The Back

Slide 118 Slide 119
CLINICAL
CLINICAL ANATOMY:
ANATOMY: THE
THE BACK
BACK
CLINICAL ANATOMY: THE BACK
THE
THE VERTEBRAL
VERTEBRAL COLUMN
COLUMN THE JOINTS OF THE VERTEBRAL COLUMN
JOINTS
JOINTSOF OFTHE
THEVERTEBRAL
VERTEBRALCOLUMNCOLUMN
-Symphyses
-Symphysesjoints
joints(secondary
(secondary
cartilaginous
cartilaginousjoints)
joints)
-designed
-designedfor forweight
weightbearing
bearing
-considerable
-considerablestrength
strength
-flexibility
-flexibility
1.
1.-INTERVERTEBRAL
-INTERVERTEBRALDISC DISC(IV
(IVDISC)
DISC)
2.
2.-ZYGAPOPHYSEAL
-ZYGAPOPHYSEALJOINTS JOINTS
3.
3.-Cervical
-Cervicalspine
spine(C3-C6):
(C3-C6):
UNCOVERTEBRAL
UNCOVERTEBRALJOINTS JOINTSOF OFLUSCHKA
LUSCHKA
4.
4.-CRANIOVERTEBRAL
-CRANIOVERTEBRALJOINTS: JOINTS:
-Atlanto-Occipital
-Atlanto-Occipitaljoints
joints TRANSVERSE SECTION OF THE CT SCAN OF THE MEDIAL
-Atlantoaxial
-Atlantoaxialjoints
joints MEDIAL ATLANTOAXIAL JOINT ATLANTOAXIAL JOINT
The MEDIAL ATLANTOAXIAL JOINT (or, the ATLANTO-DENS articulation)

In the articulated vertebral column, from the 2nd cervical vertebra (axis) to the first articulates the osteofibrous ring of the atlas with the odontoid process.
sacral vertebra, there are two types of joints in two different parts of a vertebral The osteofibrous ring of the atlas is formed anteriorly by the facet of the odontoid
segment.. Each vertebral segment is connected to each other by series of joints to give process on the posterior aspect of the anterior arch of the atlas, and posteriorly by the
enough flexibility and strength. Between the vertebral bodies a series of cartilaginous transverse ligament of the atlas, a fibrous band; and posteriorly by the transverse
joints are interposed. These are the INTERVERTEBRAL DISC. These joints are called ligament of the atlas, a fibrous band that extends horizontally
symphyses-that is, secondary cartilaginous joints united by fibrocartilage, that allow
movement between adjacent vertebrae. At the vertebral arches, the
ZYGAPOPHYSEAL (FACET) joints are formed by the articulation of the superior
articulating processes of the lower vertebra with the inferior articulating processes of the
superior adjacent vertebra. These posterior arch joints are synovial joints
Slide 120 Slide 121

THE JOINTS OF THE VERTEBRAL COLUMN THE VERTEBRAL COLUMN
THE ATLANTO-AXIAL JOINTS:
(2) Lateral atlanto-axial joints: gliding type of synovial joints
-Stabilizing ligaments: zygapophyseal articular capsule
(1) median atlanto-axial joint: pivot type of synovial joint
-Stabilizing ligaments: Transverse ligaments of atlas with the superior
and inferior longitudinal ligament(or known as the CRUCIATE LIGAMENT
-Alar ligaments
-Tectorial membrane
MOTION AT THE ATLANTO-AXIAL JOINTS:
-Rotation of head from side to side.
-Mechanism of head rotation: Cranium and C1 rotate as one unit
-Odontoid process as the pivot of rotation
-Odontoid process held in a socket formed by the anterior arch of C1
and the transverse ligament of C1.
The two lateral atlanto-axial joints are gliding type of synovial joints and are At the cervical region from C3- C6, a distinctive joint is found at the lateral and
stabilized by the articular capsules. The single median atlanto-axial joint is a pivot type posterolateral margin of the cervical intervertebral disc. This joint is called the
of joint and are stabilized the CRUCIATE LIGAMENTS composed of the transverse UNCOVERTEBRAL JOINT OF LUSCHKA , and is formed by the UNCINATE
ligament of atlas ( which is the stronger ligament band) and the superior and inferior PROCESSES of C3.-C6 and the bevelled inferolateral surfaces of the vertebral bodies
longitudinal ligaments. superior to them. The uncovertebral joints of Luschka are only found in the cervical
The 3 atlanto-axial joints provide rotational movement of the head from side to side region and specifically at the level of C3 to C6 vertebrae.
as shaking the head as a sign of “NO”. For this rotational movement to occur, the
cranium and C1 acts as one unit as it rotates on the odontoid process of C2. This
odontoid process is stabilized and embedded on a socket formed by the anterior arch
Slide 122
Slide 123

