4. Cervical SpineCervical Spine
Seven vertebraeSeven vertebrae
– C 1-7C 1-7
More flexibleMore flexible
Wide range of motionWide range of motion
– RotationRotation
– FlexionFlexion
Peripheral NervesPeripheral Nerves
– ArmsArms
– Shoulder, Chest and diaphragmShoulder, Chest and diaphragm
5. Cervical SpineCervical Spine
Spinous processes increase in length distallySpinous processes increase in length distally
C 1-2 almost transverse,C 1-2 almost transverse,
C 2- T 1 --45º to transverseC 2- T 1 --45º to transverse
Occipito Atlantoaxial complexOccipito Atlantoaxial complex ––
specialized articulation,specialized articulation,
large ROM,large ROM,
no diskno disk
– 60% axial rotation – C 1-2,60% axial rotation – C 1-2,
– difficult for occipital condyles to slide on C 1,difficult for occipital condyles to slide on C 1,
– no loss with agingno loss with aging
– Lateral bending – small, alar ligamentLateral bending – small, alar ligament
––Inter axial rotation(IAR)-- close to cord, rotate without impingementInter axial rotation(IAR)-- close to cord, rotate without impingement
6. C 3-7 – flexion -extension predominates, lateralC 3-7 – flexion -extension predominates, lateral
bendingbending
– IAR – lower vertebra (flex-ex); upper vertebra (lateralIAR – lower vertebra (flex-ex); upper vertebra (lateral
bending)bending)
– Distinct coupling pattern – lateral bending & axialDistinct coupling pattern – lateral bending & axial
rotation,rotation,
– spinous process point opposite to lateral bendspinous process point opposite to lateral bend
– Axial rotation – limited by uncinate processes & facetsAxial rotation – limited by uncinate processes & facets
Intradural sagittal diameterIntradural sagittal diameter
– 2-3mm lower in extension2-3mm lower in extension
– Posteroinferior margin of upper vertebra &Posteroinferior margin of upper vertebra &
ligamentum flavumligamentum flavum
– Cord thicker in extension> less play in extensionCord thicker in extension> less play in extension
– Canal widest at C 1-2, narrows at C 5Canal widest at C 1-2, narrows at C 5
7. Thoracic SpineThoracic Spine
Mid-back or dorsal regionMid-back or dorsal region
Ribs attached to vertebraeRibs attached to vertebrae
Relatively immobileRelatively immobile
Peripheral nervesPeripheral nerves
– IntercostalIntercostal
9. Lumbar SpineLumbar Spine
Lower backLower back
Carries the the weight of the upperCarries the the weight of the upper
bodybody
– Larger, broaderLarger, broader
Peripheral nervesPeripheral nerves
– LegsLegs
– PelvisPelvis
10. Lumbar SpineLumbar Spine
Flexion-ExtensionFlexion-Extension
– large, due to sizable disks & lack of facetlarge, due to sizable disks & lack of facet
restraintrestraint
– IAR – posterior half of disk, moves withIAR – posterior half of disk, moves with
flexion-extensionflexion-extension
Centrode – path of moving IARCentrode – path of moving IAR
Lateral bending – IAR on left side ofLateral bending – IAR on left side of
disk with right benddisk with right bend
Axial rotation – IAR in posterior nucleusAxial rotation – IAR in posterior nucleus
Disk degeneration – IAR spread outDisk degeneration – IAR spread out
11. Sagittal plane TranslationSagittal plane Translation
– 2-3 mm, normal in symptom free pts2-3 mm, normal in symptom free pts
– Up to 5 mm in L 3-4 & L4-5, 4 mm in L5-S1Up to 5 mm in L 3-4 & L4-5, 4 mm in L5-S1
Lateral bending & Axial Rotation couplingLateral bending & Axial Rotation coupling
– Spinous processes point in same direction asSpinous processes point in same direction as
lateral bendinglateral bending
– Opposite of cervical, upper thoracic,Opposite of cervical, upper thoracic,
lumbosacrallumbosacral
12. Sacral and Coccygeal regionSacral and Coccygeal region
SSacrumacrum
– Triangular structureTriangular structure
– Base of the spineBase of the spine
– Connects spine to pelvisConnects spine to pelvis
– Nerves to pelvic organsNerves to pelvic organs
CoccyxCoccyx
– Few small bonesFew small bones
– Remnant of tailRemnant of tail
13. Sacroiliac RegionSacroiliac Region
Poorly understoodPoorly understood
Partly synovial, partly syndesmoticPartly synovial, partly syndesmotic
