The Back - Dr.

Tanyee

The Back - Posterior Aspect of the trunk - Region of the body to which the head, neck and limbs are attached - Shape, size and contour varies Bony Framework - Part of Axial skeleton Vertebral column/Spine/Backbone o Forms the skeleton of neck and back o Extends from the skull to the coccyx o Main part of axial skeleton Cranium Vertebral Column Ribs Sternum 1. 2. 3. 4. 5. Functions Protects the spinal cord and spinal nerves Supports the weight of the body Provides a partly rigid and flexible axis for the body and a pivot for the head Plays an important role in posture and locomotion Transmits body weight to the lower extremities

Vertebrae Regions Cervical -7 Thoracic-12 Lumbar -5 Sacrum -5 Coccyx -4 Total = 33 Motion is possible in 24 vertebrae out of 33, sacral and coccygeal no motion Variations in vertebrae o The number of cervical vertebrae is constant o For the thoracic, lumbar and sacral vertebrae the numbers vary in 5% of cases o The thoracic vertebrae may be increased in number by the addition of the firs lumbar vertebra which may have a rib o Sacralization of the first lumbar vertebra o Lumbarization of the S1 Features of a typical vertebra o Becomes larger as the column descends o Rigid yet flexible o 3 joints are present between 2 adjacent vertebrae

1 anteriorly 2 posteriorly Stability of the column is dependent on the ff: Shape and strength of vertebrae Intervertebral disc made up of fibrocartilage Ligaments Muscles

Parts 1. Anterior element Body and intervertebral disc 2. Posterior element (vertebral/neural arch) Vertebral arches 2 Pedicles forms the sides of the arch 2 Lamina complete the arch posteriorly The vertebral arch gives rise to: o Processes (7)

Processes o Spinous process (1) found at the junction between two laminae o Transverse Processes (2) located laterally on the junction at each side between the pedicle anteriorly and the lamina posteriorly Articular Processes - projected at the junction of the lamina and pedicles, articular surfaces covered with hyaline cartilage o Superior Articular Processes (2) o Inferior Articular Processes (2) Vertebral foramen found between the body and neural arch - one on top of the other forms vertebral canal/spinal canal - structures found inside the canal are the spinal cord, blood vessels, meninges and also fatty tissue

Vertebral notches -Superior and inferior vertebral notch - The concavities above and below the pedicles ; and when the vertebrae are articulated, the notches of each contiguous pair of bones form the intervertebral foramen. Intervertebral Foramen / Neural Foramen formed by the superior notch of one vertebra and inferior notch of adjacent vertebra - allow passage of spinal nerves and blood vessels Vertebral Arches Spina Bifida the lamina of L5 failed to unite

General Characteristics of Typical Vertebra Consists of rounded body and vertebral arch posteriorly Encloses a space vertebral foramen spinal canal Vertebral arch consists of pair of pedicles and a pair of lamina Vertebral arch gives rise to 7 processes Features of Typical Cervical Vertebra Part Body Distinctive Characteristics Small and wider from side to side than anteroposteriorly; superior surface is concave and inferior surface is convex Large and triangular Transverse foramina (L.foramina transversarium); small or absent in C7 vertebral arteries and accompanying venous and sympathetic plexuses pass through foramina, except C7, which transmits only small accessory vertebral veins; anterior and posterior tubercles Superior facets directed superoposteriorly; inferior facets directed inferoanteriorly C3 - C5 short and bifid (split in two parts); process of C6 is long but that of C7 is longer ( C7 is called the vertebra prominens)

Vertebral foramen Transverse processes

Articular Processes Spinous Process

*Cervical vertebrae ( C1- C7) form skeleton of neck. They are typical vertebrae except for C1 and C2. ATYPICAL CERVICAL VERTEBRA C1 and C2 o C1 (Atlas) - kidney shaped No body No spinous process Lateral masses connected by anterior and posterior arches Concave superior articular facets C2 strongest cervical vertebra o C2 (Axis) - strongest cervical vertebra - dens/ odontoid process projects from the body superiorly Cervical Vertebra 7 o Vertebra prominence o Longest spinous process o Spine is not bifid o Transverse process is large but small transverse foramina which transmits the vertebral vein/veins

