Today we will talk about the vertebral column specifically the cervical part of it :

We will talk firstly about the general structure of the vertebral column.

The vertebral column is the lower part of the axial skeleton forming the skeleton for the neck and the back and it is made of 33 vertebrae: 7 12 5 cervical.

thoracic. lumbar.

5 sacral (they fuse together into one piece; we refer to it as the sacrum). 4 coccygeal (they fuse together into one piece; we refer to it as the coccyx).

In between these bones (vertebrae) there is a cartilaginous disc known as the intervertebral disc (IV) , they are present there to facilitate the movement between these vertebrae and providing resilience to the vertebral column to allow for the movement of the trunk. How many IV disc are there?

We have 23 IV disc: Between the 1st and 2nd vertebrae there are no disc, the sacrum and the coccyx they are fused so there is no IV disc. When we look in a saggital view we notice that the vertebral column is not straight, its curved (there are curvatures). These normal curvatures of the vertebral column, they are important in permitting the movement and weight bearing of the trunk.

We have two types of normal curvatures: The primary (which begins firstly): Usually start to develop during fetal life inside the uterus , when the fetus is shrunken on himself , the whole vertebral column is concaved anteriorly.

After birth this anterior concavity remains only in two regions of the vertebral column (the thoracic and the sacral), so in the thorax and in the sacrum we still have the primary curvatures of the vertebral column. * Secondary curvatures: After birth, during the age of (3-6) month usually when the child start to rise his head (when he start to hold his head erect), this will change the concavity in the cervical region to concaved posteriorly, when he start to walk and assumes his upright posture (8-12) month so the curvature will change in the lumbar region to posterior concavity. So we have 2 primary curvatures which appear in the thoracic and the sacral regions and 2 secondary curvatures in the cervical and the lumbar regions.

Additionally we have some abnormal curves of the vertebral column 1- Kyphosis: we refer to it as the hunch back, this is usually happens in old people (geriatric people) who are suffering from osteoporosis, they will have erosion in the anterior part of the vertebrae (in the thoracic region). 2- Lordosis: we refer to it as the hollow back, this is increase in the lumbar curvatures, lordosis happens because of weakness in the abdominal musculatures (anteriolateral abdominal muscles; external oblique and the internal oblique, which holds the vertebral column posterior with the anterior abdominal wall) or it can happen temporarily in late pregnant female to compensate and bear the weight of the fetus.

3- Scoliosis : the most common one in pubertal females , we refer to it as the curved back , this is a lateral curvature, scoliosis may happens because of asymmetrical paralysis of intrinsic back muscle one side only so the muscle at the other side is going to pull the vertebral column to its side myopathic scoliosis, or it could happen because of difference in the length of the lower limb congenital, sometimes failure of half of vertebra to develop they called it hemi vertebrae scoliosis.

So, lets summarize the abnormal curvatures:

1- Kyphosis

increased thoracic curvature.

2- Lordosis

increased lumbar curvature.

3- Scoliosis vertebral column.

lateral curvature in the

We will now talk about the IV disc we said that those discs are cartilaginous, so we refer to the joint between the vertebrae as cartilaginous joint this mean that there are limited movement not free movement as the synovial nor as the fibrous that has no movement at all. Those discs are made of 2 part : Annulus fibrosus: The outer part which is a concentric circular layer of fibrocartilage, it is there to protect the inner core of the disc nucleus pulposus and to Strengthens the disc.

Nucleus pulposus: The central core of the disc and it is the gelatinous material within the disc, which is responsible for increasing the elasticity of the disc so it acts as a shock absorber between the vertebrae.

If we look to any disc we see that the annulus fibrosus layer from back is much thinner than anteriorly, so if there is any tear in the disc because of the pressure on the disc so this will pressure the nucleus pulposus, this pressure will be exerted anteriorly and posteriorly and also laterally, the weakest area is the posterior area of the disc, so there will be tearing in annulus fibrosis and a leakage of the nucleus pulposus to the outside this is what we refer as the disc herniation, when it goes posteriorly there will be the spinal cord , so this will pressure on the spinal cord and this will produce the back pain.

The most common area to have back herniation is the lowest two discs because the largest weight is on them, between the (L4-L5) Or between (L5-S1), we all know that at the level of L4-L5 we have spinal nerves that participate in the largest nerve in our body sciatic nerve which has a root value of (L4-S3) so if there is a disc herniation in these areas there will be a leakage of nucleus pulposus and this leakage will produce pressure on the spinal cord and spinal nerves there, this pain will start to radiate from the root of these spinal nerves along with their continuation the sciatic nerve all along the back of the leg which we refer as the sciatica.

Now we will talk about the IV ligaments which fix the discs on each other, we have anterior and posterior ligaments: Anteriorly we have a very broad and thick strong ligament extends anteriolaterally along the vertebrae and the discs from the beginning of the vertebral column all the way down to the sacrum this is called anterior longitudinal ligament covering the whole anteriolateral aspect of the vertebral column. Posteriorly we have another ligament but it is much thinner and weaker covering only the middle part of posterior aspect of the vertebral bodies, this is called posterior longitudinal

ligament.

