The Innervation of the Vertebral Column

The posterior elements of the vertebral column are innervated by branches of the dorsal
rami of the spinal nerves, while the intervertebral discs and related ligaments are innervated by various branches of the ventral rami
and sympathetic nervous system.
A knowledge of this nerve supply forms the
basis for a systematic classification of the
possible sources of primary spinal pain, and
the basis for several diagnostic techniques that
use needles to provoke and anaesthetize putative sources of pain. In particular, the demonstration of a nerve supply to intervertebral
discs vindicates the concept fhat these structures intrinsically may be sources of pain.

The Innervation of the vertebral

column forms the lInk between vertebral disease and the spIne's most
common symptom - paIn. The nerve
supply of the vertebral column, therefore, has long been a matter of Interest
to clInicians dealIng with spinal paIn,
and consequently, has been a focus of
research actIvIty.
The results of recent research Into
the Innervation of the vertebral column have had, to date, three pnnclpal
ramificatIons. The broadest ramification is that detailIng the InnervatIon
of the vertebral column has enabled
the pOSSIble sources of spinal paIn to
be claSSIfIed In terms of theIr nerve
supply. Although thIS may appear
redundant In the face of eXIsting topographical and pathological claSSIfications of the causes of spinal pain,
a neurological claSSificatIon IS appropriate to the second ramification. ThiS
IS that knowledge of the course and
dlstnbutlon of the IntnnsiC nerves of
the vertebral column has permitted the
development of certaIn objective,
phySIologIcal, diagnostIc technIques.

NIKOLAI BOGDUK
Nikolai Bogduk, B.Sc.(Med.), B.S., Ph.D., Dip.Anal.,
is a Senior Lecturer in the Department of Anatomy,
University of Queensland, and a Visiting Medical
Officer to the Pain Clinic, Princess Alexandra Hospital, Brisbane.

This article is based on a paper presented at the 22nd Annual Conference

of the Anatomical Society of Austraha and New Zealand, Perth, May,
1984, and the Inaugural Meeting of the Austrahan Spmal Research SocIety,
AdelaIde, February, 1985

USIng SUitable target pOInts, needles

or electrodes can be Introduced onto
particular nerves, such as the branches
of the cerVical and lumbar dorsal rami
and used to dIagnose pain anslng from
structures Innervated by these nerves.
Electrodes can be used to stImulate
the nerves In an effort to reproduce
pain In a controlled fashion, whereas
needles can be used to Inject local
anaesthetIC to anaesthetIze selected
nerves In an attempt to relIeve paIn.
By uSing these techniques It IS pOSSIble,
In certain cases, to pin-pOInt the source
of pain In terms of ItS nerve supply.
ThIS approach IS partIcularly worthwhIle when alternatIve diagnostic techniques are Inappropnate or not avaIlable.
The thud ramIfication IS essentially
IdeologIcal. By establIshIng the nerve
supply to the cerVical and lumbar
Intervertebral diSCS, anatomical research has VindIcated the concept that
Intervertebral diSCS Intnnslcally can be
a source of paIn, as opposed to theu
role In spInal nerve compression.

Anatomy
For the purpose of descnptlon, the
innervatIon of the vertebral column
can be conSIdered In two compartments - a ventral compartment consistIng of the Intervertebral diSCS, theIr
assOCIated ligaments, and the dura
mater ventral to the spinal cord and
nerve roots; and a dorsal compartment, consIstIng of the JOints of the
vertebral arches and their lIgaments
and muscles. Throughout the vertebral
column, the ventral compartment IS
Innervated by the sinuvertebral nerves
and other branches of the ventral ramI.
The dorsal compartment is Innervated
by the branches of the dorsal ramI of
the spinal nerves.

