Anatomy Of The Spine

The Spine Acts As A

Support For The
Spinal Cord And
Nerve Pathways.
33 Vertebrae
24 Intervertebral
Discs
Spinal Nerves
Muscles
Ligaments

Spinal Cord Pathways

1. Sensory Pathways

Temperature, pressure and pain.

2. Motor Pathways

Movement of the body and limbs.

3. Autonomic Nerve Pathways

1. Sympathetic
2. Parasympathetic

Anatomy of Vertebrae

Thomson JC, Spine In : Netter atlas of orthopaedic anatomy, 1 st Ed. USA: Icon
Learning LLC, 2002. p5-6

 Vertebra body
Pedicles
Articular process
(superior and
inferior)
Lamina
Transversal process
Spinosum process
Thomson JC, Spine In : Netter atlas of orthopaedic
anatomy, 1st Ed. USA: Icon Learning LLC, 2002. p5-6

Introduction
Acute (short-term) back pain may occur
a few days weeks
Chronic > 3 months
Back pain :
1.
2.
3.
4.

Congenital
Infection
Trauma
Degenerative

PREDISPOSITION FACTOR

Work
Age
Alcohol
History of trauma
Smoking (decrease oxygen supply to the disc
and decreased the oxygen content , effect of
nicotine that constrict the artery)
Exercise
An unknown spine condition (osteoporosis,
spondylolysis, osteoarthritis of the spine,
osteoporosis, and scoliosis)

Plan ahead,
dont hurry

Move in
close
when
placing
object on
high shelf
Lift with leg
muscles
10

Tighten
stomach
muscles
Bend knees

Dont twist
Spread feet shoulder
distance apart

PATHOPHYSIOLOGY
Age bone strength and muscle
elasticity and contraction .
Loss of disc fluid and flexibilities
decrease the ability as the cushion of
vertebrae.
Spine excessive expand or compression,
disc might rupture or bulged off
Rupture compress the end nerves from the
spinal cord back pain.

Which condition that associates

with low back pain?
Bulging disc (also called protruding,
herniated, or ruptured disc)
Serious complication from the rupture of the
disc is cauda equina syndrome disc
material is push into spinal canals and
compress the end nerves of lumbar and
sacral
Sciatica is a condition in which a herniated
or ruptured disc presses on the sciatic nerve

Spinal Degeneration
Spinal Stenosis
Osteoporosis
Spondylitis
Osteomyelitis
Sacroiliitis

HOW TO DIAGNOSE?
Anamnesis
Physical examination
Radiological Imaging - to exclude
tumor or other causes of pain.

Radiologic examination

X-ray imaging
Discography
Myelograms
CT Scan
MRI

HOW TO TREAT LBP?

Most of the low back pain can be treated
without operation.
Analgesic therapy
NSAID
TCA
Opioids eg:codeine, oxycodone, hydrocodone,
dan morphine

Bed rest 12 days

Cold and hot compress
Exercise

Self- exercise for the back

Latihan (Senam) untuk

Punggung

 For irresponsive therapy

Surgery might decrease or put
away the pain :
Discectomy
Foraminotomy
IntraDiscal Electrothermal Therapy
Nucleoplasty
Spinal laminectomy (spinal
decompression)
Rhizotomy, cordotomy, DREZ

Congenital Disease Of The

Back Bones
Congenital Short
Neck
Spina Bifida
Hemi Vertebra
Muscular Torticollis

KLIPPEL FEIL SYNDROME

Congenital synostosis of the cervical vertebra
Fusion of 2 or more of the cervical vertebrae.
Clinical symtoms:
Short neck
Flexion or extension of the neck is inhibited

X-ray :
Fusion of a few cervicalis vertebrae body

CONGENITAL SCOLIOSIS
Lateral Curvature of the Spine
Etiologi :
Hemivertebra
Wedged Vertebra
Fused Vertebra
Absent of fused Rib

