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Understanding Back Pain Basics of Spine Dr.Sandeep C Agrawal Agrasen Orthopedic Hospital Gondia India

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Proplapse Intervertrebral disc,Neck Pain,Back Pain,Cervical Lumbar Pain,Lumbar spondylosis,Spondylolysis,Spondylolisthesis,Tuberculosis Spine,Potts Spine,Spine Metastases,Disc,Dissectomy,MRI. Understanding Back Pain Basics of Spine Dr.Sandeep C Agrawal Agrasen Orthopedic Hospital Gondia India

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Understanding Back Pain Basics of Spine Dr.Sandeep C Agrawal Agrasen Orthopedic Hospital Gondia India

  1. 1. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India 1 Understanding Back Pain: Basics of Spine Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India www.agrasenortho.com drsandeep123@gmail.com 09960122234
  2. 2. Spinal Anatomy ● Spine three major components: ! – Spinal column (i.e., bones and discs) – neural elements (i.e., the spinal cord and nerve roots) – supporting structures (i.e., muscles and ligaments) 2
  3. 3. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India ! • 33 vertebrae ! • 23 intervertebral disks! ! ! ! • Primary curves! • Secondary curves 3 OSTEOLOGY
  4. 4. Sagittal Plane Curves Cervical Lordosis 20°- 40° Sacral Kyphosis Lumbar Lordosis 30°- 50° Thoracic Kyphosis 20°- 40°
  5. 5. • Protection of – spinal cord and nerve roots Functions of the Spine – internal organs
  6. 6. Spinal Nerve Topography 31 pairs of spinal nerves • 8 cervical • 12 thoracic • 5 lumbar • 6 sacrococcygeal
  7. 7. Spinal Nerves Spinal cord Epidural space Dura mater and Arachnoid layers Subarachnoid space Dorsal root Ventral root Dorsal root ganglion Peripheral nerve
  8. 8. Spinal Nerve Structures Spinal Cord Foramen magnum • Extends from foramen magnum to L1 • Terminates at the conus medularis • The cauda equina begins below L1 • Filum terminale extends from conus medularis to the coccyx Conus medularis Cauda equina ● Beyond L1 the spinal cord becomes the Cauda Equina
  9. 9. ● Beyond L1 the spinal cord becomes the Cauda Equina
  10. 10. Batson’s Plexus Because of the azygos system, patient positioning is very important in posterior lumbar spine surgery. Patient’s abdomen should always hang free and without abdominal pressure. An increase in pressure will diminish flow through the azygos system and the vena cava. This results in an increase of venous flow into Batson’s plexus with a corresponding increase of blood loss. Batson’s plexus Azygos system also communicates with a valveless venous network known as BATSON’S PLEXUS. When the vena cava is partially or totally occluded, Batson’s plexus provides an alternate route for blood return to the heart.
  11. 11. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India Autonomic Nervous System SYMPATHETIC NERVOUS SYSTEM: ! Injury to the sympathetic nerve chain in the lumbar spine may result in genitourinary problems for the patient. ! ! Each sympathetic ganglion has fibers that join to the adjacent spinal nerve. ! ! ! PARASYMPATHETIC NERVOUS SYSTEM has ganglia located close to the organs they control.
  12. 12. • Flexibility of motion in six degrees of freedom Functions of the Spine Left and Right Side Bending Flexion and Extension Left and Right Rotation
  13. 13. • Structural support and balance for upright posture The spine is the axle bearing the load of the head, shoulders and thorax. The upper body weight is then distributed to the lower extremities through the sacrum and pelvis. This reduces the amount of work required by the spinal muscles and can eliminate muscle fatigue and back pain. Functions of the Spine
  14. 14. • Line of gravity Auricle of the ear Odontoid Body of C7 Anterior to thoracic spine Posterior to L3 Mid femoral heads
  15. 15. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India Intervertebral Disks: ! • Collagen fibers of anulus fibrosus are arranged in sheets: lamellae • Concentric rings surrounding nucleus 15
  16. 16. ● No discs between the Atlas (C1), Axis (C2), sacrum and Coccyx. ● Discs are not vascular and therefore depend on the end plates to diffuse needed nutrients
  17. 17. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India ! ! 1. Interbody Joints! • Capable of translations and tilts in all directions! ! ! ! ! ! ! 2. Zygapophyseal articulation! • True synovial joints! • Fibroadipose meniscoid structures 18 ARTICULATIONS
  18. 18. Vertebral Structures Superior Articular Process Inferior Articular Process Zygapophyseal Joint (Facet Joint) Pars
  19. 19. Basic Vertebral Structures Cervical Thoracic Lumbar
  20. 20. MRI
  21. 21. The Atlas (C1) Transverse Process Transverse Foramen Anterior Tubercle Articular Facet for Dens Lateral Mass LaminaPosterior Tubercle Superior Articular Facet Superior View
  22. 22. The Axis (C2) Odontoid Process (Dens) Body Transverse Process Inferior Articular Facet Superior Articular Facet Anterior View Posterior View Lateral Mass Spinous Process
  23. 23. Lower Cervical Vertebrae 
 C3 - C7 Transverse ProcessBodySulcus for Spinal Nerve Lateral Mass Lamina Pedicle Superior Articular Facet Vertebral Foramen Bifid Spinous Process Transverse Foramen Axial View
  24. 24. Thoracic Vertebrae, T1-T12 • Body - heart shaped when viewed superiorly. • Vertebral foramen - round • Pedicles - small in diameter • Spinous processes - long and projected downwards
