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Clinical anatomy of the back
MOB TCD

Clinical Anatomy of the Back
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
MOB TCD

Progress

Time
Goh et al. Clin Biomech 1999;14:439
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Spine
Consists of
• Cervical Vertebrae
• Thoracic Vertebrae
• Lumbar Vertebrae
• Sacrum
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Spine
• 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
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Vertebral Column
• Lot of stress in variety of sports
• Cervical pathology
• Pain may be referred to upper
limb
• Lumber pathology
• Lower limb
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Young Spine

Normal curvature of
infant’s spine

Normal lumbar curve
of toddler’s spine
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Low 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
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Low 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
MOB TCD

Low 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
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Typical 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
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Lumbar Vertebrae
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Lumbar 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
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Lumbar 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
MOB TCD

Lumbar 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
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Typical 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
MOB TCD

The 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
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Pars Interarticularis
• Pars interarticularis
• Portion of lamina between
superior and inferior
articular processes
• Site of spondylolysis or
spondylolisthesis
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Lumbar Spine
• Cancellous bone
• 50% compressive
strength
• Facet joints 20% in
standing upright position
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Lumbar Vertebrae
MOB TCD

Lumbar Vertebrae
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Lumbar Spine
• Cancellous bone
• 50% of the compressive
strength
• Facet joints, 20% of the
strength in the standing
upright position
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Anterior Longitudinal Ligament
• Attached mainly to the bodies
• This ligament helps to prevent us from
leaning too far back (hyperextension)
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Posterior Longitudinal Ligament
• Attached mainly to the
inter vertebral discs
• This ligament helps to
restrict forward bending
(hyperflexion)
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Ligamentum 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
MOB TCD

Ligamentum 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
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Spinal Ligaments
• Interspinous ligaments
• Strong supraspinous ligaments
• The inter-transverse ligaments
join the transverse processes
and are thin and membranous
in the lumbar region
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Fifth 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
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Arthritis of Spine
•
•
•
•

Painful
Limitation of movement
Extra projections
Narrowing of disc spaces
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Vertebral Joints
• Secondary cartilaginous joints
between the bodies
• Hyaline cartilage covering
bodies
• Disc of fibrocartilage in
between
• Synovial plane joints between
the facets
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Intervertebral 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
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Nucleus 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
MOB TCD

Nucleus 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
MOB TCD

Nucleus 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
MOB TCD

Axial Load and End-plates
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End-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
MOB TCD

End-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
MOB TCD

End-plate Susceptibility

Notochord
Schmorl & Junghanns. The human spine in health and disease.
New York: Grune & Stratton, 1965
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Facet 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
MOB TCD

Facet Joints
• Narrowing of disc space,
results in stress on
facet joint
• Highest pressure during
• Combined
• Extension
• Rotation
• Compression
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Facet Joint Syndrome
•
•
•
•
•

Extension and rotation
Pain rising from flexion
Pain worse standing
Lateral shift in extension
Point tenderness over
facet
• Referred leg pain
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Segmental Rotation

Singer et al. J Musculoskel Res 2001;5: 45-55
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Movements 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
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Nerve Supply
•
•
•
•

Nerve supply
Peripheral annulus
Facet joint
Nerve is medial branch
dorsal ramus
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Blood Supply
•
•
•
•
•

Lumbar arteries
Internal venous plexuses
External venous plexuses
Basivertebral veins
Valveless
MOB TCD

Lumbar Vertebrae
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Cancellous Bone
• Cancellous bone
• 50% compressive
strength
• Facet joints 20% in
standing upright position

Normal bone

Osteoporotic bone
MOB TCD

Anatomical Abnormalities
•
•
•
•

Spina Bifida Occulta
Facet Tropism
Kyphosis
Scoliosis
MOB TCD

Anatomical Abnormalities

Kyphosis

Scoliosis
MOB TCD

Anatomical Abnormalities
• Hemi-vertebra
• Spina Bifida
Occulta
• Facet Tropism
• Scoliosis
• Kyphosis
MOB TCD

Anatomical Abnormalities
• Unilateral lumbarisation
• Unilateral sacralisation
MOB TCD

The 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
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Epidemiology

Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837
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Epidemiology
• 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
MOB TCD

Low 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
MOB TCD

Chronic Low Back Pain
•
•
•
•
•
•

Local structures
Muscles
Ligaments
Poor lifting techniques
Joints
Bones
MOB TCD

Back Pain
Local structures
• Muscles, ligaments
• Joints
Referred pain
• Abdominal organs
• Pelvic organs
Must out rule
• Infection
• Tumours
MOB TCD

