Chapter 9Chapter 9

Spinal InjuriesSpinal Injuries

ObjectivesObjectives

Describe the basic anatomy of the spine. Describe the basic anatomy of the spine. Explain common spinal injuries that occur Explain common spinal injuries that occur

with athletic participation. with athletic participation. Identify common signs and symptoms of Identify common signs and symptoms of

spinal injuries. spinal injuries. Explain the treatments performed by an Explain the treatments performed by an

ATC for specific spinal injuries. ATC for specific spinal injuries. Describe common postural problems. Describe common postural problems.

AnatomyAnatomy

Four segmentsFour segments Sacrum (tailbone)Sacrum (tailbone) Lumbar (lower spine)Lumbar (lower spine) Thoracic (middle Thoracic (middle

spine)spine) Cervical (upper/neck Cervical (upper/neck

spine)spine)

AnatomyAnatomy

Normal anatomical Normal anatomical alignment and alignment and muscular strength muscular strength keep the spine keep the spine alignedaligned

Normal alignment and Normal alignment and curvature is called curvature is called neutral spineneutral spine

BonesBones

Separated by disksSeparated by disks Held together by Held together by

ligamentsligaments Muscles also permit Muscles also permit

many movements and many movements and stabilize the spinestabilize the spine

7 cervical vertebrae7 cervical vertebrae 12 thoracic vertebrae12 thoracic vertebrae 5 lumbar vertebrae5 lumbar vertebrae 5 sacral (fused) vertebrae5 sacral (fused) vertebrae 4 coccyx (fused)4 coccyx (fused)

BonesBones

All vertebrae have a All vertebrae have a body, a spinous body, a spinous process, and a canal process, and a canal through which the through which the spinal cord passesspinal cord passes

FunctionsFunctions Protecting the spinal cordProtecting the spinal cord Hold body upright when Hold body upright when

walkingwalking Sight for muscle Sight for muscle

attachmentattachment

BonesBones

CervicalCervical C1= atlasC1= atlas C2= axisC2= axis C7= very prominent C7= very prominent

spinespine ThoracicThoracic

Large spinous Large spinous processesprocesses

LumbarLumbar Most chronic injuries Most chronic injuries

occur to this regionoccur to this region SacralSacral

Thoracic vertebraeThoracic vertebrae

Lumbar vertebraeLumbar vertebrae

Sacrum and coccyxSacrum and coccyx

Intervertebral DisksIntervertebral Disks

FunctionFunction Absorb shockAbsorb shock Resist compression Resist compression

during activityduring activity Keep vertebrae Keep vertebrae

separateseparate Allow for movement Allow for movement

and flexibilityand flexibility Provide space for Provide space for

nerves to exit the nerves to exit the spinal cord spinal cord

Intervertebral disksIntervertebral disks

Two specific partsTwo specific parts Nucleus pulposus (jelly-like core)Nucleus pulposus (jelly-like core) Annulus fibrosus ( layer rings of cartilage that Annulus fibrosus ( layer rings of cartilage that

surround the nucleus pulposus)surround the nucleus pulposus) Disks receive no blood supply, therefore Disks receive no blood supply, therefore

do not heal well when injureddo not heal well when injured Disks are compressibleDisks are compressible

Possible to be taller first thing in the morningPossible to be taller first thing in the morning Shorter with ageShorter with age

Nucleus pulposus and annulus Nucleus pulposus and annulus fibrosisfibrosis

MusclesMuscles

Numerous muscles Numerous muscles that provide a wide that provide a wide range of movements range of movements and stabilityand stability

Spine=mast on a shipSpine=mast on a ship

MastMast SpineSpine

Many cables that Many cables that attach at various attach at various pointspoints

Many muscles Many muscles attach to different attach to different places like pelvis, places like pelvis, legs, and armslegs, and arms

Cables Cables stabilize stabilize the sailsthe sails

Muscles stabilize Muscles stabilize spine while body spine while body performs performs functions like functions like throwing, throwing, catching, and catching, and kickingkicking

