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
8 out of 10 adults will experience back pain in their lifetime
85% of these patients suffer recurrences within one year of their first episode
Back pain is the 2nd most common reason people see their doctor (after the common cold).

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 people (15-20% of total population) report back pain symptoms (National Pain Foundation, “Fast Facts,” 2003)
12 million people are impaired by back pain (American Chronic Pain Association, “Facts About Chronic Pain,” 1996)
3 million people are chronically disabled by back pain (National Pain Foundation, “Fast Facts,” 2003)
175 million working days are lost annually to chronic back pain (National Pain Foundation, “Fast Facts,” 2003)
45 Million with Back Pain

4. Spine Anatomy Cervical = C1-C7 Dorsal/Thoracic = T1-T12 Lumbar = L1-L5
Sacral = S1-S5
Dura
Normal Disc
The spine is comprised of 33 bones:
Neck (cervical area) 7 vertebrae
Mid-back (thoracic area) 12 vertebrae
Lower back (lumbar area) 5 vertebrae
Sacrum (tail-bone area) 4 or 5 fused bones
The back is a system of vertebral bones, discs and cartilage that form your backbone.
Muscles, ligaments and nerves support this vertebral system.
The function of the vertebral column is to support body weight.
Spinous Process
Body of Vertebra

5. Left and Right Rotation
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
The discs allow flexibility in your spine and act as shock absorbers.
The center of the disc is jelly-like.
It is surrounded by tough rubber-like bands that are attached to the bones (vertebral bones).
The annulus or outer wall is a thick band of support.

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
The discs allow flexibility in your spine and act as shock absorbers.
The center of the disc is jelly-like.
It is surrounded by tough rubber-like bands that are attached to the bones (vertebral bones).
The annulus or outer wall is a thick band of support.

12. Intervertebral Disc Great tensile strength 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 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
The ligaments are tough, non-elastic bands that hold the bones together. They limit motion and if over stretched the joint becomes unstable.

16. Ligaments Posterior longitudinal ligament
Anterior longitudinal ligament
Ligamentum flavum

17. The Most Common Disorders Producing Pain
Acute strains and sprains -Muscle, ligament, joint capsule Spinal Segment Osteoarthritis – 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
Cause
Improper lifting, twisting, falls or other injuries such as whiplash.
Pathology
There is often tearing, bleeding and/ or irritation of the individual muscle or ligament fibers.
Treatment
If the injury is minor, a few days of rest and avoidance of further aggravation is usually satisfactory. If the injury is severe, considerable time may be required for healing. During the healing period, muscles will often become weaker, joints will stiffen and poor posture will develop. This resulting problem can be corrected with gradual reconditioning to restore full flexibility, strength and good posture. The help of a physical therapist may be necessary.

19. Disc Strain Treatment Restricted Activities for no more than 48 hours
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 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
Cause
Slumped sitting, forward bending and lifting.
Pathology
Numbness, weakness, reflex changes in leg (for low back problems) or arm (for neck problems), as well as pain.
Treatment
Requires medical attention and physical therapy treatments such as traction. Severe cases may require surgery. Hopefully, this condition is recognized and managed when it is a small bulge and never gets to this stage.

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
Cause
Narrowing of the canal and spinal cord compression.
Pathology
Boney spurs and aging spine.
Treatment
Anti-inflammatory medications, steroid injections and physical therapy. If it doesn’t improve, surgery may be necessary.

25. Spinal Stenosis

26. SURGICAL TREATMENT OPTIONS

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.
Incision The 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 Removal Once 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 PLUS Posterior Pedicle Screws
NEEDS EXPOSURE SURGEON + FUSION SPINE SURGEON. MULTIPLE SURGICAL PROCEDURES, LONGER HOSPITIZATION, MORE SERVICES UTILIZIED, FRONT AND BACK EXPOSURES

31. Posterior Lateral Fusion
BONE IS CRUSHED INTO A BLOODY THICKENED SLURRY AND APPLIED TO THE BONE SURFACES WHERE STRIPPED, WOUND IS CLOSED

32. Posterior Lumbar Interbody Fusion-”MIS” PLIF

33. Transforaminal Lumbar Interbody Fusion- “Open” TLIF

34. “MINIMALLY INVASIVE” Direct Lateral-MAST DLIF Anterior Interbody Fusion
DLIF! ONE SURGEON. MINIMAL BLOOD LOSS. MINIMAL MUSCLE DAMAGE. HOME WITHIN 23 HOURS. SAME GOALS ACHIEVED AS IN TRADITIONAL TWO-IN-ONE ALIF!