Stiff, coarse interdigitating articular surfacesStiff, coarse interdigitating articular surfaces
IAR scatteredIAR scattered
Complete ankylosis in up to 76% over age of 50Complete ankylosis in up to 76% over age of 50
Joint motion – overcome ligamentous resistance,Joint motion – overcome ligamentous resistance,
1 leg stance1 leg stance
14. General KinematicsGeneral Kinematics
CurvatureCurvature
– SagittalSagittal
– Shape of vertebrae & disks, rib cage, inclination ofShape of vertebrae & disks, rib cage, inclination of
sacral end platesacral end plate
– Developmental phenomenon, posture, rate of growthDevelopmental phenomenon, posture, rate of growth
– Add flexibility & shock absorbing capabilityAdd flexibility & shock absorbing capability
6 degrees of freedom6 degrees of freedom
– Translation & RotationTranslation & Rotation
– 3 orthogonal planes3 orthogonal planes
– Motion usually coupledMotion usually coupled
Center of gravityCenter of gravity – in front of 2– in front of 2ndnd
sacral segmentsacral segment
16. ROMROM
– Facet joints & Intervertebral disksFacet joints & Intervertebral disks
– C spineC spine
Flexion-extension predominates, midcervicalFlexion-extension predominates, midcervical
Axial rotation, upper cervicalAxial rotation, upper cervical
Lateral bendingLateral bending
– T spineT spine
Little motion, rib cage.Little motion, rib cage.
– L spineL spine
Lateral bending, mid portionLateral bending, mid portion
Flexion-extension, lumbosacralFlexion-extension, lumbosacral
Rotation, minimalRotation, minimal
– Greater mobility at C & L spine> more stress> moreGreater mobility at C & L spine> more stress> more
clinical complaintsclinical complaints
17.
18. Shear & Tensile CharacteristicsShear & Tensile Characteristics
In direct shear testsIn direct shear tests
– Shear stiffness in horizontal directionShear stiffness in horizontal direction
260 N/mm260 N/mm22
Spine rarely fails in pure shearSpine rarely fails in pure shear
Similarly under normal physiologic activitiesSimilarly under normal physiologic activities
– Pure tensile loading doesn’t occurPure tensile loading doesn’t occur
– But annulus undergoes tensile loading duringBut annulus undergoes tensile loading during
BendingBending
Axial rotationAxial rotation
ExtensionExtension
19.
20. Compressive load characteristicsCompressive load characteristics
Cancellous boneCancellous bone
– Large deformationLarge deformation
Up to 9.5% before failureUp to 9.5% before failure
Cortical boneCortical bone
– Small deformationSmall deformation
Up to 2% before failureUp to 2% before failure
21.
22.
23. Measurements of In vivo LoadsMeasurements of In vivo Loads
Needle pressureNeedle pressure
transducertransducer
CalibratedCalibrated
– Introduced intoIntroduced into
nucleus pulpous ofnucleus pulpous of
cadaveric functionalcadaveric functional
unitunit
Inserted in vivo inInserted in vivo in
L3-4 discL3-4 disc
25. Vertebral BodyVertebral Body
Primary load-transmitting element, 80-90%Primary load-transmitting element, 80-90%
Bone Mineral Content--Bone Mineral Content-- Osteoporosis> lossOsteoporosis> loss
of horizontal trabeculaeof horizontal trabeculae
SizeSize
– Increasing size from C to L spineIncreasing size from C to L spine
Compressive load> pressure higher inCompressive load> pressure higher in
center of end plates than peripherycenter of end plates than periphery
In vivo, filled with blood> greater strength,In vivo, filled with blood> greater strength,
hydraulic shock absorberhydraulic shock absorber
Weaker anterior trabeculae, Wolff’s lawWeaker anterior trabeculae, Wolff’s law
26. Posterior ElementsPosterior Elements
Pedicles, lamina, facet joints, spinous &Pedicles, lamina, facet joints, spinous &
transverse processestransverse processes
Bony processes> lengthen moment arms ofBony processes> lengthen moment arms of
musclesmuscles
Forces on processes> transmitted to LaminaForces on processes> transmitted to Lamina
Forces on posterior elements> transmitted toForces on posterior elements> transmitted to
vertebral bodies from Pediclesvertebral bodies from Pedicles
Pars InterarticularisPars Interarticularis
– Large bending forces; excessive extensionLarge bending forces; excessive extension
