2 Anatomy of The Spine Five Divisions Four Curvatures Cervical Division (7)Thoracic Division (12)Lumbar Division (5)Sacral Division (5)Coccygeal Division (4)Four CurvaturesCervical CurvatureThoracic CurvatureLumbar CurvatureSacral CurvatureFive Divisions of the Spine: To remember how many vertebrae in each division remember the following: Breakfast is the start of the day. We start at the top of the spine (cervical vertebrae). Breakfast is at 7:00 a.m., there are 7 cervical vertebrae. Lunch is in the middle of the day. The thoracic vertebrae are in the middle of the spine. We eat lunch at 12:00 noon, there are 12 thoracic vertebrae. Dinner is at the end of our work day. The lumbar vertebrae are at the end of the spine. We eat dinner at 5:00 p.m., there are 5 lumbar vertebrae.Cervical Division – made up of 7 vertebrae, including the Atlas (C1) and the Axis (C2).Thoracic Division – made up of 12 vertebrae, these vertebrae attach to the ribs and help make up the thorax.Lumbar Division – made up of 5 vertebrae, these vertebrae make up the low back.Sacral Division – made up of 5 fused vertebrae, part of the pelvic girdle.Coccygeal Division – made up of 4 fused vertebrae, “tailbone”.Four curvatures of the spine:Cervical Curvature – Anterior curve of the spine.Thoracic Curvature – Posterior curve of the spine.Lumbar Curvature – Anterior curve of the spine.Sacral Curvature – Posterior curve of the spine.
3 Cervical Vertebrae (Atlas – C1) Parts to know:Vertebral ForamenTransverse ForamenTransverse ProcessAnterior ArchPosterior ArchLateral MassSuperior Articular FacetArticular Surface for the DensInferior Articular Facet (not pictured)Vertebral Foramen – an opening in the vertebra that allows the spinal cord to travel through; relatively large opening compared to thoracic, lumbar, or even other cervical vertebrae.Transverse Foramen – a foramen in each transverse process of a cervical vertebra through which the vertebral artery and vertebral vein pass in each cervical vertebra except the seventh.Transverse Process – a lateral process of a vertebra; very small on the atlas.Anterior Arch – an arch that connects the lateral masses of the atlas anteriorly and articulates on its central posterior aspect with the anterior articular facet of the dens of the axis; AKA: arcus anterior atlantis.Posterior Arch – connects the lateral masses of the atlas posteriorly and bears the posterior tubercle; it forms the posterior wall of the vertebral canal at this level; AKA: arcus posterior atlantis.Lateral Mass – the thick weight-bearing lateral part of the atlas on each side that articulates above with the occipital condyle and below with the axis; AKA: massa lateralis atlantis.Superior Articular Facet – one of two concave articular surfaces on the superior aspect of the lateral masses of the atlas that articulate with the occipital condyles; AKA: facies articularis superior atlantis.Articular Surface for the Dens – the posterior portion of the anterior arch that is concave, and marked by a smooth, oval or circular facet (fovea dentis), for articulation with the odontoid process (dens) of the axis.Inferior Articular Facet – (not pictured) - the articular surface of the inferior articular process of vertebrae, articulating with the superior articular facet of the vertebra below to form a zygapophysial joint (The facet joints, which are a pair of small joints at each level along the back of the spine, are designed to provide support, stability, and flexibility to the spine).
4 Cervical Vertebrae (Axis – C2) Parts to know:Vertebral ForamenTransverse ForamenTransverse ProcessDens (Odontoid Process)Superior Articular FacetLaminaBifed Spinous ProcessInferior Articular FacetVertebral Foramen – an opening in the vertebra that allows the spinal cord to travel through.Transverse Foramen (plural Foramina) – An opening in the transverse process of a cervical vertebra for the passage of the vertebral artery and vein and the sympathetic nerve plexus; AKA - vertebroarterial foramen .Transverse Process – are very small, and each ends in a single tubercle; each is perforated by the transverse foramen, which is directed obliquely upward and laterally.Dens (Odontoid Process) – The most distinctive characteristic of this bone is the strong odontoid process known as the dens which rises perpendicularly from the upper surface of the body. It forms the pivot upon which the first cervical vertebra (the atlas), which carries the head, rotates. That peculiar feature gives to the vertebra a rarely used third name: vertebra dentata.Superior Articular Facet – are round, slightly convex, directed upward and laterally, and are supported on the body, pedicles, and transverse processes.Lamina – The lamina is the flattened or arched part of the vertebral arch, forming the roof of the spinal canal; the posterior part of the spinal ring that covers the spinal cord or nerves.Bifed Spinous Process – is large, very strong, deeply channeled on its under surface, and presents a bifurcated extremity.Inferior Articular Facet - the articular surface of the inferior articular process of vertebrae, articulating with the superior articular facet of the vertebra below to form a zygapophysial joint (The facet joints, which are a pair of small joints at each level along the back of the spine, are designed to provide support, stability, and flexibility to the spine).
5 Cervical Vertebrae (C3 – C7) Parts to know:Vertebral ForamenTransverse ForamenTransverse ProcessBody (Centrum)Superior Articular FacetPedicleLaminaSpinous ProcessInferior Articular FacetVertebral Foramen – an opening in the vertebra that allows the spinal cord to travel through.Transverse Foramen – An opening in the transverse process of a cervical vertebra for the passage of the vertebral artery and vein and the sympathetic nerve plexus; AKA - vertebroarterial foramen .Transverse Process – Transverse process is a small bony projection off the right and left side of each vertebrae. The two transverse processes of each vertebrae function as the site of attachment for muscles and ligaments of the spine.Body (Centrum) – the solid central part of a vertebra, to which the arches and processes are attached.Superior Articular Facet – are round, slightly convex, directed upward and laterally, and are supported on the body, pedicles, and transverse processes.Pedicle – The pedicle is a stub of bone that connects the lamina to the vertebral body to form the vertebral arch. Two short, stout processes extend from the sides of the vertebral body and joins with broad flat plates of bone (laminae) to form a hollow archway that protects the spinal cord.Lamina – The lamina is the flattened or arched part of the vertebral arch, forming the roof of the spinal canal; the posterior part of the spinal ring that covers the spinal cord or nerves.Spinous Process – Spinous process is a bony projection off the posterior (back) of each vertebra. The spinous process protrudes where the laminae of the vertebral arch join and provides the point of attachment for muscles and ligaments of the spine.Inferior Articular Facet - the articular surface of the inferior articular process of vertebrae, articulating with the superior articular facet of the vertebra below to form a zygapophysial joint (The facet joints, which are a pair of small joints at each level along the back of the spine, are designed to provide support, stability, and flexibility to the spine).
