Sylvie Kalikoff & Brad Leavitt The Spine Sylvie Kalikoff & Brad Leavitt

“In a way, your spine is the keystone that holds your body together “In a way, your spine is the keystone that holds your body together. It's at the center of your axial skeleton... At the top of your axial skeleton is your skull, and your coccyx, or tailbone, is at the other end. Together, all these bones shelter some of the most important organs in your body. Your brain sits in its protective skull casing, and the organs in your chest are protected by 12 pairs of ribs, all of which attach directly to your spine... As if that wasn't enough, your spine is also what lets you move your arms and legs. Your arms attach to your spine and ribs via the collarbones and shoulder blades. Your legs attach to the spine through your hips. When you want to move your arms and legs, signals travel down your spinal cord, which is enclosed in your spine. Nerves carry the signals from the spinal cord to the muscles you want to move.” - Tracy Wilson

Anatomy Review Regions of the spine: Cervical Thoracic Lumbar Sacral Structure of the Discs: Discs between vertebrae allows for some motion, acting like a joint and shock absorber Outer fibrous ring: annulus fibrous Inner circle: nucleus pulposus Regions of the spine: Cervical Thoracic Lumbar Sacral Coccygeal

Spinal Development Babies are born with a C-shaped spine Spine first developing S-Shape curve to balance head Lumbar curve develops last develops during crawling Finish spinal development curves between 12-18 months when baby starts walking upright **One big thorac curve** Babies are born with C-Shaped curve Gravity helps developing the S-Shape curve as baby matures First starts developing the cervical curve **Does this out of curiosity of the world around them** Thoracic -> Cervical -> Lumbar ** tuck her legs into a frog leg position, thighs pulling up toward the chest, while laying on her belly or when you pick her up. This fetal tuck allows your baby to maintain her primary curve alignment, reducing the pressure on the spine and hips **

Importance of Good Posture

Diseases of the spine

Scoliosis Abnormal curvature of the spine Can worsen during puberty Can be genetic Neuromuscular scoliosis Idiopathic scoliosis Degenerative scoliosis puberty because rapid growth neuromuscular: poor muscle control→ CP, spina bifida idiopathic= no known cause, most common form in children degenerative= gets worse with age, most common form in adults http://www.medicinenet.com/scoliosis/article.htm

Types: Dextroscoliosis and Levoscoliosis dextro = right usually in the thoracic spine most common “S” or backward “C” levo = left usually in the lumbar spine “C” shape http://www.buzzle.com/articles/scoliosis-causes-symptoms-and-treatment.html

Treatment back braces measuring and tracking surgical→ when the degree of curvature is large in a person before reaching skeletal maturity Instrumentation with or without fusion: the insertion of metal rods to straighten the back With fusion: spinal fusion eliminates motion between vertebrae. A bone graft is used to fuse the vertebrae. http://abcnews.go.com/topics/lifestyle/health/scoliosis.htm <10 degrees is not scoliosis curves beyond 20 to 30 degrees should be monitored, if changes of more than 5 degrees between observations, see a surgeon braces prevent further movement, surgery can fix the curved spine grafts generally from iliac crest of the hip http://www.hkjpaed.org/details.asp?id=94&show=1234

Can you diagnose these X-rays? levoscoliosis of lumbar spine: L dextroscoliosis of thoracic spine: R http://mpr-spicesofmylife.blogspot.com/2009/11/levoscoliosis.html http://www.eatingbirdfood.com/my-scoliosis-story-and-where-yoga-fits-in/

Ankylosing Spondylitis (Arthritis of the Spine) Gradually causes new bone to start to form in between the joints of the spine Disease affects males 2-3x more often than females Genetically inherited- HLA-B27 gene Chronic inflammation of the spine

Ankylosing Spondylitis (Arthritis of the Spine) Symptoms: Pain in back Pain in hips, knees or ankles Stiffness Fatigue Treatment: Medication Physical Therapy Maintaining a healthy weight Medication is used to reduce inflammation physical therapy to aid in better posture

Ankylosis Advancement of Ankylosing Spondylitis Advancing fusion of spine reduces flexibility Can lead to complete loss of mobility of spine Important to stand with good posture! Ankylosis- Inflammation can lead to complete fusion of the vertebrae Spine is more brittle, (What could be a result of the spine fusing of becoming more brittle? --easier to fracture) causes forward curvature thoracic spine and limits breathing capacity If you have the disease inheritely, if you stand with bad posture then once the disease hits you’ll have permently bad posture ** No pain is associated during fusion**