Congenital scoliosis

Congenital Scoliosis

Tuberculosis Spondylitis
( Potts Disease)
Second infection (focus in another
places)
Infection is hematogenic
Location:
Lower thoracal
Upper lumbar
Also known as Potts disease

Incidence
50% from all bones and joints Tuberculosis
In Ujung Pandang about 70% of cases
Affected usually age group of 2- 10 years
old
Ratio male and female almost equal

Sites of lesion
The surface of the vertebrae body
The surface of anterior
subperiosteal vertebrae body
Spinous process and tranverse
process

Pathophysiology
Infection begins from central part,
anteriorly softening of the
corpus(body) damage of corpus
Damage of anterior part leads to
kyphosis / gibbus.

Scheme diagram on kyphosis in Potts

disease

Five stage of process

1. Implantation
2. Early destruction
3. Late destruction
4. Neurological disturbances
5. Residual deformities gibbus

Clinical symptoms
General symptoms on TB
Back pain while sitting
Pain on palpation
Deformity : gibbus /
kyphosis
Cold abscess signs

Tuberculose Spondylitis

Tuberculose Spondylitis

TB Spondylitis

Tuberculose Spondylitis

Tuberculose Spondylitis

Tuberculose Spondylitis

Postmortem Tuberculosis Spondylitis

Gambaran postmortem Spondilitis

Tuberkulosa

Laboratorium
Increase of LED and leucocytosis
Mantoux test positive
Granulation tissue biopsy or
regional lymph nodes.
On histopatologic examination
may find tubercle

Radiologic
Thorax photo
Plain photo of vertebrae :

Osteoporosis
Osteolytic
Destruction of vertebra body
Disc narrowing
Paravertebral abscess mass
Late stage kyphosis
Mielography ( when there is
compression sign on the bone
marrow)
CT scan or CT with mielography

A. Osteolytic & narrowing of intervertebral space

B. Kyphosis appearance on the vertebrae

 Lumbal kyphosis due to

multiple vertebrae
destruction
Destructed corpus
vertebrae (panah)

Tuberkulosis pada vertebra lumbal

Tuberculosis of the atlas bone

Diagnosis
Clinical examination
X-ray of the vertebrae AP & Lat
X-ray photo of thorax PA
Mantoux test

Treatment
1 Conservative Therapy

Bed rest
Improve general condition of the patient
Brace
Anti-tuberculose drugs

2 Operative
-

When conservative is fail.

When there is cold abscess or TB lesion

paraplegic dan kyphosis

MRI of the Back bones

Komplikasi
Cold abscess
Paraplegia
Pathologic dislocation

BRUCELLOSIS
Subacute infection / chronic
granulomatose of the bones & joints
Species on human :
Brucella melitensis
Brucella abortus
Brucella suis

Pathology
On the vertebrae body or sinovia of the major
joints
Granuloma with infiltration of round cell and
giant cell
Necrosis and caseosa
Abscess

Diagnosis
Clinical examination
Laboratorium
Radiologic

Clinical Appearance

Fever
Headache
Fatigue
Pain on joints and back bones
Swelling of the joints
Limited joint movement

Radiologic

Subacute athritis signs

Narrowing of joint space
Bone destructions (late)
Periarticular Osteoporosis (late)
Vertebrae body collapse
Narrowing of intervertebral disc

Brucellosis

Laboratorium
Agglutination Test
Biopsy and joint aspiration

Differential Diagnosis
Tuberculosis
Reiter Disease

Treatment
Combination of Tetrasicyclin &
streptomysin for 3-4 weeks
Abscess drainage

Spinal Cord Injury

The spinal cord does not
have to be severed and
some of SCI patients
have an intact spinal
cord on MRI.

Traumatic Spinal Cord Injury

1/5 of Spine
fractures a/w
neurological
deficits
Young Male : 15-35
yrs
Common site :
- Cervico-thoracic
- Thoraco-Lumbar

Forces Involved In Spinal

Injury
Axial compression
Fibers are pushed
together in a crushing
manner
Tends to fracture
vertebrae in multiple
pieces
Usually associated with
flexion, extension, or
rotational forces.

