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The Anatomical and Radiological Relationship Between the Pars Interarticularis and the Pedicle in the Lumbar Spine – Implications for Pedicle Screw Insertion

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The Anatomical and Radiological Relationship Between the Pars Interarticularis and the Pedicle in the Lumbar Spine – Implications for Pedicle Screw Insertion THE ANATOMICAL AND RADIOLOGICAL RELATIONSHIP BETWEEN THE PARS INTERARTICULARIS AND THE PEDICLE IN THE LUMBAR SPINE – IMPLICATIONS FOR PEDICLE SCREW INSERTION Dissertation submitted to the Tamil Nadu Dr.M.G.R Medical University in partial fulfillment of the requirement for the M.S Degree Examination Branch II (Orthopaedic Surgery) May 2018 CERTIFICATE This is to certify that the dissertation entitled “The Anatomical And Radiological Relationship Between The Pars Interarticularis And The Pedicle In The Lumbar Spine – Implications For Pedicle Screw Insertion.” is original work done by Dr. Chandan. N Done under my guidance towards the M.S Branch (Orthopaedics) Degree Examination of the Tamilnadu Dr. MGR Medical University, Chennai to be held in May 2018. Signature: Head of Department Dr. V.T.K. Titus Professor & Head of Unit Orthopaedics Christian Medical College Vellore- 632004 Principal: Christian Medical College Vellore -632004 CERTIFICATE This is to certify that the dissertation entitled “The Anatomical And Radiological Relationship Between The Pars Interarticularis And The Pedicle In The Lumbar Spine – Implications For Pedicle Screw Insertion.” is original work done by Dr. Chandan. N Done under my guidance towards the M.S Branch (Orthopaedics) Degree Examination of the Tamilnadu Dr. MGR Medical University, Chennai to be held in May 2018. Signature GUIDE: Dr Kenny S David Professor and Head of Unit Spinal Disorders Surgery Christian Medical College Vellore -632004 DECLARATION CERTIFICATE This is to declare that the dissertation titled “The anatomical and radiological relationship between the pars interarticularis and the pedicle in the lumbar spine – implications for pedicle screw insertion”, in the department of Orthopedics is my own work, done under the guidance of Dr. Kenny S. David, Professor and Head Spinal Disorders Unit, submitted in the partial fulfillment of the rules and regulation for the M.S Orthopedics degree examination of the Tamilnadu Dr. M.G.R Medical University, Chennai to be held in May 2018 . Dr. Chandan. N M.S Post Graduate Registrar Department of Orthopaedics Christian Medical College, Vellore. ACKNOWLEDGEMENTS I thank God for His enabling grace that helped me in completing this work all the people who helped in this process. I express my sincere thanks and heartfelt gratitude towards Dr. Kenny S. David, Professor & Head, Spinal Disorders, for being my guide and directing me to work on this unique topic as a part of my thesis. He has always been patient enough to listen and take time out of his busy schedule towards working on this project. I had great time working along with him and thankful for the timely help he extended when it was needed. He constantly supported and directed me towards the completion of the thesis in spite of my short comings, and I shall always be grateful to him. I shall remain indebted to Dr. Dr.Suganthy Rabi Professor & Head, Department of Anatomy for providing me the needed cadaver specimens, place and freedom to work, without her help it would have been impossible to proceed further in this project. I also extend my sincere thanks to Dr.Madhavi Assistant Professor and Dr Soumya Susan Regi Assistant Professor from the Department of Radiology for their efforts in providing with the radiological measurements in spite of their busy schedule. I also extend my gratitude to Dr. Arul Parathasarathy RM Fellow, Spinal Disorders Surgery Unit. His help in dissecting the cadaveric specimens is noteworthy. It was a wonderful experience doing the study with him and something I shall fondly remember. I also thank Dr Venkatesh, Dr. Rohit Amritanand and Dr Justin in providing me useful insight into my study and providing the necessary constructive criticism and moral support. It was my privilege to have received training from various experienced faculty from the Department of Orthopaedics for their amazing advice and teaching throughout the training period. I thank my colleagues, seniors and juniors for their constant support. And last, but not the least my parents, sisters and special mention of my wife Dr.Rebecca for her constant encouragement and prayers. Contents AIM: ............................................................................................................................... 8 OBJECTIVE: .................................................................................................................. 8 INTRODUCTION: ......................................................................................................... 9 LITERATURE REVIEW ............................................................................................. 