6 Thoracic Vertebrae (T1 – T12) Parts to know:BodySpinous ProcessSuperior DemifacetInferior DemifacetTransverse Costal FacetTransverse ProcessSuperior Articular FacetInferior Articular FacetProminent LaminaVertebral ForamenParts to know:Body – the solid central part of a vertebra, to which the arches and processes are attached; also known as the centrum.Spinous Process – Spinous process is a bony projection off the posterior (back) of each vertebra. The spinous process protrudes where the laminae of the vertebral arch join and provides the point of attachment for muscles and ligaments of the spine; projects down to help increase stability at the thoracic division.Superior Demifacet – a demifacet on the upper edge of the body of a vertebra articulating with the head of a rib; a single rib articulates with the inferior costal facet and superior costal facet of the adjacent vertebrae; The superior demifacet is on the inferior vertebra.Inferior Demifacet – the head of a rib is joined to two thoracic vertebrae via costal demifacets; half of the facet is on the superior vertebra and half of the facet is on the inferior vertebra; the inferior demifacet is on the superior vertebra.Transverse Costal Facet – a site where a rib forms a joint with the transverse process of a vertebra.Transverse Process – Transverse process is a small bony projection off the right and left side of each vertebrae. The two transverse processes of each vertebrae function as the site of attachment for muscles and ligaments of the spine as well as the point of articulation of the ribs (in the thoracic spine).Superior Articular Facet – are round, slightly convex, directed posteriorly, and are supported on the prominent lamina and transverse processes.Inferior Articular Facet - the articular surface of the inferior articular process of vertebrae, directed anteriorly; articulating with the superior articular facet of the vertebra below to form a zygapophysial joint (The facet joints, which are a pair of small joints at each level along the back of the spine, are designed to provide support, stability, and flexibility to the spine).Prominent Lamina - projects backwards and medialwards to join and complete the vertebral arch and form the posterior border of the vertebral foramen.Vertebral Foramen - an opening in the vertebra that allows the spinal cord to travel through.
7 Lumbar Vertebrae (L1 – L5) Parts to know:BodyVertebral ForamenTransverse ProcessSpinous ProcessSuperior Articular FacetInferior Articular FacetSuperior Vertebral NotchInferior Vertebral NotchParts to know:Body – the solid central part of a vertebra, to which the arches and processes are attached; also known as the centrum.Vertebral Foramen – an opening in the vertebra that allows the spinal cord to travel through; much more narrow now compared to cervical vertebral foramen.Transverse Process - Transverse process is a small bony projection off the right and left side of each vertebrae; very tiny in this division.Spinous Process – Spinous process is a bony projection off the posterior (back) of each vertebra. The spinous process protrudes where the laminae of the vertebral arch join and provides the point of attachment for muscles and ligaments of the spine; short and stubby to allow for more ROM at this division.Superior Articular Facet – are round, slightly convex, directed in (medially) towards each other to help create stability.Inferior Articular Facet – the articular surface of the inferior articular process of vertebrae, directed outward (laterally); articulating with the superior articular facet of the vertebra below to form a zygapophysial joint (The facet joints, which are a pair of small joints at each level along the back of the spine, are designed to provide support, stability, and flexibility to the spine).Superior Vertebral Notch – a concave constriction which occurs on the superior surface of the pedicle on each side of a vertebra and which are arranged so that the superior notches of one vertebra and the corresponding inferior notches of a contiguous vertebra combine to form an intervertebral foramen on each side allowing larger nerve roots to branch out of the spinal column at the lumbar division.Inferior Vertebral Notch - a two concave constriction which one occurs on the inferior surface of the pedicle on each side of a vertebra and which are arranged so that the superior notches of one vertebra and the corresponding inferior notches of a contiguous vertebra combine to form an intervertebral foramen on each side allowing larger nerve roots to branch out of the spinal column at the lumbar division.
8 Sacrum and Coccyx Parts to Know: Sacrum Base of the Sacrum Sacral CanalMedian Sacral CrestSacral CornuaSacral HiatusSacral ForamenAlaLateral Sacral CrestApex of the SacrumCoccyxCoccygeal VertebraeCoccygeal CornuTransverse ProcessesParts to Know:SacrumBase of the Sacrum - is broad and expanded, is directed upward and forward. In the middle is a large oval articular surface, the upper surface of the body of the first sacral vertebra, which is connected with the under surface of the body of the last lumbar vertebra by an intervertebral fibrocartilage.Sacral Canal - is a continuation of the vertebral canal and runs throughout the greater part of the sacral bone. Above the sacrum, it is triangular in form and below its posterior wall is incomplete, from the non-development of the laminae and spinous processes.Median Sacral Crest – an unpaired crest formed by the fused spinous processes of the upper four sacral vertebrae.Sacral Cornu – Sacral Cornu (singular); Sacral Cornua (plural); rounded process on each side of the fifth sacral vertebra that projects downward and represents an inferior articular process of the vertebra.Sacral Hiatus – normally occurring gap at the lower end of the sacrum, exposing the vertebral canal, due to failure of the laminae of the last sacral segment to coalesce.Sacral Foramen – any of 16 openings in the sacrum of which there are four on each side of the dorsal surface giving passage to the posterior branches of the sacral nerves and four on each side of the pelvic surface giving passage to the anterior branches of the sacral nerves.Ala – the upper surface of the lateral part of the sacrum adjacent to the body.Lateral Sacral Crest – crests that are rough ridges lying lateral to the sacral foramina; they represent the fused transverse processes of sacral vertebrae.Apex of the Sacrum – the tapering lower end of the sacrum that articulates with the coccyx.CoccyxCoccygeal Vertebrae – is the final segment of the vertebral column in humans and apes. Comprising three to five separate or fused coccygeal vertebrae below the sacrum.Coccygeal Cornua – two processes that project upward from the dorsum of the base of the coccyx to articulate with the sacral cornua.Transverse Processes - a lateral process of a vertebra; the transverse processes are most prominent and noticeable on the first coccygeal segment.
9 Intervertebral Discs Made up of fibrocartilage. Lie in between each vertebrae.Parts to know:Annulus FibrosusNucleus PulposusAnnulus Fibrosus – forms the periphery of the intervertebral disc and is composed of strong, fibrous tissue, with the fibers running in several different directions/layer for strength.Nucleus Pulposus – is the inner core of the vertebral disc. The core is composed of a jelly-like material that consists of mainly water, as well as a loose network of collagen fibers. The elastic inner structure allows the vertebral disc to withstand forces of compression and torsion.The job of the intervertebral discs are to act as shock absorbers for the spine.
10 Ranges of Motion for the Spine FlexionExtensionRotationLateral FlexionLumbar ROM
11 Dermatomes & Myotomes Dermatome Myotome An area of the skin supplied by nerves from a single spinal root.MyotomeA myotome is the group of muscles that a single spinal nerve root innervates.
