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Semester 2 Musculoskeletal System > L4: Dermatomes and Myotomes and the Lumbar spine > Flashcards

L4: Dermatomes and Myotomes and the Lumbar spine Flashcards

1
Q

What day in embryology does the neural tube begin to develop?

A

Day 18
Under the influence of the notochord
Segmented –> neural level

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2
Q

How many somites does the neural tube split into?

A

34-35 somites by day 30

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3
Q

What do the somites differentiate into?

A

Ventral –> sclerotome –> vertebrae and ribs
Dorsal –> dermamyotome
–> dermatome –> dermis
–> myotome –> muslce tissue

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4
Q

Why does the skin and muscle have a common nerve supply?

A

Develop single dermamyotome –> association with a specific neural level
Take nerve supply with them –> spinal (segmental) nerve

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5
Q

Define dermatome?

A

Area of skin supplied by a single spinal nerve

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6
Q

What does the Foerster dermatome map show? What are some of the landmarks that help you learn the distribution?

A 
Shows the neuronal supply to each area of skin on the body
Anterior
-Axilla level T2
-Nipples= T4/5
-Umbilicus= T10
-Groin= L1
-Knee= L3
-Small toe= S1

Posterior

  • Back of head C2
  • Back of neck C3
  • Posterior shoulder C4
  • S2 back of leg
  • S5- bum hole!
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7
Q

Describe the structure of a typical neuron?

A

Cell body
Dendrites –> thin structures–> cell body
Axon–> axon hillock

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8
Q

What is the function of a neuron?

A

Receive, process and transmit information

Chemical and electrical signals

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9
Q

What is a myelin sheath?

A

Insulating layer–> speed up conduction
CNS–> Oligodendroctyres
PNS–> Schwann cells

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10
Q

What does a bundle of axons form in the CNS?

A

A tract

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11
Q

Describe the structure of a peripheral nerve?

A 
Axon surrounded by Schwann cells 
Endoneurium--> connective tissue
Axons--> bundled--> fascicles 
Perineurium--> connective tissue 
Fascicles grouped -->nerve
Epineurium --> connective tissue
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12
Q

Describe the structure of the endoneurium? What does it contains?

A
  • -> inner sleeve contains glycocalyx and mesh of collagen
  • -> Endoneurial fluid
  • -> Similar to BBB–> stops certain molecules crossing–> Analogous to CSF
  • -> Nerve injury –> ↑ endoneurial fluid
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13
Q

What is contained within the epineurium?

A

High metabolic requirement
Blood vessels
Vasa Nervorum (small arteries)

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14
Q

What is a spinal nerve?

A

Short mixed nerve
Contains motor, sensory and autonomic fibres
Pass through intervertebral foramen

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15
Q

Compare the dorsal and ventral root?

A

Dorsal–> afferent–> sensory nerves

Ventral–> efferent –> motor neurones and autonomic fibres

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16
Q

How many pairs of spinal nerves are there? How are they named?

A

31 pairs of spinal nerves
Names according to level of VC that they emerge
Cervical spinal nerves–> named according inferior vertebrae e.g. C4 spinal nerve –> C3 vertebra superior, C4 vertebrae inferior
Thoracic/lumbar –> named according to superior vertebrae e.g. L3 spinal nerve–> L3 vertbrae superior, L4 vertebrae inferior

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17
Q

Where do the vertebra come from?

A

Sclerotome (ventral somite) –> + ribs thoracic region

Derived from two adjacent somites (half from each)

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18
Q

Where does the spinal cord pass?

A

Passes through vertebral foramen

Multiple form the spinal canal

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19
Q

Where do the spinal nerves leave?

A

Through intervertebral foramina

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20
Q

Where does the spinal cord run from?

A 
Inferior margin of medulla oblongata (skull-- foramen magnum)
Conus meduallris (L2) --> Cauda Equina
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21
Q

Why is the spinal cord shorter than the spinal canal?

A

Differential rates of growth

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22
Q

What do the sacral nerves exit through? What does S5 and coccygeal nerve exit through?

A

Sacral nerves–> sacral formaina

S5 and coccygeal –> sacral hiatus

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23
Q

What are rami?

A

The divisions of the spinal nerve after it has passed through the intervertebral foramen.

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24
Q

What are the division of the rami called? What do they supply?

A

Anterior or ventral rami–> muscles and skin of upper and lower limbs and lateral and ventral trunk
–> larger
Posterior or dorsal rami –> deep muscles and skin of the dorsal trunk
–> small

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25
Q

What nerve does each spinal nerve give off? What does this nerve do?

