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Spine Prof. Saeed Abuel Makarem • Spinal fractures are different than a broken arm or leg. • A fracture or dislocation of a vertebra can cause bone fragments that pinch or damage the spinal nerves or even the spinal cord. • Most spinal fractures occur due to • Car accidents, • Falls, • Gunshot, or • Sports. • Injuries can range from mild ligament or muscle strains, to fractures and dislocations of the vertebrae, and debilitating spinal cord damage. Spinal fractures Prof. Saeed Abuel Makarem • Depending on how severe your injury is, you may experience: • Pain, • Difficulty walking, • Unable to move your arms or legs (paralysis). • Many fractures heal with conservative treatment. • However severe fractures may require surgery. • To understand spinal fractures, it is helpful to understand how your spine are formed and works. Spinal fractures Prof. Saeed Abuel Makarem SPINAL COLUMN • • • • • • • • • • • The vertebral column is a complex construct that includes a variety of: Bones, Joints, Tendons, Nerves, Ligaments, Muscles and Vessels All woven together. The spines extends from the base of the skull to the pelvis. Ligaments, joints, muscles and tendons connect the bones together and keep them aligned. Prof. Saeed Abuel Makarem SPINAL COLUMN • • It is consists of 24 single vertebrae and 2 bones, •Sacrum and •Coccyx, which made from fused vertebrae. Of the 24 single bones, 7 vertebrae in the neck (cervical), 12 vertebrae in the chest (thoracic), and 5 supporting the lower back and are called (lumbar). Prof. Saeed Abuel Makarem TYPICAL VERTEBRA Body or Centrum: Anterior discoid, weight-bearing part of the vertebra. And Vertebral arch: 2 pedicles and 2 Laminae. They join together to complete the arch. Vertebral foramen: Between body and the arch and contains the spinal cord, ligament, fat and blood vessels. One spinous process: single posterior projection arising from the vertebral arch. 2 Superior and 2 inferior articular processes: paired projections allowing a vertebra to articulate with adjacent vertebrae. The arch carries 7 processes. 2 Transverse processes: two lateral projections from the vertebral arch. Prof. Saeed Abuel Makarem C E R V I C A L VERTEBRA Prof. Saeed Abuel Makarem ATLAS & AXIS The vertebrae in each region have unique features that help them to perform their main functions. The 7 cervical vertebrae (identified as C1 to C7). The first two (atlas & axis) are different because they perform functions not shared by the other cervical vertebrae. The neck has the greatest range of motion because of these 2 specialized vertebrae. The atlas has no body. The superior surfaces of its 2 lateral masses contain large kidney- shaped facet that articulate with the occipital condyles. This joint allows you to nod- that is to say "yes." –Atlanto-occipital joint. The axis acts as a pivot for the rotation of the atlas (and the skull above). It has a large upright process, called the odontoid process, or dens, which acts as the pivot joint. The atlantoaxial joint allows you to rotate your head that is to say "no." Prof. Saeed Abuel Makarem The "typical" cervical vertebrae (C3 to C7) are the smallest, lightest vertebrae. Their spinous processes are often short and bifid, except the 7th. Its transverse processes contain foramina through which the vertebral vessels pass. The main function of the cervical spine is to support the weight of the head (about 10 pounds). Also, it is the most movable region of the spine. TYPICAL CERVICAL VERTEBRAE Prof. Saeed Abuel Makarem THORACIC VERTEBRAE • The 12 thoracic vertebrae (T1 toT12) are larger than the cervical vertebrae. • The body is somewhat heart-shaped and has two costal demifacets on each side, which receive the heads of the ribs. • The spinous process is long and hooks sharply downward. • The range of motion in the thoracic spine is limited. Prof. Saeed Abuel Makarem LUMBAR VERTEBRAE • The 5 lumbar vertebrae (L1-- L5) have massive, block like bodies. • They have short, hatchet-shaped spinous processes. • They are the most solid of all vertebrae. • Their main function is to bear the weight of the body. • They also have a moderate range of movements. Prof. Saeed Abuel Makarem SACRUM • The sacrum is formed of 5 fused vertebrae. • It articulates with L5 above. • And below with the coccyx. • It also articulate with the hip bones at the alae, to form the sacroiliac joints. Prof. Saeed Abuel Makarem • The sacrum forms the posterior wall of the pelvis. • Its dorsal midline surface is roughened by the median sacral crest, (fused dorsal spines). • The median sacral crest is flanked laterally by the dorsal sacral foramina. • The sacral canal is the continuation of the vertebral canal. COCCYX The coccyx is formed of 3 to 5 (usually 4) tiny, irregularly shaped vertebrae. Also called the tailbone it provides attachment for ligaments and muscles of the pelvic floor. Prof. Saeed Abuel Makarem Intervertebral Discs • The vertebral bodies are separated by pads of flexible fibrocartilage called intervertebral discs. • The discs looks like a jelly doughnut • There are a total of 23 discs in the spinal column. • There are no discs between the Atlas & Axis and Sacrum & Coccyx. • The intervertebral discs forms about one fourth of the whole length of the spinal column. Its primary function: 1. It act as a shock absorber between 2 adjacent vertebrae. 