– Thicker than rest of laminaThicker than rest of lamina
– Common site of stress/fatigue fractures> weakensCommon site of stress/fatigue fractures> weakens
motion segment> spondylolithesismotion segment> spondylolithesis
27. Facet JointsFacet Joints
– Major role in controlling motionMajor role in controlling motion
– Resist torsion & shear, role in compressionResist torsion & shear, role in compression
– Lumbar FSU – facets 40% torque resistence,Lumbar FSU – facets 40% torque resistence,
40% disk, 20% ligaments40% disk, 20% ligaments
– Load sharing varies with flexion & extensionLoad sharing varies with flexion & extension
Seated position> decreased lumbar lordosis>Seated position> decreased lumbar lordosis>
increased intradiscal pressure & decreased load-increased intradiscal pressure & decreased load-
bearing of the facetsbearing of the facets
– Orientation of facetsOrientation of facets
C spine - 45º transverse, parallel frontalC spine - 45º transverse, parallel frontal
T spine - 60º transverse, 20º frontalT spine - 60º transverse, 20º frontal
L spine - 90º transverse, 45º frontalL spine - 90º transverse, 45º frontal
– Capsules lax> allow glidingCapsules lax> allow gliding
28. LigamentsLigaments
Nonsegmental longitudinal (ALL, PLL,Nonsegmental longitudinal (ALL, PLL,
supraspinous)supraspinous)
Segmental longitudinal (interspinous,Segmental longitudinal (interspinous,
intertransverse, ligamenta flava)intertransverse, ligamenta flava)
Capsular ligamentsCapsular ligaments
Limit motion, provide stability/equilibriumLimit motion, provide stability/equilibrium
ALLALL
– Interlinked to disksInterlinked to disks
– Resists extensionResists extension
– 2X tensile strength of PLL2X tensile strength of PLL
29. LigamentsLigaments
Nonsegmental longitudinal (ALL, PLL,Nonsegmental longitudinal (ALL, PLL,
supraspinous)supraspinous)
Segmental longitudinal (interspinous,Segmental longitudinal (interspinous,
intertransverse, ligamenta flava)intertransverse, ligamenta flava)
Capsular ligamentsCapsular ligaments
Limit motion, provide stability/equilibriumLimit motion, provide stability/equilibrium
ALLALL
– Interlinked to disksInterlinked to disks
– Resists extensionResists extension
– 2X tensile strength of PLL2X tensile strength of PLL
30. PLLPLL
– Narrow over vertebral bodies, flare out over disks;Narrow over vertebral bodies, flare out over disks;
thin lateral extensionthin lateral extension
– Resists flexionResists flexion
– Ossification> spinal stenosisOssification> spinal stenosis
Ligamentum FlavumLigamentum Flavum
– Elastic & strongElastic & strong
– ““shingled” configuration with laminaeshingled” configuration with laminae
– Lengthen w/ flexion, shorten w/ extensionLengthen w/ flexion, shorten w/ extension
– Loss of disk height or hyperextension> buckle intoLoss of disk height or hyperextension> buckle into
spinal canalspinal canal
Interspinous & SupraspinousInterspinous & Supraspinous
– Resist flexionResist flexion
– Long moment armsLong moment arms
31. MECHANISMS OFMECHANISMS OF
LIGAMENTOUS INJURYLIGAMENTOUS INJURY
Strain rates appear toStrain rates appear to
affect which tissue isaffect which tissue is
damaged.damaged.
Reports of high incidenceReports of high incidence
of ruptured interspinousof ruptured interspinous
ligamentsligaments
Interspinous ligamentsInterspinous ligaments
could be injured by fallingcould be injured by falling
backward and applyingbackward and applying
posterior shear forces withposterior shear forces with
the spine flexed.the spine flexed.
32. Forward-bending with aForward-bending with a
flexed spine increasesflexed spine increases
the shear forces on thethe shear forces on the
spine because of stretchspine because of stretch
of the interspinousof the interspinous
ligaments and theligaments and the
superincumbent weight.superincumbent weight.
Extensor muscles thatExtensor muscles that
cancan prevent anteriorprevent anterior
shearshear on superioron superior
vertebrae are silentvertebrae are silent
when lumbar spinewhen lumbar spine
flexion is far enough toflexion is far enough to
void protection againstvoid protection against
shear.shear.
