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Vertebral Column

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Chris Kinslow

on 19 August 2015

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Transcript of Vertebral Column

Spinal Vertebral Anatomy
29 Spinal vertebra
7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal
Remember 3 seperate joints
in a vertebral motion system
1 joint between two vertebral body and the IVD
2 articular process joints (zygopophyseal joints/facet joints)
Anatomy Review
of Structure

24 Pairs of Facet Joints
C-spine Facets: Horizontal in the upper segments and move to more vertical position 45d in the lower segments.

Cervical Uncovertebral Joints
"Pringles Chips" that form the posteriorlateral border to the disc
Intervertebral Disc
Thicker in the front for cervical and lumbar vertebra which contributes to lordosis
Locked to vertebra through end plates and annular fibers.
Axial compression, shearing, bending, and twisting...
especially when combined
place major stressors on the disc!

Spinal Junctions
Craniovertebral Junction: Occipital condyles and the atlas/axis. (OA junction)
The term Vertebral Column Describes the entire set of vertebra (exclude ribs, sternum, ilium)
Planar Joints
Hence..."I bend down to tie my shoes and by back went out!"
Cervical Thoracic Junction: CT junction
Thoracolumbar junction: TL junction
Lumbosacral Junction: LS junction
When in doubt look here for problems!
Structure
Articular surfaces are covered in hyaline cartilage

Articular surfaces have small fibrous synovial meniscoid-like fringes that project between the joint surfaces

Function is two-fold:
Space fillers during joint displacement
Actively assist in the dispersal of synovial fluid


Structure


Articular processes act as a mechanical barricade
Horizontal articular surfaces favor axial rotation
Vertical articular surfaces act to block axial rotation


Spinal Stability
Spinal Motion
Laws of Motion
Osteopathic Systems
McKenzie
Canadian Model
Surgical Interventions
Intervertebral Disc Anatomy

IVDs lie between adjacent vertebral bodies

Each disk: Three parts
Major stresses:
Axial compression
Shearing
Bending
Twisting
Nucleus pulposus
Annulus fibrosus
Cartilage end plates
End Plates Anchor the IVD to the Vertebral Body
Spinal Stability

Static – state of equilibrium, zero velocity
Dynamic – implies a change over time with constant velocity
Spinal Stability
Neutral Zone (Panjabi) - defines a region of laxity around the neutral resting position of a spinal segment

Spinal Stability

Emphasis on spinal stability exercises for your patient should be to:
Strengthen the trunk musculature
Increase the endurance of trunk muscles
Incorporate motor learning principles to address impaired motor control strategies (biofeedback)

Spinal Motion
The movements of the vertebral column occur in diagonal patterns as a combination of flexion or extension with a coupled motion of side bending and rotation

Spinal Motion

The amount of motion available at each region of the spine is a factor of a number of variables:
Spinal Motion

Type of motion is governed by:
Shape and orientation of the articulations
Ligaments and muscles of the segment
Size and location of the articulating processes

Spinal Motion


Upper cervical spine (UCS)
Minimal flexion–extension
~30-40d of axial rotation

Spinal Motion
Flexion–extension movements
~4o in the upper thoracic spine
~6o in the mid-thoracic spine
~12o in the lower thoracic spine
Spinal Motion
Lumbar spine
Gradual increase of flexion–extension
~12d at L1–L2
~20d at the L5–S1

Spinal Motion
Points to remember:
All motions of a segment are defined by motion of the upper vertebra on the lower vertebra
Rotation is to the side the anterior aspect of the vertebra is facing

Spinal Motion

Facet joints –
Glides: Up & forward or down & back
If these movements occur in the same direction, flexion or extension occurs
If the movements occur in opposite directions, side bending occurs
Rotation is always coupled with SB (LCS)

Fryette’s First Law

“When any part of the lumbar or thoracic spine is in neutral position, sidebending of a vertebra will be opposite to the side of the rotation of that vertebra.”
Fryette’s Second Law

“When any part of the spine is in a position of flexion or hyperextension, the side bending of the vertebra will be to the same side as the rotation of that vertebra.”

