1. Dr. S. Nishan Silva (MBBS)

2. At Birth The spine of a newborn is C- shaped, with one curve At About Six Months As the infant lifts his or her head during the first few months, the neck (cervical) curve and its muscles develop At About Nine 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.

3. 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: seven cervical vertebrae (C1–C7) i.e. neckcervical twelve thoracic vertebrae (T1–T12) i.e. upper back thoracic five lumbar vertebrae (L1–L5) i.e. lower backlumbar five bones (that are joined, or "fused," together in adults) to form the bony sacrumsacrum three to five bones fused together to form the coccyx or tailbone coccyx

5. The Back Posterior median furrow – vertical groove along the midline Spinous processes of vertebrae Spine of the scapula Medial end is opposite T 3 Medial border of the scapula

6. The Back Inferior angle of the scapula Iliac crests Supracristal line – intersects L 4 Sacrum – superior to cleft in the buttocks Coccyx – posterior to the anus

7. Surface Anatomy of the Back Figure 11.31a

8. 12-8 Surface Anatomy of the Trunk Scapulae Latissimus dorsi muscle erector spinae muscle infraspinatus muscle trapezius muscle teres major muscle posterior axillary fold triangle of auscutation

10. Muscles of the Back Trapezius Latissimus dorsi Erector spinae

11. Surface Anatomy of the Back Figure 11.31b

12. Anatomy Spinal cord ends below lower border of L1 Cauda equina is below L1 Mid dorsal spinal cord & neural canal space are of same diameter hence prone for complete lesion Mechanical injury - early ischaemia, cord edema - cord necrosis Neurological recovery unpredictable in cauda equina ie. peripheral nerves

13. General Anatomy Lecture

14. Anatomy  Five lumbar vertebrae  Five pairs (10 total) facet joints  Intricate ligamentous support  Anterior & posterior longitudinal  Interspinous & supraspinous

15. Anatomy  Intervertebral disks  Annulus fibrosus  Outer zone (Sharpey’s fibers)  Intermediate zone  Inner zone  20 concentric collar like rings criss- crossed for strength  Nucleus pulposus  Fluid gradually changes to fibrocartilage

17. Spinal Curves Posterior View Sagittal View Primary Secondary

18. Bone Palpation Palpate L4/L5 junction (level of iliac crests) Palpate spinous processes superiorly and inferiorly S2 spinous process at level of posterior superior iliac spine Absence of any sacral and/or lumbar processes suggests spina bifida Visible or palpable step-off indicative of spondylolisthesis

23. ANTERIOR PALPATION

24. Soft Tissue Palpation 4 clinical zones Midline raphe Paraspinal muscles Gluteal muscles Sciatic area Anterior abdominal wall and inguinal area

28. Vertebral arch 7 vertebral processes arise from vertebral arch 3 lever-like processes - provide attachments sites for ligaments and muscles Spinous process 2 Transverse processes 4 articular processes Arise from junction of pedicle and laminae

29. Vertebral Arch Space enclosed by body and vertebral arch is the vertebral foramen Successive vertebral foramen form the vertebral canal

30. Facet Joint Formed by articulation of inferior and superior processes of subsequent vertebrae Orientation in lumbar spine is toward sagittal plane, allowing flexion and extension but limiting rotation of the lumbar vertebrae Helps to prevent anterior movement of superior vertebra on inferior vertebra Articular surfaces are made up of noninnervated articular cartilage Capsule and synovial membrane are innervated with pain receptors

32. Cervical spine anatomy Anterior column - Anterior longitudinal ligament+ Anterior annular ligament and anterior half of VB. Middle column – Posterior long. Lig. + Posterior annular ligament +Posterior half of VB. Posterior Column – Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.

33. Cervical Alignment Anterior vertebral body Posterior vertebral body Spinolaminal line Spinous process tips

34. General Vertebral Anatomy Body Vertebral Arch Pedicles Laminae Vertebral Foramen Spinous Process Facets Superior Articulating Surface Inferior Articulating Surface Transverse Process Intervertebral Foramen

35. Distinguishing Features of Cervical Vertebrae Transverse foramina C1 transverse process Spinous Processes C6 and C7 C3-C6 = bifurcate None for C1 Articulating Facets

