Anatomy, Physical Examination and Imaging of …...Understand: dermatomes, * SLR test,...

Anatomy, Physical Examination

and Imaging of Thoracic

and Lumbosacral Spine

NGUYỄN THÀNH NHÂN

LEARNING OBJECTIVES

Understand:

* Basic anatomy of the spine

* Thoracic and Lumbar spine anatomy

Understand basic imaging of X ray, CT Scan and MRI

Identify and assess functions of the structures in clinical aspect:

* Identify structures: inspection, palpation

* Assess: Thoracic - Lumbar spine movements

Understand: dermatomes, * SLR test, Bragard’s test, Neri’s test, …

CONTENT

Basic anatomy of the spine

Thoracic - Lumbosacral spine anatomy

Imaging of Thoracic - Lumbar spine

Physical examination of Thoracic and Lumbar spine

Anatomy

Basic anatomy of the spine

- The vertebral column consists of 33

vertebrae,

- 5 segments: cervical, thoracic,

lumbar, sacral, and coccygeal.

- There are 7 cervical, 12 thoracic, 5

lumbar, 5 sacral, and 4

coccygeal vertebrae.

- The two major exceptions are C1

(atlas) and C2 (axis)

- Atlantoaxial joint - cervical rotation

Anatomy

Basic anatomy of the spine

[1]

Anatomy

Basic anatomy of the spine

[1]

Anatomy

Basic anatomy of the spine

- The spinal cord

- Conus medullaris: L1 - L2

- There are 8 cervical, 12 thoracic, 5

lumbar, and 5 sacral pairs, and 1

coccygeal pair of spinal nerves.

- The sacral spinal nerves

make up the cauda equina

The neural anatomy is such that the spinal cord resides within

the bony canal between C1 and L1 and/or L2. The filum

terminale extends from the conus and attaches to the coccyx.[1]

Anatomy

Basic neurology of the spine

- Gray matter

+ Spinal neurons (lower motor

neurons),

+ Interneurons

- White matter

+ The axons of LMN

+ Afferent sensory neuron axons

+ 4 funiculi: L lateral, R lateral, ventral,

dorsal

Cross section of the spinal cord delineating

white and gray matter and four funiculi. [1]

Anatomy

Basic neurology of the spine

- White matter

Cross section of the spinal cord delineating

white and gray matter and four funiculi.

+ Within the white matter are tracts

of ascending and descending axons

segregated into pathways of function

[1]

Anatomy

Basic neurology of the spine

- White matter

Cross section of the spinal cord delineating

white and gray matter and four funiculi.

+ The lateral spinothalamic tract: pain

and temperature sensation. (crosses)

+ The dorsal column pathway:

vibration sensation, two-point touch,

conscious proprioception

+ The lateral corticospinal tract:

voluntary motor function. [1]

Lumbosacral Spine

Lumbar vertebrae are characterized by massive bodies and robust spinous and transverse processes.Their articular facets are oriented somewhat parasagittally, which is thought to contribute the largerange of anteroposterior bending possible between lumbar vertebrae. Lumbar vertebrae alsocontain small mammillary and accessory processes on their bodies. These bony protuberances aresites of attachment of deep lumbosacral muscles.

Lumbar Spine Anatomy

[2]

Drawing of 2 lumbar segments viewed from anoblique angle. The outline of the facets andthe pars interarticularis has the appearance ofthe "neck" of a Scottie dog.

Lumbar Spine Anatomy

[2]

IMAGING

AP VIEW LATERAL VIEW OBLIQUE VIEW

Adult Lumbar Spine - AP View [3]

Adult Lumbar Spine - Lateral View [3]

Adult Lumbar Spine - Lumbosacral L5S1 View [3]

Adult Lumbar Spine - Oblique View [3]

Spondylolisthesis L4-L5

EXTENSION VIEW FLEXION VIEW

CT Scan

Sagittal

CT: L4 compression fracture

T2W T1W STIRT2W

MRI

Thoracic Spine X-ray: AP projection. 1, Left

ventricle. 2, Gas in stomach. 3, Right

hemidiaphragm. 4, Posterior rib. 5,Clavicle.

Thoracic Spine X-ray: AP projection. 1, Gas in Colon (Splenic

flexure). 2, Gas in stomach. 3, Left hemidiaphragm. 4, Posterior

rib. 5, Pedicle. 6, Spinous process. 7, Transverse process.