Provides stability Provides stability to ensure sails to ensure sails catch in the windcatch in the wind

Provides stability Provides stability to body so it can to body so it can function correctlyfunction correctly

MusclesMuscles Spinal extensorsSpinal extensors

Run entire length of spine Run entire length of spine posteriorlyposteriorly

Attach to ribs, pelvis, and Attach to ribs, pelvis, and vertebraevertebrae

Keep body uprightKeep body upright Upper trapezius Upper trapezius

Extends the cervical spineExtends the cervical spine Attaches to occipital bone and Attaches to occipital bone and

fans out to each side of neck and fans out to each side of neck and attaches on acromion process of attaches on acromion process of scapulascapula

MusclesMuscles

Scalene muscles ( 3 Scalene muscles ( 3 total each side)total each side) Cervical flexionCervical flexion Attach to cervical Attach to cervical

vertebrae and run vertebrae and run down to the first and down to the first and second ribssecond ribs

Help with breathing Help with breathing processprocess

MusclesMuscles

SternocleidomastoidSternocleidomastoid Cervical side bending Cervical side bending

and rotationand rotation Attaches to top of Attaches to top of

sternum and attaches sternum and attaches to mastoid process to mastoid process just behind earjust behind ear

MusclesMuscles

AbdominalsAbdominals Rectus abdominus and Rectus abdominus and

internal and external internal and external obliquesobliques

Support trunk Support trunk movementmovement

PosturePosture NormalNormal

Plumb line- imaginary vertical line that helps Plumb line- imaginary vertical line that helps determine posturedetermine posture

View from sideView from side Correct posture, plumb line should pass Correct posture, plumb line should pass

through these anatomical landmarksthrough these anatomical landmarks• Just behind earJust behind ear• Through center of shoulderThrough center of shoulder• Down through middle of the greater trochanter of Down through middle of the greater trochanter of

hiphip• Behind the patellaBehind the patella• Just in front of lateral malleolusJust in front of lateral malleolus

PosturePosture

AbnormalAbnormal Forward head postureForward head posture

• Ear projects in front of Ear projects in front of plumb lineplumb line

• Stresses back of neckStresses back of neck Rounded shouldersRounded shoulders

• Line passes through Line passes through back of shoulders back of shoulders instead of middleinstead of middle

PosturePosture

KyphosisKyphosis Excessive Excessive

rounding of the rounding of the thoracic spinethoracic spine

Decreases ability Decreases ability of spine to absorb of spine to absorb shock effectivelyshock effectively

More prone to More prone to injuryinjury

PosturePosture

LordosisLordosis Excessive forward Excessive forward

curve of the lumbar curve of the lumbar spinespine

Decreases ability of Decreases ability of spine to absorb shock spine to absorb shock effectivelyeffectively

More prone to injuryMore prone to injury

PosturePosture

ScoliosisScoliosis Side bend to spineSide bend to spine Looks crooked from a Looks crooked from a

posterior viewposterior view If undiagnosed and If undiagnosed and

suspect, should refer suspect, should refer for further assessmentfor further assessment

PosturePosture

Improving postureImproving posture Keep top of head as Keep top of head as

high as possiblehigh as possible Don’t always carry bag Don’t always carry bag

on same shoulderon same shoulder Regular exerciseRegular exercise Focus on good Focus on good

posture and it will posture and it will become habitbecome habit

Preventing spinal injuriesPreventing spinal injuries

Active processActive process Exercise Exercise Concentrate on flexibilityConcentrate on flexibility Maintain proper postureMaintain proper posture Use correct lifting techniquesUse correct lifting techniques Use back support if necessary when liftingUse back support if necessary when lifting

Injury prevention Injury prevention

Proper balance of muscles strength and flexibilityProper balance of muscles strength and flexibility Strong abs decrease stress on lumbar regionStrong abs decrease stress on lumbar region Hip strength also has effect on spineHip strength also has effect on spine Need to be strong and flexible Need to be strong and flexible

