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Cervical Spine
Seven vertebrae
C 1-7

More flexible Supports the head Wide range of motion

Rotation to left and right Flexion
Up and down

Peripheral nerves
Arms Shoulder, Chest and diaphragm


cervical region differfrom the thoracic and lumbar regions in that the cervical region bears less weight and is generally more mobile


No disks are present at either the atlantooccipital or atlantoaxial articulations; therefore, the weight of the head (compressive load) must be transferred directly through the atlanto-occipital joint to the articular facets of the axis


CLOSED PACK position Neutral or slightly extended position of the cervical region

Cervical Spine Arthrokinematics

Flexion and Extension
Atlanto-occipital joint

Occipital condyles

Roll forward Slide backward

roll backward Slide forward

Alar ligament limit the extent of arthrokinematics


Cervical Spine Arthrokinematics

Full rotation of the craniocervical =65 to 75 degrees Half of the axial rotation of the craniocervical region occurs in the atlantooccipital joint

Cervical Spine Arthrokinematics

AXIAL Rotation
Atlanto-axial joint
Designed for maximal rotation within the horizontal planne Articular facet of the atlas slide in a curved path of the articular facet of the axis Axis of rotation for the head and atlas provided by the dens Limited by contralaterally located alar ligament, aphophyseal joints

Cervical Spine Arthrokinematics

AXIAL Rotation
Intracervical aticulation
Rotation throughout C2 to C7 guided primarily by the onrientation of the facet process within apophyseal joint

Inferior facet slide posteriorly and inferiorly same sode of rotation Inferior facet anteriorly and slightly superiorly on the opposite side Rotation is greatest in the more cranial vertebral segment

Cervical Spine

Cervical Spine Arthrokinematics

SPINAL COUPLING between lateral flexion and axial rotation 45 degree of inclination of the articular facets of C2 to C7 Lateral flexion and axial rotation in the mid and low cervical region are mechanically coupled in an ipsilateral fashion

THORACIC REGION typical thoracic vertebra T2 - T9 vertebral canal narrower transverse process has the costal facet to accommodate the tubercle of the rib heads of ribs 2-9 articulate with a pair of demifacets at intervertebral junctions (costocorporeal joints) atypical thoracic vertebra (T1, T10 , T11, and T12) T10 , T11, and T12 - atypical because of the rib attachment T1 has a full costal facet

costovertebral joint - articulation between the head of a typical rib with a pair of costal facets and the adjacent margin of an intervertebral disc Costotransverse joint- articulation between the articular tubercle of a typical rib to the costal facet on the transverse process of a corresponding vertebra. Ribs 11 and 12 lack costotransverse joints.

Thoracic vertebra are well stabilized by the ribs and costovertebral and costotransverse joints.

The arthrokinematics at the apophyseal joints in the thoracic spine are generally similar to those described for C2-C7. Flexion between T5-T6 occurs by a superior and slightly anterior sliding of the inferior facets of T5 on the superior facet surfaces of T6. Extension occurs by a reverse process.

The freedom of axial rotation decreases in the thoracic spine in a cranial to caudal direction. In the mid to lower thoracic vertebra , the apophyseal joints tend to block horizontal rotation. Lateral flexion is 25 degrees - Lateral flexion of T6 on T7 occurs as the inferior facet of T6 slides superiorly on the side contralateral to the flexion and inferiorly on the side ipsilateral to the lateral flexion. Ribs drop slightly on the side of lateral flexion and rise slightly on the contralateral side.

Coupling is most evident in the upper thoracic spine where the articular facets possess a closer orientation to those in the lower cervical region. The influence of the coupling decreases and is inconsistent in the middle and lower thoracic regions.

LUMBAR REGION have massive wide bodies laminae and pedicles are short and thick transverse processes project almost laterally short mammillary processes project from the posterior surfaces of each superior articular process (for attachment of mulifidi muscles) articular facets are near sagittal

SACRUM - triangular bone during adulthood fused into one COCCYX small triangular bone consisting of four fused vertebrae base of coccyx joins the apex of the sacrum at the sacrococygeal joint

typical intervertebral junction has 3 components: 1. the transverse and spinous processes 2. apophyseal joints 3. an interbody joint the spinous process and transverse process increase the mechanical leverage of muscles and ligaments

apophyseal joints or zygapophyseal joints responsible for guiding intervertebral motion

interbody joints connect an intervertebral disc with a pair of vertebral bodies

intervertebral discs - 25% of the total height of the vertebral column

the vertebral column has 24 pairs of apophyseal joints (plane joints)

horizontal facet surfaces favor axial rotation, whereas vertical facet surfaces block axial rotation

