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Section 10 - Trunk & Spinal Column
Learning Outcomes: Students will be able to:
The spine, also known as the spinal or vertebral column, is a column of individual vertebrae stacked one on top another. The spine has four major functions:
Figure 1
Regions of the Spine
Cervical Spine (neck) contains seven vertebrae (C1-C7) with the convexity of the curve anterior (lordosis).
Thoracic Spine (upper and middle back) contains twelve vertebrae (T1-T12) with the convexity of the curve posterior (kyphosis).
Lumbar Spine (low back) contains five vertebrae (L1-L5) with the convexity of the curve anterior (lordosis).
Sacrococcygeal spine (pelvic) contains the sacrum consisting of five fused vertebrae (S1-S5) and the coccyx consisting of four partially or fully fused vertebrae (Co1-Co4) with the convexity of the curve posterior (kyphosis).
Development of Spinal Curves
Primary Curves (thoracic and sacrococcygeal) are formed before birth.
Secondary Curves (cervical and lumbar) are formed after birth.
Note: The terms of kyphosis and lordosis are sometimes used to describe excessive curvatures in the thoracic and lumbar spinal regions respectively. However, they are also used to simply describe the direction of the curves with the cervical and lumbar regions projecting anteriorly (lordosis – a position of extension), and the thoracic and sacrococcygeal regions projecting posteriorly (kyphosis – a position of flexion).
Atlantooccipital & Atlantoaxial Joints
Atlantooccipital (condyloidal)
- Occiptial condyles of skull sitting on the articular fossa of the atlas. ≈15° flexion/extension from anatomical.
Atlantoaxial composed of two lateral facet joints (arthrodial) and one median joint named atlanto-odontoid (trochoidal).
Rotation of atlas (C1) around the fingerlike process (odontoid process or dens) of the axis (C2) during rotation of the head.
Figure 2
Joints of the Spine
Spinal joints involve two adjacent vertebrae which is known as a spinal segment. Each spinal segment is made up of an anterior median joint (intervertebral disc joint) and two posterolateral joints (vertebral facet joints). Naming a spinal segment is done by referencing the levels of the two vertebrae involved. For example, the joint between the third thoracic vertebrae and the fourth thoracic vertebrae is called the T3-T4 spinal segment.
Vertebral Facet Joints: the articulation between the inferior articular process/facet of the superior vertebra and the superior articular process/facet of the inferior vertebra. The orientation (plane of joint) of the facets determine the movement that is best allowed at that level of the spine. From C1-C2 to L5-S1,the facet joints are arthrodial joints.
Cervical facets: oriented in an oblique plane (45º between the transverse and frontal planes) allowing motion in the transverse plane (neck right and left rotation) and frontal plane (neck right and left lateral flexion).
Thoracic facets: generally oriented in a frontal plane facilitating trunk right and left lateral flexion (limited by rib cage).
Lumbar facets: generally oriented in the sagittal plane mostly allowing lumbar flexion and extension.
Figure 3
Spinal Movements & Range of Motion
Cervical Region: Flexion 50-60°, Extension 50-60°, Right and Left Lateral Flexion 45°, Rotation 80°
Thoracic Region: Flexion 35º, Extension 25º, Right and Left Lateral Flexion 25º, Right and Left Rotation 30º
Lumbar Region: Flexion 30°, Extension 20°, Right and Left Lateral Flexion 20°-30º, Right and Left
Rotation 5°
Vertebral Facets & Spinal Motion
Spinal Flexion: Both facets “open”
Spinal Extension: Both facets “close”
Side Bending and Rotation: Concavity side “closes” and convexity side “opens”.
Figure 4
Intervertebral Disc Joint: is located between the bodies of two adjacent vertebrae and classified as an amphiarthrodial – symphysis joint. The disc is composed of 1) an outer annulus fibrosus and 2) an inner nucleus pulposus. The disc is attached to the bodies of the vertebrae via the vertebral endplates. The disc allows for movement, absorbs shock, helps bear the weight of the body, and helps maintain the opening of the intervertebral foramina.
Figure 5
How to Keep Intervertebral Discs Healthy
-Exercise Regularly -Avoid Smoking
-Drink Plenty of Water -Avoid Alcohol
-Eat a healthy diet -Avoid Repetitive
Flex/Ext Exercises
Myotome & Dermatome Testing
As previously mentioned, spinal nerves have motor fibers and sensory fibers. The motor fibers innervate certain muscles, while the sensory fibers innervate certain areas of skin.