  25. 25. Lumbar Vertebrae, L1-L5 • Body - L1 to L5 progressive increase in mass • Pedicles - longer and wider than thoracic; oval shaped • Spinous processes - horizontal, square shaped • Transverse processes - smaller than in thoracic region • Intervertebral foramen - large, but with increased incidence of nerve root compression
  26. 26. The Sacrum Sacral Horns Sacral Ala Pedicles Dorsal Foramina Sacral Hiatus Coccyx Posterior View Inverted triangle shape
  27. 27. The Sacrum Coccyx Lateral View Sacral Promontory Sacral Tilt 30°-60° Sacral Canal 1 2 3 4 5 Sacral Hiatus
  28. 28. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India ! Lumbosacral articulation:! • 5th lumbar vertebra and 1st sacral segment. ! • 1st sacral segment is inclined slightly anteriorly and inferiorly, forms an angle with horizontal: lumbosacral angle 35
  29. 29. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India • Increase in angle : increase in lumbar lordosis ! • Increase shearing stress at lumbosacral joint 36
  30. 30. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India ❖ Anterior longitudinal ligament is strong and well developed in this region ! ! ❖Posterior Longitudinal Ligament is only a thin ribbon in lumbar region, whereas ligamentum flavum is thickened here 38
  31. 31. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India • Flexion generates compression forces on anterior side of disc tending to migrate nucleus pulposus posteriorly! ! ! ! ! ! ! ! • Limited by tension in posterior annulus fibrosus and posterior ligament system 39
  32. 32. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India • Increase in lumbar lordosis! • Posterior tilting , gliding of superior vertebra! • Lumbar extension reduces the diameter of ! intervertebral foramina Lumbar Extension:
  33. 33. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India • Fewer ligaments checks extension! ! • During lumbar extension nucleus pulposus displaces anteriorly
  34. 34. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India ! Lumbo-pelvic rhythm:! ! • The kinematic relationship between! lumbar spine ! and ! hip joints ! during sagittal plane movements 42
  35. 35. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India • Bending forward- lumbar flexion (40⁰) followed by ! anterior tilting of pelvis at hip joint (70⁰)! ! • Return to erect- posterior tilting at pelvis at hips followed ! by extension of lumbar spine 43
  36. 36. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India ! PARS INTERARTICULARIS FRACTURES:! • Region between superior and inferior articular facets! • Weakest bony portion of vertebral neural arch 44
  37. 37. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India 45 Spondylolysis Spondylolisthesis
  38. 38. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India • Common at L5-S1 and L4-L5 46
  39. 39. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India INTERVERTEBRAL DISC PROLAPSE:! • Common site: L4-L5 & C5-C6! 47
  40. 40. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India LUMBAR CANAL STENOSIS:! • Narrowing of lumbar canal! • Congenital OR Acquired 48
  41. 41. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India 'Red Flags' in the Medical History: Potentially Serious Conditions That May Present as Low Back Pain Fracture • Major trauma (motor vehicle accident, fall from height)
 • Minor trauma or strenuous lifting in an older or osteoporotic patient Tumor or infection • Age >50 years or <20 years 
 • History of cancer 
 • Constitutional symptoms (fever, chills, unexplained weight loss) 
 • Recent bacterial infection 
 • Intravenous drug use 
 • Immunosuppression (corticosteroid use, transplant recipient, HIV infection) 
 • Pain worse at night or in the supine position Cauda equina syndrome • Saddle anesthesia 
 • Recent onset of bladder dysfunction 
 • Severe or progressive neurologic deficit in lower extremity 'Red Flags' in the Medical History: Potentially Serious Conditions That May Present as Low Back Pain
  42. 42. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India Lumbar Puncture
  43. 43. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India Epidural anesthesia
  44. 44. 52 Humor And Laughter Are Important! ! Humor in our daily lives is an essential ingredient! of happiness. So, learn to look on the funny! side of things. Even serious situations. Have you had a good laugh today? ! If you haven't, then please do - don't! let the day go to waste! Laughter! melts the distances between people. THANK YOU
  45. 45. There is only one difference between Dream & Aim.  Dreams require effortless Sleep &  Aim (Ambition In Mind)  requires sleepless efforts.  Sleep for Dreams & Wake up for Aims. This presentation is for  doctors and students in general.! . Graphics,Images and jpeg files are taken from Google and yahoo  Image  to heighten the specific points in this presentation. ! • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. ! • It is intended for use only by the doctors of orthopaedic surgery.! . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. ! • Every body is allowed to copy or download and use the material best suited to him. ! There is no financial involvement.!  • For any correction or suggestion please contact drsandeep123@gmail.com.!

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