LUMBAR INTERVERTEBRAL DISCS consists of a central nucleus pulposus and and annular fibrosus nucleus pulposus is a pulplike gel located in the mid to posterior part of the disc in youth the nucleus pulposus within the lumbar discs consists of 70-90% water allwoing shock absorption capable of dissipating loads across vertebrae

nucleus pulposus is thickened into a gel by proteoglycans each proteoglycan is an aggregate of many water-binding glycosaminoglycans linked to core proteins. interspersed throughout the proteoglycans are type II collagen, elastin fibers and other proteins. The collagen helps support the proteoglycan network

annulus fibrosus - consists of 15-25 concentric layers or rings of collagen fibers in the annulus, collagen makes up about 50-60% of the dry weight compared to 1520% in the nucleus pulposus. outermost layers of the annulus fibrosus consists of type I and type II collagen in contrast to lumbar region, the annulus fibrosus in the cervical region does not have complete cervical rings that surround the nucleus

vertebral endplates - thin cartilaginous caps of connective tissue that cover the superior and inferior surfaces of the vertebral bodies

at birth, endplates are very thick accounting for 50% of the height of each intervertebral space, in the adult 5%
IV disc as a hydrostatic pressure distributor shock absorbers

- function as growth plates for the vertebra

Biomechanics responsible for the shear forces at L5S1 and L3-L4

Motions of the spinal column. (A) Flexion/extension (forward/backward bending). (B) Lateral flexion (side bending). (C) Rotation. (D) Anterior/posterior shear. (E) Lateral shear. (F) Distraction/compression.

Source: Therapeutic Exercise : Foundations and Techniques by Carolyn Kisner and Lynn Allen Colby (2007)

Herniated discs and nerve root impingements are relatively uncommon in the thoracic spine. This may be due to the low intervertebral mobility and high stability by the rib cage.

Thoracic postural abnormalities are commonprone to the effects of gravity and torsion. The two most common are kyphosis and scoliosis. About 42 degrees of natural kyphosis is present while standing.

Scheuermann disease (juvenile kyphosis) and osteoporosis are the 2 most common conditions associated with kyphosis. Scheuermann disease (juvenile kyphosis) - a hereditary condition that starts in adolescence, of unknown etiology. - characterized by wedging of the anterior side of the vertebral bodies

Osteoporosis of the spine - often associated with excessive thoracic kyphosis in the elderly. Compression fractures in osteoporotic thoracic vertebra eventually lead to reduced height in the vertebral bodies. ideal spinal posture- the line-of-force due to body weight falls slightly to the concave side of the apex of the normal cervical and thoracic curvatures.

Vertebra weakened from osteoporosis and dehydrated intervertebral discs may be unable to resist the anterior compression forces. Over time, the compression forces reduce the height of the anterior side of the interbody joint, causing more kyphosis.

SCOLIOSIS- curvature deformity of the vertebral column characterized by abnormal curvature in all three planes, most notably in the frontal and horizontal. affects the thoracic spine more structural or functional -

Functional scoliosis - can be corrected by an active shift in posture, whereas structural scoliosis is a fixed deformity that cannot be corrected fully by an active shift in posture. 90% are idiopathic - no apparent cause

LUMBAR REGION L1 - L4 region facet surfaces are oriented nearly vertically with a moderate to strong sagittal bias-about 25 degrees from the sagittal plane. Favors sagittal plane movement.

L5 - S1 junction L5-S1 junction has an interbody joint anteriorly and a pair of apophyseal joints posteriorly. Facet surfaces of the L5-S1 apophyseal joints are usually oriented in a more frontal plane than those of other lumbar regions. There is a sharp frontal to sagittal plane transition from the thoracic to the lumbar regions which accounts for the tendency of thoracolumbar hypertension as well as the high incidence of traumatic paraplegia .

