By- Dr. Armaan SinghBy- Dr. Armaan Singh

Clinical Anatomy of the Back

PROGRESS

TimeTime

Goh et al. Clin Biomech 1999;14:439

SPINEConsists of

• Cervical Vertebrae

• Thoracic Vertebrae

• Lumbar Vertebrae

• Sacrum

• 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

Spine

VERTEBRAL COLUMN• Lot of stress in variety of sports

• Cervical pathology

• Pain may be referred to upper limb

• Lumber pathology

• Lower limb

YOUNG SPINE

Normal curvature of infant’s spine

Normal lumbar curve of toddler’s spine

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

• 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

Low Back Pain in Sports

• Must know the sport

• Must understand the biomechanics and stresses involved in the sport

• Must examine the spine in the appropriate position

Low Back Pain in Sports

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

LUMBAR VERTEBRAE

LUMBAR VERTEBRAE• 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

LUMBAR VERTEBRAE• 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

• 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

Lumbar Vertebrae

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

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

PARS INTERARTICULARIS• Pars interarticularis

• Portion of lamina between superior and inferior articular processes

• Site of spondylolysis or spondylolisthesis

LUMBAR SPINE• Cancellous bone

• 50% compressive strength

• Facet joints 20% in standing upright position

LUMBAR VERTEBRAE

LUMBAR VERTEBRAE

LUMBAR SPINE• Cancellous bone

• 50% of the compressive

strength

• Facet joints, 20% of the strength in the standing upright position

ANTERIOR LONGITUDINAL LIGAMENT• Attached mainly to the bodies

• This ligament helps to prevent us from leaning too far back (hyperextension)

POSTERIOR LONGITUDINAL LIGAMENT• Attached mainly to the inter

vertebral discs

• This ligament helps to restrict forward bending (hyperflexion)

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

• 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

Ligamentum Flava

SPINAL LIGAMENTS• Interspinous ligaments

• Strong supraspinous ligaments

• The inter-transverse ligaments join the transverse processes and are thin and membranous in the lumbar region

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

ARTHRITIS OF SPINE• Painful

• Limitation of movement

• Extra projections

• Narrowing of disc spaces

VERTEBRAL JOINTS• Secondary cartilaginous joints between

the bodies

• Hyaline cartilage covering bodies

• Disc of fibrocartilage in between

• Synovial plane joints between the facets

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

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

NUCLEUS PULPOSUS• 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

NUCLEUS PULPOSUS• 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 platefracture and not to rupture of the annulus

• End plate failure is a possible precursor of disc degeneration

AXIAL LOAD AND END-PLATES

END-PLATE MECHANICS • Functionally, the vertebral end-plate

displays characteristics of a trampoline

• With the sub-end-plate trabecularbone acting as springs to sustainand 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

END-PLATE MECHANICS • 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

END-PLATE SUSCEPTIBILITY

Schmorl & Junghanns. The human spine in health and disease. New York: Grune & Stratton, 1965

