1. The spine

2. Outline
Anatomy
Scolosis
Kyphosis
Spondylolisthesis

3. At Birth
The spine of a newborn is C-shaped, with one curve
At About 6 Months
As the infant lifts his or her head during the first few months, the neck (cervical) curve and its muscles develop
At About 9 Months
As the infant learns to crawl and stand, the lower back (lumbar) curve and its muscles develop. Strong back muscles help give your child the strength and balance to walk and run.

4. Spine components Spinal column (bones and discs)
Neural elements (spinal cord and nerve roots)
Supporting structures (muscles and ligaments)

5. A. The spinal column
The spinal column consists of individual bones called vertebrae, the building blocks, which provide support for the spine. These vertebrae are connected in the front of the spine by intervertebral discs.
The spinal column consists of:
7 cervical vertebrae (C1–C7) i.e. neck
12 thoracic vertebrae (T1–T12) i.e. upper back
5 lumbar vertebrae (L1–L5) i.e. lower back
5 bones (that are joined, or "fused," together in adults) to form the bony sacrum
3-5nbones fused together to form the coccyx or tailbone

6. Vertebra Consist of: Large vertebral body in the front
2 strong bony areas called pedicles connecting the vertebral body
An arch of bony structures in the back (posterior arch) = (the spinous process).
BODY
PEDICLE
spinous process
transverse process

7. Atlas The atlas is the topmost vertebra
The Atlas has no body, and this is due to the fact that the body of the atlas has fused with that of the next vertebra (the Axis)
it has no spinous process, is ring-like, and consists of an anterior & posterior arch and 2 lateral masses

8. Axis The 2nd cervical vertebra (C2) of the spine is named the axis
The most distinctive characteristic of this bone is the strong dens which rises perpendicularly from the upper surface of the body.

10. B. Neural Elements:
The neural elements consist of the spinal cord and nerve roots. The spinal cord runs from the base of the brain down through the cervical and thoracic spine.
Below the L1–L2 level the spinal cord ends, as an array of nerve roots continues, looking somewhat like a horse's tail (cauda equina).
At each vertebral level of the spine there are a pair of nerve roots. These nerves go to supply particular parts of the body.

11. Intervertebral discs Make up ¼ length of the spinal column.
There are no discs between the Atlas, axis & Coccyx.
Discs are Avascular and therefore depend on the end plates to diffuse needed nutrients

12. Discs are composed of 2 parts:
Tough outer portion (annulus fibrosus) composed of concentric sheets of collagen fibers that seal the gelatinous nucleus and evenly distribute pressure and force imposed on the vertebral column.
Soft inner core (nucleus pulposus) contains a loose network of fibers suspended in a mucoprotein gel.
The outer portion and inner core of the spinal disc fit together like two concentric cylinders and are interconnected by cartilaginous end-plates

13. C. the supporting structures:
Ligaments
Fascia
Muscles
Nerves

14. Ligaments
Ligaments are rope-like bands of tissue that connect bones together. Most ligaments are lined up to keep joints from bending in the wrong way
The most important ones are:
Anterior and posterior longitudinal ligaments
Ligamentum flavum
Intervertebral discs

15. Fascia
Fascia is similar to ligaments, but fascia is more like a sheet than a rope.
The most important of which is the thoracolumbar fascia (TLF) which has the following functions:
As the spinal muscles work, the TLF pulls tightly the low back, keeping the lumbar spine from bending out of the neutral position.
It augments the power generated by spinal muscles.

16. Muscles
Because of their location toward the center of the body, and because of their importance in spine stability, these key stabilizers are called "core, paraspinal" muscles
Core muscles help grip and hold the spine. They keep each spinal segment from shifting and sliding as you do your activities

17. Nerves
Motor nerves signal the key muscles to grip and hold and to guide and control the spine.
Sensory nerves transmit sensations such as heat, cold, touch, pressure, and pain. They also give us our sense of position

18. Spinal curve function Absorbs the shocks of walking on hard surfaces.
More weight can be supported by a curved spine than if it were straight.
Additional space for the viscera is provided by the concavities of the thoracic and pelvic regions.
S-curvature protects the vertebral column from breakage.

19. Spinal column function
Protection of the spinal cord.
Providing stiffening for the body and attachment for the pectoral and pelvic girdle and many other muscles.
Providing motion for the human skeleton.
The S-curvature enables the vertebral column to absorb the shocks of walking on hard surfaces

20. Schober’s test Erect position.
Select 2 bony points,10cm apart and mark it.
Maximum flexion on lumbar with fix knee.
The 2 points should separate by at least a further 5cm

21. Cobb’s angle Risser’s sign
Scoliosis
Cobb’s angle
Risser’s sign

22. Scoliosis
A condition that involves complex lateral and rotational curvature of the spine.
The spine is curved and sometimes twisted
Most common type of spinal deformity
It is seen from behind (the back)
Dextroscoliosis is a scoliosis with the convexity on the right side.
Levoscoliosis is a scoliosis with the convexity on the left side.
Classification:
Postural – correctable
Structural - fixed