THE VERTEBRAL COLUMN
The uncovertebral joint of Luschka maintains the distance between the uncus or
uncinate process of the lower vertebrae and the inferolateral beveled border of superior The NUCLEUS PULPOSUS is a pulplike gel located in the mid posterior part of the
vertebra. By maintaining this distance, the intervertebral foramen, through which the disc. Consisting of 70% to 90% water, the nucleus pulposus functions as a modified
cervical spinal nerve passes, is kept patent. shock absorber that dissipates and transfers loads between consecutive vertebrae. It is
The integrity of the joint of Luschka is intimately related to a well-functioning thickened by relatively large branching proteoglycans. Each proteoglycan is an
cervical intervertebral disc. If the cervical intervertebral disc becomes degenerate as aggregate of many water-binding glycosaminoglycans link to core protein. It also
what happens in degenerative osteoarthritis of the spine (as shown above at the level contains type II collagen fibers, elastic fibers and noncollagenous proteins
where the pink-colored spinal nerve is located), the joint of Luschka also degenerates, The annulus fibrosus consists of 10 to 20 concentric layers, or rings of collagen
the distance between the uncinate process of the lower vertebra and the beveled fibers. Like dough surrounding jelly in a doughnut, the collagen rings encase and
inferolateral border of the superior vertebra is lost, and both bony surfaces come in physically entrap the liquid-based central nucleus pulposus. The annulus fibrosus is
contact with each other. This will result in the formation of bony spurs that encroach thicker anteriorly than posteriorly. This difference in thickness is one of the anatomical
the intervertebral foramen decreasing its diameter and crowding on the spinal nerve that reasons for the posterior direction of disc herniation.
exits through it.
Compression force increases the hydrostatic pressure within the entrapped and Its fiber contents consist of type II collagen and elastic fibers.
water-logged nucleus pulposus. The increase in pressure absorbs shock across the
interbody joint.
The annulus fibrosus contains material similar to that found in the nucleus pulposus,
differing only in proportion. In annulus fibrosus, collagen makes up about 50 to 60% of Slide 125
the dry weight, as compared with only 15 to 20% in the nucleus pulposus.

Slide 124 THE JOINTS OF VERTEBRAL
COLUMN
WATER DIFFUSION TO
THE NUCLEUS PULPOSUS
-inferior surfaces
vertebral bodies: hyaline
JOINTS OF THE VERTEBRAL COLUMN
cartilage
- permits diffusion of
THE NUCLEUS PULPOSUS
fluid coming from the
-Location: Midposterior part
capillaries from the
-Composition: vertebral bodies to the
-70 to 90 % water intervertebral discs.
- Ground substance:
PROTEOGLYCAN
(glycosaminoglycan + protein
core)
-Noncollagenous proteins
- fibers: type II collagen
fibers and elastic fibers
The slide above shows the nucleus pulposus is taken out leaving the inferior surface
of the vertebra. This surface is covered with thin hyaline cartilage which allow diffusion
of fluid from the capillaries, that penetrate the bone underlying the hyaline cartilage,
into the intervertebral disc space. Since the protein that composed the ground substance
of the nucleus pulposus is hydrophilic, fluid that diffused into the intervertebral disc is
The nucleus pulposus is located off-center to the midposterior part of the imbibed.
intervertebral disc. It is 70-90% water. It is colloidal in nature composed of
proteoglycan molecules and noncollagenous protein. Each proteoglycan is an aggregate
of branching glycosaminoglycan attached to a core of protein.
Slide 126 therefore, separates relative to its neighboring vertebra. Shear and torsion forces are
produced during virtually all movements of the vertebral column. Because of the
alternating pattern of layering of the annulus fibrosus, only the collagen fibers oriented
to the direction of the slide or twist become taut. Fibers in every other layer slacken.
CLINICAL ANATOMY: THE BACK Slide 127