A

Meningeal branch
Re-enters spinal canal–> Intervertebral foramen
Supplies the vertebrae, ligaments of VC, blood vessels and meninges

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26
Q

Which part of the spinal cord gives out sympathetic fibres and which gives out parasympathetic fibres?

A

Sympathetic –> Thoracolumbar outflow –> T1-L2

Parasympathetic –> crainosacral outflow –> C1-8 and S1-5

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27
Q

What additional nerve is there in the thoracolumbar region? What is it contained within?

A

Preganglionic sympathetic nerve
White ramus (rami) communicans –> synapses
Exits via grey ramus (rami) communicans –> Post rami communicans

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28
Q

Why are they called the white and grey rami communicans?

A

White–> myelinated axons

Grey –> unmyelinated axons

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29
Q

What does the posterior (dorsal) rami divide into? What do they supply?

A

Divides into medial and lateral branches

  • -> supply muscles and skin
  • -> Inline with intervertebral foramen
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30
Q

Explain the anterior (ventral) rami distribution?

A

Skin and muscle of trunk–> segmented T2-L1
C1-C4 head, neck and shoulder
C5- T1–> upper limb (arm)
L1-S5 –> lower limb (leg)

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31
Q

What is the name of the plexus in the upper limb and the lower limb? What spinal nerves enter each?

A

Upper limb –> brachial plexus C5-T1

Lower limb –> Lumbosacral plexus L1-S5

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32
Q

What is significant about the anterior (ventral) rami in the limbs?

A

Supplies both the anterior (ventral) and posterior (dorsal) skin of the limbs

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33
Q

What do we mean by functional overlap?

A

Spinal nerve–> specific area –> does overlap a bit

Spinal nerve damage–> loss of sensation usually less extensive than expected

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34
Q

What is the axial line?

A

Junction between two dermatomes
Discontinuous spinal level
Midline of body in trunk
Limb–> anterior (ventral) and posterior (dorsal) axial lines –> mark the centre of the anterior and posterior compartments

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35
Q

In development which way do the limbs rotate?

A

Upper limb–> laterally 90 degrees
–> elbow and extensor muscles on posterior and lateral surface
Lower limb–> medially 90 degrees
–> knee and extensor muscles on anterior aspect

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36
Q

What is the pre-axial and post-axial borders?

A

Mark the border where flexors and extensors meet
Development
Pre-axial–> cephalic side
Post-axial–> caudual side

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37
Q

What marks the pre-axial and post-axial borders in a developed human?

A

Veins
Upper limb
–> Cephalic vein –> pre-axial border–> Lateral
–> Basilic vein–> post-axial border–> medial
Lower limb
–> Long (great) saphenous vein –> pre-axial border –> anteromedial aspect
–> Short (small) saphenous vein –> post-axial border –> posterior (posterolateral)

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38
Q

What happens to nerves in the brachial plexus?

A

Axons from single spinal nerves follow multiple different routes in plexus and emerge in several different peripheral nerves

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39
Q

What is unusual about peripheral nerves? What is the clinical consequence?

A

Contains fibres from more than one spinal nerve
Area of skin supplied–> doesn’t match dermatome map
Cutaneous innervation of that nerve
Sensory and motor nerves?

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40
Q

What is a myotome?

A

Group of muscle fibres supplied by a single spinal nerve

Usually muscle fibres in different muscles

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41
Q

How does a motor unit differ from a myotome?

A

Single motor neurone (single axon) and the muscle fibres it supplies
Myotome group of muscle fibres supplied by a single spinal nerve

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42
Q

What movements are associated with C5?

A

Shoulder abduction
External rotation
(Elbow flexion)

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43
Q

What movements are associated with C6?

A

Elbow flexion
Wrist extension
Supination
(Internal rotation of shoulder)

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44
Q

What movements are associated with C7?

A

Elbow extension
Wrist flexion
Pronation
(Finger flexion and extension)

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45
Q

What movements are associated with C8?

A

Finger flexion
Finger extension
(thumb extension, wrist ulnar deviation)

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46
Q

What movements are associated with T1?

A

Finger abduction and adduction

47
Q

What movements are associated with L2?

A

Hip flexion

48
Q

What movements are associated with L3?

A

Knee extension

hip adduction

49
Q

What movements are associated with L4?

A

Ankle dorsiflexion

50
Q

What movements are associated with L5?

A

Great toe extension

Ankle inversion, hip abduction

51
Q

What movements are associated with S1?

A

Ankle plantar flexion

ankle eversion, hip extension

52
Q

What movements are associated with S2?

