Anatomy Lect 5 Trunk & Spine

1. Anatomy
Lecture 5
Trunk & Spine
Physician Assistant Program
Miami Dade College

2. Nothing great was ever achieved
without enthusiasm.
Ralph Waldo Emerson

3. Spinal Anatomy
The spine has three
major components:
–the spinal column
(i.e., bones and
discs)
–neural elements
(i.e., the spinal cord
and nerve roots)
–supporting
structures (i.e.,
muscles and
ligaments)

5. Vertebrae
C=7
T=12
L=5
S=5
C=3-4 (1)
31 pairs of
spinal nerves

7. Spinal Anatomy
Term
# of
Vertebrae
Body Area Abbreviation
Cervical 7 Neck C1 – C7
Thoracic 12 Chest T1 – T12
Lumbar 5 (or 6) Low Back L1 – L5
Sacrum 5 (fused)Pelvis S1 – S5
Coccyx 3-4 (1) Tailbone None

8.  The spine has four
natural curves.
–The cervical and lumbar
curves are lordotic.
–The thoracic and sacral
curves are kyphotic.
–The curves help to
distribute mechanical
stress as the body
moves.
Pathologic Lateral
Curvature
–Scoliosis

9. Spinal Anatomy & Physiology
Protection
Spinal Cord and Nerve
Roots
Many internal organs
Base for Attachment
Ligaments
Tendons
Muscles
Structural Support
Head, shoulders, chest
Connects upper and
lower body
Balance and weight
distribution
Flexibility and
Mobility
Flexion (forward
bending)
Extension (backward
bending)
Side bending (left and
right)
Rotation (left and
right)
Combination of above
Other
Bones produce red
blood cells
Mineral storage

10. Back Pain
10% of population/year seen
80% c/o back pain in lifetime
–30-70 yr/old
–Competitive sports, accidents

11. Spinal Anatomy
The Central Nervous System is
composed of the brain and spinal
cord.
The brain has 12 Cranial Nerves.
The spinal cord, which originates
immediately below the brainstem,
extends to the first lumbar vertebra
(L1).
Beyond L1 the spinal cord becomes
the Cauda Equina

12. Spinal Anatomy
Nerve impulses travel to and from
the brain through the spinal cord to
a specific location by way of the
Peripheral Nervous System (PNS).
The PNS is the complex system of
nerves that branch off from the
spinal nerve roots.

13. Spinal Anatomy
The CNS extends to the Peripheral Nervous
System (PNS),
–a system of nerves that branch beyond the spinal
cord, brain, and brainstem.
The PNS includes the Somatic Nervous
System (SNS) and the Autonomic
Nervous System (ANS).
The somatic nervous system includes the
nerves serving the musculoskeletal system
and the skin.
It is voluntary and reacts to outside stimuli
affecting the body.
The autonomic nervous system is
involuntary automatically seeking to
maintain homeostasis or normal function.

14. Spinal Anatomy
The ANS is further divided into the
Sympathetic Nervous System and the
Parasympathetic Nervous System.
The sympathetic nervous system is an
involuntary system often associated with
the flight or fight response.
The parasympathetic nervous system is
responsible for promoting internal harmony
such as regular heartbeat during normal
activity. Associated with the rest or digest
response.

15. Cerebrospinal Fluid (CSF)
Cerebrospinal fluid is a clear fluid found in
the brain chambers (Ventricles), spinal
canal, and spinal cord.
This fluid is secreted from the Choroids
Plexus, a vascular part in the ventricles of
the brain.
CSF bathes and circulates among these
tissues and acts as a shock absorber to
protect against injury.
The fluid contains different electrolytes,
proteins, and glucose.
In an average adult the total volume of CSF
is about 150 milliliters.

16. Meninges
Meninges are membranes that cover and
protect the brain and spinal cord.
There are three primary types:
–(1) The dura mater, or dura, is the gray outer layer
of the spinal cord and nerve roots.
It is made of strong connective tissue.
–(2) The arachnoid mater resembles a loosely woven
fabric of arteries and veins.
This layer is thinner than the dura mater.
The Subarachnoid space is filled with cerebrospinal fluid.
–(3) The pia mater is the innermost layer and is a
delicate and highly vascular membrane providing
blood to the neural structures.