The intervertebral discs add considerable stability to the vertebral column, as well as
being shock absorber. The stabilizing function of the disc is due primarily to the
structural configuration of the collagen fibers within the annulus fibrosus. These
collagen fibers are oriented in a precise geometric pattern. In the lumbar region,
collagen rings lie about 65 degrees from the vertical, with fibers of adjacent layers
travelling in opposite directions. This structural arrangements resists distraction (vertical The vertebral column is the primary support structure for the trunk and the neck,
separation), shear(sliding) and torsion (twisting). If the imbedded collagen fibers ran which, in turn, supports the head. Distally, however, the ground reaction forces are also
nearly vertical, the discs would resist distraction forces but not sliding or torsion . In exerting and transmitting loads to the vertebral column. Although highly dependent on
contrast, if the fibers ran parallel to the top of the vertebral body, the disc would resist the position of the spine, approximately 80% of the load across two lumbar vertebrae is
shear and torsional forces but not distraction forces. The 65-degree angle likely carried through the interbody joint. The remaining 20% is carried by posterior
represents a geometric compromise that allows tensile resistance against the usual structures, such as the apophyseal joints (facet joints) and the laminae.
movements at the lumbar spine. Distraction forces are an inherent component of flexion, The intervertebral discs are uniquely designed as shock absorbers, protecting the
extension and lateral flexion, occurring as one vertebral body tips slightly and, bone from the compression forces produced by body weight and muscle contraction.
Compression forces push the endplates inward and toward the nucleus pulposus. Being
filled mostly with water and therefore essentially incompressible, the nucleus responds
by deforming radially and outwardly against the annulus fibrosus. Radial deformation is THE VERTEBRAL COLUMN
resisted by the tension created within the stretched rings of the collagen and elastic
fibers. Internal resistance reinforces the walls of the annulus fibrosus. As a result, back
pressure is created against the nucleus pulposus and endplates, reinforcing the entire
disc and passing the load to the next vertebra. When compressive force is removed
from the endplates, the stretched elastic and collagen fibers return to their original
preload length and prepare for another cycle of shock absorption. The disc provides
little resistance to small compressive loads, but more resistance to large ones. The disc
thereby allows flexibility at low loads and provides stability at high loads.
The shock absorption mechanism protects the disc in 2 ways. First, compressive
forces are diverted from the nucleus pulposus, toward the annulus fibrosus, and back to
the nucleus and endplates. Such diversion takes time, thereby reducing the rate of
loading, although not necessary the magnitude of the load. Second, the mechanism
allows compressive forces to be shared by multiple structures, thereby limiting pressure
on any single tissue.
Slide 128
Slide 129
:
-
The structure of the intervertebral disc changes with age. The older disc has less
proteoglycan content and, therefore, less ability to attract, imbibed and retain water. The
water content of the nucleus pulposus at birth is 88%, but decreases to 65 to 75% by the Most HNPs occur posterolaterally or posteriorly. This usual direction of protusion of
age of 75 years. The aged disc contains more collagen and less elastin, rendering it more the nucleus pulposus is due to the fact that this side is relatively thin and does not
fibrous and less resilient. A drier or more dessicated and less elastic nucleus pulposus is receive any support from the posterior or anterior longitudinal ligament. Posterolateral
less able to cushion the vertebral body against excessive compression forces. As a herniation compresses the nerve root while central posterior herniation compresses the
result, the vertebral bodies and endplates may experience microfractures and bony spinal cord.
resorption, ultimately leading to progressive and permanent age-related loss in height. HNP is one of the major causes of back pain. However, not all back pain is caused
The amount of loss is greater in person with severe OSTEOPOROSIS of the vertebral by HNP. The percentage of persons with low back pain due to HNP is uncertain but
column and those with osteoporotic compression fractures, leading to an exaggerated likely significant. This condition has generated extensive research on methods of
kyphosis known as “widow’s hump” diagnosis, mechanisms of herniation, rehabilitation and efficacy of surgery.
Slide 131
Slide 130
THE JOINTS OF THE VERTEBRAL COLUMN
The above left slide shows the arrangement of the posterior longitudinal ligament at
the posterior side of the vertebral body. This ligament only covers a narrow portion of
the intervertebral disc and, leaves the posterolateral area in the vicinity of the
intervertebral foramen where the spinal nerve exits. This bare area is the usual site of
disc herniation.
The slide at the right hand side shows the large area covered by the anterior
longitudinal ligament. It extends to the anterolateral part of the intervertebral disc.
Slide 132 Slide 133

THE VERTEBRAL COLUMN CLINICAL ANATOMY: THE BACK
THE ANTERIOR LONGITUDINAL THE JOINTS OF THE VERTEBRAL
LIGAMENT COLUMN
-Wide area of coverage of the

anterior aspect of the vertebral ANATOMIC BASIS OF
body HERNIATED NUCLEUS
- posterolateral aspect of the PULPOSUS
intervertebral disc is not
covered by ligaments -narrow posterior
-vulnerable area for disc side vs. wide
herniation anterior side of the
annulus fibrosus
The slide above shows the difference in width of the anterior vs. posterior side of the
annulus fibrosus. The posterior side is narrow compared to the anterior side of the
annulus fibrosus. The risk of posterior herniation of nucleus pulposus is greater than the
risk of anterior herniation
Slide 134 The second mechanism involves a series of multiple, low magnitude compression
forces, often imposed over a flexed lumbar spine. This mechanism of prolapse generally
occurs gradually from cumulative microtrauma, such as that which may occur from
many years of repetitive lifting or bending with an excessively flexed back.
Slide 135

In the causation of HNP, two mechanisms are typically involved. First, it involves a
very large, sudden compression force that is being applied over the lumbar spine that is
flexed or, most likely, flexed and axially rotated. This happens in an event like falling
from a height and landing on the buttocks or; in lifting a large load.
In this situation, a flexed and/or twisted lumbar spine renders the disc mechanically
vulnerable to protrusion. A flexed spine stretches or thins the posterior side of the
annulus fibrosus as the nuclear gel is forced posteriorly, often under large hydrostatic The above illustration shows to different positions of the lumbar vertebral column.
pressure. This amount of hydrostatic pressure increases with greater trunk muscle At the left, the motion is exemplified by the anterior pelvic tilt. This maneuver causes
activation, usually in response to large external torques. With sufficiently high extension of the lumbar vertebral region and increases the lumbar lordosis. This motion
hydrostatic pressure, the nuclear gel creates or finds a preexisting fissure in the posterior exerts pressure at the posterior aspect of the intervertebral disc and causes an anterior
annulus. A partially rotated spine renders only half the posterior fibers of the annulus shift to the nucleus pulposus away from the spinal nerve exiting from the
taut, thereby reducing the potential resistance that can be applied against approaching corresponding intervertebral foramen. Take note that this maneuver also decreases the
nuclear gel. diameter of the intervertebral foramen. On the other hand, the illustration at the right
side shows a sitting position that decreases the lumbar lordosis producing a round back Types of HNP: A. Protrusion: The displaced nucleus pulposus remains within the
and flexed lumbar region. This position exerts pressure at the anterior part of the annulus fibrosus, but may create a pressure bulge on the spinal cord
intervertebral disc and causes posterior migration of the nucleus pulposus. It is B. Prolapse: Displaced nucleus pulposus reaches the posterior edge
postulated that a habitual posture that produces rounded back and flexed lumbar of the disc, but remains confined within the outer layers of the annulus fibrosus.
vertebral region may, in time, cause overstretching of the ligaments at the posterior C. Extrusion: annulus fibrosus ruptures, allowing the nucleus pulposus to
aspect of the intervertebral disc. Such overstretching renders the posterior aspect of the completely escape from the disc into the epidural space
intervertebral disc vulnerable to a sudden compressive flexion force acting on the D. Sequestration: Parts of the nucleus pulposus and fragments of
lumbar vertebral region. This flexion compression force, though lesser in magnitude, annulus fibrosus become lodged within the epidural space
causes rupture of the intervertebral disc and herniation of the nucleus pulposus. Take
note that flexion of the lumbar vertebral region increases the intervertebral foramen.
While it gives a lot of space for the spinal nerve, it does not give any resistance to an
herniating nucleus pulposus.
Slide 136

