Clinical anatomy of the back

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  • Cover slide
  • The late natural history the thoracic kyphosis is for progressive deformation:
    This deformation occurs within the vertebral bodies in women with a greater contribution from disc degeneration in males.[Goh et al 1999]
    Those sports that predispose the individual to hyper-kyphosis during the adolescent years and beyond, should be studied to determine the association between the structural deformation and back pain.
    [[Those of us destined to keyboard activity will identify with the evolutionary trend depicted above]]
  • As can be seen on the left, the vertebral end-plate is a tenuous cartilaginous membrane which from direct measurement is approximately 0.5mm thick, connected to trabecular bone within the cortical shell.
    Lesions of the end-plate arising from sporting activities are reported to be frequent. Typical aetiology involves dynamic compressive axial loads, common in landing sports: eg: gymnastics
    Discal material is extruded through the end-plate into the vertebral body. At the time of injury, the lesion may be painful due to the inflammatory response to the lesion. It has been postulated that such injury predisposes the disc to early degenerative change [Roberts et al, 1997 European Spine Journal 6: 387]
    The late stage of healing involves sclerosis of bone around the site of injury, demonstrated on the right [arrow] form a CT at T11-12
  • The notochordal streak, as depicted by Schmorl & Junghanns from their classic text, showing a foetal specimen [left] and the progressive apoptosis of these cells during maturation and differentiation of the disc and vertebral body.
    Typically, Schmorl’s nodes occur close to this site, suggesting both a functional and genetic predisposition to compressive load failure of the end-plates in some individuals.
  • In a recent CT study, 42 patients suspected of disc and facet joint pain were rotated within the CT scanner prior to scanning. They were fixed into this position for both right and left side scans which were compared with their neutral [conventional] scan images.
    Very slight separation of the facet joints occurred at most levels and particularly where the anatomical alignment was mostly coronal [usually the lowest segments].
    Joints with a more sagittal alignment, typically the upper lumbar spine, appeared to offer greater resistance to torsion.
  • Spine injuries can occur through overuse, overload, trauma or a combination of these events.
    Injuries may occur to any component of the mobile segment: disc, vertebral bodies or facet joints, however disc and end-plate lesions are the most commonly affected.
  • The reported statistics for back pain according to Cooke & Lutz [2000] are:
    Lifetime prevalence of back pain in the community = 60-80%
    Back pain recurrence = 70-90%
    Progression to chronic back pain = 5-10%
    Back pain a common feature in most sports, particularly competitive contact sports.
    Back pain is higher in young athletes compared with age matched controls and,
    Back pain may occur in response to various conditions of load, fatigue and trauma
  • The reported statistics for back pain according to Cooke & Lutz [2000] are:
    Lifetime prevalence of back pain in the community = 60-80%
    Back pain recurrence = 70-90%
    Progression to chronic back pain = 5-10%
    Back pain a common feature in most sports, particularly competitive contact sports.
    Back pain is higher in young athletes compared with age matched controls and,
    Back pain may occur in response to various conditions of load, fatigue and trauma
  • The incidence of end-plate lesions in sport participants varies, however, these may result from pre-existing anatomical abnormalities.
    In the case of Scheuermann’s disease, there can be multiple end-plate lesions over many segments.
    According to Sorenson, the characteristics of this disease involve four or more segments with lesions of the end-plates, and corresponding vertebral wedging.
    Accentuated kyphosis and a painful thoraolumbar spine are the main clinical features.
  • AFL is a dynamic game that involves various types of play and physical encounters. Injuries are common, predominantly to the knee [ACL], hamstring and groin regions.
    In a major survey of AFL injuries undertaken by Drs Seward & Orchard, identified a recurrence rate of 32% for injuries to the neck, back, and ribs.