A

Great toe flexion

knee flexion

53
Q

What does Hilton’s law say?

A

Nerve supplying muscle also supplies joint capsule and skin overlaying the insertion point of a muscle

54
Q

What is clinical significant about dermatomes and myotomes?

A

Determine which nerve is damages by assessing which muscles and skin area affected
Peripheral nerves–> multiple areas of damage more than one spinal nerve

55
Q

When assessing a patient for a spinal cord injury what are you trying to determine?

A

Trying to determine the clinical neural level of injury

56
Q

What do we mean by neural level?

A

The lowest level of fully intact sensation and motor function

57
Q

What is the vertebral column made of?

A

Vertebrae, intervertebral discs and sacrum

58
Q

What are the different divisions of the vertebral column?

A

Cervical (7), thoracic (12), lumbar (5), sacral (5 fused) and coccygeal (4 fused)

59
Q

How are the intervertebral discs named?

A

Named relative to the vertebrae on each side of disc

60
Q

Which parts of the spine are the most mobile?

A

The cervial and lumbar region

61
Q

Which parts of the spine are the least mobile?

A

The thoracic–> attached to ribs
Sacrum 5 fused
Coccyx 4 fused

62
Q

There are four curvatures in the spine, what are the called and when do they develop?

A

Thoracic and Sacral cruvatures –> primary –> kyphotic
–> primary –> during development
–> kyphotic anterior curvature
Cervial and lumbar curvatures –> secondary –> lordotic
–> secondary –> develop after birth –> holding head, sitting up –> IVD become wedge shaped
–> lordotic –> concave posteriorly
Balance each other out–> maintain centre of gravity in stable states
Great flexibility and resilience

63
Q

How does the size of the vertebral bodies change as go inferiorly? Why?

A

Vertebral bodies increase in size
Compressive forces increase
Sacral vertebra–> fused, widened, anteriorly concave–> transmit forces through pelvis into legs

64
Q

What are the functions of the vertebral column?

A
  • ->Support weight of skull, pelvis, upper limbs and thoracic cage
  • -> Protection
  • -> Posture and locomotion
  • -> Hematopoesis
65
Q

Describe the anatomy of a lumba vertebra?

A
  • -> kidney bean shaped vertebral body
  • -> Vertebral arch (posterioly)–> (Pedicle, transverse process, lamina)
  • -> Vertebral foramen (conus meduallris, cauda equina, meninges)
  • -> Processes
    • -> 2 transverse processes
    • -> 2 superior articular processes
    • -> 2 inferior articular process
    • -> spinous process

Diagram page 68

66
Q

What type of bone is the vertebral body? Why?

A

10% cortical bone

90% cancellous bone –> reduces weight and hematopoesis

67
Q

What are the vertebrae end plates?

A

The superior and inferior surface of the vertebral body
Covered in hyaline cartilage
Articulate with IVD

68
Q

What structures make up the vertebral arch/ posterior elements? What is its function?

A

Pedicle–> Between vertebral body and transverse processes
Transverse process –> attachment site
Lamina (laminae)–> between transverse processes and spinuous process
Spinous process –> attachment site
Protective tunnel

69
Q

What is the function of the superior and inferior articular processes?

A

Create a mobile joint
Superior articular facet articulates with the inferior articular facet on an adjacent vertebral body
Zygapophyseal/ Facet joint–> synovial joint, hylaine cartilage

70
Q

What is the intervertebral foramen? What passes though?

A

Space between the superior and inferior articular facets on adjacent vertebra
Created by the vertebral notch
Spinal nerves pass through

71
Q

Label a diagram of the lumbar vertebrae?

A

Answer on page 68

72
Q

What determines the amount of flexion and rotation permissable at the facet joints? Specific angles of the lumbar facets? What movement is permitted?

A 
Angle of the articular facets
Lumbar facet 
--> 90 degree in axial plane (perpendicular)
--> 45 degree in coronal plane 
-->Superior facet--> posteriomedially
-->Inferior facet --> anterolaterally  
Flexion and extension
73
Q

What is the structure of the intervertebral disc?

A

Split into nucleus pulposus (central) and annulus fibrosus (peripheral)
70% water, 20% collagen and 10% proteoglycans

74
Q

What is the main function of the annulus fibrosus? How is its structure linked to its function?

A 
Shock absorber
Highly resillient under compression 
Lamella of annular bands collagen in different orientations
Outside--> Type 1
Inside--> fibrocartilagenous 
Avascular and aneural
75
Q

What is the nucleus pulpous? What is its structure?

