Clinical anatomy of the back

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2. Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Clinical Anatomy of the Back

3. Progress
TimeTime
Goh et al. Clin Biomech 1999;14:439
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4. Spine
Consists of
•Cervical Vertebrae
•Thoracic Vertebrae
•Lumbar Vertebrae
•Sacrum
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5. •The strength of the skeletal
column is due to the size and
shape of the vertebrae
•Its flexibility is due to the many
joints that are close together
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Spine

6. Vertebral Column
•Lot of stress in variety of sports
•Cervical pathology
•Pain may be referred to upper
limb
•Lumber pathology
•Lower limb
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7. Young Spine
Normal curvature of
infant’s spine
Normal lumbar curve
of toddler’s spine
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8. Low Back Pain in Sports
•70% of population will suffer
from back pain at some time
•10% - 15% of sports injuries
are spinal injuries
•0.6% - 1% have neurological
complications
Deyo & Tsui-Wu. Spine 1987;12:264-8
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9. •Majority of sports injuries
to lumbar spine
•Soft tissue and many are
not reported
•Fractures
•Fracture dislocation
•Abrasions, bruising
•Contusions
Tall & De Vault. Clin Sports Med 1993;12:441-8
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Low Back Pain in Sports

10. •Must know the sport
•Must understand the
biomechanics and stresses
involved in the sport
•Must examine the spine
in the appropriate position
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Low Back Pain in Sports

11. Typical Vertebrae
•Basic parts
•Body and neural arch
•Which consists of
pedicles, lamina and spine
•The transverse processes
arise from the pedicles
•Superior and inferior
articular processes
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12. Lumbar Vertebrae
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13. •Body kidney shaped
•No articular facets for ribs
•Inferior facets face anterolateral
•Superior facets face posteromedial
•Intervertebral notch increase in
size
•Accessory processes base
of transverse process
•Mammillary process on posterior
aspect of superior articular
process
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Lumbar Vertebrae

14. •Body is convex anteriorly
•Foramina on the posterior
aspect are for the basic
vertebral veins, which drain
into the internal vertebral
plexus
•The walls of the veins,
which are valve less, have
afferent nerve fibers
•Secondaries can spread
from pelvis, prostate,
adrenal glands lungs and
breast
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Lumbar Vertebrae

15. •The superior and inferior
surfaces of the body are flat
and covered by a thin layer
of hyaline cartilage
•The body of the vertebra
consists of trabecular or
cancellous bone
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Lumbar Vertebrae

16. Typical Lumbar Vertebrae
•Superior and inferior
articular processes
•Arise from the junction of
the pedicles and lamina
•Superior face
posteromedially
•With rough mammillary
processes on the posterior
border
•Inferior face anterolaterally
•Accessory processes at the
base of transverse process
•Prevents rotation
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17. The Lumbar Facets
•Vary from the sagittal
disposition at the first and
second, to almost coronal in
the lower
•Facet tropism is when the facet
on one side is in the sagittal
plane and the other is in the
coronal plane, which adds to
rotational stress
•This change may occur in the
lower thoracic vertebrae
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18. Pars Interarticularis
•Pars interarticularis
•Portion of lamina between
superior and inferior
articular processes
•Site of spondylolysis or
spondylolisthesis
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19. Lumbar Spine
•Cancellous bone
•50% compressive
strength
•Facet joints 20% in
standing upright position
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20. Lumbar Vertebrae
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21. Lumbar Vertebrae
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22. Lumbar Spine
•Cancellous bone
•50% of the compressive
strength
•Facet joints, 20% of the
strength in the standing
upright position
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23. Anterior Longitudinal Ligament
•Attached mainly to the bodies
•This ligament helps to prevent us from
leaning too far back (hyperextension)
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24. Posterior Longitudinal Ligament
•Attached mainly to the
inter vertebral discs
•This ligament helps to
restrict forward bending
(hyperflexion)
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25. Ligamentum Flava
•Runs between the laminae
of the neural arches
•Helps to restrict hyperflexion
•It extends to the capsule
of the facet joint
•It is highly elastic and ensures
that the ligament does not
buckle in extension
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26. •Gives elasticity to the posterior
aspect of the facet joints
•Helps form the posterior
boundary of the intervertebral
foramen
•The ligamentum flava is
thicker in the lumbar region
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Ligamentum Flava