17. DermatomesDermatomes
is an area of
skin supplied
by fibers from
a single spinal
nerve root.

18. Intervertebral discs
The cartilaginous discs between vertebrae
absorb and distribute shock and keep the
vertebrae from grinding together during
movement
The intervertebral discs make up one fourth
of the spinal column's length.
There are no discs between the Atlas (C1),
Axis (C2), sacrum and Coccyx.
Discs are not vascular and therefore depend
on the end plates to diffuse needed
nutrients.
The cartilaginous layers of the end plates
anchor the discs in place.

19. Intervertebral discs
The intervertebral discs are
fibrocartilaginous cushions serving as
the spine's shock absorbing system,
which protect the vertebrae, brain, and
other structures (i.e. nerves).
The discs allow some vertebral motion:
extension and flexion.
Individual disc movement is very
limited – however considerable motion
is possible when several discs combine
forces.

20. Intervertebral discs
Intervertebral discs are
composed of an annulus
fibrosus and a nucleus
pulposus.
–The annulus fibrosus is a strong
radial tire–like structure made up
of lamellae; concentric sheets of
collagen fibers connected to the
vertebral end plates. The sheets
are orientated at various angles.
–The annulus fibrosus encloses the
nucleus pulposus.

22. Intervertebral discs
Although both the annulus fibrosus and
nucleus pulposus are composed of water,
collagen, and proteoglycans (PGs), the
amount of fluid (water and PGs) is greatest
in the nucleus pulposus.
PG molecules are important because they
attract and retain water.
The nucleus pulposus contains a hydrated
gel–like matter that resists compression.
The amount of water in the nucleus varies
throughout the day depending on activity.

24. Facet joints
Each vertebra has two sets of facet joints.
One pair faces upward (superior articular
facet) and one downward (inferior articular
facet).
There is one joint on each side (right and
left).
Facet joints are hinge–like and link
vertebrae together.
They are located at the back of the spine
(posterior).

26. Facet joints
Facet joints are synovial joints.
–This means each joint is surrounded by a capsule
of connective tissue and produces a fluid to
nourish and lubricate the joint.
The joint surfaces are coated with cartilage
allowing joints to move or glide smoothly
(articulate) against each other.
These joints allow flexion (bend forward),
extension (bend backward), and twisting
motion.
The spine is made more stable due to the
interlocking nature to adjacent vertebrae

28. Ligaments in the spine
Three of the more important ligaments in
the spine
–The Ligamentum Flavum forms a cover over the
dura mater: (a layer of tissue that protects the
spinal cord.)
This ligament connects under the facet joints to create a
small curtain over the posterior openings between the
vertebrae.
–The Anterior Longitudinal Ligament attaches to the
front of each vertebra. This ligament runs up and
down the spine (vertical or longitudinal).
–The Posterior Longitudinal Ligament runs up and
down behind the spine and inside the spinal canal.

30. Spinal Anatomy
Injury or mild trauma to the cervical spine
can cause a serious or life-threatening
medical emergency [e.g. spinal cord injury
(SCI) or fracture].
Pain, numbness, weakness, and tingling
are symptoms that may develop when one
or more spinal nerves are injured, irritated,
or stretched.
The cervical nerves control many bodily
functions and sensory activities.

31. Spinal Anatomy
C1: Head and neck
C2: Head and neck
C3: Diaphragm
C4: Diaphragm. Upper body
muscles (e.g. Deltoids, Biceps)
C5: Diaphragm. Wrist flexors
C6: Wrist extensors
C7: Triceps. Hands
C8: Hands

32. Spinal Anatomy

35. (Odontoid
Process)

42. Normal Cervical Spine

48. Spine injuries
Cervical spine injury:
–Most often, a spine injury results from a
collision, and there may be associated
head injury.
–The head and neck must be immobilized
immediately, and ease of breathing and
level of consciousness (LOC) must be
ascertained.
–If spine injury is suspected, it is wise to
be extremely cautious until a proper
diagnosis (dx) is made.
This is the best way to prevent conversion of a
repairable injury to a catastrophic one.

49. Whiplash
Whiplash" is a nonmedical term to
describe hyperextension injury to the
neck resulting from an indirect force,
usually a rear-end automobile collision.
The diagnosis of whiplash is often one
of exclusion.
Most injuries are to soft tissues such as
the disks, muscles and ligaments, and
cannot be seen on standard X-rays

52. Neck sprain/strain
People who are involved in motor vehicle
crashes or who take hard falls in a contact
sport or around the house may get a real
"pain in the neck."
This pain can result from a ligament sprain
or muscle strain.
stretch or tear resulting from a sudden
movement that causes the neck to extend to
an extreme position
Tx:
–NSAIDS, Muscle relaxers, Narcotics
–Soft collar or not??

