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

• The apex of lumbar lordosis L3-L4

1 2 3 4 5 3. Lumbar Spine Anatomy

Typical lumbar vertebra (L2)

• Body

• Vertebral foramen/canal

• Intervertebral foramen

• Pedicle

• Transverse process

• Lamina

• Spinous process

• Facet joints

• Pars interarticularis

inferior Inferior superior Superior Anterior (oblique) ALateralP Posterior (oblique) Superior 4. Lumbar Spine Anatomy

Ligaments

• Anterior longitudinal ligament

• Posterior longitudinal ligament

• Ligamentum flavum

• Interspinous ligaments

• Supraspinous ligament

• 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

• Aorta

• Vena cava

• Iliac arteries

• Iliac veins

• Midsacral vessels

9. Thoracic Vertebrae

Bodies

Pedicles

Laminae

Spinous Processes

Transverse Processes

Inferior & Superior Facets

Distinguishing Feature

• Costal Fovea

• • T1

• • T2-T8

• • T9-12

10. Thoracic Vertebrae and Rib Junction

Thoracic Spine

• Costovertebral Joint

• Costotransverse Joint

Motions

• All available

• Flexion and extension limited

• 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.

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