Anterior spondylolisthesis - general term that describes an anterior slipping or displacement of one vertebra - often occurs at L5 - S1 - associated with bilateral fracture or deficit at the pars articularis (a section of the posterior lumbar vertebra between the superior and inferior facets) called spondylolysis which is the usual cause of spondlolisthesis.

severe spondylolisthesis causes may cause damage to the cauda equina increased lumbar lordosis increases the normal sacrohorizontal angle (N=40 degrees) thereby increasing the anterior shear force between L5 and S1 exercises with lumbar hyperextension are CI to those with spondylolisthesis especially if unstable or progressive.

the force vector of the lumbar erector spinae muscle causes an anterior shear force parallel to the superior body of the sacrum; the greater the contraction, the greater the anterior shear especially if it creates more lordosis the anteriorly directed shear forces produced by the lumbar erector spinae occur primarily at L5-S1 and not the entire lumbar region

LUMBAR SPINE KINEMATICS lumbar spine- normal 40 - 50 degrees of lordosis sagittal plane orientation of the facets during flexion between L2 and L3, the inferior articular facets slide superiorly and anteriorly relative to the superior facets of L3

compression forces from the body weight are transferred away from the apophyseal joints (which normally support about 20% of the total load in erect standing) and toward the discs and vertebral bodies flexion of the lumbar spine increases the intervertebral foramen by 19% and may relieve pressure symptoms of lumbar spinal nerve root compression.

however, prolonged lumbar flexion will compress the anterior disc and if the posterior annulus fibrosus is weak, the nucleus pulposus can herniate--herniated nucleus pulposus (prolapsed disc)

LUMBAR EXTENSION increases the lumbar lordosis when lumbar extension is combined with full hip extension, there is anterior pelvic tilting hyperextension of the lumbar spine or hyperlordosis damages the apophyseal joints and can compress interspinous ligaments causing LBP -also causes narrowing of the intervertebral foramen

hyperextension of the lumbar spine should be avoided by those with nerve root compression caused by stenosed intervertebral foramen. Full extension deforms the nucleus pulposus anteriorly limiting the posterior migration

reduces pressure within the disc and reduces the contact pressure between the nuclear material and neural tissues. --"centralization" of symptoms: pain felt before in the lower extremities migrates towards the low back (nuclear material is pushed forward reducing contact pressure)

emphasizing lumbar extension exercises and postures as a way to reduce radiating pain and radiculopathy from a posterior herniated nucleus pulposus- popularized by Robin McKenzie McKenzie exercises - therapeutic approaches that emphasize active and passive extension to relieve symptoms and improve function in persons with known posterior or posterior lateral disc herniation may not be beneficial for all types of low back pain

A. bending forward normally - 40 degrees from the lumbar spine plus 70 from the hip joint (pelvis on femoral) B. there is limited hip flexion from tight hamstrings. Greater lumbar and lower thoracic flexion is required. C. there is limited lumbar mobility and thus, more hip flexion is required

LUMBOPELVIC RHYTHM DURING TRUNK EXTENSION from a bent position: Extension of the trunk from a flexed position with the knees extended is initiated by extension of the hips, followed by extension of the lumbar spine. The demand on the lumbar extensor muscles increases only after the trunk has been sufficiently raised and the external moment arm, relative to the body weight, has been minimized. Once standing upright, hip and back muscles are typically inactive as long as the force vector resulting from body weight falls posterior to the hip joint. An anterior pelvic tilt accentuates lumbar lordosis, a posterior pelvic tilt reduces lumbar lordosis

abnormal lumbopelvic rhythm occurs if there is restriction at the hip joint and at the lumbar spine

KINESIOLOGIC CORRELATIONS BETWEEN ANTERIOR PELVIC TILT AND INCREASED LUMBAR LORDOSIS Active anterior pelvic tilt - caused by contraction of the hip flexors and back extensors. strengthening and increasing the postural control of these muscles favors a more lordotic posture maintaining the natural lordotic curvature in the lumbar spine - fundamental principle of McKenzie exercises for persons with a posteriorly herniated nucleus pulposus

exaggerated lumbar lordosis in physiologically undesirable; may be caused by muscle weakness of hip extensor and abdominal muscles in a child with severe muscular dystrophy - involved in hip flexion contracture with increased passive tension (tightness in the hip flexor muscles) negative consequences of exaggerated lumbar lordosis1. compression of the apophyseal joints 2. increased anterior shear at the lumbosacral angle that might lead to spondylolisthesis

KINESIOLOGIC CORRELATIONS BETWEEN POSTERIOR PELVIC TILT AND DECREASED LUMBAR LORDOSIS active posterior tilt - produced by contraction of hip extensors and abdominal muscles strengthening and increasing the postural control of these muscles to reduce lumbar lordosis- basis of Williams flexion exercises


5-7 degrees of horizontal plane rotation occur on each side for lumbar rotation clinical measurements often exceed this amount because of extraneous motion from the hip joint (pelvis rotating on the femur) and the lower thoracic region

axial rotation between L1 and L2 to the right occurs as the left inferior articular facet of L1 approximates or compresses against the left superior articular facet of L2, Simultaneously, the right inferior articular facet of L1 separates (distracts) slightly fro the right superior articular facet of L2.