12 Intrinsic Muscles of the Spine A deep layer of muscles3 layers of the musclesDeepest (Transversospinalis Group) layer – Semispinalis, multifdus and rotator muscles.Intermediate (Erector Spinae Group) layer – divided into 3 columns:Spinalis muscles - medial column closest to spine.Longissimus muscles – intermediate column; next closest to the spine.Iliocostalis muscles – lateral column; furthest from the spine.Superficial Layer – Splenius muscles.
13 Deep Layer - Transversospinalis Group Semispinalis CapitisOrigin –C7 and T1 – T6 transverse processes and C4 – C6 articular processes.Insertion – Between the superior and inferior nuchal lines of the occipital bone.Action – Extension and lateral flexion of the cervical neck and head, and rotation to the opposite side.
14 Deep Layer - Transversospinalis Group Semispinalis CervicisOrigin – Transverse processes of T1 – T6.Insertion – Spinous processes of C2 – C5.Action – Acting bilaterally, extension of the cervical spine. Acting unilaterally, lateral flexion of the neck and head and rotation to the opposite side.
15 Deep Layer - Transversospinalis Group Semispinalis ThoracisOrigin – The transverse processes of T6 – T10.Insertion – The spinous processes of T1 – T4 and C6 – C7.Action – Extends the spine and rotates it towards the opposite side.
16 Deep Layer - Transversospinalis Group Multifidus GroupOrigin – Posterior surface of the sacrum, the dorsal end of the iliac crest, the transverse processes of L1 – L5, T1 – T12 and the articular processes of C4 – C7.Insertion – Spinous processes of all of the vertebrae except for C1.Action – Acting unilaterally, lateral flexion and rotation to the opposite side. Acting bilaterally, extension of the spine.A series of pairs of small muscles extending the full length of the spine just superficial to the rotators and each spanning 2 – 3 intervertebral spaces before inserting.
17 Deep Layer - Transversospinalis Group Rotators GroupOrigin – Transverse processes of the vertebrae.Insertion – Bases of the spinous processes (lamina) 1-2 vertebrae above.Action – Acting unilaterally, rotation of the spine to the opposite side. Acting bilaterally, extension of the spine.
18 Deep Layer - Transversospinalis Group InterspinalesOrigin & Insertion – Pairs of small muscles joining the spinous processes of adjacent vertebrae, one on each side of the interspinous ligament. Continuous in the cervical region extending from the axis to the 2nd thoracic vertebra and in the lumbar region from the 1st lumbar to the sacrum.Action – Extension of the spine.
19 Deep Layer - Transversospinalis Group IntertransversariiOrigin & Insertion – Pairs of small muscles, anterior and posterior, on each side of the spine joining the transverse processes of adjacent vertebrae. They extend from the Atlas (C1) to the first thoracic vertebra (T1) and from the 10th thoracic (T10) to the last lumbar vertebra (L5).Action – Acting unilaterally, lateral flexion of the spine.
20 Intermediate Layer – Erector Spinae Group – Medial Column Spinalis CapitisOrigin – C5 – C7 and T1 – T3 vertebrae (spinous processes).Insertion – Occiput between the superior and inferior nuchal lines.Action - Extension, rotation, and lateral bending of C- spine.Spinalis capitis is usually inseparably connected with the semispinalis capitis.
21 Intermediate Layer – Erector Spinae Group – Medial Column Spinalis CervicisOrigin – The lower portion of the ligamentum nuchae, spinous processes of C7 and sometimes T1 - T2.Insertion – The spinous process of the Axis (C2) and sometimes the spinous processes of C3 - C4.Action – Acting unilaterally, lateral flexion of the C-spine. Acting bilaterally, extension of the spine.
22 Intermediate Layer – Erector Spinae Group – Medial Column Spinalis ThoracisOrigin – The spinous processes of L2, L1, T12, T11.Insertion – The spinous processes of the upper thoracic vertebrae (T4 – T8).Action – Acting unilaterally, lateral flexion or the thoracic spine. Acting bilaterally, extension of the thoracic spine.
23 Intermediate Layer – Erector Spinae Group – Intermediate Column Longissimus CapitisOrigin – Transverse processes of T1 - T5 and the articular processes of C4 – C7.Insertion – The posterior margin of the mastoid process.Action – Acting bilaterally, extends the head; acting unilaterally, laterally flexes and rotates the head to the same side.
24 Intermediate Layer – Erector Spinae Group – Intermediate Column Longissimus CervicisOrigin – Transverse processes of T1 – T5.Insertion – Transverse processes of C2 – C6 and sometimes the Atlas (C1).Action – Acting unilaterally, laterally flexes the neck. Acting bilaterally, extension of the neck.
25 Intermediate Layer – Erector Spinae Group – Intermediate Column Longissimus ThoracisOrigin – The common broad, thick tendon with the iliocostalis lumborum, fibers from the transverse and accessory processes of the lumbar vertebrae and thoracolumbar fascia.Insertion – The tips of the transverse processes of all thoracic vertebrae and the lower 9-10 ribs between the tubercles and the angles.Action – Acting unilaterally, laterally flexes the vertebral column. Acting bilaterally, extension of the vertebral column; draws ribs down.
26 Intermediate Layer – Erector Spinae Group – Lateral Column Iliocostalis CervicisOrigin – Superior borders of the angles of rib 3 – 6.Insertion – The posterior tubercles of the transverse processes of the 4th, 5th, and 6th cervical vertebrae (C4 – C6).Action – Acting bilaterally, extension of the spine. Acting unilaterally, laterally flexes the vertebral column.
27 Intermediate Layer – Erector Spinae Group – Lateral Column Iliocostalis ThoracisOrigin – Superior borders of the angles of the lower 6 ribs medial to the tendons of insertion of the iliocostalis lumborum.Insertion – Into the angles of the upper 6 or 7 ribs and into the transverse process of the 7th cervical vertebra.Action – Acting bilaterally, extension of the spine. Acting unilaterally, laterally flexes the spine.
28 Intermediate Layer – Erector Spinae Group – Lateral Column Iliocostalis LumborumOrigin – Anterior surface of a broad and thick tendon which originates from the sacrum, spinous processes of the lumbar and 11th and 12th thoracic vertebrae, and from the medial lip of the iliac crest.Insertion – Inferior borders of the angles of the lower 6 or 7 ribs.Action – Acting bilaterally, extension of the spine, acting unilaterally, laterally flexes the spine.
29 Superficial Layer Splenius Capitis Origin – Inferior one-half of ligamentum nuchae and spinous processes of C7 – T4.Insertion – Mastoid process and lateral portion of the superior nuchal line.Action – Unilaterally, rotate the head and neck to same side, laterally flex the head and neck to the same side; bilaterally, extend the head and neck.
30 Superficial Layer Splenius Cervicis Origin – Spinous processes of T3 – T6.Insertion – Transverse processes of C1 – C3.Action – Unilaterally, rotate the head and neck to same side, laterally flex the head and neck to the same side; bilaterally, extend the head and neck.