53. SPINAL INJURIES
The incidence of traumatic spinal cord
injuries (SCI) in the United States has
been estimated at 30 cases per
million population at risk.
Ninety percent of SCI are related to
motor vehicle crashes.

54. Spinal Cord Injury
Pre-hospital management
–C-spine precautions
In hospital management
–If rapid sequence intubation is
performed, then careful in-line cervical
stabilization (not traction) should be
applied.

55. Consider neck injury in all
patients with head injury !!!
–Immobilization of neck first
step
–Maintain BP and oxygenation
to prevent further injury
–Bladder catheterization as
awareness of bladder filling
impaired/absent

56. Rectal tone, perianal sensation and
wink, should be assessed.
Cervical spine radiographs require an
anteroposterior view, a lateral view,
and an odontoid view.
Plain film radiography of the
traumatized portion of the spine is
required when the following are
present:

57. To X-ray or Not to X-ray
Canadian C-Spine
Rules
NEXUS study
(b)midline pain or bony
tenderness, crepitus,
or step-off;
(c) neurologic deficit;
(d) presence of
distracting injuries;
(e) altered mental
status (including
intoxication);
(f) complaint of
paresthesia or
numbness

58. Closed spinal cord injured (SCIs)
should be treated with high-dose
methylprednisolone.
Removal of the patient from the long
spine board within 2 hrs, with full
spine precautions, is recommended to
prevent skin breakdown and pressure
sores.
Stable patients may be further imaged
with specific spinal radiographs, CT
scans, or MRI.

59. Neurosurgical or orthopedic consultation is
required for clinically significant spinal
fractures or SCI.
Any patient with an unstable spine, nerve
root compression, uncontrollable pain, or
intestinal ileus should be admitted to the
hospital.
Patients with significant vertebral or spinal
cord trauma should be managed at a
regional trauma or spinal cord injury center.

60. Various fractures, dislocations, blunt and
penetrating injury patterns, and disk
herniations may lead to SCI or nerve root
impingement syndromes.
Unstable bony injury may exist without
actual SCI or nerve root trauma.
Vertebral fractures may have localized pain
on palpation of the injured spine, muscle
spasms, splinting, and resistance to
movement.
Palpable crepitus, deformity, and step-off
may also be present on examination of the
midline.

61. ExaminationExamination
Severe spinal cord injury
–Deep Tendon reflex (DTR’s) usually
absent below level of lesion
–Sensory level to pinprick may be found on
chest
–High cervical lesions (C3-C5) affect all
arm muscles and ventilation
–Midcervical lesions affect extension but
not flexion at elbow
–Low cervical lesions affect hand muscle
function but may preserve elbow flexion
and extension
–Thoracic lesions result in paraplegia

62. Partial spinal cord injury
–May be seen with acute neck
extension (hyperextension)
–Typically get central spinal cord
syndrome or anterior spinal
artery syndrome with bilateral
arm weakness and normal leg
strength

63. Anterior cord syndromes involve the
loss of motor function and pain and
temperature sensation distal to the
level of injury with preservation of
light touch, vibration, and
proprioception.
A central cord syndrome, associated
with hyperextension injuries, presents
with motor weakness more prominent
in the arms than in the legs and with
variable sensory loss.

64. The Brown-Sequard syndrome most
often results from penetrating trauma
and is caused by a hemisection of the
spinal cord. There is loss of ipsilateral
motor function, proprioception, light
touch sensation, and loss of contralateral
pain and temperature sensation.
The cauda equina syndrome is less of
a spinal cord lesion than it is a peripheral
nerve injury, and it presents with variable
motor and sensory loss in the lower
extremities, sciatica, bowel or bladder
dysfunction, and “saddle anesthesia.”

66. Paresthesias, sensory disturbances, motor
deficits, reflex abnormalities, and spinal
shock may be present with bony fractures
and SCI.
Injury to the corticospinal tract produces
an ipsilateral upper motor neuron lesion that
results in
–increased deep tendon reflexes, spasticity,
weakness, and a +Babinski sign.
Injury to the dorsal column, located in the
posterior aspect of the spinal cord, results in
–loss of ipsilateral light touch sensation and
proprioception.

67. Injury to the spinothalamic tracts
results in
–contralateral pain and temperature sensory
losses.
–These fibers decussate in the anterior
aspect of the spinal cord at the vertebral
level.
Injury to the nerve roots produces an
ipsilateral lower motor neuron lesion
and a radiculopathy that may result in
–decreased deep tendon reflexes, weakness,
and sensory loss in that nerve distribution.

