1
Q
Vertebral Body Osteoporosis
A
- Common metabolic bone disease
- Osteoporosis: demineralization of bones from disruption of calcium balance
- Most common in thoracic vertebrae & post-menopausal females
2
Q
Laminectomy
A
- Def: Surgically removing the spinous process + adjacent laminae in vertebral column
- Posterior exposure of spinal cord
- Preformed to relieve pressure from tumor, herniated IV disc, or bony hypertrophy (excess growth)
3
Q
Dislocation of Cervical Vertebrae
A
- Cervical vertebrae have horizontal articular facets, so they arent locked together as tight, making dislocation easy in neck
- Since the cervical vertebral canals are large you can dislocate them w/out damaging the spinal cord
- If no “facet jumping” occurs (locking of displaced facets) the problem usually resolves itself, have to get an MRI to see if there is spinal cord soft tissue damage
4
Q
Fracture and Dislocation of Atlas
A
- Rupture of transverse ligament –> Jefferson/Burst Fracture –> spinal cord damage
- You can get hit on top of the head (dive into pool headfirst) and it usually doesn’t hurt the spinal cord becuase the bony ring actually gets bigger
5
Q
Fracture and Dislocation of Atlas
A
- Fractures of the vertebral arch of the axis = most common cervical vertebrae injury
1. Traumatic/Cervical Spondylolysis of C2 or Hangman’s Fracture –> hyperextension of head
2. Whiplash –> Combined hyperextension of head and neck
3. Quadripelegia –> Incomplete dislocation of Axis
4. Fractures of the Dens –> Horizontal blow to head
5. Osteopenia –> Loss of bone mass
6
Q
Lumbar Spinal Stenosis
A
- Def: Stenotic (narrowing) of vertebral foramen in lumbar vertebrae.
- Compresses nerves becuase they get bigger as you go down, more vulnerable to IV disc bulging
7
Q
Cervical Rib
A
- C7 transverse process = enlarged
- The supernumerary rib can place pressure on subclavian artery or inferior trunk of brachial plexus and can cause thoracic outlet syndrome
8
Q
Caudal Epidural Anesthesia
A
- Anesthetic agents are injected into the fat of the sacral canal that surrounds the sacral nerves
- You can do this through the sacral hiatus cause it will act on the S2-Co1 cauda equina spinal nerves and block all inferior to those
- Or if you go in through the posterior sacral foramina this is called transsacral epidural anesthesia
9
Q
Injury of Coccyx
A
- Caused by an abrupt fall onto the butt
- Fracture of coccyx = dislocation of sacrococcygeal joint
- Sometimes you have to surgically remove the bone to help relieve pain
- Coccygodynia = pain after coccygeal trauma (from difficult childbirth)
10
Q
Abnormal Fusion of Vertebrae (5%)
A
- Hemisacralization* –> L5 partly w/ sacrum
- Sacralization of L5 veretbrae* –> L5 fully w/ sacrum
- Lumbarization of S1 Vertebrae* –> S1 separated w/ sacrum and fused with L5, painful cause other lumbar veretbrae start to degenerate (they dont have as strong of connections)
11
Q
Effect of Aging on Vertebrae
A
- Bone loss and the slight change in shape of veretbraes may account for the loss of height that occurs w/ aging
- IV discs + vertebrae age –> causes compressive forces –> Osteophytes (bony spurs) develop –> called spondylosis –> normal w/ aging
- Spondylosis = vertebral discs
- Osteoarthrosis = zygapophysial joints
12
Q
Anomalies of Vertebrae
A
- Spina bifida occulta:* L5 and/or S1 vertebral arches fail to develop normally & fuse to vertebral canal
- Minor form = Small dimple w/ tuft of hair in lower back (back problems in infants)
- Severe types:
- Spina bifida cystica:* veretebral arches fail to develop completely and the meninges herniate
(meningocele = spina bifida w/ meningeal cyst)
(Meningomyelocele = Neruo symptoms like paralysis, from neural tube closure defect)
13
Q
Aging of Intervertebral Discs
A
- W/ advanced age nuclei pulposi dehydrate –> Discs become stiffer
- Annulos fibrosis gets all the vertical load and gets squished! Making the discs wider (increase in size w/ age)
- Degenerative disc disease = disc narrowing = not normal aging
14
Q
Back Pain
A
Five sources of the very common “back pain”
- Fibroskeletal structures: periosteum, ligaments, anuli fibrosi of IV discs
- Sharp pain of fracture is from periosteal (membrane covering the bone)
- Pain from dislocations = ligaments (Ex. Disc herniation is from anulus fibrosis pinning the posterior longitudinal ligament) - Meninges: coverings of the spinal cord (rare)
- Synovial Joints: capsules of the zygapophysial joints
- Aging (osteoarthrosis) or disease (rheumatoid arthritis) of joints - Muscles: Intrinsic muscles of the back
- Reflexive cramping (spasms) producing ischemia (local loss of blood supply), often as a result of guarding (contraction in anticipation of pain) - Nervous tissue: Spinal nerves/roots exiting the IV foramina
- Referred pain from subcutaneous (dermatome)
- Localized Lower Back Pain = Muscular, Joint, or Fibroskeletal in Orgin
15
Q
Herniation of Nucleus Pulposus (Herniation of IV Disc)
A
IV discs are so strong (90% water) in young people that sometimes you will fracture a vertebrae before the discs ruptures.
