Clinical anatomy of_the_back by- dr. armaan singh

1. By- Dr. Armaan SinghBy- Dr. Armaan Singh
Clinical Anatomy of the Back

2. PROGRESS
TimeTime
Goh et al. Clin Biomech 1999;14:439

3. SPINE
Consists of
• Cervical Vertebrae
• Thoracic Vertebrae
• Lumbar Vertebrae
• Sacrum

4. • 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
Spine

5. VERTEBRAL COLUMN
• Lot of stress in variety of sports
• Cervical pathology
• Pain may be referred to upper limb
• Lumber pathology
• Lower limb

6. YOUNG SPINE
Normal curvature of
infant’s spine
Normal lumbar curve
of toddler’s spine

7. 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. • 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
Low Back Pain in Sports

9. • Must know the sport
• Must understand the biomechanics and
stresses involved in the sport
• Must examine the spine
in the appropriate position
Low Back Pain in Sports

10. 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. LUMBAR VERTEBRAE

12. 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. 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. • 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
Lumbar Vertebrae

15. 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. 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. PARS INTERARTICULARIS
• Pars interarticularis
• Portion of lamina between superior
and inferior articular processes
• Site of spondylolysis or
spondylolisthesis

18. LUMBAR SPINE
• Cancellous bone
• 50% compressive strength
• Facet joints 20% in standing
upright position

19. LUMBAR VERTEBRAE

20. LUMBAR VERTEBRAE

21. LUMBAR SPINE
• Cancellous bone
• 50% of the compressive
strength
• Facet joints, 20% of the strength in
the standing upright position

22. ANTERIOR LONGITUDINAL LIGAMENT
• Attached mainly to the bodies
• This ligament helps to prevent us from leaning too far
back (hyperextension)

23. POSTERIOR LONGITUDINAL LIGAMENT
• Attached mainly to the inter
vertebral discs
• This ligament helps to restrict
forward bending (hyperflexion)

24. 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. • 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
Ligamentum Flava

26. 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. 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. ARTHRITIS OF SPINE
• Painful
• Limitation of movement
• Extra projections
• Narrowing of disc spaces

29. VERTEBRAL JOINTS
• Secondary cartilaginous joints between
the bodies
• Hyaline cartilage covering bodies
• Disc of fibrocartilage in between
• Synovial plane joints between the facets

30. 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. 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. 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. 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. AXIAL LOAD AND END-PLATES

35. 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. 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. END-PLATE SUSCEPTIBILITY
Schmorl & Junghanns. The human spine in health and disease.
New York: Grune & Stratton, 1965
Notochord

38. 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. • Narrowing of disc space, results in
stress on
facet joint
• Highest pressure during
• Combined
• Extension
• Rotation
• Compression
Facet Joints

40. 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. SEGMENTAL ROTATION
Singer et al. J Musculoskel Res 2001;5: 45-55

42. • Flexion limited by
disc problems
• Lateral flexion
• Extension limited by
facet joint problems
• Very little rotation
• Extension and rotation
affect facet joints
MOVEMENTS OF LUMBAR SPINE

43. NERVE SUPPLY
• Nerve supply
• Peripheral annulus
• Facet joint
• Nerve is medial branch dorsal
ramus

44. BLOOD SUPPLY
• Lumbar arteries
• Internal venous plexuses
• External venous plexuses
• Basivertebral veins
• Valveless

45. LUMBAR VERTEBRAE

46. CANCELLOUS BONE
• Cancellous bone
• 50% compressive strength
• Facet joints 20% in standing
upright position
Normal bone Osteoporotic bone

47. ANATOMICAL ABNORMALITIES
• Spina Bifida Occulta
• Facet Tropism
• Kyphosis
• Scoliosis

48. ANATOMICAL ABNORMALITIES
Kyphosis Scoliosis

49. ANATOMICAL ABNORMALITIES
• Hemi-vertebra
• Spina Bifida Occulta
• Facet Tropism
• Scoliosis
• Kyphosis

50. ANATOMICAL ABNORMALITIES
• Unilateral lumbarisation
• Unilateral sacralisation

51. 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. EPIDEMIOLOGY
Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837

53. Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837-65
EPIDEMIOLOGY
• Back pain in the community is 60% - 80%
• Recurrence of back pain is
70% - 90%
• Progression to chronic back pain is 5% -
10%