HERNIATED NUCLEUS
PULPOSUS
>TYPES OF DISC
HERNIATION
-Protrusion
-Prolapse
-Extrusion
-Sequestration
Slide 137 Slide 138

FACTORS THAT FAVOR DISC HERNIATION IN THE LUMBAR
SPINE
1. Propensity for fissures or tears in the posterior
annulus that allows a path for the flow of nuclear
material
2. Sufficiently hydrated nucleus structurally capable
of exerting high pressure
3. inability of the posterior annulus to resist high
magnitude of radial pressure from the nucleus
4. axial loading applied over a bent (flexed) and
twisted spine.
Despite the abundance of literature and anecdotal evidence, a single unifying cause-
and-effect explanation for all forms of disc herniation is lacking. The four factors listed
above are particularly important. Disc prolapse can occur even in the absence of trauma
or mechanical overload. A habitual chronic sitting posture involving a rounded and
flexed lumbar posture certainly may predispose a person to posterior migration of the
nucleus pulposus. A chronically flexed lumbar posture may, in time, overstretch the
posterior part of the annulus to a point where it is unable to resist a potent hyperflexion-
induced posterior migration of the nucleus. This explanation, however, is subject to
scrutiny because the incidence of disc prolapse in the lumbar region is very low in
culture whose people habitually squat with near maximal flexed lumbar spines.
The healthy lumbar disc with intact annulus fibrosus is remarkably resistant to disc
herniation, even from a large flexion force. The reason for the relatively high incidence
of disc prolapse in western culture is still not fully understood.
Slide 139 Slide 140

CLINICAL ANATOMY: THE BACK THE VERTEBRAL COLUMN
THE VERTEBRAL COLUMN LIGAMENTS OF THE
LIGAMENTOUS SUPPORT OF THE VERTEBRAL VERTEBRAL COLUMN:
COLUMN 1. Anterior longitudinal
ligament
Functions of Spinal Ligaments 2. Posterior longitudinal
-Limit spinal motion ligament
3. Ligamentum flavum
-Maintain natural spinal curvature 4. Interspinous ligament
-Maintain spinal stability 5 Supraspinous ligament
6. Apophyseal capsule
-Indirectly protect the spinal cord. 7. Intertransverse
ligament
The vertebral column is supported by an extensive set of ligaments which limit Above slide is a sagittal section of a spine showing the ligaments that stabilize and
spinal motion, maintain natural spinal curvature, maintain natural spinal curvature, support the spine. These ligaments are the following:
maintain spinal stability, and indirectly protect the spinal cord 1. Anterior longitudinal ligament
2. Posterior longitudinal ligament
3. Ligamentum Flavum
4. Interspinous ligament
5. Supraspinous ligament
6. Capsule of the apophyseal joint
7. Intertransverse ligament (not shown in this slide)
Slide 141 Slide 142

LIGAMENTS OF THE VERTEBRAL COLUMN
VERTEBRAL COLUMN
CORONAL CUT OF THE
LIGAMENTUM FLAVUM VERTEBRAL SPINE
The ligamentum flavum means “the yellow ligament” reflecting its high content of The slides above shows the conspicuous yellow color of the ligamentum flavum
yellow elastic connective tissue. It originates on the anterior surface of a lamina of the compared to the other ligaments. Note the relative thickness and segmental arrangement
vertebra above and inserts on the posterior surface of the lamina of the vertebra below. of the ligamentum flavum as it spans from one vertebra above to another vertebra
The ligaments are thickest in the lumbar region. Passive tension in a series of stretched below. Such segmental arrangement is also seen in interspinous ligament and the
ligamentum flava limits flexion throughout the vertebral column, thereby protecting the capsule of the apophyseal joint.
intervertebral disc from excessive compression. The ligamentum flava is the most
elastic ligament of the spine and is “PRE-TENSIONED”(possessed tension at rest)
when the spine is at neutral position.
Slide 143 Slide 144

