The Lumbar Spine And Associated Disorders Flashcards
(47 cards)
1
Q
How many vertebrae are there?
A
33 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal
2
Q
Which regions of the vertebral column are mobile?
A
• Mobile – Cervical and Lumbar • Relatively Immobile – Thoracic • Fused Vertebrae • 9 vertebrae fused to give 2 innominate structures – Sacrum (fusion of 5 vertebrae) – Coccyx (fusion of 4 vertebrae)
3
Q
What are the functions of the vertebral column?
A
- Central bony pillar of the body.
- Supports the skull, pelvis, upper limbs and the thoracic cage.
- Protection of the spinal cord and the cauda equina
- Movement - Highly flexible structure of bones, intervertebral discs and ligaments
- Haemopoiesis – red marrow
4
Q
Describe teh structure of a lumbar vertebra
A
General characteristics:
• Kidney shaped vertebral body
•Vertebral arch posteriorly
•Vertebral foramen: contains conus, cauda equina and meninges
Vertebral arch: Gives rise to 7 processes •x1 Spinous Process •x2 Transverse Process •x2 Superior Articular Process •X2 Inferior Articular Process
5
Q
What is a vertebral body?
A
- Largest part of the vertebra –
- 10% Cortical Bone
- 90% Cancellous Bone
- Usually the main weight bearing Greater Compressive forces distally part of the vertebra
- End Plates – Superior and Inferior Articular surfaces covered with hyaline cartilage
- Linked to adjacent vertebral bodies by intervertebral discs
- Size Vertebra increases from superior to inferior?
6
Q
What are vertebral processes
A
- 1 spinous process,
- 2 transverse processes (left and right)
- 2 superior articular processes (facets) interlock with the vertebra above
- 2 inferior articular processes (not shown) interlock with the vertebra below.
7
Q
What is the vertebral arch?
A
- Lamina connects transverse process to spinous process
- Pedicle connects transverse process to body
- Pedicles longer and larger bigger intervertebral foramen
- Lamina + pedicle = vertebral arch
8
Q
What is a facet joint?
A
• Lined with hyaline cartilage
• Paired
• Spinal nerves emerge through intervertebral foramina
• Orientated in a sagittal plane
• Interlocking design
– Prevents anterior displacement of vertebrae
– Orientation determines amount of flexion and rotation permitted
9
Q
What are the movements of the lumbar spine?
A
Flexion and extension
Lateral flexion
Rotation
10
Q
What are the types of joints in the spine?
A
- Fibrous – (ligaments) non- mobile
- Cartilaginous – Partially mobile
- Synovial Joints
11
Q
What are intervertebral discs?
A
• Account for 25% of the length of the vertebral column
• 70% Water, 20% Collagen, 10% Proteglycans (proteoglycans keep water in the disc)
• Lose height with age (proteoglycans lose ability to retain water)
• Slightly wedge-shaped posteriorly
• Consist of two regions:
– nucleus pulposus (central)
– annulus fibrosus (peripheral)
12
Q
What is an annulus fibrosus?
A
- Highly complex design
- Made from lamellae of annular bands in varying orientations
- Type 1collagen
- Avascular and Aneural
- Surrounds nucleus pulposus
- Is the major ‘shock absorber’
- Highly resilient under compression - stronger than the vertebral body
13
Q
What is the nucleus pulposus?
A
- Remnant of notochord
- Gelatinous, Type 2 Collgen
- High osmotic pressure
- Disc Height changes throughout day
- Disc Height changes with age
- Surrounded entirely by annulus fibrosus
- Centrally located in the infant
- Located more posteriorly in the adult
14
Q
What is the function of the ligaments of the vertebral column
A
- Provide stability
- Major ligaments: anterior longitudinal and posterior longitudinal ligament (anterior and posterior to vertebral bodies)
- Anterior is stronger than posterior
15
Q
What is the anterior longitudinal ligament?
A
- Anterior tubercle of atlas to sacrum
- Blends with periosteum of vertebral bodies
- Mobile over intervertebral discs
- Prevents hyperextension
Becomes taught when leaning back
Prevents extension
16
Q
What is the posterior longitudinal ligament?
A
- Body of axis to sacral canal
- Continues superior to axis as ‘tectorial membrane’
- Weaker than ALL
- Prevents hyperflexion
- Reinforces annulus centrally leading to paracentral disc prolapses
Becomes taught when leaning forwards
17
Q
What are the ligamentum flavum
A
• Yellow in colour: elastin elastic fibres
• Between laminae of adjacent vertebrae
• Stretched during flexion of the spine
See slide for position
18
Q
What are interspinous ligaments?
A
- Relatively weak sheets of fibrous tissue
- Unite spinous processes along adjacent borders
- Well developed only in the lumbar region (stability in flexion)
- Fuse with supraspinous ligaments
See slide for positioning
19
Q
What are supraspinous ligaments
A
• Tips of adjacent spinous processes • Strong bands of white fibrous tissue • Lax in extension • Tight in flexion (mechanical support for vertebral column) See slide for positioning
20
Q
Where is the body weight distributed through the spine?
A
• Weight 80% vertebral bodies and 20% facet joints
• Older disc dehydration – greater forces through the facet joints
As you get older
More forcee through facet joints - 35% not 20%
21
Q
What are the sacrum and coccyx?
A
- Sacrum consists of 5 fused vertebrae
- Articulates with L5 superiorly , ilium laterally, and coccyx inferiorly
- Learn the osteology yourselves (ADD to this)
- Coccyx consists of 4 fused vertebrae
- Easily fractured during falls
- Remnant of ‘tail’
22
Q
What are lordosis and kyphosis
A
Kyphosis = concave anteriorly Lordosis = convex anterirly
23
Q
Describe the curvature of the vertebral column
A
Cervical - lordosis Thoracic - kyphosis Lumbar - lordosis As ray - kyphosis Coccyx - kyphosis
24
Q
How des the vertebral column develop in the fetus?