27. Spinal Ligaments
•Interspinous ligaments
•Strong supraspinous ligaments
•The inter-transverse ligaments
join the transverse processes
and are thin and membranous
in the lumbar region
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28. Fifth Lumbar Vertebrae
•Larger, superior and inferior
articular facets in the same
plane
•Fifth lumbar vertebrae has
large transverse processes
•Arise from the body as well
as the pedicles
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29. Arthritis of Spine
•Painful
•Limitation of movement
•Extra projections
•Narrowing of disc spaces
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30. Vertebral Joints
•Secondary cartilaginous joints
between the bodies
•Hyaline cartilage covering
bodies
•Disc of fibrocartilage in
between
•Synovial plane joints between
the facets
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31. Intervertebral Discs
•Annulus fibrosis
•Concentric lamina run
obliquely
•Type I collagen at periphery,
type II near nucleus
•Weakest portion is the
postero-lateral and posterior
•Periphery has a nerve
supply
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32. Nucleus Pulposus
•Gelatinous, hydrophilic, proteoglycan gel in
collagen matrix
•Lies posterior in the disc
•There are no nerve endings in a mature disc
•Nerve endings are found in the posterior longitudinal
ligament and the dura
•Nutrition of the disc is by diffusion via the central 40%
of the cartilaginous end plate
•The discs are thicker in the cervical and lumbar
sections of the vertebral column
•Where there is more movement. The largest disc is
between L5 S1
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33. •Hydration of the annulus and nucleus is
proportional to the applied compressional
stress
•In vivo, there is a loss of 1 cm standing
height over the course of the day
•A disc loaded in vitro for four hours by
100% body weight will lose 6% of the
fluid from the nucleus and 13% from the
annulus
•May be due to end plate fracture
•There is more rotational stress in the posterior part of
the disc
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Nucleus Pulposus

34. •The position of the spine determines
where the compressional forces are
greatest
•The posterior longitudinal ligament is
thin and expanded at the level of the
disc
•High compressional loading at
L4,L5,S1 may be due to end plate
fracture and not to rupture of the annulus
•End plate failure is a possible precursor of disc
degeneration
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Nucleus Pulposus

35. Axial Load and End-plates
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36. End-plate Mechanics
•Functionally, the vertebral end-plate
displays characteristics of a trampoline
•With the sub-end-plate trabecular
bone acting as springs to sustain
and dissipate axial load
•Despite the thinness of the vertebral
end-plate
•The hydraulic nature of marrow and
blood vessels within the vertebral body,
act to dampen axial loads, unless the
local point pressure is too high
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37. •End-plate lesions can be induced
experimentally before a disc will
prolapse through the anulus,
suggesting a protective mechanism
over annular injury and potentially
cord or root compression
•Excessive loads may result in
perforation of the end-plate, usually
in the region of the nucleus and
often in the path of the
developmental notchord
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End-plate Mechanics

38. End-plate Susceptibility
Schmorl & Junghanns. The human spine in health and disease.
New York: Grune & Stratton, 1965
Notochord
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39. Facet Joints
•L1,L2 Facets sagittal
plane
•Lower joints in coronal
plane
•Synovial plane joints
•Meniscoid structures
•Synovial membrane
some contain fat
•Supplied by medial
branch of dorsal ramus
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40. •Narrowing of disc space,
results in stress on
facet joint
•Highest pressure during
•Combined
•Extension
•Rotation
•Compression
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Facet Joints

