Thoraco-lombar spine

P. Gottlieb MD

Anatomy

Spine
33 vertebræ :
• • • • • Cervical C –7 Thoracic Th –12 Lumbar L – 5 (L1-5) Sacral S -5 (fixed vertebræ) Coccygeal C- 4 (fixed vertebræ)

Vertebra
• Body • Posterior part:
– vertebral foramen – vertebral or neural arch • consists of 2 pedicles and 2 laminæ • supports 7 processes: 4 articular, 2 transverse,1 spinous

  

Spine
intervertebral foramina: • transmit spinal nerves • between transverse processes in cervical region, and in front of them in thoracic and lumbar regions   

ANATOMY
Lumbar spine - 3 joint for each motion segment

Thoracic spine
facets on bodies • and transverse processes articulation with ribs

Spinal Motion Segment
The Spinal Motion Segment is the functional unit of the spine. • 2 vertebra • Joints • Ligaments & joint capsules

Spinal Motion Segment
spinal ligaments – from C1 to sacrum 7

Spinal Motion Segment Thoracic spine –costovertebral articulation
Costotransverse • Costocorporeal • Less motion • High stability •

X - RAYS

L Spine AP ANATOMY

L Spine Lat ANATOMY

Sacralisation

L1 L2 L3 L4 L5

L1 L2 L3 L4 L5

C.T SCAN

Th SPINE CT ANATOMY
)CT-myelo(

aorta T6 ‫וף החוליה‬ ‫צלע‬ transverse proces spinal cord spinous proces

L SPINE CT ANATOMY

L3 ‫ף החוליה‬ L3 ‫ עם שורש‬lateral rece transverse proce ‫ק הטקלי‬ lamin spinous proce

‫‪L SPINE CT ANATOMY‬‬

‫גוף החוליה 3‪L‬‬ ‫שורש 3‪L‬‬ ‫שק הטקלי‬

L SPINE CT ANATOMY
L4 - L3 ‫דיסק בין חוליות‬ ‫פורמינה נוירלית‬ ‫ עליון של‬articular process L4 ‫חוליה‬

‫ תחתון של‬articular process L3 ‫חוליה‬

M.R.I

L SPINE MRI ANATOMY

L SPINE MRI ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMY

Non Specific Low Back Pain
The patient’s pain cannot be fully explained by a physical cause.
• 80% of cases. • Good prognosis. • Many names: Lumbago, Muscle spasm, back sprain/strain…

DD for specific back pain
* Degenerative .1 Deformity .2 Inflammatory & infectious .3 Muscular .4 Neoplastic .5 Metabolic .6 Traumatic .7 Referred .8 Psychological .9 Secondary Gains .10 • • • • • • • • • •

DEFORMITY
• Spondylolisthesis • Scoliosis • Hyperkyphosis

SPONDYLOLYSIS- “scottic “dog appearance

SPONDYLOLYSIS- “scottic “dog appearance pedicle -‫עין‬
superior articular facet - ‫אוזן‬ Pars interarticularis

inferior articular facet - ‫ל‬

‫‪SPONDYLOLYSIS‬‬

‫שבר דו”צ של החלק בין מפ‬

‫מפרק פצטלי‬

‫‪SPONDYLOLISTHESIS‬‬

‫ה ‪ - I‬פחות מ 4/1 של אורך‬ ‫ה‪ ENDPLATE‬של 1‪S‬‬

‫ה ‪ - II‬יותר מ 4/1 אך פחות מ 2/1‬ ‫של אורך ה‪ENDPLATE‬‬ ‫של 1‪S‬‬

‫ה ‪ - III‬יותר מ 2/1 של אורך‬ ‫ה‪ ENDPLATE‬של 1‪S‬‬

‫ה ‪ - IV‬יותר מ 4/3‬

Spondylolysis

Spondylolisthesis

CONGENITAL DISEASE SCOLIOSIS

INFECTION
• Discitis / Osteomyelitis
– Bacterial – TB – Fungal/parasitic

MRI

X-ray

INFLAMMATION
• 1. Ankylosing Spondylitis • 2. Rheumatoid Arthritis • 3. Seronegative Spondarthritides

MUSCULAR
Strain • Fibromyalgia – trigger points •

NEOPLASTIC
. EXTRADURAL
A. PRIMARY -Benign -malignanat B. SECONDARY* 2. INTRADURAL A. EXTRAMEDULARY B. INTRAMEDULARY
* Most common

CT

1

BONE TUMORS
SECONDARY A. Breast B. Lung C. Prostate D. Kidney E. Thyroid Multiple Myeloma (most common primary malignant)

METABOLIC
1. OSTEOPOROSIS 2. OSTEOMALACIA 3. PAGET’S

DEGENERATIVE
1. DISC DEGENERATION 2. PROLAPSED/HERNIATED DISC 3. ARTHROSIS 4. SPINAL STENOSIS

DISC DEGENERATION
• Is the natural history of any disc • May cause mechanical back pain • Pain may be referred to buttock and thigh.

