understanding back pain basics of spine dr.sandeep c agrawal agrasen orthopedic hospital gondia...
Post on 22-Jan-2018
2.204 Views
Preview:
TRANSCRIPT
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
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
!• 33 vertebrae !• 23 intervertebral disks!!
!
!• Primary curves!• Secondary curves
3
OSTEOLOGY
Sagittal Plane CurvesCervical 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 NervesSpinal 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.
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.
• Flexibility of motion in six degrees of freedom
Functions of the Spine
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.
Functions of the Spine
• Line of gravity
Auricle of the ear
Odontoid
Body of C7
Anterior to thoracic spine
Posterior to L3
Mid femoral heads
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
● 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
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
Vertebral StructuresSuperior Articular Process
Inferior Articular Process
Zygapophyseal Joint
(Facet Joint)
Pars
Basic Vertebral Structures
Cervical Thoracic Lumbar
MRI
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
PediclesDorsal
Foramina
Sacral Hiatus
CoccyxPosterior View
Inverted triangle shape
The Sacrum
CoccyxLateral View
Sacral Promontory
Sacral Tilt
30°-60°
Sacral Canal
12
3
4
5
Sacral Hiatus
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
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
• Increase in angle : increase in lumbar lordosis !• Increase shearing stress at lumbosacral joint
36
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
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
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:
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
• Fewer ligaments checks extension!!• During lumbar extension nucleus pulposus displaces anteriorly
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
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
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
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
45
Spondylolysis Spondylolisthesis
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
• Common at L5-S1 and L4-L5
46
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
INTERVERTEBRAL DISC PROLAPSE:!• Common site: L4-L5 & C5-C6!
47
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
LUMBAR CANAL STENOSIS:!• Narrowing of lumbar canal!• Congenital OR Acquired
48
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
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Lumbar Puncture
Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
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.!
top related