2. It also acts as a cartilaginous joints that allow for slight mobility. 3. It also acts as ligaments that hold the vertebrae together. • Intervertebral discs are avascular and receive its nutrition from the vertebral Prof. Saeed Abuel Makarem end plates. Intervertebral Discs Prof. Saeed Abuel Makarem The intervertebral discs are formed of an outer annulus fibrosus and an inner soft, jellylike material (nucleus pulposus). The annulus fibrosus is a strong radial tire–like structure made up of concentric lamellae of collagen fibers connected to the vertebral end plates. The nucleus pulposus contains a mucoprotein gel–like material that is sealed by the annulus fibrosus. The nucleus pulposus needs to be well-hydrated in order to maintain its strength and softness. It serve as the major carrier of the body’s axial load that resists compression. Intervertebral Discs Prof. Saeed Abuel Makarem • Both the annulus fibrosus and nucleus pulposus are composed of: 1. Water, 2. Collagen, and 3. Proteoglycans (PGs). • The amount of fluid (water & PGs) is greatest in the nucleus pulposus. • PG molecules are important as they can attract and retain water in the discs. • The amount of water in the nucleus varies throughout the day depending on the body activity. • Unfortunately, the amount of water becomes less by old age. Intervertebral Discs • The vertebral discs in the spine is an interesting and unique structure. • The nucleus acts like a ballbearing when you move, allowing the vertebral bodies to roll over the incompressible gel. • The gel-filled nucleus is composed mostly of fluid. • This fluid absorbed during the night as you lie down and is pushed out during the day as you move upright. Prof. Saeed Abuel Makarem HERNIATED DISC • With age, our discs increasingly lose the ability to reabsorb fluid and become brittle and flatter. • This is why we get shorter as we grow older. • Also diseases, such as osteoarthritis & osteoporosis, can cause bone spurs (osteophytes) to grow. • Injury and strain can cause the nucleus to herniate, out of the annulus and compresses the nerve roots causing back pain. Prof. Saeed Abuel Makarem • The herniated disc is usually prevented to herniate posteriorly because of the presence of the posterior longitudinal ligament,(PLL). • Herniation is mostly posterolateral. • So disk herniation impinge on a spinal nerves rather than on the spinal cord itself! HERNIATED DISC Prof. Saeed Abuel Makarem Curvatures • The S-shaped curves of the vertebral column work together with the discs to prevent shock to the head when we walk or run. • They also make the body trunk flexible. • Curves act like a coiled spring to absorb shock, maintain balance, and allow range of motion throughout the spinal column. • The spinal curves in the thoracic and sacral regions are referred to as primary curves as they are present when we are born. • Later, the secondary curves develop. • The cervical curve appears by the 6th month, when the baby begins to set and hold his head. • While the lumbar curve develops by the end of the 1st year, when the baby begins to walk. Prof. Saeed Abuel Makarem. Muscles and Posture • Muscles and correct posture maintain the natural spinal curves. • Good posture involves training your body: • To stand up, • To walk, • To sit, • To lie down, and • To carry weight. • So that the least amount of strain are placed on the spine during movement or weight-bearing activities. • Excess body weight, big abdominal belly, weak muscles, and other factors can affect the spinal alignment. Prof. Saeed Abuel Makarem Spine • It is important to know that: • • • • • Strong Bones Strong Muscles, Flexible Tendons, Flexible Ligaments & Sensitive Nerves. All Contribute to a healthy spine. • Keeping your spine healthy is vital if you want to live an active life without back pain. Prof. Saeed Abuel Makarem Abnormal Spinal Curves • An icreased curvature of the thoracic spine is called kyphosis, or hunch back. • An abnormal curve of the lumbar spine is called lordosis, or sway back. • An abnormal curve from sideto-side is called scoliosis. Kyphosis Prof. Saeed Abuel Makarem Lordosis Scoliosis Muscles Two main muscle groups that affect the spine are extensors and flexors. Extensor muscles enable us to stand up & lift objects. Extensors are attached to the back of the spine. Flexor are in the front and include the abdominal muscles. These muscles enable us to flex, or bend forward, and are important in lifting and