Clinical Anatomy

Back

Objectives
Describe the parts of
vertebrae and learn
distinguishing features for
each.
Analyze why flexion is
limited in the thoracic
region and extension is
maximum in the lumbar
region.

Objectives

Draw and label the parts of a

spinal nerve. Recognize the
different types of fibers a spinal
nerve carries.
Draw a schematic transverse
section through the spinal cord,
meninges, and vertebrae
Understand the structure and
function of the dorsal and
ventral spinal nerve roots and
rami

Objectives
Describe the Meninges and the
clinical significance of where to
perform a spinal tap
Recognize why the superficial
muscles of the back have no
action on the vertebral column
Recognize the actions of intrinsic
muscles of the back on the
vertebral column and evaluate
possible causes of low back pain

Overview

Back-extends from the neck to

the buttocks
Skin and subcutaneous tissue
Superficial layer of muscles:
function is to
Deep layer of muscles>function
is to
Vertebral column
Ribs
Pelvic girdle

Back

VERTEBRAE

Vertebrae
How many vertebrae?
How are they arranged?
What happens to the size of the
vertebrae?
I-V discs, what is their function??
How many IV discs are there?

Vertebral column
Curvatures of the vertebral
column
Cervical
Thoracic
Lumbar
sacral

Vertebrae
Typical features
Vertebral body
Vertebral arch
Pedicle
Lamina
Vertebral foramen
Epiphyseal rim
Seven processes:
2TP, 1SP, 2superior and 2 inferior
articular processes

SUMMARY OF VERTEBRAL CHARACTERSTICS

VERTEBRAE
Cervical

DISTINCTIVE FEATURES
Small bodies, large vertebral foramina, foramina in transverse
processes, anterior and posterior tubercles, bifid spinous processes,
transverse foramina

Thoracic

Heart-shaped bodies, long spinous processes angled posteroinferiorly;

costal facets for rib articulation on bodies and transverse processes

Lumbar

Large kidney-bean-shaped bodies, sturdy laminae, thick and short

spinous processes, mammillary processes on the posterior surface of
the superior articular facets (processes)

Sacral

Fused as sacrum, four pairs of dorsal and ventral foramina for nerve
exit and triangular sacral canal

Coccygeal

Fused as small triangular bonethe coccyx

Vasculature of Vertebral Column

Segmental branches of vertebral and
ascending cervical arteries in the neck
The major segmental arteries of the
trunk:
Posterior intercostal arteries in the
thoracic region
Subcostal and lumbar arteries in
the abdomen
Iliolumbar and lateral and medial
sacral arteries in the pelvis

Spinal cord and back

Objectives

Draw and label the parts of a spinal nerve.

Understand the different types of fibers a spinal
nerve carries.
Describe the Meninges and the clinical
significance of where to perform a spinal tap.
Draw a schematic transverse section through
the spinal cord, meninges, and vertebrae
Understand the structure and function of the
dorsal and ventral spinal nerve roots and rami
Know the levels of the principle dermatomes
Describe the vasculature supply of the spinal
cord and vertebral column

Spinal cord
Originates at the inferior end of the
medulla oblongata and terminates
as conus medullaris
Is approximately 42 to 45 cm long
from the foramen magnum to L2
Is connected from the conus
medullaris to the coccyx by the
filum terminale (a strand of
connective tissue that connects
exits from the dural sac and passes
through the sacral hiatus)

Spinal cord
Cervical enlargement - corresponds
roughly to the brachial plexus nerves,
which innervate the upper limb. It includes
spinal cord segments from about C4 to T1.
The vertebral levels of the enlargement are
roughly the same (C4 to T1).
Lumbosacral enlargement - corresponds to
the lumbosacral plexu nerves, which
innervate the lower limb. It comprises the
spinal cord segments from L2 to S3 and is
found about the vertebral levels of T9 to
T12.

