Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.

il

The Thoraco-lumbar spine Dr Masharawi Youssef

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

Adaptation of the spine to the upright position throughout evolution

Development of vertebral curvatures V.B. wedging shape

Minimal energy = Integral component of our spinal engine

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 4

Vertebral body sagittal wedging

Masharawi et al (Clinical Anatomy 2008)

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

Adaptation of the spine to the upright position throughout evolution (cont.)

Morphological changes of the Lx-ZAJ
Decrease in sup./inf. Length of inf. facets Increase in interfacet angle & distance Gradual increase in coronal orientation in human Vs chimpanzees

Processes modification for muscle attachements

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

Lumbar Vertebrae
large bodies, thick pedicles, flat transverse processes (in the upper 4 vertebrae)

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

Vertebral body
A thin (but relatively stiff) cortical shell surrounds cancellous bone The top and bottom with deformable & porous cartilage plate = endplates One vertical and two oblique trabecular arrangement Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il
yossefm@post.tau.ac.il

Vertebral body
Different levels have same cancellous bone therefore vertebral strength depends on its size/morphology Decrease in strength with age ( rapid rate 20-40 y.o.) Definite relationship between strength (stress of failure) and relative osseous tissue
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 9

Zygoapophyseal joints
Typical synovial joints Hyaline cartilage &capsule Fibroadipose meniscoids

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

10

Biomechanical features of ZAJ

The ZAJ play an important role in stability and motion control of the spine
(Hyun-Yoon and Byung (Hyun1997)

ZAJ:3% to 25% of compressive load

King 1984)

(Yang and

ZAJ protect the discs from shear forces and excessive flexion & axial rotation
al 1993, Adams and Hutton 1983)

(Grobler et

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

11

Biomechanical features of ZAJ (Cont.)

ZAJ orientation in the transverse plane affect the degree of rotation in W.B
Cassidy et al 1992) (Ahmed et al 1990)

.(Van Schaik 1997,

ZAJ orientation cause rotational coupling in Lx spine

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

12

Transverse facet angles

Masharawi et al.( Spine 2004)

OVERALL VIEW OF TRANSVERSE FACET ANGLES (Left & Right, Superior & Inferior)
120 LSTFA 21 ALL 110 100 90 Means in degrees 80 70 60 50 40 30 20 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 Level of vertebra RSTFA 22 ALL LITFA 23 ALL RITFA 24 ALL

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

13

Facet Tropism/asymmetry
(Masharawi et al Spine 2005)

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

14

The Intervertebral Disc (IVD)

The nucleus usually lies eccentrically, close to the posterior margin of the disc In young adults it is comprised of 70 90% water with a few cartilage cells Capable of transmitting applied pressure in all directions.
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 15

1. Intervertebral disc 2. Vertebral body 3. Dura mater 4. or epidural space Extradura 5. Spinal cord 6. space Subarachnoid

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

16

The annulus fibrosus

Comprised of predominantly type I collagen fibers (designed to resist tension such as occurs during rocking or twisting movements) Arranged in 10-12 sheets (lamellae) Within each lamella the collagen fibers lie at an angle of ~ 60 degrees The annulus functions as a ligament in resisting distraction, bending, sliding and twisting movements of the intervertebral joint
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

17

The cartilage endplate

Formed by a 1mm thick layer of cartilage covering the nucelus pulposus but not the entire extent of the annulus. Outer fibers insert into ring apophysis while inner fibres form a capsule enclosing the nucleus pulposus

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

18

Nutrition of the intervertebral discs occurs via diffusion from arteries in the outer annulus Some suggestion at as water returns after being squeezed out by compression, it carries nutrients with it. (Holm et al 1981).

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

19

Artist's illustration showing the vascular supply to the disc space from the cartilaginous endplate.

1 = segmental radicular artery; 2 = interosseous artery; 3 = capillary tuft; 4 = disc anulus.

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

20

Normal age related changes in the disc

Nucleus Type II collagen of nucleus starts to resemble type I collagen of annulus Water content decreases to 74% by 8th decade Markolf and Morris 1974) Number of healthy cells decreases Concentration of proteoglycans decreases
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 21

Age related changes (cont.)

The Annulus
Collagen fibril size decreases Concentration of elastic fibers in annulus decreases Circumferential clefts and fissures form Water content = 80% first decade, 67% by 30 yo, increases to 87% by 8th decade (Kramer et al 1985)
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 22

Generally, with age

IVD becomes more convex (loss of height not a normal age related change) Lumbar mobility, after the age of 18 has been shown to decrease with age (Hindle et al 1990, Taylor and Twomey 1980 ).