The above illustration shows the stress/strain curved of the ligamentum flavum in The SUPRASPINOUS AND INTERSPINOUS LIGAMENTS are attached between
relation to flexion-extension of a spinal segment. From a neutral extension to full the adjacent spinous processes from C7 to the sacrum. These ligaments function to limit
flexion there is increase in tension(stress) and the ligamentum flavum has flexion of the vertebral column. In the craniocervical region, the supraspinous ligament
elongated(strain) 35% of its original resting length. Flexion beyond physiologic limits becomes the LIGAMENTUM NUCHAE which provides a midline structure for muscle
can rupture the ligament and permit compressive damage to the intervertebral disc. The attachments, and passive support for the head.
ligamentum flavum lies just posterior to the spinal cord. Severe hyperextension of the The ligamentum nuchae accounts for the difficulty encountered when palpating the
spine can buckle the ligamentum flavum inward and can pinch the delicate spinal cord. spinous process in the mid to upper cervical region.
Slide 145

The anterior longitudinal ligament is a long, straplike structure attaching between

the basilar part of the occipital bone and the entire length of the anterior surface of all
vertebral bodies including the sacrum where it merges with the SACROILIAC JOINT
CAPSULE. This strong ligament is narrow at its cranial end and widens caudally. It has
two sets of fibers- superficial and deep fibers. The superficial fibers span the vertebral
In young slender person, flexion of the neck makes the ligamentum nuchae taut and
segments; the deep fibers blend with the annulus fibrosus and reinforce it. It provides
can be palpated as a tight midline structure at the mid and upper portion of the posterior
axial stability to the vertebral column by limiting extension or excessive lordosis in the
cervical region. The ligamentum nuchae is the anatomic reason for difficulty in
cervical and lumbar regions.
palpating the spinous processes of the middle and the superior cervical vertebrae. The
spinous process that can be palpated is that of the 7th cervical vertebra.
Slide 146
Slide 147 Slide 148

LIGAMENTS OF VERTEBRAL ANTERIOR LONGITUDINAL LIGAMENTS OF THE VERTEBRAL
COLUMN LIGAMENT COLUMN
>POSTERIOR LONGITUDINAL
CHARACTERISTICS LIGAMENT.
-One of the strongest -attachment: throughout the
ligaments of the body length of the posterior surface
-provides axial stability to the of all vertebral bodies between
spine the axis (C1) and the sacrum
- function: Adds vertical stability
-maintain cervical and sacral
to the vertebral column
lordosis curves
-limits flexion
-resists hyperextension forces
-reinforces the posterior
acting on the spine annulus fibrosus
The anterior longitudinal ligament consists of longitudinal fibers, which are firmly The posterior longitudinal ligament is a continuous band of ligament that extends
attached to the intervertebral discs and to the margins of the vertebral bodies, but are the entire length of the posterior surfaces of all vertebral bodies between the axis(C1)
loosely attached to the middle parts of the bodies. In the latter situation the ligament is and the sacrum. It is located within the vertebral canal, just anterior to the spinal cord.
thick and fills up the concavities of the anterior surfaces, and makes the front of the The posterior and anterior longitudinal ligaments are named according to their
vertebral column more even. It is composed of several layers of fibers, of which the relationship to the vertebral body ,not the spinal cord. Throughout its length, the
most superficial are the longest and extend over 3 or 4 vertebrae. The intermediate layer posterior longitudinal blends with and reinforces the intervertebral discs. Cranially, this
of fibers extend between 2 to 3 vertebrae, while the deepest reach from one vertebra to ligament is a broad structure, and then narrowing as it descends toward the lumbar
the next. At the sides of the bodies the ligament consists of few fibers which connect region. The slender lumbar region limits its ability to restrain a posterior
adjacent vertebrae. bulging(slipped) disc. This ligament provide axial stability to the spine.
Slide 149 Slide 150

LIGAMENTS OF VERTEBRAL POSTERIOR LONGITUDINAL
COLUMN LIGAMENT
Characteristics:
-narrower in width
compared to the anterior
longitudinal ligament
-wider at the superior end
of the vertebra; narrower as
it approaches the lumbar
region of the vertebral
column
-one of the weakest
ligaments
The posterior longitudinal ligament consists of smooth, glistening fibers which are The INTERTRANSVERSE LIGAMENT are attached in between adjacent
attached to the intervertebral discs and to the margins of the vertebral bodies, but are transverse processes and functions to limit contralateral flexion. It is well-developed in
separated from the middle parts of the bodies by the emerging basivertebral veins, and the thoracic region while only few fibers exist in the cervical region. In the lumbar
by veins which drain these into the anterior vertebral plexuses. In the cervical and region, these ligaments are thin and membranous.
thoracic regions the ligament is broad and of nearly uniform width, but in the lower
thoracic and lumbar regions, it presents with denticulated appearance, being narrow
over the vertebral bodies and broad over the discs. It consists of superficial layers
bridging the in interval between 3 to 4 vertebrae, and deeper layers which extend
between adjacent vertebrae.
Slide 151 2. The anterior longitudinal ligament and the capsules of the apophyseal joints
are among the strongest ligamentous tissues in the body.
3. The supraspinous ligament is the most flexible ligament
4. The posterior longitudinal ligament and the interspinous ligaments are among
the weakest ligaments.
THE SPINE LIGAMENTS
Slide 152