33. Functional Consideration for theFunctional Consideration for the
Interspinous andInterspinous and
Supraspinous LigamentsSupraspinous Ligaments
Supraspinous ligaments areSupraspinous ligaments are
parallel to the compressiveparallel to the compressive
axis.axis.
Importance of ligaments inImportance of ligaments in
resisting flexion appears to beresisting flexion appears to be
overstated.overstated.
Supraspinous ligament appearsSupraspinous ligament appears
to beto be most importantmost important
ligamentous restraint to flexion.ligamentous restraint to flexion.
34. Interspinous ligamentsInterspinous ligaments areare
oblique to the compressiveoblique to the compressive
axis of the spine, perhapsaxis of the spine, perhaps
providing restraint toproviding restraint to
flexion throughout theflexion throughout the
ROM.ROM.
Interspinous ligamentsInterspinous ligaments
protect against posteriorprotect against posterior
shear forces of theshear forces of the
superior vertebra on thesuperior vertebra on the
inferior vertebra.inferior vertebra.
37. Vertebral MusclesVertebral Muscles
Spine buckles with small compressiveSpine buckles with small compressive
forces without musclesforces without muscles
Anterior, posterior, lateralAnterior, posterior, lateral
Gross-function – span several motionGross-function – span several motion
segssegs
Fine-function – span 1 or 2 segsFine-function – span 1 or 2 segs
Deep back muscles are major spineDeep back muscles are major spine
movers; many other groupsmovers; many other groups
38.
39. MultifidiMultifidi
Multifidi span only aMultifidi span only a
few segments andfew segments and
run parallel to therun parallel to the
compression axis.compression axis.
There forces onlyThere forces only
effect specific areaseffect specific areas
of the spine.of the spine.
Extensor of theExtensor of the
spinespine
40. Abdominal MusclesAbdominal Muscles
RECTUSRECTUS
ABDOMINISABDOMINIS
Major trunk flexorMajor trunk flexor
Sections preventSections prevent
buckling of musclebuckling of muscle
during trunk flexion.during trunk flexion.
Some say no functionalSome say no functional
difference in upper anddifference in upper and
lower segmentslower segments
My next studyMy next study
41. Special Case of the Quadratus Lumborum andSpecial Case of the Quadratus Lumborum and
Psoas MajorPsoas Major
Psoas major appearsPsoas major appears
to be primarily a hipto be primarily a hip
flexor, with little role inflexor, with little role in
lumbar stabilization.lumbar stabilization.
Psoas major dispersesPsoas major disperses
bending stressesbending stresses
across the wholeacross the whole
lumbar spine during hiplumbar spine during hip
flexion.flexion.
42. Special Case of the Quadratus Lumborum andSpecial Case of the Quadratus Lumborum and
Psoas MajorPsoas Major
QuadratusQuadratus
lumborum appearslumborum appears
to be important asto be important as
lumbar stabilizer.lumbar stabilizer.
53. Intervertebral DiscIntervertebral Disc
Soft fibro-cartilaginous cushionsSoft fibro-cartilaginous cushions
– Between two vertebraBetween two vertebra
– Allows some motionAllows some motion
– Serve as shock absorbersServe as shock absorbers
Total – 23 discsTotal – 23 discs
¼¼ thth
of the spinal column's lengthof the spinal column's length
AvascularAvascular
Nutrients diffuse through end platesNutrients diffuse through end plates
54. Intervertebral Disc AnatomyIntervertebral Disc Anatomy
Spongy centerSpongy center
– NucleusNucleus
pulposuspulposus
Surrounded bySurrounded by
a tougher outera tougher outer
fibrous ringfibrous ring
– Anulus fibrosusAnulus fibrosus
55. Nucleus PulposusNucleus Pulposus
Has more water and PGsHas more water and PGs
PG are macro-moleculesPG are macro-molecules
– Attract and retain waterAttract and retain water
– Hydrophilic gel–like matterHydrophilic gel–like matter
Resists compressionResists compression
Amount of waterAmount of water
– Activity relatedActivity related
– Varies throughout the dayVaries throughout the day
56. Nucleus PulposusNucleus Pulposus
– Eccentrically positioned posteriorlyEccentrically positioned posteriorly
– Young & healthyYoung & healthy
50% cross-sectional50% cross-sectional
90% water, bound to proteoglycans90% water, bound to proteoglycans
– Aging> dessication> increase viscosity> fissuringAging> dessication> increase viscosity> fissuring