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

23

Generally, with age

Increased stiffness of the IVD is presumed responsible for the decrease in flexion range (Bogduk and Twomey 1991 ). If normal age related changes increase the stiffness of the IVD, instability would not seem to be a consequence of normal age induced changes.
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 24

Anatomical consideration of Spondylosis deformans(S.D.)

Etiology and pathogenesis still unknown (Load > compression >injury) = wrong (Load > increase torsion > injury) = right
(Gracovetzky and Lacono 1985)

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

25

Anatomical consideration of Spondylosis deformans (S.D.)

Osteophytes: cortical overgrowth with subsequent medullary bone Jones et al 1988, Resnick 1985) Common findings in S.D 60%-80% of patients over 50y.o. (Resnick 1985) Men>women (Resnick 1985) Unequal distribution in the spine

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

26

Anatomical consideration of S.D. (contin.)

Defect in the vertebral rim Osteoarthritis of ZAJ Endplate damage/Schmorls nodes Decrease in V.B. heights

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

27

Degeneration

Facet erosion

Facet eburnation

Osteophytes and Rim discontinuity

Dr Masharawi Youssef e-mail: eEndplate yossefm@post.tau.ac.il

damage Scmorls nodes 28

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

29

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

30

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

31

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

32

Scoliosis

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

33

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

34

Spondylolysthesis: degenerative or traumatic

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

35

Isthmic Spondylolysis
Definition

Isthmic spondylolysis is a cleft in the neural arch of a lumbar vertebra occurring either unilaterally or bilaterally at the pars interarticularis most commonly at L5.

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

36

Isthmic Spondylolysis (ISP)

Patho-mechanism and incidence Heredity, repeated stress (e.g. athletes), lumbar hyperlordosis, and anatomical vertebral features have been suggested as possible causative agents.

Occurs in 3% to 7% of the general population, varying during growth (4.4% at age 5-7 years, increasing to 6% at age 18).
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 37

Discussion
During flexion/extension of the spine, the load on the neural arch increases considerably from L1 to L5 when the highest mechanical stress is at the pars interarticularis of L5 (Dietrich and Kurowski 1985). Therefore in ISP The presence of smaller and flatter facets may increase the mechanical stress on the pars interarticularis
(Masharawi et al ESJ 2007)
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 38

Discussion (cont.)
In the normal condition, the sagittaly oriented lumbar facets facilitate flexion and extension of the spine while limiting axial rotation. (Kapandji 1972) Therefore in ISP The more frontally oriented lumbar facets may result in a greater amount of joint surface area during sagittal movements if long enough or repetitive, can end with SP at L5 (Masharawi et al Spine 2007).
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 39

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

40

The cause and effect question

What comes first, the anatomical changes in the neural arch or the pars defects?

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

41

We suggest an interactive model of isthmic spondylolysis

(Masharawi et al Spine and ESJ 2007)

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

42

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

43

Lumbar lordosis Females > males (ca. 10 degrees)

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

44

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

45

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

46

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

47

DISH
Diffuse Idiopathic Skeletal Hyperostosis
: - /- )(Enthesopaty

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

84

).DISH (cont
: " " - )
2991 ( Crubezy and Trinkaus

) ) Candle flame hyperostosis

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

94

).DISH (cont
""

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

05

).DISH (cont
: DISH %51 %02 ) 5891 (Resnick

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

15

).DISH (cont
: )( obesity + + , II A ) 5891 .(Mata et al 1997 , Resnick et al1978, Utsinger et al

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

25

).DISH (cont
DISH ) : ( " "

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

35

SPONDYLOARTHROPATIES (SpA)
- Ankylosing spondilitis - Juvenile ankylosing spondilitis - Late onset spondyloarthropaty - Psoriatic arthritis - Reiters syndrome - Enteropathic arthritis
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il 54

SpA (cont.)
: SpA- (SIJ, Annulus, ZAJ ) "Spondylitis .1
(FUSION) : "Sacroileitis (15%) /: ,costovertebral, costotransverse

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

55

SpA (cont.)
( ALL, PLL,) /

:Enthesopathy/Enthesitis .2

HLA-B27 3. 6 : 50% <Psoriatic spondilitis ,75% < Enteropathic arthritis ,80%< -Reiters ,90%< AS
Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

56

).SpA (cont
4. : )(Undifferentiated SpA -

:Dr Masharawi Youssef e-mail eyossefm@post.tau.ac.il

75

SpA (cont.)
" Seronegative SpA SpA , Rheumatoid factor , Rheumatoid arthritis %08

Dr Masharawi Youssef e-mail: eyossefm@post.tau.ac.il

58