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Analytical Anatomy Practical 2 > Surgery UE > Flashcards

Surgery UE Flashcards

0
Q

Boyle’s Law

A

Inverse relationship between pressure and volume. explains movement of air during inspiration and expiration (high volume, low pressure=gas in)

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1
Q

Describe the motion of a single rib during inspiration and expiration (include Boyle’s Law)

A

“Bucket Handle Action” because the ribs are “hinged” anteriorly and posteriorly and the curved portion is free to move.
Boyle’s Law: Explains movement of air during inspiration (high volume, low pressure=gas in) and expiration

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2
Q

What joints are involved in the motion of ribs

A
  1. Costovertebral (CV)
  2. Costotransverse (CT) rib articulates with the transverse processes of the corresponding vertebra. Anterior rib articulation cranially superior articulation caudally.
  3. Sternocostal. Articulation with the sternum ribs 1-7
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3
Q

Costovertebral (CV)

A

The 6th rib articulates with the 6th and 5th vertebral bodies

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4
Q

Costotransverse (CT)

A

Rib articulates with the transverse processes of the corresponding vertebra
anterior rib articulation cranially, superior articulation caudally

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5
Q

Sternocostal Joint

A

Articulation with the sternum, ribs 1-7

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6
Q

What muscles are involved during inspiration

A

Quiet: diaphragm, scalene, external intercostals

Forced: Serratus posterior superior and inferior, levator cocostae, SCM, Lats, iliocostalis thoracis and cervicis, pec major and minor, SA, QL

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7
Q

What muscles are involved during Expiration

A

Quiet: Passive due to relaxation of diaphragm and elastic recoil of thorax and lungs

Forced: 4 Abdominals, Transverses thoracis, internal intercostales

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8
Q

Observe the orientation of the facet joint of the thoracic spine
Describe the possible/theoretical motions of the thoracic spine based on its facet orientation

A

Facet joints become progressively more vertical
Motion occur in all 3 planes: Not much in thoracic spine during physical assessment because the rib cage restricts some motion
Flex/Ext ROM increases from upper to lower throacic.
Axial Rotation decrease from upper to lower segments due to the facet joint orientation.
Lateral SB does not systematically change very much from the upper to lower thoracic spine

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9
Q

Define Kyphosis

A

Kyphosis is the curvature that is concave on the anterior side (or convex posteriorly) of the spine

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10
Q

What portion of the spine demonstrates a kyphotic curve

A

Normal spine at rest the thoracic spine and sacrum display kyphosis.
Kyphotic curve of the T-spine can be assessed using X-Ray
Normal kyphotic curve angle is about 40 deg
Natural curvature within the vertebral column are not fixed they change shape during movements and different postures

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11
Q

How is a kyphotic curve assessed

A

X-Ray
Cobb Angle calculated from perpendicular line drawn on a standard thoracic spine radiograph
a line extends through teh superior endplate of the vertebral body which marks the beginning of the thoracic curve (T4) and the inferior endplate of the vertebral body marking the end of the thoracic curve (T12).
Normal curve 40 deg, increase as kyphosis increase

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12
Q

How does increased kyphosis affect the cervical spine

A

Excessive thoracic kyphosis translates the cervical spine and head anteriorly
To compensate and maintain head position
Cervical spine may increase its lordosis curve

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13
Q

How does increased kyphosis affect the loading on the thoracic and cervical spines

A

Increased kyphosis increase the external moment arm (from the throacic AOR to the line of body weight).
In static position int=ext torque (force*moment arm).
Since body weight force vector and int moment arm of the muscles are constant. increasing the ext moment arm due to kyphosis means and increased muscle force necessary. Increase the shear and compression load on T&C-Spine. Also reduce contact area b/w vertebra. pressure=force/contact area.both the potential increase in compressive force (due inc in muscle force) and decrease in contact area will dramatically increase the pressure

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14
Q

Determine the axis rotation for the cervical spine

A

The sagittal plane AOR runs in the ML direction is anterior on the vertebral body
Transverse rotation, it’s longitudinal through the vertebral body.
The frontal plane AOR (AP direction) is less clear

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15
Q

Is the total cross-sectional area for the anterior neck muscles the same as for the posterior neck muscles?

