Spine

Vertebrae

  • Types

    • 7 cervical

    • 12 thoracic

    • 5 lumbar

    • 5 sacral (fused)

    • Coccyx

 

Features

  • Body (or anterior mass)

  • Spinous process

    • Projects posteriorly

    • A series of levels for muscles of postures and muscles of active movement

    • Protects the spinal cord

  • Lateral (transverse) process

    • Articulations with ribs (thoracic spine)

    • Facet Joint

  • Pedicle

    • Bony process that projects backward from the body of the vertebrae and connect with the laminae

  • Lamine

    • Bon process on either side of the neural arch

    • Project backward and inward from the pedicles

  • Facet Joint

    • Joint in-between vertebrae excepts C1 and C2

    • Flex/extension

    • Lateral flexion and rotation

 

 

Atlas (C1)

  • Doesn't have a vertebral body

  • Holds up the skulls

  • It rotates on C2, facets, flexion /extension

 

Axis (C2)

  • Dens

    • Bony element that extends superiorly from C2

  • Allos for C1 to rotate and pivot

 

Cervical Vertebrae Movement

  • Lateral flexion

  • Extension

 

Thoracic Vertebrae Movement

  • More rotation than lateral flexion and extension

 

Lumbar Vertebrae Movement

  • Allows for lateral flexion but no rotation

 

Spine ROM

 

Occipitocervical Joint, C1

  • Flex/ext 50 degree

  • Rotation 4 degree

  • Lateral bend 8 degree

 

Atlantoaxial joint C1-C2

  • Flex/ext 10 degree

  • Rotation 50 degree

  • Lateral bend 0 degree

 

Subaxial Cervical Spine

  • Flex/Ext 50 degree

  • Rotation 50 degree

  • Lateral Bend 60 Degree

 

Thoracic Spine

  • Flex/Ext 75 degree

  • Rotation 70 degree

  • Lateral bend 75 degree

 

Lumbar Spine

  • Flex/Ext 85 degree

  • Rotation 10 degree

  • Lateral bend 30 degree

 

Interverbal Disc

  • Fibrocartilaginous between joints

  • Acts as cushion and shock-absorbing

  • Allows for flexibility

  • Prevent grinding

Joint

  • Fibrocartilaginous

    • Between disc and vertebral bodys

  • Synovial

    • Face joint 4 per vertebrae

 

Annulus Fibrosis

  • Arranged in 15-25 concentric layer

  • They are angled and it changes with alternated layers, creates a strong configuration

  • Made of collagen fibres

  • Outer 1/3 of AF is inervated and has blood supply

  • Is able to stretch and also have slack on opposite sides of the disc

  • During rotation, the fibres that run counter to direction of movement are stretched while the opposite is relaxed. This causes max tension and the nucleus  be compressed

    • Rotation is compression of spinal disx

    • This is why flexion with axial rotation tears the annulus and drives nucelus back leading to disc herniation

 

Nucleus pulposus

  • Centre of the disc and is like a liquid

  • It is incompressible so applied load creates outward pressure in all directions inside the disc

 

  • Sitting puts the most force on disc stand standing

  • Laying down on your back has the least amount of force

 

Ligaments

  • Anterior and posterior longitudinal ligaments

    • Connect vertebral body

  • Ligament flava

    • Connect laminae

    • Increased in elastin

  • Intertransverse ligaments

    • Connect transverse

  • Interspinous and supraspinous ligaments

    • Connect spinous phrase

 

 

 

Muscles

  • Causes movement and stabilize

    • Erector spinae

      • Superficial

    • Transpersonal

      • Deep

    • Many others

  • Movement

    • Flexion and extension

      • Cervical, thoracic, lumbar

    • Lateral flexion (moderate)

      • Cervical, thoracic (minimal), lumbar

    • Rotation

      • Cervical and thoracic

 

Transversospinalis Muscle Group

  • Action

    • Bilateral contraction

      • extends the spin

    • Unilateral contraction

      • Lateral flexion

      • Rotates the vertebral column to the opposite side

      • If the muscle contracts on the right, it will turn your head and spin left

 

Spinal Nerve

  • 8 Cervical Nerves

    • C1-7 is located above their respected vertebraes

    • C8 is between C1 and T1 vertebrae's

  • 12 Thoracic nerves

    • T12 is between T12 and L1

  • 5 Lumbar

  • 5 Sacral

  • 1 Coccygeal nerve

  • Sciatic nerve arises from

    • L4 to S3

General considerations

Causes

  • Congenital predisposition

  • Previous trauma

  • Mechanical factors

    • Poor posture (lifting, bending)

    • Obesity

  • Acute or repetitive trauma

 

