BACK VIVAS
2011-2, 2007-2
XR: Lateral Cx-spine
Demonstrate the bony features of the Atlas and Axis.
- Ant and post arch of C1
- Odontoid process, aka peg or dens
- Body, lamina, spinous process C2
Describe the movements of the head on the neck.
Rotation occurs at level C1 on C2:
- Via the synovial atlantoaxial joints, 2 lateral 1 median
- Lateral atlantoaxial joints: gliding of inferior facets of
lateral masses of C1 and superior facets of C2
- Median atlantoaxial joint: pivoting of anterior arch of
C1 and dens of C2
Flexion and extension (nodding) as well as some lateral
flexion and rotation occur at the atlanto-occipital joints –
superior facets of lateral masses of C1 with the occipital
condyles
What are the components of the soft tissue shadow
located anterior to the upper cervical vertebrae 2007-2
1. Anterior longitudinal ligament
2. Longus colli muscle
3. Prevertebral fascia
4. Retropharyngeal space
5. Alar fascia
6. Buccopharyngeal fascia
7. Pharyngeal muscle
2010-1, 2005-1
Cervical Spine XR
Identify the major bony features of the
cervical spine on this xray
- Atlas: Anterior and posterior arches
- Axis: Dens, spinous process
- C3-7: Body, pedicle, lamina, superior and inferior articular process, spinous process
- Zygapophysial (facet) joint
- Intervertebral disc space
Describe the ligaments which maintain alignment of the cervical spine 2010-1&2
- Anterior Longitudinal ligament -> Anterior atlantoaxial and atlanto-occipital membrane
- Posterior longitudinal ligament -> Tectorial membrane
- Ligamentum flavum (between lamina) -> Posterior atlantoaxial and atlanto-occipital membrane
- Interspinous ligaments
- Supraspinous (tips of spinous processes) to C7, then -> nuchal ligament
- Intertransverse ligament
- Transverse ligament of the atlas
- Cruciate ligament
- Alar ligament
Extra: The 5 lines of stability
1. Prevertebral (anterior) soft tissue
2. Anterior vertebral bodies
3. Posterior vertebral bodies
4. Spino-lamina line
5. Tips of spinous processes
One line of disruption indicates a stable fracture
Two or more lines of disruption indicate an unstable fracture
2010-2, 2006-1
PEG XR aka Oral atlanto axial view
Demonstrate the bony features of the upper cervical vertebrae on this x-ray?
Lateral mass of Atlas (C1), Body of Axis (C2), Dens of Axis (C2), Lateral atlanto-axial joints, Spinous
process of Axis (C2), Mandible w/ rami, Occiput w/ occiptal condyles, atlanto-occiptal joint
2011-2, 2007-2, C2 only: 2009-2, 2003-2
Bone: C1-C2
Name these bones. Demonstrate their features and describe the structures stabilising the
atlantoaxial joint.
Stabilising structures:
- Anterior arch of Atlas
- Transverse ligament, part of the…
- Cruciate ligament, including superior
and inferior longitudinal bands
- Anterior longitudinal ligament ->
Anterior atlantoaxial membrane ->
Anterior atlantoccipital membrane
- Posterior longitudinal ligament ->
Tectorial membrane
- Alar ligaments (check rotation)
- Capsule of lateral atlanto-axial joints
Bone: C2
What are the major ligaments attaching to this bone
and where do they attach? 2009-2
- Tectorial membrane (PLL): post. part of body in canal via foramen magnum to cranial cavity
- Anterior atlanto-axial membrane (ALL): Anterior body to anterior arch of atlas
- Posterior atlanto-axial membrane (LF): Laminae to posterior arch of atlas
- Alar: Sides of dens to lateral margins of the foramen magnum
-
Cruciate - inferior longitudinal part: from post. body of C2 -> transverse ligament between
tubercles of lateral masses of C1, and superior longitunal part to anterior rim of foramen magnum
2004-2
Bone: mid cervical
Identify the major parts of this bone
1. Body (smaller than triangular vertebral foramen)
2. Transverse Process with foramen transversarum (vertebral artery and veins except C7 veins only)
3. Lamina (w/ pedicles form the vertebral arch) – note pars interarticularis
4. Spinous Process – often bifid
5. Superior and Inferior Articular Processes
Describe the joint between adjacent cervical vertebrae
1. Intervertebral Joint
- Symphyses (i.e. secondary cartilaginous joints)
- Anulus fibrosus (inserted into epiphysial rims) and nucleus pulposus
2. Zygapophyseal aka facet joints
- Plane synovial joints
- Between adjacent superior and inferior articular surfaces
- Surrounded by joint capsule that is loose in the cervical region
What movements occur at the facet joints?