The vertebral column is a structure composed of small bone segments. Each bone
segment is placed on top of each other. Without out its inherent supporting structures
like the ligaments and muscular structures, such anatomic arrangement is basically
unstable. However, the presence of the supporting structures the vertebral column can
withstand deforming forces to a certain degree. Static and immediate stability is
provided by the ligaments while dynamic stability is supported by the stabilizing
muscles.
Comparing the relative strength of the ligaments in restraining motion in the
vertebral segment. The following are the validated observations: The slide above shows acceleration (or whiplash) injuries. Hyperextension injury to
1. The main restraint come from the capsules of the apophyseal joints and from the craniocervical region (A) exceeds cervical flexion (B).
the ligamentum flava. In the lumbar region these two ligamentous structures (capsules
of the apophyseal joints and the ligamentum flavum) constitute 52% of the restraint.
Slide 153 Slide 154

The above slide is shows the mechanics of whiplash injury to the cervical spine. The The neural arch ligaments are those ligaments found in the posterior aspect of the
usual scenario is a car accident in which a driver inside a car that is in dead stop and, vertebral foramen. These are the ligamentum flavum, interspinous ligament,
who is unaware of being hit from behind by a speeding car. At impact, the supraspinous ligament, intertransverse ligaments. These ligaments are regarded as one
craniocervical region goes into hyperextension. A large mass moment of inertia of a functional unit
relatively heavy head creates a large angular velocity of the head that is proportionately
transmitted to the cervical region. This creates a large strain on the soft tissues
anteriorly. These soft tissues include the flexor muscles and the viscera of the anterior
neck. If cervical hyperextension becomes extreme, it can rupture the anterior
longitudinal ligament, posterior longitudinal ligament, the capsule of the
apophyseal/zygapophyseal joints. The loss of the restraining function of these ligaments
allows one vertebra slipping past another vertebra resulting in injury to the spinal cord.
Slide 155 Slide 156
CLINICAL ANATOMY: THE BACK CLINICAL ANATOMY: THE BACK

THE VERTEBRAL COLUMN THE VERTEBRAL COLUMN
The joint capsules surround and reinforce each apophyseal joint. The capsule is The connective tissues that surround the vertebral column limit extremes of motion.
relatively loose, especially in the cervical region where ample range of motion is By restricting motion, connective tissues- including those within muscle- help protect
required. Although relatively loose in a neutral posture, the capsule of the apophyseal the delicate spinal cord and maintain optimal posture
joint is under tension when stretched. In the lumbar region, the capsule is shown to
accommodate up to 1000 N (approx. 225 lb) of tension before failure. The tension limits
the exremes of all intervertebral motions with the exception of extension. The capsules
of the apophyseal joints is reinforced by the adjacent muscles(MULTIFIDUS) and
connective tissue (LIGAMENTUM FLAVUM), particularly evident in the lumbar
region
Slide 157

In most, if not all vertebral motions the ANNULUS FIBROSUS is the most
consistent structure that limits motion of the vertebral column. This is followed by the
capsule of the apophyseal joints.
In the cervical region, the presence of structures like the trachea and esophagus also
limit cervical extension. The anterior part of the annulus fibrosus and anterior
longitudinal ligament are the consistent connective tissues that limit extension of the
vertebral column
Slide 158
Slide 159 Slide 160

CONNECTIVE TISSUES THAT MAY LIMIT
MOTIONS OF THE VERTEBRAL COLUMN
>LATERAL FLEXION:
THE TYPICAL INTERVERTEBRAL
-Intertransverse ligament
JUNCTION
-Contralateral annulus fibrosus
(THE VERTEBRAL COLUMN
-capsule of the apophyseal joints SEGMENT)
In cases of trauma or overuse, biologic tissues may generate excessive tension as a The typical INTERVERTEBRAL JUNCTION is the segment of the vertebral
means to protect an injured vertebral segment. Spasm in local muscles following column where the articulating joints are found. It is, therefore, the seat of vertebral
acceleration-deceleration (“whiplash”) injury of the neck is a common expression of movements. Motion in one intervertebral junction is actually very limited but the
this protective guarding. In cases of disease, such as severe rheumatoid disease, limited summation of movements in the 25 moving vertebrae is translated into significant
spinal mobility has no protective function, but is instead an intrinsic part of the range of vertebral motion in the different anatomic planes.
pathologic process.
Slide 161 Slide 162
• THE INTERVERTEBRAL
JUNCTION
• THE SPINOUS AND
TRANSVERSE PROCESSES
-function as outriggers, or
lever
>mechanical advantage for
initiating motion as well as
restricting motion
>dynamic stability
The INTERVERTEBRAL JUNCTION is composed of 3 parts: 1. the SPINOUS The spinous and transverse processes are sites of attachments for muscles and
PROCESS AND THE TRANSVERSE PROCESSES; 2. THE APOPHYSEAL ligaments. These bony structures act as OUTRIGGERS, or LEVERS, providing and
JOINTS; 3. THE INTERBODY JOINT. increasing the mechanical advantage of muscles and ligaments for the purpose of
All three share common functions, although each has predominant function. causing and restricting movements, and stabilizing the vertebral column.
Slide 163 Slide 164
The APOPHYSEAL JOINTS are primarily responsible for guiding intervertebral