  • Copyright slide
  • Clinical anatomy of the back

    1. 1. MOB TCD Clinical Anatomy of the Back Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 2. MOB TCD Progress Time Goh et al. Clin Biomech 1999;14:439
    3. 3. MOB TCD Spine Consists of • Cervical Vertebrae • Thoracic Vertebrae • Lumbar Vertebrae • Sacrum
    4. 4. MOB TCD Spine • The strength of the skeletal column is due to the size and shape of the vertebrae • Its flexibility is due to the many joints that are close together
    5. 5. MOB TCD Vertebral Column • Lot of stress in variety of sports • Cervical pathology • Pain may be referred to upper limb • Lumber pathology • Lower limb
    6. 6. MOB TCD Young Spine Normal curvature of infant’s spine Normal lumbar curve of toddler’s spine
    7. 7. MOB TCD Low Back Pain in Sports • 70% of population will suffer from back pain at some time • 10% - 15% of sports injuries are spinal injuries • 0.6% - 1% have neurological complications Deyo & Tsui-Wu. Spine 1987;12:264-8
    8. 8. MOB TCD Low Back Pain in Sports • Majority of sports injuries to lumbar spine • Soft tissue and many are not reported • Fractures • Fracture dislocation • Abrasions, bruising • Contusions Tall & De Vault. Clin Sports Med 1993;12:441-8
    9. 9. MOB TCD Low Back Pain in Sports • Must know the sport • Must understand the biomechanics and stresses involved in the sport • Must examine the spine in the appropriate position
    10. 10. MOB TCD Typical Vertebrae • Basic parts • Body and neural arch • Which consists of pedicles, lamina and spine • The transverse processes arise from the pedicles • Superior and inferior articular processes
    11. 11. MOB TCD Lumbar Vertebrae
    12. 12. MOB TCD Lumbar Vertebrae • • • • • Body kidney shaped No articular facets for ribs Inferior facets face anterolateral Superior facets face posteromedial Intervertebral notch increase in size • Accessory processes base of transverse process • Mammillary process on posterior aspect of superior articular process
    13. 13. MOB TCD Lumbar Vertebrae • Body is convex anteriorly • Foramina on the posterior aspect are for the basic vertebral veins, which drain into the internal vertebral plexus • The walls of the veins, which are valve less, have afferent nerve fibers • Secondaries can spread from pelvis, prostate, adrenal glands lungs and breast
    14. 14. MOB TCD Lumbar Vertebrae • The superior and inferior surfaces of the body are flat and covered by a thin layer of hyaline cartilage • The body of the vertebra consists of trabecular or cancellous bone
    15. 15. MOB TCD Typical Lumbar Vertebrae • Superior and inferior articular processes • Arise from the junction of the pedicles and lamina • Superior face posteromedially • With rough mammillary processes on the posterior border • Inferior face anterolaterally • Accessory processes at the base of transverse process • Prevents rotation
    16. 16. MOB TCD The Lumbar Facets • Vary from the sagittal disposition at the first and second, to almost coronal in the lower • Facet tropism is when the facet on one side is in the sagittal plane and the other is in the coronal plane, which adds to rotational stress • This change may occur in the lower thoracic vertebrae
    17. 17. MOB TCD Pars Interarticularis • Pars interarticularis • Portion of lamina between superior and inferior articular processes • Site of spondylolysis or spondylolisthesis
    18. 18. MOB TCD Lumbar Spine • Cancellous bone • 50% compressive strength • Facet joints 20% in standing upright position
    19. 19. MOB TCD Lumbar Vertebrae
    20. 20. MOB TCD Lumbar Vertebrae
    21. 21. MOB TCD Lumbar Spine • Cancellous bone • 50% of the compressive strength • Facet joints, 20% of the strength in the standing upright position
    22. 22. MOB TCD Anterior Longitudinal Ligament • Attached mainly to the bodies • This ligament helps to prevent us from leaning too far back (hyperextension)
    23. 23. MOB TCD Posterior Longitudinal Ligament • Attached mainly to the inter vertebral discs • This ligament helps to restrict forward bending (hyperflexion)