– Pascal’s lawPascal’s law
Fluid mass within closed container> local increase inFluid mass within closed container> local increase in
pressure> transmit around entire side wall (annulus)pressure> transmit around entire side wall (annulus)
Young nucleus> even distribution of loadYoung nucleus> even distribution of load
Old nucleus> undue concentration on vertebral body edgesOld nucleus> undue concentration on vertebral body edges
– Small displacement w/ ROM, ball-bearing likeSmall displacement w/ ROM, ball-bearing like
– Compressive stress predominatesCompressive stress predominates
57. Anulus FibrosusAnulus Fibrosus
Strong radial tire–like structureStrong radial tire–like structure
Series of lamellaeSeries of lamellae
Concentric sheets of collagenConcentric sheets of collagen
fibersfibers
– Connected to end platesConnected to end plates
– Orientated at various anglesOrientated at various angles
– Under compressionUnder compression
Become horizontalBecome horizontal
Encloses nucleus pulposusEncloses nucleus pulposus
58. Annulus FibrosusAnnulus Fibrosus
– 90 collagen sheets90 collagen sheets
– Fibers of adjacent sheets 30º to each otherFibers of adjacent sheets 30º to each other
– Hyaline cartilage plates & bony ring epiphysesHyaline cartilage plates & bony ring epiphyses
of vertebral bodiesof vertebral bodies
– Vertical component – tension resistor duringVertical component – tension resistor during
flex-ex & lateral bendingflex-ex & lateral bending
– Horizontal component – rotary stressHorizontal component – rotary stress
– Axial load – tensile stressAxial load – tensile stress
59. AnnulusAnnulus
In BendingIn Bending
– Increased tensile force posteriorlyIncreased tensile force posteriorly
– Increased compressive force anteriorlyIncreased compressive force anteriorly
In RotationIn Rotation
– Reorientation of collagenous fibersReorientation of collagenous fibers
– Tightening of fibers traveling in oneTightening of fibers traveling in one
directiondirection
– Loosening of fibers traveling in oppositeLoosening of fibers traveling in opposite
directiondirection
60. DiskDisk
Major restraint to motionMajor restraint to motion
Viscoelastic behavior, demonstrates Creep &Viscoelastic behavior, demonstrates Creep &
HysteresisHysteresis
AvascularAvascular
– End-plate microfractures> vascular ingrowth &End-plate microfractures> vascular ingrowth &
granulation tissue> altered mechanical behaviorgranulation tissue> altered mechanical behavior
– End-plates influence the nutrition; diffusionEnd-plates influence the nutrition; diffusion
Lumbar FSULumbar FSU
– Disk – 40% of torque resistanceDisk – 40% of torque resistance
– Rest by posterior element and ligamentsRest by posterior element and ligaments
Diurnal change in heightDiurnal change in height
– 1% shorter at night; 2% for children; 0.5% for elderly1% shorter at night; 2% for children; 0.5% for elderly
– 50% of height lost during first 2 hours in upright50% of height lost during first 2 hours in upright
Healthy disks creep slowerHealthy disks creep slower
61. Intervertebral Disc FunctionsIntervertebral Disc Functions
Movement of fluid within the nucleusMovement of fluid within the nucleus
– Allows vertebrae to rock back and forthAllows vertebrae to rock back and forth
– FlexibilityFlexibility
Act to pad and maintain the spaceAct to pad and maintain the space
between the twenty-four movablebetween the twenty-four movable
vertebraevertebrae
Act as shock absorbersAct as shock absorbers
Allow extension and flexionAllow extension and flexion
62. Intradiscal PressureIntradiscal Pressure
– Compressive loads in vivo: 500N standing,Compressive loads in vivo: 500N standing,
700N sitting700N sitting
– Increased to 3000 to 6000N during lifting ofIncreased to 3000 to 6000N during lifting of
moderate weights, decreases with load closermoderate weights, decreases with load closer
to bodyto body
– Estimate of P = 1.5X compressive loadEstimate of P = 1.5X compressive load
divided by the cross sectional areadivided by the cross sectional area
– Disk pressure is usually uniformDisk pressure is usually uniform
– Pressure lowest in supine positionPressure lowest in supine position
– Disk usually does not fail, but end platesDisk usually does not fail, but end plates
fracturefracture
63.