very limited axial rotation within the lumbar region; just over 1 degree of axial rotation at L3-L4

due to a strong sagittal orientation of the lumbar apophyseal joints the direction of rotation is on the anterior side of any part of the axial skeleton, not the spinous process in theory, an axial rotation of 3 degrees at any lumbar intervertebral junction would damage the articular facet surfaces and tear the collagen fibers in the annulus fibrosus the natural resistance to axial rotation provides vertical stability on the lower end of the column; the multifidus and relatively rigid sacroiliac joints reinforce the stability


About 20 degrees of lateral flexion occur on each side in the lumbar region Normally, the nucleus pulposus deforms slightly away from the direction of the movement toward the convex side of the bend

SITTING POSTURE AND ITS EFFECTS ON ALIGNMENT WITHIN THE LUMBAR AND CRANIOCERVICAL REGIONS poor slouched position - pelvis is posteriorly tilted and the lumbar spine relatively flexed (flattened). increased external moment arm between the vertical line of force of the upper body and lumbar vertebra - can deform the nucleus pulposus posteriorly especially in the L4-L5, overstretch and weaken it, reducing its ability to block a posteriorly protruding nucleus pulposus

flat posture of the low back is associated with a protracted position of the craniocervical region - a forward head posture the ideal sitting posture includes the natural lordosis ( and increased anterior pelvic tilt) extends the lumbar spine - with chin-in position

SUMMARY thoracic spine - frontal orientation of facets -lateral flexion thoraco-lumbar spi ne - cranial to caudal direction permits increasing amounts of flexion and extension at the expense of axial rotation the lumbar spine, in combination with flexion and extension of the hips, forms the pivot point for sagittal plane motions of the trunk


designed for stability and effective transfer of load between the vertebral column and the lower extremities

analogous to the sternoclavicular of the shoulder complex injury and pain are not apparent

sacrum anchored by the 2 sacroiliac joints is the keystone of the pelvic ring

SI joint located anterior to the posterior sacroiliac spine

during childhood the SI joint is a diarthrodial joint but starting puberty, it transforms to a modified synarthrodial joint

SI joint - may develop osteoarthritis often associated with ankylosing spondylitis

LIGAMENTS anterior sacroiliac ligament - thickening of the anterior and inferior regions of the capsule. iliolumbar and anterior sacroiliac reinforce the anterior side of the SI joint interosseous ligament - consists of very strong and short fibers that fills most of the gap that exists at the posterior and sperior margins of the joint - like syndesmosis

SI joint- innervated by sensory nerves and are capable of relaying pain from most of the literature cites dorsal rami of L5-S3 and less of ventral rami of L5-S2 pain at the ipsilateral lower lumbar and medial buttock often near the posterior superior iliac spine

thoracolumbar fascia- plays a role in the mechanical stability of the low back including the SI joint - has 3 layers: anterior, middle and posterior that compartmentalize the posterior muscles of the lower back - anchored at the transverse processes of the lumbar vertebra and inferiorly to the iliac crests -stability is enhanced by attachments of the gluteus maximus and latissimus dorsi lateral raphe - fused ends of the middle and posterior layers of the thoracolumbar fascia ; this blends with the fascia of the transversus abdominis and with the internal oblique muscles

KINEMATICS OF THE SI JOINT nutation and counternutation - refer to the movements of the SI joint at the near sagittal plane nutation - means "to nod" ; the relative anterior tilt of the base (top) of the sacrum relative to the ilium counternutation - relative posterior tilt of the base of the sacrum relative to the ilium

FUNCTIONAL CONSIDERATIONS (SI JOINT) SI joints perform 2 functions: stress relief mechanism within the pelvic ring and a stable means for load transfer between the axial skeleton and the limbs

SI joint helps disseminate damaging stress at the pelvic ring if it were solid and continuous structure increased nutation during child birth rotates the lower part of the sacrum posteriorly, thereby increasing the size of the pelvic outlet for the passage of the infant SI joint pains are common in women during pregnancy due to weight load, hormonal-induced laxity, and increased lumbar lordosis the close-packed position of the SI joint is full nutation


body weight tends to cause nutation torque, forces from the femoral heads cause counternutation torque --locks the SI joint due to gravity - enough for sitting and standing - the first line of stability

for larger and dynamic loading of the SI joint , muscles and ligaments reinforce the stability on top of the effect caused by gravity

contraction of the erector spinae causes a nutation torque, contraction of the rectus abdominis and biceps femoris causes a counternutation torque

biceps femoris increase the tension at the sacrotuberous ligament

strengthening of the muscles (transversus, internal oblique, gluteus maximus, erector spinae, latissimus dorsi- those attached at the thoracolumbar fascia) add to the stability of the SI joint the typical intervertebral junction has three elements: 1. spinous and transverse processes for attachment of muscles and ligaments 2. interbody joints for intervertebral adhesion and shock absorption 3. apophyseal joints for guiding the kinematics of each region