    24. 24. MOB TCD Ligamentum Flava • Runs between the laminae of the neural arches • Helps to restrict hyperflexion • It extends to the capsule of the facet joint • It is highly elastic and ensures that the ligament does not buckle in extension
    25. 25. MOB TCD Ligamentum Flava • Gives elasticity to the posterior aspect of the facet joints • Helps form the posterior boundary of the intervertebral foramen • The ligamentum flava is thicker in the lumbar region
    26. 26. MOB TCD Spinal Ligaments • Interspinous ligaments • Strong supraspinous ligaments • The inter-transverse ligaments join the transverse processes and are thin and membranous in the lumbar region
    27. 27. MOB TCD Fifth Lumbar Vertebrae • Larger, superior and inferior articular facets in the same plane • Fifth lumbar vertebrae has large transverse processes • Arise from the body as well as the pedicles
    28. 28. MOB TCD Arthritis of Spine • • • • Painful Limitation of movement Extra projections Narrowing of disc spaces
    29. 29. MOB TCD Vertebral Joints • Secondary cartilaginous joints between the bodies • Hyaline cartilage covering bodies • Disc of fibrocartilage in between • Synovial plane joints between the facets
    30. 30. MOB TCD Intervertebral Discs • Annulus fibrosis • Concentric lamina run obliquely • Type I collagen at periphery, type II near nucleus • Weakest portion is the postero-lateral and posterior • Periphery has a nerve supply
    31. 31. MOB TCD Nucleus Pulposus • Gelatinous, hydrophilic, proteoglycan gel in collagen matrix • Lies posterior in the disc • There are no nerve endings in a mature disc • Nerve endings are found in the posterior longitudinal ligament and the dura • Nutrition of the disc is by diffusion via the central 40% of the cartilaginous end plate • The discs are thicker in the cervical and lumbar sections of the vertebral column • Where there is more movement. The largest disc is between L5 S1
    32. 32. MOB TCD Nucleus Pulposus • Hydration of the annulus and nucleus is proportional to the applied compressional stress • In vivo, there is a loss of 1 cm standing height over the course of the day • A disc loaded in vitro for four hours by 100% body weight will lose 6% of the fluid from the nucleus and 13% from the annulus • May be due to end plate fracture • There is more rotational stress in the posterior part of the disc
    33. 33. MOB TCD Nucleus Pulposus • The position of the spine determines where the compressional forces are greatest • The posterior longitudinal ligament is thin and expanded at the level of the disc • High compressional loading at L4,L5,S1 may be due to end plate fracture and not to rupture of the annulus • End plate failure is a possible precursor of disc degeneration
    34. 34. MOB TCD Axial Load and End-plates
    35. 35. MOB TCD End-plate Mechanics • Functionally, the vertebral end-plate displays characteristics of a trampoline • With the sub-end-plate trabecular bone acting as springs to sustain and dissipate axial load • Despite the thinness of the vertebral end-plate • The hydraulic nature of marrow and blood vessels within the vertebral body, act to dampen axial loads, unless the local point pressure is too high
    36. 36. MOB TCD End-plate Mechanics • End-plate lesions can be induced experimentally before a disc will prolapse through the anulus, suggesting a protective mechanism over annular injury and potentially cord or root compression • Excessive loads may result in perforation of the end-plate, usually in the region of the nucleus and often in the path of the developmental notchord
    37. 37. MOB TCD End-plate Susceptibility Notochord Schmorl & Junghanns. The human spine in health and disease. New York: Grune & Stratton, 1965
    38. 38. MOB TCD Facet Joints • L1,L2 Facets sagittal plane • Lower joints in coronal plane • Synovial plane joints • Meniscoid structures • Synovial membrane some contain fat • Supplied by medial branch of dorsal ramus
    39. 39. MOB TCD Facet Joints • Narrowing of disc space, results in stress on facet joint • Highest pressure during • Combined • Extension • Rotation • Compression