Features of Thoracic Vertebra Part Body Vertebral foramen Transverse processes (TP) Distinctive characteristic Heart shaped; has one or two facets for articulation with head of a rib (H) Circular and smaller than in cervical and lumbar regions Long and strong and extends postrolaterally; length diminishes from T1-T12 (T1-T10 have facets for articulation with tubercle of a rib) Superior facets directed posteriorly and slightly laterally; inferior facets directed anteriorly and slightly medially Long and slopes postero inferiorly; tip extends onlevel of vertebral body below

Articular processes

Spinous process (SP)

Costal facet can be found on each side of the vertebral body or on the transverse processes and will articulate with the tubercle of the rib Features of Lumbar Vertebrae Part Body Vertebral foramen Transverse processes (TP) Articular processes Distinctive Characteristics Massive; kidney shaped when viewed from above or below Triangular; larger than in thoracic region and smaller than in cervical region Long and slender; accessory process on posterior surface of the base of each process Superior facets directed posteromedially (or medially); inferior facets directed anterolaterally (or laterally); mammillary process on posterior surface of each superior articular process Short and sturdy

Spinous process (SP) Thoracic natural bending Lumbar flexion and extension

VERTEBRAE Curves In the fetus, the vertebral column has one continuous anterior concavity. As development proceeds, the lumbosacral angle appears. After birth when the child becomes able to raise his or her head, the cervical vertebra becomes concave posteriorly. At the end of first year, when the child is able to stand upright the lumbar part becomes concave posteriorly (secondary lumbar lordosis).

The primary curve is due to anatomic structure of the vertebra, neural arch is thicker than the anterior element (body). o Primary Curves Thoracic and Sacral Concavity is anterior Secondary Curves Cervical and Lumbar (when the child is able to stand up) Concavity is posterior due to thicker intervertebral disc But during old age, intervertebral disc becomes dehydrated and thinner so it assumes anterior concavity.

Abnormal Curves o Kyphosis hunch back, caused by muscle weakness, collapse (osteoporosis, infectious process), trauma Exaggeration in the sagittal curvature in the thoracic vertebrae o Lordosis- exaggeration in the sagittal curvature in the lumbar region Adaptive changes as in pregnancy Problem in the hip congenital hip anomaly Sagittal view o Scoliosis- lateral deviation of the vertebral column 80% unknown cause (idiopathic) S or long C curve depending on severity AP view *dominant hand principle

Arterial Blood Supply Cervical o Vertebral (branch of subclavian) and ascending cervical artery Thoracic o Posterior intercostal arteries (coming from thoracic aorta) Lumbar o Subcostal artery (from thoracic aorta) and lumbar arteries (from abdominal aorta) Sacral o Iliolumbar, Lateral and Medial Sacral (bifurcation of common iliac) Lateral and Iliolumbar Arises from internal iliac artery Medial Sacral (from bifurcation of common iliac) Venous System o External venous plexus lies external and surrounds the vertebral column, divided into anterior and posterior o Internal Venous plexus lies within the vertebral canal, divides also into anterior and posterior o Basivertebral veins veins that empty into the internal venous plexus o Intervertebral veins empties blood from internal plexus to the general circulation, go with the spinal nerves. Thoracic called intercostal veins *They are valvelesscaliber remains the same.