Acute Low Back Pain
•
•
•
•
•
•

Non-specific low back pain
Usually settles quickly
History
Examination
Pain relief
Stay as active as possible
within limit of pain
MOB TCD

Acute 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
MOB TCD

Investigate 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
MOB TCD

Chronic Low Back Pain
Pain referred
• Abdominal organs
• Pelvic organs
Must out rule
• Infection
• Tumours
MOB TCD

Pain Referred
MOB TCD

Young Athlete
• Junior rugby team 15
years of age
• M. Scheuermann
• 5 Spina bifida occulta
• The scrum half had
degenerative facet joint
changes
MOB TCD

Sacroiliac Joint – Sciatic Nerve
MOB TCD

Spinal Stenosis
• Congenital or acquired
• Abnormally short pedicles or
lamina
• Formation of osteophytes
• Osteo-arthritis of facet joints
• Pain aggravated by walking
• Relieved by rest
MOB TCD

Spinal Stenosis
MOB TCD

Predisposing Factors
•
•
•
•
•
•
•
•

Intrinsic factors
Anatomical abnormalities
Biomechanical
Extrinsic factors
Sport
Surfaces
Equipment
Training
MOB TCD

Predisposing Factors Back Pain
• Poor posture
• Overweight
• Unfit
MOB TCD

Predisposing Factors
• Poor core stability
• Weak abdominal
muscles
• Weak gluteal muscles
• Muscle imbalance
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Predisposing Factors
• Poor core stability
• Weak abdominal
muscles
• Weak gluteal muscles
• Muscle imbalance
• Pronated or cavus feet
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Predisposing Factors
• Badly designed furniture
• No back support
• Poor posture at work
MOB TCD

Acute Low Back Pain
MOB TCD

Annular 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
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Annular Bulge
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Disc Lesion
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Young Athlete
• Junior rugby team 15
years of age
• M. Scheuermann
• 5 Spina bifida occulta
• The scrum half had
degenerative facet joint
changes
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Scheuermann’s Disease

Greene et al. J Pediatr Orthop 1985;5:1
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Spondylolisthesis
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Pars Interarticularis
• Pars interarticularis, portion
of lamina between superior
and inferior articular
processes
• Site of spondylolysis or
spondylolisthesis
MOB TCD

Spondylolisthesis
MOB TCD

Spondylolysis and Spondylolisthesis
MOB TCD

Pars Interarticularis; Facet Joint
MOB TCD

Spondylolisthesis
Rapid Flexion and Extension
•
•
•
•
•
•
•
•

Gymnastics, flips
Vaulting
Ballet, arabesque
Lifting during dance
Diving
Butterfly swimming
Decathlon
Pole vaulting
MOB TCD

Ankylosing Spondylitis, Infection
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 pathology

MOB TCD
MOB TCD

Mechanism of Injuries
• Compression or weight
loading
• Torque or rotation
• Tensile stresses produced
by excessive motion of
spine
• Hyperextension and flexion
Watkins & Dillin, 1985
MOB TCD

Compression or Weight Loading
•
•
•
•
•
•
•

Sports requiring
Massive strength
High body weight
Weight lifter
Hooker and No 8
Wrestling
Line back American football

Watkins & Dillin, 1985
MOB TCD

Weight 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
MOB TCD

Axial Compressive Loading
•
•
•
•
•
•
•

Head on collisions
Motor sports
Boating accidents
Wrestling
Horseback riding
Bicycling
Bobsleigh
MOB TCD

Axial Compressive Loading
MOB TCD

Axial Compressive Loading
MOB TCD

Axial Compressive Loading
MOB TCD

Compression Stress
MOB TCD

Rotational Stress
MOB TCD

Rotational Stress
MOB TCD

Spondylolisthesis
Rapid Flexion and Extension
•
•
•
•
•
•
•
•

Gymnastics, flips
Vaulting
Ballet, arabesque
Lifting during dance
Diving
Butterfly swimming
Decathlon
Pole vaulting
MOB TCD

Australian Football League

Seward & Orchard. 2000 AFL Injury Report, Australian Sports Commission
MOB TCD

Golf
• 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
MOB TCD

Sustained Postures - Hyperextension
MOB TCD

Sustained Postures - Hyperextension
MOB TCD

Sustained Postures - Hyperextension
MOB TCD

Sustained Postures - Flexion
MOB TCD

Scoliosis due to Unilateral Sports
•
•
•
•
•

Racquet sports
Fencing
Sweep rowing
Javelin
Freestyle unilateral
breathing
MOB TCD

