orthopedics 5th year, 3rd lecture (dr. hamid)
DESCRIPTION
The lecture has been given on May 11th, 2011 by Dr. Hamid.TRANSCRIPT
- 1. Thoracic and Lumbar Spine Anatomy
2. Lumbar Anatomy
- 5 vertebrae L1-L5
- 5 intervertebral discs
- 5 pair of exiting nerve roots
- Lumbar lordosis L1-S1 ranges from 3080
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- The apex of lumbar lordosis L3-L4
1 2 3 4 5 3. Lumbar Spine Anatomy
- Typical lumbar vertebra (L2)
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- Body
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- Vertebral foramen/canal
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- Intervertebral foramen
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- Pedicle
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- Transverse process
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- Lamina
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- Spinous process
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- Facet joints
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- Pars interarticularis
inferior Inferior superior Superior Anterior (oblique) ALateralP Posterior (oblique) Superior 4. Lumbar Spine Anatomy
- Ligaments
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- Anterior longitudinal ligament
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- Posterior longitudinal ligament
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- Ligamentum flavum
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- Interspinous ligaments
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- Supraspinous ligament
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- Intertransverse ligaments
1 3 4 5 6 2 5. Lumbar Spine Anatomy:Nerve Structures
- The spinal cord and nerve roots are often affected by skeletal problems
- Discs and bony tissue can interfere with normal nerve function and cause pain
6. Lumbar Spine Anatomy:Nerve Structures
- Conus medularis
- The point at which the thick, single strand of the spinal cord ends
- Typically at T12 or L1
Note: in this illustration, the posterior elements of the spine, along with the dura mater and arachnoid mater, are not shown. 7. Lumbar Spine Anatomy:Nerve Structures
- Cauda equina
- The point at which individual nerve roots continue down through the spinal canal
Note: in this illustration, the posterior elements of the spine, along with the dura mater and arachnoid mater, are not shown. 8. Lumbar Spine Anatomy:Vascular Structures
- The aorta and vena cava bifurcate around the level of the L3/L4 disc space
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- Aorta
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- Vena cava
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- Iliac arteries
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- Iliac veins
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- Midsacral vessels
9. Thoracic Vertebrae
- Bodies
- Pedicles
- Laminae
- Spinous Processes
- Transverse Processes
- Inferior & Superior Facets
- Distinguishing Feature
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- Costal Fovea
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- T1
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- T2-T8
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- T9-12
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10. Thoracic Vertebrae and Rib Junction
- Thoracic Spine
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- Costovertebral Joint
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- Costotransverse Joint
- Motions
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- All available
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- Flexion and extension limited
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- T7-T12
11. Spinal deformities 12. Introduction :
- Spinal deformities
- Coronal plane : scoliosis
- Sagittal plane : hyperkyphosis or hyperlordosis.
- Scoliosis :
- diff ;
- types :
13. 1-postural scoliosis :
- Short leg
- Pelvic tilt
- Local muscle spasm:sciatic scoliosis.
14. 15. 2-Structural scoliosis :
- bony abn.vertebral rotation
- fixed.
- Secondary curve.
- deformity is liable to increase .
- thoracic region -rib hump .
16. 17. 18. 19. 20. Types of structural scoliosis :
- Idiopathic scoliosis most common.
- Congenital or osteopathic bony anomalies.
- Neuropathic.
- Myopathic (ass. Muscular dystrophies).
- Miscellaneous
- ,degenerative.
21. Clinical features :
- Hx
- Deformity : .
- Backache :.
- Ask about family hx.
- abn. during pregnancy or child birth.
22. Examination:
- Spine -deviated from midline.
- forward bending makes the curve more obvious.
- Level and direction of the major curve
- Hip , scapula,forward,lateral bending,side on posture.
- rib hump on the convex side of the curve.
- Occipitis over the midline
- Neurological exam.
- Leg length
- General exam. cardiac and pulmonary functions .
23. Imaging:
- Plain X-ray, full erectPA .lat.spine iliac
- Oblique views.
- Cobbs angle .
- Skeletal maturity - Rissers sign
- CT,MRI,
- Pulmaonary function,biochemical test
24. 25. Cobbs angle 26. 27. Rissers sign 28. 29. Idiopathic scoliosis :
- About 80% of all cases of scoliosis,.
- Divided into 3 groups :
- adolescent ,
- juvenile,
- infantile.
30. 1-adolescent idiopathic scoliosis :
- age .
- gender ,
- type ,classification-king
- Progression-pridictors
31. 32. Rx. :
- Aims of Rx. .
- Non-operative Rx
- ==Exercise
- ==Bracing
- Milwaukee brace .
- Boston brace .
33. 34. Rx. :
- Operative Rx.indications
- ==Objectives of operative Rx.