31 Postural Concerns Kyphosis Lordosis Scoliosis Forward head Flatback SwaybackKyphosis – characterized by an increased thoracic curve and by scapulae that are protracted, which produces a rounded shoulder appearance. Kyphosis is usually associated with a forward head posture. Scheuermann’s disease is a disease of unknown etiology that usually affects adolescent males. This condition is not only painful but also may cause progressive thoracic or lumbar kyphosis. Hunchback, usually seen in older people.Lordosis – Lordotic posture is characterized by an increased curve in the lumbar spine and an increase both in anterior tilt of the pelvis and in hip flexion. Lordosis combined with kyphosis and a forward head posture is referred to as a kypho-lordotic posture. Gymnast posture, butt out chest forward.Scoliosis – is a lateral curvature of the spine. The athlete with scoliosis exhibits a recognizable abnormal curve in one direction and a compensatory secondary curve in the opposite direction. Scoliosis can be functional or structural. A functional scoliosis can be caused by some nonspinal defect such as unequal leg length, muscle imbalance, or nutritional deficiency. Structural scoliosis remains twisted. With the athlete in this position, one side of the spine may be more prominent than the other. Side to side curve (“S” back).Forward Head – If the upper back exhibits a kyphotic posture in standing or sitting, there will be a compensatory change in the position of the head and neck. To keep the eyes level in spite of a slumped or rounded shoulder posture, the athlete must extend the cervical spine, which tends to produce short but strong neck extensors and weak, long neck flexors. Thus, the head will be held in a forward position. Turtle head.Flatback – Flatback posture is caused by a decreased lumbar curve and an increase in posterior pelvic tilt and in hip flexion. Loss of lumbar curve.Swayback – A swayback posture involves and anterior shifting of the entire pelvis that results in hip extension. The thoracic segment shifts posteriorly, causing flexion of the thorax on the lumbar spine. Thus, there is a decrease in lordosis in the lumbar spine and an increase in kyphosis in the thoracic spine. Leaning back.
32 Common Injuries Brachial Plexus Neurapraxia (Burner/Stinger) Low Back StrainsSciaticaHerniated Lumbar DiskSpondylosis and SpondylolisthesisScheuermann’s Disease (Dorsolumbar Kyphosis)Lumbar Vertebrae Fracture and DislocationMyofascial Pain SyndromeLumbar SprainsBack ContusionsCervical FractureCervical DislocationAcute Strains of the Neck and Upper BackCervical Sprain (Whiplash)Acute Torticollis (Wryneck)Cervical Cord and Nerve Root InjuriesCervical Spine StenosisCervical Disk Injuries
33 Brachial Plexus Neurapraxia (Burner/Stinger) EtiologySigns & SymptomsStingerManagementEtiology – Transient neuropraxia, resulting from stretching or compression of the brachial plexus, is the most common of all cervical neurological injuries in the athlete. Neurapraxia involves a disruption in normal function of a peripheral nerve without any degenerative changes. Other terms commonly used to indicate this condition are stinger, burner, or pinched nerve. The primary mechanism of injury is stretching of the brachial plexus when the neck is forced laterally to the opposite side while the shoulder is depressed, as would occur with a shoulder block in football. A second mechanism compresses the brachial plexus when the neck is extended, compressed and rotated toward the affected side. An injury mimicking the stretch palsy is the direct injury to the upper brachial plexus from the edge of the shoulder pads impacting the area (direct blow to the brachial plexus). The tip-off here is that there is usually exquisite tenderness over the trapezius and the rhomboid muscles are spared, if there is associated weakness.Signs & Symptoms – With the common burner or stinger, the athlete usually comes off the field with pain and numbness, radiating into all fingers of the hand. This implies involvement of, at least, cervical roots 6, 7, and 8. But if there is associated weakness (most of the time there isn’t) it is limited to the deltoid and biceps/brachialis muscles (especially the deltoid) implicating the C5 root. Therefore, if there is no weakness of the deltoid during on-the-field testing, the athlete can return to play when asymptomatic. The player complains of burning sensation, numbness and tingling, and pain extending from the shoulder down to the hand, with some loss of function of the arm and hand that lasts for several minutes. Rarely, symptoms may persist for several days. Neck ROM is usually normal. Repeated brachial plexus nerve stretch injuries may result in neuritis, muscular atrophy, and permanent damage.Management – Once the symptoms have completely resolved and there are no associated neurological symptoms, the athlete may return to full activity. Thereafter the athlete should begin strengthening and stretching exercises for the neck musculature. A football player should be fitted with shoulder pads and a cervical neck roll, or cowboy collar, to limit neck ROM during impact.
34 Low back Strains Etiology Signs & Symptoms Management Etiology – There are two mechanisms to the typical lower back strain in sports activities. The first happens from a sudden extension contraction on an overloaded, unprepared, or underdeveloped spine, usually in combination with trunk rotation. The second is the chronic strain, commonly associated with faulty posture, that involves excessive lumbar lordosis. However, other postures such as flat-back posture or scoliosis can predispose an athlete to strain.Signs & Symptoms – Evaluation should be performed immediately after injury to rule out a possible fracture. Discomfort in the low back may be diffused (spread out) or localized in one area. In the case of muscle strain, pain will be present on active extension and with passive flexion. There is no radiating pain farther than the buttocks or thigh and no neurological involvement that causes muscle weakness, sensation impairment, or reflex impairments.Management – In the acute phase of this injury, it is essential that cold packs and or ice massage be used intermittently throughout the day to decrease muscle spasm. An elastic wrap or corset-type brace will help compress the area. A graduated program of stretching and strengthening begins slowly in the acute stage. Progressive strengthening exercises should concentrate on extension, whereas stretching should focus on both flexion and extension. Injuries of moderate-to-severe intensity may require complete bed rest to help break the pain-muscle spasm cycle. The physician may prescribe oral analgesic medication. Cryotherapy, ultrasound, and abdominal support are often beneficial following the acute phase. Exercise must not cause pain.
35 Sciatica Etiology Signs & Symptoms Management Etiology – An inflammatory condition of the sciatic nerve that can accompany recurrent or chronic low back pain. The term sciatica has been incorrectly used as a general term to describe all low back pain without reference to exact causes. Sciatica is commonly associated with peripheral nerve root compression from intervertebral disk protrusion, structural irregularities within the vertebral foramina, or tightness of the piriformis muscle. The sciatic nerve is particularly vulnerable to torsion or direct blows that tend to impose abnormal stretching and pressure on it as it emerges from the spine, thus effecting a traumatic condition.Signs & Symptoms – Sciatica may begin either abruptly or gradually. It produces a sharp shooting pain that follows the nerve pathway along the posterior and medial thigh. There may also be some tingling and numbness along its path. The nerve may be extremely sensitive to palpation. Straight leg raising usually intensifies the pain.Management – In the acute stage, rest is essential. The cause of the inflammation must be identified and treated. If the is a disk protrusion, lumbar traction may be appropriate. Stretching of a tight piriformis muscle may also decrease symptoms. Since recovery from sciatica usually occurs within two to three weeks, surgery should be delayed to see if symptoms resolve. Oral antiinflammatory medication may help reduce inflammation.