JOINTS

Joints of Vertebral Bodies Joints of Vertebral Arches Craniovertebral Joint Uncovertebral Joint of Luschka Costovertebral Joint Sacroiliac Joint

Stability of a joint Depends on the following: Bony configuration Ligaments Muscles

Ligaments of the Spine Intervertebral Disc Anterior Longitudinal Ligament Posterior Longitudinal Ligament Ligamentum Flavum Interspinous Ligament Supraspinous Ligament Ligamentum Nuchae Intertransverse Ligament 1. Intervertebral Disc PARTS ANNULUS FIBROSUS- outer fibrous layer NUCLEUS PULPOSUS- gelatinous central mass FEATURES No disc between C1 and C2 Disc thickness vary in different regions Thickest in the lumbar region Disc is thicker anteriorly in the cervical and lumbar Uniform thickness in the thoracic region Contributes 25% to vertebral height Nucleus Pulposus maximum water content at birth and decreases with age Shock absorber for axial forces Semi- fluid ball bearing during flexion, extension, rotation and lateral flexion Avascular Nourishment by diffusion vertebral bodies and annulus fibrosus.

2. Anterior Longitudinal Ligament FIBROUS BAND THAT COVERS AND CONNECT THE ANTEROLATERAL ASPECT OF VERTEBRAL BODIES ABD DISC EXTENDFROM SACRUM-ANTERIOR TUBERCLE OF C1 ANTERIOR RIM OF FORAMEN MAGNUM HELPS PREVENT HYPEREXTENSION 3. Posterior Longitudinal Ligament MUCH WEAKER AND NARROWER RUNS W/IN THE CANAL ALONG THE POSTERIOR ASPECT OF THE BODY ATTACHES TO POSTERIOR EDGE OF THE BODIES AND DISC FROM C2-SACRUM PREVENTS HYPEREXTENSION AND DISC PROTRUSION W/ PAIN NERVE ENDINGS

4. Ligamentum Flavum YELLOW LIGAMENT CONNECTS THE ADJOINING LAMINA FORMS PART OF THE POSTERIOR WALL OF THE CANAL RESISTS SEPARATION OF LAMINA ARRESTING ABRUPT FLEXION OF VERTEBRA- PROTECTING THE DISC

5. Interspinous Ligament UNITE ADJACENT SPINOUS PROCESSES WEAK 6. Supraspinous Ligament STRONG, CORDLIKE BLENDS W/ LIGAMENTUM NUCHAE 7. Intertransverse Ligament CONNECTS ADJACENT TRANSVERSE PROCESSES 8. Ligamentum Nuchae THICK FIBROUS TISSUE ATTACHES TO EXTERNAL OCCIPITAL PROTUBERANCE,POSTERIOR BORDER OF FORAMEN MAGNUM TO THE SPINOUS PROCESSES OF CERVICAL VERTEBRAE *In Lumbar Puncture Structures to be hit ( posterior going anterior) 1. Supraspinous ligament 2. Interspinous ligament 3. Yellow ligament 4. Subdural space/Subarachnoid Space

JOINTS OF VERTEBRAL BODY SECONDARY CARTILAGENOUS JOINT(SYMPHYSIS) DESIGNED FOR WEIGHT BEARING AND STRENGTH ARTICULATING SURFACES OF ADJACENT VERTEBRAE ARE CONNECTED BY DISC AND LIGAMENTS

ZYGOAPOPHYSIAL JOINT(FACET JOINT) PLANE SYNOVIAL TYPE OF JOINT BETWEEN SUPERIOR AND INFERIOR ARTICULAR PROCESSES GLIDING MOVEMENT INNERVATED BY ARTICULAR BRANCHES OF POSTERIOR RAMI OF SPINAL NERVES

UNCOVERTEBRAL JOINT OF LUSCHKA BETWEEN THE UNCINATE(HOOK LIKE) PROCESSES OF VERTEBRA AND BEVELLED SURFACES OF VERTEBRA ABOVE THEM LOCATED AT LATERAL/POSTEROLATERAL MARGINS OF IV DISC THESE JOINT LIKE STRUCTURE ARE COVERD WITH CARTILAGE AND CONTAIN ACAPSULE FILLED WITH FLUID