- ----Fixation types
35. 36. 37. 38. Complications :
- Surgicalearly,late
- non surgical
39. Main Surgical Indications
- RelentlessCurve Progression
- Major CurveProgression in spite of bracing
- Inability to wean the patient from the brace
- Significant thoracic and lumbarPAIN
- Progressive thoracic lordosis
- Progressiveloss of pulmonary function
- Emotional/psychological pressures
- Severecosmetic changesin the shoulders and trunk
40. 2- juvenile idiopathic scoliosis :
- Present at age 4-9 years.
- Uncommon .
- Has similar charac.To those of the adolescent type but worse prognosis.
- Surgical correction may be needed before puberty or bracing until the age of 10 if the child is very young.
41. 3- infantile idiopathic scoliosis :
- Presenting under 3 years of age .
- Rare
- Males are more affected & most curves are left thoracic.
- 90% of infantile curves resolve spontaneously but progressive curves can become very severe & carry a high incidence of cardiopulmonary dysfunction.
42. 43. Osteopathic congenital scoliosis :
- The commonest bony cause is vertebral anomalies : hemivertebra , wedge vertebra, fused vertebra & absent or fused rib .
- Overlying tissue often show angioms ,naevi ,excess hair ,dimples or a pad of fat and spina bifida .
- Fractures and bone softening may lead to scoliosis as in rickets and osteogenesis imperfecta .
- Usually mild but some cases progress into severe deformities.
- Rx. Is more difficult & specialized than that of idiopathic infantile scoliosis & surgical correction carry significant risk of cord injury.
44. 45. 46. Neuropathic & myopathic scoliosis :
- Causes include :
- Poliomyelitis
- Cerebral palsy
- Syringomyelia
- Muscle dystrophies.
47. Neuromuscular Deformity
- Poliomyelitis :Lower Motor Neuron Disease which depends on the muscle groups most severely involved and on the overpull created by unopposed muscle groups on the opposite side.
- Cerebral Palsy:Upper Motor Neuron Disease which causes muscle imbalance.
- Myopathic Forms:Muscular Dystrophies
48. 49. Neuropathic & myopathic scoliosis :
- Rx. :
- Mild curves : no Rx.
- Moderate curves : - idiopathic scoliosis.
- Severe curves -, operative Rx, is indicated.
50.
- Neuromuscular scoliosis-severe scoliosis secondary to quadriplegic cerebral palsy .
51. Neurofibromatosis
- Causes severekyphosis and scoliosis
- Result of severevertebral body distortions.
- Can lead toparaparesis and parapalegia
- Should be treated aggressively with bothanterior and posterior fusion .
52. Post op. 53. 54. 55. 56. Kyphosis: 57. Kyphosis :
- Postural kyphosis .
- Structural kyphosis :
- A kyphos or gibbus .
58. 59. 60. 61. 62. Thorax kyphosis 63. Types of kyphosis :
- Childhood-Congenital TB,dysplsia.
- Adolescent kyphosis (Sheuermanns dis. )
- Adult-trauma,TB-AS
- Kyphosis in the elderly-degenerative and osteoporosis.
64. Congenital kyphosis :
- Failure of formation type1.comon,worsecord compression,--6y.40
- Failure of segmentation type 2 .
- Combination of both .
65. Failure of segmentation. Left: block vertebra. Right: unilateral unsegmented bar . 66. Adolescent kyphosis (Sheuermanns disease) :
- With increasing growth and muscular activity , affected vertebrae in thoracic spine may give way slightly and become wedge shaped and the normal kyphosis is exaggerated .
- In the lumbar spine forces are more evenly distributed and deformity does not occur.
67. Clinical features :
- age.
- gender.
- Cl/p
- deformity :
- backache and fatigue.
68. Examination :
- Smooth thoracic kyphosis- marked hump.
- Below it -lumber lordosis.
- Deformity.not correctable-changes posture
- Mild scoliosis is not uncommon.
69. Rare complications include :
- Spastic paresis of the lower limb.
- Cardiopulmonary dysfunction in severe thoracic deformity .
- pt. with thoracic kyphosis may develop lumbar backache.
70. X-rays :
- Lat.view-end platesT6-T10 irregular .
- body may become wedge shaped.
- Schmorls node.
- Angle of deformity is measured as scolios.
- Overall kyphosis angle >40 is abnormal.
- Mild scoliosis is common
71. Lateral X-ray 72. Preoperative lateral of a patient with an 85 thoracic deformity secondary to Scheuermann kyphosis . 73. Postoperative lateral 74. (Sheuermanns disease) : 75. Kyphosis measure : 76. DDx. :
- Postural kyphosis :
- Discitis , osteomyelitis, &TB spondylitis:
- Spondyloepiphyseal dysplasia:
77. Out come :
- The condition is often quite painful during adolescence & symptoms subside after a few years .
- There may be a recurrent backache in later life but the condition is rarely disabling.
78. Rx. :
- Back straightening exercises r indicated if curves < 40 degrees .
- Bracing is indicated if curves 40-60 degrees in a child who still has some years of growth ahead .
- Operative Rx. Is indicated for curves >60 degrees.
79. Kyphosis in elderly
- A-degenerative
- B-osteoporosis
- -post menopausal
- -senile
80. 81. 82.
- Thank you