X-Ray of Ankylosis

Spinal Stenosis Stenosis= abnormal narrowing Causes: overgrowth of bone: bone spur formation, Paget’s disease herniated disks trauma: dislocations, fractures tumors aging osteoarthritis/wear and tear can cause bone spur formation→ grow in spinal canal and take up room Paget’s disease: abnormal breakdown of bone followed by abnormal growth of bone herniated disk: wear of the soft cushions between vertebrates the older you get, the more likely http://www.spinecenteroftexas.com/spinal-stenosis/

Lumbar Spinal Stenosis lumbar = lower back nerve compression in the lower back due to narrowing of the spinal canal Symptoms: sciatica: pain, tingling, cramping, weakness and numbness due to a compressed sciatic nerve lower back, butt, leg pain sciatica: pain in lower back, butt and leg http://www.basicspine.com/blog/lumbar-spinal-stenosis-narrowing-spine/

Cervical Spinal Stenosis cervical = upper back narrowing of the spinal canal in the neck region symptoms: symptom free unless nerves get compressed pain, tingling, cramping, weakness and numbness neck, arms, hands loss of balance and coordination loss of bladder control http://clinicalcases.org/2004/09/spinal-cord-compression-presenting.html

Treatment Epidural injections Physical therapy and exercise Spinal cord stimulation Radiofrequency neurotomy Anti-inflammatory medication exercise and physical therapy: not a cure but prevents further debilitation epidural = around the spinal cord injections of cortisone: corticosteroid+ numbing agent, temporary pain relief→ days or years, depends spinal cord stimulation is for chronic pain: implanted device that generates pulsed electrical signals that make pain feel numbed to a tingling sensation radiofrequency neurotomy: thermal denervation, needle injected at nerve source of pain, pain is temporarily relieved http://www.vancouverspinedoctor.com/spinal-stenosis.php

Spina Bifida Four Types: Occult Spinal Dysraphism (OSD) Dimple in lower back of baby’s back Spina Bifida Occulta Meningocele spinal cord is pushed out through the spine like a sac Spina Bifida Cystica (Myelomeningocele) most severe case of spina bifida spinal column does not close all the way while in the womb (No known cause) Occult Spinal Dysraphism (OSD)- infant's spine does not grow the proper way. Can cause harm to the spinal cord as the child grows Spina Bifida Cystica (Myelomeningocele)- most severe case of spina bifida spinal cord and nerves go through the Meningocele causes nerve damage Causes fluid to go to a child's head, head grows too big, and it results in brain damage

Spina Bifida Treatment: OSD requires surgery to prevent nerve damage Myelomeningocele requires surgery within 2 or 3 days after birth Prevention Recommended that women take 400 micrograms of folic acid daily during pregnancy Prevent nerve damage as the child develops

Prevention of Spina Bifida January 1998: folic acid was mandatorily fortified in cereal enriched grain products by the FDA

Injuries of the Spine

Herniated Disc: A herniated disc is the result of a ruptured nucleus pulposa, or disc degeneration Can put pressure on spinal nerves leading to pain Risk factors: improper lifting, gender, weight, lifestyle, repeated strain on back men are more prone, being overweight, sedentary lifestyle VIDEO

Symptoms Pain depends on location of herniated disc upper back→ arm, hand, shoulder pain lower back→ butt, leg pain numbness, tingling VIDEO http://www.livewellpainclinic.com/slipped_disc.aspx

Treatment Surgical Non-surgical Physical therapy, exercise Anti-inflammatory pain medication Epidural injections Surgical Only if non surgical treatments do not work after an extended period of time Microdiscectomy Artificial disc replacement Spinal Fusion physical therapy and exercise can relieve pressure on nerve root

Microdiscectomy Artificial Disc Replacement Spinal Fusion Lumbar herniated disc gently moves nerve root to release pressure 90-95% success rate, 5% develop recurrent herniated disc PT rehabilitation Artificial Disc Replacement new procedure allows for more back flexibility than spinal fusion Spinal Fusion old, traditional procedure generally lumbar spine eliminates motion between vertebrae, eliminating the rubbing of the disk and pinching of a nerve. recurrent herniated disc commonly occurs within the first 3 months post operatively microdisectomy often cures leg pain but there is remaining lower back pain VIDEO

