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Thoracic and Lumbar Spine Anatomy
Lumbar Anatomy <ul><li>5 vertebrae L1-L5 </li></ul><ul><li>5 intervertebral discs  </li></ul><ul><li>5 pair of exiting ner...
Lumbar Spine Anatomy <ul><li>Typical lumbar vertebra (L2) </li></ul><ul><ul><li>Body </li></ul></ul><ul><ul><li>Vertebral ...
Lumbar Spine Anatomy <ul><li>Ligaments </li></ul><ul><ul><li>Anterior longitudinal ligament  </li></ul></ul><ul><ul><li>Po...
Lumbar Spine Anatomy:  Nerve Structures <ul><li>The spinal cord and nerve roots are often affected by skeletal problems </...
Lumbar Spine Anatomy:  Nerve Structures <ul><li>Conus medularis  </li></ul><ul><li>The point at which the thick, single st...
Lumbar Spine Anatomy:  Nerve Structures <ul><li>Cauda equina </li></ul><ul><li>The point at which individual nerve roots c...
Lumbar Spine Anatomy:  Vascular Structures <ul><li>The aorta and vena cava bifurcate around the level of the L3/L4 disc sp...
Thoracic Vertebrae <ul><li>Bodies </li></ul><ul><li>Pedicles </li></ul><ul><li>Laminae </li></ul><ul><li>Spinous Processes...
Thoracic Vertebrae and Rib Junction <ul><li>Thoracic Spine </li></ul><ul><ul><li>Costovertebral Joint </li></ul></ul><ul><...
Spinal deformities
Introduction : <ul><li>Spinal deformities  </li></ul><ul><li>Coronal plane : scoliosis  </li></ul><ul><li>Sagittal plane :...
1-postural scoliosis : <ul><li>Short leg </li></ul><ul><li>Pelvic tilt  </li></ul><ul><li>Local muscle spasm  :sciatic sco...
 
2-Structural scoliosis : <ul><li>bony abn.  vertebral rotation  </li></ul><ul><li>fixed. </li></ul><ul><li>Secondary curve...
 
 
 
 
Types of structural scoliosis : <ul><li>Idiopathic scoliosis “most common”. </li></ul><ul><li>Congenital or osteopathic “b...
Clinical features : <ul><li>Hx </li></ul><ul><li>Deformity : . </li></ul><ul><li>Backache :  . </li></ul><ul><li>Ask about...
Examination: <ul><li>Spine -deviated from midline  . </li></ul><ul><li>forward bending makes the curve more obvious. </li>...
Imaging: <ul><li>Plain X-ray, full erectPA .lat.spine iliac </li></ul><ul><li>Oblique views  . </li></ul><ul><li>Cobb’s an...
 
Cobb’s angle
 
Risser’s sign
 
Idiopathic scoliosis : <ul><li>About 80% of all cases of scoliosis,. </li></ul><ul><li>Divided into 3 groups : </li></ul><...
1-adolescent idiopathic scoliosis : <ul><li>age . </li></ul><ul><li>gender , </li></ul><ul><li>type ,classification-king <...
 
Rx. : <ul><li>Aims of Rx. . </li></ul><ul><li>Non-operative Rx  </li></ul><ul><li>==Exercise </li></ul><ul><li>==Bracing  ...
 
Rx. : <ul><li>Operative Rx.indications </li></ul><ul><li>==Objectives of operative Rx. </li></ul><ul><li>----Fixation type...
 
 
 
Complications : <ul><li>Surgical—early,late  </li></ul><ul><li>non surgical </li></ul>
Main Surgical Indications <ul><li>Relentless  Curve Progression </li></ul><ul><li>Major Curve  Progression in spite of bra...
2- juvenile idiopathic scoliosis : <ul><li>Present at age 4-9 years. </li></ul><ul><li>Uncommon . </li></ul><ul><li>Has si...
3- infantile idiopathic scoliosis : <ul><li>Presenting under 3 years of age . </li></ul><ul><li>Rare  </li></ul><ul><li>Ma...
 
Osteopathic “congenital “ scoliosis : <ul><li>The commonest bony cause is vertebral anomalies : hemivertebra , wedge verte...
 
 
Neuropathic & myopathic scoliosis : <ul><li>Causes include : </li></ul><ul><li>Poliomyelitis  </li></ul><ul><li>Cerebral p...
Neuromuscular Deformity <ul><li>Poliomyelitis :  Lower Motor Neuron Disease which depends on the muscle groups most severe...
 