Forces Involved In Spinal

Injury
Distraction
Bony, disc, or
soft tissue
elements are
pulled apart
Usually
associated with
flexion or
extension forces

Forces Involved In Spinal

Injury

Flexion

Severe forward
bending of the
neck or trunk
Causes
compressive force
on the anterior
vertebral column

Forces Involved In Spinal

Injury
Extension
Severe backward
bending of the neck
or trunk
Causes fractures to
the spinous process
and lamina

Spinal Shock
Complete absence of all reflex activity
below the injury level, immediately
following spinal injury.
Hypotension with bradycardia
Limits the ability to assess the extent
of paralysis and prediction of recovery
Considered over with the return of BC
reflex or by 48 hrs in few pts in whom
the reflex never returns.
May last up to 2 weeks

Complications of SCI
1.
2.
3.
4.
5.
6.

Skin breakdown / pressure sore.

Pneumonia
Spasticity
Heterotrophic Ossification
Osteoporosis
Urinary complications

Complications of SCI
7. Autonomic Dysreflexia

Also known as Autonomic Hyperreflexia

caused by noxious stimuli below the level of

injury.

results in a very high BP and bradycardia.

may result in stroke if unrecognized.

Symptoms include pounding headache,

sweating and flushing above the injury
level, nasal congestion, piloerection, chest
pain, visualdisturbance

Complications of SCI
8. Deep vein thrombosis
9. Neuropathic pain
pain arising from damaged nerves.

10. Post-Traumatic cystic myelopathy

(Syringomelia)

Clinical Evaluation
Ask patient for neurological symptoms
numbness, tingling or paralysis

Inspection and palpation

Abdominal bruising
oedema or bruising
tenderness
gap or step
muscle spasm
pain on movement

Clinical Evaluation
Non-contiguous spine injury occur in
5-20% of cases
Up to 15 % a/w major visceral
involvement
Head Injury : Must rule out Cx injury.

Neurological Assessment
Difficult to assess if pt is unconscious.
observe for involuntary movements
delay full assessment later

Needs cooperation from patient

Use a neurological chart
Neurological level
Polytrauma: Spine injury until proven
otherwise

Neurological Evaluation

Power
Sensory
Deep tendon reflexes
Primitive reflexes

Primitive reflexes
Mediated by sacral nerve roots
PR exam, BC reflex, perianal
sensation, anal wink
In 90% of cases, these reflexes
returns in 48 hrs, after which,
complete neurology indicates
complete spinal cord injury.

Muscle Grading Chart

GRADE

0
1
2
3
4
5

Zero
Trace
Poor
Fair
Good
Normal

MUSCLE ACTION
Total paralysis
Visual contraction
Active mvm, gravity
eliminated
Against gravity
Against resistence
Full resistence

Frankel / ASIA Impairment

Scale
A Complete. No motor or sensory fn.
B Incomplete. Sensory but not motor fn is
preserved below neurological level.
C Incomplete. Motor fn is preserved below
neurological level with power of less than 3/5
D Incomplete. Motor fn is preserved below
neurological level with power of more than 3/5
E Normal motor and sensory function

Effects of SCI
1. Complete SCI

Total loss of sensation and voluntary

movement.

2. Incomplete SCI

Partial loss of sensation and voluntary

movements e.g. paralysis but intact
sensory.
More common.
Four syndromes

Complete SCI
1.Quadriplegia (Tetraplegia)
Loss of motor and sensory function of all
four limbs due to damage to the cervical
spinal cord.
Some may have loss of ability to breath.

2.Paraplegia
Loss of motor and sensory function at the
lower limbs due to damage to thoracic or
lumbar spinal cord.
The upper limbs are normal.

Incomplete SCI
1.
2.
3.
4.

Anterior Cord Syndrome

Posterior Cord Syndrome
Central Cord Syndrome
Brown-Sequard Syndrome

Anterior Cord Syndrome

Loss of motor function only.
10 15% will recover.