    40. 40. MOB TCD Facet Joint Syndrome • • • • • Extension and rotation Pain rising from flexion Pain worse standing Lateral shift in extension Point tenderness over facet • Referred leg pain
    41. 41. MOB TCD Segmental Rotation Singer et al. J Musculoskel Res 2001;5: 45-55
    42. 42. MOB TCD Movements of Lumbar Spine • Flexion limited by disc problems • Lateral flexion • Extension limited by facet joint problems • Very little rotation • Extension and rotation affect facet joints
    43. 43. MOB TCD Nerve Supply • • • • Nerve supply Peripheral annulus Facet joint Nerve is medial branch dorsal ramus
    44. 44. MOB TCD Blood Supply • • • • • Lumbar arteries Internal venous plexuses External venous plexuses Basivertebral veins Valveless
    45. 45. MOB TCD Lumbar Vertebrae
    46. 46. MOB TCD Cancellous Bone • Cancellous bone • 50% compressive strength • Facet joints 20% in standing upright position Normal bone Osteoporotic bone
    47. 47. MOB TCD Anatomical Abnormalities • • • • Spina Bifida Occulta Facet Tropism Kyphosis Scoliosis
    48. 48. MOB TCD Anatomical Abnormalities Kyphosis Scoliosis
    49. 49. MOB TCD Anatomical Abnormalities • Hemi-vertebra • Spina Bifida Occulta • Facet Tropism • Scoliosis • Kyphosis
    50. 50. MOB TCD Anatomical Abnormalities • Unilateral lumbarisation • Unilateral sacralisation
    51. 51. MOB TCD The Spine in Sports • • • • • • • Spine injury epidemiology Contact vs. non-contact sports Spine injury mechanisms Overuse – overload – overlooked Vertebral end-plate injury Disc injury Future issues
    52. 52. MOB TCD Epidemiology Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837
    53. 53. MOB TCD Epidemiology • Back pain in the community is 60% - 80% • Recurrence of back pain is 70% - 90% • Progression to chronic back pain is 5% - 10% Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837-65
    54. 54. MOB TCD Low Back Pain in Sports • Majority of sports injuries are to the lumbar spine • Many soft tissue injuries are not reported • Fractures • Fracture dislocation • Abrasions, bruising • Contusions Tall & De Vault. Clin Sports Med 1993;12:441-8
    55. 55. MOB TCD Chronic Low Back Pain • • • • • • Local structures Muscles Ligaments Poor lifting techniques Joints Bones
    56. 56. MOB TCD Back Pain Local structures • Muscles, ligaments • Joints Referred pain • Abdominal organs • Pelvic organs Must out rule • Infection • Tumours
    57. 57. MOB TCD Acute Low Back Pain • • • • • • Non-specific low back pain Usually settles quickly History Examination Pain relief Stay as active as possible within limit of pain
    58. 58. MOB TCD Acute Low Back Pain • Nerve root pain • Leg pain worse than back pain • Numbness and pins and needles • Neurological signs • Refer to specialist • If it does not resolve in first 4 weeks
    59. 59. MOB TCD Investigate Low Back Pain • • • • • • • • • Under 20 or over 55 years Non-mechanical pain Past history cancer Thoracic pain Steroids or HIV Unwell, weight loss Widespread neurology Structural deformity Gait disturbance or sphincter disturbance
    60. 60. MOB TCD Chronic Low Back Pain Pain referred • Abdominal organs • Pelvic organs Must out rule • Infection • Tumours
    61. 61. MOB TCD Pain Referred
    62. 62. MOB TCD Young Athlete • Junior rugby team 15 years of age • M. Scheuermann • 5 Spina bifida occulta • The scrum half had degenerative facet joint changes
    63. 63. MOB TCD Sacroiliac Joint – Sciatic Nerve
    64. 64. MOB TCD Spinal Stenosis • Congenital or acquired • Abnormally short pedicles or lamina • Formation of osteophytes • Osteo-arthritis of facet joints • Pain aggravated by walking • Relieved by rest
    65. 65. MOB TCD Spinal Stenosis
    66. 66. MOB TCD Predisposing Factors • • • • • • • • Intrinsic factors Anatomical abnormalities Biomechanical Extrinsic factors Sport Surfaces Equipment Training
    67. 67. MOB TCD Predisposing Factors Back Pain • Poor posture • Overweight • Unfit
    68. 68. MOB TCD Predisposing Factors • Poor core stability • Weak abdominal muscles • Weak gluteal muscles • Muscle imbalance