Spinal cord
Has the following features in cross
section
Dorsal median sulcus and ventral
median fissure that divide cord into
symmetrical halves
Central canal carrying cerebrospinal
fluid (CSF)
White matter surrounding an Hshaped core of grey matter (ventral
and dorsal horns)

Spinal cord
Structure of Spinal Nerves 31 pairs
of spinal nerves
8 cervical, 12 thoracic, 5 lumbar, 5
sacral, 1 coccygeal
C1C7 exit superior to corresponding
vertebrae
C8 exits inferior to the C7 vertebra
T1Co exit inferior to corresponding
vertebrae

Spinal cord
Ventral roots

Carry efferent (motor) fibers with

their cell bodies in the ventral horn of
the cord
May contain presynaptic autonomic
fibers

Dorsal roots

Carry afferent (general and visceral

sensory) fibers with their cell bodies
in the dorsal root ganglion (DRG)
May be absent in C1 and Co

Spinal cord
Ventral and dorsal roots: combine
to form a (mixed) spinal nerve which
exits through the intervertebral
foramen and divides almost
immediately into (mixed) ventral
and dorsal rami
Caudal equina: spinal nerve roots
inferior to the conus medullaris,
travelling obliquely to exit vertebral
canal

Segmental
Level
Cervical

Number of
Nerves
8 (C1-C8)

Thoracic

12 (T1-T12)

Lumbar

5 (L1-L5)

Sacral

5 (S1-S5)

Nerves S1-S4 branch into anterior and posterior rami within the
sacrum, with the respective rami passing through the anterior and
posterior sacral foramina

Coccygeala

1 (Co1)

The 5th sacral and coccygeal nerves pass through the sacral hiatus

a The

Level of Exit from Vertebral Column

Nerve C1a (suboccipital nerve) passes superior to arch of vertebra C1
Nerves C2-C7 pass through IV foramina superior to the
corresponding vertebrae
Nerve C8 passes through the IV foramen between vertebra C7 and
T1
Nerves T1-L5 pass through IV foramina inferior to the corresponding
vertebrae

first cervical nerves lack posterior roots in 50% of people, and the coccygeal nerves may be

Spinal segments
Because the vertebral column grows longer
than the spinal cord, spinal cord segments do
not correspond to vertebral segments in
adults, especially in the lower spinal cord.
In the fetus, vertebral segments do
correspond with spinal cord segments. In the
adult, however, the spinal cord ends around
the L1/L2 vertebral level, forming a structure
known as the conus medullaris. For example,
lumbar and sacral spinal cord segments are
found between vertebral levels T9 and L2.

Meninges
Dura mater:
Tough fibroelastic membrane

Attached to the margins of the foramen magnum and

posterior longitudinal ligament
Separated by the epidural space from vertebral
periosteum
Extends as a sac from the margin of the foremen
magnum to the level of S2
Pierced by spinal nerves
Anchored to the coccyx by the external filum
terminale
Forms dural root sleeves covering the spinal
nerves before fusing with the epineurium

Meninges
Arachnoid mater:
Delicate, avascular, fibroelastic membrane
lining dural sac
Opposed to dura by CSF pressure
Is external to the subarachnoid space,
between arachnoid and pia, containing CSF,
traversed by strands of connective tissue
(arachnoid trabeculae)
Contains the lumbar cistern, an
enlargement of subarachnoid space
between L2 and S2

Meninges
Pia mater:
Highly vascular innermost layer
covering roots of spinal nerves
Continues as the filum terminale
Suspends the spinal cord within
the dural sac by lateral
extensions between the anterior
and posterior roots, called
denticulate ligaments

Dermatomes
A well-defined strip of skin extending from the
anterior to the posterior midline, supplied by a
single spinal nerve
Cervical supply neck and upper limb
Thoracic supply trunk (T1 also supplies upper
limb)
C5 abuts T1 on the superior anterior chest wall
Lumbar predominantly supply anterior lower
limb
Sacral predominantly supply posterior lower
limb

LEVEL
C5
T4
T10
L1
L3/4
S2S4

SOMATIC SUPPLY
Clavicles
Nipples
Level of umbilicus
Inguinal ligament
Over the knee
Perineum