In addition to them there are ligaments supporting the arches (the arch is formed by two pedicles and two laminae): Between the transverse processes we call it Intertransverse ligament. Between the spinous processes we call it Interspinous ligament. At the tip of the spinous processes we call it supraspinous ligament. Between the laminae we call it Ligamentum flavum or Flava ligaments, they are joining the laminae with each other, they call it Flava which is a Latin word that means yellowish because they are made up of elastic fibers, so they are very elastic.

Now we have a very important ligament at the region of the neck Nuchal ligament it is an additional ligament for the vertebral column but its just in the neck, Nucha is a French word that means the back of the neck whereas occipit is a Latin word that means the back of the head. This ligament start from the external occipital protuberance, it extends from there and as it descend down it forms a linear elevation form the external occipital protuberance to the posterior margin of foramen magnum which we call external occipital crest or median nuchal line, then it descend down and merge with the supraspinous ligaments and the tips of the spinous processes all the way down until C7 providing a very important support to the back of the neck.

Now we will talk about the main topic of the lecture the cervical vertebrae: They can be classified as typical and atypical vertebrae according to the absence or additional characteristics that they posses .. We have 7 processes for each vertebra:

Spinous, 2 transverse, 2 superior articular and 2 inferior articular.

What are the characteristics to have a typical cervical vertebra?

In the cervical vertebrae the body is usually small and rectangular in shape whereas in the thoracic the body is heart shaped and in the lumbar kidney shaped. There are transverse foramina in the transverse processes; those foramina are not present in the thoracic or the lumbar vertebrae, those foramina protects and allows for the vertebral artery which is a branch from the subclavian artery to pass through these foramina all the way up into the skull but as soon as it branch from the subclavian artery it will be too close to C7 so this artery will not pass through the transverse foramen of C7 instead it pass anterior to C7, so this artery will pass through the transverse foramina of (C6-C1) and then it will enter the

foramen magnum inside the skull where the two vertebral arteries form both sides will fuse together into one large artery basilar artery which supply the brain stem and the inferior aspect of the brain. So the brain receives its blood supply by the: Internal carotid arteries which supplies the superioanterior aspect of the brain. The two vertebral arteries which fuse to form the basilar artery that supplies the brain stem and the inferioposterior aspect of the brain.

So C7 does have a transverse foramina but the vertebral artery doesnt pass through them to prevent the sharp angulation therefore avoid the blockage of this artery so this is the first exception that make C7 atypical vertebra.

 Short bifid spine, what we mean by bifid is that the tip of the spinous process has two head, the exception here is also C7 which has a long one and it isnt bifid (only one head), and you can easily feel this bony prominence at the root of the neck posteriorly, this bony prominence indicates the spinous process of C7 and its used by the physician to count vertebrae. Their vertebral foramina in which the spinal cord pass are very large and triangular in shape; the vertebral foramen as we move down, it get much smaller and sharper, so the biggest vertebral foramen we can see is in the cervical region the it get smaller in the thoracic and even much smaller in the lumbar and the sacral regions. So these are the 4 main characteristics of the typical cervical vertebrae:

Small rectangular body.

Transverse foramina.

Short bifid spines.

Large vertebral foramen.

So we have typical and atypical cervical vertebrae: C1, C2 and C7 are atypical vertebrae. C3, C4, C5, C5 are typical vertebrae.

So what makes C7 atypical vertebra: 1-It has a transverse foramina but the vertebral arteries doesnt pass through them instead the vertebral vein does. 2-The spinous process is long and not bifid. This is a picture of C7.

 Now we will talk about the 1st cervical vertebrae C1 (Atlas):

Why C1 is atypical: There is no body. No spinous process instead it has tubercle (posterior tubercle). Anterior arch and posterior arch Two small masses of bones laterally located they call them the lateral masses of Atlas to provide articulation of Atlas superiorly with the skull through Atlanto-Occipital joint; it articulate with the condyles of the occipital bone, and inferiorly Atlas articulate with the 2nd cervical vertebra C2 Axis through Atlanto-Axial joint.

The name Atlas comes from the Greek mythology the Titans God which has the name Atlas who is holding the Universe on his shoulders; so this vertebra is holding the whole head skull.

Now we will talk about the 2nd cervical vertebra Axis:

Its atypical because it has an additional feature rather than the 4 that we mentioned: An additional body; that separated from the Atlas and get attached to the Axis in which we call the odontoid process or the Dens of Axis which bind with the Atlas anteriorly at the Atlanto-Axial joint, Dens is a Latin word that mean the tooth, Atlas is like a ring this Dens come inside it this Dens act like an axis which allow for the rotation of the Atlas rotation of the head like when you saying NO , this rotational movement is facilitated by the Atlanto-Axial joint, so the axis is actually acting like an axis to the Atlas and thats why they called it Axis.