68. Spinal shock:
is characterized by warm, pink, dry
skin;
adequate urine output;
and relative bradycardia.
Other signs of autonomic dysfunction
may accompany spinal shock, such as
–ileus,
–urinary retention,
–fecal incontinence,
–and priapism.

69. DIAGNOSIS AND DIFFERENTIAL
The history is useful in defining the
mechanism of SCI, thus allowing the
clinician to anticipate specific potential
injury patterns.
The physical examination should focus on
complete palpation of the spine, testing the
symmetry of reflexes, motor strength, pain
sensation, and light touch and
proprioception in each extremity.

71. ImagingImaging
Portable X-ray of C-spine
–Lateral must include all 7 vertebra and
odontoid
Extension and flexion radiographs if plain
X-rays normal
–Check for cervical spine stability in patient with
neck pain
CAT scan
–Subluxations or fractures
–Neuro abnormality present
MRI
–Readily demonstrates spinal cord hemorrhage
or contusion
–Images bone poorly

72. A computed tomography (CT) scan with or
without myelography or a magnetic
resonance imaging (MRI) scan may be
required to further evaluate the extent of
the spinal injury.
Once a bony abnormality is identified, a key
component of the differential is the degree
of stability associated with that particular
type of injury.
Fractures of the odontoid with rupture of
the transverse atlantal ligament are
extremely unstable.

73. A Hangman’s fracture is an unstable fracture of
the pedicles of the posterior arch of C2 caused by
extension and distraction injury.
A Jefferson fracture is an axial load compression
fracture of the anterior and posterior arches of C1
and is an unstable fracture.
Extension “teardrop” fractures are unstable
fractures where the anterior longitudinal ligament
avulses the anterior-inferior corner of the vertebral
body.

74. Hangman’s fx
Lateral radiograph reveals markedly increased prevertebral
swelling (two short arrows) associated with the fracture at the
posterior aspect of C2 pedicles (medium arrow). Displacement
is obvious by following the posterior spinal line (long arrow).

75. Jefferson Fx
Anteroposterior tomogram at the craniocervical
junction demonstrates lateral mass of C1 (arrows)
lying lateral to the lateral masses of C2 (arrowheads)
on both the left and right sides as a result of spread
of the ring of C1.

76. Teardrop
fracture

77. Classification of Odontoid Fx’s

78. Brachial plexus
Acute brachial
plexus neuritis is
an uncommon
disorder of
unknown etiology
that is easily
confused with
other neck and
upper extremity
abnormalities, such
as cervical
spondylosis and
cervical
radiculopathy.

79. Brachial Plexus
1-3 Patients with acute brachial
plexus neuritis present with a
characteristic pattern of acute or
subacute onset of pain followed by
profound weakness of the upper
arm and amyotrophic changes
affecting the shoulder girdle and
upper extremity

81. Brachial Plexus
In traumatic setting, it is caused by
distraction of the arm and head.
Ninety percent of brachial plexus
injuries in children are caused by a
traumatic stretching of the plexus
during birth.

82. Torticollis
Torticollis (from the Latin
torti, meaning twisted
and collis, meaning neck)
refers to presentation of
the neck in a twisted or
bent position.
Torticollis manifests in
involuntary contractions
of the neck muscles,
leading to abnormal
postures and movements
of the head.

83. Spinal Anatomy
Thoracic Vertebrae
The thoracic vertebrae increase in
size from T1 through T12.
They are characterized by small
pedicles, long spinous processes,
and relatively large intervertebral
foramen (neural passageways),
which result in less incidence of
nerve compression.

85. 1 Vertebral
Body
2 Spinous
Process
3
Transverse
Process
4 Pedicle
5 Foramen
6 Articular
Process

88. Spinal Anatomy

90. Spinal Anatomy
The rib cage is joined
to the thoracic
vertebrae.
At T11 and T12, the
ribs do not attach and
are so are called
"floating ribs."
The thoracic spine's
range of motion is
limited due to the
many rib/vertebrae
connections and the
long spinous
processes.

92. Spinal Anatomy
Lumbar Vertebrae

97. Spinal Anatomy
The lumbar vertebrae graduate in size from
L1 through L5.
–Most people have five lumbar vertebrae although
it is not unusual to have six
These vertebrae bear much of the body's
weight and related biomechanical stress.
The pedicles are longer and wider than
those in the thoracic spine.
The spinous processes are horizontal and
more squared in shape.
The intervertebral foramen (neural
passageways) are relatively large but nerve
root compression is more common than in
the thoracic spine.

