Hand General Principles Hand Anatomy & Biomechanics Tendon Zones & Repair Principles Nerve Anatomy (Median, Ulnar, Radial) Vascular Supply of the Hand Physical Examination & Special Tests Fractures & Injuries Phalangeal Fractures Metacarpal Fractures Thumb Injuries (UCL, Bennett, Rolando) Scaphoid Fractures Perilunate & Lunate Dislocations Carpal Fractures Distal Radius & Ulna Fractures (Wrist) Tendon, Nerve & Ligament Injuries Flexor Tendon Injuries Extensor Tendon Injuries Mallet Finger, Boutonnière Deformity Nerve Injuries (Median, Ulnar, Radial) Ligament Injuries Special Considerations Complex Regional Pain Syndrome (CRPS) Congenital Hand Problems Dupuytren's Disease Infections Carpal Tunnel Kienböck's Disease

< Back Intervertebral Disc Previous Next

< Back Sacral Fractures Sacral Fractures Previous Next

< Back Thoracic Spine Fractures kocaelispor Previous Next

< Back Thoracic Disc Herniation Previous Next

< Back Lumbar Spine Fractures kocaelispor Previous Next

< Back Hangman’s Fracture kocaelispor Previous Next

< Back Lumbar Disc Herniation Previous Next

< Back Compression Fractures sa Previous Next

< Back Osteoporotic Spine Fractures Osteoporotic Spine Fractures Previous Next

< Back Dr. Omer POLAT Anatomy & Biomechanics Overview The human spine is a complex, segmented column providing both mobility and stability for the body. It consists of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 fused coccygeal segments. These vertebrae are interconnected through discs, ligaments, and muscles, forming a biomechanically dynamic structure that supports axial load, enables movement, and protects the spinal cord. Each vertebra comprises a vertebral body and a posterior arch. The body, primarily cancellous bone, functions as the main weight-bearing element. The posterior arch, composed mainly of cortical bone, includes pedicles, laminae, and spinous and transverse processes, which provide attachment points for ligaments and muscles. Between adjacent vertebral bodies lie the intervertebral discs, acting as flexible cushions that absorb compressive forces while allowing controlled motion. Cervical Spine The cervical spine includes seven vertebrae (C1–C7) , forming a lordotic curve in the sagittal plane. C1 (Atlas): ring-shaped, lacks a body, and transmits cranial load through its lateral masses. The atlanto-occipital joint allows flexion–extension (“nodding”) but limited rotation. C2 (Axis): characterized by the odontoid process (dens) , which forms a pivot for C1 rotation, allowing approximately 50% of total cervical rotation. C7: has a prominent, non-bifid spinous process; vertebral arteries typically do not pass through its transverse foramen. Cervical motion includes flexion, extension, lateral bending, and rotation , made possible by the facet orientation and ligamentous configuration. Major cervical ligaments include: Anterior longitudinal ligament (ALL): runs along anterior vertebral bodies, limits hyperextension. Posterior longitudinal ligament (PLL): along posterior vertebral bodies, limits hyperflexion. Ligamentum flavum (LF): connects adjacent laminae; elastic fibers assist in returning to extension. Interspinous and supraspinous ligaments: resist flexion. Nuchal ligament: a continuation of the supraspinous ligament from C1–C7, providing attachment for deep cervical muscles. Transverse ligament of the atlas: stabilizes the dens, maintaining atlantoaxial integrity. Thoracic Spine Composed of 12 vertebrae (T1–T12) , the thoracic spine is kyphotic and articulates with the ribs via costovertebral and costotransverse joints . Typical vertebrae (T2–T8) are heart-shaped and smaller than lumbar bodies. Facet joints are oriented in the coronal plane , permitting limited rotation but restricting flexion–extension. The rib cage enhances structural rigidity, reducing mobility but protecting thoracic organs. Normal thoracic kyphosis ranges between 20° and 50° (average ~35°). Lumbar Spine The five lumbar vertebrae (L1–L5) form a lordotic curve , designed to bear increasing axial loads toward the sacrum. Vertebral bodies enlarge caudally to support greater weight. Facet joints are oriented in the sagittal plane , allowing flexion–extension while limiting rotation. The vertebral foramen is triangular, smaller than cervical but larger than thoracic. Intervertebral discs constitute about 20% of total spinal length , consisting of the annulus fibrosus , nucleus pulposus , and cartilaginous endplates . Discs are largely avascular in adults , adapted for compression but less resistant to torsion. Under normal conditions: The vertebral body carries ~80% of axial load. Facet joints bear the remaining ~20%. In degenerative disc disease, disc height loss shifts up to 70% of load to the facets, increasing posterior stress. Flexion contribution: 75% at L5–S1 , 15–20% at L4–L5 , 5–10% at L1–L4 . Ligaments of the Lumbar Spine Lumbar stability depends on both static (ligamentous) and dynamic (muscular) structures. Anterior longitudinal ligament (ALL): limits hyperextension; major stabilizer of the anterior column. Posterior longitudinal ligament (PLL): resists hyperflexion and confines disc herniation, especially posterolaterally. Ligamentum flavum (LF): elastic, connects laminae; thickens with age, contributing to spinal stenosis. Interspinous ligament (ISL): between spinous processes; tenses during flexion. Supraspinous ligament (SSL): connects the apices of spinous processes from C7 to sacrum; resists excessive flexion. Muscles of the Lumbar Spine Lumbar musculature plays a vital role in postural control, motion, and load transfer . Erector spinae group (spinalis, longissimus, iliocostalis): composed mainly of slow-twitch type I fibers; maintain posture and control trunk extension. Multifidus muscle: short, segmental fibers with a large physiological cross-sectional area, providing segmental stability . Rich connective tissue increases endurance and contributes to passive stiffness. Dysfunction or atrophy is strongly linked to chronic low back pain. Sacrum and Coccyx The sacrum consists of five fused vertebrae forming a wedge-shaped bone that articulates laterally with the iliac bones via the sacroiliac joints . The sacral canal continues from the lumbar spinal canal, terminating at the sacral hiatus , where the coccyx begins. There are four pairs of anterior and posterior foramina , through which the sacral spinal nerves exit. The coccyx , formed by fusion of four small vertebrae, represents the vestigial tailbone and provides attachment for pelvic floor muscles. The sacrum serves as the keystone of the pelvis , transferring spinal load to the lower extremities and contributing to the stability of the lumbopelvic complex. References: Gray H, Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 42nd ed. Elsevier, 2020. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Lippincott Williams & Wilkins, 1990. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. 5th ed. Elsevier, 2012. Adams MA, Dolan P. Spine biomechanics. J Biomech. 2005;38(10):1972–1983. Pal GP, Routal RV. Anatomy and biomechanics of the human vertebral column. Clin Anat. 1999;12(5):324–339. Previous Next