Lumbar Dorsal Rami

Although the lumbar dorsal rami
are nomInally mentIoned In textbooks
of anatomy (Hovelacque 1927, Romanes 1972, WarWIck and Williams
1973), descnptlons of the skeletal diStrIbution of these nerves are consplC-

The Australian Journal of PhYSiotherapy Vol 31, No 3, 1985

89

The Innervation of the Vertebral Column

uously absent. Demand for more anatomical data was prompted

principally by clInIcal interest In the
zygapophyseal JOInts. When It was
postulated that these JOInts mIght be
a source of back paIn, It became
relevant to determIne theIr pattern of
innervation. ThIS Issue, as well as the
comprehensive, detailed anatomy of
the lumbar dorsal ramI has been studied repeatedly sInce 1956, wIth each
study contributing new Information
(Pedersen et al1956, LeWIn et a11964,
Lazorthes and Jusklewenskl 1964,
Bradley 1974, Bogduk et al 1982,
Auteroche 1983, Pans 1983).
The LI-4 dorsal ramI are, themselves, very short nerves that anse
from the lum bar spinal nerves and
pass backwards Into the Intertransverse spaces where they dIvIde Into
their branches. The L5 dorsal ramus
differs, in that it is longer and travels
over the top of the ala of the sacrum
(Figure 1). The L 1-4 dorsal ramI/dIvide
into 2 or 3 branches. A medIal branch
and a lateral branch are represented
at all levels. An Intermediate branch
may arise independently from the dorsal ramus, or In common wIth the
lateral branch. The lateral branches
are distributed to the ihocostahs muscles, and those from L 1-3 become
cutaneous over the buttock. The Intermediate branches form an Intersegmental plexus that Innervates the longissimus muscle.
It is the medial branches that are
of paramount clinIcal interest. Each
of these nerves runs across the top of
a transverse process and then along
the junction of the root of the transverse process WIth the root of the
superior articular process (FIgure 1).
Hooking medIally around the base of
the superior articular process, each
nerve is covered by the mamIllo-accessory ligament and then crosses the
vertebral lamina before ~upplYIng
the
multifidus muscle and an interspInal
muscle and ligament. As it crosses the
vertebral lamina, each medIal branch
supplies two zygapophyseal JOInts: the
one above and the one below Its course
90

Intermediate branch Innervates the

lowest fibres of longIssImus. The medIal branch has a dlstnbutlon and
course analogous to those of other
medIal branches, supplyIng the lowest
fibres of multIfIdus and the lumbosacral zygapophyseal JOInt.

Cervical Dorsal Rami

Ibp ~----Io+~l~=tf

Ibp --I---{-I-~,

Figure 1: An Illustration of the left

lumbar dorsal rami (reproduced from
Bogduk et aI, 1982, With permission of
the publishers of the Journal of Anatomy). TP= transverse process, ZJ =
zygapophyseal Jomt; vr = ventral ramus; 1b = lateral branch of dorsal
ramus; Ib = intermediate branch, Ibp
= intermediate branch plexus, mb =
medial branch; a = articular branch, IS
= interspinous branch.

(FIgure 1). Recent studies have revealed that each zygapophyseal JOInt
receIves an addItional InnervatIon ventrally, from the related dorsal ramus
proper (Auteroche 1983, Pans 1983).
Each joint, therefore, receIves a multiple innervatIon: from a dorsal ramus,
and two medial branches.
The L5 dorsal ram us forms only a
medIal branch and a branch that resembles the IntermedIate branches of
the other lumbar dorsal ramI. The