A

The posterior neck muscles (extensor) have a considerably larger cross-sectional area (greater force production)

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16
Q

Are the lever arms for the anterior neck muscles similar to that of the posterior neck muscles

A

In general posterior muscles also have a larger lever arm than the anterior muscles. The posterior neck muscles (extensor) therefore can generate more muscle torque (t=force*lever arm)

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17
Q

What implications does this have for whiplash injury?

A

Whiplash injuries refer to injrueis resulting from neck hyperflexion adn hyperextension
difficult to prevent from musclar perspective
Cervial spine and associated musculature is desinged to counter gravity (by ext the head and neck to keep the mass of teh head over the BOS)
Anterior neck muscle not well-designed to resist a rapid posterior acceleration of the head
Injury more likely to occur during neck hyper-extension (ROM)
Could result to injury to both anterior (muscle strain)and posterior structures (fracture of the facet joint)

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18
Q

Coupled-motions of the lower cervical spine? Why? (VBI)

A

Rotation and SB are to the SAME side regardless of cervical flexion or extension
Coupled motions of the lower cervical spine are primarily due to the orientation of the facet joint (more superior anterior relative to posterior)

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19
Q

Osteokinematic Motion of the cervical spine during VBI test

A

Extension plus ipsilateral rotation and SB of the C-spine

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20
Q

What potentially occurs to the right vertebral artery

right artery is the ipsilateral artery. right rotation is performed

A

Position is very similar to the position of the Spurling’s Test. Any bony spurring/osteophyte formation in the lower cervical spine may compress or irritate the artery, thereby cause occlusion of the artery on the right (ipsilateral) side.
Excessive rotation of C1-C2 can also lead to ipsilateral “kinking” effect (imagine bending a garden hose to shut off water flow)
Possible when there is disruption to alar ligament, leading to joint instability

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21
Q

What potentially occurs to the Left vertebral artery (left artery is contralateral artery: rotation is performed to the right)

A

Rotational motion of the C1-C2 the artery on the contralateral side is bent around the C1-C2 kinking the artery and reducing the blood flow to the brain.

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22
Q

Conclusion about VBI

A

Purposefully occluding blood flow on the ocntralateral side
Positive
1. Ipsilateral bone spurring
2. Kinking on the ipsilateral artery in teh upper cervical spine with excessive rotation due to the joint instability and/or disruption of the alar ligament

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23
Q

Identify the muscle of the anterior and posterior cervical spine

A

Anterior: SCM, Longus Capitis, Longus Colli, Scalene Anterior, Scalene Medius, Scalenes Posterior

Posterior: SCM,Trapezius, Spenius Capitis/Cervicis, Spinalis Capitis, Semispinalis Capitis/Cervicis, Longissimus Capitis/Cervicis

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24
Q

Articulating facets of C1 with occiput in relation to cardinal planes

A

The articulating facets of the C1 are concave and lie in the transverse plane tilted slightly posterior and medial.
They tend to cradle the occiput and allow some flexion/extension (nodding) and minimal Sidebending and rotation

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25
Q

Name of variation in C2 morphology of Spinous Processes. Do spinal nerves exit superior or inferior to the vertebral body with the same name?

A

The spinous process are typically bifid with the C2 spinous process being the first palpable spinous process. The nerve exit superior to the vertebra for which they are named in the cervical spine.
True for C1-C7 the C8 nerve root exits inferior to C7 and from that level on the nerve exit inferior to the vertebrae for which they are named

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26
Q

What vertebrae does the dens osseous structure belong?

A

Dens is part of the C2 vertebra

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27
Q

What is the purpose of the transverse ligament and danger of a rupture?

A

The transverse ligament holds the dens against the anterior arch of the atlas.
Rupture of this ligament can lead to impingement on the spinal cord as C1 may glide anteriorly unchecked. The spinal cord would then be pinched between the dens and the posterior arch of the atlas.
Vertebral artery may also be compromised.
Function of the transverse ligament should be understood and translated to the clinical tests such as the Sharp-Purser Test

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28
Q

Nerve Trough

A

The nerve troughs are more anterior than most people think

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29
Q

Most cranial vertebral body of the cervical spine

A

The most superior vertebral body belongs to the axis. The atals consists only of a body-less ring

30
Q

Transverse ligament location and attachments

A

The attachment site for both ends is the posterior aspect of the anterior arch of C1

31
Q

Alar ligament location and attachments

A

The alar ligament runs from the lateral aspect of the odontoid process (dens) to the margins of the foramen magnum