64.
65. Creep CharacteristicsCreep Characteristics
Grade 0 - Non-degenerative disc ( more viscoelastic)
Grade 2 – Mild degenerative disc (less sustenance)
Grade 3 – Severe degenerative disc ( more deformation)
66.
67. Pathology of Intervertebral DiscPathology of Intervertebral Disc
InjuryInjury
Annular InjuryAnnular Injury
– Annular ringsAnnular rings
SoftenedSoftened
OverstretchedOverstretched
TornTorn
– Normal viscoelasticity is exceededNormal viscoelasticity is exceeded
– Cannot stabilize or limit motionCannot stabilize or limit motion
– Nucleus pulposus exerts pressure onNucleus pulposus exerts pressure on
weak partweak part
– Buckling occurs -Buckling occurs - Disc BulgeDisc Bulge
68. Pathology of Intervertebral DiscPathology of Intervertebral Disc
InjuryInjury
ExtrusionExtrusion
– Fragmentation ofFragmentation of
nucleus pulposusnucleus pulposus
– Nuclear materialNuclear material
dissects its waydissects its way
through breaches inthrough breaches in
annulus fibrosusannulus fibrosus
69. Pathology of Intervertebral DiscPathology of Intervertebral Disc
InjuryInjury
ProlapsesProlapses
– Fissures provideFissures provide
pathway forpathway for
irritating nuclearirritating nuclear
fluid to escapefluid to escape
onto perineuralonto perineural
tissue *tissue *
Persistent andPersistent and
chronic back painchronic back pain
** -- Hampton et alHampton et al
70. Theory of weight bearingTheory of weight bearing
Nucleus pulpousNucleus pulpous imbibes waterimbibes water
Develops internal pressureDevelops internal pressure
Pressure exerted in all directionsPressure exerted in all directions
– Lateral forcesLateral forces
Against annulusAgainst annulus
– Superiorly and inferiorly directed forcesSuperiorly and inferiorly directed forces
Against end platesAgainst end plates
– Increases stiffnessIncreases stiffness
Of end plate and annulus fibrosusOf end plate and annulus fibrosus
71. Sagittal plane translationSagittal plane translation
– 2-3 mm, normal in symptom free pts2-3 mm, normal in symptom free pts
– Up to 5 mm in L 3-4 & L4-5, 4 mm in L5-S1Up to 5 mm in L 3-4 & L4-5, 4 mm in L5-S1
Lateral bending & axial rotation couplingLateral bending & axial rotation coupling
– Spinous processes point in same direction asSpinous processes point in same direction as
lateral bendinglateral bending
– Opposite of cervical, upper thoracic,Opposite of cervical, upper thoracic,
lumbosacrallumbosacral
72. Theory of weight bearingTheory of weight bearing
(cont’d)(cont’d)
75. Back PainBack Pain
Pain is a protective mechanismPain is a protective mechanism
Nerve endings near the spine receiveNerve endings near the spine receive
abnormal stimulationabnormal stimulation
Signals are transmitted from affected areaSignals are transmitted from affected area
to the brainto the brain
– They are interpreted as painThey are interpreted as pain
A reflex action follows in the backA reflex action follows in the back
– Muscles go into spasmMuscles go into spasm
To protect the backTo protect the back
To keep the damaged area immobileTo keep the damaged area immobile
76. Types of painTypes of pain
Based on sourceBased on source
– MechanicalMechanical
– ChemicalChemical
Based on affected regionBased on affected region
– LocalLocal
– ReferredReferred
Based on natureBased on nature
– TransientTransient
– AcuteAcute
– ChronicChronic
77. Causes of LBPCauses of LBP
DysfunctionDysfunction
Predisposing factorsPredisposing factors
– Postural stressPostural stress
– Work related stressWork related stress
