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SPINE
Dr Pankaj N Surange
MBBS, MD, FIPP
Interventional Pain and Spine specialist
Anatomical Planes
The CORONAL PLANE, also
A-P X-ray of a called the FRONTAL PLANE, is a
scoliotic spine in vertical cut that divides the body
into front and back sections.
the coronal plane. Physicians look at the coronal plane
when they view an A-P (anterior-
posterior) x-ray of the spine to
evaluate scoliosis.
Anatomical Planes
Lateral X-ray of a The SAGITTAL or MEDIAN
PLANE is a vertical cut that
kyphotic spine in
divides the body into left and right
the sagittal sections. The sagittal view is seen
plane. by surgeons on a lateral x-ray of
the spine.
Anatomical Planes
CT Scan of a The AXIAL or TRANSVERSE
PLANE is a horizontal cut that
thoracic vertebra divides the body into upper and
in the axial plane. lower sections. To best view the
axial plane of the spine, surgeons
will often obtain a CT scan with
axial cuts.
Functions of the Spine
• Protection of
– spinal cord and nerve roots
– internal organs
Functions of the Spine
• Flexibility of motion in six degrees of freedom
Flexion and Extension Left and Right Left and Right Rotation
Side Bending
Functions of the Spine
• Structural support and
balance for upright posture
The spine is the axle bearing the load
of the head, shoulders and thorax. The
upper body weight is then distributed
to the lower extremities through the
sacrum and pelvis.
This reduces the amount of work
required by the spinal muscles and can
eliminate muscle fatigue and back pain.
Functions of the Spine
To achieve these functions, the spine
must have:
• Resistance to axial loading forces,
accomplished by:
– Kyphotic and lordotic sagittal plane
curves
– Increased mass of each vertebra
from C1 to the sacrum
• Elasticity accomplished by:
– Alternating lordotic and kyphotic
curves
– Multiple MOTION SEGMENTS
The Motion Segment
• The FUNCTIONAL UNIT of the spine
• Composed of:
– Two adjacent
– vertebrae
The intervertebral disc
– Connecting ligaments
– Two facet joints and
capsules
Sagittal Plane Curves
• Primary Curves • Secondary Curves
Sagittal Plane Curves
Cervical Lordosis 20°- 40°
Sacral Kyphosis
Regions of the Spine
• Cervical
– Upper cervical: C1-C2
– Lower cervical: C3-C7
• Thoracic: T1-T12
• Lumbar: L1- L5
• Sacrococcygeal: 9 fused
vertebrae in the sacrum and
coccyx.
Regions of the Spine
• Line of gravity
Auricle of the ear
Odontoid
Body of C7
Anterior to thoracic
spine
Posterior to L3
Vertebral
Body
Pedicle Vertebral
Foramen
Transverse
Process
Lamina
Superior
Spinous Articular
Process Process
Vertebral Structures
Superior
Pars Articular
Process
Zygapophyseal
Inferior
Joint
(Facet Joint) Articular
Process
Vertebral Structures
• Pedicle notches
Slight
Notch
Intervertebral
Foramen
Vertebral Arches
• Anterior Arch
Comprised of:
– Vertebral body
– Anterior 1/3 of the pedicles
• Posterior Arch
Comprised of:
– Posterior 2/3 of the pedicles
– Lamina
– Processes
The Atlas (C1)
Anterior
Articular Facet
Tubercle
for Dens
Transverse
Process
Superior
Articular
Facet
Transverse Lateral
Foramen Mass
Posterior Lamina
Tubercle
Superior View
The Axis (C2)
Lateral
Body Odontoid Mass
Process
(Dens)
Superior
Articular
Facet
Inferior
Articular Spinous
Transverse
Facet Process
Process
Anterior View Posterior View
Lower Cervical Vertebrae
• C3 to C7
– May be referred to as
the subaxial region
– Disc at every level
– Vertebral structures
are similar
Lower Cervical Vertebrae
C3 - C7
Superior
Lateral Articular Facet
Mass
Vertebral
Lamina Foramen
Uncinate
Process
Uncovertebral Joint
Sulcus for
(Joint of Luschka)
Spinal Nerve
Anterior View
Vertebra Prominens (C7)
Spinous
Process
Axial View
Thoracic Vertebrae
• Body - progressive increase in mass
from T1 to T12
Superior Articular
Process
Inferior Articular
Process
Lumbar Vertebrae, L1-L5
• Body - L1 to L5 progressive increase
in mass
• Pedicles - longer and wider than
thoracic; oval shaped