The Dr. mentioned that from now on, if we want to study any joint in anatomy, we have to answer the following questions regarding to it: Type: fibrous, cartilaginous or synovial, if it was synovial, what is the shape of the joint. Articulations. Movements. Supporting ligaments; especially if it was synovial, because in the synovial joints the bones are not in contact with each other instead there is space, so what connects them. It is the ligaments that extends from on bone to the other If there are any additional characteristics; like the presence of a disc like the TM joint TMJ, the Dr. said that there only two

joints in our body that have a complete circular disc which are the TMJ and the other is a H.W.

We will now study the Atlanto-occipital and the Atlanto-Axial joints.

Type: synovial because there is a free movement between the skull and the Atlas, condyloid because there are two smooth rounded condyles that comes from the occipital bone of the skull, so we call this joint condyloid synovial joint. Articulations: lateral mass of Atlas and the condyles of the skull. Movement: the movement by which you move your head by saying YES, so just Flexion and Extension between the Atlas and the skull (skull and vertebral column), and when you bend your head we call it lateral flexion .

 Supporting ligaments: there are two ligaments:

1- Posterior Atlanto-Occipital membrane that extend from the posterior arch of Atlas and goes to the foramen magnum from the back posterior margin of foramen magnum.

2-Anterior Atlanto-Occipital membrane that extend from the anterior arch of atlas and goes to the foramen magnum from the front anterior margin of foramen magnum.

 Movement: rotational movement between the Atlas and the Axis which start within the vertebral column itself (the skull has nothing to do with it).

Articulations between the Atlas and the Axis: there are three joints; two lateral Atlanto-Axial joints between lateral masses of Atlas and inferiorly with the Axis and a median Atlanto-Axial joint between the anterior arch of Atlas and the Dens of Axis.

Type: The two lateral Atlanto-Axial joints are Plane or Sliding Synovial joints, the other one is a Pivot Synovial joint.

The articulation of the median Atlanto-Axial joint: Anterior arch of Atlas. Dens of Axis. Transverse ligament of Atlas: A ligament that is a part of articulation because without this ligament the Axis will not going to connect with the Atlas, this ligament is extending in a transverse direction from one lateral mass of Atlas to another lateral mass in the opposite side.

The supporting ligaments for that joint; this joint is very important and losing the connection of this joint will lead to a severe trouble because of the sensitivity of this area, these ligaments are arranged into three layers from the front to the back: 1-Apical ligament: That fix the Dens in its place, extend from tip of the Dens to the anterior margin of foramen magnum. 2-Alar ligaments: That fixes the Dens laterally on the sides, extends from the side of the Dens to the lateral margins of foramen magnum. These three ligaments form the first layer of ligaments.

3-Cruciate ligament: which means crucified (like a plus +), its composed of 3 parts: Horizontal transverse part: It is the same of the transverse ligament of Atlas which we talked about. Vertical ones, to additionally fix the Dens opposite to the arch of Atlas: 1- Superior longitudinal ligament: extend from the transverse ligament of Atlas all the way up into the foramen magnum.

2- Inferior longitudinal ligament: extend from the transverse ligament of Atlas all the way down to into the body of the Axis. This is the second layer of ligaments. 4-tectorial membrane: this means the tent that will cover all of the ligaments, which is the superior continuation of the posterior ligament (that we said that it is thin and weak in the 8th page). This is the third layer of ligaments.

Despite all of these ligaments it is very common to have dislocation in this joint. The strongest one of them is the horizontal part of cruciate ligament, if you lose it you will lose the whole joint, all of the rest is not that important so sometimes when you some people that have the ability

to move their head more than the normal people by 30% you will see that there is tearing in the Alar ligaments.

Rupture of the transverse ligament of Atlas; complete dislocation, if you lose this ligament, the Dens will be projecting backward so it will leave the arch and goes backward, once the Axis goes back, it either injuring the medulla or the spinal cord: If it hits the medulla: Direct death. If it hits the spinal cord: Quadriplegia. The usual cause of death Whiplash Injures which is the most common kind of Auto-Mobile injuries.

Atlanto-axial subluxation:

Subluxation means partial dislocation or laxity; not complete dislocation, it will not cause to big problems but there is back pain.

The Dr. said to read the Hyoid bone by yourselves so I include the slide regarding to it.

Hyoid bone:
U-shaped bone inf. to mandible

anterior upper cervical region

Part of axial Skeleton.

Forms a base for the tongue.

123-

Consist of: Body. Two grater horns. Two lesser horns.

Muscular Attachments of Hyoid: Ant. Sup.: Mandible (Geniohyoid, Mylohyoid, Ant. Digastric).

Post. Sup.: Temporal bone (Stylohyoid, Post. Digastric).

Ant. Inf.: Sternum (Sternohyoid, Sternothyroid & Thyrohyoid).

Post. Inf.: Scapula (Omohyoid).

P.S: I included all the notes from the slide in this script.

Finally I did it, this was one of the hardest things to write, hope that you will enjoy your reading .

Forgive me for any mistakes as I tried my best with this lecture.

I want to thank my friend Hamza Al-Ogaily for his support .

Your colleague: Ibrahim Mahmood Bayram.

When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.