32
Q

If cranium and move it into left SB.
Which alar becomes taut?
Explain the kinematics created by the Alar ligament during this movement

A

As the occiput LEFT sidebends, the RIGHT superior Alar ligament becomes taut.
LEFT side bend results in the alar ligament pulling C2 into LEFT rotation of the vertebral body, resulting in C1 positioned in a RELATIVE right rotation on C2

33
Q

Following which is True

A
  1. Right SB of the occiput creates tension in the superior left Alar ligament
  2. The transverse ligament attaches to the anterior arch of the atlas at both ends
  3. Right SB of the occiput results in the right rotation of C1 on C2. FLASE
34
Q

Difference between the T4 and coso-transverse joint and the T10 costo-transverse joint

A

The costo-transverse joints become progressively more weight-bearing as you move caudally through the thoracic spine. The upper costo-transverse joints are ligamentous type whereas the lower joints are synovial type of joints. Thus the lower costo-transverse joints have more mobility than the upper costo-transverse joint

35
Q

Rule of 3

A

Clinical rule that attempts to generalize the orientation of the thoracic spinous processes. There are certainly deviation as can be appreciated by observing the wide variability of several cadavers.
Upper 3 thoracic vertebra (T1-T3) have SP that project direcly posterior and therefore the tip of SP in the same place as TP of that same vertebra
T4-T6 SP project slightly downward and therefore the tip of SP is in the plane that is halfway between its own TP and that of the TP of the caudal vertebrae
T7-T9 have SP that project moderately downward and therefore the tip of the SP is in a plane with TP of the caudal vertebra
T10-T12 have SP that project from a position similar to T9 and rapidly regress until T12 is more like T1 (own plane)

36
Q

Muscles attach to the 1st rib

A

Anterior and middle scalene muscles attach to the first rib

37
Q

What structures are immediately adjacent to the first rib

A

Brachial plexus, subclavian artery and subclavian vein (pass between anterior adn middle scalene on way to axilla).

38
Q

Conditions sensitive to 1st rib spatial relationship

A

Elevated first rib and/or scalene muscle tightness can be a potential cause of thoracic outlet syndrome.
Other causes include cervical rib
Thoracic outlet syndrome refers to the neuro vascular symptoms produce in the upper extremity due to compression of the brachial plexus and/or subclavian artery.

39
Q

Scoliosis Anatomy

A

Deformity of the vertebral column characterized by abnormal curvatures in all 3 planes most notably in the coronal and transverse. Occurs most commonly in the thoracic region but may affect other regions

40
Q

Scoliosis Demographics

A

Typically described by the location direction and number of fixed coronal curvatures within the vertebral column. The most common pattern of scoliosis consists of a single lateral curve with an apex in the T7-T9 region. There may also be secondary or compensatory curves most often in thoracolumbar or lumbar regions. Direction of the primary curve is defined by the side of convexity of the lateral deformity (right thoracic apex indicates teh most lateral point of the curve is in the thoracic spine with the convex side in the right half of the body).

41
Q

Types of Scoliosis

A

Functional
Structural
Idiopathic Adolescent

42
Q

Functional Scoliosis

A

Corrected by an active shift in posture

43
Q

Structural Scoliosis

A

Fixed deformity that can’t be corrected fully by an active shift in posture
80% Idiopathic with no mechanical cause, no apparent biologic cause
Congenital scoliosis is caused by a failure in vertebral formation or segmentation
it may be associated with several neuromuscular diease like cerebral palsy, muscular dystrophy or generalized disease like Marfan’s syndrome
Infantile, Juvenile, Adolescent

44
Q

Idiopathic Adolescent Scoliosis

A

Most common type

progressive affects adolescent females about 4x as much as males

45
Q

Adolescent Idiopathic Scoliosis

Natural History

A

Once descovered curve must be evaled for progression
lateral forces in anterior spine have to be counteracted by the musculo-ligamentous structure in the posterior spine. when this fails curve progression can increase during periods of growth
progression is most likely to occur during the rapid adolescent growth

46
Q

Peak Height Velocity

A

Adolescent Idiopathic Scoliosis
Chagnes in a pt height measurements over time and is reported to be about 8cm/yr for girls (11-13yr). and 9.5 cm/yr for boys (13-15)

47
Q

Certain factors have been found to be related to higher risk of curve progression for Idiopathic Adolescent Scoliosis