A 
Remnant notochord
Gelatinous
Type 2 
High oncotic pressure --> smaller at night --> water squeezed out 
Infant central --> adult more posterior
76
Q

What are the ligaments in the vertebral column?

A

Anterior and posterior longitudinal ligaments
Ligamentum Flavum
Interspinous ligaments
Supraspinous ligament

77
Q

Where are the anterior and posterior longitudinal ligaments located?

A

Anterior and posterior to vertebral body
Anterior –> Anterior tubercule of C1 (atlas) to sacrum
–> attaches to periosteum of VB
–> loosely attached of IVD
Posterior –> Body of axis (C2) to sacral canal
–> continuous with tectorial membrane of atlanto-axis joint

78
Q

What is the function of the anterior and posterior longitudinal ligaments?

A

Anterior –> stop hyperextension

Posterior–> stop hyperflexion

79
Q

Where is the ligamentum flavum located? What is its function?

A

Between laminae of adjacent vertebrae

Streched during flexion–> return posture to normal

80
Q

Where is the interspinous ligament found? Where is it the most developed? Composition?

A 
Between the spinous process
Lateral side can see it
Fuse with supraspinous ligament
Lumbar region 
Weak sheets--> fibrous tissue
81
Q

What is the function of the interspinous ligament?

A

Prevent hyperflexion

82
Q

Where is the supraspinous ligament located? Composition?

A

Tip of spinous process
Fuse with the interspinous ligament
Strong band of fibrous tissue

83
Q

What is the function of the supraspinous ligament?

A

Prevents hyperflexion

Lax during extension

84
Q

What is the anatomy (structure, articulations) of the sacrum and coccyx?

A 
Sacrum --> 5 fused vertebrae
Superiorly articulates with L5
Inferiorly articulates with coccyx
Laterally --> ilium of pelvis
Coccyx --> 4 fused vertebrae
85
Q

What is the sacroilliac joint?

A

Joint between the sacrum and iliium bones

86
Q

Where does the spinal cord run in the sacrum?

A

Sacral canal
Cauda equina
Terminates at sacral hiatus –> S4

87
Q

How do the sacral and coccygeal nerve exit the sacral canal?

A

Pass through posterior sacral foramina

88
Q

What attaches (provides longitudinal support) the spinal cord to the coccyx?

A

The filium terminale
Continuation of pia mater from conus medularis
20cm long

89
Q

Why do people get smaller with age?

A

IVD compression
Annular fibrosis degeneration (wear and tear)
Nucleus pulposus–> thinner–> dehydration and degeneration
Vertebrae–> wedge shaped –> osteoporotic compression fractures

90
Q

What is it called when the secondary curvatures start to disappear in old age? What changes occur?

A 
Senile kyphosis
Primary curvature re-established
AF of IVD wear and tear
NP looses turgor and becomes thinner
Loss of height accompanied by osteoporotic fractures--> secondary curvatures disappear
91
Q

Which vertebrae does the centre of gravity pass through?

A 
C1/2
C7/T1
T12/L1
L5/S1
Weak points
92
Q

Look at some X-rays, CT, MRI and isotope radiographs and identify the key features?

A

Page 75-78

93
Q

What is mechanical back pain?

A

Pain when the spine is loaded

Worsens with exercise and is relieved by rest

94
Q

How common is mechanical back pain? What are the risk factors?

A

Extremely common
50% of UK–> at least 24hrs in any one year
50% of those–> >4week
80% of population > 24hrs
Risk factors –> obesity, poor posture, sedentary lifestyle with deconditioning of paraspinal (core) muscles, poorly designed seating, incorrect manual handling

95
Q

What are the degenerative changes associated with the vertebral column?

A

IVD dehydrates with age–> decreases height of disc–> bulging and ↑stress on joints

96
Q

What are the names of the conditions associated with degenerative diseases?

A

Marginal osteophytosis–> bony spurs (syndesmophytes) develop adjacent to end plates of the disc
Osteoarthritic changes–> increased stress on the joints –> Facet joints innervated by meningeal nerve –> feels painful
Disc height↓ and arthritis = Small vertebral formanina –> compression of spinal nerve–> radicular or nerve pain

97
Q

What is another name for a slipped disc? What are the different stages?

A

Herniation

  1. Disc degeneration: Chemical changes–> aging –> dehydration –> bulge
  2. Prolapse: protrusion of the nucleus pulposus–> slight impingement into spinal canal–> contained with Annulus fibrosis
  3. Extrusion: NP–> breaks though AF–> contained in disc space
  4. Sequestration: NP separates from main body of disc–> enters spinal canal
98
Q

What is the most common site for a slipped disc? What age is it most common? How long does it take to resolve?