Spinal Fractures Types: Flexion Fracture: compression fracture or axial burst fracture Extension Fracture Rotation Fracture: transverse process fracture, fracture-dislocation Causes: Trauma→ car accident, fall from height, sports injury Symptoms: Back pain ranging in severity and location depending on location of the fracture

Flexion Fracture Compression Fracture thoracic or lumbar spine caused by osteoporosis weakening of the bone causes the front of the vertebrae to break down Axial Burst Fracture results from high force axial loading vertebrae loses height in front and back

Extension Fracture Vertebrae pulled apart Common in car accidents in car accidents: seat belt keeps lower body in place but upper body moves forward at high speed http://www.scientificspine.com/spinal-diseases/seat-belt-fracture.html

Rotation Fracture Fracture-Dislocation Transverse Process Fracture Both fracture and dislocation occur simultaneously One vertebrae pushes another Spinal cord compression Rotation Fracture Transverse Process Fracture Fracture to a bony protrusion Rare Result of extreme sideways bending of the spine

Treatment Non-surgical Treatment Surgical Treatment Generally required when there are bone fragments, nerve injury, extreme loss of vertebral height. If nerve injury, remove pressure from spinal cord Return bone to proper position using screws, rods, or cages. Non-surgical Treatment Rest and ice Bracing or casting Rehabilitation exercises, slow return to mobility Stabilization after burst fracture http://orthoinfo.aaos.org/topic.cfm?topic=a00368

What kinds of fractures are these? L: fracture/dislocation M: extension fracture R:axial burst fracture http://learningradiology.com/archives2013/COW%20566-Burst%20fx/burstcorrect.html http://radiopaedia.org/articles/cervical-spine-fractures http://www.radpod.org/2007/04/27/teardrop-fracture/

Paralysis Incomplete Injury Complete Injury Ability for the spinal cord to and from the brain is not completely lost Sensation and movement is weakened Complete Injury Complete lack of sensory and motor functions Paralysis

Cervical Spinal Cord Injury C1 - C7 Cause weakness or paralysis in the arms and legs Symptoms: respiratory issues, sexual dysfunction, loss of physical sensation, bladder, and bowel problems Treatment: Neck brace neck is very flexible, hard to stabilize -Quadriplegia - Paralysis in the arms and legs - Cervical Spinal Cord controls signals to the back of the head, neck and shoulders, arms and hands, and diaphragm

Thoracic Spinal Cord Injury T1-T12 Paralysis or weakness in legs Symptoms: Loss of physical sensation, sexual dysfunction, bladder, and bowel problems Trunk brace to improve stability after injury Paraplegia- Paralysis in the legs **Less common because it is protected by the rib cage Thoracic Spinal Cord controls signals to back and part of the abdomen

Lumbar Spinal Cord Injury L1-L5 Paralysis or weakness in the legs Symptoms: Loss of physical sensation, sexual dysfunction, bladder, and bowel problems These injuries require surgery and external stabilization Lumbar Spinal Cord controls lower part of admonmen, the back, the buttocks, external genital organs, and parts of the legs

Sacral Spinal Cord Injury S1- S5 Weakness or paralysis in hips and legs Symptoms: Sexual dysfunction, loss of bladder and bowel function Sacral spinal cord sends signals to the thighs, lower part of the legs, the feet, and genital organs

References http://www.mayoclinic.org/diseases-conditions/spinal-stenosis/basics/causes/con-20036105 http://www.spine-health.com/conditions/spinal-stenosis/what-spinal-stenosis http://www.mayoclinic.org/diseases-conditions/spinal-stenosis/basics/symptoms/con-20036105 http://www.spine-health.com/conditions/spinal-stenosis/spinal-stenosis-treatment http://www.mayfieldclinic.com/PE-ESI.htm#.VicVNBCrTVp https://treatingpain.com/treatment/spinal-cord-stimulation http://www.mayoclinic.org/diseases-conditions/herniated-disk/basics/symptoms/con-20029957 http://www.ajnr.org/content/20/4/697.full http://orthoinfo.aaos.org/topic.cfm?topic=a00348 http://orthoinfo.aaos.org/topic.cfm?topic=a00368 http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.4514603/k.77E9/Spinal_Cord_Injury_Types.htm http://blog.intellidance.ca/blog/2-15-2011/c-s-how-nurture-your-babys-spine-development http://spinabifidaassociation.org/ https://embryology.med.unsw.edu.au/embryology/index.php/Abnormal_Development_-_Folic_Acid_and_Neural_Tube_Defects http://www.medicinenet.com/ankylosing_spondylitis/page4.htm