SUMMARY at C1-C2 articular surface - nearly horizontal throughout the cervical spine - 45 degrees between the horizontal and frontal the craniocervical region has the greatest potential for 3-dimensional movement of any region in the vertebral column

24 pairs of apophyseal joints at the thoracic region are oriented close to the frontal plane - the expected lateral flexion is limited because of the ribs --relatively rigid required for the mechanics of ventilation and to protect the heart and the lungs

the near sagittal plane orientation of the middle and upper apophyseal joints within the lumbar region allows flexion and extension of the lower end of the vertebral column while resisting horizontal plane rotation

L5-S1 junction has a frontal plane bias at the apophyseal joints providing important restraint to potentially damaging anterior shear force between the end of the lumbar spine and the base of the sacrum

RISK FACTORS FOR DEGENERATIVE JOINT DISEASE Genetics (primary) Advanced age Poor disc nutrition Occupation (physical work history) Arthropometrics (body size and proportion) Long term exposure to total body vibration

SCOLIOSIS - structural or functional - abnormal curvatures in all 3 planes, most notably in the frontal and horizontal most often involves the thoracic spine
functional scoliosis can be corrected by an active shift in posture structural scoliosis is a fixed deformity that cannot be corrected fully by an active shift in posture

80% of all structural scoliosis are idiopathic, condition has no apparent cause progressive idiopathic scoliosis affects adolescent females 4x more than males typical scoliosis

scoliosis is described by location, direction, and number of fixed frontal plane curvatures (lateral bends) within the vertebral column the most common pattern of scoliosis - a single lateral curve with an apex in the T7-T9 region other patterns may involve a secondary or compensatory curve most often in the thoracolumbar or lumbar regions

the direction of the primary lateral curve is defined by the side of the convexity of the lateral deformity

the magnitude of the lateral curvature is typically measured on x-ray drawing the Cobb angle with scoliosis, there's asymmetry of the rib cage, ribs on the concave side are pulled together, on the convex side, ribs are spread apart the degree of torsion (horizontal plane deformity) is measured on an anteriorposterior x-ray by noting the rotated position of the pedicles

fixed contralateral coupling deformity in structural scoliosis- has a fixed contralateral spinal coupling involving lateral flexion and axial rotation; the spinous processes are rotated in the horizontal plane, toward the side of the concavity ; this explains why the rib hump is at the convex side factors considered in the treatment of adolescent idiopathic scoliosis: 1. magnitude of the frontal plane curve 2. degree of progression 3. if the child is at a growth spurt 4. cosmetic appearance of the deformity

the younger the child and the greater is the frontal plane curve, the more likely is the progression of scoliosis objectives of bracing- to prevent a small curve from progressing to a large one objective of surgery: to stabilize the curve and provide partial correction thoracic Cobb angle of about 40 degrees or less- strong candidates for bracing greater than 50 degrees - strong candidates for surgery between 40 - 50 degrees - gray area as to which treatment is effective

significantly reduced thoracic kyphosis, compromise in pulmonary function and ineffectiveness of bracing - warrant surgery

40 - 50 degrees of natural kyphosis exist while one is standing

hyperkyphosis- may be as a result of trauma and related spinal instability, abnormal growth, and development of vertebra, severe degenerative disease, or marked osteoporosis

a modest increase in thoracic kyphosis with reduction in height is normal part of aging and is usually not debilitating

2 most common conditions associated with progressive thoracic kyphosis: Scheuermann's kyphosis (juvenile kyphosis) and osteoporosis Scheuermann's kyphosis (juvenile kyphosis) most common cause of kyphosis In adolescence idopathic , with excessive anterior wedging of thoracic and upper lumbar vertebra with a genetic predisposition structural scoliosis

OSTEOPOROSIS may lead to thoracic kyphosis seen in elderly women - a chronic metabolic bone disease affecting post menopausal women - not a normal part of aging - may lead to multiple vertebral fractures causing a decrease in height on the anterior side of the bodies (anterior wedging of the bodies)

with significant dehydration of discs present, can lead to more reduction in height
widow's hump- deformity with severe thoracic hyperkyphosis

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