The Australian Journal of PhYSIotherapy Vol 31, No 3, 1985

The anatomy of the cerVIcal dorsal

ramI IS somewhat complex maInly WIth
respect to the nerves at the C 1 and
C2 level. The detaIls of thIS anatomy
and theIr clInIcal ImplIcatIons are reVIewed elsewhere (Bogduk 1982).
At the C3-8 levels, the dorsal ramI
have a unIform and SImple anatomy.
As at lumbar levels, the dorsal rami
themselves are very short and he In
the Intertransverse spaces. Each forms
a lateral and a medIal branch. SometImes the medIal branch may be double. The lateral branches Innervate the
more superfICIal postenor cerVical
muscles whereas each medial branch
crosses the subadjacent transverse
process and Winds around the waIst
of the adjacent articular pIllar (FIgure
2) and supplIes the multIfIdus and
semIspInalIs cerVIciS muscles. The relationshIp of the medIal branches to
the articular pIllars IS constant, and
along thIS part of ItS course each
medial branch gIves off artIcular
branches to the zygapophyseal JOInts
above and below (FIgure 2).
The C3 dorsal ramus forms two
medIal branches. One follows a course
analogous to that of the medIal
branches at lower levels whIle the
other, destined to become the thIrd
OCCIpItal nerve, crosses the lower half
of the C2-3 zygapophyseal JOInt. ArtIcular branches to thIS JOInt are derIved from the thud OCCIpItal nerve as
It crosses the JOInt, or from a communIcating loop between the C2 and
C3 dorsal ramI that also crosses the
dorsal aspect of the JOInt (FIgure 2).

Thoracic Dorsal Rami

The most detaIled descnptlon of the
thoraCIC dorsal ramI, currently avall-

The Innervation of the Vertebral Column

does not address theIr skeletal dIStflbutlon. It can only be presumed that
It must be analogous to that of the
cervIcal and lumbar dorsal ramI.

Sinuvertebral Nerves

Figure 2: An Illustration of a .deep

dissection of the cervical dorsal rami
(reproduced from Bogduk, 1982, with
permission of the publishers of Spine)
The superficial posterior neck muscles
have been resected The lateral
branches (1 b) of the dorsal rami and
the nerves to the mtertransversarll (nl)
have been transected, leavmg only the
medial branches (m) mtact. The C1
dorsal ramus supplies the obllquus
superior (os), obllquus mferlor (01) and
the rectus capitis (rc) muscles The
medial branches of the C2 and C3
dorsal rami respectively form the
greater occipital (gon) and third OCCipItal (ton) nerves. Communlcatmg loops
(c) connect the C1, 2 and 3 dorsal rami
Branches (nnS) of the C2,3) medial
branches mnervate the semlspmalls
capitis, while the C3-8 medial branches
send articular branches (a) to the zygapophyseal Jomts before mnervatmg
multifidus (M) and semlspmalls cervlCIS (SSCe), and those at C4 and C5
form superficial cutaneous branches
(s) TP = transverse process of atlas,
SP = spmous process of T1

able, IS that In Hovelacque's (1927)

textbook, but as wIth prevIous textbook descnptlons of the cervIcal and
lumbar dorsal ramI, thIS descnptlon

The sInuvertebral nerves are recurrent branches of the ventral ramI that
re-enter the Intervertebral foramIna to
be dIstrIbuted WIthIn the vertebral
canal. They are mIxed nerves, each
formed by a somatIc root from a
ventral ramus and an automatic root
from a grey ramus communIcantes.
The earlIest descnptlons of these
nerves (L uschka 1850, SoulIe 1905,
Hovelacque 1927) were focussed at
thoracIc levels and each slnuvertebral
nerve was descrIbed as sendIng
branches to the neck of the nb, to the
vessels of the vertebral canal, the
vertebral bodIes, the dura mater and
the postenor longItudInal lIgament.
There was no mentIon of a dIstnbutIon
to the Intervertebral dISCS, and the
InnervatIon of the thoraCIC dISCS stIll
remaIns unstudIed. It was the putatIve
InnervatIon of the lumbar Intervertebral dISCS, however, that prompted
further study of the sInuvertebral
nerves.
Although earlIer, contrary descnptlons of the lumbar sInuvertebral
nerves eXIst (SpurlIng and Bradford
1939, SpurlIng and Grantham 1940),
and are sometImes stIll propagated
(Lamb 1979, Anderson 1980, Wyke
1980), (see Bogduk 1985 for reVIew),
formal studIes of these nerves are In
agreement (Lazorthes et a11947, Pedersen et a1 1956, Bogduk et al 1981).
Each lumbar sInuvertebral nerve enters
the vertebral canal Just below a pedIcle, lyIng close to the bac k of the
vertebral body. Each forms an ascendIng branch that passes rostrally,
parallel to the postenor longItudInal
lIgament, as far as the next hIgher
Intervertebral diSC. It supplIes thIS dISC
and the postenor longItudInal lIgament, en route. A shorter, descendIng
branch ramifies In the dISC and lIgament at the level of entry of the parent
nerve (Figure 3). In addItIon to thIS