98. Spinal Anatomy
Just below the last Thoracic (T12) and
first Lumbar (L1) vertebra the spinal
cord ends at the Conus Medullaris.
From this point the spinal nerves,
resembling a horse’s tail become
known as the Cauda Equina
extending to the coccyx.
These nerves are suspended in spinal
fluid.

112. Sciatica: Sciatic Nerve Compression
The sciatic nerve is the longest and largest
nerve in the body measuring three-quarters
of an inch in diameter.
The sciatic nerve originates in the sacral
plexus; a network of nerves in the
lumbosacral spine.
The lumbosacral spine refers to the lumbar
spine and the sacrum combined.
The nerve and its nerve branches enable
movement and feeling (motor and sensory
functions) in the thigh, knee, calf, ankle, foot
and toes.

113. 1 Sciatic
Nerve
2 Sacrum
3 Hip Bone
Yellow
Structures
= Nerves
Red
Structures
= Arteries
Blue
Structures
= Veins
(Lumbosacr
Spine-Post
View)

114. Sciatica: Sciatic Nerve Compression
If the sciatic nerve is injured or becomes
inflamed, it causes symptoms called sciatica.
Sciatica can cause intense pain along any part
of the sciatica nerve pathway - from the
buttocks to the toes.
If the nerve is compressed, caused by
conditions such as a bulging or herniated disc,
DJD, spinal stenosis, Isthmic Spondylolisthesis
or tumor (rare), symptoms may include a loss
of reflexes, weakness and numbness besides
severe pain.
Sciatic nerve pain can make everyday activities
such as walking, sitting and standing difficult.

116. Sciatica: Sciatic Nerve Compression
Sciatic nerve fibers begin at the 4th and
5th lumbar vertebra (L4, L5) and the
first few segments of the sacrum.
The nerve passes through the sciatic
foramen just below the Piriformis
muscle (rotates the thigh laterally), to
the back of the extension of the hip and
to the lower part of the Gluteus
Maximus (muscle in the buttock, thigh
extension).

117. Sciatica
The sciatic nerve then runs vertically
downward into the back of the thigh,
behind the knee branching into the
hamstring muscles, calf, and further
downward to the feet.
Rarely is sciatic nerve damage
permanent and paralysis is seldom a
danger as the spinal cord ends before
the first lumbar vertebra.

118. Sciatica
However, increasing trunk or leg
weakness, or bladder and/or bowel
incontinence is an indication of Cauda
Equina Syndrome, a serious disorder
requiring emergency treatment.

119. Sciatica
Piriformis Syndrome is caused by an entrapment
(pinching) of the sciatic nerve as it exits the Greater
Sciatic notch in the gluteal region
The second common site of entrapment is when the
sciatic nerve actually pierces the piriformis muscle itself.
–This can occur in about 1% to 10% of all humans.
In this case myospasm and or contraction of the
piriformis muscle itself can lead to pain along the back
of the thigh to the knee, loss of sensation or numbness
and tingling in the sole of the foot.
–This particular syndrome can often mimic its more notorious
counterpart known as sciatica.
Sciatica is directly due to a lumbar disc pressing on the
sciatic nerve as it exits the intervertebral foramen in the
lumbar spine.

121. Spinal Stenosis
Spinal stenosis is a narrowing of the
spinal canal, which places pressure on
the spinal cord
As people age, the ligaments of the
spine can thicken and harden
(calcification).
Bones and joints may also enlarge, and
bone spurs (osteophytes) may form.
Bulging or herniated discs are also
common.

122. Spinal Stenosis
The narrowing of the spinal canal
itself does not usually cause any
symptoms.
It is when inflammation of the
nerves occurs at the level of
increased pressure that patients
begin to experience problems.
When these conditions occur in the
spinal area, they can cause the
spinal canal to narrow, creating
pressure on the spinal nerve

123. Spinal Stenosis
Patients with lumbar spinal stenosis
may feel pain, weakness, or
numbness in the legs, calves or
buttocks.
In the lumbar spine, symptoms often
increase when walking short distances
and decrease when the patient sits,
bends forward or lies down.

124. Spinal Stenosis
Cervical spinal stenosis may cause
similar symptoms in the shoulders,
arms, and legs; hand clumsiness and
gait and balance disturbances can also
occur.
In some patients the pain starts in the
legs and moves upward to the buttocks;
in other patients the pain begins higher
in the body and moves downward.
This is referred to as a “sensory march”.