23. Postural scoliosis
The deformity is secondary or compensatory to some condition outside the spine
Disappear with changes in posture (on flexion)
No bony abnormality
Condition that lead to postural scoliosis are:
Short leg (when pt sit cancelling leg asymmetry- curve disappear)
Pelvic tilt due to contracture of the hip
Local muscle spasm associated with prolapsed lumbar disc

24. Structural scoliosis
Accompanied by bony abnormality or vertebral rotation
Deformity is fixed – do not disappear with changes in posture
Secondary curves develop to counterbalance the primary deformity
Structural curve becomes more obvious on flexion

25. Types of structural scoliosis
Scoliosis due to known causes
Osteopathic: is due to Congenital vertebral anomalies
Neuropathic: due to asymmetrical muscle weakness (cerebral palsy and Poliomyelitis)
3. Myopathic: in muscular dystrophies
4. Neurofibromatosis
Idiopathic scoliosis (more common)
Infantile <3yrs
Juvenile 4-9 yrs
Adolescent >10yrs
(most common)

26. Patterns of Idiopathic Scoliosis
Infantile thoracic:
60% male
90% convex to the left
Associated with ipsilateral plagiocephaly (Oblique lateral deformity of the skull )
May be resolving or progressive(severe)
Adolescent thoracic:
90% female
90% convex to the right
Rib rotation exaggerates the deformity
50% develop curves of greater than 70˚

27. Thoracolumbar:
Slightly more common in females
Slightly more common to right
Features mid-way between adolescent thoracic and lumbar
Lumbar:
More common in females
80% convex to left
One hip prominent but no ribs to accentuate the deformity. Therefore not noticed early, but backache in adult life
E. Combined:
Two primary curves, one in each direction. Even when radiologically severe, clinical deformity relatively slight because always well balanced.

28. Clinical features The symptoms of scoliosis can include:
Cosmetic deformity.
Pain in adulthood, especially if left untreated
Uneven musculature on one side of the spine
A rib "hump" and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis
Uneven hip and shoulder levels
Asymmetric size or location of breast in females
Unequal distance between arms and body
Clothes that do not "hang right", i.e.. with uneven hemlines
Slow nerve action (in some cases)

29. Adolescent idiopathic scoliosis
Age: 10-15y.
F>M
Deformity is the only symptom
Severity depends on which part of the spine involved. Higher curves are noticed earlier.
More prominent on flexion unlike postural curves
The shoulder is elevated on the side of convexity and the hip sticks out on the side of concavity
Thoracic scoliosis the breasts are asymmetrical and the rib angles protrude

30. Investigations X-ray A scolie is an X-ray taken from the rear.
An AP-Lateral is taken from the side.
Should include full length view of the spine
The angle of curvature (cobb’s angle) is measured
X-ray of the pelvis may show Risser’s sign (iliac apophysis has ossified and fused)- sign of skeletal maturity, progression is minimal afterwards

33. Cobb’s Angle

34. Treatment
The aim is to prevent the curve becoming severe and correcting the existing deformities.
The younger the child and thee higher the curve the worse the prognosis
A period of preliminary observation may be needed before deciding between conservative and operative treatment
At 4-monthly intervals the patient is examined, photographed and X-rayed so that the curves can be measured and checked for progression
Conservative treatment Vs. Operative treatment

35. Conservative treatment
Barcing:
For progressive curves between
For well balanced double curves
With younger children until they reach adolescence (iliac apophysis ossified and fused)
Prevent recurrence after spinal fusion
Milwaukee brace, more recently Boston brace
Operative treatment
Curves that progress more than 400
50% correction is regarded satisfactory

37. Boston brace
Milwaukee brace

38. Kyphosis

39. Kyphosis Describe both Normal gentle rounding of the dorsal spine
Abnormal excessive dorsal curvature - deformity.

40. Types Postural kyphosis
It is common (‘round back’ or ‘drooping shoulders’) and may be associated with other postural defects such as flat-feet
Structural kyphosis
Fixed and associated with changes in the shape of the vertebrae. It may occur in:
Osteoporosis of the spine
Ankylosing spondylitis
Scheuermann’s disease (adolescent kyphosis)

41. Kyphos (Gibbus)
Is a Sharp posterior angulation due to localized collapse or wedging of one or more vertebrae.
This may be a result from:
Congenital defect
Fracture
Spinal tuberculosis

43. Scheuermann’s disease (adolescent kyphosis)
This is a developmental disorder of the growing spine in which there is irregular ossification and possibly some fragmentation of the vertebral body epiphyses
The result is irregularity of mature vertebral end-plates and could be associated with small central herniations of disc material into the vertebral body (schmorl’s nodules)
Later on when muscle activity increases kyphosis is exaggerated