41. Facet Joint Syndrome
•Extension and rotation
•Pain rising from flexion
•Pain worse standing
•Lateral shift in extension
•Point tenderness over
facet
•Referred leg pain
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42. Segmental Rotation
Singer et al. J Musculoskel Res 2001;5: 45-55
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43. Movements of Lumbar Spine
•Flexion limited by
disc problems
•Lateral flexion
•Extension limited by
facet joint problems
•Very little rotation
•Extension and rotation
affect facet joints
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44. Nerve Supply
•Nerve supply
•Peripheral annulus
•Facet joint
•Nerve is medial branch
dorsal ramus
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45. •Lumbar arteries
•Internal venous plexuses
•External venous plexuses
•Basivertebral veins
•Valveless
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Blood Supply

46. Lumbar Vertebrae
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47. Cancellous Bone
•Cancellous bone
•50% compressive
strength
•Facet joints 20% in
standing upright position
Normal bone Osteoporotic bone
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48. Anatomical Abnormalities
•Spina Bifida Occulta
•Facet Tropism
•Kyphosis
•Scoliosis
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49. Anatomical Abnormalities
Kyphosis Scoliosis
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50. Anatomical Abnormalities
•Hemi-vertebra
•Spina Bifida
Occulta
•Facet Tropism
•Scoliosis
•Kyphosis
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51. Anatomical Abnormalities
•Unilateral lumbarisation
•Unilateral sacralisation
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52. The Spine in Sports
•Spine injury epidemiology
•Contact vs. non-contact sports
•Spine injury mechanisms
•Overuse – overload – overlooked
•Vertebral end-plate injury
•Disc injury
•Future issues
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53. Epidemiology
Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837
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54. Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837-65
•Back pain in the community
is 60% - 80%
•Recurrence of back pain is
70% - 90%
•Progression to chronic back
pain is 5% - 10%
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Epidemiology

