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1

What are the muscles of the back?

Trapezius
- Transverse cervical a.
- Spinal Accessory n.
Levator Scapulae, Rhomboid Minor, Rhomboid Major
- Dorsal Scapular a.
- Dorsal Scapular n.
Serratus Posterior Superior
- Ventral Rami of intercostal n.
Latissimus Dorsi
- Thoracodorsal a.
- Thoracodorsal n.
Serratus Posterior Inferior
- Ventral Rami of intercostal n.
Erector Spinae
- Dorsal Rami of segmental spinal n.

2

What do Dorsal Rami innervate?

Skin of Back and epaxial (dorsal side) muscles

3

How do the dorsal and ventral primary rami form?

Off of each side of the spinal cord:
- Dorsal/Ventral Rootlets form Dorsal/Ventral Roots
- Dorsal/Ventral Roots combine to form Spinal Nerve (DRG 1st)
- Spinal nerve splits to form Primary Dorsal Rami and Primary Ventral Rami

The Dorsal Rootlets/Roots are only sensory neurons
The Ventral Rootlets/Roots are only motor neurons
- Sensory/Motor becomes combined in the spinal nerve and then afterwards into the rami

4

What are the vertebral characteristics associated w/ kyphoplasty?

Vertebral Body,
Pedicles
Transverse Processes
Lamina
Spinous Process
Superior/Inferior Articular Processes
Intervertebral Foramina
Superior, Inferior, Transverse Costal Facets (Thoracic only)
Transverse Foramina (Cervical Only)

For kyphoplasty, have to insert needle at 45 degree angle between transverse Process and Spinous process into compressed Vertebrae
- expand balloon and inject the glue which fixes compression

5

What are the planes of the body?

Coronal (frontal)
Sagittal (median)
Transverse (horizontal)

6

Describe the nervous system components present in the vertebral canal and intervertebral foramen.

Vertebral Canal
- Spinal cord
- Meninges
- Epidural Fat
- Internal Vertebral (Epidural) Venous Plexus

In the Intervertebral Foramina
- Dorsal (and DRG) and ventral nerve roots
- Spinal Nerve
- if the disc is herniated it will be in there too compressing nerve root

7

Describe the boundaries of the intervertebral foramen and the structures which may cause stenosis of the foramen.

Boundaries of the intervertebral Foramen are the Superior and Inferior vertebral notches
- Anterior border is the vertebral body
- Posterior border is the ligamentum flavum

Stenosis can be caused by:
- Facet inflammation
- Ligamentum flavum hypertrophy
- Disc pathology

8

Describe the dural layers of the spinal cord, and the spaces associated with them.

Dura Mater
- subdural space and epidural space

Arachnoid Mater
- Subarachnoid space that contains CSF

Pia Mater
- denticulate ligaments

9

Describe safe anatomical areas for spinal taps and epidural injections.

To Draw sample of CSF for spinal tap you have to enter below LV2
- above LV2 risks damaging spinal cord
- below LV2 the cauda equina can accommodate needle

For Epidurals:
- enter the epidural space before the dura mater

10

Describe the structures penetrated during a spinal tap procedure.

Skin
Epidural Fat
Supraspinous Ligament
Ligamentum Flavum
Epidural Space
Dura Mater
Subdural Space
Arachnoid Mater
Subarachnoid space for CSF!

11

Describe the anatomy relevant to common sites of intervertebral disc protrusion

99% of disc hernations occur at LV 4/5, LV5/SV1, CV4/5 or CV5/6
- CV herniations affect spinal nerve of higher # CV
- LV herniations affect spinal nerve of lower # LV

12

Define “dermatome”, “autonomous zone” and “myotome”.

dermatome
- area of skin innervated by single spinal nerve

autonomous zone
- area of skin where overlap of dermatomes not likely

Myotome
- A group of muscles that a single spinal nerve root innervates

• Ex. C5 = shoulder abduction
o C6 = elbow flexion/wrist extension
o C7 = elbow extension/wrist flexion
o C8 = finger flexion
o T1 = finger abduction

13

Use dermatome and myotome signs to localize a spinal cord/nerve lesion.

Study the dermatome & myotome chart for arm.

14

Discuss the curvatures of the spine in normal and abnormal states

Normal
 Primary curvatures (kyphotic)
• Thoracic and sacral

 Secondary curvatures (lordotic)
• Cervical and lumbar

Abnormal
 Scoliosis
• Lateral curvature of the spine

15

• Discuss kyphoplasty in the context of severe osteoporosis

o Used to repair compressed vertebral bodies
o Surgical
 Enter through pedicle to avoid puncturing spinal cord
 Inflate balloon and inject material to return vertebral body to normal shape

16

Describe the components of the spinal cord/spinal nerve?

Spinal segment Ex. T1
- Dorsal/Ventral Rootlets =>Roots
 Dorsal - Sensory
• Dorsal root ganglion
 Ventral - Motor

Combine to make a spinal nerve

One pair of spinal nerves for each spinal segment
- Exit vertebral canal below vertebra of the same number EXCEPT in the cervical region which exit above vertebra of the same number (C8 exits above T1)

Split into a dorsal primary ramus and ventral primary ramus
- this is mixed at this point (sensory/motor)

17

Which structures may impinge on the spinal nerve?