SPINAL CORD
BLOOD SUPPLY TO THE SPINAL CORD

Anterior spinal artery

Is a single artery running in
ventromedian fissure
Arising from branches of the
vertebral arteries (with
contributions from the ascending
cervical, deep cervical, intercostal,
lumbar, and sacral arteries)
Supplies the anterior two thirds of
the spinal cord and vertebral
bodies

Posterior spinal arteries

Are paired, longitudinal
arteries arising from
vertebral or posterior inferior
cerebellar arteries
Supply posterior one third of
the spinal cord and vertebral
bodies

SEGMENTAL ARTERIES
Anterior and posterior segmental
medullary arteries are derived from the
spinal branches of the ascending cervical,
deep cervical, posterior intercostal, and
lumbar arteries.
The medullary segmental arteries are
located chiefly where the need for a good
blood supply to the spinal cord is
greatestthe cervical and lumbar
enlargements

SEGMENTAL ARTERIES

These arteries enter the vertebral

canal through the intervertebral
foramina and reinforce the
anterior and paired posterior
spinal arteries.
It is the segmental medullary
arteries that primarily provide
additional vascularization to the
spinal cord

SEGMENTAL ARTERIES
Great anterior segmental artery (of
Adamkiewicz)
Occurs on the left side in 65% of
individuals
Contributes to two thirds of the circulation
to the inferior spinal cord
It typically arises from a left posterior
intercostal artery, which branches from
the aorta, and supplies the lower two
thirds of the spinal cord via the anterior
spinal artery

RADICULAR ARTERIES
The dorsal and ventral radicular
arteries are also derived from the
spinal branches of the ascending
cervical, deep cervical, posterior
intercostal, and lumbar arteries.
These arteries course along most
nerve roots (all except those
supplied by a segmental medullary
artery) and supply blood to the
dorsal and ventral roots of the
spinal nerves and their coverings.

RADICULAR ARTERIES
The dorsal and ventral radicular
arteries typically do not reach
the anterior or posterior spinal
arteries.
Most radicular arteries are small
and supply only the nerve roots;

VEINS OF SPINAL CORD

Veins: Usually 3 anterior and 3 posterior
longitudinal spinal veins with tributaries from
the posterior medullary and radicular veins.
They drain into the valveless vertebral venous
plexus.
Vertebral venous plexus is continuous with the
cranial dural venous sinuses and contains no
valves
Internal vertebral plexus (lying in the
extradural space) drains the spinal cord
External vertebral plexus connects with
azygos vein, superior and inferior vena
cavae

Clinical relevance

Compression of spinal nerve roots

Lumbar spinal puncture
Spinal anesthesia
Epidural anesthesia
Ischemia of spinal cord
Spinal cord injuries

Clinical points
Epidural hematomas
Subdural hematomas
Meningitis

Muscles of back
Superficial back,

Muscles of the back

The extrinsic back muscles include
superficial and intermediate muscles
that produce and control limb and
respiratory movements, respectively
The intrinsic (deep) back muscles
include muscles that specifically act
on the vertebral column, producing
its movements and maintaining
posture

SUPERFICIAL EXTRINSIC MUSCLES OF BACK

MUSCLE

ORIGIN

INSERTION

Trapezius

Ligamentum
nuchae; spines
of C7T12

Lateral clavicle,
acromion,
spine of
scapula,
Intertubercular
groove of
humerus

Latissimus Spines of T6
dorsi
T12,
thoracolumbar
fascia, iliac
crest
Levator
Transverse
scapulae processes C1
C4

Superior
medial border
of scapula

ACTION
Elevates,
retracts, and
rotates
scapula
Extends,
adducts,
medially
rotates
humerus
Elevates
scapula

INNERVATION
CN XI, spinal
root, spinal
nerves C3C4
Thoracodorsal

Dorsal
scapular
C3and 4

MUSCLE

ORIGIN INSERTI
ON
Rhomboi Spines Inferior
d minor of C7 medial
T1
border
of
scapula
Rhomboi Spines Inferior
d major of T2 medial
border
T5
of
scapula