125. Spinal Stenosis
The pain may radiate like sciatica,
may be a cramping pain, or the pain
can be constant.
Severe cases of stenosis can also
cause bladder and bowel problems,
but this rarely occurs.
Also paraplegia or significant loss of
function also rarely, if ever, occurs.

127. Spinal Stenosis
Tx:
NSAIDs
Corticosteroid injections (epidural steroids) can help
reduce swelling and treat acute pain that radiates to
the hips or down the leg.
–This pain relief may only be temporary and patients are
usually not advised to get more than 3 injections per 6-
month period.
Rest or restricted activity (this may vary depending
on extent of nerve involvement).
Physical therapy and/or prescribed exercises to help
stabilize the spine, build endurance and increase
flexibility.
Surgical

128. Spondylolysis
In spondylolysis, there is a defect in
the pars interarticularis (which literally
means the "piece between the
articulations").
So spondylolysis means a defect in
the thin isthmus of bone connecting
the superior and inferior facets, and
could be unilateral or bilateral
Although the defect can be found at
any level, the commonest vertebra
involved is the L5.

129. Spondylolysis
In cases of bilateral spondylolysis, the
posterior articulations can no longer
provide the posterior stability, and
anterior slipping of the L5 vertebra
over the sacrum could result.
This slip is called Spondylolisthesis.
Spondylolysis is the MCC of
spondylolisthesis

130. Spondylolisthesis
Spondylolisthesis occurs when one vertebra
slips forward in relation to an adjacent
vertebra, usually in the lumbar spine.
The symptoms that accompany a
spondylolisthesis include pain in the low
back, thighs, and/or legs, muscle spasms,
weakness, and/or tight hamstring muscles.
Some people are symptom free and find
the disorder exists when revealed on an x-
ray.
In advanced cases, the patient may appear
swayback with a protruding abdomen,
exhibit a shortened torso, and present with
a waddling gait.

131. Spondylolisthesis
can be congenital (present at birth) or
develop during childhood or later in
life.
The disorder may result from the
physical stresses to the spine from
carrying heavy things, weightlifting,
football, gymnastics, trauma, and
general wear and tear.
As the vertebral components
degenerate the spine's integrity is
compromised.

132. Spondylolisthesis

133. Foot Drop
Foot Drop is an abnormal
neuromuscular (nerve and muscle)
disorder that affects the patient's
ability to raise their foot at the ankle.
Drop foot is further characterized by
an inability to point the toes toward
the body (dorsiflexion) or move the
foot at the ankle inward or outward.
Pain, weakness, and numbness may
accompany loss of function.

134. Foot Drop
Walking becomes a challenge due
to the patient's inability to control
the foot at the ankle.
The foot may appear floppy and the
patient may drag the foot and toes
while walking.
Patients with foot drop usually
exhibit an exaggerated or high-
stepping walk called Steppage Gait
or Footdrop Gait.

135. Foot Drop: Causes of Injury
The peroneal nerve is susceptible to
different types of injury.
Some of these include nerve compression
from lumbar disc herniation (e.g. L4, L5,
S1), trauma to the sciatic nerve,
spondylolisthesis, spinal stenosis, spinal
cord injury, bone fractures (leg, vertebrae),
stroke, tumor, diabetes, lacerations,
gunshot wounds, or crush-type injuries.
Drop foot is found in some patients with
Amyotrophic Lateral Sclerosis (ALS),
Multiple Sclerosis (MS), and Parkinson's
Disease.
Sometimes the peroneal nerve becomes
injured when stretched during hip or knee
replacement surgery.

136. Herniated Disc
Herniation of the nucleus pulposus
(HNP) occurs when the nucleus
pulposus (gel-like substance)
breaks through the anulus fibrosus
(tire-like structure) of an
intervertebral disc.

140. Herniated Disc
A herniated disc occurs most often in
the lumbar region of the spine
especially at the L4-L5 and L5-S1
levels
This is because the lumbar spine
carries most of the body's weight.

141. Herniated Disc
People between the ages of 30-50
appear to be vulnerable because
the elasticity and water content of
the nucleus decreases with age.
The progression to an actual HNP
varies from slow to sudden onset of
symptoms

142. Herniated Disc
There are four stages: (1) disc
protrusion (2) prolapsed disc (3) disc
extrusion (4) sequestered disc.
Stages 1 and 2 are referred to as
incomplete, where 3 and 4 are
complete herniations.