• Spinous processes - horizontal,
square shaped
• Transverse processes - smaller than
in thoracic region
• Intervertebral foramen - large, but
with increased incidence of nerve
root compression
The Sacrum
Inverted triangle shape Sacral Horns
Sacral Ala
Dorsal
Pedicles Foramina
Sacral
Hiatus
Coccyx
Posterior View
The Sacrum
Sacral Tilt
30°-60°
Sacral 1
Promontory 2
Sacral Canal 3
Sacral Hiatus
4
5
Coccyx
Lateral View
Intervertebral Disc
• Intervertebral disc
• End plate
– Cartilaginous layer
– Bony layer
• Apophyseal ring
Intervertebral Disc
• Fibrocartilaginous joint of the
motion segment
• Make up ¼ the length of the
spinal column
• Present at levels C2-C3 to L5-
S1
• Allows compressive, tensile,
and rotational motion
• Largest avascular structures
in the body
Intervertebral Disc
Annulus
• Annulus Fibrosus Fibrosus
– Outer portion of the disc
– Made up of lamellae
• Layers of collagen fibers
• Arranged obliquely 30°
Lamellae
• Reversed contiguous
layers
– Great tensile strength
Intervertebral Disc
• Nucleus Pulposus Nucleus
Pulposus
– Inner structure
– Gelatinous
– High water content
– Resists axial forces
Intervertebral Disc
Blood Supply
Rib
Lateral View
Sacroiliac Joint
The superior lateral surface on
either side of the sacrum articulates Sacrum
with the inner aspects of the pelvis. Ilium
This area forms the capsular, synovial
SACROILIAC JOINT.
Lateral Posterior
occipitoatlantal occipitoatlantal
ligament ligament
Anterior View
Upper Cervical Ligaments
Occipitoaxial Ligament Complex
Occipitoaxial
ligament
Apical
ligament Alar ligaments (2)
Lower Cervical, Thoracic,
and Lumbar Ligaments
Anterior Longitudinal
Ligament (ALL)
The INTERTRANSVERSE
LIGAMENTS extend from the
inferior surface of the entire
length of the transverse process
to the superior surface of the
adjacent transverse process.
Ligamentum
nuchae
Lower Cervical, Thoracic,
and Lumbar Ligaments
The SUPRASPINOUS
LIGAMENT is a very strong band
connecting the tips of
contiguous spinous processes. It Supraspinous
extends from C7 to the sacrum. ligament
Above C7 these fibers are
part of the LIGAMENTUM
NUCHAE.
Ligamentum
nuchae
Lower Cervical, Thoracic,
and Lumbar Ligaments
LIGAMENTUM FLAVUM
Also called the YELLOW
LIGAMENT
Consists of elastic fibers
oriented vertically that extend from
the anterior inferior surface of the
lamina above to the superior
posterior surface of the lamina
below.
The ligamentum flavum tends to
thicken as it progresses down the
spine, beginning at the axis (C2)
and extending to the sacrum.
Ligamentum
flavum
Lumbosacral Ligaments
The ILIOLUMBAR LIGAMENTS
extend from the transverse
Iliolumbar
processes of L4 and L5 to the iliac
crest. ligaments
Anterior View
Sacroiliac Ligaments
The SACROILIAC LIGAMENTS are Short sacroiliac
as follows: ligaments
• short sacroiliac ligaments:
composed of horizontal fibers
extending from the sacrum to
the posterior part of the iliac
bone
Long sacroiliac
ligaments
• long sacroiliac ligaments:
composed of fibers extending
vertically from the sacrum to
the posterior superior iliac
spine Posterior View
Posterior Spinal Muscle Groups
The superficial posterior
muscles are collectively called the
ERECTOR SPINAE, comprising three
groups:
Iliocostalis
Erector Longissimus
Spinae
Spinalis
Posterior Spinal Muscle Groups
The middle, or intermediate, muscle group of the spine
is called the SEMISPINALIS GROUP:
semispinalis
capitis
semispinalis
cervicis
semispinalis
thoracis
Posterior Spinal Muscle Groups
The deep muscle layer
consists of the following Rotatores
groups: (longus and brevis)
Levatores costae
(longus and brevis)
Rotatores
cervices
Rotatores
Multifidus thoracis
Rotatores
lumborum
Intertransversarii
attachments
between spinous
processes
Arteries of the Cranial and Cervical Region
Two VERTEBRAL
ARTERIES, one located on each
side the cervical vertebrae. These
arteries are branches of the right
Foramen
and left subclavian vs. that exit from
lacerum
aorta.