Scoliosis due to Unilateral Sports
MOB TCD

Running
•
•
•
•
•
•

Poor posture
Poor abdominal
Pronated feet
Muscle imbalance
Leg length discrepancy
Osteoporosis
MOB TCD

Cricket
• Bowlers
• Rotational forces
• Extension followed by
rotation and flexion
MOB TCD

Thank You
“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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Clinical anatomy of the back

  • 2. MOB TCD Clinical Anatomy of the Back Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
  • 3. MOB TCD Progress Time Goh et al. Clin Biomech 1999;14:439
  • 4. MOB TCD Spine Consists of • Cervical Vertebrae • Thoracic Vertebrae • Lumbar Vertebrae • Sacrum
  • 5. MOB TCD Spine • 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
  • 6. MOB TCD Vertebral Column • Lot of stress in variety of sports • Cervical pathology • Pain may be referred to upper limb • Lumber pathology • Lower limb
  • 7. MOB TCD Young Spine Normal curvature of infant’s spine Normal lumbar curve of toddler’s spine
  • 8. MOB TCD Low 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
  • 9. MOB TCD Low 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
  • 10. MOB TCD Low 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
  • 11. MOB TCD Typical 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
  • 13. MOB TCD Lumbar 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
  • 14. MOB TCD Lumbar 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
  • 15. MOB TCD Lumbar 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
  • 16. MOB TCD Typical 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
  • 17. MOB TCD The 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
  • 18. MOB TCD Pars Interarticularis • Pars interarticularis • Portion of lamina between superior and inferior articular processes • Site of spondylolysis or spondylolisthesis
  • 19. MOB TCD Lumbar Spine • Cancellous bone • 50% compressive strength • Facet joints 20% in standing upright position
  • 22. MOB TCD Lumbar Spine • Cancellous bone • 50% of the compressive strength • Facet joints, 20% of the strength in the standing upright position
  • 23. MOB TCD Anterior Longitudinal Ligament • Attached mainly to the bodies • This ligament helps to prevent us from leaning too far back (hyperextension)
  • 24. MOB TCD Posterior Longitudinal Ligament • Attached mainly to the inter vertebral discs • This ligament helps to restrict forward bending (hyperflexion)
  • 25. MOB TCD Ligamentum 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
  • 26. MOB TCD Ligamentum 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
  • 27. MOB TCD Spinal Ligaments • Interspinous ligaments • Strong supraspinous ligaments • The inter-transverse ligaments join the transverse processes and are thin and membranous in the lumbar region
  • 28. MOB TCD Fifth 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
  • 29. MOB TCD Arthritis of Spine • • • • Painful Limitation of movement Extra projections Narrowing of disc spaces
  • 30. MOB TCD Vertebral Joints • Secondary cartilaginous joints between the bodies • Hyaline cartilage covering bodies • Disc of fibrocartilage in between • Synovial plane joints between the facets
  • 31. MOB TCD Intervertebral 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
  • 32. MOB TCD Nucleus 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
  • 33. MOB TCD Nucleus 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
  • 34. MOB TCD Nucleus 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
  • 35. MOB TCD Axial Load and End-plates
  • 36. MOB TCD End-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
  • 37. MOB TCD End-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
  • 38. MOB TCD End-plate Susceptibility Notochord Schmorl & Junghanns. The human spine in health and disease. New York: Grune & Stratton, 1965
  • 39. MOB TCD Facet 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
  • 40. MOB TCD Facet Joints • Narrowing of disc space, results in stress on facet joint • Highest pressure during • Combined • Extension • Rotation • Compression
  • 41. MOB TCD Facet Joint Syndrome • • • • • Extension and rotation Pain rising from flexion Pain worse standing Lateral shift in extension Point tenderness over facet • Referred leg pain
  • 42. MOB TCD Segmental Rotation Singer et al. J Musculoskel Res 2001;5: 45-55
  • 43. MOB TCD Movements 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
  • 44. MOB TCD Nerve Supply • • • • Nerve supply Peripheral annulus Facet joint Nerve is medial branch dorsal ramus
  • 45. MOB TCD Blood Supply • • • • • Lumbar arteries Internal venous plexuses External venous plexuses Basivertebral veins Valveless
  • 47. MOB TCD Cancellous Bone • Cancellous bone • 50% compressive strength • Facet joints 20% in standing upright position Normal bone Osteoporotic bone