gr

Figure 3: An Illustration of the anatomy

of typical lumbar smuvertebral nerves
(reproduced from Bogduk, 1983, With
permission of the publishers of Spine)
The view IS of the left half of the floor
of the vertical canal. A ventral ramus
(VA) and dorsal root ganglion (drg)
have been retracted to reveal the orlgm
of a smuvertebral nerve (svn) from a
somatic root (s) from the ventral ramus
and an autonomic root (a) from a grey
ramus communicans (gr). Ascendmg
(a) and descendmg (D) branches are
distributed to the postenor longltudmal
ligament (PLL) and the mtervertebral
diSCS (IVD) at the level of entry of the
nerve and at the next level above.

skeletal dIstrIbution, each lumbar

sInuvertebral nerve IS dlstnbuted to
the vessels of the vertebral canal and
to the ventral aspect of the dura mater.

The Australian Journal of Physiotherapy Vol 31, No 3, 1985

91

The Innervation of the Vertebral Column

Enigmatically, despite textbook descriptions of the thoraCIC sInuvertebral

nerves and numerous studies of the
lumbar sInuvertebral nerves, the cervical sinuvertebral nerves have remained undescnbed untl1 recently.
Hovelacque (1927) had noted the origin of the cervical slnu vertebral nerves
from the cervical ventral rami and the
sympathetic nerves accompanyIng the
vertebral artery, but did not explore
theu dIstnbution wIthIn the vertebral
canal. Others have studIed the meningeal distnbutlon of these nerves usIng histologIcal techniques, but dId
not focus on theIr macroscopic anatomy or skeletal dIstrIbutIon, other
than a mentIon (Kimmel 1960) that
the C 1-3 slnuvertebral nerves, en route
to the posterIor cranial fossa, Innervate the ligaments of the median atlanto-axlal JOInt.
A recent study (WIndsor et a11985)
has revealed the anatomy of the cervical slnuvertebral nerves. Not surprISIngly, It IS lIke that of the lumbar
nerves. Each cervical slnuvertebral
nerve cucumvents a pedIcle and ascends to the dISC at the next hIgher
level, supplying that disc, the one at
its level of entry, and the Intervening
posterior longitudInal lIgament (Figure
4).
The distribution of sinuvertebral
nerves to the dura mater, at all levels
of the vertebral column has been well
studied (Kimmel 1960, Edgar and
Nundy 1964). The salIent features are
that each sinuvertebral nerve forms
ascending and descending meningeal
branches. At lower thoraCIC and lumbar regions the descendIng branches
are the longer, extending up to two
segments caudally, while the ascendIng
branch ascends up to one segment. A
reciprocal pattern IS seen at upper
thoracic and cervIcal levels where the
ascending branches extend two to three
segments rostrally but the descending
branch only up to one segment caudally. There IS conSiderable overlap
between nerves from different segments, but most conspicuously,
branches of the slnuvertebral nerves
92

Figure 4: A sketch of the cervical

slnuvertebral nerves as seen In a specImen In which the spinal cord and the
left halves of the neural arches have
been removed Each slnuvertebral
nerve IS formed by a somatic root from
the ventral ramus of a spinal nerve (sn)
and an autonomic root (ar) from the
sympathetiC nerves that accompany
the vertebral artery Within the vertebral canal each slnuvertebral nerve
diVides Into ascending (a) and descending (d) branches that Innervate
the Intervertebral discs (Ivd) and postenor longitudinal ligament (pll) En
route to the postenor cranial fossa,
the C1-3 slnuvertebral nerves cross
and Innervate the ligaments of the
atlanta-axial JOints

are distrIbuted only to the ventral

surface of the dura mater. The postenor dura IS deVOid of nerve endIngs

Ventral Rami
It had been generally unrecognized,
untIl recently, that In addItion to
branches from the sInuvertebral
nerves, Intervertebral diSCS receive an