DISC DEGENERATION
MRI

Normal Dehydrat ed Narrowed space & end plate changes (Modic I)

DISC PROLAPSE
Tears in the annulus • Nerve Root fibrosus allow nuclear material to displace .into the spinal canal
Herniated Nucleus Pulposus

DISC PROLAPSE
• Young adults. • Symptoms are caused by:
– Painful sensation from the annulus – back & buttock pain – Radicular pain from nerve root inflammation. – Motor & sensory deficit from nerve root pressure.

DISC PROLAPSE

L2 Burst Fracture: Dedicated Protocol

Dedicated

Screening

Screening

Dedicated

MD-CT in Thoracolumbar Spine Trauma
 Questionable radiographic finding  Back-pain with negative or inadequate radiographs  Screening ? (part of chest - abd. - pelvic CT)  Complex fracture for detailed assessment and classification  Teaching - Surgical planning

Selected Thoracolumbar Spine Injuries Emphasizing MDCT
Compression fractures Burst fractures Flexion-distraction (Chance-type injuries) Extension Fracture – dislocations Shearing

Denis Concept of Stability
3- columns of spine (anterior, middle, posterior) Stable – resists movement in physiologic loads Mechanically unstable – 2 adjacent injured columns allowing abnormal motion Neurologically unstable – movement allowed that creates or worsens neurologic deficit

Type of traumatic fractures 4 groups
Compression fractures .1 Anterior) column only) 1 flexion

Type of traumatic fractures
Burst fractures .2 (columns (or 3 2 Mainly axial load

Type of traumatic fractures
Chance’s fracture .3 column injury 3 Flexion distraction

Type of traumatic fractures
Fracture dislocation .4 columns 3 High energy several mechanisms

T12 compression fracture

Thoracic spine fractures

Seat belt fracture
• Usually - L1 or L2 • fracture of the posterior body Smith’s fracture • fracture

Seat belt fracture
Horizontal fracture of the pedicles, laminae, transverse processes

Fracture - dislocation

)Compression Fractures )50%
Anterior column height loss Middle column intact - stable Partial disruption of posterior column in tension depending on degree of compression (40-50%) Anterior (89%) or lateral Involves one, both, or neither endplate Rx: extension brace or traction rods and pedicle screws

Compression Patterns

Anterior Wedge Compression

Compression with posterior injury

Burst Fractures
Fractures involve middle column Widened pedicular distance (AP spine) Laminar fractures Retropulsed bone fragment with potential neurologic deficit (corresponds poorly with degree of retropulsion) Extremely consistent pattern Posterior dural tears with potential root herniation 65% neurologic deficit

Burst Fracture Patterns

L2 Burst

L2 Burst

L1 burst

Flexion-Distraction

Flexion-Distraction ))Chance -1948
 Seatbelt acts as pivot point in flexion  One-level injury through bone “classic” )47%) or ligament and disc ) 11%)  Two-level injury injury through bone )26%) or ligament and disc )16%)  Neurologic deficit low )10-20%)  Consider unstable  Consider abdominal aorta, bowel, pancreatic injury )35 - 50%)

Flexion Distraction Mechanisms 1 and 2 levels

Classic Chance fracture

Smith Variant

Vanishing pedicle sign

Smith fracture

Vanishing pedicle

MPR Chance 2levels

Bilateral facet dislocation

Flexion- distraction

Extension Injuries
Uncommon and variable extent Extension sprain, subluxation, and dislocation Impaction of spinous processes, laminae, and articular masses Pre-vertebral edema more likely Fused spines )Ank Spond, DISH, severe spondylosis prone to injury)

T-spine extension fracturedislocation

Spinal osteoporotic fractures
The most common “pathologic” fracture

Spinal osteoporotic fractures

Osteoporotic Vertebral Fractures
• 700,000 per year in US. • Is it a benign problem ?? - NO !! • Pain > inactivity > more bone loss > more fractures • Deformity > reduced lung function • Possible neurologic deficit

Osteoporotic Vertebral Fractures
Increased mortality
• 5 y survival worse than age matched peers • Hip # - high death rate within 6 mo but back to baseline at 2 y • Vertebral # - steady decline in survival

Osteoporotic Vertebral Fractures
Kado, Arch Intern Med 1999 .Prospective, 8 years, 9575 patients • .VCF increase mortality rate in 23-34% • Most common cause of death: pulmonary • .diseases

Mimics of T/L spine fractures
 Schmorl’s nodes (disc material herniation into body – sclerosis)  Scheueremann’s disease (adolescent, at least 4 contiguous mid-thoracic bodies endplate depression)  Kummel’s Disease (posttrauma ? avascular necrosis)  Anatomic variants: Mild anterior wedging, limbus vertebra  Chronic compression fracture  Pathologic fracture

Metastasis Mimics Thoracic Spine Fracture

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