Neuropathic & myopathic scoliosis : <ul><li>Rx. :  </li></ul><ul><li>Mild curves : no Rx. </li></ul><ul><li>Moderate curve...
<ul><li>Neuromuscular scoliosis-severe scoliosis secondary to quadriplegic cerebral palsy .  </li></ul>
Neurofibromatosis <ul><li>Causes severe  kyphosis and scoliosis </li></ul><ul><li>Result of severe  vertebral body distort...
Post op.
 
 
 
Kyphosis:
Kyphosis : <ul><li>Postural kyphosis . </li></ul><ul><li>Structural kyphosis : </li></ul><ul><li>A kyphos or gibbus .  </l...
 
 
 
 
Thorax kyphosis
Types of kyphosis : <ul><li>Childhood-Congenital TB,dysplsia. </li></ul><ul><li>Adolescent kyphosis (Sheuermann’s dis. ) <...
Congenital kyphosis : <ul><li>Failure of formation “type1”.comon,worsecord compression,--6y.40 </li></ul><ul><li>Failure o...
Failure of segmentation. Left: block vertebra. Right: unilateral unsegmented bar .
Adolescent kyphosis (Sheuermann’s disease) : <ul><li>With increasing growth and muscular activity , affected vertebrae in ...
Clinical features : <ul><li>age. </li></ul><ul><li>gender. </li></ul><ul><li>Cl/p </li></ul><ul><li>deformity :  </li></ul...
Examination : <ul><li>Smooth thoracic kyphosis- marked hump. </li></ul><ul><li>Below it -lumber lordosis. </li></ul><ul><l...
Rare complications include : <ul><li>Spastic paresis of the lower limb. </li></ul><ul><li>Cardiopulmonary dysfunction in s...
X-rays : <ul><li>Lat.view-end platesT6-T10 irregular . </li></ul><ul><li>body may become wedge shaped. </li></ul><ul><li>S...
Lateral X-ray
Preoperative lateral of a patient with an 85° thoracic deformity secondary to Scheuermann kyphosis .
Postoperative lateral
(Sheuermann’s disease) :
Kyphosis measure :
DDx. : <ul><li>Postural kyphosis :  </li></ul><ul><li>Discitis , osteomyelitis, &TB spondylitis: </li></ul><ul><li>Spondyl...
Out come : <ul><li>The condition is often quite painful during adolescence & symptoms subside after a few years . </li></u...
Rx. : <ul><li>Back straightening exercises r indicated if curves < 40 degrees . </li></ul><ul><li>Bracing is indicated if ...
Kyphosis in elderly <ul><li>A-degenerative  </li></ul><ul><li>B-osteoporosis </li></ul><ul><li>-post menopausal </li></ul>...
 
 
<ul><li>Thank you </li></ul>
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Orthopedics 5th year, 3rd lecture (Dr. Hamid)

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The lecture has been given on May 11th, 2011 by Dr. Hamid.

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Transcript of "Orthopedics 5th year, 3rd lecture (Dr. Hamid)"

