Orthopedics 5th year, 1st lecture (Dr. Hamid)

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The lecture has been given on May 4th, 2011 by Dr. Hamid.

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Orthopedics 5th year, 1st lecture (Dr. Hamid)

  1. 1. Anatomy of the Cervical Spine
  2. 2. Cervical Spine Anatomy <ul><li>Primary function </li></ul><ul><ul><li>Mobility, support, and protection of spinal canal and neural structures </li></ul></ul>
  3. 3. Cervical Spine Anatomy <ul><li>Vertebrae (7) </li></ul><ul><li>Intervertebral discs (6) </li></ul><ul><li>Pairs of exiting nerve roots (8) </li></ul><ul><li>Cervical lordosis Occ-C7 averages 40° </li></ul><ul><ul><li>Most of the lordosis occurs at the C1-C2 segment </li></ul></ul>1 2 3 4 5 6 7
  4. 4. Cervical Spine Anatomy <ul><li>Approximately 50% of flexion-extension motion occurs at occiput-C1 </li></ul><ul><li>Approximately 50% of rotation occurs at C1-C2 </li></ul><ul><li>Lesser amounts of flexion-extension, rotation, and lateral bending occur segmentally between C2-C7 </li></ul>
  5. 5. Cervical Spine Anatomy
  6. 6. Cervical Spine Anatomy <ul><li>Atypical vertebral </li></ul><ul><li>structure C1 (atlas) </li></ul><ul><li>Vertebral canal/foramen </li></ul><ul><li>Anterior arch </li></ul><ul><li>Anterior tubercle </li></ul><ul><li>Transverse process </li></ul><ul><li>Posterior arch </li></ul><ul><li>Transverse foramen </li></ul><ul><li>Lateral mass </li></ul>Superior Inferior Occipital condyles Foramen magnum
  7. 7. Cervical Spine Anatomy <ul><li>Atypical cervical </li></ul><ul><li>vertebra C2 (axis) </li></ul><ul><li>Odontoid process or dens </li></ul><ul><li>Vertebral canal/foramen </li></ul><ul><li>Facet joints </li></ul><ul><li>Transverse process </li></ul><ul><li>Transverse foramen </li></ul><ul><li>Bifid spinous process </li></ul><ul><li>Lamina </li></ul>anterior view posterior view
  8. 8. Cervical Spine Anatomy <ul><li>The odontoid process of the axis (C2) extends cranially to form the axis of rotation with atlas (C1) </li></ul>
  9. 9. Cervical Spine Anatomy <ul><li>Ligaments </li></ul><ul><ul><li>The cervical spine also features a complex arrangement of ligaments to supplement its structure and mobility </li></ul></ul>
  10. 10. Cervical 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>Intertransverse ligaments </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Ligamentum nuchae </li></ul></ul>
  11. 11. Cervical 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>Intertransverse ligaments </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Ligamentum nuchae </li></ul></ul>
  12. 12. Cervical 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>Intertransverse ligaments </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Ligamentum nuchae </li></ul></ul>
  13. 13. Cervical 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>Intertransverse ligaments </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Ligamentum nuchae </li></ul></ul>
  14. 14. Cervical 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>Intertransverse ligaments </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Ligamentum nuchae </li></ul></ul>
  15. 15. Cervical 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>Intertransverse ligaments </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Ligamentum nuchae </li></ul></ul>
  16. 16. Cervical Spine Anatomy <ul><li>Neural elements </li></ul><ul><ul><li>8 pair of cervical nerves </li></ul></ul><ul><ul><li>Exit the spinal canal superior to the vertebrae for which they are numbered </li></ul></ul><ul><ul><ul><li>C1 nerves exit the canal between Occ & C1 </li></ul></ul></ul><ul><ul><ul><li>C2 nerves exit the canal between C1 & C2 </li></ul></ul></ul><ul><ul><ul><li>C8 nerves exit the canal between C7 & T1 </li></ul></ul></ul>
  17. 17. Cervical Spine Anatomy <ul><li>Arteries </li></ul><ul><ul><li>Carotid arteries </li></ul></ul><ul><ul><ul><li>Located anterior and bilateral to the spine </li></ul></ul></ul><ul><ul><li>Vertebral arteries </li></ul></ul><ul><ul><ul><li>Enter the transverse foramen at C6 and continue through C1 </li></ul></ul></ul>
  18. 18. Cervical Spine Anatomy <ul><li>Veins </li></ul><ul><ul><li>Jugular veins </li></ul></ul><ul><ul><ul><li>Located bilateral and anterior to the spine. </li></ul></ul></ul><ul><ul><li>Vertebral veins </li></ul></ul><ul><ul><ul><li>Located within the transverse foramen of C1-C7 </li></ul></ul></ul>
  19. 19. Cervical Spine Anatomy Neural and Circulatory Elements
  20. 20. Torticollis
  21. 24. <ul><li>Infantile –congenital – </li></ul><ul><li>Cause and discription </li></ul><ul><li>Clinical feature </li></ul>
  22. 25. DDX X-ray Treatment <ul><li>Secondary torticollis </li></ul>
  23. 30. Prolapsed Intervertebral Discs