Pathological IV disc
• Nucleus pulposes is what herniates after bulging and breakdown of the annulus fibrosis

Stenosis of vertebral canal
• Facet inflammation
• Ligamentum flavum hypertrophy

18

Describe the basic anatomy, blood supply, and lymphatic drainage of the breast.

Anatomy
 Overlies ribs 2-6
 Suspensory ligaments (of Cooper)
 Lactiferous ducts empty into lactiferous sinuses, then out the nipple
 Areola
 Nipple

Blood supply
 Internal thoracic (mammary) a. and lateral thoracic a.

Lymphatic drainage
 Axillary nodes (75% of lymph drains here)
 Supraclavicular nodes
 Parasternal nodes

19

• Describe the anatomical mechanisms of mastectomy-induced lymphedema and winging of the scapula.

Lymphedema
 Side effect of removing lymph nodes because the channels may not drain correctly or connect so lymph accumulates in the arms

Winging of the scapula
 Because the long thoracic n. is superficial to the serratus anterior m. it can be cut or injured during mastectomy, which paralyzes the serratus anterior m. causing winging of the scapula.

20

• Learn how to perform the Neer Sign and Hawkins test in a physical exam.

Neer sign
 Internally rotate humerus and lift arm above shoulder

Hawkins test
 Flex elbow and internally rotate humerus

21

Explain the sub-acromial space and its role in shoulder pain.

Between acromion and head of the humerus

Contents
 Subacromial bursa
 Supraspinatus tendon
 Capsular ligaments

Space can be reduced by
 Inflammation of bursa, tendon, muscle tear
 Instability of the humeral head
 Bone spur

Perform Neer sign and Hawkins test to determine impingement syndrome
 Weakened rotator cuff caused the humeral head to displace superiorly by the pull of the deltoid m.

22

Relate shoulder dystocia to Erb’s palsy, and describe the functional deficits associated with upper brachial plexus injury

Shoulder dystocia occurs during delivery of a fetus when the shoulders get stuck behind the pubic symphysis and the head is pulled with the shoulders stationary, stretching the upper trunk of the brachial plexus

o Erb’s palsy
 Internally rotated arm
• “waiter’s tip” hand
• Nothing is opposing them
o The external rotators are nonfunctional
 Numbness around shoulder and anterolateral aspect of arm and forearm, thumb
• C5-C6
 Weakness abducting arm

23

Compare and contrast upper and lower brachial plexus injuries

Upper
 C5-C6
• Difficulty abducting arm
• Arm medially rotated
• No sensory to lateral part of arm and thumb

Lower
 C8-T1
• Claw hand
o Ulnar n. problem
• Klumpke’s palsy
• No sensation on pinky

24

• Describe the distal attachment pattern of the rotator cuff muscles, and the two main functions of the rotator cuff.

Greater tubercle
 Supraspinatus
 Infraspinatus
 Teres minor

Lesser tubercle
 Subscapularis

Primary functions of rotator cuff muscles
 Stabilize head of humerus in glenoid fossa
 Assist in abduction and rotation of humeral head

25

Describe the difference between “shoulder separation and shoulder dislocation”

Shoulder separation
 Torn ligaments around shoulder
• Weight of arm can pull scapula downward, looking like dislocation

Shoulder dislocation
 Displacement of the humeral head out of the glenoid fossa

26

Describe the anatomical difference between central and peripheral nervous systems

CNS
 Brain and spinal cord
 Ogliodendrocytes
• Myelinating cells of the CNS

PNS
 31 pairs of spinal nerves
 12 cranial nerves
 Peripheral autonomic ganglia and nerves
 Schwann cells
• Myelinating cells of the PNS

27

Describe the embryological origin of the neural tube and neural crest

Neuroectoderm
 Notochord induces formation of neuroectoderm

Neural tube
 Cell bodies inside the brain and spinal cord

Neural crest
 Cell bodies outside the brain or spinal cord

28

Describe the nerve components and reflex arcs of somatic innervation

GSE
 Motor
 Innervates skeletal muscles
 Cell bodies found in the ventral horn

GSA
 Sensory
 Pain, touch temperature from somatic structures
 Cell bodies found in the DRG

Reflex arcs
 Monosynaptic
• One motor neuron
• 1 GSA (PUN) neuron in to ventral horn
• 1 GSE neuron from ventral horn to target structure

Bisynaptic
• 1 GSA neuron to dorsal horn
• 1 interneuron from dorsal to ventral horn
o Secondary sensory neuron
• 1 GSE neuron from ventral horn to target

29

Describe the difference between upper motor neurons and lower motor neurons and recognize clinical signs of damage to each

UMN
 CNS
 No direct contact with target structure
 Communicate with LMN
• Often inhibitory
 Damage causes
• Hyperreflexia
o Random muscle jerking b/c loss of inhibitory fxn
• Hypertonia
• Muscle weakness
• Ex. CP, stroke,

LMN
 Directly contacts target structure
 All spinal motor neurons and some cranial nerves are LMNs
 Damage
• Muscle weakness/paralysis
• Atrophy
• Hyporeflexia
• Atonia
• Ex. Polio, ALS

30

Describe the characteristics and sequelae of compartment syndrome.

Case Study Initial findings:
• Sensation is present in all fingers
• He cannot actively extend wrist or fingers
• Severe pain with passive extension of wrist
• Finger and thumb flexion weak
• Radial and ulnar pulse present

1 hr later
• Pain is worse
• Loss of all sensation in hand
• Loss of motor function
• Fingers are cool
• No radial pulse