54. 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. CHRONIC LOW BACK PAIN
• Local structures
• Muscles
• Ligaments
• Poor lifting techniques
• Joints
• Bones

56. BACK PAIN
Local structures
• Muscles, ligaments
• Joints
Referred pain
• Abdominal organs
• Pelvic organs
Must out rule
• Infection
• Tumours

57. 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. 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. 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. CHRONIC LOW BACK PAIN
Pain referred
• Abdominal organs
• Pelvic organs
Must out rule
• Infection
• Tumours

61. PAIN REFERRED

62. YOUNG ATHLETE
• Junior rugby team 15 years of age
• M. Scheuermann
• 5 Spina bifida occulta
• The scrum half had degenerative
facet joint changes

63. SACROILIAC JOINT – SCIATIC NERVE

64. 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. SPINAL STENOSIS

66. PREDISPOSING FACTORS
• Intrinsic factors
• Anatomical abnormalities
• Biomechanical
• Extrinsic factors
• Sport
• Surfaces
• Equipment
• Training

67. PREDISPOSING FACTORS BACK PAIN
• Poor posture
• Overweight
• Unfit

68. PREDISPOSING FACTORS
• Poor core stability
• Weak abdominal muscles
• Weak gluteal muscles
• Muscle imbalance

69. PREDISPOSING FACTORS
• Poor core stability
• Weak abdominal muscles
• Weak gluteal muscles
• Muscle imbalance
• Pronated or cavus feet

70. PREDISPOSING FACTORS
• Badly designed furniture
• No back support
• Poor posture at work

71. ACUTE LOW BACK PAIN

72. 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. ANNULAR BULGE

74. DISC LESION

75. YOUNG ATHLETE
• Junior rugby team 15 years of age
• M. Scheuermann
• 5 Spina bifida occulta
• The scrum half had degenerative
facet joint changes

76. SCHEUERMANN’S DISEASE
Greene et al. J Pediatr Orthop 1985;5:1

77. SPONDYLOLISTHESIS

78. PARS INTERARTICULARIS
• Pars interarticularis, portion of lamina
between superior and inferior articular
processes
• Site of spondylolysis or spondylolisthesis

79. SPONDYLOLISTHESIS

80. SPONDYLOLYSIS AND SPONDYLOLISTHESIS

81. PARS INTERARTICULARIS; FACET JOINT

82. SPONDYLOLISTHESIS
RAPID FLEXION AND EXTENSION
• Gymnastics, flips
• Vaulting
• Ballet, arabesque
• Lifting during dance
• Diving
• Butterfly swimming
• Decathlon
• Pole vaulting

83. ANKYLOSING SPONDYLITIS, INFECTION

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

85. 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. 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. 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. AXIAL COMPRESSIVE LOADING
• Head on collisions
• Motor sports
• Boating accidents
• Wrestling
• Horseback riding
• Bicycling
• Bobsleigh

89. AXIAL COMPRESSIVE LOADING

90. AXIAL COMPRESSIVE LOADING

91. AXIAL COMPRESSIVE LOADING

92. COMPRESSION STRESS

93. ROTATIONAL STRESS

94. ROTATIONAL STRESS

95. SPONDYLOLISTHESIS
RAPID FLEXION AND EXTENSION
• Gymnastics, flips
• Vaulting
• Ballet, arabesque
• Lifting during dance
• Diving
• Butterfly swimming
• Decathlon
• Pole vaulting

96. AUSTRALIAN FOOTBALL LEAGUE
Seward & Orchard. 2000 AFL Injury Report, Australian Sports Commission

97. 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. SUSTAINED POSTURES -
HYPEREXTENSION

99. SUSTAINED POSTURES -
HYPEREXTENSION

100. SUSTAINED POSTURES -
HYPEREXTENSION

101. SUSTAINED POSTURES - FLEXION

102. SCOLIOSIS DUE TO UNILATERAL SPORTS
• Racquet sports
• Fencing
• Sweep rowing
• Javelin
• Freestyle unilateral breathing

103. SCOLIOSIS DUE TO UNILATERAL SPORTS

104. RUNNING
• Poor posture
• Poor abdominal
• Pronated feet
• Muscle imbalance
• Leg length discrepancy
• Osteoporosis

105. CRICKET
• Bowlers
• Rotational forces
• Extension followed by rotation
and flexion