Sei sulla pagina 1di 91

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
L1
L2
L2
L3
L3
L4
L4 L5
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 ‪L3‬‬


‫שורש ‪L3‬‬
‫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 ‪ 1/4‬של אורך‬
‫ה‪ ENDPLATE‬של ‪S1‬‬

‫ה ‪ - II‬יותר מ ‪ 1/4‬אך פחות מ ‪1/2‬‬


‫של אורך ה‪ENDPLATE‬‬
‫של ‪S1‬‬

‫ה ‪ - III‬יותר מ ‪ 1/2‬של אורך‬


‫ה‪ ENDPLATE‬של ‪S1‬‬

‫ה ‪ - IV‬יותר מ ‪3/4‬‬
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 CT
A. EXTRAMEDULARY
B. INTRAMEDULARY

* Most common

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

Herniated
Tears in the annulus • Nerve Root Nucleus
Pulposus
fibrosus allow nuclear
material to displace
.into the spinal canal
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 2-
levels
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
fracture-
dislocation
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
Thank you