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Understanding Lumbar Spine Anatomy 101

Understanding Lumbar Spine Anatomy 101. David P. Rouben, M.D. Norton Spine Specialists-Rouben & Casnellie Louisville, KY. REALITY CHECK. 8 out of 10 adults have back pain 85% suffer recurrences Back pain is the 2nd most common reason people see their doctor.

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Understanding Lumbar Spine Anatomy 101

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  1. Understanding Lumbar Spine Anatomy 101 David P. Rouben, M.D. Norton Spine Specialists-Rouben & Casnellie Louisville, KY

  2. REALITY CHECK • 8 out of 10 adults have back pain • 85% suffer recurrences • Back pain is the 2nd most common reason people see their doctor

  3. Back Disorders: A Widespread Problem Key Points • $80 billion in lost work & productivity • 175 million working days are lost annually due to chronic back pain • Significant improvement in outcomes in past decade Choose Fusion 12 Million Impaired by Back Pain 45 Million with Back Pain

  4. Spine Anatomy Cervical = C1-C7 Dorsal/Thoracic = T1-T12 Lumbar = L1-L5 Sacral = S1-S5 Dura Normal Disc Body of Vertebra Spinous Process

  5. Functions of the Spine • Arc of motion in six Spatial Planes Flexion and Extension Left and Right Side Bending Left and Right Rotation

  6. Vertebral Structures(Axial View) Body Pedicle Vertebral Canal Transverse Process Lamina Articular Process Spinous Process

  7. Structural Spinal Segment(Sagittal view) • Vertebrae body above • Disc • Vertebral body below

  8. Vertebral Structural Columns(Axial View) • Anterior Column • 2/3 of segment surface area • Anterior 1/3 of Pedicle • Anterior Longitudinal Ligament • Posterior Longitudinal Ligament • Disc • Vertebral Body

  9. Vertebral Structural Columns(Axial View) • Posterior Column • Posterior 1/3 of Segment Surface Area • Posterior 2/3 pedicles • Posterior Process • Facet Joints • Ligamentum Flavum • Transverse Process • Interspinous Ligament

  10. Vertebral Structures(Posterior View) Superior Articular Process Pars Zygapophyseal Joint (Facet Joint) Inferior Articular Process

  11. Intervertebral Disc • Fibrocartilaginous joint of the motion segment • Makes up ¼ the length of the spinal column • Present at levels C2-C3 to L5-S1 • Allows compressive, tensile, and rotational motion • Largest avascular structures in the body

  12. Intervertebral Disc Annulus Fibrosus • Annulus Fibrosus • Outer portion of the disc • Made up of lamellae • Layers of collagen fibers • Arranged obliquely 30° • Reversed contiguous layers Lamellae • Great tensile strength

  13. Intervertebral Disc Nucleus Pulposus • Nucleus Pulposus • Inner structure • Gelatinous • High water content • Resists axial forces

  14. Intervertebral Disc • Largest avascular structure • Blood supply by diffusion through end plates • Even partial damage to the blood supply leads to dessication (so called degeneration) of the disc

  15. Spinal Ligaments • Protect the Spinal Segment from excessive excursion

  16. Ligaments Posterior longitudinal ligament Anterior longitudinal ligament Ligamentum flavum

  17. The Most Common Disorders Producing Pain Acutestrains and sprains -Muscle, ligament, joint capsule Spinal SegmentOsteoarthritis – Facet Joint Disc strain-Annular Tear -progressing to Disc Protrusion-Extrusion-Sequestration

  18. Acute Strains and Sprains • Cause Improper lifting, twisting, falls or other injuries • Pathology Tearing, Stretching, and/or Separation of muscles or ligaments with commensurate Bleeding • Treatment • If minor injury, no more than two days of rest • If severe injury, Progress to Physical therapy

  19. Disc Strain Pathology Annulus disruption/Chemical “itis” Pain will be often severe to the back and buttock as well as to the leg  Treatment Restricted Activities for no more than 48 hours Anti-inflammatories, Muscle relaxants, analgesics Exercises- Physical Therapy Time and Patience-Usually Self-Limiting

  20. Annular Disruption/Tears“Disc Bulge”

  21. Disc Protrusion (Progressive Disc Strain) Annulus Tear becomes a Symmetric or Asymmetric Protrusion

  22. Disc Extrusion Protrusions can Progress to become Disc Extrusions

  23. Disc Sequestration Disc Extrusions can Progress to become Disc Sequestrations

  24. Lumbar Spinal Stenosis • Cause A “Segmental” Problem (vertebrae/Disc/vertebrae) Narrowing of the Central or Lateral canal or Foramina with neural root compression • Pathology Thickening of the Ligamentum Flavum + Discal Compression+ Facet Arthropathy+ Intervertebral Collasp • Treatment • Anti-inflammatory medications, steroid injections, physical therapy • Surgery may be necessary due to pain, lifestyle compromise, motor loss

  25. Spinal Stenosis

  26. SURGICALTREATMENTOPTIONS

  27. Common Lumbar Surgical Techniques Laminectomy/Laminotomy (+ or –) Discectomy Decompression (+ or –) Discectomy Fusion Options- ALIF “2 in 1”- ALIF + (PLIF or TLIF or Posterior) Posterior or Transverse Process or Facet 360 Degree-PLIF/TLIF/DLIF

  28. Laminotomy/ Laminectomy

  29. Anterior Lumbar Interbody Fusion(ALIF) The ALIF operation is performed with the patient lying on his or her back. IncisionThe surgeon makes an incision in the patient's abdomen to access the spine. To have a clear view of the spine, the surgeon then retracts the abdominal and vascular structures. Disc RemovalOnce the spine is in view, the surgeon removes a portion of the degenerated disc from the affected disc space.

  30. TRADITIONAL “TWO-IN-ONE” ALIF Exposure PLUS Cage/Plate PLUSPosterior Pedicle Screws

  31. Posterior Lateral Fusion

  32. Posterior Lumbar Interbody Fusion-”MIS” PLIF

  33. Transforaminal Lumbar Interbody Fusion- “Open” TLIF

  34. “MINIMALLY INVASIVE” Direct Lateral-MAST DLIFAnterior Interbody Fusion

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