55. Low Back Pain in Sports
•Majority of sports injuries
are to the lumbar spine
•Many soft tissue injuries
are not reported
•Fractures
•Fracture dislocation
•Abrasions, bruising
•Contusions
Tall & De Vault. Clin Sports Med 1993;12:441-8
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56. Chronic Low Back Pain
•Local structures
•Muscles
•Ligaments
•Poor lifting techniques
•Joints
•Bones
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57. Back Pain
Local structures
•Muscles, ligaments
•Joints
Referred pain
•Abdominal organs
•Pelvic organs
Must out rule
•Infection
•Tumours
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58. Acute Low Back Pain
•Non-specific low back pain
•Usually settles quickly
•History
•Examination
•Pain relief
•Stay as active as possible
within limit of pain
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59. Acute Low Back Pain
•Nerve root pain
•Leg pain worse than back
pain
•Numbness and pins and
needles
•Neurological signs
•Refer to specialist
•If it does not resolve in
first 4 weeks
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60. Investigate Low Back Pain
•Under 20 or over 55 years
•Non-mechanical pain
•Past history cancer
•Thoracic pain
•Steroids or HIV
•Unwell, weight loss
•Widespread neurology
•Structural deformity
•Gait disturbance or sphincter
disturbance
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61. Chronic Low Back Pain
Pain referred
•Abdominal organs
•Pelvic organs
Must out rule
•Infection
•Tumours
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62. Pain Referred
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63. Young Athlete
•Junior rugby team 15
years of age
•M. Scheuermann
•5 Spina bifida occulta
•The scrum half had
degenerative facet joint
changes
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64. Sacroiliac Joint – Sciatic Nerve
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65. Spinal Stenosis
•Congenital or acquired
•Abnormally short pedicles or
lamina
•Formation of osteophytes
•Osteo-arthritis of facet joints
•Pain aggravated by walking
•Relieved by rest
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66. Spinal Stenosis
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67. Predisposing Factors
•Intrinsic factors
•Anatomical abnormalities
•Biomechanical
•Extrinsic factors
•Sport
•Surfaces
•Equipment
•Training
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68. Predisposing Factors Back Pain
•Poor posture
•Overweight
•Unfit
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69. Predisposing Factors
•Poor core stability
•Weak abdominal
muscles
•Weak gluteal muscles
•Muscle imbalance
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70. Predisposing Factors
•Poor core stability
•Weak abdominal
muscles
•Weak gluteal muscles
•Muscle imbalance
•Pronated or cavus feet
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71. Predisposing Factors
•Badly designed furniture
•No back support
•Poor posture at work
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72. Acute Low Back Pain
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73. Annular tears
•Loaded compression with
rotatory component
•As little as 3 degrees of
high torque rotation
•Facets protect disc
•As annulus fails, facets
joints may be injured
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74. Annular Bulge
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75. Disc Lesion
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76. Young Athlete
•Junior rugby team 15
years of age
•M. Scheuermann
•5 Spina bifida occulta
•The scrum half had
degenerative facet joint
changes
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77. Scheuermann’s Disease
Greene et al. J Pediatr Orthop 1985;5:1
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78. Spondylolisthesis
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79. Pars Interarticularis
•Pars interarticularis, portion
of lamina between superior
and inferior articular
processes
•Site of spondylolysis or
spondylolisthesis
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80. Spondylolisthesis
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81. Spondylolysis and Spondylolisthesis
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82. Pars Interarticularis; Facet Joint
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83. Spondylolisthesis
Rapid Flexion and Extension
•Gymnastics, flips
•Vaulting
•Ballet, arabesque
•Lifting during dance
•Diving
•Butterfly swimming
•Decathlon
•Pole vaulting
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84. Ankylosing Spondylitis, Infection
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85. 465 Athletes Low Back Pain
(M318;F147)
male (39) female(14)
Spina Bifida Occulta (SBO)
6.6%(21) 4.1%(6)
Lumbarisation
3.5%(11) 1.4%(2)
Sacralisation
2.2% (7) 6.1% (9)
Spondylolisthesis (13)
30% had SBO; 21 of 56 had other pathology
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86. Mechanism of Injuries
•Compression or weight
loading
•Torque or rotation
•Tensile stresses produced
by excessive motion of
spine
•Hyperextension and flexion
Watkins & Dillin, 1985
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87. Compression or Weight Loading
•Sports requiring
•Massive strength
•High body weight
•Weight lifter
•Hooker and No 8
•Wrestling
•Line back American football
Watkins & Dillin, 1985
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88. Weight Lifting
•40 % weight lifters have
low back pain
•Greatest stress is when weight
is lifted above the head
•Dangerous time is shift from
spinal flexion to extension
Aggrawal et al. Br J Sports Med 1979;13:58-61
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89. Axial Compressive Loading
•Head on collisions
•Motor sports
•Boating accidents
•Wrestling
•Horseback riding
•Bicycling
•Bobsleigh
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90. MOB TCD
Axial Compressive Loading

91. MOB TCD
Axial Compressive Loading

92. MOB TCD
Axial Compressive Loading

93. Compression Stress
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94. Rotational Stress
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95. Rotational Stress
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96. Spondylolisthesis
Rapid Flexion and Extension
•Gymnastics, flips
•Vaulting
•Ballet, arabesque
•Lifting during dance
•Diving
•Butterfly swimming
•Decathlon
•Pole vaulting
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97. Australian Football League
Seward & Orchard. 2000 AFL Injury Report, Australian Sports Commission
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98. Golf
•Highest incidence of back
injuries in professional sports
•Torsional stress is lessened by
spreading the stress over the
entire spine
•Rigid abdominal control
•Parallel shoulders and pelvis
Watkins and Dillin, 1985
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99. Sustained Postures - Hyperextension
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100. MOB TCD
Sustained Postures - Hyperextension

101. MOB TCD
Sustained Postures - Hyperextension

102. Sustained Postures - Flexion
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103. Scoliosis due to Unilateral Sports
•Racquet sports
•Fencing
•Sweep rowing
•Javelin
•Freestyle unilateral
breathing
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104. Scoliosis due to Unilateral Sports
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105. Running
•Poor posture
•Poor abdominal
•Pronated feet
•Muscle imbalance
•Leg length discrepancy
•Osteoporosis
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106. Cricket
•Bowlers
•Rotational forces
•Extension followed by
rotation and flexion
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107. Thank You
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108. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”