< Back Dr. Recep DINCER Spinal Cord Injury Management Acute spinal cord injury (SCI) is a devastating condition resulting in high morbidity and long-term disability. Management focuses on rapid diagnosis, spinal immobilization, airway protection, and maintenance of perfusion with a target mean arterial pressure of ≥85–90 mmHg. The pathophysiology involves a primary mechanical insult followed by secondary injury cascades—ischemia, inflammation, and apoptosis—which are key therapeutic targets. High-dose steroids are no longer routinely recommended due to limited benefit and adverse effects. Early surgical decompression, ideally within 24 hours, has been shown to improve neurological outcomes in selected patients (STASCIS trial). Emerging therapies such as neuroprotective agents, stem cell transplantation, and neuroprosthetic technologies are under investigation. A structured multidisciplinary approach combining early stabilization, evidence-based acute care, and long-term rehabilitation remains the cornerstone of SCI management. Introduction Acute spinal cord injury (SCI) is a catastrophic event that results in significant morbidity and long-term disability. The annual incidence ranges from 10 to 80 cases per million worldwide, with motor vehicle accidents, falls, sports injuries, and violence being the most common etiologies. · Pathophysiology of SCI involves two major phases: Primary Injury - Mechanical disruption due to fracture, dislocation, compression, or penetrating trauma. - Immediate axonal disruption and vascular damage. Secondary Injury - Occurs minutes to weeks after trauma. - Mechanisms: ischemia, excitotoxicity, ionic imbalance, oxidative stress, lipid peroxidation, apoptosis, and inflammation. - Secondary injury is the main target of medical and surgical interventions. Initial Evaluation and Assessment Prehospital Care - Immobilization: Rigid cervical collar and spinal board use until spinal injury is excluded. - Airway, Breathing, Circulation (ABC): Prioritize airway control with cervical spine protection. - Rapid transport to a designated trauma center. Emergency Department Assessment - Neurological Examination: American Spinal Injury Association (ASIA) Impairment Scale (AIS) used to grade severity. - Imaging: Plain radiographs, CT scan (gold standard for bony injury), MRI (superior for cord compression, hemorrhage, disc, and ligamentous injury). Acute Medical Management Airway and Breathing - High cervical injuries (C1–C4) may require immediate intubation or tracheostomy. - Mechanical ventilation as indicated. Circulatory Support - Neurogenic shock: Characterized by hypotension and bradycardia. - Target mean arterial pressure (MAP): Maintain ≥85–90 mmHg for the first 7 days (AANS/CNS guidelines). - Vasopressors (e.g., norepinephrine) preferred. Pharmacological Management - Methylprednisolone (NASCIS trials): Historically used but remains controversial due to infection and GI complications. - Riluzole: sodium channel blocker; phase II–III clinical trials ongoing. - GM1 ganglioside: promising in preclinical studies but failed in phase III trials. - Minocycline: anti-inflammatory antibiotic; phase II showed motor improvement, phase III underway. -Granulocyte Colony-Stimulating Factor (G-CSF): early trials suggest improved outcomes. - Other preclinical agents: magnesium, fibroblast growth factor, hepatocyte growth factor. DVT and Ulcer Prophylaxis - Low molecular weight heparin, compression devices, frequent repositioning, specialized mattresses. Neuroregenerative Approaches - Rho-ROCK inhibitors (e.g., Cethrin): early promise, but phase III trial stopped for futility. - Anti-Nogo-A antibody: enhances axonal sprouting in animal models, not yet in clinical trials. - Cell-based therapies: Schwann cells, olfactory ensheathing cells, mesenchymal stem cells under investigation; clinical results remain inconsistent. Surgical Management · Indications for Surgery - Persistent spinal cord compression. - Instability of the vertebral column. - Progressive neurological deficit. - Associated unstable fractures or dislocations. Timing of Surgery - Early decompression (<24 hours): Supported by STASCIS trial, associated with improved neurological recovery. Prognosis - Complete injuries (AIS A): Lower likelihood of neurological recovery. - Incomplete injuries (AIS B–D): Higher potential for improvement, especially if early surgical decompression is performed. - Factors influencing prognosis: age, initial severity, level of injury, timing of intervention. Future Directions - Neuroregeneration and stem cell transplantation. - Neuroprosthetics and brain-computer interfaces. - Biomarkers for prognosis and individualized treatment. - Advanced rehabilitation technologies: robotic-assisted gait training, exoskeletons, virtual reality therapies. Key Points - Acute SCI requires rapid diagnosis and structured management. - Initial management: immobilization, airway protection, hemodynamic stabilization, early imaging. - High-dose steroids are no longer routinely recommended. - Early surgical decompression (<24 hours) improves neurological outcomes in selected patients. - Long-term rehabilitation is critical for maximizing functional recovery and quality of life. References 1. Fehlings MG, et al. Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the STASCIS Trial. PLoS ONE. 2012. 2. Hadley MN, Walters BC, et al. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery. 2013. 3. AANS/CNS Joint Section. Management of Acute Cervical Spine and Spinal Cord Injuries. J Neurosurg Spine. 2013. 4. Tator CH, Fehlings MG. Review of the Secondary Injury Theory of Acute Spinal Cord Trauma. J Neurosurg. 1991. 5. Wilson JR, et al. Acute Traumatic Spinal Cord Injury: Current Evidence and Future Directions. Spine. 2020. Previous Next