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Anatomy, Physical Examination and Imaging of Thoracic and Lumbosacral Spine

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Anatomy, Physical Examination and Imaging of Thoracic and Lumbosacral Spine Anatomy, Physical Examination and Imaging of Thoracic and Lumbosacral Spine NGUYỄN THÀNH NHÂN LEARNING OBJECTIVES Understand: * Basic anatomy of the spine * Thoracic and Lumbar spine anatomy Understand basic imaging of X ray, CT Scan and MRI Identify and assess functions of the structures in clinical aspect: * Identify structures: inspection, palpation * Assess: Thoracic - Lumbar spine movements Understand: dermatomes, * SLR test, Bragard’s test, Neri’s test, … CONTENT Basic anatomy of the spine Thoracic - Lumbosacral spine anatomy Imaging of Thoracic - Lumbar spine Physical examination of Thoracic and Lumbar spine Anatomy Basic anatomy of the spine - The vertebral column consists of 33 vertebrae, - 5 segments: cervical, thoracic, lumbar, sacral, and coccygeal. - There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal vertebrae. - The two major exceptions are C1 (atlas) and C2 (axis) - Atlantoaxial joint - cervical rotation Anatomy Basic anatomy of the spine [1] Anatomy Basic anatomy of the spine [1] Anatomy Basic anatomy of the spine - The spinal cord - Conus medullaris: L1 - L2 - There are 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral pairs, and 1 coccygeal pair of spinal nerves. - The sacral spinal nerves make up the cauda equina The neural anatomy is such that the spinal cord resides within the bony canal between C1 and L1 and/or L2. The filum terminale extends from the conus and attaches to the coccyx.[1] Anatomy Basic neurology of the spine - Gray matter + Spinal neurons (lower motor neurons), + Interneurons - White matter + The axons of LMN + Afferent sensory neuron axons + 4 funiculi: L lateral, R lateral, ventral, Cross section of the spinal cord delineating white and gray matter and four funiculi.[1] dorsal Anatomy Basic neurology of the spine - White matter + Within the white matter are tracts of ascending and descending axons segregated into pathways of function Cross section of the spinal cord delineating white and gray matter and four funiculi.[1] Anatomy Basic neurology of the spine - White matter + The lateral spinothalamic tract: pain and temperature sensation. (crosses) + The dorsal column pathway: vibration sensation, two-point touch, conscious proprioception + The lateral corticospinal tract: voluntary motor function. Cross section of the spinal cord delineating white and gray matter and four funiculi.[1] Lumbosacral Spine Lumbar Spine Anatomy Lumbar vertebrae are characterized by massive bodies and robust spinous and transverse processes. Their articular facets are oriented somewhat parasagittally, which is thought to contribute the large range of anteroposterior bending possible between lumbar vertebrae. Lumbar vertebrae also contain small mammillary and accessory processes on their bodies. These bony protuberances are sites of attachment of deep lumbosacral muscles. [2] Lumbar Spine Anatomy Drawing of 2 lumbar segments viewed from an oblique angle. The outline of the facets and the pars interarticularis has the appearance of the "neck" of a Scottie dog. [2] IMAGING AP VIEW LATERAL VIEW OBLIQUE VIEW Adult Lumbar Spine - AP View [3] Adult Lumbar Spine - Lateral View [3] Adult Lumbar Spine - Lumbosacral L5S1 View [3] Adult Lumbar Spine - Oblique View [3] Spondylolisthesis L4-L5 EXTENSION VIEW FLEXION VIEW CT Scan Sagittal CT: L4 compression fracture T2W T1W STIR T2W MRI THORACIC SPINE Thoracic Spine X-ray: AP projection. 1, Left Thoracic Spine X-ray: AP projection. 1, Gas in Colon (Splenic ventricle. 2, Gas in stomach. 