  1. 1. Thoracic and Lumbar Spine Anatomy
  2. 2. Lumbar Anatomy <ul><li>5 vertebrae L1-L5 </li></ul><ul><li>5 intervertebral discs </li></ul><ul><li>5 pair of exiting nerve roots </li></ul><ul><li>Lumbar lordosis L1-S1 ranges from 30°–80° </li></ul><ul><ul><li>The apex of lumbar lordosis L3-L4 </li></ul></ul>1 2 3 4 5
  3. 3. Lumbar Spine Anatomy <ul><li>Typical lumbar vertebra (L2) </li></ul><ul><ul><li>Body </li></ul></ul><ul><ul><li>Vertebral foramen/canal </li></ul></ul><ul><ul><li>Intervertebral foramen </li></ul></ul><ul><ul><li>Pedicle </li></ul></ul><ul><ul><li>Transverse process </li></ul></ul><ul><ul><li>Lamina </li></ul></ul><ul><ul><li>Spinous process </li></ul></ul><ul><ul><li>Facet joints </li></ul></ul><ul><ul><li>Pars interarticularis </li></ul></ul>inferior Inferior superior Superior Anterior (oblique) A Lateral P Posterior (oblique) Superior
  4. 4. Lumbar Spine Anatomy <ul><li>Ligaments </li></ul><ul><ul><li>Anterior longitudinal ligament </li></ul></ul><ul><ul><li>Posterior longitudinal ligament </li></ul></ul><ul><ul><li>Ligamentum flavum </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Supraspinous ligament </li></ul></ul><ul><ul><li>Intertransverse ligaments </li></ul></ul>1 3 4 5 6 2
  5. 5. Lumbar Spine Anatomy: Nerve Structures <ul><li>The spinal cord and nerve roots are often affected by skeletal problems </li></ul><ul><li>Discs and bony tissue can interfere with normal nerve function and cause pain </li></ul>
  6. 6. Lumbar Spine Anatomy: Nerve Structures <ul><li>Conus medularis </li></ul><ul><li>The point at which the thick, single strand of the spinal cord ends </li></ul><ul><li>Typically at T12 or L1 </li></ul>Note: in this illustration, the posterior elements of the spine, along with the dura mater and arachnoid mater, are not shown.
  7. 7. Lumbar Spine Anatomy: Nerve Structures <ul><li>Cauda equina </li></ul><ul><li>The point at which individual nerve roots continue down through the spinal canal </li></ul>Note: in this illustration, the posterior elements of the spine, along with the dura mater and arachnoid mater, are not shown.
  8. 8. Lumbar Spine Anatomy: Vascular Structures <ul><li>The aorta and vena cava bifurcate around the level of the L3/L4 disc space </li></ul><ul><ul><li>Aorta </li></ul></ul><ul><ul><li>Vena cava </li></ul></ul><ul><ul><li>Iliac arteries </li></ul></ul><ul><ul><li>Iliac veins </li></ul></ul><ul><ul><li>Midsacral vessels </li></ul></ul>
  9. 9. Thoracic Vertebrae <ul><li>Bodies </li></ul><ul><li>Pedicles </li></ul><ul><li>Laminae </li></ul><ul><li>Spinous Processes </li></ul><ul><li>Transverse Processes </li></ul><ul><li>Inferior & Superior Facets </li></ul><ul><li>Distinguishing Feature </li></ul><ul><ul><li>Costal Fovea </li></ul></ul><ul><ul><ul><li>T1 </li></ul></ul></ul><ul><ul><ul><li>T2-T8 </li></ul></ul></ul><ul><ul><ul><li>T9-12 </li></ul></ul></ul>
  10. 10. Thoracic Vertebrae and Rib Junction <ul><li>Thoracic Spine </li></ul><ul><ul><li>Costovertebral Joint </li></ul></ul><ul><ul><li>Costotransverse Joint </li></ul></ul><ul><li>Motions </li></ul><ul><ul><li>All available </li></ul></ul><ul><ul><li>Flexion and extension limited </li></ul></ul><ul><ul><li>T7-T12 </li></ul></ul>
  11. 11. Spinal deformities
  12. 12. Introduction : <ul><li>Spinal deformities </li></ul><ul><li>Coronal plane : scoliosis </li></ul><ul><li>Sagittal plane : hyperkyphosis or hyperlordosis . </li></ul><ul><li>Scoliosis : </li></ul><ul><li>diff ; </li></ul><ul><li>types : </li></ul>
  13. 13. 1-postural scoliosis : <ul><li>Short leg </li></ul><ul><li>Pelvic tilt </li></ul><ul><li>Local muscle spasm :sciatic scoliosis. </li></ul>
  14. 15. 2-Structural scoliosis : <ul><li>bony abn. vertebral rotation </li></ul><ul><li>fixed. </li></ul><ul><li>Secondary curve. </li></ul><ul><li>deformity is liable to increase . </li></ul><ul><li>thoracic region -rib hump . </li></ul>
  15. 20. Types of structural scoliosis : <ul><li>Idiopathic scoliosis “most common”. </li></ul><ul><li>Congenital or osteopathic “bony anomalies”. </li></ul><ul><li>Neuropathic. </li></ul><ul><li>Myopathic (ass. Muscular dystrophies). </li></ul><ul><li>Miscellaneous </li></ul><ul><li>,degenerative. </li></ul>