Injury preventionInjury prevention

Proper lifting proceduresProper lifting procedures Maintaining slight curve in lumbar spine while Maintaining slight curve in lumbar spine while

lifting with knees and hips…not backlifting with knees and hips…not back Keep head upKeep head up Injury most often occurs when spine is too Injury most often occurs when spine is too

rounded or flexed and causes a strain or disk rounded or flexed and causes a strain or disk injuryinjury

Back supports common in many work Back supports common in many work environmentsenvironments

Treatment of lumbar spine injuries Treatment of lumbar spine injuries and conditionsand conditions

Ligament injuriesLigament injuries

Often occur from Often occur from forced excessive forced excessive trunk flexion or flexion trunk flexion or flexion and rotation at the and rotation at the same timesame time Example: a football Example: a football

player tackled and player tackled and forced forwardforced forward

• Posterior aspect of the Posterior aspect of the vertebral joints can vertebral joints can separate and stretch separate and stretch ligamentsligaments

Ligament injuriesLigament injuries

Characteristics of a lumbar sprainCharacteristics of a lumbar sprain Pain to one side of the spinePain to one side of the spine Limited movement due to pain and muscle Limited movement due to pain and muscle

spasmspasm Often difficult to differentiate a sprain from a Often difficult to differentiate a sprain from a

strainstrain Can test by pushing each of the vertebrae Can test by pushing each of the vertebrae

anteriorly, should not be painfulanteriorly, should not be painful Do not perform if signs/symptoms of a fracture Do not perform if signs/symptoms of a fracture

are presentare present

Ligament injuriesLigament injuries

Treat like any other Treat like any other acute injuryacute injury PRICEPRICE Always use ice in first Always use ice in first

48 hours of an acute 48 hours of an acute injuryinjury

Return to activity Return to activity includesincludes Proper flexibilityProper flexibility Proper strengtheningProper strengthening Pain free motionPain free motion

Muscle and tendon injuriesMuscle and tendon injuries

Rare to see a ruptured muscle at the spineRare to see a ruptured muscle at the spine Characteristics of strainCharacteristics of strain

Pain to one sidePain to one side Muscle spasmMuscle spasm Lack of movementLack of movement Pain on the opposite side from the direction the Pain on the opposite side from the direction the

athlete bends (bend to right, pain on left)athlete bends (bend to right, pain on left) Pain from sprain usually localized (small area), pain Pain from sprain usually localized (small area), pain

from strain usually travels length of musclefrom strain usually travels length of muscle

Muscle and tendon injuriesMuscle and tendon injuries

Treat with PRICETreat with PRICE Return to activityReturn to activity

Proper stretchingProper stretching Proper strengtheningProper strengthening Pain free activityPain free activity

Observe athlete for proper posture and Observe athlete for proper posture and lifting techniquelifting technique

Bone InjuriesBone Injuries

Caused by Caused by CompressionCompression

• Forcefully landing on buttocksForcefully landing on buttocks Direct blowDirect blow

Bone injuriesBone injuries

SpondylolysisSpondylolysis Most common in gymnastsMost common in gymnasts Stress fracture at the pars interarticularisStress fracture at the pars interarticularis Fracture that fails to heal can separate, causing spinal Fracture that fails to heal can separate, causing spinal

instabilityinstability

SpondylolysthesisSpondylolysthesis

Occurs when a Occurs when a spondylolysis slips spondylolysis slips forward on the forward on the vertebrae below itvertebrae below it

Most often occurs Most often occurs when L5 slips forward when L5 slips forward on S1 (as shown)on S1 (as shown)

Bone injuriesBone injuries

Spondylolysis and spondylolisthesis are Spondylolysis and spondylolisthesis are serious injuriesserious injuries

Need physician examNeed physician exam Require rest and possible lumbar braceRequire rest and possible lumbar brace Extensive rehab strengthening trunk Extensive rehab strengthening trunk

musclesmuscles

Bulging diskBulging disk

Not common in young Not common in young athletesathletes

Some call slipped Some call slipped disk, not appropriate disk, not appropriate termterm

