Dr.

Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Understanding Back
Agrasen Hospital
Gondia
Pain:
Maharashtra
India Basics of Spine
www.agrasenortho.com
drsandeep123@gmail.com
09960122234

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

Spinal Anatomy

Spine three major

components:
!
Spinal column (i.e.,
bones and discs)
neural elements (i.e.,
the spinal cord and
nerve roots)
supporting structures
(i.e., muscles and
ligaments)

2
 OSTEOLOGY
!
33 vertebrae !
23 intervertebral disks!
!
!
!
Primary curves!
Secondary curves

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Sagittal Plane Curves
Cervical Lordosis 20-
40

Thoracic Kyphosis 20- 40

Lumbar Lordosis 30- 50

Sacral Kyphosis
 Functions of the Spine
Protection of
spinal cord and nerve roots
internal organs
 Spinal Nerve Topography

31 pairs of spinal nerves

8 cervical
12 thoracic
5 lumbar
6 sacrococcygeal
 Spinal Nerves
Spinal Epidural
cord space
Dura mater and
Arachnoid layers
Dorsal root
Subarachnoid
space
Dorsal root
ganglion

Ventral Peripheral
root nerve
 Spinal Nerve Structures
Foramen
magnum
Spinal Cord

Extends from foramen magnum to

L1
Terminates at the Conus
conus medularis
medularis
The cauda equina begins Cauda
below L1
equina
Filum terminale extends from
conus medularis to the coccyx

Beyond L1 the spinal cord becomes the Cauda Equina

 Beyond L1 the spinal cord becomes the Cauda Equina
 Batsons Plexus
Because of the azygos Batsons
system, patient positioning is plexus
very important in posterior
lumbar spine surgery.
Patients abdomen should
always hang free and without
abdominal pressure. An increase
in pressure will diminish flow
through the azygos system and
the vena cava. This results in an
increase of venous flow into
Batsons plexus with a
corresponding increase of blood
loss.

Azygos system also communicates with a valveless venous

network known as BATSONS PLEXUS. When the vena cava is
partially or totally occluded, Batsons plexus provides an
alternate route for blood return to the heart.
 Autonomic Nervous System

SYMPATHETIC NERVOUS SYSTEM:

!
Injury to the sympathetic nerve chain in the
lumbar spine may result in genitourinary
problems for the patient.
!
!
Each sympathetic ganglion has fibers that
join to the adjacent spinal nerve.
!
!
!
PARASYMPATHETIC NERVOUS SYSTEM has
ganglia located close to the organs they control.

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Functions of the Spine

Flexibility of motion in six degrees of freedom

Flexion and Extension Left and Right Left and Right Rotation
Side Bending
 Functions of the Spine
Structural support and
balance for upright posture
The spine is the axle bearing the
load of the head, shoulders and
thorax. The upper body weight is
then distributed to the lower
extremities through the sacrum and
pelvis.
This reduces the amount of work
required by the spinal muscles and
can eliminate muscle fatigue and
back pain.
 Line of gravity
Auricle of the
ear
Odontoid
Body of C7

Anterior to thoracic
spine

Posterior to L3

Mid femoral heads

Intervertebral Disks:
!
Collagen fibers of anulus fibrosus are
arranged in sheets: lamellae
Concentric rings surrounding nucleus

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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 No discs between the Atlas (C1), Axis (C2), sacrum
and Coccyx.
Discs are not vascular and therefore depend on the
end plates to diffuse needed nutrients
! ARTICULATIONS
!
1. Interbody Joints!
Capable of translations and tilts in all directions!
!
!
!
!
!
! 18

2. Zygapophyseal articulation!
True synovial joints!
Fibroadipose meniscoid structures

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Vertebral Structures
Superior
Pars Articular
Process

Zygapophyseal
Inferior
Joint
Articular
(Facet Joint) Process
 Basic Vertebral Structures

Cervical Thoracic Lumbar

MRI
 The Atlas (C1)
Anterior
Articular Facet
Tubercle
for Dens
Transverse
Process
Superior
Articular
Facet

Transverse Lateral Mass

Foramen

Posterior Lamina
Tubercle
Superior View
 The Axis (C2)
Lateral
Body Odontoid Mass
Process
(Dens)

Superior
Articular
Facet

Inferior
Articular Spinous
Transverse
Facet Process
Process
Anterior View Posterior View
 Lower Cervical Vertebrae
C3 - C7

Sulcus for Transverse

Body Process
Spinal Nerve
Transverse
Foramen
Pedicle

Superior
Lateral Articular Facet
Mass

Vertebral
Lamina Foramen

Axial View Bifid Spinous Process

 Thoracic Vertebrae, T1-T12
Body - heart shaped when
viewed superiorly.