    69. 69. MOB TCD Predisposing Factors • Poor core stability • Weak abdominal muscles • Weak gluteal muscles • Muscle imbalance • Pronated or cavus feet
    70. 70. MOB TCD Predisposing Factors • Badly designed furniture • No back support • Poor posture at work
    71. 71. MOB TCD Acute Low Back Pain
    72. 72. MOB TCD Annular tears • Loaded compression with rotatory component • As little as 3 degrees of high torque rotation • Facets protect disc • As annulus fails, facets joints may be injured
    73. 73. MOB TCD Annular Bulge
    74. 74. MOB TCD Disc Lesion
    75. 75. MOB TCD Young Athlete • Junior rugby team 15 years of age • M. Scheuermann • 5 Spina bifida occulta • The scrum half had degenerative facet joint changes
    76. 76. MOB TCD Scheuermann’s Disease Greene et al. J Pediatr Orthop 1985;5:1
    77. 77. MOB TCD Spondylolisthesis
    78. 78. MOB TCD Pars Interarticularis • Pars interarticularis, portion of lamina between superior and inferior articular processes • Site of spondylolysis or spondylolisthesis
    79. 79. MOB TCD Spondylolisthesis
    80. 80. MOB TCD Spondylolysis and Spondylolisthesis
    81. 81. MOB TCD Pars Interarticularis; Facet Joint
    82. 82. MOB TCD Spondylolisthesis Rapid Flexion and Extension • • • • • • • • Gymnastics, flips Vaulting Ballet, arabesque Lifting during dance Diving Butterfly swimming Decathlon Pole vaulting
    83. 83. MOB TCD Ankylosing Spondylitis, Infection
    84. 84. 465 Athletes Low Back Pain (M318;F147) male (39) female(14) Spina Bifida Occulta (SBO) 6.6%(21) 4.1%(6) Lumbarisation 3.5%(11) 1.4%(2) Sacralisation 2.2% (7) 6.1% (9) Spondylolisthesis (13) 30% had SBO; 21 of 56 had other pathology MOB TCD
    85. 85. MOB TCD Mechanism of Injuries • Compression or weight loading • Torque or rotation • Tensile stresses produced by excessive motion of spine • Hyperextension and flexion Watkins & Dillin, 1985
    86. 86. MOB TCD Compression or Weight Loading • • • • • • • Sports requiring Massive strength High body weight Weight lifter Hooker and No 8 Wrestling Line back American football Watkins & Dillin, 1985
    87. 87. MOB TCD Weight Lifting • 40 % weight lifters have low back pain • Greatest stress is when weight is lifted above the head • Dangerous time is shift from spinal flexion to extension Aggrawal et al. Br J Sports Med 1979;13:58-61
    88. 88. MOB TCD Axial Compressive Loading • • • • • • • Head on collisions Motor sports Boating accidents Wrestling Horseback riding Bicycling Bobsleigh
    89. 89. MOB TCD Axial Compressive Loading
    90. 90. MOB TCD Axial Compressive Loading
    91. 91. MOB TCD Axial Compressive Loading
    92. 92. MOB TCD Compression Stress
    93. 93. MOB TCD Rotational Stress
    94. 94. MOB TCD Rotational Stress
    95. 95. MOB TCD Spondylolisthesis Rapid Flexion and Extension • • • • • • • • Gymnastics, flips Vaulting Ballet, arabesque Lifting during dance Diving Butterfly swimming Decathlon Pole vaulting
    96. 96. MOB TCD Australian Football League Seward & Orchard. 2000 AFL Injury Report, Australian Sports Commission
    97. 97. MOB TCD Golf • Highest incidence of back injuries in professional sports • Torsional stress is lessened by spreading the stress over the entire spine • Rigid abdominal control • Parallel shoulders and pelvis Watkins and Dillin, 1985
    98. 98. MOB TCD Sustained Postures - Hyperextension
    99. 99. MOB TCD Sustained Postures - Hyperextension
    100. 100. MOB TCD Sustained Postures - Hyperextension
    101. 101. MOB TCD Sustained Postures - Flexion
    102. 102. MOB TCD Scoliosis due to Unilateral Sports • • • • • Racquet sports Fencing Sweep rowing Javelin Freestyle unilateral breathing
    103. 103. MOB TCD Scoliosis due to Unilateral Sports
    104. 104. MOB TCD Running • • • • • • Poor posture Poor abdominal Pronated feet Muscle imbalance Leg length discrepancy Osteoporosis
    105. 105. MOB TCD Cricket • Bowlers • Rotational forces • Extension followed by rotation and flexion
    106. 106. MOB TCD Thank You
    107. 107. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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