A
- Flexed in a single curvature
- C-shaped
- Concave anteriorly = kyphosis
- This curvature is known as the Primary Curvature
- Primary curvature is retained throughout life in Thoracic, Sacral and Coccygeal regions
25
How does the vertebral column develop from foetus to young adult?
• The primary curvature is remodelled to add two
SECONDARY CURVATURES
• The cervical spine develops the first posterior concavity (cervical lordosis) when young child begins to lift its head
• The lumbar spine loses it’s primary kyphosis during crawling
• When the child begins to stand- up and walk, lumbar lordosis develops.
• Lumbar lordosis is the second secondary curvature
26
Describe the vertebral column in a young adult
* 4 distinct curvatures
* Sinusoidal profile - confers great flexibility and resilience
* 2 kyphoses (anterior flexions): thoracic and sacrococcygeal
* Kyphoses are continuations of the primary curvature of the foetus
* 2 lordoses (posterior flexions): cervical and lumbar
* Lordoses are SECONDARY CUVATURES (developmental)
27
Describe the vertebral column non old age
* Secondary curvatures start to disappear
* Loss of disc and osteoporotic fractures
* Continuous primary curvature is re-established
* ‘Senile kyphosis’
28
How does the vertebral column change during pregnancy
Exaggeration of the lumbar lordosis
- supports the weight of the fetus
- head above pelvis
29
How does the weight of the body pass through the vertebral column and how are the sacral vertebrae adapted to this?
* The weight of the body is projected into lower limbs about a line that passes centrally through the natural curvatures of the vertebral column
* Sacral vertebrae: fused, widened & concave anteriorly to transmit weight of the body through pelvis to legs
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Centre of gravity
• Passes through vertebral column at:
– C1 & C2
– C7 & T1
– T12 & L1
– L5 & S1
• ‘Weak points’ of vertebral column
• Curves need to be balanced to aid walking and stop us falling
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30
What is mechanical back pain?
* Pain when the spine is loaded (sitting, standing, not lying)
* Worse with exercise relieved by rest
* Intermittent
* Often triggered by innocuous activity
* Predisposition overweight, unhealthy lifestyle, deconditioned core muscles
31
How can lumbar back pain get confused with age related changes ?
* Nucleus pulposus dehydrates with age
* Loss of disc height disc – DISC BULGE
* Load stresses on the IV disc alter → reactive ‘marginal osteophytosis’ adjacent to affected endplates SYNDESMOPHYTES
* Increased load stress on the facet joints FACET JOINT OSTEOARTHRITIS(innervated by meningeal branch of spinal nerve → pain)
* Decreased size of intervertebral and vertebral foramen and compression of cauda equina or exiting spinal nerve roots
32
Describe the natural ageing of the spine
See slide for images
33
What is prolapse in terms of a slipped disc?
• Prolapse: protrusion of the nucleus
pulposus with slight impingement
into the spinal canal (contained)
34
What is extrusion in terms of a slipped disc?
• Extrusion: nucleus pulposus
breaks through annulus fibrosus,
but remains within the disc space.
35
What is sequestration in terms of a slipped disc?
• Sequestration: nucleus pulposus
breaks through annulus fibrosus
and separates from the main body
of the disc in the spinal canal.
36
Where does a slipped disc usually occur?
* Most commonly occurs at L4/5 or L5/S1
| * Usually herniates posterolaterally, causing compression of spinal nerve roots
37
Name types of disc prolapse?
* Paracentral – 96%
* Far Lateral – 2%
* Canal Filling – CES – 2%
38
What is sciatica?
• Sciatica is compression of the nerve roots which contribute to the sciatic nerve
39
Which nerve roots contribute towards the sciatic nerve?
L4, L5, s1, S2, S3
40
Name some types of sciatica
• Based on Dermatomes
• L4 Sciatica
Anterior thigh, Anterior knee, medial shin
* L5 Sciatica
* Lateral Thigh, lateral calf, dorsum of foot
* S1 Sciatica
* Posterior Thigh, Posterior, Calf, Heel, Sole of Foot
41
Which nerve root is compressed in sciatica
See slide for diagram
42
In whomst does disc prolapse occur most frequently
* Occurs in 30 to 50 year olds
| * Natural History = 90% resolve by 3 months
43
What is cauda equina syndrome
* Canal filling disc compressing the Lumbar and Sacral Nerve roots
* Occurs in 30 – 50 year olds
* 2% all PIDs
* Bilateral Sciatica
* Perianal Numbness
* Painless Retention of Urine
* Urinary/ Faecal Incontinence
* Need to Treat within 48 Hours of Sphincter Symptoms to be in good prognostic group
* Intermittent Self Catherisation
* DRE
* Sexual Dysfunction
44
What is lumbar canal stenosis
See notes
| • 70% stay the same • 15% progressive worse • 15% Better
45
What is claudication
Pain in legs when walks
| • Neurogenic • Vascular
46
What is spondylolisthesis and what causes it?
* A slip of the one vertebra on another
| * Abnormality in Vertebral Arch
47
Name types of spondylolisthesis
* Dysplastic – Congenital - Abnormality in facet joint
* Isthmic – Developmental
- Abnormality in pars interarticularis
- Back Pain in Adolescence
- Gymnasts and fast bowlers
• Degenerative
- Middle aged ladies
- Facet Joint Arthritis
* Iatrogenic – remove too much lamina and facet joint
* Pathological - tumour affects the neural arch