controlling the arch in the lower back. Prof. Saeed Abuel Makarem MUSCLES OF THE BACK • Most of the body weight lies anterior to the spinal column. • So the axis of gravity descends anterior to the vertebral column, knee and ankle. • The deep muscles of the back are important in maintaining the spinal alignment and the normal postural curves of the spinal column in the standing position. • There are 3 groups of muscles in the back: – Superficial muscles associated with the shoulder girdle. – Intermediate muscles involved in respiration. – Deep muscles belonging to the spinal column. SUPERFICIAL MUSCLES The superficial muscles belong to the upper limb. These are: • Trapezius • Latissimus dorsi • Levator scapulae • Rhomboids minor • Rhomboids major INTERMEDIATE MUSCLES The intermediate muscles are associated with respiration. These are: • Serratus posterior superior. • Serratus posterior inferior. • Levatores costarum. DEEP MUSCLES • The deep muscles of the back form a deep, broad muscular column, which occupies the hollow on each side of the spinous processes. • They extend from the sacrum to the skull. • This muscle mass is composed from many small muscles of different length. • Each individual muscle causes one or several vertebrae to be extended or rotated on the vertebra below. CLASSIFICATION OF THE DEEP MUSCLES OF THE BACK • Superficial vertically running muscles: – Erector spinae • Iliocostalis • Longissimus • Spinalis • Intermediate oblique running muscles: – Transversospinalis • Semispinalis • Multifidus • Rotatores • Deepest muscles – Interspinalis – Intertransversarii BLOOD AND NERVE SUPPLY • Arterial supply: Dorsal branches of the posterior intercostal arteries. • Venous drainage: Posterior intercostal veins. • Nerve supply: Posterior rami of the spinal nerves Misalignment • Back muscles stabilize your spine. • Poor muscle tone or a large belly can pull your entire body out of alignment. • Misalignment puts incredible strain on the spine. Facet joints • The facet joints of the spine allow spinal motion. • Each vertebra has four facet joints, • One pair that connects to the vertebra above (superior facets) • One pair that connects to the vertebra below (inferior facets). Prof. Saeed Abuel Makarem Ligaments • The ligaments are strong fibrous bands that hold the vertebrae together, stabilize the spine, and protect the discs. • The three major ligaments of the spine are: • Anterior longitudinal ligament (ALL), • Posterior longitudinal ligament (PLL). • The ALL and PLL are continuous bands that run from the top to the bottom of the spinal column along the vertebral bodies. • They prevent excessive movement of the vertebrae, and hold the vertebral bodies and discs together. • Ligamentum flavum, • The ligamentum flavum attaches between the lamina of all vertebrae. Prof. Saeed Abuel Makarem What Types of Vertebral Injuries May Occur? • The two main types of injuries to the spinal bones (vertebrae) are fractures and dislocations. • A fracture is a break to any part of the vertebra. • A dislocation is when the vertebrae do not line up correctly or are out of place. • These injuries may cause damage to the spinal nerves or the spinal cord. • There are several types of fractures and dislocations that can occur. Prof. Saeed Abuel Makarem Compression fracture • This usually results from a hyperflexion (front to back) injury where part of the vertebral column is forced forward and downward. Prof. Saeed Abuel Makarem Burst Fracture • A burst fracture is a very serious form of compression fracture. • In this type the bone is shattered from the injury. • Bone fragments may pierce the spinal cord. • The injury usually occurs from a downward or upward force along the spine. • It is often result in serious spinal cord injury. Prof. Saeed Abuel Makarem Subluxation • In subluxation, the joints in the back of the vertebrae are weakened by abnormal movement of the bones. • It is a partial dislocation of the vertebrae. • It happens if the muscles and ligaments in the spine are injured. • It may also cause injury to the spinal cord. Prof. Saeed Abuel Makarem • A dislocation also may occur when ligaments are badly stretched from the injury. • This allows too much movement of the vertebrae. • The vertebrae may "lock" over each other on one or both sides. • A spinal cord injury may occur, depending on how much extra movement is allowed by the torn ligaments. • The vertebrae that are not lined up correctly are returned to a normal position by a "reduction". Traction or surgery is often required for a reduction. • A brace, vest, or surgery to fuse the vertebrae is sometimes needed to keep the vertebrae lined up correctly. Dislocation Prof. Saeed Abuel Makarem Fracture- Dislocation • This occurs when there is a fracture and a dislocation of the vertebrae. • There is usually serious ligament and soft tissue injury and this may also cause injury to the spinal cord Prof. Saeed Abuel Makarem