– Disuse and loss of mobilityDisuse and loss of mobility
– ObesityObesity
– Debilitating conditionsDebilitating conditions
Precipitating factorsPrecipitating factors
– MisuseMisuse
– OveruseOveruse
– Abuse or traumaAbuse or trauma
78. ScoliosisScoliosis
A medio-lateralA medio-lateral
curve of thecurve of the
vertebral columnvertebral column
Exceeding 10Exceeding 1000
– TypesTypes
StructuralStructural
NeuromuscularNeuromuscular
IdiopathicIdiopathic
Non-structuralNon-structural
– TreatmentTreatment
ExercisesExercises
BracingBracing
80. LordosisLordosis
In the sagittal planeIn the sagittal plane
– ‘‘S’ shapeS’ shape
As a small childAs a small child
– When starts to sitWhen starts to sit
– Cervical lordosisCervical lordosis
Toddler and adultToddler and adult
– When starts to standWhen starts to stand
– Lumbar lordosisLumbar lordosis
– Allows spring-like actionAllows spring-like action
81. KyphosisKyphosis
An exaggerated curvature in theAn exaggerated curvature in the
sagittal planesagittal plane
Long rounded curveLong rounded curve
((round backround back))
Sharp posterior angulationSharp posterior angulation
((hump backhump back))
Possible causesPossible causes
– Wedge compression fractureWedge compression fracture
– Ankylosing spondylitisAnkylosing spondylitis
– Senile osteoporosisSenile osteoporosis
– Destructive tumors of spineDestructive tumors of spine
82. Intervertebral DiscIntervertebral Disc
Intervertebral disk make up 20-30% ofIntervertebral disk make up 20-30% of
the height of the column and thicknessthe height of the column and thickness
varies from 3mm in cervical region,varies from 3mm in cervical region,
5mm in thoracic region to 9 mm in the5mm in thoracic region to 9 mm in the
lumbar region.lumbar region.
Ratio between the vertebral body heightRatio between the vertebral body height
and the disk height will dictate theand the disk height will dictate the
mobility between the vertebra –mobility between the vertebra –
– Highest ratio in cervical region allows forHighest ratio in cervical region allows for
motionmotion
– Lowest ratio in thoracic region limits motionLowest ratio in thoracic region limits motion
86. Lateral ViewLateral View Posterior ViewPosterior View
RodWire Bar CagePlate Screw
Pedicle Screw
Threaded Cage
Facet Screw
Arthrodesis = surgical fixation of a jointArthrodesis = surgical fixation of a joint
Stiffer arthrodesis = better healing environment (currently believed)Stiffer arthrodesis = better healing environment (currently believed)
87. Mechanical CausesMechanical Causes
Biological CausesBiological Causes
Stimulating stressesStimulating stresses
No slide between bone fusion interfaceNo slide between bone fusion interface
No separation between bone fusion interfaceNo separation between bone fusion interface
OsteoinductionOsteoinduction
Blood supplyBlood supply
OsteoconductionOsteoconduction
NOTE: FBI stands for Fusion Bone Interface
OsteoinductionOsteoinduction The ability to mediate the induction of osteosis exceptionally in a nonbony location
OsteoconductionOsteoconduction The ability to act as a scaffold for new osteosis in a bony environment
Blood supplyBlood supply Provide sufficient nutrition for osteosisStimulating stressesStimulating stresses Bone is laid down where needed and resorbed where not needed Wolff’s lawWolff’s law
Separation at FBISeparation at FBI Bone contact surfaces are separated by external load bone non-union
Slide at FBISlide at FBI Bone contact surfaces slide along each other causing by external load bone non-union