What causes a disc rupture/fracture adjacent vertebral bodies? –> Violent hyperflexion + sports with downward/twisting pressure on back & neck
- nucleus pulposis ruptures through annulus fibrosis posteriorlaterally (usually)
- Acute localized back pain: from pressure on ligaments + inflammation
- Chronic Back Pain is usually referred radiating pain, percieved as coming from the area (dermatome) supplied by that nerve
- Except for cervical, when the IV disc protrudes it compresses the spinal nerves one vertebrae below it
- 95% of lumbar @ L4/5 or L5/S1 level (IV space narrows)
- Sciatica: Pain radiating from lower back down to posterior/laterall thigh = L5/S1 sciatic nerve compression
16
Q
Spinal Fusion & Intervertebral Disc Replacement
A
- Degenerative Disc Disease:* Results from a big decrease in IV disc space –> produces spinal stenosis (narrowing of vertebral canal)
- Treated w/ Laminectomy to relieve pressure on nerves, sometimes they use spinal fusion (arthrodesis) to eliminate back movement, use rods and artificial discs
17
Q
Injury and Disease of Zygapophysial Joints
A
Zygapophysial Joints are close to IV foramina where spinal nerves come out of the vertebral canal
- If these joints are injured –> develop osteophytes (osteoarthritis) –> spinal nerves affected –> pain along dermatomes –> spasm in muscles from myotomes (all muscles recieving innervation from one spinal nerve)
- Treatment? Denervation of lumbar zygapophysial joints
- -* These nerves are sectioned near the joints and destroyed by radiofrequency percutaneous rhizolysis
18
Q
Fractures & Dislocations of Vertebrae
A
- Spondylolysis:* Fracture of the bones connecting the superior & inferior articular processes (interlocking mechanism = broken)
- Spondylolisthesis:* Dislocation between adjacent vertebrae
19
Q
Fracture of Dens of Atlas
A
Interesting: The transverse ligament of the atlas that holds the dens in place is stronger than the dens itself
- Dens fracture @ base –> no blood supply –> avascular necrosis (death)
- Fracture of vertebral body below dens –> heals better because blood supply is in tact
20
Q
Rupture of Transverse Ligament of Atlas
A
Transverse ligament of atlas ruptures –> dens set free –> atlanto-axial subluxation –> incomplete dislocation of median atlanto-axial joint
- Spinal cord = compressed
- Can cause paralysis of all four limbs (quadriplegia) or medulla of bainstem (death)
- 1/s of atlas ring = dens, 1/3 = spinal cord, 1/3 = fluid
21
Q
Rupture of Alar Ligaments
A
Too much flexion & rotation of the head can tear the alar ligaments.
- You know if they are torn cause the patient can move their head 30% further on contralateral side
22
Q
Back Strains, Sprains, and Spasms
A
What prevents them? STRETCH PEOPLE!
- Back Sprain: Ligaments (excessive extension/rotation)
- Back Strain: Overly strong muscular contraction
- Sports/Lifting w/ back injurys
- Tearing of muscle fibers (usually erector spinae), weight isint balanced, don’t use legs to lift then back and vertebrae have to do all the work
- After injury –> as a protective mechanism –> muslces spasm (sudden involuntary contraction, cramps)
23
Q
Reduced Blood Supply to the Brainstem
A
Winding course of Vertebral A.’s –> through foramina transversarii of transverse processes of cervical vertebrae –> through suboccipital triangle
- Arteriosclerosis* (hardening of arteries)
- Reduces blood flow of vertebral artery and if you have your head turned for a long time (like backing up a car) you might get dizzy and pass out! no blood flow to brainstem!