36 Herniated Lumbar Disk Etiology Signs & Symptoms Management Etiology – The lumbar disks are subject to constant abnormal stresses that stem from faulty body mechanics, trauma, or both, which, over a period of time, can cause degeneration, tears, and cracks in the annulus fibrosis. The disk most often injured lies between the L4 – L5 vertebrae. The L5 – S1 disk is the second most commonly affected.In sports, the mechanism of a disk injury is the same for the lumbosacral sprain – forward bending and twisting that places abnormal strain on the lumbar region. The movement that provides herniation or bulging of the nucleus pulposus may be minimal, and associated pain may be significant. Besides soft tissue injuries, such a stress may herniate and already degenerated disk by causing the nucleus pulposus to protrude into or through the annulus fibrosis. A disk that progressively degenerates may develop into a prolapsed disk, in which the nucleus pulposus moves completely through the annulus fibrosis. If the nucleus pulposus moves into the spinal canal and comes in contact with a nerve root, the result could become an extruded disk. This protrusion of the nucleus pulposus may place pressure on the cord of spinal nerves and thus cause radiating pains similar to those of sciatica. A sequestrated disk occurs when the material of the nucleus pulposus separates from the disk and begins to migrate.Pressure within the intervertebral disks changes with various positions or postures. Studies that used intervertebral disk pressure in the standing position as a constant found that pressure was decreased by 75% when the spine was in the supine position and by 25% when in a side-lying position. Pressure was increased by 33% when the athlete was sitting, by 33% when the athlete was standing slightly bent forward, by 45% while the athlete was sitting slightly bent forward, by 52% while the athlete was standing bent far forward, and by 63% when the athlete was sitting bent well forward.Signs & Symptoms – There is usually a sharp, centrally located pain that radiates unilaterally in a dermatomal (dermatome - an area of the skin supplied by nerves from a single spinal root) pattern to the buttocks and down the back of the leg, or pain that spreads across the back. The athlete may describe weakness in the lower limb. Symptoms are usually worse in the morning with axial loading such as when the athlete gets out of bed. Onset may be sudden or gradual, and pain may increase after the athlete sits and tries to resume activity. Forward bending and sitting increases pain. Backward bending reduces pain. The athlete’s posture will exhibit a slight forward bend with side bending away from the side of pain. Side bending toward the side of pain is limited and increases pain. There is tenderness around the painful area. Straight leg raising to 30 degrees increases pain. Tendon reflexes may be diminished. Muscle testing may reveal weakness with bilateral differences. A Valsalva maneuver (the action of attempting to exhale with the nostrils and mouth, or the glottis, closed. This increases pressure in the middle ear and the chest, as when bracing to lift heavy objects, and is used as a means of equalizing pressure in the ears) increases the pain as does coughing, sneezing, or laughing. The athlete has difficulty putting on shoes and socks.Management – Initial treatment should involve pain-reducing modalities such as ice and/or electrical stimulation. Manual traction combined with passive backward bending or extension makes the athlete more comfortable. The goal is to reduce the protrusion and restore normal posture. Thus, the athlete should be taught appropriate posture self-correction exercises. As pain and posture return to normal, back extensor and abdominal strengthening should be used.If the disk is extruded or sequestrated, all the athletic trainer can do is modulate the pain with electrical stimulation. Flexion exercises and lying supine in a flexed position may help with comfort. Sometimes the symptoms will resolve with time. But if there are any signs of nerve damage, surgery may be required to eliminate pain and dysfunction.
37 Spondylolysis and Spondylolisthesis Etiology“Scotty Dog” FractureSigns & SymptomsManagementEtiology – Spondylolysis (AKA “Scotty dog” Fracture) refers to a degeneration of the vertebrae and, more commonly, a defect in the pars interarticularis of the articular processes of the vertebrae. The condition is often attributed to a congenital weakness, and the defect occurs as a stress fracture. It is more common among boys. Spondylolysis may produce no symptoms unless a disk herniation occurs or there is sudden trauma such as hyperextension. Sports movements that characteristically hyperextended the spine, such as the back arch in gymnastics, the lifting of weights, the football block, the tennis serve, the volleyball spike, and the butterfly stroke in swimming, are most likely to cause this condition.Commonly, spondylolysis begins unilaterally. If it extends bilaterally, however, there may be some slipping of one vertebra on the one below it. This condition, called a spondylolisthesis, is considered to be a complication of spondylolysis that often results in hypermobility of a vertebral segment, called a step deformity. Spondylolisthesis’s highest incidence is with L5 slipping on S1. Although pars interarticularis defects are more common among boys, the incidence of slippage is higher in girls. It is possible that a spondylolisthesis may be asymptomatic. The athlete with this condition will usually have a lumbar hyperlordosis postural impairment. A direct blow or sudden twist or chronic low back strain may cause the defective vertebra to displace itself forward on the sacrum. A spondylolisthesis is easily detectable on x-ray.Signs & Symptoms - The athlete complains of persistent mild to moderate aching pain across the low back or a stiffness in the low back with increased pain after, but no usually during, physical activity. There is usually a complaint that the low back area feels tired and fatigues easily. The athlete feels the need to change positions frequently or to self-manipulate the low back to reduce the pain. Movements of the trunk are full ROM and painless with some hesitation in forward bending. At extreme ranges held for 30 seconds, an aching pain develops. The athlete feels weak when straightening from forward bending. There may be tenderness localized to one segment. When applying posteroanterior pressure to the spinous process during palpation, the athletic trainer may note some segmental hypermobility. If displacement is great enough, there may be some neurological signs.Management – Bracing and , occasionally, bed rest for one to three days will help reduce pain. The major focus in rehabilitation should be directed toward exercises that control or stabilize the hypermobile segment. Progressive trunk strengthening exercises, especially through the midrange, should be incorporated. Dynamic core stabilization exercises that concentrate on abdominal muscles should also be used. Braces are most helpful during high-level activities. Hypermobility of a lumbar vertebra may make the athlete more susceptible to lumbar muscle strains and ligament sprains. Thus, it may be necessary for the athlete to avoid vigorous activity.