  • 48. MOB TCD Anatomical Abnormalities • • • • Spina Bifida Occulta Facet Tropism Kyphosis Scoliosis
  • 50. MOB TCD Anatomical Abnormalities • Hemi-vertebra • Spina Bifida Occulta • Facet Tropism • Scoliosis • Kyphosis
  • 51. MOB TCD Anatomical Abnormalities • Unilateral lumbarisation • Unilateral sacralisation
  • 52. MOB TCD The 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
  • 53. MOB TCD Epidemiology Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837
  • 54. MOB TCD Epidemiology • 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
  • 55. MOB TCD Low 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
  • 56. MOB TCD Chronic Low Back Pain • • • • • • Local structures Muscles Ligaments Poor lifting techniques Joints Bones
  • 57. MOB TCD Back Pain Local structures • Muscles, ligaments • Joints Referred pain • Abdominal organs • Pelvic organs Must out rule • Infection • Tumours
  • 58. MOB TCD Acute Low Back Pain • • • • • • Non-specific low back pain Usually settles quickly History Examination Pain relief Stay as active as possible within limit of pain
  • 59. MOB TCD Acute 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
  • 60. MOB TCD Investigate 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
  • 61. MOB TCD Chronic Low Back Pain Pain referred • Abdominal organs • Pelvic organs Must out rule • Infection • Tumours
  • 63. MOB TCD Young Athlete • Junior rugby team 15 years of age • M. Scheuermann • 5 Spina bifida occulta • The scrum half had degenerative facet joint changes
  • 64. MOB TCD Sacroiliac Joint – Sciatic Nerve
  • 65. MOB TCD Spinal Stenosis • Congenital or acquired • Abnormally short pedicles or lamina • Formation of osteophytes • Osteo-arthritis of facet joints • Pain aggravated by walking • Relieved by rest
  • 67. MOB TCD Predisposing Factors • • • • • • • • Intrinsic factors Anatomical abnormalities Biomechanical Extrinsic factors Sport Surfaces Equipment Training
  • 68. MOB TCD Predisposing Factors Back Pain • Poor posture • Overweight • Unfit
  • 69. MOB TCD Predisposing Factors • Poor core stability • Weak abdominal muscles • Weak gluteal muscles • Muscle imbalance
  • 70. MOB TCD Predisposing Factors • Poor core stability • Weak abdominal muscles • Weak gluteal muscles • Muscle imbalance • Pronated or cavus feet
  • 71. MOB TCD Predisposing Factors • Badly designed furniture • No back support • Poor posture at work
  • 72. MOB TCD Acute Low Back Pain
  • 73. MOB TCD Annular 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
  • 76. MOB TCD Young Athlete • Junior rugby team 15 years of age • M. Scheuermann • 5 Spina bifida occulta • The scrum half had degenerative facet joint changes
  • 77. MOB TCD Scheuermann’s Disease Greene et al. J Pediatr Orthop 1985;5:1
  • 79. MOB TCD Pars Interarticularis • Pars interarticularis, portion of lamina between superior and inferior articular processes • Site of spondylolysis or spondylolisthesis
  • 81. MOB TCD Spondylolysis and Spondylolisthesis
  • 83. MOB TCD Spondylolisthesis Rapid Flexion and Extension • • • • • • • • Gymnastics, flips Vaulting Ballet, arabesque Lifting during dance Diving Butterfly swimming Decathlon Pole vaulting
  • 85. 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 pathology MOB TCD
  • 86. MOB TCD Mechanism of Injuries • Compression or weight loading • Torque or rotation • Tensile stresses produced by excessive motion of spine • Hyperextension and flexion Watkins & Dillin, 1985
  • 87. MOB TCD Compression or Weight Loading • • • • • • • Sports requiring Massive strength High body weight Weight lifter Hooker and No 8 Wrestling Line back American football Watkins & Dillin, 1985
  • 88. MOB TCD Weight 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
  • 89. MOB TCD Axial Compressive Loading • • • • • • • Head on collisions Motor sports Boating accidents Wrestling Horseback riding Bicycling Bobsleigh
  • 96. MOB TCD Spondylolisthesis Rapid Flexion and Extension • • • • • • • • Gymnastics, flips Vaulting Ballet, arabesque Lifting during dance Diving Butterfly swimming Decathlon Pole vaulting
  • 97. MOB TCD Australian Football League Seward & Orchard. 2000 AFL Injury Report, Australian Sports Commission
  • 98. MOB TCD Golf • 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
  • 99. MOB TCD Sustained Postures - Hyperextension
  • 100. MOB TCD Sustained Postures - Hyperextension
  • 101. MOB TCD Sustained Postures - Hyperextension
  • 103. MOB TCD Scoliosis due to Unilateral Sports • • • • • Racquet sports Fencing Sweep rowing Javelin Freestyle unilateral breathing
  • 104. MOB TCD Scoliosis due to Unilateral Sports
  • 105. MOB TCD Running • • • • • • Poor posture Poor abdominal Pronated feet Muscle imbalance Leg length discrepancy Osteoporosis
  • 106. MOB TCD Cricket • Bowlers • Rotational forces • Extension followed by rotation and flexion
  • 108. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