24
Q
Congenital Absense of a Body Part, Organ, or Tissue
A
- Poland Syndrome:* uilateral upper limb development (agenesis)
- Ex. Pectoralis major is absent on one side
25
Injury of Long Thoracic Nerve and Paralysis of Serratus Anterior
Injury of long thoracic N. --\> Paralysizes Serratus Anterior --\> *winged scapula*
-Happens when limbs are limbs are elevated (ex. knife fight) becuase L.T.N. is superficial or bullets or masectomy surgery
26
Triangle of Auscultation
Near the inferior angle of the scapula is a small triangular gap in the musculature, good for examining lungs
- Superior border of Latissimus Dorsi, Medial Scapula, & Lateral Trapezius
- Can increase this area by having the patient cross their arms and lean forward
27
Injury of Spinal Accessory Nerve
*Spinal accessory nerve palsy:* "dropped" shoulder with ipsolateral weakness when the shoulders are shrugged against resistance
28
Injury of Thoracodorsal Nerve
* Paralysis of latissimus dorsi:* person is unable to climb (raise the trunk of their upper limbs) and use crutches
- Vulnerable during many types of surgeries
29
Injury to Dorsal Scapular Nerve
- Rhomboid and Levator Scapulae affected
30
Injury to Axillary Nerve
- Deltoid and Teres Minor atrophy
- Usually injured @ head of humerus fracture, dislocation of glenohumeral joint, or incorrect use of crutches
- Deltoid = common site for intramuscular drugs
31
Fracture-Dislocation of Proximal Humeral Epiphysis
Results from a direct blow or indirect injury to the shoulder of a child or adolescent.
Because the glenohumeral joint capsule is reinforced by the rotator cuff it is stronger than the epiphysial plate
32
Rotator Cuff Injuries
Injury or disease may damage the musculotendinous rotator cuff, causing the glenohumeral joint to be unstable.
- Supraspinatus = most commonly torn
* Degenerative Tendinitis of Rotator Cuff:* common in old people
33
Compression of Lumbar Spinal Nerve Roots
As you go down the spine:
Spinal nerves increase and IV foramina decrease --\> Increases the chance spinal nerve roots will be compressed (especially @ L5) if osteophytes (bony spurs) develop or herniation occurs
34
Myelography
*Myelography* = Radioplaque contrast procedure that allows visualization of spinal cord + spinal nerve roots
They take out CSF w/ lumbar puncture and replacing it w/ a contrast material into the subarachnoid space
35
Development of Meninges and Subarachnoid Space
Arachnoid + Pia Mater form **leptomeninges**
They develop as a single layer from the mesenchyme surrounding the embryonic spinal cord
36
Lumbar Spinal Puncture
Lumbar Puncture/Spinal tap = Withdraw of CSF from lumbar cistern, Important for evaluating CNS disorders
- *Meningitis* & disease of CSF may alter the cells in CSF or change the conc. of its chemicals and you can see if blood is present
- LP preformed w/ patient on side with knees to chest (flexion of vertebral column facilitates insertion of needle)
- You feel for the iliac crests (*supracristal plane*) and put the needle (lumbar puncture needle w/ stylet) in between the spinous process of L3/4 or L4/5. Needle "pops" through ligamentum flavum and dura, arachnoid, and enters lumbar cistern. When you remove stylet the CSF comes out at about one drop per second.
37
Spinal Anesthesia
An anesthetc agent is injected into the subarachnoid space.
- Headache may follow due to leakage of CSF through lumbar puncture
38
Epidural Anesthesia (Blocks)
An anesthetic agent is injected into the epidural space in same position as LP or through the sacral hiatus
39
Ischemia of Spinal Cord
The segmental reinforcements of the blood supply to the spinal cord from the segmental medullary arteries are important in supplying blood to the anterior and posterior spinal arteries.
Deficient blood supply (ischemia) of the spinal cord affects its function and can lead to muscle weakness and paralysis.
40
Spinal Cord Injuries
* Spinal cord shock:* Protrusion of cervical IV disc into the vertebral canal after a neck injury
* Osteoarthritis of Zygapophysial Joints* or a protruding IV disc can put pressure on spinal nerve roots of cauda equina
Lumbar Spondylosis (degenerative joint disease) = localized pain and stiffness
*Transection of the spinal cord* --\> loss of all sensation and voluntary movement inferior to that lesion
C1-C3 = no function below head, **need ventilator** to maintain respiration
C4-5 = quadriplegia
C6-8 = loss of lower limp, some upper limb function, may be able to feed themsel or use wheel chair
T1-T9 = *parapelgia* (paralysis of both lower limbs)
T10-L1 = Can move some thigh, walk w/ long leg braces
L2-L3 = Have most leg muscle function, might need short leg braces for walking
MSK Midterm
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