  24. 31. Introduction <ul><li>Male predominance </li></ul><ul><li>30 – 50 yrs </li></ul><ul><li>Smokers </li></ul><ul><li>Sudden flexion& Twisting </li></ul>
  25. 32. <ul><li>FUNCTION OF SPINE </li></ul><ul><li>– Combination of stability and </li></ul><ul><li>mobility due to 2 types of joints. </li></ul><ul><li>􀂄 Facet Joints </li></ul><ul><li>􀂄 Intervertebral disc </li></ul>
  26. 33. <ul><li>TYPES OF JOINTS </li></ul><ul><li>A- Facet joint- Typical (Diathrodial) </li></ul><ul><li>􀂄 Lined with synovial membrane </li></ul><ul><li>􀂄 Minimal resistance to movemetns </li></ul><ul><li>B- IVD. </li></ul><ul><li>lining </li></ul><ul><li>􀂄 Disc- Bears load associated with erect </li></ul><ul><li>postur </li></ul><ul><li>􀂄 Allows movements between ….. Bodies </li></ul>
  27. 34. <ul><li>ANATOMY OF </li></ul><ul><li>INTERVERTEBRAL DISC </li></ul><ul><li>1- Annulus- concentric laminae of collagen </li></ul><ul><li>fibrils. </li></ul><ul><li>– Outermost – Sharpey fibers attached to bone . </li></ul><ul><li>Tough - type I collagen </li></ul><ul><li>– Inner – less tough – type II collagen </li></ul><ul><li>2- Nucleus pulposus </li></ul><ul><li>only type II collagen </li></ul>
  28. 36. Nerve root <ul><li>Medial & inferior to the pedicle at </li></ul><ul><li>each level </li></ul><ul><li>More susceptiple for mechanical </li></ul><ul><li>deformation </li></ul><ul><li>--lack an epineurium </li></ul><ul><li>--reduced collagen content </li></ul><ul><li>--more parallel orientation of n.fibres </li></ul>
  29. 37. fig
  30. 38. Pathology <ul><li>Normal aging </li></ul><ul><li>-disc degeneration-displacement of facet joint </li></ul><ul><li>-acute disc herneation-pain </li></ul><ul><li>-2ndary effect-aquired SS </li></ul><ul><li>---Effects of pressure on the nerve root </li></ul>
  31. 39. Pathophysiology <ul><li>Effects of pressure on the nerve root </li></ul><ul><li>-Compressive </li></ul><ul><li>-Deformation-str,& fun,changes </li></ul>
  32. 40. Classification <ul><li>A-Site;5-6,6-7 </li></ul><ul><li>B-Direction; posterolat </li></ul><ul><li>C-Amount </li></ul><ul><li>---Bulge </li></ul><ul><li>--Herniation </li></ul><ul><li>1-Protrusion </li></ul><ul><li>2-extrusion </li></ul><ul><li>3- sequestration </li></ul><ul><li>Effects of prolapse </li></ul>
  33. 42. Clinical picture
  34. 43. <ul><li>Pressure on Dura </li></ul><ul><li>Pressure on root </li></ul><ul><li>Pressure on cord </li></ul><ul><li>Mixed </li></ul>
  35. 44. Imaging <ul><li>X-ray </li></ul><ul><li>MRI </li></ul><ul><li>CT scans with or without myelography </li></ul><ul><li>-intolerant to MRI </li></ul><ul><li>-Unsuitable for MRI </li></ul><ul><li>gadolinium-enhanced MRI </li></ul><ul><li>This will help to delineate which part of the previous operation site is disc and which is epidural fibrosis (the latter enhancing). </li></ul>
  36. 45. DDX <ul><li>Acute muscular&ST strain </li></ul><ul><li>Neuralgic amyatrophy </li></ul><ul><li>Infection </li></ul><ul><li>Tumor </li></ul><ul><li>Rotator cuff syndrome </li></ul>
  37. 46. Treatment <ul><li>usually have a good prognosis </li></ul><ul><li>. In up to four-fifths of patients, symptoms </li></ul><ul><li>will resolve spontaneously within a 12-week </li></ul><ul><li>period. </li></ul><ul><li>However, if pain persists beyond this time </li></ul><ul><li>there is a slow resolution of pain in the </li></ul><ul><li>majority of patients. </li></ul>
  38. 47. <ul><li>By approximately 4 years there is no difference in the incidence of pain in </li></ul><ul><li>patients treated non-operatively or surgically. </li></ul><ul><li>Surgical results will deteriorate after </li></ul><ul><li>symptoms have been present for 1 </li></ul><ul><li>year. </li></ul>
  39. 48. Non-operative treatment <ul><li>ANALGESICS&ANTIINFLAMATORY </li></ul><ul><li>REST-collar </li></ul><ul><li>Reduce-traction </li></ul>
  40. 49. Indications for diskectomy <ul><li>Strong indications for surgical intervention </li></ul><ul><li>-Acute mylopathy or myloradiculopathy </li></ul><ul><li>-Progressive Neurological deficit </li></ul><ul><li>Relative indications </li></ul><ul><li>Failure of conservative treatment-refractory </li></ul><ul><li>Significant motor deficit </li></ul><ul><li>Severe incapacitating pain - does not respond to any form of treatment </li></ul>
  41. 50. surgical treatment <ul><li>--ANTERIOR OPEN APPROACH </li></ul><ul><li>--POSTERIOR OPEN APPROACH </li></ul><ul><li>--Microdisectomy </li></ul><ul><li>--Chemonucleolysis </li></ul><ul><li>--percutanious </li></ul>
  42. 51. Complications <ul><li>1--Approach related </li></ul><ul><li>2--mechanical intraop; </li></ul><ul><li>3-early postop , wound infections , Discitis </li></ul><ul><li>Haematoma-Airway obs </li></ul><ul><li>4-late postop-Non-union-Instability-deformity </li></ul>
  43. 54. THANK YOU THANK YOU

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