Bone To Be FusedBone To Be Fused Bone FusionBone FusionBone FusionBone Fusion
92. What is the CORE?What is the CORE?
Lumbo-pelvic-hip complexLumbo-pelvic-hip complex
Location of center of gravity (CoG)Location of center of gravity (CoG)
Efficient core allows forEfficient core allows for
Maintenance of normalMaintenance of normal length-tension relationshipslength-tension relationships
Maintenance of normalMaintenance of normal force couplesforce couples
Maintenance of optimal arthrokinematicsMaintenance of optimal arthrokinematics
Optimal efficiency in entire kinetic chain duringOptimal efficiency in entire kinetic chain during
movementmovement
Acceleration, deceleration, dynamic stabilizationAcceleration, deceleration, dynamic stabilization
Proximal stability for movement of extremitiesProximal stability for movement of extremities
93. Core Stabilization ConceptsCore Stabilization Concepts
A specific core strengthening program can:A specific core strengthening program can:
IMPROVEIMPROVE dynamic postural controldynamic postural control
EnsureEnsure appropriate muscular balanceappropriate muscular balance && jointjoint
arthrokinematicsarthrokinematics in the lumbo-pelvic-hip complexin the lumbo-pelvic-hip complex
AllowAllow for expression offor expression of dynamic functional performancedynamic functional performance
throughout the entire kinetic chainthroughout the entire kinetic chain
Increase neuromuscular efficiencyIncrease neuromuscular efficiency throughout the entirethroughout the entire
bodybody
Spinal stabilizationSpinal stabilization
Must effectively utilize strength, power, neuromuscular control &Must effectively utilize strength, power, neuromuscular control &
endurance of the “prime movers”endurance of the “prime movers”
Weak core = decreased force production & efficiencyWeak core = decreased force production & efficiency
Protective mechanism for the spineProtective mechanism for the spine
Facilitates balanced muscular functioning of the entire kineticFacilitates balanced muscular functioning of the entire kinetic
chainchain
Enhances neuromuscular control to provide a more efficient bodyEnhances neuromuscular control to provide a more efficient body
positioningpositioning
100. SciaticaSciatica
- radiating pain down the leg- radiating pain down the leg
RadiculopathyRadiculopathy
- radiating pain down the leg as a result of nerve root irritationradiating pain down the leg as a result of nerve root irritation
Back PainBack Pain
irritation of the posterior primary ramusirritation of the posterior primary ramus
- facet capsule, local musculature- facet capsule, local musculature
sinuvertebral branch - posterior annulussinuvertebral branch - posterior annulus
change in disc loading and shape, biomechanicschange in disc loading and shape, biomechanics
loss of viscoelasticity.loss of viscoelasticity.
90% of radiating pain have long-standing prior episodic low back90% of radiating pain have long-standing prior episodic low back
painpain
104. Epidural steroid injectionEpidural steroid injection
If leg pain persist beyond 4 weeksIf leg pain persist beyond 4 weeks
Maximum 3 injection per yearMaximum 3 injection per year
Response vary greatlyResponse vary greatly
- Hagen,2002 : short-term effect 40%. no significant- Hagen,2002 : short-term effect 40%. no significant
long-term effectlong-term effect
- Wiesel, 1995 : 82% relief for 1 day, 50% for 2 weeks,- Wiesel, 1995 : 82% relief for 1 day, 50% for 2 weeks,
16% for 2mo.16% for 2mo.
- White 1983 : 77% avoid surgery after injection- White 1983 : 77% avoid surgery after injection
- Carette, 2002 : neither significant functional- Carette, 2002 : neither significant functional
benefit nor reduction in need forbenefit nor reduction in need for
surgerysurgery
105. Indication of SurgeryIndication of Surgery
Ideal candidateIdeal candidate
history, physical examination, radiographic finding, are consistenthistory, physical examination, radiographic finding, are consistent
with one anotherwith one another
when discrepancy exist, the clinical picture should serve as thewhen discrepancy exist, the clinical picture should serve as the
principal guide.principal guide.
Absolute surgical indicationAbsolute surgical indication
cauda equina syndromecauda equina syndrome
acute urinary retension/incontinence,acute urinary retension/incontinence,
saddle anesthesia, back/buttock/leg pain, weakness, difficultysaddle anesthesia, back/buttock/leg pain, weakness, difficulty
walkingwalking
Relative indicationRelative indication
progressive weaknessprogressive weakness
no response to conservative treatmentno response to conservative treatment
106. Facet JointFacet Joint
Synovial jointSynovial joint
Rich innervation with sensory nerve fiberRich innervation with sensory nerve fiber
Same pathologic process as other large synovial jointSame pathologic process as other large synovial joint
Load share 18% of the lumbar spineLoad share 18% of the lumbar spine
107. Vital FunctionsVital Functions
Restricted intervertebral joint motionRestricted intervertebral joint motion
Contribution to stabilityContribution to stability
Resistence to axial, rotational, and bending loadResistence to axial, rotational, and bending load
Preservation of anatomic relationshipPreservation of anatomic relationship
Biochemical CompositionBiochemical Composition
Water : 65 ~ 90% wet wt.Water : 65 ~ 90% wet wt.
Collagen : 15 ~ 65% dry wt.Collagen : 15 ~ 65% dry wt.
Proteoglycan : 10 ~ 60% dry wt.Proteoglycan : 10 ~ 60% dry wt.
Other matrix protein : 15 ~ 45% dry wt.Other matrix protein : 15 ~ 45% dry wt.
108. Vertebral End-PlateVertebral End-Plate
Cartilaginous and osseous componentCartilaginous and osseous component
Nutritional support for the nucleusNutritional support for the nucleus
Passive diffusionPassive diffusion