The Australian Journal of PhYSiotherapy Vol 31, No 3, 1985

InnervatIon from outSide the vertebral

canal. A pIlot study (Taylor and
Twomey 1979) Indicated that branches
to the lumbar Intervertebral diSCS arose
from the lumbar ventral rami as they
emerged from the Intervertebral foramIna. ThIS was subsequently confumed (Bogd uk et a1 1981). Branches
from the ventral rami Innervate the
posterolateral corner of the lumbar
Intervertebral diSCS. The lateral and
antenor aspects, along With the antenor longitudInal hgament, are Innervated by branches from the grey ram I
communIcantes (FIgure 5).
That lumbar dISCS do, In fact, receive an InnervatIon has now been
estabhshed beyond doubt, for contrary
to opposing opinIon (Wyke 1980),
several studIes have now demonstrated
nerve fibres and nerve endings as
deeply as the penpheral third of the
annulus flbrosus In specimens of antenor, postenor, and lateral segments
of lumbar diSCS (Mahnsky 1959, Shlnohara 1970, Bogduk et a11982; YoshIzawa et a1 1980).
The Innervation of thoraCIC dISCS
has not been studied, but the cervical
dISCS appear to have an Innervation
SImIlar to that of lumbar dISCS. Hovelacque (1927) had descnbed branches
to the lateral aspects of the cervical
diSCS from the vertebral nerve, and
thiS has been confIrmed (WIndsor et
a1 1985). Moreover, whIle reveahng
only a few examples of dlssectable
nerves to the front of the cervical
diSCS, a recent study (W Indsor et a1
1985), uSing histological methods,
showed nerve fibres and nerve endings
In specimens of diSC matenal obtained
at operation for antenor cervical fuSion, confirming Ferhc's (1963) earher
report of the same phenomenon.

Clinical Applications
Any component of the vertebral
column that receIVes an InnervatIon IS
theoretically capable of beIng a primary source of pain. In thiS context,
the term 'pnmary' IS used to denote
pain that occurs when nerve endings

The Innervation of the Vertebral Column

The sources of pnmary splndl paIn

can be classIfied accordIng to theIr
nerve supply. Thus, sources Innervated
by the dorsal ramI Include the zyga'"
pophyseal JOInts, the InterspInous lIgaments and the postenor spInal muscles. Sources Innervated by the
sInuvertebral nerves Include the Intervertebral dISCS, the posterIor longItudInal lIgament, the vessels of the
vertebral canal, and the dura mater.
Added to thIS lIst may be the vertebral
bodIes, for although nerve endIngs
have not been demonstrated In vertebral bodIes, It IS conceIvable that
IntrInSIC dIsease of the bodIes could
Irntate nerves runnIng WIth the vessels
WIthIn them. WhIle the Intervertebral
dISCS have been lIsted In the dlstnbution of sInuvertebral nerves, It must
be noted that these structures receIve
an addItional InnervatIon from the
ventral ramI, and the latter may proVIde an addItIonal or alternatIve pathway for the medIatIon of paIn from
these litructures. Further elaboratIon
of thIS claSSIfIcatIon, In terms of pathology, IS avaIlable In other publIcatIons (Bogduk 1980a, 1980b, 1982,
1983, 1984a, 1984b).

Figure 5: The distribution of nerves to

the external aspects of the lumbar
mtervertebral discs (reproduced from
Bogduk, 1983, with permission of the
publishers of Spme) TP = transverse
process; ALL = antenor longltudmal
ligament, VR = ventral ramus, ST =
sympathetic trunks, gr = grey ram I
communicantes, 1 = branches to anterior longitudinal ligament, 2 =
branches to the lateral aspects of mtervertebral diSCS, 3 = branches from
grey rami, 4 = branches from ventral
ramI.

are stImulated by IntnnsiC leSIons of

the vertebral column or dura. ThIS
contrasts WIth leSIons that produce
paIn by Irntating spInal nerve trunks.
The mechanIsm of thIS latter form of
paIn and ItS clInIcal dIstInctIon are
revIewed elsewhere (Bogduk 1984b).