A

L4/5 and L5/S1 due to mechanical loading
30-50yr olds
90% resolve in 3 months

99
Q

With a slipped disc which nerves are most vulnerable?

A

1) Where cross the IVD (paracentrally) -traversing nerve

2) Where they exit the spinal canal in the intervertebral foramen (far laterally) -exiting nerve

100
Q

What is the most common sort of herniation?

A

Paracentral prolapse –> 96% cases–> not reinforced by the posterior longitudinal ligament –> traversing nerve root most at risk
2% laterally –> Exiting nerve root at risk
2% centrally

101
Q

What is the common name for radicular leg pain? Define it? Where is the pain experienced?

A

Sciatica
Pain caused by irritation or compression of one or more of the nerve roots that contributes to sciatic nerve (L4,5, S1,2,3)
Buttocs and back–> radiates to dermatome supplied by nerve

102
Q

What is the typical distribution of pain in sciatica?

A

L4: Anterior thigh, knee and medial leg
L5: Lateral thigh, leg and dorsum of foot
S1: Posterior thigh, leg, heel and sole of foot
If compression causes paraesthesia –> tingling/pins and needles–> only experienced in affected dermatome

103
Q

What is cauda equina syndrome?

A

Compression of the lumbar and sacral nerve roots
5% caused by disc prolapse
Other included –> tumour, spinal infection/abscess, spinal stenosis secondary to arthritis, vertebral fracture, spinal haemorrhage, late stage ankylosing spondylitis

104
Q

What are the symptoms of cauda equina syndrome?

A 
Bilateral sciatica 
Perianal numbness (saddle anaesthesia)
Painless retention of urine
Urinary/ feacal incontinence
Erectile dysfunction
105
Q

Why is caudia equina a medical emergancy?

A

Compression of the lumbar and sacral nerves
Decompression required with 48hr
>48hr prognosis is poor
Consequences serious–> chronic neuropathic pain, impotence, self catheterisation to pass urine, faecal incontinence or impaction, loss of sensation and lower limb weakness

106
Q

What happens in spinal canal stenosis?

A

Abnormal narrowing of spinal canal
Compress spinal cord or nerve roots
Due to: Disc bulging, facet joint osteoarthritis, ligamentum flavum hypertrophy
Others–> fracture of VB, spondylolithesis, trauma

107
Q

What are the symptoms of spinal canal stenosis?

A 
Discomfort whilst standing (95% patients)
Discomfort or pain in region affected
Bilateral symptoms
Numbness at or below level of stenosis
Weakness at or below...
Neurogenic claudication
108
Q

What is neurogenic claudication?

A

Symptom
-Cramping pain or weakness in legs and therefore tends to limp
-Pain or pins and needles in legs on prolonged standing and walking, radiating in a sciatica distribution
-Due to compressions in spinal nerves –> emerge lumbrosacral spinal cord
Venous engorgement (exercise)–> reduced arterial flow and transient ischaemia–> pain or paraesthesia
-Relieved by flexion movements and rest

109
Q

What is spondylolilthesis?

A

Displacement of the vertebrae above relative to the one below
Classified according to underlying cause
–> instability of facet joints, degenerative, fractures in neural arch, infection, defect in pars interarticularis (between superior and inferior articular facets)

110
Q

What is the difference between spondylolysis and spondylolsthesis?

A

Spondylolysis–> fracture without displacement

Spondylolisthesis–> anterior displacement of upper vertebrae

111
Q

What are some of the symptoms of spondylolisthesis? How is it treated?

A

Instability of VC
Some asymptomatic
Some discomfort–> lower back pain, incapacitating mechanical pain, sciatica, neurological claudication
Treatment–> screws and rods to hold in place

112
Q

Why do you perform a lumbar puncture? Where does fluid come from?

A

Diagnostic test–> variety of CNS disorders including meningitis, MS etc
Withdrawal of fluid from the subarachnoid space of lumbar cistern

113
Q

Between which lumbar vertebrae do you perform a lumbar puncture?

A

Between L3 and L4 or L4 and L5

At the level between the highest point of the iliac crests –> supracristal plane

114
Q

What layers would the needle pass through?

A

Skin–> Subcutaneous fat –> supraspinous ligament–> interspinous ligament–> ligamentum flavum–> epidural fat and veins –> dura mater–> arachnoid mater into subarachnoid space

Semester 2 Musculoskeletal System (12 decks)

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