143. Disc Herniation
Pain resulting from herniation may
be combined with a radiculopathy.
The deficit may include sensory
changes (i.e. tingling, numbness)
and/or motor changes (i.e.
weakness, reflex loss).
caused by nerve compression

145. Herniated Disc
Dx
–The spine is examined with the patient laying
down and standing.
–Due to muscle spasm, a loss of normal spinal
curvature may be noted.
–Radicular pain may increase when pressure is
applied to the affected spinal level.
A Lasegue test, also known as Straight-leg
Raise Test, is performed.
–The patient lies down, the knee is extended, and
the hip is flexed.
–If pain is aggravated or produced, it is an
indication the lower lumbosacral nerve roots are
inflamed.

146. Herniated Disc
Other neurological tests are
performed to determine loss of
sensation and/or motor function.
–Abnormal reflexes are noted; changes
may indicate the location of the
herniation.
Radiographs are helpful, but the MRI
is the best method

148. Cauda Equina Syndrome
occurs from a central disc herniation
and is serious requiring immediate
surgical intervention.
The symptoms include bilateral leg
pain, loss of perianal sensation
(anus), paralysis of the bladder, and
weakness of the anal sphincter.

150. Scoliosis
Scoliosis is an abnormal
curvature of the spine.
MC spinal deformity
evaluated
In scoliosis, the spine
curves to the side when
viewed from the front, and
each vertebra also twists
on the next one in a
corkscrew fashion.
Girls:boys = 2:1
Usually > 10 y/o

151. Scoliosis

152. In most cases (85%), the cause of scoliosis
is idiopathic.
The other 15% of cases fall into 2 groups:
Nonstructural (functional): a temporary
condition when the spine is otherwise
normal.
–The curvature occurs as the result of another
problem.
–Examples include 1 leg being shorter than another
from muscle spasms or from appendicitis.
Structural: the spine is not normal
–The curvature is caused by another disease
process such as a birth defect, muscular
dystrophy, metabolic diseases, connective tissue
disorders, or Marfan syndrome.

153. Scoliosis
Tx:
–10-15* curve = f/u in 6 mo re-eval
Forward bending, and scoliometer test
–15-20* curve = serial XR’s Q 3-4 mo
Or 6-8 mo for smaller curves or older pt’s
–>20* curve = ortho referral for possible
bracing
Depending on degree and age of pt

154. Kyphosis
Increased convex curvature of thoracic
spine (Round back)
TB of spine causes progressive scoliosis
(Pott’s disease)
Idiopathic (Scheuermann’s) defined as:
–anterior wedging of 5° or more in at least 3
adjacent vertebral bodies
Associated c respiratory distress
Tx:
–45-60* curve = observed 3-4 mo c PT
–>60* curve or persistent pain = brace
possible surgery

156. Ankylosing Spondylitis
Inflammation c progressive fusion of
vertebrae
It is a chronic, multisystem inflammatory
disorder of the sacroiliac (SI) joints and the
axial skeleton.
AS is characterized as a seronegative
spondyloarthropathy.
The disorder often is found in association
with other seronegative
spondyloarthropathies including reactive
arthritis, psoriasis, juvenile chronic arthritis,
ulcerative colitis, and Crohn’s disease.

157. Ankylosing Spondylitis
The etiology is not understood
completely; however, a strong
genetic predisposition exists.
A direct relationship between AS and
the major histocompatibility human
leukocyte antigen (HLA)-B27 has
been determined
Involvement of the SI joints is
required to establish the diagnosis

158. Ankylosing Spondylitis
Limited ROM
Extra-articular manifestations:
–Eyes, cardiac, kidneys, & interstitial lung ds
Labs:
–ESR, HLA-B27
XR:
–“Bamboo spine”
–Osteopenia
Tx:
–NSAIDS, PT
–Tx underlying conditions
–Surgery

160. Spine Fractures
A compression fracture is a condition in
which a vertebra is crushed only in the front
part of the spine, causing a wedge shape.
If a vertebra is crushed in all directions, the
condition is called a burst fracture.
–Burst fractures are much more severe than
compression fractures.
–The bones spread out in all directions and may
damage the spinal cord.
–This damage can cause paralysis or injury to the
nerves, which control the body's ability to move or
feel sensations.
15-20% of thoracolumbar fractures present
with a neurologic deficit

161. Wedge Fracture Burst Fracture

163. Chance Fracture
With flexion-distraction mechanisms
such as those observed in passengers
restrained with lap seatbelts, a
progression of injury from the
posterior column of the
thoracolumbar spine is observed
anteriorly.
The diagnosis is best made on good
quality radiographs obtained in 2
planes (anteroposterior [AP] and
lateral).