THORACIC SPINE

Thoracic Spine X-ray: Lateral view. 1, Right

hemidiaphragm. 2, Left

hemidiaphragm. 3, Vertebral body. 4, Rib.

Thoracic Spine X-ray: Lateral view. 1,Posterior

rib. 2, Vertebral body. 3, Intervertebral discal space.

THORACIC SPINE

Physical Examination Of Thoracic Spine

Visual Examination

Physical Examination Of Thoracic Spine

Visual Examination

Physical Examination Of Thoracic Spine

Palpation

Physical Examination Of Thoracic Spine

Percussion

Physical Examination Of Thoracic Spine

MovementsActive Movements

Physical Examination Of Thoracic Spine

MovementsActive Movements

Physical Examination Of Thoracic Spine

MovementsActive Movements

Physical Examination Of Thoracic Spine

MovementsActive Movements

Physical Examination Of Thoracic Spine

Neurologic Evaluation of the Thoracic Spine

Physical Examination Of Thoracic Spine

Physical Examination Of Thoracic Spine

Physical Examination Of Thoracic Spine

Physical Examination Of Thoracic Spine

Inspection

When the patient enters the room

▪ He or she is distressed?

▪ Is the patient leaning to one side?

▪ Is the patient able to walk,

▪ Is the gait normal?

▪ The pelvis?

▪ The patient is limited in any motion,

▪ Note the extent of any pain.

Physical Examination Of Lumbosacral Spine

[1]

Inspection

Once the patient is undressed,

▪ Look for signs of trauma, blisters, scars, discoloration,

redness, contusions, lumps, bumps, fat pads, and

other marks.

▪ Hairy patches or café au lait spots

▪ Look for a lateral curvature, or scoliosis

Physical Examination Of Lumbosacral Spine

[1]

Palpation

Posterior Lumbar, Sacral, and Coccygeal Spine

▪ Sit on a stool behind the

standing patient. Place

your thumbs on the

midline of the patient’s

back at the level of the

iliac crest. This should be

the junction between L4

and L5.

Physical Examination Of Lumbosacral Spine

[1]

Palpation

C7

D7

D12

L4-L5

Palpation

Posterior Lumbar, Sacral, and Coccygeal Spine

Physical Examination Of Lumbosacral Spine

[1]

Palpation

Paraspinal Muscles

▪ Detect tenderness, spasm, muscular defect, and

asymmetries.

Physical Examination Of Lumbosacral Spine

[1]

Palpation

Anterior Lumbar, Sacral, and Coccygeal Spine

Physical Examination Of Lumbosacral Spine

[1]

Movements

Active Movements

Physical Examination Of Lumbosacral Spine

Forward Bending

Forward Bending Test

[1]

Movements

Active Movements

Physical Examination Of Lumbosacral Spine

Backward Bending

[1]

Movements

Active Movements

Physical Examination Of Lumbosacral Spine

Side Bending

[1]

Movements

Active Movements

Physical Examination Of Lumbosacral Spine

Trunk Rotation

[1]

Movements

Passive Movements

Physical Examination Of Lumbosacral Spine

Rotation

[1]

Movements

Resisted Movements

Physical Examination Of Lumbosacral Spine

Rotation

[1]

Movements

Resisted Movements

Physical Examination Of Lumbosacral Spine

Flexion

[1]

Movements

Resisted Movements

Physical Examination Of Lumbosacral Spine

Side Bending

[1]

Tests

Physical Examination Of Lumbosacral Spine

Straight Leg Raise (Lasègue)

[1]

Tests

Physical Examination Of Lumbosacral Spine

Bragard’s Test – Neri’s Test

[1]

Tests

Physical Examination Of Lumbosacral Spine

Neurologic Evaluation of the Lumbar Spine

[1]

Tests

Physical Examination Of Lumbosacral Spine

Neurologic Evaluation of the Lumbar Spine

[1]

KEY MUSCLES - MYOTOME

KEY MUSCLES - MYOTOME

References

1. Todd J.Albert, Alexander R. Vaccaro. Physical Examinatiom of the Spine 2th edition. Thieme Medical Publishers, 2017.

2. Stephen Kishner, Maxim Moradian, Jan K Morello. Lumbar Spine Anatomy. Update: Aug 12 2015. emedicine.Medscape.com

3. Wiki – Radiography.net