Posterior Cord Syndrome

Loss of sensation and proprioception
with intact motor.

Central Cord Syndrome

Loss of upper limb sensation and
motor functions with normal lower
limb.

Brown-Sequard Syndrome
Same Side
Motor paralysis Loss of fine
touch
and proprioception

Opposite Side
Loss of pain and
temperature sense.

Cervical (Neck) Injuries

Usually results in
quadriplegia.
C4 level requires a ventilator.
C5 has only shoulder and
biceps control.
C6 has wrist control.
C7 to T1 have poor hand
dexterity.

Thoracic Injuries
Usually results in paraplegia.
T1 to T8 has poor trunk control.
T9 and below has good trunk control
with good sitting balance.

Lumbar and Sacral Injuries

Poor control of hip flexors and legs.
May be able to walk with assistance.

Other Impairments with SCI

1. Loss of bladder and bowel function.
2. Loss of sexual function (infertility in
males)
3. Loss of ability to breathe.
4. Loss of ability to regulate
temperature and blood pressure.
5. Inability to sweat below the injured
level.

Investigations
Plain X-Ray - AP , Lat, Swimmers,
depressed shoulders, open mouth
view, lateral flexion and extension
views.
CT Scan
MRI spinal cord integrity,
pathological fractures

Is There A Cure For SCI?

The spinal cord does
not have the ability
to regenerate.
Extensive research
involving stem cells
There is still no cure
for SCI at the
moment.

Do They Recover?
Incomplete injuries - some amount of
recovery can be expected even up to
18 months after the injury.
Very few patients make full recovery.

Lumbar canal stenosis

Classification
Spinal stenosis can be classified based on the
anatomic location of narrowing:

Rhatomy S, Spinal stenosis In : Orthopaedic spine, Jakarta : Orthopedi UI, 2010,

p88-94

Classification-arnoldi (1976)
Congenital
Stenosis

Acquired Stenosis

Others

1. Developmental
2. Achondroplasia

1. Degenerative
2. Degenerative &
Disc Herniation
3. Degenerative &
Congenital
4. Disc Herniation

1.
2.
3.
4.
5.

Pagets
Spinal Tumour
Infection (TB)
Post-surgery
Trauma

Rhatomy S, Spinal stenosis In : Orthopaedic spine, Jakarta : Orthopedi UI, 2010,

p88-94

Degenerative cascade

Simptom

Diagnosis

Management
Non-operative :
Bed rest
Drugs
Analgesics
NSAID
Muscle
relaxants
Physiotherapy

Operative
Irresponsive with
non-operative
therapy
Serious
neurology deficit
Decompression
Laminectomy

Spondylolisthesi
s

DEFINITION
Definition :
Spondylolisthesis comes
from yunani words.
Spondylo means vertebra
Listhesis means
dislocation.
Spondilolisthesis :
dislocation of the
vertebrae or columna
vertebralis that connects
with the vertebrae above.

CLASSIFICATION
Classification System of Wiltse,Newman, dan
MacNab

Clas
s

Type

Age

Dysplatic

Child

Congenital
dysplasia
superior facet

II

Isthmic

5-50

Caused by spondylolysis (L5-S1)

A.Lytic-fatigue fracture of pars
interarticularis
B. Elongated but intact pars
interarticularis
C.
Acute
fracture
of
pars
interarticularis

III

Degenerative

IV

Traumatic

* most common

Pathology/other

Older Facet
arthrosis
subluxation (L5-S1)
Youn
g

of

leading

S1

to

Acute fracture in some other

portion of vertebra that allows a
slip to occur

Meyerding Classification
Grade

< 25 %

75%

II

< 50 %

20%

III

< 75 %

IV

< 100 %

> 100%

Grade V
Spondyloptosis

Freq

<5%

Diagnosis

Treatment

Reference
Rasjad,Chairuddin.Pengantar Ilmu
Bedah Ortopedi.Yasif
Watampone.Jakarta.2009

Thank you