36. Atlas 1 st Cervical Vertabrae Lack of Body Superior Articular Foveae Inferior Articulating Foveae Fovea Dentis

37. Axis C2 Dens Rotation between skull and atlas

38. C7 Body Spinous process Transverse Foramina Anterior element

39. Articulations within cervical region Lateral Atlantoaxial Joints Superior facets and inferior facets of atlas Flat and in transverse plane Rotation Side toward rotation Side away from rotation Median Atlantoaxial Joints Dens of axis and anterior arch of atlas Tectorial membrane Cruciform ligament

40. Articulation within cervical spine Atlanto-occipital Occipital condyles of skull and superior articulating surface of atlas Rotation

41. Articulations within cervical spine Body-to-body articulation Fibrocartilogenous Intervertebral Disk Annulos fibrosis Nucleus puplosis

42. Articulations within cervical spine Cervical facet joints Parallel to frontal plane 45 degrees to transverse plane Rotation

43. Ligaments within cervical spine Ligamentum Nuchae Interspinous Ligament Ligamentum Flava Posterior Atlanto- occipital membrane Intertransverse Ligament

44. Curvature of cervical spine Lordotic Curve

45. Cervical spine movement Flexion/Extension Atlanto-occipital Rotation Atlanto-axial joint

46. Brachial Plexus Nerve Roots C5,6,7,8,T1 Trunks Upper Middle Lower Divisions Anterior Posterior Cords Lateral Posterior Medial

47. Throat Anatomy 1. Thyroid gland 2. Trachea 3. Brachiocephalic artery 4. Common carotid artery 5. Internal jugular vein 6. Superior vena cava

48. Thoracic Vertebrae Bodies Pedicles Laminae Spinous Processes Transverse Processes Inferior & Superior Facets Distinguishing Feature Costal Fovea T1 T2-T8 T9-12

49. Thoracic Vertebrae and Rib Junction Functions of Thoracic Spine Costovertebral Joint Costotransverse Joint Motions All available Flexion and extension limited T7-T12

50. Lumbar Spine Bodies Pedicles Laminae Transverse Process Spinous Process Articular Facets

51. Lumbar Spine Thoracolumbar Fascia

52. Lumbar Spine Iliolumbar Ligaments Functions of Lumbar Spine Resistance of anterior translation Resisting Rotation Weight Support Motion

53. Spinal Ligaments Anterior Longitudinal Posterior Longitudinal Ligamentum Flavum Interspinous Ligaments Supraspinous Ligaments Intertransverse Ligaments

55. Intervertebral Disks Ratio between disk thickness and vertebral body height Disk Composition Nucleus pulposis Annulus Fibrosis

58. Vertebral venous plexus

59. Deep Muscles of the Back (Erector Spinae)

60. Iliocostalis Iliocostalis lumborum Iliocostalis Thoracis IliocostalisCervicis

62. Iliocostalis Lumborum O Common tendon origin in sacrum, iliac crest, lumber vertebrae I Lower borders ribs 6-12 N Dorsal rami of spinal nerves F Bilateral Spinal extension Maintenance of erect posture Stabilization of spine during flexion Unilateral Lateral flexion Ipsilateral rotation

63. Iliocostalis Thoracis O Upper borders rib 6-12 I Lower borders ribs 1-6 N Dorsal rami of spinal nerves F Bilateral Same as above Unilateral Same as above

64. Iliocostalis Cervicis O Angles ribs 1-6 I C4-6 transverse processes N Dorsal rami of spinal nerves F Same as above

65. Longissimus Longissimus Thoracis Longissimus Cervicis Longissimus Capitus

66. Longissimus Thoracis O Common tendon origin in sacrum, iliac crest, lumber vertebrae I T1-12 transverse processes N Dorsal rami of spinal nerves F Same as above

67. Longissimus Cervicis O T1-5 transverse processes I C2-6 transverse processes N Dorsal rami of spinal nerves F Same as above

68. Longissimus Capitus O T1-5 transverse processes C5-7 articular processes I Posterior mastoid process N Dorsal rami of spinal nerves F Extends and rotates head

69. Spinalis Spinalis Thoracis Spinalis Cervicis Spinalis Capitus

70. Spinalis Thoracis O Common tendon origin in sacrum, iliac crest, lumber vertebrae I T3-8 spinous processes N Dorsal rami pf spinal nerves F Same as above

71. Spinalis Cervicis O C6-T12 spinous processes I C2 spinous process N Dorsal rami of spinal nerves F Same as above

72. Spinalis Capitis O Spinous processes of lower cervical and upper thoracic I Between superiior and inferior nuchal line on occiput N Dorsal rami of spinal nerves F Same as above