motion, much like the train tracks guide the direction of the train. The following factors
greatly influence the direction of intervertebral motion: 1. geometry of the articular
facets, 2. size, 3. spatial orientation of the articular facets
The vertebral column contains 24 pairs of apophyseal joints. Each apophyseal joint
is formed by the articulation between opposing facet surfaces. Mechanically, these joints
are classified as plane joints. Although exceptions and natural variations are common,
the articular surfaces of most apophyseal joints are flat. Slightly curved joint surfaces
are present primarily in the upper cervical and throughout the lumbar spines.
The word “apophysis” means bony “outgrowth” illustrating the protruding nature of
the articular processes.
Slide 165 predominant motion at each spinal region include the sizes of the intervertebral discs,
shapes of the vertebrae, local muscle action and attachment of the ribs or ligaments.
Slide 166
Acting as mechanical barricades, the apophyseal joints permit certain movements

and block others.
The orientation of the plane of the facet surface within each joint influences the
kinematics at different regions of the vertebral column. As a general rule, horizontal
facet surfaces favor axial rotation, whereas vertical facet surfaces (in either sagittal or
frontal planes) block axial rotation. Most apophyseal joint surfaces, however, are
oriented somewhat between the horizontal and vertical. The above illustration shows the
typical joint orientation for articular facets in the cervical, thoracic and lumbar region. The INTERBODY JOINT functions primarily for shock absorption and load
The plane of the facet surfaces explains, in part, why axial rotation is far greater in distribution. In addition, it adds stability between the vertebrae, serves as the
the cervical than in the lumbar region. Additional factors that influence the predominant approximate site of the axes of rotation, and functions as a DEFORMABLE
motion at each spinal region includes the ff: 1. the sizes of the intervertebral discs, 2. INTERVERTEBRAL SPACER. As spacers, the intervertebral discs constitute 25% of
shapes of the vertebrae, 3. local muscle actions, 4. attachments of the ribs and the total height of the vertebral column. The larger the ratio between the height of the
ligaments. body and the height of the disc, the greater the relative movement between consecutive
The plane of the facet surfaces explains, in part, why axial rotation is far greater in bodies. The greatest space between vertebrae occurs in the cervical and lumbar regions
the cervical region than in the lumbar region. Additional factors that influence the
Slide 168
Slide 167
CLINICAL ANATOMY: THE BACK:

INTERBODY JOINT:
> spatial relationship between
The neural tissue, bony tissues
and the joint tissues
- neural tissue enclosed by a
Rigid bony tissue
- interbody joint (intervertebral
disc) also forms a boundary to
the neural space.
- neural tissue very near to the
of motion
Normal interaction of all 3 parts of the intervertebral junction is required for normal
vertebral movement. Mechanical dysfunction in any part can cause articular
The INTERBODY JOINT also demonstrate the spatial relationship of the neural tissue, derangement and/ or impingement of the neural tissues. Understanding the spatial
the hard bony tissues, and the joint tissues. The delicate neural tissue is enclosed in a relationships between the neurology, osteology, and arthrology of the vertebral column
very rigid bony structure in a limited space. Since the vertebral column is composed of is an essential element in understanding the cause and treatment of spinal pain and
several segments that allow motion of considerable degree, the joints are also within the dysfunction, regardless of etiology.
immediate vicinity of the neural tissue. In the above illustration,a healthy intervertebral disc at C2-C3 and the uncovertebral
joint of Luschka leave C3 spinal nerve undisturbed. Contrary to the IV disc at C3-C4
which is degenerate- that is, the IV disc is dessicated leading to loss of the intervertebral
joint space height. The uncovertebral joint of Luschka is destroyed leading to the
formation of bony spurs which encroaches into the intervertebral foramen thereby
compressing the C4 spinal nerve.
Slide 170
Slide 169
As shown in the above illustration lumbar extension generates compression force in

the intervertebral junction causing an inferior articular facet to move closer to its partner
The spatial relationship between the bony, soft tissue(spinal nerve) and the joint can facet which is the superior articular facet of the lower vertebra. This motion is
be affected by motion (like flexion) as shown by the above illustration. In the neutral exemplified by a manuever called the anterior pelvic tilt. This manuever extends the
position, the facet surfaces within the apophyseal joint are in maximal contact. The size lumbar spine and increases the lumbar lordosis. This action tends to shift the nucleus
of the intervertebral foramen relative to the circumference of the existing nerve is pulposus anteriorly and reduces the diameter of the intervertebral foramen.
indicated in red. In full flexion, the contact between the articular surfaces of the facet
joint are becomes reduced. However, the opening for the passage of the nerve is
increased several times.
Slide 171 Slide 172
• THE SPINAL CORD