Fryette’s Third Law

“If motion in one plane is introduced to the spine, any motion occurring in another direction is thereby restricted.”
Combined Motion

Using a biomechanical model:

Restriction of Ext/SB/Rot to the same side of the pain is termed a closing restriction
Can’t Close

Restriction of Flex/SB/Rot to the opposite side of the pain is termed an opening restriction
Can’t Open

Combined Motion

Motions that involve flexion and sidebending away from the symptoms tend to invoke a stretch to the structures on the side of the symptoms
Examination

In recent years, attempts have been made to use a variety of methods to classify spinal pain (particularly LBP) into syndromes
“Syndrome” implies that the specific diagnosis is unknown
Collection of signs and symptoms that characterize a particular condition
Examination
The criteria that have thus been used to categorize a syndrome include the following:
Osteopathic System

Palpation of the soft tissues over paired TPs of the spine
Osteopathic System
Position Testing:
The rotational dysfunction can be palpated as a much firmer end-feel
Osteopathic System
A marked segmental rotation is evident at the limit of Extension
Indicates that one of the facets is unable to complete its inferior motion (down & back glide)
Osteopathic System
Example…if you palpate the segment (while the patient is in Ext) and feel the segment is rotated to the left…the right facet joint is not moving normally
Osteopathic System

If a segmental rotation is evident in full flexion, this indicates that one of the facets cannot complete its superior motion

Osteopathic System
If a rotational impairment of a segment exists only in neutral (is not evident in either full Flex or full Ext), the cause of the impairment is probably not mechanical in origin but rather
neuromuscular
If a marked rotation is evident at a segment, and this rotation is consistent throughout Flex, Ext and Neutral, then the cause is probably an
anatomic anomaly (e.g.,scoliosis)
rather than an articular problem
McKenzie System
A mechanical diagnostic and classification approach
McKenzie System
Centralization of symptoms is the “immediate or eventual abolition of the most distal extent of referred or radicular pain toward the midline of the spine in response to therapeutic loading strategies”
McKenzie System
History taking is key with the McKenzie System
McKenzie System
Dynamic tests are studied first, then static tests
McKenzie System
Static tests are often used as ancillary tests to confirm the findings of the dynamic tests
McKenzie System
The results of the test(s) are then classified into three main syndromes:
McKenzie System

Proposed to result from sustained loading of the tissues during end range positions/postures
McKenzie System
Proposed to result from an adaptive shortening of some soft tissues and an overstretching of others
McKenzie System
Thought to result from a displacement in the position of joint structures (IVD)
Divided into posterior (#1-6) disk derangements and anterior (#7) disk derangements (Table 22-5)
McKenzie System

On exam, patient may present with a lateral shift
FIGURE 22-5 McKenzie classification algorithm.

McKenzie System
Treatment-Based Classification System

Designed for patients judged to be in the acute stage, with the determination of acuity based on:
Treatment-Based Classification System
Treatment-Based Classification System
Patients judged to be in the acute stage are assigned to a classification that guides the initial intervention:
Treatment-Based Classification System
Mobilization/Manipulation:
Classification
Treatment-Based Classification System

Key examination findings:
Treatment-Based Classification System

Key finding - presence of centralization with movement of the lumbar spine based on the McKenzie method
Patient is treated with specific exercises in the direction producing the centralization
Treatment-Based Classification System

Traction:
Reserved for patients with signs and symptoms of nerve root compression who are unable to centralize with any lumbar movements
Lt to Rt: Cyriax, Jull, Sahrmann, McKenzie, Janda, Kaltenborn, Maitland

