Section 1: Anatomy

A. Vertebral
Column
B. Spinal Cord
C. Peripheral
Nerves
D. Pain pathways
E. Dermatomes

Section 1A: Anatomy - Vertebral Column

The vertebral column is made up of 24 separate (pre-sacral) vertebrae, 5

fused vertebrae of the sacrum and 4 coccygeal vertebrae.
Of the pre-sacral vertebrae there are:

7 cervical
12 thoracic
5 lumbar
Clinical Pearl: Spinous processes are generally palpable over the midline. The
spinous processes of the cervical and lumbar spine (see below) are nearly
horizontal while those of the thoracic spine point caudally. This is important
for neuraxial blocks when the angle of the needle needs to be directed more
cephalad for thoracic as opposed to cervical or lumbar blocks.

The vertebral column forms a double C due to two anteriorly

convex curvatures in the cervical and lumbar regions.
Clinical Pearl: These curves are important
because, when a patient is lying supine after
a neuraxial block, the local anesthetic tends
to pool in the lowest point, generally
between T5 and T7.

http://hippocrates.ouhsc.edu/showcase/Gross/Lab3/Lab3.htm

Vertebral column - Supporting Structures

Ventrally the vertebral bodies and intervertebral disks are

connected and supported by the anterior and posterior longitudinal
ligaments.
Dorsally, the ligamentum flavum, interspinous ligament, and
supraspinous ligaments provide further stability.
Clinical Pearl: In performing a spinal or epidural block, what are the
layers one pierces?

Clinical Pearl - Answer:

Sagittal section of
lumbar vertebrae
showing the course of a
lumbar puncture needle
through the labeled
structures (1) skin, (2)
subcutaneous tissue, (3)
supraspinous ligament,
(4) between spinous
processes, (5)
interspinous ligament,
(6) ligamentum flavum,
(8) dura mater, (7) into
the subarachnoid space
between the nerve roots
of the cauda equina.
(9) Lumbar vertebrae,
(10) Intervertebral disc,
and (11) Needle

Boon JM, Abrahams PH, Meiring JH and T Welch, Lumbar Puncture:

Anatomical Review of a Clinical Skill. Clinical Anatomy 17: 544-553, 2004.

Anatomy of the Cervical Spine

http://www.eurospine.org/p31000268.html

The body of a typical cervical vertebra (C3-7) is wider side to side than anteroposteriorly.
The vertebral foramen is large and triangular.
The articulating surfaces between superior facets point almost vertically,
Spinous processes are short and bifid in the cervical region.
Clincal Pearl: The most prominent cervical spinous process is C7.

A typical cervical vertebra

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijn/vol4n1/cervical.xml

Thoracic Spine

www.dynawell.biz/clin_spin_spin_s.asp

The body of a typical thoracic vertebrae (1) is somewhat heart-shaped with one or two costal facets for
articulation with rib.
The vertebral foramen (5) is smaller and more circular than those of the c-spine and l-spine.
The transverse processes (3) are strong, long with the length diminishing as one moves caudally.
The spinous processes (2) are long and slope posteroinferiorly with the tip extending to level of vertebral body
below.
Clinical Pearl: With arms placed at the sides, the T7 level is usually at the same level as the inferior angle of the
scapulae.

Lumbar Spine

www.dynawell.biz/clin_spin_spin_s.asp

The body of a lumbar vertebra is massive and kidney-shaped upon axial view.
The vertebral foramen is triangular and smaller than in the c-spine.
The transverse processes are long and slender with accessory processes on the posterior surface
of base of each process.
The spinous processes are short and sturdy.
Clinical Pearl: A line drawn between the highest points of both iliac crests usually crosses over the
body of L4 or the L4-L5 interspace.

Sacrum and Coccyx

The sacrum results from the fusion of the five sacral
vertebrae. The sacral hiatus is the failure of the laminae of
S5 and usually part of S4 to fuse in the midline. This bony
defect allows access to the sacral canal. The sacral canal
contains the terminal portion of the dural sac, which
typically ends cephalad to a line joining the posterior
superior iliac spines, or S2.
Clinical Pearls: A parallel line drawn connecting the
posterior superior iliac spine crosses the S2 posterior
foramina. In slender persons, the sacrum is easily palpable,
and the sacral hiatus is felt as a depression just above or
between the gluteal clefts and above the coccyx.

Bony landmarks of the pelvis

www.gla.ac.uk/ibls/fab/glossary/buttock.html

Section 1B: Anatomy - Spinal Cord

The spinal cord lies within the spinal canal of the vertebral column and is made up of its coverings
(meninges), fatty tissue, and a venous plexus.

In the term newborn, it extends down to the lower border of L3; in late adolescence, the spinal cord attains its adult
position, terminating at the level of the intervertebral disk between L1 and L2.
Clinical Pearl: Performing a lumbar puncture below L1 in an adult and L3 in a child avoids potential needle trauma to the cord.