Effects

  • Pain, tenderness, spasm, restricted ROM

  • Neurologic Ssx

    • Radiating pain, sciatica

    • Weakness, numbness, absent DTR

 

 

Sprain and Strains

  • Hx

    • Twisting or lifting

    • Recurrence is common

  • Ssx

    • Pain and tenderness

    • Muscle spasm (delayed onset)

    • Restricted ROM (early or delayed onset)

    • Increase warmth

    • If any neurologic Ssx are pressure, assume fracture dislocation or disc injury, stabilize and transport to hospital

Tx

  • Rest, supine, no more than 2 days

  • NSAID/pain meds

  • Cold therapy first and heat later

  • Physio and massage

  • Comprehensive rehab program

    • Flexibility, strengthening and task specific

  • Correct predisposing factors (posture)

  • Gradual return to activity

 Herniated Lumbar Disk

  • When lumbar discs are subject to constant abnormal stresses that stem from faulty body mechanics, trauma or both

  • Causes degeneration, tears and cracks in the annulus fibrosus

    • Often between L4-L5

    • L5-S1

Mechanism for injury

  • Forward bending/testing and places abnormal strain on the lumbar region

  • Movt that produces herniation, bulging of the nucleus pulposus

  • Can cause an already degenerated disk's nucleus pulposus to protrude through the annulus fibrosis

  • Pressure in the intervertebral disk changes with various position or postures

    • Pressure increases as patient begin to lean farther forward

 

 

Symptoms

  • Sharp pain that radiates on skin from a specific nerve root in spin, down in buttocks, back of leg or pain that spready across back

  • Weakness in lower limbs

  • Symptoms worse in morning with axial loading, getting out of bed

  • Can be sudden or gradual

  • Pain increase after sitting and resumes activity

  • Forward bending and siting increase pain,

  • Backward bending reduces

  • Posture will result in a side bend away from pain

  • Tenderness around painful area

  • Straight leg raise 30 degrees increase pain

  • Tendon reflex is diminished

  • Valsalva maneuver increases pain

 

Management

  • Pain-reducing modalities

    • Ice, elec stim

  • Passive backward bending

  • Tech appropriate posture self-correction exercises

  • Strengthen core muscles like multifidi and transversus abdominis

  •  improve 3 months after onset of symptoms

  • If no improvement consider surgery

Lumbar Disc Herniation

  • Nucleus pulposus breaks through annulus fibrosis

  • Often occurs between L4/L5 and L5/S1

  • Vulnerable between ages 30 to 50 as elasticity and water content of nucleus pulposus decreases with age

 

4 stages

Disc protrusion

  • Bulging disc

  • Cracks in the annulus fibrosis begin to appear

Prolapsed disc

  • Nucleus pulposus moves completely through annulus fibrosis

Extruded Disc

  • Nucleus pulposus moves into spinal canal and comes in contact with a nerve root

Sequestered Disc

  • Portion of nucleus pulposus separated from disc and begins to migrate in spinal canal

 

Intervertebral Disc Disease

Hx

  • From twisting and lifting

  • Herniation of nucleus pulposus

  • Compression of nerve root(s) or spinal cord

Effect

  • Pain and tenderness

  • Muscle spasm (delayed onset)

  • Restricted ROM (early or delayed onset)

  • Increase warmth

  • If any neurologic Ssx are pressure, assume fracture dislocation or disc injury, stabilize and transport to hospital

  • Instability

  • Osteoarthritis, osteophytes, stenosis

Tx

  • Conservative if possible

    •  

    • Rest, supine, no more than 2 days

    • NSAID/pain meds

    • Cold therapy first and heat later

    • Physio and massage

  • Surgery for discectomy, laminectomy, or fusion

 

Fractures

  • Axial load

    • Cervical spine becomes compressed with lots of force, head into boards at hockey or helmet to helmet in football

  • Ssx

    • Point tenderness, decrease ROM

    • Pain in neck, chest and extremities

    • Numbness/weakness in trunk/limbs

  • Tx

  • Stabilize, c-spine collar, spine board

  • If unconscious assume c-spine injury

 

Spine treatment

  • Key is balance

    • Demands with functional capacity

    • Expectations with realistic goals

  • Main Points

    • Take time to heal and rest, most important

    • Cold, heat, NSAIDs, brace

    • Physio, massage therapy, chiro

    • Rehab, indefinite

    • Correct predisposing factors

    • May need to change job or sport

 

McGill Big 3

  • Strengthens the muscles that stabilize the spine and build endurance

    • Bird dog

    • Trunk raise

    • Side plank

  • 10 seconds of activity

  • 2 seconds rest