3, Right flexure). 2, Gas in stomach. 3, Left hemidiaphragm. 4, Posterior hemidiaphragm. 4, Posterior rib. 5,Clavicle. rib. 5, Pedicle. 6, Spinous process. 7, Transverse process. THORACIC SPINE Thoracic Spine X-ray: Lateral view. 1, Right Thoracic Spine X-ray: Lateral view. 1,Posterior hemidiaphragm. 2, Left rib. 2, Vertebral body. 3, Intervertebral discal space. hemidiaphragm. 3, Vertebral body. 4, Rib. Physical Examination Of Thoracic Spine Visual Examination Physical Examination Of Thoracic Spine Visual Examination Physical Examination Of Thoracic Spine Palpation Physical Examination Of Thoracic Spine Percussion Physical Examination Of Thoracic Spine Movements Active Movements Physical Examination Of Thoracic Spine Movements Active Movements Physical Examination Of Thoracic Spine Movements Active Movements Physical Examination Of Thoracic Spine Movements Active Movements Physical Examination Of Thoracic Spine Neurologic Evaluation of the Thoracic Spine Physical Examination Of Thoracic Spine Physical Examination Of Thoracic Spine Physical Examination Of Thoracic Spine Physical Examination Of Thoracic Spine Physical Examination Of Lumbosacral Spine Inspection [1] When the patient enters the room ▪ He or she is distressed? ▪ Is the patient leaning to one side? ▪ Is the patient able to walk, ▪ Is the gait normal? ▪ The pelvis? ▪ The patient is limited in any motion, ▪ Note the extent of any pain. Physical Examination Of Lumbosacral Spine Inspection [1] Once the patient is undressed, ▪ Look for signs of trauma, blisters, scars, discoloration, redness, contusions, lumps, bumps, fat pads, and other marks. ▪ Hairy patches or café au lait spots ▪ Look for a lateral curvature, or scoliosis Physical Examination Of Lumbosacral Spine Palpation [1] Posterior Lumbar, Sacral, and Coccygeal Spine ▪ Sit on a stool behind the standing patient. Place your thumbs on the midline of the patient’s back at the level of the iliac crest. This should be the junction between L4 and L5. Palpation C7 D7 D12 L4-L5 Physical Examination Of Lumbosacral Spine Palpation [1] Posterior Lumbar, Sacral, and Coccygeal Spine Physical Examination Of Lumbosacral Spine Palpation [1] Paraspinal Muscles ▪ Detect tenderness, spasm, muscular defect, and asymmetries. Physical Examination Of Lumbosacral Spine Palpation [1] Anterior Lumbar, Sacral, and Coccygeal Spine Physical Examination Of Lumbosacral Spine Movements [1] Active Movements Forward Bending Forward Bending Test Physical Examination Of Lumbosacral Spine Movements [1] Active Movements Backward Bending Physical Examination Of Lumbosacral Spine Movements [1] Active Movements Side Bending Physical Examination Of Lumbosacral Spine Movements [1] Active Movements Trunk Rotation Physical Examination Of Lumbosacral Spine Movements [1] Passive Movements Rotation Physical Examination Of Lumbosacral Spine Movements [1] Resisted Movements Rotation Physical Examination Of Lumbosacral Spine Movements [1] Resisted Movements Flexion Physical Examination Of Lumbosacral Spine Movements [1] Resisted Movements Side Bending Physical Examination Of Lumbosacral Spine Tests [1] Straight Leg Raise (Lasègue) Physical Examination Of Lumbosacral Spine Tests [1] Bragard’s Test – Neri’s Test Physical Examination Of Lumbosacral Spine Tests [1] Neurologic Evaluation of the Lumbar Spine Physical Examination Of Lumbosacral Spine Tests [1] Neurologic Evaluation of the Lumbar Spine KEY MUSCLES - MYOTOME KEY MUSCLES - MYOTOME References 1. Todd J.Albert, Alexander R. Vaccaro. Physical Examinatiom of the Spine 2th edition. Thieme Medical Publishers, 2017. 2. Stephen Kishner, Maxim Moradian, Jan K Morello. Lumbar Spine Anatomy. Update: Aug 12 2015. emedicine.Medscape.com 3. Wiki – Radiography.net.
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