Hinweis der Redaktion

  1. Cover slide
  2. The late natural history the thoracic kyphosis is for progressive deformation: This deformation occurs within the vertebral bodies in women with a greater contribution from disc degeneration in males.[Goh et al 1999] Those sports that predispose the individual to hyper-kyphosis during the adolescent years and beyond, should be studied to determine the association between the structural deformation and back pain. [[Those of us destined to keyboard activity will identify with the evolutionary trend depicted above]]
  3. As can be seen on the left, the vertebral end-plate is a tenuous cartilaginous membrane which from direct measurement is approximately 0.5mm thick, connected to trabecular bone within the cortical shell. Lesions of the end-plate arising from sporting activities are reported to be frequent. Typical aetiology involves dynamic compressive axial loads, common in landing sports: eg: gymnastics Discal material is extruded through the end-plate into the vertebral body. At the time of injury, the lesion may be painful due to the inflammatory response to the lesion. It has been postulated that such injury predisposes the disc to early degenerative change [Roberts et al, 1997 European Spine Journal 6: 387] The late stage of healing involves sclerosis of bone around the site of injury, demonstrated on the right [arrow] form a CT at T11-12
  4. The notochordal streak, as depicted by Schmorl & Junghanns from their classic text, showing a foetal specimen [left] and the progressive apoptosis of these cells during maturation and differentiation of the disc and vertebral body. Typically, Schmorl’s nodes occur close to this site, suggesting both a functional and genetic predisposition to compressive load failure of the end-plates in some individuals.
  5. In a recent CT study, 42 patients suspected of disc and facet joint pain were rotated within the CT scanner prior to scanning. They were fixed into this position for both right and left side scans which were compared with their neutral [conventional] scan images. Very slight separation of the facet joints occurred at most levels and particularly where the anatomical alignment was mostly coronal [usually the lowest segments]. Joints with a more sagittal alignment, typically the upper lumbar spine, appeared to offer greater resistance to torsion.
  6. Spine injuries can occur through overuse, overload, trauma or a combination of these events. Injuries may occur to any component of the mobile segment: disc, vertebral bodies or facet joints, however disc and end-plate lesions are the most commonly affected.
  7. The reported statistics for back pain according to Cooke & Lutz [2000] are: Lifetime prevalence of back pain in the community = 60-80% Back pain recurrence = 70-90% Progression to chronic back pain = 5-10% Back pain a common feature in most sports, particularly competitive contact sports. Back pain is higher in young athletes compared with age matched controls and, Back pain may occur in response to various conditions of load, fatigue and trauma
  8. The reported statistics for back pain according to Cooke & Lutz [2000] are: Lifetime prevalence of back pain in the community = 60-80% Back pain recurrence = 70-90% Progression to chronic back pain = 5-10% Back pain a common feature in most sports, particularly competitive contact sports. Back pain is higher in young athletes compared with age matched controls and, Back pain may occur in response to various conditions of load, fatigue and trauma
  9. The incidence of end-plate lesions in sport participants varies, however, these may result from pre-existing anatomical abnormalities. In the case of Scheuermann’s disease, there can be multiple end-plate lesions over many segments. According to Sorenson, the characteristics of this disease involve four or more segments with lesions of the end-plates, and corresponding vertebral wedging. Accentuated kyphosis and a painful thoraolumbar spine are the main clinical features.
  10. AFL is a dynamic game that involves various types of play and physical encounters. Injuries are common, predominantly to the knee [ACL], hamstring and groin regions. In a major survey of AFL injuries undertaken by Drs Seward & Orchard, identified a recurrence rate of 32% for injuries to the neck, back, and ribs.
  11. Copyright slide