Nucleus pulposus Nucleus pulposus bulges through bulges through annulus fibrosisannulus fibrosis

Bulging diskBulging disk

Rarely bulges toward front of spineRarely bulges toward front of spine Covered with thick ligament (anterior longitudinal Covered with thick ligament (anterior longitudinal

ligament)ligament) Most people have postures that flex the spine forward Most people have postures that flex the spine forward

most of the time which pushes nucleus pulposus most of the time which pushes nucleus pulposus toward the posterior aspecttoward the posterior aspect

Puts pressure on the nerves exiting the spinal cordPuts pressure on the nerves exiting the spinal cord Causes numbness, tingling, and pain down the legCauses numbness, tingling, and pain down the leg Can cause low back pain that increases while sittingCan cause low back pain that increases while sitting

Bulging diskBulging disk

TreatmentTreatment Improve postureImprove posture Improve body mechanics and lifting Improve body mechanics and lifting

techniquestechniques RestRest Traction Traction StrengtheningStrengthening

Cervical spineCervical spine Ligament injuriesLigament injuries

Caused by forceful Caused by forceful movement beyond movement beyond normal rangenormal range

• HyperflexionHyperflexion• HyperextensionHyperextension

Cause neck and arm Cause neck and arm painpain

Always rule out spinal Always rule out spinal cord injurycord injury

PRICE, no CPRICE, no C Strengthen, regain full Strengthen, regain full

ROMROM

Cervical spineCervical spine

Return to activity guidelinesReturn to activity guidelines Full strengthFull strength Full ROMFull ROM Full confidenceFull confidence No symptomsNo symptoms Physician clearancePhysician clearance

Muscle and tendon injuriesMuscle and tendon injuries

Can also be caused by whiplashCan also be caused by whiplash CharacteristicsCharacteristics

Muscle spasmMuscle spasm Limited ROMLimited ROM Weakness against resistanceWeakness against resistance Pain and tendernessPain and tenderness Treat like a sprain (PRI)Treat like a sprain (PRI) Same return to activity guidelinesSame return to activity guidelines Manual resistance work well for rehabManual resistance work well for rehab

Bone injuriesBone injuries

FracturesFractures Often a result of axial Often a result of axial

loadingloading

DislocationsDislocations often result of a often result of a

combination of combination of excessive flexion and excessive flexion and rotationrotation

Fractures and dislocationsFractures and dislocations

Similar signs and Similar signs and symptomssymptoms Pain around cervical Pain around cervical

vertebraevertebrae WeaknessWeakness NumbnessNumbness Tingling down armsTingling down arms Dislocation usually has Dislocation usually has

deformitydeformity

Fractures and dislocationFractures and dislocation

Care/treatmentCare/treatment Immobilize and spineboardImmobilize and spineboard Helmet proceduresHelmet procedures Call EMSCall EMS

Disk injuriesDisk injuries

Not as common as in lumbar spineNot as common as in lumbar spine Person reports more neck pain with sitting Person reports more neck pain with sitting

and forward flexionand forward flexion Some discomfort down the back and Some discomfort down the back and

between the shouldersbetween the shoulders TreatmentTreatment

Improve postureImprove posture Cervical extension exercisesCervical extension exercises tractiontraction

Brachial plexus injuriesBrachial plexus injuries

Exit through the cervical spineExit through the cervical spine Stretching nerves causes stinger/burnerStretching nerves causes stinger/burner

Can last seconds or minutesCan last seconds or minutes Severe even longer (weeks)Severe even longer (weeks)

TreatmentTreatment StrengtheningStrengthening ROM stretchingROM stretching Neck roll (FB) to limit lateral flexionNeck roll (FB) to limit lateral flexion

Brachial plexusBrachial plexus

Return to play guidelinesReturn to play guidelines No symptomsNo symptoms Full strengthFull strength Full ROMFull ROM Problem-free neck and shoulder eval by ATC Problem-free neck and shoulder eval by ATC

and team physicianand team physician