Vertebral foramen - round

Pedicles - small in diameter

Spinous processes - long

and projected downwards
 Lumbar Vertebrae, L1-L5
Body - L1 to L5 progressive
increase in mass
Pedicles - longer and wider than
thoracic; oval shaped
Spinous processes - horizontal,
square shaped
Transverse processes - smaller
than in thoracic region
Intervertebral foramen - large,
but with increased incidence of
nerve root compression
 The Sacrum

Inverted triangle shape Sacral Horns

Sacral Ala
Dorsal
Pedicles
Foramina

Sacral
Hiatus
Coccyx
Posterior View
 The Sacrum
Sacral Tilt
30-60

Sacral 1
Promontory 2

Sacral Canal 3
Sacral Hiatus
4
5

Coccyx
Lateral View
!
Lumbosacral articulation:!
5th lumbar vertebra and 1st sacral segment. !
1st sacral segment is inclined slightly anteriorly and
inferiorly, forms an angle with horizontal: lumbosacral
angle

35

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Increase in angle : increase in lumbar lordosis !
Increase shearing stress at lumbosacral joint

36

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Anterior longitudinal ligament
is strong and well developed in
this region
!
!
Posterior Longitudinal Ligament
is only a thin ribbon in lumbar
region, whereas ligamentum flavum
is thickened here
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Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Flexion generates compression forces on
anterior side of disc tending to migrate nucleus
pulposus posteriorly!
!
!
!
!
!
!
!
39

Limited by tension in posterior annulus fibrosus and

posterior ligament system

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Lumbar Extension:
Increase in lumbar lordosis!

Posterior tilting , gliding of superior vertebra!

Lumbar extension reduces the diameter of !

intervertebral foramina

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Fewer ligaments checks extension!
!
During lumbar extension nucleus pulposus displaces
anteriorly

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

!
Lumbo-pelvic rhythm:!
!
The kinematic relationship between!
lumbar spine !
and !
hip joints !
during sagittal plane movements

42

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Bending forward- lumbar flexion (40) followed by !
anterior tilting of pelvis at hip joint (70)!
!
Return to erect- posterior tilting at pelvis at hips
followed !
by extension of lumbar spine

43

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

!
PARS INTERARTICULARIS FRACTURES:!
Region between superior and inferior articular facets!
Weakest bony portion of vertebral neural arch

44

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Spondylolysis Spondylolisthesis

45

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Common at L5-S1 and L4-L5

46

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

INTERVERTEBRAL DISC PROLAPSE:!
Common site: L4-L5 & C5-C6!

47

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 LUMBAR CANAL STENOSIS:!
Narrowing of lumbar canal!
Congenital OR Acquired

48

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 'Red Flags' in the Medical History: Potentially Serious Conditions That May Present as Low Back Pain

'Red Flags' in the Medical History:

Potentially Serious Conditions That
May Present as Low Back Pain
Fracture
Major trauma (motor vehicle accident, fall from height)
Minor trauma or strenuous lifting in an older or osteoporotic
patient
Tumor or infection
Age >50 years or <20 years
History of cancer
Constitutional symptoms (fever, chills, unexplained weight
loss)
Recent bacterial infection
Intravenous drug use
Immunosuppression (corticosteroid use, transplant
recipient, HIV infection)
Pain worse at night or in the supine position
Cauda equina syndrome
Saddle anesthesia
Recent onset of bladder dysfunction
Severe or progressive neurologic deficit in lower extremity

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

Lumbar Puncture

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Epidural anesthesia

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

 Humor And Laughter Are Important!
!

Humor in our daily lives is an essential

ingredient!
of happiness. So, learn to look on the funny!
side of things. Even serious situations.

Have you had a good laugh today? !

If you haven't, then please do - don't!
let the day go to waste! Laughter
52 !
melts the distances between people.

THANK YOU
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There is only one difference between

Dream & Aim.
Dreamsrequire effortless Sleep &
Aim(Ambition In Mind) requires
sleepless efforts.
Sleep for Dreams & Wake up for
Aims.