A 
Girl>Boys
Premenarchal 
Younger Chronological Age 
Risser sign of 0
Double curve> single curve
thoracic curve> lumbar curve
more severe curves 
direct correlation has been noted between decreasing vital capacity and increasing curve severity
48
Q

Mechanics of Scoliosis Coupling

A

Deformity in structural scoliosis has a remarkably fixed contralateral spinal coupling pattern (lateral flexion and axial rotation)
Left lateral flexion (right scolisiosis) is associated with right axial rotation
Ribs are forced to follow this rotation producing a rib prominence on the convex side that becomes more evident on bending forward
MORE PRONOUNCED ON ANTERIOR SPINAL COLUMN. RESULT FROM DIFFERENCES IN THE GROWTH RATE BETWEEN ANTERIOR AND POSTERIOR COLUMS

49
Q

Vertebral Deformities Scoliosis (CTO scan)

A

CT scans of the apical vertebrae reveal numerous deformities
Slight torsion between teh verterbal body and the posterior structures
-vertebral body is rotated toward the convex side of the curve
-torque of the musculo-ligamentous on the posterior aspect of the spine (towrad convex side) results in the thickening of the convex pedicle. Pedicle on concave side is narrowed
-Increase longitudinal pressure on the concave side results in decreased longitudinal growth but increased appositional bone growth. therefore the depth of the vertebral body (in anterior view) is shorter on the concave side and lengthened on the convex side (wedge angle)
-Depth of the vertebral body (lateral view) is shortened on the posterior aspect and lengthened on the anterior aspect creating a lordotic bony deformation. Normal anatomy is a shortened anterior aspect to allow for a kyphotic curve in the spine
-tip of the SP is pointed posterior then curves toward the convex side

50
Q

CT scan of Upper end vertebrae

A

show slight torsion between the vertebral body and the posterior components of the vertebrae. there is also a greater tilt vertebral body than the posterior structures as the ligaments and muscles attempt to correct the horizontal tilt

51
Q

Rib Deformity Scoliosis (Concave side)

A
  • Concave side
  • crowded together while those on the convex side are spread out.
  • muscles and other soft tissues are also shortened and lengthened on teh concave and convex sides respectively
52
Q

Rib Deformities (Concave side)

A
  • Concave side
  • Sharper posterior angle with torsion around the longitudinal axis. ribs on the concave side have a flattened posterior angle
53
Q

Scoliosis Evaluation

A
  • Back Pain (about 32%) idiopathic scoliosis
  • height associated with height peak velocity. limb length (pelvic tilt and compensatory scoliosis)
  • Assymetry: shoulder, scapula, ribs, waistline, plumb line to gluteal crease (hypokyphotic)
  • Adam Test
  • Neuro Exam (abdominal reflex found with some intraspinal disorder)
54
Q

Non-Operative Treatment for Scoliosis

A

Observation: young pt 50 deg. Milwaukee brace eplaced. work 23hr/day more wear less curve progression

55
Q

Surgery for Scoliosis Indications

A

Increase curve in growing child
severe deromity (>50deg) with asymmetry of trunk in adolescent
pain uncontrolled by non-operative treatment
thoracic lordosis: detrimental effect on pulmonary function and is worsened by bracing
significant cosmetic deformity

56
Q

Surgery Scoliosis

A

Posterior spinal fusion and bone grafting

  • most common surgery
  • original implants Harrington rods were straight stainless steel rods connected to the cephalic and caudal regions of the spine. Major correcting force with the Harrington instrumentation is distraction these rods were connected to the spine via hooks
  • Contemporary implants are segmental. affortd teh surgeon greater control over psitioinng rotation of teh spine. icnreased staility of segmentatl instrumentation permits early mobilziaton with ambulation the day after surgery wihtout external support such as a body cast or brace.
57
Q

Surgery Scoliosis Techniques (posterior)

A

-Soft tissue is cleared to expose teh vertebrae to be fused from SP lamina and facet to TP
Inf, sup or both facets are removed allowing for movement in teh correction
regiomve some intersegmental ligamentd include Flavum
Use pedicle screws that are very adustable for fine-tuning
pedicles in thoracic spine are smallare and more variable that lumbar spine making this technqiue very challenging
-rods bent for kyphotic curve
-rods first apply to concave side to top pedicle scew. second to convex side
-vertebrae are de-rotated in Transverse plane for rib hump
-convex side reduced concave side distracted to address teh vertebral body tilt

58
Q

Surgery Scoliosis Techniques (anterior)

A

-Shortening of teh convex side. advantage of this are lower risk of neurolgical injury and no disturbance of paraspinal muscles
more complex and pumonary function adversely affected or diaphragm
endoscopically
boney fusion using autografts or allographs
-older stiff pt need release anterior intervertebral soft tissue perfomring psoterior fusion
-avid crankshaft: still growing child, anterior spinal fusion along with posterior fusion.

