wedge fracture with rupture of the interspinous ligaments is unstable, because the anterior and the posterior column are disrupted.
A burst fracture is always unstable because at least the anterior and middle column are disrupted.
1 column injured unstable.
Burst fx caused by 1 flexion and 2 axial compression
Chance fx: flexion/distraction fx, all 3 columns fail in tension
Criteria to predict soft-tissue injury from bony vertebral injury are:
Angulation greater than 20 degrees.
Translation of 3.5 mm or more.