38 Scheuermann’s Disease (Dorsolumbar Kyphosis) EtiologySigns & SymptomsManagementEtiology – Scheuermann’s disease is characterized by kyphosis that results from wedge fractures of 5 degrees or greater in three or more consecutive vertebral bodies with associated disk space abnormalities and irregularity of the epiphyseal endplates. This degeneration allows the disk’s nucleus pulposus to prolapse into a vertebral body. Characteristically, there is an accentuation of the kyphotic curve and backache in the young athlete. Adolescents engaging in sports such as gymnastics and swimming – the butterfly stroke particularly – are prone to this condition. Scheuermann’s disease is idiopathic (relating to or denoting any disease or condition that arises spontaneously or for which the cause is unknown), but the occurrence of multiple minor injuries to the vertebral epiphyses seems to be an etiological factor. These injuries apparently disrupt circulation to the epiphyseal endplate, causing avascular necrosis.Signs & Symptoms – In the initial stages, the young athlete will have kyphosis of the thoracic spine and lumbar lordosis without back pain. In later stages, there is point tenderness over the spinous processes, and the young athlete may complain of backache at the end a very physically active day. Hamstring muscles are characteristically very tight.Management – The major goal of management is to prevent progressive kyphosis. In the early stages of the disease, extension exercises and postural education are beneficial. Bracing, rest, and antiinflammatory medication may also be helpful. The athlete may stay active but should avoid aggravating movements.
39 Lumbar Vertebrae Fracture and Dislocation EtiologyCompression FractureFracture DislocationSigns & SymptomsManagementEtiology – Fractures of the vertebral column, in terms of bone injury, are not serious in themselves, but they pose dangers when related to spinal cord damage. Vertebral fractures of the greatest concern in sports are compression fractures and fractures of the transverse and spinous processes.The compression fracture may occur as a result of hyperflexion of the trunk. Falling from a height and landing on the feet or buttocks may also produce a compression fracture. The vertebrae that are most often compressed are those in the dorsolumbar curves. The vertebrae usually are crushed anteriorly by the traumatic force of the body above the site of the injury. The crushed vertebral body may spread out fragments and protrude into the spinal canal, compressing and possibly even cutting the cord.Fractures of the transverse and spinous processes result most often from kicks or other direct impact to the back. Because these processes are surrounded by large muscles, fractures produce extensive soft-tissue injury. The fractures themselves present little danger and will usually permit the athlete considerable activity within the range of pain tolerance. Most care and treatment will be oriented toward therapy of the soft-tissue pathology.Dislocations of the lumbar vertebrae in sports are rare and occur only with an associated fracture. This infrequently is due to the orientation of the facet joints in the lumbar vertebrae.Signs & Symptoms – Recognition of the compression fracture is difficult without an x-ray examination. A basic evaluation may be made through knowledge of the history and through point tenderness over the affected vertebrae. Fractures of the transverse and spinous processes may be directly palpable. There will be point tenderness with some localized swelling along with muscle guarding to protect the area.Management – If the symptoms and signs associated with a fracture are present, the injured athlete should be spine boarded/immobilized to prevent further injury. X-ray examination is necessary to rule out a fracture.
40 Myofascial Pain Syndrome EtiologySigns & SymptomsManagementEtiology – Myofascial pain syndrome is defined as a regional pain with referred pain to a specific area that occurs with pressure or palpation of tender spots or trigger points with in a specific muscle. A trigger point is an area of tenderness in a tight band of muscle. Palpation of the trigger point produces pain in a predictable distribution of referred pain. There may also be some restricted ROM because of pain. Pressure on the trigger point produces a twitch or jump response from the pain. Pain can be increased by passive or active stretching of the involved muscle. In the athlete, painful or active trigger points most often develop because of some mechanical stress to the muscle. This stress could involve either an acute muscle strain or static postural positions that produce constant tension in the muscle. Trigger points occur most typically in the neck, upper back, and lower back. In the lower back, there are two muscles in which trigger points commonly occur: the piriformis and the quadratus lumborum.The piriformis was discussed in the chapter on the hip. It is an external rotator of the thigh and is located posterior to the hip joint in the sciatic notch. The piriformis muscle is important because of its proximity to the sciatic nerve. The sciatic nerve either pierces the piriformis or courses directly above or below it.The quadratus lumborum originates on the 12th rib and the transverse processes of L1 through L4. It inserts on the iliac crest. The quadratus lumborum elevates the pelvis.Signs & Symptoms – Palpation of or pressure on a trigger point in the piriformis muscle in the sciatic notch refers pain to the posterior sacroiliac region, to the buttocks, and occasionally down to the posterior or posterolateral thigh. Pain is a deep ache that increases with exercise or with prolonged sitting while the hip is adducted, flexed, and medially rotated. Isometric abduction and passive internal rotation will increase pain. Sciatic pain may also occur with diminished sensation in the leg.A trigger point in the quadratus lumborum produces a sharp, aching pain in the lateral lower back or flank. Pain may be referred to the upper buttocks and posterior sacroiliac region and sometimes to the abdominal wall. Pain increases when the athlete stands for long periods, moves from sitting to standing, or coughs or sneezes. There will be muscle spasm with the pain that is localized to one side. Pain increases when the athlete side bends toward the side of the trigger point.Management – Rehabilitation exercises should include both stretching and strengthening of the involved back muscle. The key in treating myofascial pain is to stretch the muscle back to a normal resting length and thus relieve the irritation that created the trigger point. The athlete should be placed in a comfortable position that also stretches the involved muscle. Active stretching should be mild and progressive. The use of electrical stimulation in combination with ultrasound is helpful in relieving the pain associated with a trigger point. A spray and stretch technique has also been used successfully (using a vapocoolant spray). Progressive strengthening exercises should also be included.
41 Lumbar Sprains Etiology Signs & Symptoms Management Etiology – Sprains may occur in any of the ligaments in the lumbar spine. The most common sprain involves lumbar facet joints. Facet joint sprains typically occur when the athlete bends forward while lifting or moving some object. A traumatic force overextends the spinal joints and causes a sudden onset of a deep, sharp pain. It can occur with a single episode or with chronic repetitive stress that causes a gradual onset that becomes progressively worse with activity.Signs & Symptoms – The pain is localized and is located just lateral to the spinous process. Pain become sharper with certain movements or postures, and the athlete will limit movement in painful ranges. Passive anteroposterior or rotational movements of the vertebrae will increase pain. Pain can be reproduced with certain movements.Management – Like sprains to other joints in the body, the lumbar sprain will require some time to heal. Initial treatment should include PRICE to reduce pain. Joint mobilizations that use anteroposterior and rotational glides can be used to help decrease pain. Strengthening exercises for abdominals and back extensors as well as stretches in all directions should be limited to pain-free ROM. The athlete should be instructed in trunk stabilization exercises. A brace or support should be worn to limit movement during early return to activity. It is important to guard against the development of postural changes that may occur in response to pain.
42 Back Contusions Etiology Signs & Symptoms Management Etiology – Back contusions rank second to strains and sprains in incidence. Because of its surface area, the back is quite vulnerable to bruises in sports. Football produces the greatest number of these injuries. A history that includes a significant impact to the back could indicate an extremely serious condition. Contusion of the back must be distinguished from a vertebral fracture. In some instances, this distinction is possible only through and x-ray examination.Signs & Symptoms – The bruise causes local pain, muscle spasm, and point tenderness. A swollen, discolored area may also be visible.Management – Cold and pressure should be applied immediately for approximately the first 72 hours or longer if necessary, along with rest. Ice massage combined with gradual stretching benefits soft-tissue contusion in the region of the lower back. Recovery usually ranges from two days to two weeks. Ultrasound is effective in treating deep muscle contusions.
