Written Examination Part IV. (36 pts) - Essay: Back and Upper Limb (October 5, 2007)

Anatomy of the Spinal Canal

A 36 y.o.f. comes to your office with complaints of severe low back pain and episodes of urinary incontinence. She is 22 weeks gestation and had developed low back pain over the last few weeks. Concerned about exposing her fetus to analgesics she sought treatment from an alternative health provider. Since then the pain has been severe, constant, and it to the point that she is having difficulty walking. On exam, she is in obvious distress. Her pelvic exam displayed poor rectal sphincter tone and “saddle anesthesia.” Review the anatomy of the spinal canal. Include boundaries, bones, articulations, ligaments, spaces, contents, vascularization, relationships, and lymphatic drainage. (12 pts)

• General Comment
  • Osseofibrous canal protecting the spinal cord
• Boundaries
  • Vertebral foramen
    • Anterior - posterior longitudinal ligament, vertebral body
    • Posterior - lamina
    • lateral right and left - pedicle
  • Intervertebral region
    • Anterior - intervertebral disk
    • Posterior - ligamentum flavum
    • Lateral right and left - intervertebral foramen, zygapophyseal
  • Superior - foramen magnum
  • Inferior - Sacral hiatus
• Bones
  • Seven cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal = 33 (9 fused)
  • C1 and C2
  • Cervical - bifid spines
  • Thoracic - Rib articulations
  • Lumbar - large bodies
  • Sacral - fused
• Articulations
  • Intervertebral disk
  • Zygapophyseal joint
  • Costotransverse and costovertebral joints
• Ligaments and Limitation of Movements
  • Anterior longitudinal ligament - limit extension
  • Posterior longitudinal ligament - limit flexion
  • Ligamentum flavum - limit flexion
  • Interspinous - limit flexion
  • Supraspinous - limit flexion
• Spaces and Contents
  • Epidural space - between bone/ligament and dura mater
    • Internal anterior and posterior vertebral plexuses
    • Epidural fat
  • Subarachnoid space - between arachnoidea and pia mater
    • Cerebral Spinal Fluid
  • Spinal cord - C1 to L2
  • Thecal sac (dural sac) - C1 to S2
  • Filum terminalis internal and external - coccyx
• Vascularization
  • Radicular arteries
    • Augment anterior and posterior spinal arteries
    • Adamkewitz
  • Anterior and posterior internal vertebral venous plexuses
    • Valveless - spread of infection
• Relationships
  • Wall of canal - epidural space - dura mater - arachnoidia - subarachnoid space - pia mater
• Lymphatic drainage
  • Paraaortic nodes

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Anatomy of the Rotator Cuff

A 55 y.o. female comes to your office with persistent right shoulder pain. She states she had begun a weight-training program recently. After increasing her weight on the military press she noted the next morning that her shoulder was quite painful. She felt she may have slept on it wrong but it has not been improving and she is now having difficulty raising her arm above her head. On physical exam, her "oil can" test is positive on the right side. She has difficulty abducting her right arm above her shoulder. She cannot hold her right arm up when you apply resistance during abduction. Review the anatomy of the rotator cuff. Include bones, muscles, movements, vascularization, innervation, relationships, and lymphatic drainage. (12 pts).

• General Comments
  • The rotator cuff, celebrated for its role in lateral rotation, mediates lateral rotation, medial rotation, 15 deg of abduction, and weak adduction.
  • The tendon of supraspinatus is particularly vulnerability to tearing due to the restricted space between it and the acromion.
• Bones: Scapula and Humerus
  • Glenoid fossa
  • Acromion
  • Corocoid process
• Muslces
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis
• Movements
  • Abduction: 15 deg by supraspinatus
  • Adduction: weak by teres minor
  • Lateral rotation: infraspinatus and teres minor
  • Medial rotation: subscapularis
• Vascularization
  • Scapular anastomosis av
  • Shoulder anastomosis av
  • Anterior humeral circumflex av
  • Posterior humeral curcumflex av
  • Subscapular av
• Innervation
  • Suprascapular nerve
  • Axillary nerve
  • Upper and lower subscapular nerves
• Relationships *Subacromial bursa and arch
  • Tendon of the long head of the biceps
• Lymphatic drainage
  • Axillary nodes
  • Cervical nodes
• Clinical Significance
  • Rotator cuff tear - supraspinatus

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Anatomy of the Carpal Tunnel

A 56 y.o. female presents with complaints of "numb hands" in the morning. She states her hands are numb when she first awakens and will resolve after she shakes her hands for a few seconds. She has awakened, occasionally at night with pain in her hands that, again, improves soon after she awakens and rubs them. Physical exam displays no neurovascular compromise in her upper extremities. There is no thenar or hypothenar atrophy. Her Phalen's and Tinnel's tests are positive. Review the anatomy of the carpal tunnel. Include bones, ligaments, contents, relationships, nerve injury, and lymphatic drainage. (12 pts)

• General Comments
• Bones
• Ligaments
• Contents
• Relationships
• Nerve injury
• Lymphatic drainage

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-- LorenEvey - 23 Oct 2007

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