Notochord

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

• Narrowing of disc space, results in stress on facet joint

• Highest pressure during

• Combined

• Extension

• Rotation

• Compression

Facet Joints

FACET JOINT SYNDROME• Extension and rotation

• Pain rising from flexion

• Pain worse standing

• Lateral shift in extension

• Point tenderness over facet

• Referred leg pain

SEGMENTAL ROTATION

Singer et al. J Musculoskel Res 2001;5: 45-55

• Flexion limited by disc problems

• Lateral flexion

• Extension limited by facet joint problems

• Very little rotation

• Extension and rotation affect facet joints

MOVEMENTS OF LUMBAR SPINE

NERVE SUPPLY• Nerve supply

• Peripheral annulus

• Facet joint

• Nerve is medial branch dorsal ramus

BLOOD SUPPLY• Lumbar arteries

• Internal venous plexuses

• External venous plexuses

• Basivertebral veins

• Valveless

LUMBAR VERTEBRAE

CANCELLOUS BONE• Cancellous bone

• 50% compressive strength

• Facet joints 20% in standing upright position

Normal bone Osteoporotic bone

ANATOMICAL ABNORMALITIES• Spina Bifida Occulta

• Facet Tropism

• Kyphosis

• Scoliosis

ANATOMICAL ABNORMALITIES

Kyphosis Scoliosis

ANATOMICAL ABNORMALITIES• Hemi-vertebra

• Spina Bifida Occulta

• Facet Tropism

• Scoliosis

• Kyphosis

ANATOMICAL ABNORMALITIES• Unilateral lumbarisation

• Unilateral sacralisation

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

EPIDEMIOLOGY

Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837

Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837-65

EPIDEMIOLOGY• Back pain in the community is 60% - 80%

• Recurrence of back pain is70% - 90%

• Progression to chronic back pain is 5% - 10%

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

CHRONIC LOW BACK PAIN• Local structures

• Muscles

• Ligaments

• Poor lifting techniques

• Joints

• Bones

BACK PAINLocal structures

• Muscles, ligaments

• Joints

Referred pain

• Abdominal organs

• Pelvic organs

Must out rule

• Infection

• Tumours

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

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

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

CHRONIC LOW BACK PAINPain referred

• Abdominal organs

• Pelvic organs

Must out rule

• Infection

• Tumours

PAIN REFERRED

YOUNG ATHLETE• Junior rugby team 15 years of age

• M. Scheuermann

• 5 Spina bifida occulta

• The scrum half had degenerative facet joint changes

SACROILIAC JOINT – SCIATIC NERVE

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

SPINAL STENOSIS

PREDISPOSING FACTORS• Intrinsic factors

• Anatomical abnormalities

• Biomechanical

• Extrinsic factors

• Sport

• Surfaces

• Equipment

• Training

PREDISPOSING FACTORS BACK PAIN• Poor posture

• Overweight

• Unfit

PREDISPOSING FACTORS• Poor core stability

• Weak abdominal muscles

• Weak gluteal muscles

• Muscle imbalance

PREDISPOSING FACTORS• Poor core stability

• Weak abdominal muscles

• Weak gluteal muscles

• Muscle imbalance

• Pronated or cavus feet

PREDISPOSING FACTORS• Badly designed furniture

• No back support

• Poor posture at work

ACUTE LOW BACK PAIN

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

ANNULAR BULGE

DISC LESION

YOUNG ATHLETE• Junior rugby team 15 years of age

• M. Scheuermann

• 5 Spina bifida occulta

• The scrum half had degenerative facet joint changes

SCHEUERMANN’S DISEASE

Greene et al. J Pediatr Orthop 1985;5:1

SPONDYLOLISTHESIS

PARS INTERARTICULARIS• Pars interarticularis, portion of lamina

between superior and inferior articular processes

• Site of spondylolysis or spondylolisthesis

SPONDYLOLISTHESIS

SPONDYLOLYSIS AND SPONDYLOLISTHESIS

PARS INTERARTICULARIS; FACET JOINT

SPONDYLOLISTHESISRAPID FLEXION AND EXTENSION

• Gymnastics, flips

• Vaulting

• Ballet, arabesque

• Lifting during dance

• Diving

• Butterfly swimming

• Decathlon

• Pole vaulting

ANKYLOSING SPONDYLITIS, INFECTION

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

MECHANISM OF INJURIES• Compression or weight loading

• Torque or rotation

• Tensile stresses produced by excessive motion of spine

• Hyperextension and flexion

Watkins & Dillin, 1985

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

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

AXIAL COMPRESSIVE LOADING• Head on collisions

• Motor sports

• Boating accidents

• Wrestling

• Horseback riding

• Bicycling

• Bobsleigh

AXIAL COMPRESSIVE LOADING

AXIAL COMPRESSIVE LOADING

AXIAL COMPRESSIVE LOADING

COMPRESSION STRESS

ROTATIONAL STRESS

ROTATIONAL STRESS

SPONDYLOLISTHESISRAPID FLEXION AND EXTENSION

• Gymnastics, flips

• Vaulting

• Ballet, arabesque

• Lifting during dance

• Diving

• Butterfly swimming

• Decathlon

• Pole vaulting

AUSTRALIAN FOOTBALL LEAGUE

Seward & Orchard. 2000 AFL Injury Report, Australian Sports Commission

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

SUSTAINED POSTURES - HYPEREXTENSION

SUSTAINED POSTURES - HYPEREXTENSION

SUSTAINED POSTURES - HYPEREXTENSION

SUSTAINED POSTURES - FLEXION

SCOLIOSIS DUE TO UNILATERAL SPORTS• Racquet sports

• Fencing

• Sweep rowing

• Javelin

• Freestyle unilateral breathing

SCOLIOSIS DUE TO UNILATERAL SPORTS

RUNNING• Poor posture

• Poor abdominal

• Pronated feet

• Muscle imbalance

• Leg length discrepancy

• Osteoporosis

CRICKET• Bowlers

• Rotational forces

• Extension followed by rotation and flexion