The meninges are composed of three layers: the pia, arachnoid, and dura mater.
3 spaces are created around these layers:

Subarachnoid: located between the pia and arachnoid maters and containing CSF (location of anesthetic injection for
spinal block)
Subdural space: located between the closely adherent arachnoid and dura maters; poorly defined
Epidural space: located within the spinal canal between the dura mater and the ligamentum flavum (locations of anesthetic
injection for neuraxial anesthesia)

The anterior and posterior nerve roots at each

spinal level join and exit the intervertebral foramina
forming spinal nerves from C1 to S5. At the cervical
level, nerves arise above their respective vertebrae, but
at T1 they start exiting below their vertebrae.

There are 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and

1 or 2 coccygeal spinal nerves
Autonomic sympathetic outflow is thoracolumbar (T1-L2)
while parasympathetic is craniosacral (cranial and sacral
nerves)

http://www.caep.ca/template.asp?id=1DFFFBCA07BC42FBBD2A936874776242

The anterior aspect of

the vertebral canal
(posterior view of the
vertebral bodies). A
portion of the spinal
cord has been
removed, as well as a
central piece of dura
mater. SC=spinal
cord; DM=dura mater;
PL=posterior
longitudinal ligament.

Close view of the

spinal meninges.
DM=dura mater;
AM=arachnoid
mater.

Anatomy of the Spinal Cord and surface landmarks

Diagram above is courtesy of and copyright to Apparelyzed, a spinal cord injury peer support group.

Section 1C: Anatomy - Peripheral Nerves

DRo

VRo

Posterior view of a spinal nerve. DRo=dorsal root; VRo=ventral root; SN=spinal

nerve; VRa=ventral ramus; DRa=dorsal ramus.

Section 1C: Anatomy - Peripheral Nerves

Nerves are large bundles of nerve fibers or axons and can contain motor and/or
sensory axons which can by myelinated, unmyelinated, or a mixture.

http://fig.cox.miami.edu/~cmallery/150/neuro/c7.48.8.node.ranvier.jpg

Each individual axon has its own cell membrane or axolemma and can
additionally be enclosed in many layers of myelin
Myelin increases the speed of nerve conduction by insulating the axolemma
and forcing the action current to flow to the nodes of Ranvier where the
sodium channels that serve to generate and propagate nerve impulses are
concentrated (more on physiology of sodium channels later)

A typical peripheral nerve consists of several axon bundles, or fascicles. Each fiber
has its own connective tissue covering, the endoneurium. Each fascicle of axons is
encased by a second connective tissue layer, the epithelial-like perineurium, and
the entire nerve is wrapped in a loose outer sheath called the epineurium. To reach
its site of action (the nerve axon), a local anesthetic molecule must traverse four or
five layers of connective tissue or lipid membranous barriers, or both.

www.med.mun.ca

Classification of Peripheral Nerves

Historically, nerve fibers and their neurons are grouped according to fiber
size, presence of myelin sheath, conduction velocity, and physiologic
properties.
What is most important to physicians is how local anesthetics affect these
different sensory fibers.
Local anesthetics block axonal conduction in nociceptive afferents resulting
in analgesia as well as attenuating other sensations and causing muscle
relaxation via loss of motoneuronal activity. The therapeutic effects are
restricted to body parts innervated by the nerves (or part of the spinal cord)
exposed to the drug.
The following is a chart showing nerve fiber classification.

Classification of Peripheral Nerves

Historically, nerve fibers and their neurons are grouped according to fiber
size, presence of myelin sheath, conduction velocity, and physiologic
properties.
What is most important to physicians is how local anesthetics affect these
different sensory fibers.
Local anesthetics block axonal conduction in nociceptive afferents resulting
in analgesia as well as attenuating other sensations and causing muscle
relaxation via loss of motoneuronal activity. The therapeutic effects are
restricted to body parts innervated by the nerves (or part of the spinal cord)
exposed to the drug.
The following is a chart showing nerve fiber classification.

Nerve Fiber Classification

Fiber Type

Sesnsory
Classification

Modality

Diameter
(mm)

Conduction
(m/s)

Local
Anesthetic
Sensitivity

Myelination

Motor

12-20

70-120

Yes

Type 1a

Proprioception

12-20

70-120

++

Yes

Type 1b

Proprioception

12-30

70-120

++

Yes

Type 2

Touch pressure
Proprioception

5-12

30-70

++

Yes

Motor (muscle
spindle)

3-6

15-30

++

Yes

Pain
Cold temperature
Touch

2-5

12-30

+++

Yes

Preganglionic
autonomic fibers

<3

3-14

++++

Some

Pain
Warm and cold
temperature
Touch

0.4-1.2

0.5-2

++++

No

Postganglionic
sympathetic
fibers

0.3-1.3

0.7-2.3

++++

No

Type 3

B
C
Dorsal root

C
sympathetic

Type 4

Peripheral nerve fibers are classified A-C according to axonal diameter, covering, and conduction velocity Swernsory fibers are categorized 1-4.
Adapted from Morgan GE, Mikhail JS, Murray MJ: Clinical Anesthesiology, 4th Edition: www.accessmedicine.com

