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

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

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

!
• 33 vertebrae !
• 23 intervertebral disks!
!
!
!
• Primary curves!
• Secondary curves
3
OSTEOLOGY

Sagittal Plane Curves
Cervical Lordosis 20°-
40°
Sacral Kyphosis
Lumbar Lordosis 30°- 50°
Thoracic Kyphosis 20°- 40°

• Protection of
– spinal cord and nerve roots
Functions of the Spine
– internal organs

Spinal Nerve Topography
31 pairs of spinal nerves
• 8 cervical
• 12 thoracic
• 5 lumbar
• 6 sacrococcygeal

Spinal Nerves
Spinal
cord
Epidural
space
Dura mater and
Arachnoid layers
Subarachnoid
space
Dorsal root
Ventral
root
Dorsal root
ganglion
Peripheral
nerve

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

● Beyond L1 the spinal cord becomes the Cauda Equina

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.

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.

• Flexibility of motion in six degrees of freedom
Left and Right
Side Bending
Flexion and Extension Left and Right Rotation

• 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.

• Line of gravity
Auricle of the
ear
Odontoid
Body of C7
Anterior to thoracic
spine
Posterior to L3
Mid femoral heads

Intervertebral Disks:
!
• Collagen fibers of anulus fibrosus are
arranged in sheets: lamellae
• Concentric rings surrounding nucleus
15

● 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

!
!
1. Interbody Joints!
• Capable of translations and tilts in all directions!
!
!
!
!
!
!
2. Zygapophyseal articulation!
• True synovial joints!
• Fibroadipose meniscoid structures
18
ARTICULATIONS

Vertebral Structures
Superior
Articular
Process
Inferior
Articular
Process
Zygapophyseal
Joint
(Facet Joint)
Pars

Basic Vertebral Structures
Cervical Thoracic Lumbar

The Atlas (C1)
Transverse
Process
Transverse
Foramen
Anterior
Tubercle
Articular Facet
for Dens
Lateral Mass
LaminaPosterior
Tubercle
Superior
Articular
Facet
Superior View

The Axis (C2)
Odontoid
Process
(Dens)
Body
Transverse
Process
Inferior
Articular
Facet
Superior
Articular
Facet
Anterior View Posterior View
Lateral
Mass
Spinous
Process

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

Thoracic Vertebrae, T1-T12
• Body - heart shaped when
viewed superiorly.
• Vertebral foramen - round
• Pedicles - small in diameter
• Spinous processes - long
and projected downwards

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

The Sacrum
Sacral Horns
Sacral Ala
Pedicles
Dorsal
Foramina
Sacral
Hiatus
Coccyx
Posterior View
Inverted triangle shape

The Sacrum
Coccyx
Lateral View
Sacral
Promontory
Sacral Tilt
30°-60°
Sacral Canal
1
2
3
4
5
Sacral Hiatus

!
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

• Increase in angle : increase in lumbar lordosis !
• Increase shearing stress at lumbosacral joint
36

❖ 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

• 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

• Increase in lumbar lordosis!
• Posterior tilting , gliding of superior vertebra!
• Lumbar extension reduces the diameter of !
intervertebral foramina
Lumbar Extension:

• Fewer ligaments checks extension!
!
• During lumbar extension nucleus pulposus displaces
anteriorly

!
Lumbo-pelvic rhythm:!
!
• The kinematic relationship between!
lumbar spine !
and !
hip joints !
during sagittal plane movements
42

• 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

!
PARS INTERARTICULARIS FRACTURES:!
• Region between superior and inferior articular facets!
• Weakest bony portion of vertebral neural arch
44

45
Spondylolysis Spondylolisthesis

• Common at L5-S1 and L4-L5
46

INTERVERTEBRAL DISC PROLAPSE:!
• Common site: L4-L5 & C5-C6!
47

LUMBAR CANAL STENOSIS:!
• Narrowing of lumbar canal!
• Congenital OR Acquired
48

'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

Lumbar Puncture

Epidural anesthesia

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

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.!

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

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