164. Chance Fracture
Prompt recognition followed by
appropriate reduction and
immobilization usually results in a
good clinical outcome.
Always exclude associated injuries
(eg, intra-abdominal trauma) at the
time of presentation, as these are
observed in up to 50% of cases

165. Chance Fracture
Chance fracture represents a pure
bony injury extending from posterior
to anterior through the spinous
process, pedicles, and vertebral body,
respectively.
This fracture most commonly is found
in the upper lumbar spine, but it may
be observed in the midlumbar region
in children.

166. Chance fracture

167. PEARL
Non-Traumatic back pain in
>~55 y/o consider AAA
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168. 'Red Flags' in the Medical History:
Potentially Serious Conditions That
May Present as Low Back Pain
Fracture
• Major trauma (motor vehicle accident, fall from height)
• Minor trauma or strenuous lifting in an older or
osteoporotic patient
Tumor or infection
• Age >50 years or <20 years
• History of cancer
• Constitutional symptoms (fever, chills, unexplained weight
loss)
• Recent bacterial infection
• Intravenous drug use
• Immunosuppression (corticosteroid use, transplant
recipient, HIV infection)
• Pain worse at night or in the supine position
Cauda equina syndrome
• Saddle anesthesia
• Recent onset of bladder dysfunction
• Severe or progressive neurologic deficit in lower extremity

172. Meningitis is an inflammation of the
leptomeninges and underlying
subarachnoid cerebrospinal fluid (CSF)
Encephalitis literally means an
inflammation of the brain, but it usually
refers to brain inflammation caused by a
virus.

173. Meningitis
myriad of infectious and noninfectious etiologies
–Streptococcus pneumoniae (1.1) in all except neonates
–Neisseria meningitidis (0.6), usually local outbreaks
among young adults, epidemics internationally, and
increased incidence in late winter or early spring
–Group B streptococci (0.3), in newborns
–Listeria monocytogenes (0.2) in newborns, elderly, and
immunocompromised
–Haemophilus influenzae, type b (0.2) in unvaccinated
children and adults
Meningitis is caused by the following pathogens in
each age group:
–Neonates - Group B or D streptococci, nongroup B
streptococci, Escherichia coli, and L monocytogenes
–Infants and children - H influenzae (48%), S pneumoniae
(13%), and N meningitidis
–Adults - S pneumoniae, (30-50%), H influenzae (1-3%), N
meningitidis (10-35%), gram-negative bacilli (1-10%),
staphylococci (5-15%), streptococci (5%), and Listeria
species (5%)

174. Meningitis
Classic symptoms (not evident in infants or seen
often in the elderly) include the following:
–Headache
–Nuchal rigidity (generally not present in children <1 y or
in patients with altered mental status)
Kernig sign: Passive knee extension in supine patient elicits
neck pain and hamstring resistance.
Brudzinski sign: Passive neck or single hip flexion is
accompanied by involuntary flexion of both hips.
–Fever and chills
–Photophobia
–Vomiting
–Prodromal upper respiratory infection (URI) symptoms
(viral and bacterial)
–Seizures (30-40% in children, 20-30% in adults)
–Focal neurologic symptoms (including focal seizures)
–Altered sensorium (confusion may be sole presenting
complaint, especially in elderly)

175. Meningitis
Head CT
CXR
LP
administer first dose(s) of antibiotics
+/- steroids within 30 minutes of
presentation to ED.

176. Lumbar Puncture

177. Epidural anesthesia

178. Metastatic Carcinoma

179. Osteoporosis
Lack of matrix formation
–atrophy or weightlessness. Osteoblasts perform
under pressure
Decreased sex hormones:
–estrogen (esp. postmenopausal) and androgen.
Cushings:
–Cortisol inhibits osteoblast activity
Compression fractures of vertebra - loss of
height
Osteomalacia:
–Matrix present, not calcified
–Bending of long bones

181. 'Excellence is an art won by training and habituation. We do not act rightly because
we have virtue or excellence, but rather we have those because we have acted rightly.
We are what we repeatedly do. Excellence, then, is not an act but a habit.'
Aristotle
A journey of a thousand miles begins with a single step. A journey of a thousand miles begins with a single step.
  
Lao TsuLao Tsu

““I find that the harder I work, the more luck I seem to have”.I find that the harder I work, the more luck I seem to have”.
  
Thomas JeffersonThomas Jefferson
Self conquest is the greatest of victories.
Plato
“Imagination is everything. It is the preview of life’s
coming attractions.”
Albert Einstein