The constancy of the course of the

medIal branches of the dorsal ramI,
across the transverse process at the
lum bar levels and around the artIcular
pIllars at cerVIcal levels permIts the
locatIon of these nerves to be plotted
on radIographs. Consequently, needles
or electrodes can be accurately Introduced onto these nerves for dIagnostIC
and therapeutIc procedures, the detaIls
of WhICh are explained elsewhere (Bogduk and Long 1980, SIUljter and
Mehta 1981, Bogduk 1982).
The advent of these technIques has
brought WIth It a greater awareness of
the InCIdence of spInal paIn due to
dIsorders of the postenor elements of
the vertebral column, as opposed to
dISC dIsease. These technIques now
permIt screenIng for these dIsorders
and the ObjectIve confIrmatIon or exclUSIon of theIr presence. Furthermore, they are enabhng studIes of the
senSItIVity of other dIagnOStic proce-

dures, In partIcular, manual dIagnOSIS.

One study, thus far, has compared
the dIagnOSIS made by a manIpulatIve
therapIst WIth that based on dIagnostIC
blocks, and attests to a remarkably
hIgh senSItIVIty of manual dIagnOSIS
In patients WIth zygapophyseal dIsorders (lull 1984).
The concept of prImary disc pain
was based on the observatIon that
paIn could be produced dUrIng dIScography (HIrsch 1949, LIndholm
1950, SImmons and Segl1 1975, Park
1980). In thIS procedure cerVIcal or
lum bar dISCS are dIstended WIth InjeCtIons of contrast medIum or salIne.
The InjectIon IS locahsed to the dISC
and does not affect the nerve roots.
The observatIon that paIn could be
evoked by thIS procedure IndIcated
that the dISCS must have an IntrInSIC
nerve supply, but prevaIlIng anatomIcal eVIdence and opInIon denIed thIS.
The paIn was, therefore, enIgmatiC
and consequently the valIdity of diScography as a diagnostIc procedure
was dIsputed. The resolutIon of the
nerve supply to the lumbar and cervIcal dISCS now prOVIdes the hItherto
mISSIng anatomIcal substrate for pnmary dISC paIn, and VIndIcates the
onglnal concept.
Comparable to the concept of dISC
paIn IS that of prImary dural pain.
The dura, by haVing an IntnnsiC Innervation, IS a pOSSIble source of
prImary paIn, caused by mechanIcal
or chemical IrrItatIon of nerve root
sleeves. That such IrrItatIon can produce pain has been demonstrated experImentally (El Mahdi et a1 1981).
The ImphcatIon IS that, In condItIons
lIke dISC hernIation, paIn can be due
to irrItatIon of the dura rather than
to nerve compreSSIon. What remaIns
IS for thIS concept to attract a greater
conSIderatIon In the dIfferential dIagnosIs of spInal paIn than It has hItherto
attracted.

Concluding Remarks
Research Into the InnervatIon of the
vertebral column has In recent years

The Australian Journal of PhySiotherapy Vol 31, No 3, 1985

93

The Innervation of the Vertebral Column

expanded the conceptual and practIcal

armamentanum for the dIagnOSIS of
spinal paIn, at least wlth respect to
the cerVIcal and lumbar vertebral column. Companson of modern lIterature wIth that of the past reveals an
expanded awareness of the pOSSIble
causes of paIn, but moreover, better
means of obJecttvely valIdatIng dIfferential dIagnoses. A major frontIer,
however, remaIns and that IS the thoracic vertebral column. The thoraCIC
region has been the 'CInderella' of
spInal paIn research, ostenSIbly because of the apparent Infrequency of
thoracic spinal paIn, but thoraCIC pain
syndromes are becomIng recognIsed
with Increased frequency. Therefore,
there is now a need for studIes of the
neurology of the thoraCIC regIon to be
undertaken, so that dIagnostIC techniques, comparable to those avaIlable
for the neck and low back, can be
deVIsed.

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Anderson J (1980), PathogeneSIs of back pam,
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