Nerve Damage: Nerves are typically injured through compression or tensile/stretching forces. When a nerve root in the brachial or lumbosacral plexus is damaged, certain patterns of motor and sensory deficits occur in the corresponding limbs. Myotomes and dermatomes are used to evaluate these deficits.
Myotome Testing
The myotomes may be tested, in the form of isometric resisted muscle testing, for weakness of a particular group of muscles. Results may indicate lesion to the spinal cord nerve root level, or intervertebral disc herniation pressing on the spinal nerve roots. All tests should be compared bilaterally.
**Link to view myotome testing procedures: (www.youtube.com/watch?v=rKiTwagLYck)
Lower Extremity Myotomes
Nerve Root Level
Patient Position
Joint & Movement Resisted (tested)
L1-L2
Sitting
Hip flexion
L3
Knee extension
L4
Long sit
Ankle dorsiflexion
L5
Big toe extension
S1
Prone
Ankle plantarflexion, Foot eversion, and Hip extension
S2
Knee flexion
Dermatome Testing
To test for sensory nerve root damage, the corresponding dermatomes supplied by that nerve root may be tested for abnormal sensation (Hypoesthesia = decreased sensation, Hyperesthesia = excessive sensation, Anesthesia = artificially induced loss of pain sensation, and Paresthesia = numbness, tingling, burning sensation) To test for sensitivity of a dermatome: heat, cold, a pin, cotton ball, paper clip, the pads of the fingers, or fingernails may be used. The patient, with their eyes closed, should be asked to provide feedback regarding their response to the various stimuli. All tests should be compared bilaterally.
Dermatomes of the Lower Extremity
Cutaneous Distribution of the Lower Extremity
Figure 6
Figure 7
A cutaneous distribution pattern is an area or patch of skin supplied by a specific sensory peripheral nerve. That nerve maybe be made up of sensory fibers from one or more nerve levels. Here are some examples of lower extremity nerve cutaneous distributions.
Nerve Root
Dermatome Afferent
(Sensory)
Myotome Efferent
(Motor)
Functional Application
L1
Touch: Lower abdomen, groin, lumbar region from 2nd to 4th vertebrae, upper and outer aspect of the buttocks
Quadratus Lumburum
Sensation to low back, over trochanter and groin
L2
Touch: Lowe lumbar region, upper buttock, anterior aspect of thigh
Iliopsoas
Quadriceps
-Hip flexion
-Sensation to back, front of thigh to knee
Touch: Medial aspect of thigh to knee, anterior aspect of lower 1/3 of the thigh to just below the patella
Psoas
-Knee extension, hip flexion
-Sensation to back, upper buttock, anterior thigh and knee, medial lower let
Touch: Medial aspect of lower leg and foot, inner border of foot, great toe
Tibialis Anterior
Extensor Hallucis Longus
Digitorum Digitorum Longus
Peroneals
-Ankle dorsiflexion, subtalar and transverse tarsal inversion
-Sensation to medial buttock, lateral thigh, medial leg, dorsum of foot, great toe
Touch: Lateral border of leg, anterior surface of lower leg, top of foot to middle three toes
Extensor Digitorum Longus
Gluteus Maximus and Medius
Dorsiflexors
-Great toe extension, subtalar and transverse tarsal inversion
-Sensation to upper lateral leg, anterior surface of the lower leg, middle three toes
Touch: Posterior aspect of the lower ¼ of the leg, posterior aspect of the foot, including the heel, lateral border of the foot and sole
Gastrocnemius
Soleus
Hamstrings
-Ankle plantarflexion, knee flexion, subtalar and transverse tarsal inversion
-Sensation to lateral leg, lateral foot, lateral two toes, plantar aspect of foot
Touch: Posterior central strip of the leg from below the gluteal fold to ¾ of the way down the leg
Gluteus Maximus
-Knee Flexion, Ankle plantarflexion, toe flexion
-Sensation to posterior thigh & upper posterior leg
Spinal Ligaments
1. Ligamentum Nuchae
2. Supraspinal
3.Ligamentum Flavum
4.Interspinal
5.Intertransverse
6.Anterior Longitudinal
7.Posterior Longitudinal
Figure 12
Figure 13
Figure 14
Figure 15
Selected Major Muscles of the Spine (including skull and pelvis)
Sternocleidomastoid
Origin:
Insertion:
Actions:
Nerve Innervation:
Splenius Cervicis & Capitis
Suboccipitals
Selected Major Muscles of the Spine
Quadratus Lumborum
Rotatores
Multifidus
Selected Major Muscles of the Spine – Erector Spinae Muscle Group
Erector Spinae: Spinalis
Erector Spinae: Longissimus
Erector Spinae: Iliocostalis
Muscles of the Abdominal Wall
Rectus Abdominis
Internal Abdominal Oblique
External Abdominal Oblique
Transverse Abdominis
Abdominal Aponeurosis
A large sheet of fibrous connective tissue located anteriorly in the
abdominal region (right and left sides) providing attachment sites for
the external abdominal oblique, internal abdominal oblique, and the
transverse abominus muscles.