Canadian Biomechanical Model
Canadian Biomechanical Model

Selective tissue tension principles of Cyriax,
Muscle energy concepts of the American osteopaths
Combined movement testing of Edwards
Manipulative techniques of Stoddard
Various approaches to stabilization therapy
Exercise protocols of McKenzie
Muscle balancing concepts of Janda, Jull, and Sahrmann
Movement reeducation principles of the neurodevelopment and sensory integrationist clinicians


Canadian Biomechanical Model
The basis of the Canadian approach is that if you understand the anatomy and biomechanics...the pathologic mechanisms can be extrapolated using a series of testing procedures. These tests include:
Canadian Biomechanical Model
The PPIVM tests are used to:
Canadian Biomechanical Model
In the PAIVM tests, the clinician:
Assesses the joint glides or accessory motions of each joint
Determines the type of end-feel encountered
Surgical Interventions
To name a few…
ACDF = Anterior Cervical Disectomy and Fusion

IDET = Intradiscal Electrothermal Annuloplasty

Discectomy / Microdisectomy

Laminectomy

Arthrodesis (Fusion)
Anterior Cervical Disectomy and Fusion
A cervical disc herniation can be removed through an anterior approach to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness and tingling
Intradiscal Electrothermal Annuloplasty
IDET is a minimally invasive outpatient surgical procedure developed over the last few years to treat patients with chronic low back pain that is caused by tears or small herniations of their lumbar discs
Provides a new alternative to other surgical procedures for patients who suffer from back pain caused by certain types of disc problems
Fairly advanced procedure
Uses electrothermal catheters
Works by cauterizing the nerve endings within the disc wall to help block the pain signals


Disectomy

Small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal
Laminectomy
Open decompression
Typically performed to alleviate pain caused by neural impingement that can result from spinal stenosis
Athrodesis
Artificial induction of joint ossification between two bones via surgical intervention
Performed to relieve pain in a joint which cannot be managed by medications, splints, or other interventions
Can be done via:
Bone graft (autograft or allograft)
Synthetic bone substitutes
Metal implants
Combination of the above methods


References

Dutton, M. (2012). Dutton’s Orthopaedic Examination, Evaluation and Intervention (3rd ed.). New York, McGraw-Hill.


TRANSLATION: When you’re standing in a neutral position (no flexion or hyperextension) and you side bend to the RIGHT. Your spine will ROTATE to the LEFT (the opposite side).

TRANSLATION: When you flex or hyperextend your spine and you side bend to the RIGHT… your spine will ROTATE to the RIGHT (same side).

TRANSLATION: For example, when you perform forward flexion, there won’t be as much motion in the other planes.
Motions that involve extension and sidebending toward the side of the symptoms produce a compression of the structures on the side of the symptoms
In the spine, classifying syndromes has become popular, as it is thought that a patient is more likely to respond to a type of intervention unique to that syndrome
Pathoanatomy
Presence or absence of radiculopathy
Location and type of pain
Duration of the symptoms
Activity and work status
Impairments identified during the examination

Direction of motion that reproduces, peripheralizes, or centralizes the symptoms
Position Testing:
Detects palpable positional irregularity and altered tissue tension at a segment when the spine is positioned in flexion or extension compared with neutral
Vertebral dysfunctions occur in a combo of movements in three planes
The direction of the rotation is named after the more posterior of the two TPs
Osteopathic model tests in extension, flexion then neutral
The direction of the resulting rotation (think anterior vertebral body) informs the clinician as to which of the facets is not moving
Position Testing in Extension:
This impairment can be described 3 different ways:
The right facet joint cannot extend (or “close”)
The right facet joint is Flex/Rot/SB left around the axis of the right facet joint
The right facet joint is unable to perform any motions that require an inferior glide, such as Ext, Rt SB, Rt Rot
In a nutshell…it’s based on:
Providing a mechanical diagnosis
Providing a mechanical treatment based on the mechanical diagnosis
Prevention of recurrence, achieved by:
Emphasizing the patient’s responsibility for their own recovery
Fully exploring the patient’s self-generated forces before progression to externally applied forces
Centralization occurs most commonly with end range repeated movements of Ext
Can be associated with an increase in spinal pain
Normally indicates improvement in the patients condition
Provides the clinician with a directional preference
Peripheralization of symptoms indicates movement in the opposite direction and is usually associated with a poorer prognosis
Impression of clinical presentation
Site of pain
Stage of disorder
Severity of the presenting condition
Identification of red flags
Baseline of mechanical presentation (listed, kyphotic, Minor's sign)
Any aggravating/relieving factors
Functional limitations
Postures and transitions
Dynamic tests involve performing a single motion within the movement plane direction being studied, followed by repetitive motion in the same movement plane direction
Clinician monitors the mechanics and symptoms and how they respond to the repetitive motion
Used also to further explore the effects of loading when dynamic testing yields no definitive conclusion
Postural

