1. MOB TCDClinical Anatomy of the Back Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

2. MOB TCDProgressTime Goh et al. Clin Biomech 1999;14:439 3. MOB TCDSpine Consists of Cervical Vertebrae Thoracic Vertebrae Lumbar Vertebrae Sacrum 4. MOB TCDSpine 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 5. MOB TCDVertebral Column Lot of stress in variety of sports Cervical pathology Pain may be referred to upper limb Lumber pathology Lower limb 6. MOB TCDYoung SpineNormal curvature of infants spineNormal lumbar curve of toddlers spine 7. MOB TCDLow 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 8. MOB TCDLow Back Pain in Sports 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 9. MOB TCDLow 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 10. MOB TCDTypical 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 11. MOB TCDLumbar Vertebrae 12. MOB TCDLumbar 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 13. MOB TCDLumbar 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 14. MOB TCDLumbar Vertebrae 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 15. MOB TCDTypical 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 16. MOB TCDThe 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 17. MOB TCDPars Interarticularis Pars interarticularis Portion of lamina between superior and inferior articular processes Site of spondylolysis or spondylolisthesis 18. MOB TCDLumbar Spine Cancellous bone 50% compressive strength Facet joints 20% in standing upright position 19. MOB TCDLumbar Vertebrae 20. MOB TCDLumbar Vertebrae 21. MOB TCDLumbar Spine Cancellous bone 50% of the compressive strength Facet joints, 20% of the strength in the standing upright position 22. MOB TCDAnterior Longitudinal Ligament Attached mainly to the bodies This ligament helps to prevent us from leaning too far back (hyperextension) 23. MOB TCDPosterior Longitudinal Ligament Attached mainly to the inter vertebral discs This ligament helps to restrict forward bending (hyperflexion) 24. MOB TCDLigamentum 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 25. MOB TCDLigamentum Flava 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 26. MOB TCDSpinal Ligaments Interspinous ligaments Strong supraspinous ligaments The inter-transverse ligaments join the transverse processes and are thin and membranous in the lumbar region 27. MOB TCDFifth 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 28. MOB TCDArthritis of Spine Painful Limitation of movement Extra projections Narrowing of disc spaces 29. MOB TCDVertebral Joints Secondary cartilaginous joints between the bodies Hyaline cartilage covering bodies Disc of fibrocartilage in between Synovial plane joints between the facets 30. MOB TCDIntervertebral 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 31. MOB TCDNucleus 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 32. MOB TCDNucleus 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 33. MOB TCDNucleus 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 plate fracture and not to rupture of the annulus End plate failure is a possible precursor of disc degeneration 34. MOB TCDAxial Load and End-plates 35. MOB TCDEnd-plate Mechanics Functionally, the vertebral end-plate displays characteristics of a trampoline With the sub-end-plate trabecular bone acting as springs to sustain and 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 36. MOB TCDEnd-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 37. MOB TCDEnd-plate SusceptibilityNotochord Schmorl & Junghanns. The human spine in health and disease. New York: Grune & Stratton, 1965 38. MOB TCDFacet 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 39. MOB TCDFacet Joints Narrowing of disc space, results in stress on facet joint Highest pressure during Combined Extension Rotation Compression 40. MOB TCDFacet Joint Syndrome Extension and rotation Pain rising from flexion Pain worse standing Lateral shift in extension Point tenderness over facet Referred leg pain 41. MOB TCDSegmental RotationSinger et al. J Musculoskel Res 2001;5: 45-55 42. MOB TCDMovements of Lumbar Spine Flexion limited by disc problems Lateral flexion Extension limited by facet joint problems Very little rotation Extension and rotation affect facet joints 43. MOB TCDNerve Supply Nerve supply Peripheral annulus Facet joint Nerve is medial branch dorsal ramus 44. MOB TCDBlood Supply Lumbar arteries Internal venous plexuses External venous plexuses Basivertebral veins Valveless 45. MOB TCDLumbar Vertebrae 46. MOB TCDCancellous Bone Cancellous bone 50% compressive strength Facet joints 20% in standing upright positionNormal boneOsteoporotic bone 47. MOB TCDAnatomical Abnormalities Spina Bifida Occulta Facet Tropism Kyphosis Scoliosis 48. MOB TCDAnatomical AbnormalitiesKyphosisScoliosis 49. MOB TCDAnatomical Abnormalities Hemi-vertebra Spina Bifida Occulta Facet Tropism Scoliosis Kyphosis 