  16. 21. Clinical features : <ul><li>Hx </li></ul><ul><li>Deformity : . </li></ul><ul><li>Backache : . </li></ul><ul><li>Ask about family hx. </li></ul><ul><li>abn. during pregnancy or child birth. </li></ul>
  17. 22. Examination: <ul><li>Spine -deviated from midline . </li></ul><ul><li>forward bending makes the curve more obvious. </li></ul><ul><li>Level and direction of the major curve </li></ul><ul><li>Hip , scapula,forward,lateral bending,side on posture. </li></ul><ul><li>rib hump on the convex side of the curve. </li></ul><ul><li>Occipit is over the midline </li></ul><ul><li>Neurological exam. </li></ul><ul><li>Leg length </li></ul><ul><li>General exam. cardiac and pulmonary functions . </li></ul>
  18. 23. Imaging: <ul><li>Plain X-ray, full erectPA .lat.spine iliac </li></ul><ul><li>Oblique views . </li></ul><ul><li>Cobb’s angle . </li></ul><ul><li>Skeletal maturity - Risser’s sign </li></ul><ul><li>CT,MRI, </li></ul><ul><li>Pulmaonary function,biochemical test </li></ul>
  19. 25. Cobb’s angle
  20. 27. Risser’s sign
  21. 29. Idiopathic scoliosis : <ul><li>About 80% of all cases of scoliosis,. </li></ul><ul><li>Divided into 3 groups : </li></ul><ul><li>adolescent , </li></ul><ul><li>juvenile, </li></ul><ul><li>infantile. </li></ul>
  22. 30. 1-adolescent idiopathic scoliosis : <ul><li>age . </li></ul><ul><li>gender , </li></ul><ul><li>type ,classification-king </li></ul><ul><li>Progression-pridictors </li></ul>
  23. 32. Rx. : <ul><li>Aims of Rx. . </li></ul><ul><li>Non-operative Rx </li></ul><ul><li>==Exercise </li></ul><ul><li>==Bracing </li></ul><ul><li>Milwaukee brace . </li></ul><ul><li>Boston brace . </li></ul>
  24. 34. Rx. : <ul><li>Operative Rx.indications </li></ul><ul><li>==Objectives of operative Rx. </li></ul><ul><li>----Fixation types </li></ul>
  25. 38. Complications : <ul><li>Surgical—early,late </li></ul><ul><li>non surgical </li></ul>
  26. 39. Main Surgical Indications <ul><li>Relentless Curve Progression </li></ul><ul><li>Major Curve Progression in spite of bracing </li></ul><ul><li>Inability to wean the patient from the brace </li></ul><ul><li>Significant thoracic and lumbar PAIN </li></ul><ul><li>Progressive thoracic lordosis </li></ul><ul><li>Progressive loss of pulmonary function </li></ul><ul><li>Emotional/psychological pressures </li></ul><ul><li>Severe cosmetic changes in the shoulders and trunk </li></ul>
  27. 40. 2- juvenile idiopathic scoliosis : <ul><li>Present at age 4-9 years. </li></ul><ul><li>Uncommon . </li></ul><ul><li>Has similar charac. To those of the adolescent type but worse prognosis. </li></ul><ul><li>Surgical correction may be needed before puberty or bracing until the age of 10 if the child is very young. </li></ul>
  28. 41. 3- infantile idiopathic scoliosis : <ul><li>Presenting under 3 years of age . </li></ul><ul><li>Rare </li></ul><ul><li>Males are more affected & most curves are left thoracic. </li></ul><ul><li>90% of infantile curves resolve spontaneously but progressive curves can become very severe & carry a high incidence of cardiopulmonary dysfunction. </li></ul>
  29. 43. Osteopathic “congenital “ scoliosis : <ul><li>The commonest bony cause is vertebral anomalies : hemivertebra , wedge vertebra, fused vertebra & absent or fused rib . </li></ul><ul><li>Overlying tissue often show angioms ,naevi ,excess hair ,dimples or a pad of fat and spina bifida . </li></ul><ul><li>Fractures and bone softening may lead to scoliosis as in rickets and osteogenesis imperfecta . </li></ul><ul><li>Usually mild but some cases progress into severe deformities. </li></ul><ul><li>Rx. Is more difficult & specialized than that of idiopathic infantile scoliosis & surgical correction carry significant risk of cord injury. </li></ul>
  30. 46. Neuropathic & myopathic scoliosis : <ul><li>Causes include : </li></ul><ul><li>Poliomyelitis </li></ul><ul><li>Cerebral palsy </li></ul><ul><li>Syringomyelia </li></ul><ul><li>Muscle dystrophies. </li></ul>