ACTION
Retracts and
rotates
scapula

Retracts and
rotates
scapula

INNERVATIO
N
Dorsal
scapular

Dorsal
scapular

INTERMEDIATE EXTRINSIC MUSCLES OF BACK

MUSCLE

ORIGIN

INSERTION ACTIO INNERVATIO

N
N

Serratus
posterior
superior

Spines of
C7T3

Superior
border of
ribs 25

Elevate Intercostal
s ribs nerves T2
T5

Serratus
posterior
inferior

Spines of
T11L2

Inferior
border of
ribs 812

Depres Intercostal
ses
nerves T9
ribs
T12

Triangle of auscultation
It has the following boundaries:
Superiorly and medially, by the
inferior portion of the Trapezius
Inferiorly, by the Latissimus Dorsi
Laterally, by the medial border of
the scapula

BACK
DEEP BACK

MUSCLE

ORIGIN

INSERTION

ACTION

Superficial layer: splenius

Splenius capitis
Splenius cervicis

Ligamentum nuchae
Spinous processes of
C7T3/4

Capitis: Mastoid,
nuchal line
Cervicis: Transverse
processes C1C4

Unilaterally: Laterally
flex and rotate head
Together: extend
head and neck

Angles of ribs

Unilaterally: laterally
flex column,
Together: extend
vertebral column and
head

Intermediate layer: erector spinae

Iliocostalis
Longissimus

Spinalis

Sacrum, iliac crests,

and lumbar spinous
processes

Thoracic and C
ervical transverse
processes, and to
mastoid process
Thoracic spinous
processes, skull

Deep layer: transversospinalis

Occipital bone,
Semispinalis Transverse
processes C4
spinous processes
T12
46 segments
above
Multifidus
Sacrum, ilium,
Spinous processes
transverse
24 segments
processes T1T3 above
Rotatores

Transverse
processes

Spinous processes
12 segments
above

Extend and
rotate column
contralaterally
Stabilize
vertebrae
during small
movements
Locally extend
and rotate
vertebral
column

Minor deep layer

Interspinales

C and L spinous
processes

Spinous process above

Aid in
extension of
rotation of
column

Intertransvers C and L transverse

arii
processes

Transverse processes
above

Levatores
costarum

Ribs, between tubercle

and angle

Aid in
lateral
flexion of
column
Elevate ribs,
aid in lateral
flexion

Tips of transverse
processes C7T11

Intermediate layer

Interspinales , intertransversii,Levtores costorum

Flexion

Extension

Bilateral action of Deep neck muscles

Longus coli
1, semispinalis
Scalene
cervicis and
Sternocleidomast iliocostalis cervicis
oid
2, splenius cervicis
and levator
scapulae
3, splenius capitis
4, multifidus
5, longissimus
capitis
6, semispinalis
capitis
T, trapezius

Lateral Bending

Rotation (not shown)

Unilateral action of Unilateral action of

Iliocostalis cervicis Rotatores Semispinalis
Longissimus capitis capitis and cervicis
and cervicis Splenius Multifidus Splenius cervicis
capitis and cervicis
Intertransversarii
and scalenes

Suboccipital Muscles
Muscle
Origin
Rectus capitis
Spinous process of
posterior major
vertebra C2

Insertion
Lateral part of inferior nuchal line
of occipital bone

Rectus capitis
posterior minor

Posterior tubercle of
posterior arch of
vertebra C1

Medial part of inferior nuchal line

of occipital bone

Obliquus capitis
inferior

Posterior tubercle of
posterior arch of
vertebra C2

Transverse process of vertebra C1

Obliquus capitis
superior

Transverse process of
vertebra C1

Occipital bone between superior

and inferior nuchal lines

Suboccipital Triangle
Aspect of Triangle
Superomedial boundary

Structures
Rectus capitis posterior major

Superolateral boundary

Obliquus capitis superior

Inferolateral boundary

Obliquus capitis inferior

Floor

Posterior atlanto-occipital membrane and

posterior arch of vertebra C1

Roof

Semispinalis capitis

Contents

Vertebral artery and suboccipital nerve