24 METHODOLOGY ....................................................................................................... 39 RESULTS: .................................................................................................................... 53 DISCUSSION ............................................................................................................... 68 CONCLUSIONS .......................................................................................................... 77 LIMITATIONS: ........................................................................................................... 77 BIBLOGRAPHY .......................................................................................................... 78 ANNEXURES .............................................................................................................. 87 SCANNED COPY OF IRB LETTER ...................................................................... 87 THESIS DATA ......................................................................................................... 88 AIM: To describe the relationship between pars interarticularis with the pedicle in lumbar vertebra and to use that relationship as a consistent landmark for pedicle screw insertion between T12 and L4 vertebra. OBJECTIVE: To demonstrate that the lateral border of the pars interarticularis can be used as a consistent and reproducible anatomical landmark between T12 to L4 vertebra to guide pedicle screw placement. INTRODUCTION: Anatomy of Lumbar Spine: "Lumbar" is derived from the Latin word "lumbus," meaning lion and is designed for both stability and flexibility - lifting, twisting, and bending. The lumbar spine is made up of 5 vertebral segments, termed lumbar segment (L1- L5). Characteristics of Lumbar Spine: The five vertebrae of the lumbar spine (L1-L5) are the biggest and unfused vertebrae in the vertebral column, enabling them to support the weight of the entire torso. Through the lower segments, L4-L5 and L5-S1, most of the body weight gets transmitted and are more prone for degenerative changes. The lumbar spine forms the lumbosacral joint at sacrum (L5-S1) this allows for considerable rotation, so that the pelvis and hips may swing when walking and running. The vertebral bodies are large and kidney-shaped. They are deeper anteriorly than posteriorly, producing the lumbosacral angle (the angle between the long axis of the lumbar region and that of the sacrum). Parts of lumbar vertebrae: Transverse processes are long and slender. Articular processes have nearly vertical facets. Spinous processes are short and broad. Accessory processes can be found on the posterior aspect of the base of each transverse process. They act as sites of attachment for deep back muscles. Mammillary processes can be found on the posterior surface of each superior articular process. They act as sites of attachment for the muscles. Joints: There are two types of joint in the lumbar spine. Between vertebral bodies – adjacent vertebral bodies are joined by intervertebral discs, made of fibrocartilage. This is a type of cartilaginous joint Between vertebral arches – formed by the articulation of superior and inferior articular processes from adjacent vertebrae. It is a synovial type joint. Ligaments: The joints of the lumbar vertebrae are inter connected by several ligaments. They can be divided into two groups; those present throughout the vertebral column and those unique to the lumbar spine. Anterior and posterior longitudinal ligaments: Long ligaments that run the length of the vertebral column, covering the vertebral bodies and intervertebral discs. Ligamentum flavum: Connects the laminae of adjacent vertebrae. Interspinous ligament: Connects the spinous processes of adjacent vertebrae. Supraspinous ligament: Connects the tips of adjacent spinous processes. The lumbosacral joint (between L5 and S1 vertebrae) is strengthened by the iliolumbar ligaments. These are fan-like ligaments radiating from the transverse processes of the L5 vertebra to the pelvis The vertebral foramen is triangular in shape through which neural elements pass The spinal cord travels from the base of the skull through the spinal column and ends at about T12-L1, where the thoracic spine meets the lumbar spine. At this junction numerous nerve roots from the spinal cord continue down and branch out, forming the “cauda equina" named for its resemblance to a horse tail. T12-Thoracic Vertebra: The twelfth thoracic vertebra (or the T12 vertebra) is the largest of the thoracic vertebrae. T12 bears the most weight of any thoracic vertebra, making it the strongest thoracic vertebra, but also more prone for injuries due to the transitional nature from more rigid to more mobile segment of the spinal column. T12 vertebra has anatomical features of both a thoracic and lumbar vertebra. Its structure is similar to the other thoracic
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