abdominal aponeuroses meet in the midline.
muscles into segments and are a continuation of the abdominal
Aponeurosis.
Figure 22
Functions of the Abdominal Wall
Abdominal Considerations
Protection ____________________________
Support of Viscera _____________________
Elimination ___________________________
Forced Expiration ______________________
Stabilization of Trunk and Pelvis __________
Trunk Movement ______________________
Parturation ___________________________
Kinesiology of the Abdominal Muscles: List in order
the importance or degree of involvement of the
abdominals in the following activities.
_____ Straight leg raises (unilateral) _____ Pull-ups
_____ Straight leg raises (bilateral) _____ Curl-ups
_____ Sit-ups _____ Ambulation
_____ Push-ups
Causes for weakness of the abdominal wall
Abdominal Ptosis: Sagging abdomen
Beevor’s Sign: Looking for umbilicus displacement
Figure 24
Thoracolumbar Fascia
A large sheet of fibrous connective tissue located posteriorly in the
thoracic and lumbar trunk regions (right and left sides) providing
attachment sites for the muscles and to add stability to the trunk.
encased withing the thoracolumbar fascia.
attachment into the thoracolumbar fascia.
processes in the lumbar region.
abdominus muscles attach to it.
iliac crest, providing attachment for the gluteus maximus.
Lower Crossed Syndrome
Note: Not always but a lower crossed syndrome will
often be associated with an upper crossed syndrome.
Causes
or other deformities of foot, knee, or hip
Considerations
Therapeutic Interventions for Lower Crossed Syndrome
In the spaces below identify the muscles that are “weak” and those that are “tight” with respect to Lower Crossed
Syndrome and then identify therapeutic interventions to help correct the problem.
Therapeutic Intervention – How would you isolate to
strengthen the weak muscles?
stretch the tight muscles?
Scoliosis – Lateral deviation(s)/curve(s) of the spine with coupled vertebral rotation to the opposite side: Spinous processes rotate toward concavity of curve and the vertebral bodies rotate toward the convexity of the curve. The convexity of the curve is the reference side of the curve for nomenclature (right convexity = right curve).
Congenital spinal deformities, neuron-
muscular problems, leg length difference
cerebral palsy, muscular dystrophy
Idiopathic scoliosis is broken down into four categories based on age:
1) Infantile: children ages 3 and under
2) Juvenile: ages 3 to 9
3) Adolescent: ages 10-18
4) Adult: after skeletal maturity.
The most common form of Scoliosis, representing 80% of idiopathic scoliosis cases, is Adolescent Idiopathic Scoliosis, which develops around the onset of puberty. People with a family history of spinal deformity are at greater risk for developing scoliosis.
Early detection is essential.
Signs of Scoliosis – common characteristics:
Figures 27, 28
Adam’s Forward Bend Test: with their feet together
have the patient bend forward, bending 90º at the waist.
(angulation = Razor back sign) in thoracic
area
and paraspinal muscle prominence in the
lumbar
area.
Figure 29
Types/Classifications of Curves
Figure 30
Figure 31
Nomenclature
Simple “C”
Compound “S” (double
major curve)
Degree Curvature and Therapeutic Interventions
If curvature of curve is:
= significant
= back bain
= arthritis
= degenerative disc disease
Cobb Method for Measuring Degree of Scoliosis
Choose the most tilted vertebrae above and below the
apex of the curve. The angle between intersceting lines
drawn perpendicular to the top of the vertebrae and the
bottom of the vertebrae is the Cobb Angle.
Figure 32
Figure 33
Sample of Review Questions
tend to provide relief for this patient?
that could occur?
surgery?
to the back extensor muscle group?