73. Transversospinal Muscles Semispinalis thoracis Semispinalis Cervicis Semispinalis Capitus

74. Semispinalis Thoracis O T6-10 transverse processes I C6 – T4 spinous processes N Sorsal rami of spinal nerves F Same as above

75. Semispinalis Cervicis O T1-T6 spinous processes I C2-5 spinous processes N Dorsal rami of spinal nerves F Same as above

76. Semispinalis Capitis O C4-7 transverse processes T1-7 vertebrae I Between superior and inferior nuchal lines of occiput N Dorsal rami of spinal nerves F Same as above

77. Multifidus O Transverse processes C4-L5 Sacrum PSIS I Spinous process of vert above origin N Spinal nerve roots F Extend and lateral flexion of vertebral column

78. Quadratus Lumborum O Iliolumbar Ligament Iliac crest I Lower border 12 th rib L1-L4 transverse processes N ventral branches of T12 and L1 to L4. F Pelvis elevation Trunk extension Trunk lateral flexion Pulls down rib 12 to fix origin of diaphragm

79. Rotatores O Transverse processes from axis to sacrum I Laminae of vert above N Direct branches over spinal nerve roots F Spine extension Rotation to opposite side

81. Range of Motion Flexion Extension Lateral Bending Rotation

83. Flexion - 80º Extension - 35º Side bending - 40º each side Twisting - 3-18º

85. Neurologic Exam: Sensory  Sensory dermatomes  C2-C3: Occipital area and angle of jaw  C4: Supraclavicular area  Axillary Nerve Patch: Lateral aspect of shoulder  C5: Lateral upper arm  C6: Lateral forearm, thumb, and index finger  C7: Middle finger and palmar aspect of hand  C8: Small finger, ring finger, and medial portion of palmar surface

86. Neurologic Exam: Sensory  Sensory dermatomes  T1: Medial side of forearm and elbow  T2: Medial aspect of upper arm  T3: Medial aspect of upper arm  T10: Umbilicus  L2: Medial mid-thigh  L3: Superior aspect of medial knee (vastus medialis)  L4: Knee and medial arch  L5: Dorsum of the foot  S1: Lateral border and lateral aspect of foot  S2: Popliteal fossa

87. Neurologic Exam: Motor  C1-C2: Neck flexion  C1-C2: Neck extension  C3: Neck lateral flexion  C4: Shoulder elevation  C5: Shoulder abduction and external rotation  C6: Elbow flexion and wrist extension  C7: Elbow extension and wrist flexion  C8: Thumb abduction and ulnar deviation

88. Neurologic Exam: Motor  T1: Finger approximation  L2: Hip flexion  L3: Knee extension  L4: Dorsiflexion  L5: Great toe extension, ankle dorsiflexion, ankle eversion  S1: Plantarflexion  S2: Knee flexion

89. Neurologic Exam: Reflexes  Biceps (C5-C6)  Supinator (C5-C6)  Triceps (C7-C8)  Upper abdominal (T8-T10)  Lower abdominal (T11-T12)  Patella (L3-L4)  Achilles tendon (S1-S2)  Babinski

90. Myotomes

91. Map of Dermatomes – Anterior View Figure 14.17a

92. Map of Dermatomes – Posterior View Figure 14.17b

94. Cervical

96. Read

97. Back Pain

99. Common Sources of LBP Somatic dysfunction Muscle in “spasm” Nerve root In somatic dysfunction, some muscles become overactive (“spasm”) and other muscles become inactive.

100. Joint receptors vasculature viscera Connective tissues Muscles Internal organs Blood vessels Bones and ligaments Joint Receptors Muscle Spindles Nocioceptors Pressure, temperature chemical Humoral Factors circulating hormones (gender-specific response) immune proteins cortisol

102. Disc Diseases

108. Radicular Signs Pain radiation to buttocks – Sciatica Posterior thigh pain Parasthesia – nerve root impringement

110. Lower Spinal conditions

111. Spondylolysthesis

113. Spondylolysis

114. Facet joint pain

116. Spinal injuries Watch video

117. Atlas Fractures

118. Type  Odontoid Treated with external orthrosis

123. Spinal Column Injury Subaxial (C3-C7) # Whiplash injury: Traumatic injury to the soft tissue in the cervical region Hyperflexion, hyperextention No fractures or dislocations Most common automobile injury Recover 3-6 months

124. Hangman’s Fracture