44. Types Thoracic scheuermann’s disease
More common than the other
Usually appear in mid-thoracic vertebrae
M>F
Teenager, round shouldered, backache, fatigue, kyphosis which do not improve with change in posture
Treatment: conservative (brace for 18m) or operative
Thoracolumbar scheuermann’s disease

45. Lateral radiograph of thoracic spine shows endplate irregularity and vertebral wedging characteristic of Scheuermann's disease

46. Spondylolisthesis

47. Definition
The vertebrae (mostly L4 & L5) becomes misaligned anteriorly (slips forward) in relation to the vertebra below.
This forward slippage - as noted in the figure at the right is caused by a problem or defect within the pars interarticularis.
Occasionally, facet joint and/or posterior neural arch defects may also cause this syndrome as well.
Spondylolysis non-slipped pars defect & is almost always a precursor to the actual forward slippage.

48. Spondylolisthesis

49. Spondylolisthesis

50. Developmental anatomy
The first theory proposed a failure of ossification during embryonic development, leading to a pars interarticularis defect at birth
The second theory demonstrated that the pars defect began to appear around age six and became progressively more common till age 16. After age 16, the incidence fell and rarely developed after adolescence
It is currently thought that the defect develops from small stress fractures that fail to heal and form a chronic nonunion.

51. Classification Dysplastic spondylolisthesis Isthmic spondylolisthesis
Degenerative spondylolisthesis
Traumatic spondylolisthesis
Pathological spondylolisthesis
Iatrogenic spondylolisthesis

52. Dysplastic spondylolisthesis
Is a true congenital spondylolisthesis that occurs because of malformation of the lumbosacral junction with small, incompetent facet joints.
Very rare, but tends to progress rapidly
Often associated with more severe neurological deficits.

53. Isthmic spondylolisthesis
SUB-TYPE A:
Most common type in people <50y.
It is believed that "biomechanical stress," such as repetitive mechanical strain from heavy work or sports, causes a fatigue fracture within the pars interarticularis.
SUB-TYPE B:
Characterized by a elongated pars without separation.
Secondary to "repeated, minor trabecular stress fractures of the pars.", the pars may fail to heal and result as a full pars defect.
SUB-TYPE C:
Extremely rare and result from an acute pars fracture, often as result of traumatic lumbar hyperextension injury.

54. Degenerative spondylolisthesis
Most common form over 50 years of age and rarely occurs in those under 50.
There is no fracture or elongation of the pars interarticularis and the neural arch is intact.
The mechanisms of forward displacement are thought to involve a combination of "zygapophyseal joint arthrosis, disc degeneration, and remodeling of the articular processes and pars."
Finally, so some strange reason, Degenerative Spondylolisthesis has an affinity for affecting Females, at L4, who are over 40.

55. Traumatic spondylolisthesis
Extremely rare
Results from a traumatically-induced fracture to the neural arch other than the pars region.
One of the examples is The "Hangman's Fracture" in the cervical spine's second vertebra (Axis) is a common and often deadly example of such a traumatically induced phenomenon. This type of fracture is extremely rare in the lumbar spine.

56. Pathological spondylolisthesis
Generalized or systemic disorders of bone may affect the neural arch of the spine and allow spondylolysis or spondylolisthesis to occur.
Osteoperosis
Paget's disease
Metastatic carcinoma

57. Iatrogenic spondylolisthesis
Is a complication of lumbar anterior interbody fusion (LAIF), which ironically is often used to stabilize spondylolisthesis. Either the vertebrae above o below develops a pars fracture.
Laminectomy procedures, which are used for decompressing symptomatic disc herniations in the spine, will result in an overload of weight-bearing stress on the contralateral pars and, in some patients, result in a pars fracture.

58. Symptoms Spondylolysis commonly is asymptomatic. Symptoms (25%)
Nerve symptoms are similar to symptoms seen with a herniated disc.
Leg pain
Electric shock-like symptoms traveling down the leg
Numbness or tingling in the legs and feet
Muscle weakness of the legs
Cauda equina syndrome (medical emergency)
Bowel or bladder problem
Numbness around the genitals

59. Limitations of Techniques
Radiography of the lumbar spine is limited by its inability to detect stress reactions in the pars interarticularis that have not progressed to complete fracture.
CT of the lumbar spine is not sensitive for detecting early acute stress reactions in the pars interarticularis where there is only marrow edema and microtrabecular fracture.
MRI of the lumbar spine can easily identify acute stress reactions in the pars interarticularis. However, direct identification of pars defects (old stress) may be slightly more difficult with MRI than with CT.

60. Treatment
If the slip is small and the symptoms are manageable, then treatment is most often with observation. In children, this may include activity restrictions, such as withholding the child from participation in some sports.
When the slip is more significant, there may be a higher risk of the problem progressing, and surgery may be favored. In addition, patients who have symptoms of nerve compression are more likely to have surgery recommended.