43 Cervical Fracture Etiology Signs & Symptoms Management Louisville InjurySigns & SymptomsManagementRutgers InjuryFear the SpearEtiology – Fortunately, the incidence of neck fracture is relatively uncommon in athletics. The spinal cord is well protected by a bony vertebral canal, a connective tissue sheath, fat, and fluid cushioning. Despite this protection, vertebral dislocations and fractures have the potential to result in paralysis. The athletic trainer must constantly be prepared to handle such a situation should it arise. Sports that have the highest incidence of cervical fractures are gymnastics, ice hockey, diving, football, and rugby.Axial loading of the cervical vertebra from the top of the head combined with flexion of the neck can result in an anterior compression fracture or possibly a dislocation. Fractures are most common in the 4th, 5th, or 6th cervical vertebra. If the head is also rotated when contact is made, a dislocation may occur along with the fracture. Fractures can also occur during a sudden forced hyperextension of the neck.Signs & Symptoms – The athlete may have one or more of the following signs of cervical fracture: neck point tenderness and restricted movement, cervical muscle spasm, cervical pain and pain in the chest and extremities, numbness in the trunk and/or limbs, weakness or paralysis in limbs and/or trunk, loss of bladder and/or bowel control.Management – An unconscious athlete should be treated as if a serious neck injury is present until the possibility is ruled out by a physician. Extreme caution must be used in moving the athlete. The ATC must always be aware that an athlete can sustain a catastrophic spinal injury from improper handling and transportation. In the case of an athlete that is wearing protective equipment (Ex. Football player) the equipment should be left on in place to prevent any unnecessary movement of the spine until it have been determined by a physician that it is safe to remove the equipment. Most protective equipment can be x-rayed through for the physicians to see if there is any fracture present.
44 Cervical Dislocation Etiology Signs & Symptoms Management Etiology – Cervical dislocations are not common, but they do occur more frequently in sports than do fractures. Cervical dislocations usually result from violent flexion and rotation of the head. Most injuries of this type happen in pool diving accidents. The mechanism is analogous to the situation that occurs in football when blocks and tackles are poorly executed. The cervical vertebrae are more easily dislocated than are the vertebrae in the other spinal regions, principally because of their horizontally arranged articular facets. The superior articular facet moves beyond its normal ROM and either completely passes the inferior facet (luxation) or catches on its edge (subluxation). The latter is far more common and, as in the case of the complete luxation, most often affects the 4th, 5th, or 6th vertebra.Signs & Symptoms – For the most part, a cervical dislocation produces many of the same signs as a fracture. Both can result in considerable pain, numbness, and muscle weakness or paralysis. The most easily discernible difference is the position of the neck in a dislocation: unilateral dislocation causes the neck to be tilted toward the dislocated side with extreme muscle tightness on the elongated side and a relaxed muscle on the tilted side.Management – Because a dislocation of a cervical vertebra has a greater likelihood of causing injury to the spinal cord, even greater care must be exercised when moving the patient. The should be treated and transported as if a catastrophic injury may have occurred until a physician can rule it out.
45 Acute Strains of the Neck and Upper Back EtiologySigns & SymptomsManagementEtiology – In a strain of the neck or upper back, the athlete usually turned the head suddenly or has forced flexion, extension, or rotation. Muscles involved are typically the upper trapezius, sternocleidomastoid, the scalenes, and the splenius capitis and cervicis.Signs & Symptoms – Localized pain, tenderness, and restricted motion are present. Muscle guarding resulting from pain is common, and the athlete is reluctant to move the neck in any direction.Management – Care usually includes the use of PRICE immediately after the strain occurs and the application of a cervical collar. Follow-up management may include ROM exercises, followed by isometric exercises, and progressing to full-range isotonic strengthening exercises; cryotherapy or superficial heat; and analgesic medications as prescribed by the physician.
46 Cervical Sprain (Whiplash) EtiologySigns & SymptomsManagementEtiology – A cervical sprain can occur from the same mechanism as the strain but usually results from a more violent motion. More commonly, cervical sprain occurs from a sudden snap of the head, such as when an athlete is tackled or blocked while unprepared. Frequently, muscle strains occur with ligament sprains. A sprain of the neck produces tears in the major supporting tissue of the anterior or posterior longitudinal ligaments, the interspinous ligament, and the supraspinous ligament.Signs & Symptoms – The sprain displays all the signs of the strained neck but the symptoms persist longer. There may also be tenderness over the transverse and spinous processes that serve as sites of attachment for the ligaments.Pain may not be experienced initially but always appears the day after the trauma. Pain stems from the inflammation of injured tissue and a protective muscle spasm that restricts motion.Management – As soon as possible, the athlete should have a physician evaluation to rule out the possibility of fracture, dislocation, or disk injury. Neurological examination is performed by the physician to ascertain spinal cord or nerve root injury. A soft collar may be applied to reduce muscle spasm. PRICE is used for hours while the injury is in the acute stage of healing. For an athlete with a severe injury, the physician may prescribe 2-3 days of bed rest along with analgesics and antiinflammation agents. Therapy might include cryotherapy or heat and massage. Mechanical traction may also be prescribed to relieve pain and muscle spasm.
47 Acute Torticollis (Wryneck) EtiologySigns & SymptomsManagementEtiology – Acute torticollis, a very common condition, is more frequently called wryneck, or stiff neck, or occasionally acute cervical joint lock. The athlete usually complains of pain on one side of the neck upon awakening. Wryneck usually occurs when a small piece of synovial membrane lining the joint capsule is impinged or trapped within a facet joint in the cervical vertebra. This problem also can occasionally follow exposure to a cold draft of air or holding of the head in an unusual position over a period of time.Signs & Symptoms – During inspection, there is palpable point tenderness and muscle spasm. Head movement is restricted to the side opposite of the irritation with marked muscle guarding. X-ray examination will rule out a more serious injury.Management – Various therapeutic modalities may be used to modulate pain in an attempt to break a pain-spasm-pain cycle. Muscle guarding can be reduced through joint mobilizations that involve gentle traction, rotation, and lateral bending, first in the pain-free direction, then in the direction of pain. The athlete may find it helpful to wear a soft cervical collar for comfort. This muscle guarding will generally last for two to three days while the athlete progressively regains motion.