Dysfunction

Derangement
Postural Syndrome
Pain is typically of a gradual onset, dull, local, midline, symmetric, and never referred
Prolonged postures worsen the pain
Movement resolves the pain
On exam, the patient:
Demonstrates no spinal deformity or loss of range
Repeated movements do not produce the symptoms
Onset of symptoms is provoked with sustained end-range positions (>15 minutes)
Dysfunction Syndrome:
Intermittent pain is local, adjacent to the midline of the spine, and not referred
Exception occurs in the case of an adherent nerve root (ANR) where the pain may be felt in the buttock, thigh, or calf
End-range activities and positions worsen the pain
Activities that avoid end-range positions lessen the symptoms
On exam, the patient:
Demonstrates a loss of motion or function (symmetric or asymmetric)
Repeated movements do not alter the symptoms
Derangement Syndrome:
Pain is usually of a sudden onset and associated with paresthesia or numbness, is dull or sharp and can be central, unilateral, symmetric, or asymmetric
May be referred into the buttock, thigh, leg, or foot
Varies in both intensity and distribution
Bending, sitting, or sustaining positions worsen a posterior derangement
Patients feel better when walking and lying
Walking and standing worsen an anterior derangement
Patients feel better in sitting and other flexed positions
Derangement Syndrome:
There is always a loss of motion and function
Certain motions produce, increase, or cause the symptoms to peripheralize, whereas other motions decrease, abolish, or centralize the symptoms
McKenzie advocates a variety of loading principles for the reduction of the derangement
1. Alignment of various body structures
2. Effect of movements on symptoms
3. Nature of the patient’s symptoms
4. Degree of disability
5. Goals for management
1. Mobilization
2. Stabilization (SI or Lumbar)
3. Specific Exercise (flex, ext, lateral shift correction)
4. Traction
Palpation revealing asymmetry of PSIS and 3 out of 4 of these test are +
The standing flexion test
The prone-knee flexion test
The supine to long-sitting test
Intervention:
Manipulation techniques
Muscle energy techniques
ROM exercises for the lumbosacral spine
Intervention involves the use of mechanical traction or auto-traction in an attempt to produce centralization
Patients judged to be in a more chronic stage are treated with a conditioning program designed to improve strength, flexibility, and conditioning, or with a work reconditioning program
1. Cyriax upper and lower quarter scanning examinations for differential diagnosis
2. Uncombined (plane) and combined movement testing
3. Passive
physiological
intervertebral Mobility (PPIVM) tests
4. Passive
accessory
intervertebral motion (PAIVM) tests
Determine the amount of
segmental mobility
available in the spine
Assess the ability of each segment to move through its normal ROM
Results will either be normal, hypermobile or hypomobile
Additional positive findings for a hypomobility would be:

A reduced range in a capsular or non-capsular pattern in the active motion tests
A reduced joint glide
A change in the end-feel from the expected norm for that joint
Procedure allows the offending disc to be surgically removed resulting in surgical decompression
A fusion surgery is almost always done at the same time as the discectomy in order to stabilize the cervical segment
Three sub-systems that contribute to stability:
Passive System – anatomical structures contributing to stability
Active System – muscles, source of active stiffness
Central Nervous System – feedforward (anticipatory) and feedback (reflex) control
The neutral zone is the position of the segment in which:
Minimal loading is occurring in the passive structures and active structures
Spinal motion is produced with minimal internal resistance

Train your patient in the neutral zone
Movements of the spine
Produced by agonistic and synergistic muscles, which initiate and perform the movements
Antagonistic muscles control and modify the movements
Disk-vertebral height ratio
Compliance of the fibrocartilage
Dimensions/shape of adjacent vertebral end plates
Age
Disease
Gender
Look at the facets. How to the move, What movement do they block. Rehab, mobilize accordingly
Relative ROM at each vertebral segment
Lower cervical spine (LCS)
Increasing flexion–extension
~10d at the C2–3 level
~20d at C5–6 and C6–7
Axial rotation is ~5–6d
Axial rotation
~5–6o in the upper thoracic spine
Side bending
~6o in the upper thoracic spine
Relative ROM at each vertebral segment
Relative ROM at each vertebral segment
Side bending
Greatest at L3–L4 where it is ~8–9d
Axial rotation
Minimal
Coupling –
Two or more individual motions are coupled when one motion is always accompanied by another motion
Connecting vertebrae and discs
Curvature of the spine
Thought to be to the opposite side in the UCS
Thought to be to the same side in LCS 
Geometry of the individual vertebrae
Position Testing in Extension:

Position Testing in Flexion:
Example…if the segment is found to be left-rotated (when palpated in flexion), the left facet joint is not moving normally
1. The left facet joint cannot flex (or “open”)
2. The left facet joint is Ext/Rot/SB left
3. The left facet joint is unable to perform any motions that require an superior glide, such as Flex, Rt SB, Rt Rot
This impairment can be described in 1 of 3 ways:
Position Testing in Neutral:
These neuromuscular impairments are usually found at the spinal junctions, particularly the TL and CT junctions
If the cause of the rotational impairment is
articular (facet joint)
, the positional testing in neutral gives the clinician an idea as to the starting position of the corrective technique
Better, Worse, Same
Stabilization Classification
1.

Hx of frequent episodes of symptoms precipitated by minimal perturbations
2. Frequent use of manipulation with short-term relief of symptoms
3. Trauma
4.Reduced symptoms with the prior use of a corset
Interventions:
1. Strengthening Exercises back extensors and abs
2. Stabilization Exercises
Specific Exercises Classification
Patients educated to avoid positions found to peripheralize symptoms
If corrected the deformity produces centralization, the patient is taught specific exercises designed to correct the lateral shift

Eclectic approach founded upon an amalgam of doctrines and techniques that incorporate:
Biomechanical concepts of the Norwegians
5. Segmental stability tests
Similar to Spring Test
If the joint glide is restricted, the cause is an articular restriction such as the joint surface or capsule
If the joint glide is normal, then the restriction must be from an extraarticular source such as a periarticular structure or muscle

Typically performed for a herniated lumbar disc
More effective for treating radiculopathy than lower back pain
Healing may take months
Patient typically feel (almost) immediate relief post-surgically
Spinal Stenosis is caused by degenerative changes that result in enlargement of the facet joints
The laminectomy is designed to remove a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and a better healing environment
Structure

Most facet joints are oriented somewhere between the horizontal and vertical planes:
Thoracic – almost
vertical
direction
Facilitates rotation and resists anterior displacement
Cervical – relatively
horizontal
especially UCS, 45d LCS
Allows for rotation
Lumbar -
vertical
with a J-Shaped surface
Restricts rotation and anterior shear
Uncinate process increases stability by limiting SB and posterior translation
Form the oncovertebral joints which guide flexion and extension
Chapter 22 Vertebral Column
Full transcript