Section 1D: Anatomy - Pain Pathways

Pain is conducted along three-neuron pathways that transmit noxious stimuli

from peripheral tissues to the cerebral cortex
The cell body of the first neuron, the primary afferent, is located in the
dorsal root ganglion (DRG) which lies in the vertebral foramina at each
spinal cord (SC) level. The axon of this neuron bifurcates sending one end
as a peripheral nerve to the tissue it innervates and one to the dorsal horn
of the SC. Pain fibers from the face and head are carried by the trigeminal,
facial, glossopharyngeal, and vagus nerves.
In the dorsal horn, the axon synapses with the cell body of the secondorder neuron whose axons cross the midline and ascend in the contralateral
spinothalamic tract (ST) to the thalamus. It can also synapse with
interneurons, sympathetic neurons, and ventral horn motor neurons. As
afferent fibers enter the spinal cord, they segregate according to size, with
large, myelinated fibers running medially, and small, unmyelinated fibers
laterally. Pain fibers may ascend or descend one to three spinal cord
segments in the tracts of Lissauer before synapsing with second-order
neurons in the grey matter of the dorsal horn. In many instances they
communicate with second-order neurons through interneurons.

Spinal Cord Laminae

The grey matter of the SC has been divided by Rexed into 10 laminae.

The first six laminae make up the dorsal horn, receive almost all afferent
neural activity, and represent the main site of pain modulation by
ascending and descending pathways.
These second-order neurons can be either nociceptive-specific (receiving
only noxious stimuli) or wide dynamic range (WDR) neurons (which receive
afferent input from A, A, or C fibers.
Nociceptive specific neurons are arranged somatotopically in lamina I and
normally only respond to intense stimuli.
WDR neurons are found predominantly in lamina V, have larger receptive
fields than nociceptive specific, and respond with increasing rate of firing
upon repeated stimulation.
Below is a table characterizing the 10 laminae.

http://medical-dictionary.thefreedictionary.com/basal+lamina

Spinal Cord Laminae

Lamina

Predominant Function

Input

Name

Somatic nociception
thermoreception

A, C

Marginal Layer

II

Somatic nociception
thermoreception

C, A

Substantia gelatinosa

III

Somatic
mechanoreception

A, A

Nucleus propius

IV

mechanoreception

A, A

Nucleus propius

Visceral and somatic

nociception and
mechanoreception

A, A, (C)

Nucleus propius, wide

dynamic range

VI

Mechanoreception

Nucleus propius

VII

Sympathetic

VIII
IX
X

Motor

Intermediolateral column
A

Motor horn

Motor horn

Central canal

Adapted from Clinical Anesthesiology 4th edition by Morgan, Mikhail and Murray.

Second-Order Neurons

Most nociceptive C fibers synapse with second-order neurons in laminae I

and II.
Ad fibers synapse in laminae I and V and a few in X.
Lamina II, also called the substantia gelatinosa contains mainy interneurons
and so processes and modulates impulses from cutaneous nociceptors.
It is of special interest because it is believed to be the site of action of opioids.

Visceral afferents terminate in Lamina V and some in lamina I thus making

these two lamina points of convergence between the somatic and visceral
inputs.
This convergence accounts for the clinical phenomenon known as referred pain.

Third-Order Neurons

In the thalamus lie the cell bodies of the third-order neurons

(thalamic nuclei). The axons of second-order neurons in the ST
tract synapse here; the lateral division with the ventral posterolateral
nucleus and the medial tract to the medial thalamus.
The lateral ST tract is believed to carry information related to the
location, intensity, and duration of pain.
The medial ST tract mediates autonomic and emotional aspects of pain.

Third order neurons terminate in the post-central gyrus of the

parietal cortex and the superior wall of the sylvian fissure.

Section 1E: Dermatomes and myotomes

Clinical Pearl: Knowledge of dermatomes is useful for testing levels of neuraxial blocks.

Body Landmark

Dermatome

Myotome

Spinal cord
segment

Back of Head

C2

Deltoid

C5

Shoulder

C4

Biceps

C6

Thumb

C6

Triceps

C7

Middle Finger

C7

Hypothenar muscle

T1

Small finger

C8

Quadriceps femoris

L4

Nipple

T4-T5

Extensor hallusis

L5

Umbilicus

T10

Gastrocnemius

S1

Inguinal region

L1

Rectal sphincter

S3-S4

Big toe

L4-L5

Small toe

S1

Genitalia and perianal S4-S5

region
Adapted from Adel Afifi, Bergmann Ronald. Functional Neuroanatomy. McGraw-Hill; 2005.

Dermatomes and peripheral nerves-anterior view

http://www.regionalabc.org/images/med-illustartion/ant-dermatome.jpg

Dermatomes and peripheral nerves-posterior view

http://www.regionalabc.org/images/med-illustartion/post-dermatome.jpg