Clinical spinal anatomy for students v2

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Clinical spinal anatomy for students v2

  1. 1. Clinical spinal anatomy Mr. Daniel Chan FRCSEd FRCSOrth Consultant Orthopaedic Spinal Surgeon PEOC/RD and E
  2. 2. Anatomy of the Spine Cervical spine 7 vertebrae C1 - C7 Thoracic spine 12 vertebrae T1-T12 (D1-D12) Lumbar Spine 5 vertebrae L1-L5 Sacrum & Coccyx 5 fused vertebrae S1-S5 3-5 Coccygeal segments
  3. 3. • Axial skeleton • Protection of neural structures • Flexible weight bearing column • Anterior compression column • Posterior tension column • Facets resist rotation and anterior displacement ANTERIOR COLUMN • solid column of vertebral bodies • compression-resistant POSTERIOR COLUMN • hollow column of neural canal • tension-resistant
  4. 4. Sagittal profile • To maintain upright balance • Cervical and lumbar lordosis • Thoracic and sacral kyphosis
  5. 5. 0 1 2 3 4 5 6 7 upper cervical spine - Axial lower cervical spine – Sub-Axial
  6. 6. Anatomy - Osteology • Occiput – Inion – external occipital protuberance – Transverse sinus close proximity – Occipital screws just below inion (thick) • Typical - C3-6 • Atypical - Atlas, Axis, C7 (vertebra prominens)
  7. 7. C0-C2 Joint surfaces very unstable Stability via ligaments Major stabiliser C1-C2 Restricts rotation of occiput on dens Major ligs of subaxial spine + lig flavum + inter + supra spinous ligs
  8. 8. Steel’s Rule of Thirds 1/3 Dens 1/3 Cord 1/3 Space
  9. 9. Feel your own!
  10. 10. For feeling the pulse! Tripod = VB + 2 Facets / Lateral masses Scalenes ant + med
  11. 11. Uncinate Process Uncovertebral Joints of Luschka Limit Lateral Translation or Bending Guide Rail for Flexion / Extension
  12. 12. Anatomy - Articulations • Arc of motion: • Flexion/Extension 145° • Axial rotation 180° • Lateral flexion 90°
  13. 13. Anatomy - Articulations • 50% cervical flex / ext @ Co-C1 • 50% cervical rot @ C1-C2 • Rest motion in sub-axial spine by “coupling” action of motion segments • Sub-axial cervical facet joint orientation unique – 45˚ sagittal – 0˚ coronal
  14. 14. Anatomy - Neural • • 8 Cervical nerves 7 Vertebrae • • • Dorsal root + DRG = sensory Ventral root = motor Unite = spinal nerve • • • Dorsal ramus = to the back Ventral ramus = to the front Sinuvertebral nerve = to the spinal column
  15. 15. Anatomy - Neural
  16. 16. Pedicles small and highly variable Therefore – lateral mass screws 1mm 15o Starting point 1mm Vertebral artery medial to centre of anterior to entry lateral mass point
  17. 17. Place a flat probe in the facet joint of the level to be fused to indicate the cephalad angulation of the drill or ‘K’ wire
  18. 18. posterior atlanto occipital membrane spinal cord suboccipital nerve atlas atlanto -axial joint axis vertebral artery greater occipital nerve
  19. 19. Atlanto-axial dislocationssurgical stabilisation • Magerl transarticular screw fixation
  20. 20. Atlanto-axial dislocationssurgical stabilisation • Gallie C1/2 wiring
  21. 21. Atlanto-axial dislocation Surgical stabilisation • Brook Jenkins C1/2 fusion
  22. 22. (Goel) Harm’s C1/2 fixation
  23. 23. DF injury • example
  24. 24. DF injury • Reduction of unifacet dislocation
  25. 25. DF injury - redisplacement
  26. 26. • Roger’s wiring • Bohlman’s triple wiring
  27. 27. Posterior stabilisation
  28. 28. Lateral mass fixation
  29. 29. Thoracic Anatomy 12 Vertebrae, Smaller than Lumbar Facets Frontally Orientated in A-P View Spinous Processes Longer, Distally Orientated Transition at Thoracolumbar Junction T9-12
  30. 30. Anatomy – general considerations •transverse processes short but thick, orientated postero-laterally, articulate with ribs •Pedicles smaller •Spinal Canal smaller diameter •Ribs articulate with vertebral bodies
  31. 31. Anatomy – body and pedicles •Left side flattened due to aorta •Heart shaped •Pedicles smallest at T3-6 (3-4mm) •Centre projects intersection 1-2mm medial to lateral lamina with parallel line superior 1/3 tp.
  32. 32. Anatomy -costovertebral joints and ribs •1st, 11th and 12th ribs soleley with named vertebra •2-10 with rostral neighbour •Articulate with anterior tp
  33. 33. Structures anterior to thoracic spine
  34. 34. Tomita Procedure • 55/M(AM) • Back pain+ paraparesis • T7 Mets • Tokuhashi Score-12 • Hypernephroma primary
  35. 35. Tomita procedure (Spine 1997; 22: 324-333)
  36. 36. 3 months 28 months No recurrence
  37. 37. Lumbar Spine • L1 to L4 ‘Typical’ Lumbar Vertebrae - wide strong kidney shaped bodies with parallel endplates; - a wide posterior arch fusing to form a horizontally projecting spinous process - Superior facets face posteromedially, Inferior facets face anterolaterally and therefore allow flexion/extension but limit rotation
  38. 38. Anterior longitudinal ligament Posterior longitudinal ligament Intervertebral disc Ligamentum flavum Interspinous ligament Supraspinous ligament
  39. 39. Pars interarticularis Spondylolysis: The Scotty Dog Spondylolytic spondylolisthesis
  40. 40. • NUCLEUS PULPOSUS – GAGS. Hydrated Aggrecans – Hydrostatic structure • ANNULUS FIBROSUS – fibrocartilagenous structure with different “meshtype” layers
  41. 41. Cauda equina and Nerves roots L4 L5
  42. 42. Degenerative • Disc herniations
  43. 43. Anatomy • • • Thoracolumbar fascia Cluneal nerves Sacrospinalis – Iliocostalis – Longissimus – Spinalis • • • multifidus rotators intertransversarii
  44. 44. Anatomy • crest on pars • crest on TP • converge on superior facet
  45. 45. Sacral anatomy • lateral sacral crest • junction with superior facet
  46. 46. Sacral anatomy • converge to promontary • diverge to ala
  47. 47. Plan screw trajectory MRI Plain X rays
  48. 48. Anterior relations
  49. 49. Cross section anatomy - L4 L5 • root medial and inferior to pedicle • great vessels anterior L4 L5
  50. 50. Cross section anatomy - S1 • “bare” area • L5 root S1
  51. 51. L4/5 exposure L5S1 exposure
  52. 52. May the force be with you
  53. 53. Clinical Instability Clinical Instability The loss of the ability of the spine under The loss of the ability of the spine under physiological loads to maintain its pattern physiological loads to maintain its pattern of displacement so that there is no initial or of displacement so that there is no initial or additional neurological deficit, no major additional neurological deficit, no major deformity, and no incapacitating pain deformity, and no incapacitating pain White and Panjabi Clin Orthopaedics 1975

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