50. MOB TCDAnatomical Abnormalities Unilateral lumbarisation Unilateral sacralisation 51. MOB TCDThe 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 52. MOB TCDEpidemiologyCooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837 53. MOB TCDEpidemiology Back pain in the community is 60% - 80% Recurrence of back pain is 70% - 90% Progression to chronic back pain is 5% - 10%Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837-65 54. MOB TCDLow 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 55. MOB TCDChronic Low Back Pain Local structures Muscles Ligaments Poor lifting techniques Joints Bones 56. MOB TCDBack Pain Local structures Muscles, ligaments Joints Referred pain Abdominal organs Pelvic organs Must out rule Infection Tumours 57. MOB TCDAcute Low Back Pain Non-specific low back pain Usually settles quickly History Examination Pain relief Stay as active as possible within limit of pain 58. MOB TCDAcute 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 59. MOB TCDInvestigate 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 60. MOB TCDChronic Low Back Pain Pain referred Abdominal organs Pelvic organs Must out rule Infection Tumours 61. MOB TCDPain Referred 62. MOB TCDYoung Athlete Junior rugby team 15 years of age M. Scheuermann 5 Spina bifida occulta The scrum half had degenerative facet joint changes 63. MOB TCDSacroiliac Joint Sciatic Nerve 64. MOB TCDSpinal Stenosis Congenital or acquired Abnormally short pedicles or lamina Formation of osteophytes Osteo-arthritis of facet joints Pain aggravated by walking Relieved by rest 65. MOB TCDSpinal Stenosis 66. MOB TCDPredisposing Factors Intrinsic factors Anatomical abnormalities Biomechanical Extrinsic factors Sport Surfaces Equipment Training 67. MOB TCDPredisposing Factors Back Pain Poor posture Overweight Unfit 68. MOB TCDPredisposing Factors Poor core stability Weak abdominal muscles Weak gluteal muscles Muscle imbalance 69. MOB TCDPredisposing Factors Poor core stability Weak abdominal muscles Weak gluteal muscles Muscle imbalance Pronated or cavus feet 70. MOB TCDPredisposing Factors Badly designed furniture No back support Poor posture at work 71. MOB TCDAcute Low Back Pain 72. MOB TCDAnnular 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 73. MOB TCDAnnular Bulge 74. MOB TCDDisc Lesion 75. MOB TCDYoung Athlete Junior rugby team 15 years of age M. Scheuermann 5 Spina bifida occulta The scrum half had degenerative facet joint changes 76. MOB TCDScheuermanns DiseaseGreene et al. J Pediatr Orthop 1985;5:1 77. MOB TCDSpondylolisthesis 78. MOB TCDPars Interarticularis Pars interarticularis, portion of lamina between superior and inferior articular processes Site of spondylolysis or spondylolisthesis 79. MOB TCDSpondylolisthesis 80. MOB TCDSpondylolysis and Spondylolisthesis 81. MOB TCDPars Interarticularis; Facet Joint 82. MOB TCDSpondylolisthesis Rapid Flexion and Extension Gymnastics, flips Vaulting Ballet, arabesque Lifting during dance Diving Butterfly swimming Decathlon Pole vaulting 83. MOB TCDAnkylosing Spondylitis, Infection 84. 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 pathologyMOB TCD 85. MOB TCDMechanism of Injuries Compression or weight loading Torque or rotation Tensile stresses produced by excessive motion of spine Hyperextension and flexion Watkins & Dillin, 1985 86. MOB TCDCompression or Weight Loading Sports requiring Massive strength High body weight Weight lifter Hooker and No 8 Wrestling Line back American footballWatkins & Dillin, 1985 87. MOB TCDWeight 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 88. MOB TCDAxial Compressive Loading Head on collisions Motor sports Boating accidents Wrestling Horseback riding Bicycling Bobsleigh 89. MOB TCDAxial Compressive Loading 90. MOB TCDAxial Compressive Loading 91. MOB TCDAxial Compressive Loading 92. MOB TCDCompression Stress 93. MOB TCDRotational Stress 94. MOB TCDRotational Stress 95. MOB TCDSpondylolisthesis Rapid Flexion and Extension Gymnastics, flips Vaulting Ballet, arabesque Lifting during dance Diving Butterfly swimming Decathlon Pole vaulting 96. MOB TCDAustralian Football LeagueSeward & Orchard. 2000 AFL Injury Report, Australian Sports Commission 97. MOB TCDGolf 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 98. MOB TCDSustained Postures - Hyperextension 99. MOB TCDSustained Postures - Hyperextension 100. MOB TCDSustained Postures - Hyperextension 101. MOB TCDSustained Postures - Flexion 102. MOB TCDScoliosis due to Unilateral Sports Racquet sports Fencing Sweep rowing Javelin Freestyle unilateral breathing 103. MOB TCDScoliosis due to Unilateral Sports 104. MOB TCDRunning Poor posture Poor abdominal Pronated feet Muscle imbalance Leg length discrepancy Osteoporosis 105. MOB TCDCricket Bowlers Rotational forces Extension followed by rotation and flexion 106. MOB TCDThank You 107. BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.