59
Q

Surgery Scoliosis Complications

A

Pseudoarthrosis

Loss of lumbar lordosis leading to back and hip pain

60
Q

Cervical Laminectomy Indications

A
  • Multilevel degenerative disc disease resulting in cervical stenosis and myelopathy
  • Cervical Stenosis resulting from ossification of the posterior longitudinal ligament
  • tumor
  • epideral abscess
61
Q

Cervical Laminectomy Cons

A
  • Postoperative axial discomfort from denervation and devascularization of the paraspinal muscles
  • atrophy of teh paraspinals that could potentially result in kyphosis and instability
  • C5 paresis is a risk
62
Q

Cervical Laminectomy Technique

A
  • SP, Lamina, alteral masses exposes by elevating the paraspinal muscles
  • lamina cut and removed
  • bone spurs removed from around the spinal cord and nerve root
  • pedicle screw rods or plates
  • bone graft also inserted into facet to further fuse ten spine (complications nerve root and vertebral artery)
63
Q

Cervical Skip Laminectomy Pros

A

Tend to have better surgical outcomes than both transitional laminectomy and laminoplasty including reduced axial pain decreases incidence of paresis and decreased atrophy of the deep extensors

64
Q

Cervical Laminoplasty Cons

A

Decrease in cervical sagittal motion and postoperative axial discomfort
Could cause atrophy of deep extensor muscles

65
Q

Cervical Laminoplasty Pros

A

May have less complications that the standard laminectomy and allows for the preservation of posterior elements

66
Q

Cervical Laminectomy Post-Operative Management

A

After laminectomy a drain is inserted and removed after 24-48 hours
May place in soft cervical collar
After skip laminectomy pt able to sit up walk on the first preoperative day while wearing Philadelphia collar. pt can wear as desired
After Laminoplasty early mobilization and neck exercises are encouraged. Collar may or may not be work

67
Q

Cervical Laminectomy Outcomes/Complications

A
  1. Removal of one or more dorsal elements leads to tensile forces being applied to the facet joint instead of the usual compressive forces. also decreased stiffness and increase motion has been observed
  2. Instability leading to progressive kyphosis and worsening of the neurological status has bee reported
  3. Possible reasons for neurological worsening: intra-operative neuro trauma, sharp angulation of dural sac at limits of decompression, DESTABILIZATION occurs with greater frequency as width of laminectomy in increased leads to flexion deformity or kyphosis
  4. Prevention of destabilization: limited spinal integrity disruption, addition of a stability augmentation procedure.
68
Q

Post Laminectomy Cervical KyphosisCauses

A

Arthritic changes leading to decrease in anterior column height, loss of muscle attachments, muscle denervation or fibrosis secondary to aggressive surgical exposure and resection

69
Q

Post Laminectomy Cervical Kyphosis

A

Competence of posterior column structures particularly facet joints is essential for maintenance of lordotic posture

70
Q

Post Laminectomy Cervical Kyphosis Pathological Developments

A

Lead to progressive deformity

  • anterior shift of weight bearing axis (compressive overload of anterior column which may acclerate arhtitic chagnes. icnreased tension on postieor column)
  • cervical extensors are placed at a mechanical disadvantege
  • chronic tensile forces may lead to attenuation of dorsal ligamnetous structures and facet capsules
  • spinal cord may be pulled agaisnt the apex of teh kyphotic deformity resulting in irrriation, dysfucntion and pathological damge to the cord
71
Q

Post Laminectomy Cervical Kyphosis Symptoms

A

Neck pain,
muscle fatigue (from always having to contract extensors to support the head against gravity),
Radiculopathy
myelopathy
some cases difficulty in maintaining horzontal gaze

72
Q

Post Laminectomy Cervical Kyphosis Treatment

A

Goal is to decompress neural elements and reestablish normal vertical axis
Anterior column lengthening and posterior column shortening is achieved by using grafts and or implants

Analytical Anatomy Practical 2 (1 decks)

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