48 Cervical Cord and Nerve Root Injuries EtiologySigns & SymptomsSpinal Cord Hemorrhage (C2-C7)Spinal Cord ContusionManagementEtiology – The spinal cord and nerve root may be injured via four basic mechanisms: laceration by bony fragments, hemorrhage (hematomyelia - a hemorrhage into the spinal cord), contusion, and shock. These mechanisms may be combined into a single trauma or may act as separate conditions.LACERATION: Laceration of the cord is usually produced by the combined dislocation and fracture of a cervical vertebra. The jagged edges of the fragmented vertebral body cut and tear nerve roots or the spinal cord and cause varying degrees of paralysis below the point of injury.HEMORRHAGE: Hemorrhage develops from all vertebral fractures and from most dislocations as well as sprains and strains. It seldom causes harmful effects in the musculature extradurally (situated or occurring outside the dura mater) or even within the arachnoid space (In the central nervous system, the subarachnoid cavity (subarachnoid space) is the anatomic space between the arachnoid membrane and pia mater), where it dissipates faster than it can accumulate. However, hemorrhage within the cord itself causes irreparable damage.CONTUSION: Contusion in the cord or nerve roots can arise from any force that is applied to the neck violently but does not cause cervical dislocation or fracture. Such an injury may result from sudden displacement of a vertebra that compresses the cord and then returns to its normal position. This compression causes edematous swelling within the cord, resulting in varying degrees of temporary and/or permanent damage.CERVICAL CORD NEUROPRAXIA: Occasionally a situation arises in which an athlete, after receiving a severe twist or snap of the neck, presents all of the signs of a spinal cord injury. The athlete is unable to move certain parts of the body and complains of a numbness and a tingling sensation in the arms. After a short while, all these signs leave. The athlete is then able to move the limbs quite freely and has no symptoms other than a sore neck. This condition is considered a cervical cord neuropraxia and is caused by cervical spine stenosis. In such cases, the athlete should be cared for in the same manner used for any severe neck injury.SPINAL CORD SHOCK: Spinal cord shock is usually seen with severe trauma to the spinal cord, most often a cord transaction, in which there is an immediate loss of function below the level of the lesion. The limbs are flaccid, in contrast to the later development of spasticity. Also there is a total loss of deep tendon reflexes, again in contrast to the later development of hyperreflexia (An exaggerated response of the deep tendon reflexes, usually resulting from injury to the central nervous system or metabolic disease).Signs & Symptoms – Each of these situations can result in various types of paralysis that affect the motor and/or sensory systems. The level of injury obviously will determine the extent of the functional deficits. Spinal cord lesions may be either complete or incomplete. A complete lesion is one in which the spinal cord has been totally severed and there is a complete loss of all motor function and sensation below the level of the injury. Recovery of significant function below the level of injury is unlikely, although some nerve root function may eventually recover one to two levels below the injury. Complete cord lesions at or above C3 will impair respiration and result in death. Lesions at spinal segment levels below C4 will allow for return of some nerve root function as follows:C4-C5 – Return of deltoid function.C5-C6 – Return of elbow flexion and wrist extension.C6-C7 – Return of elbow and finger extension and wrist flexion.C7-T1 – Return of grip function.Incomplete lesions can result in central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome, or posterior cord syndrome. Central cord syndrome is caused by hemorrhage or ischemia in the central portion of the cord and results in complete quadriplegia with nonspecific sensory loss and in sexual as well as bowel-bladder dysfunction. Brown-Sequard syndrome is caused by an injury to one side of the spinal cord that results in loss of motor function, touch, vibration, and position sense on one side of the body, and loss of pain and temperature sensation on the other side. Anterior cord syndrome is caused by an injury to the anterior two-thirds of the cord that results in loss of motor function and pain and temperature sensation. However, sexual and bowel-bladder function are present. Posterior cord syndrome, although rare, is caused by injury to the posterior cord. Motor function is completely intact.Management – Like suspected cervical fractures and dislocations, suspected injuries of the spinal cord must be handled with extreme caution. Care must be taken to minimize potential damage to the spinal cord. In cases in which evidence of spinal cord damage accompanied by varying degrees of paralysis exists immediately with injury, management efforts must attempt to minimize additional trauma to the cord. Spine boarding and immobilization are a must and transport to ER needs to happen ASAP.
49 Cervical Spine Stenosis EtiologySigns & SymptomsSimilar to cervical fracture – like football videos we watchedManagementEtiology – Cervical spine stenosis is a syndrome characterized by a narrowing of the spinal canal in the cervical region that can impinge the spinal cord. This stenosis occurs either as a congenital variation or from some change in the vertebrae, including the development of bone spurs, osteophytes (a bony outgrowth associated with the degeneration of cartilage at joints) or disc bulges. There are two methods of determining cervical spine stenosis: the Torg ratio and the space available for the cord (SAC). The Torg ratio is determined by dividing the sagittal spinal-canal diameter by the corresponding sagittal vertebral-body diameter. The SAC is determined by subtracting the sagittal spinal-cord diameter from the corresponding sagittal spinal-canal diameter. The Torg ratio and SAC are measured in millimeters. The SAC measure relies more on the spinal canal compared with the Torg ratio and, therefore, may be a more effective indicator of spinal stenosis. This is relevant clinically because neurologic injury related to stenosis is a function of the spinal canal and the spinal cord and not the vertebral body. A ratio of the sagittal canal diameter relative to anteroposterior width of the same vertebrae at its midpoint of less than .80 suggests cervical stenosis.Signs & Symptoms – Transient quadriplegia may occur from axial loading, hyperextension, or hyperflexion. Neck pain may be absent initially. The symptoms may be purely sensory with burning or tingling, or the athlete may have some associated motor weakness in either the arms or the legs or all four extremities. Complete recovery normally occurs within ten to fifteen minutes but may be delayed. Following neurological recovery, full neck ROM is possible.Management – Cervical spine stenosis may be present without any symptoms and signs. The presence of transient quadriplegia necessitates extreme caution initially. The athlete must have diagnostic tests, including X-rays or MRI to determine the extent of the problem. Athletes, particularly those in contact sports, who have been identified as having some degree of cervical stenosis should be advised of the potential risks of continued participation in that sport. There is a growing consensus among physicians that continued participation should be discouraged.
50 Cervical Disk Injuries EtiologySigns & SymptomsManagementEtiology – Herniation of a cervical disk is relatively common and can affect athletes in any sport. A herniation usually develops from an extruded posterolateral disk fragment or from degeneration of the disk. The primary mechanism involves sustained repetitive cervical loading during contact sports.Signs & Symptoms – The symptoms and signs include neck pain with some restriction in neck motion. There is radicular pain (nerve root) in the upper extremity with associated motor weakness or sensory changes.Management – Initial treatment involves rest and immobilization of the neck to decrease discomfort. Neck immobilizations may help the athlete regain some range of motion. Cervical traction may also help reduce symptoms. If conservative treatment is not helpful or if the neurological deficits increase, surgery may be necessary.
51 For Your Quizzes You should be able to: Label the type of vertebrae and their different parts.Label the different muscles of the spinal column.Identify the different types of vertebrae and their parts by using the vertebral models.Identify the different types of injuries discussed for the cervical, thoracic, and lumbar regions of the spinal column/back.