  31. 47. Neuromuscular Deformity <ul><li>Poliomyelitis : Lower Motor Neuron Disease which depends on the muscle groups most severely involved and on the overpull created by unopposed muscle groups on the opposite side. </li></ul><ul><li>Cerebral Palsy: Upper Motor Neuron Disease which causes muscle imbalance. </li></ul><ul><li>Myopathic Forms: Muscular Dystrophies </li></ul>
  32. 49. Neuropathic & myopathic scoliosis : <ul><li>Rx. : </li></ul><ul><li>Mild curves : no Rx. </li></ul><ul><li>Moderate curves : - idiopathic scoliosis. </li></ul><ul><li>Severe curves -, operative Rx, is indicated. </li></ul>
  33. 50. <ul><li>Neuromuscular scoliosis-severe scoliosis secondary to quadriplegic cerebral palsy . </li></ul>
  34. 51. Neurofibromatosis <ul><li>Causes severe kyphosis and scoliosis </li></ul><ul><li>Result of severe vertebral body distortions. </li></ul><ul><li>Can lead to paraparesis and parapalegia </li></ul><ul><li>Should be treated aggressively with both anterior and posterior fusion . </li></ul>
  35. 52. Post op.
  36. 56. Kyphosis:
  37. 57. Kyphosis : <ul><li>Postural kyphosis . </li></ul><ul><li>Structural kyphosis : </li></ul><ul><li>A kyphos or gibbus . </li></ul>
  38. 62. Thorax kyphosis
  39. 63. Types of kyphosis : <ul><li>Childhood-Congenital TB,dysplsia. </li></ul><ul><li>Adolescent kyphosis (Sheuermann’s dis. ) </li></ul><ul><li>Adult-trauma,TB-AS </li></ul><ul><li>Kyphosis in the elderly-degenerative and osteoporosis. </li></ul>
  40. 64. Congenital kyphosis : <ul><li>Failure of formation “type1”.comon,worsecord compression,--6y.40 </li></ul><ul><li>Failure of segmentation “type 2” . </li></ul><ul><li>Combination of both . </li></ul>
  41. 65. Failure of segmentation. Left: block vertebra. Right: unilateral unsegmented bar .
  42. 66. Adolescent kyphosis (Sheuermann’s disease) : <ul><li>With increasing growth and muscular activity , affected vertebrae in thoracic spine may give way slightly and become wedge shaped and the normal kyphosis is exaggerated . </li></ul><ul><li>In the lumbar spine forces are more evenly distributed and deformity does not occur. </li></ul>
  43. 67. Clinical features : <ul><li>age. </li></ul><ul><li>gender. </li></ul><ul><li>Cl/p </li></ul><ul><li>deformity : </li></ul><ul><li>backache and fatigue. </li></ul>
  44. 68. Examination : <ul><li>Smooth thoracic kyphosis- marked hump. </li></ul><ul><li>Below it -lumber lordosis. </li></ul><ul><li>Deformity.not correctable-changes posture </li></ul><ul><li>Mild scoliosis is not uncommon. </li></ul>
  45. 69. Rare complications include : <ul><li>Spastic paresis of the lower limb. </li></ul><ul><li>Cardiopulmonary dysfunction in severe thoracic deformity . </li></ul><ul><li>pt. with thoracic kyphosis may develop lumbar backache. </li></ul>
  46. 70. X-rays : <ul><li>Lat.view-end platesT6-T10 irregular . </li></ul><ul><li>body may become wedge shaped. </li></ul><ul><li>Schmorl’s node . </li></ul><ul><li>Angle of deformity is measured as scolios. </li></ul><ul><li>Overall kyphosis angle >40 is abnormal. </li></ul><ul><li>Mild scoliosis is common </li></ul>
  47. 71. Lateral X-ray
  48. 72. Preoperative lateral of a patient with an 85° thoracic deformity secondary to Scheuermann kyphosis .
  49. 73. Postoperative lateral
  50. 74. (Sheuermann’s disease) :
  51. 75. Kyphosis measure :
  52. 76. DDx. : <ul><li>Postural kyphosis : </li></ul><ul><li>Discitis , osteomyelitis, &TB spondylitis: </li></ul><ul><li>Spondyloepiphyseal dysplasia: </li></ul>
  53. 77. Out come : <ul><li>The condition is often quite painful during adolescence & symptoms subside after a few years . </li></ul><ul><li>There may be a recurrent backache in later life but the condition is rarely disabling. </li></ul>
  54. 78. Rx. : <ul><li>Back straightening exercises r indicated if curves < 40 degrees . </li></ul><ul><li>Bracing is indicated if curves 40-60 degrees in a child who still has some years of growth ahead . </li></ul><ul><li>Operative Rx. Is indicated for curves >60 degrees. </li></ul>
  55. 79. Kyphosis in elderly <ul><li>A-degenerative </li></ul><ul><li>B-osteoporosis </li></ul><ul><li>-post menopausal </li></ul><ul><li>-senile </li></ul>
  56. 82. <ul><li>Thank you </li></ul>
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