They ascend through the Vertebral
transverse foramen of C6 through artery
C1,entering the skull through the
foramen magnum where they join Carotid
together to form the BASILAR
artery
ARTERY.
Anterior to the cervical
vertebrae are the CAROTID
ARTERIES, which ascend through
the FORAMEN LACERUM and
join with the vertebral arteries to
form the CIRCLE OF WILLIS.
Arteries of the Cranial and Cervical Region
Circle of Willis
Basilar Internal
artery carotid
arteries
Vertebral
arteries
Arteries of the Thoracic and Lumbosacral Regions
Vertebral
artery Aortic arch
Ascending Descending
aorta aorta
Thoracic
Abdominal segmental
aorta arteries
Bifurcation
of the aorta Lumbar
segmental
External iliac arteries
artery (left &
right) Internal
iliac artery
Femoral artery (left & right)
(left & right)
Segmental Arteries
At each vertebral level from T4 to the sacrum, a pair
of SEGMENTAL ARTERIES branches posteriorly from
the aorta to supply blood to the vertebral body, posterior
elements, spinal cord, and costal structures.
Anterior spinal
artery
Spinal
branch
Posterior
branch
Intercostal
artery
Segmental
arteries
Anastomoses
Aorta
Veins of the Cervical and Thoracic Region
The most important venous structures in the
cervical spine are the internal and external
JUGULAR VEINS. The internal jugular veins follow
a path similar to the carotid arteries. They should
always be considered during any anterior cervical
spine procedure.
External
jugular
Internal
jugular
Anterior
jugular
Veins of the Thoracic and Lumbar Region
Internal
jugular
Superior
vena cava
Azygos
vein
Thoracic
segmental Hemiazygos
veins vein
Lumbar
Inferior segmental
vena cava veins
Common
iliac veins
Batson’s Plexus
The AZYGOS SYSTEM is a large
network of veins draining blood from
the intestines and other abdominal Batson’s
organs back to the heart. The
plexus
segmental veins drain into the azygos
vein located on the right side of the
abdomen, or into the hemiazygos vein
located on the left side.
The azygos system also
communicates with a valveless
venous network known as BATSON’S
PLEXUS. When the vena cava is
partially or totally occluded, Batson’s
plexus provides an alternate route for
blood return to the heart.
The vessels of Batson’s plexus
may be referred to as epidural veins
Batson’s Plexus
Because of the azygos Batson’s
system, patient positioning is plexus
very important in posterior
lumbar spine surgery.
The patient’s abdomen
should always hang free and
without abdominal pressure. An
increase in pressure will
diminish flow through the
azygos system and the vena
cava. This results in an increase
of venous flow into Batson’s
plexus with a corresponding
increase of blood loss.
Spinal Nerve Structures
Spinal Cord Foramen
• Contained in epidural space magnum
• Network of sensory and motor
nerves
• Firm, cord-like structure
• Extends from foramen magnum to
L1
• Terminates at the Conus
conus medularis medularis
• The cauda equina begins Cauda
below L1 equina
• Filum terminale extends from
conus medularis to the coccyx
Meninges
Within the spinal canal, the spinal cord is surrounded by the
EPIDURAL SPACE, filled with fatty tissue, veins, and arteries. The fatty
tissue acts as a shock absorber.
Subdural space
Arachnoid
layer
Dura mater
Spinal Nerve Topography
Ventral Peripheral
root nerve
Autonomic Nervous System
Independent of voluntary control.
The PARASYMPATHETIC
NERVOUS SYSTEM has ganglia located
close to the organs they control.
Thank You!