POINTS REQUIRED
1. Upper facets face obliquely up and back
2. Lower facets face down and forwards
3. Flexion/Extension, lateral flexion (abduction)
4. No rotation
2011-2, 2011-1, 2009-1, 2007-1, 2003-2
Bone: Thoracic Vertebra
Identify this bone, and demonstrate its bony
features.
- Body
- Pedicle
- Transverse processes
- Articular facets: Superior and inferior
- Costal facets: Superior/Inferior costal facets
(head of rib), Transverse costal facet (tubercle
of rib)
- Spinous process
- Lamina
- Vertebral foramen
- Intervertebral notch (space for intervertebral
foramina)
What movements are possible at thoracic
vertebrae?
- Rotation: the facets joint planes are aligned
vertically on arc centred on vertebral bodies
- Some lateral flexion, very limited flexion +
extension – stability is conferred though
connections to sternum
Demonstrate the ligaments.
- Anterior longitudinal
- Posterior longitudinal
- Interspinous
- Supraspinous
- Ligamentum flavum
- Intertransverse
How does this differ from vertebrae in other
regions 2009-1
Cervical: smaller body, larger canal, very small
and often bifid spinous process, canal for
vertebral artery, facet joints flatter, no ribs.
Lumbar: larger body, smaller canal, spinous
process square and more directly posterior, no
articulations for ribs, more prominent transverse
processes.
What changes occur from upper to lower thoracic vertebrae. 2003-2
- Body: heart to kidney shape
- Spinous process: from long vertical to short horizontal
- Facets on transverse process: concave to flat, A-P to lat-med directed
- Costal facets on body: from demi to single on 10,11,12
- Spinal canal: from round to triangular
2011-1, 2009-1, 2007-1, 2005-2, 2003-2, LP only: 2009-2, 2006-1, 2003-1
Bone: Lumbar Vertebra
Identify this bone, and demonstrate its
bony features.
- Body
- Pedicle (to upper half)
- Transverse processes
- Superior and inferior articular facets
- Spinous process
- Lamina Vertebral foramen
- Intervertebral foramina
- Also: Groove for medial branch of post
ramus spinal nerve with mamillary
process above, and accessory tubercle
below
What movements occur in the lumbar spine?
- Flexion + extension (sagitally orientated facet joint planes)
- Lateral flexion
- Very limited rotation
What structures are traversed when you perform a lumbar puncture?
1.
2.
3.
4.
5.
6.
Sterilized skin
Subcutaneous fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum (“pop”)
Epidural space w/ Extradural fat and venous
plexus
7. Dura mater
8. Arachnoid mater
9. CSF in subarachnoid space
What level would you LP an adult and why?
- Supracristal plane (highest point of iliac crest) ~L4
- Between L3/4 or L4/5
- The cord ends behind L2 in adults (conus
medullaris), but L4/5 at birth
- In vertebral cistern = filum terminale, less likely to
be damaged than cord b/c mobile in this space
What factors are responsible for stability between adjacent lumbar vertebrae? 2007-1, 2003-2
1. Bony: Large body with intevertbral joint/discs (not really bony), orientation of facets
2. Ligamentous: Anterior longitudinal, posterior longitudinal supraspinous, interspinous,
intertransverse, ligamentum flavum
3. Muscular: thick mass of muscle both anterior and posterior (erector spinae)
2005-2
Which area is this vertebra from and why?
- Lumbar vertebra
- No costal facets
- No foramen transversarium
- Triangular vertebral foramen
- Articular facets lie in AP plane
- Kidney shaped body
- Large Mamillary bodies
Extra: The Scotty Dog on posterolateral oblique view – note the pars interacrticularis = neck
2010-2
BONE: Sacrum
Identify the features of this bone?
-
Sacrum consists of 5 fused bones and the coccyx
4 pairs of sacral foramina – S1-S4 anterior larger than posterior
Ala
Sacroiliac joint
Superior Articular facets
Lumbrosacral joint
5 Vertical lines – median, intermediate and lateral