A. Ave. length(European
males): 45 cms.
B. Ave weight: 30 g.
C. Proximal end: upper
border of the atlas
D. Distal end: In front of the
intervertebral disc between L1
and L2.
E. occupies superior 2/3 of
the vertebral canal
F. Variations
This section deals with the study of the structures within the vertebral canal and its The spinal cord is a continuation of the Medulla Oblongata which is distal part of
extensions through the intervertebral canal. These structures are the following: the brainstem. It is approximately cylindrical structure that is flattened anteriorly and
1. Spinal Cord and its blood vessels posteriorly, and occupies the superior 2/3 of the vertebral canal.
2. Spinal nerves, spinal roots, spinal rami The upper limit is located at the level of the upper border of the ATLAS; the
3. Meninges or the theca and its spaces, cerebrospinal fluid lower end is located at the junction of the L1 and L2 vertebrae as the CONUS
MEDULLARIS. The lower level varies, and there are normal variations especially in
females. The lower end may be as high as the caudal third of the 12th thoracic
vertebrae or as low as the disc between the 2nd and 3rd lumbar vertebrae.
In about 1% of the general population, especially in short-statured individuals, the
cord extends below the 2nd lumbar vertebra. Because of this variation, neither lumbar
puncture nor spinal (intrathecal) anesthesia should be attempted above the level of the
third vertebra.
through the dural sac to the appropriate intervertebral foramina- the “Law of Descent”.
The resultant descending distribution of spinal roots forms the CAUDA EQUINA.
Slide 173 In adults, the spinal cord is shorter than the vertebral column; hence there is a
progressive obliquity of the spinal nerve roots as the cord descends. Because of the
increasing distance between the spinal cord segments and the corresponding vertebra,
the length of the nerve roots increases progressively as the inferior end of the vertebral
column is approached. The lumbar and the sacral rootlets are the longest. They descend
CLINICAL ANATOMY: THE BACK until they reach the IV foramina of exit in the lumbar and sacral regions of the vertebral
THE SPINAL CORD column respectively. The bundle of spinal nerve roots in the lumbar cistern
(subarachnoid space) within the vertebral canal caudal to the termination of the spinal
cord resembles a horse’s tail, hence the name CAUDA EQUINA.
The inferior end of the spinal cord has a conical shape and tapers into the
MEDULLARY CONE(L. conus medullaris). From its inferior end, TERMINAL
FILUM(L. filum terminale) descends among the spinal nerve roots of the cauda equina.
It consists primarily of PIA MATER but its proximal end also includes vestiges of
neural tissue, connective tissue, and neuroglial tissue. The terminal filum takes on layers
of arachnoid and dura mater as it penetrates the inferior end of the dural sac and passes
through the sacral hiatus to attach ultimately to the coccyx posteriorly. The terminal
filum serves as an anchor for the end of the dural sac, the continuation of the dura
inferior to the medullary cone.
The spinal cord is enlarged in two regions for innervation of the limbs:
-The CERVICAL ENLARGEMENT extends from the C4 through the T1
segments of the spinal cord and most of the anterior rami of the spinal nerves arising
from it form the BRACHIAL PLEXUS of nerves, which innervates the upper limbs.
The BRACHIAL PLEXUS is a major network of nerves supplying the upper limb. It is
The spinal cord, spinal meninges, spinal nerve roots, and neurovascular structures formed by the union of the ANTERIOR RAMI of C1-T1 nerves, which constitute the
that supply them are in the VERTEBRAL CANAL. roots of the plexus.
In the newborn, the inferior end of the spinal cord usually is opposite the -LUMBOSACRAL (LUMBAR) ENLARGEMENT extends from the L1 through
intervertebral disc between L2 and L3 vertebrae. In adults, the spinal cord usually ends the S3 segments of the spinal cord, and the anterior rami of the spinal nerves arising
opposite the intervertebral disc between L1 and L2 vertebrae; however its tapering end, from it constitute the LUMBAR and SACRAL plexuses of nerves which innervates the
the CONUS MEDULLARIS, may terminate as high as T12 or as low as L3. lower limb. The spinal nerve roots arising from the lumbosacral enlargement and the
During the fetal stage, until the end of the third fetal month, the spinal cord is as medullary cone form the CAUDA EQUINA, the bundle of spinal nerve roots running
long as the vertebral canal and extends to the level of the of the 4th sacral vertebra. through the LUMBAR CISTERN(SUBARACHNOID SPACE).
After the 4th fetal month, the vertebral column outgrows the spinal cord. It appears A total of 31 pairs of spinal nerves are attached to the spinal cord: 8 cervical, 12
that the cord regresses to the upper lumbar levels; however, the spinal roots descend thoracic, 5 lumbar, 5 sacral and 1 coccygeal.
Slide 175
Slide 174

THE SPINAL CORD THE SPINAL CORD
CROSS SECTION THROUGH STRUCTURES FOUND INSIDE THE
THORACIC VERTEBRA VERTEBRAL CANAL
• 1. Spinal cord and its

meningeal coverings
• 2. Spinal Nerve roots
• 3. Vascular structures
-Vertebral venous
(Batson’s)plexus
-vertebral arterial vessels
4. Epidural loose fatty
connective tissues
The above slide shows the position of the spinal cord in relation to the surrounding
The cervical enlargement is the source of the large spinal nerves that supply the structures. It is almost central and being protective by the osseous vertebral column; by
upper limbs. It extends from the third cervical to the second thoracic segments. Most of the surrounding muscles; ligaments; meninges; cerebrospinal fluid.
these spinal nerves contribute to the BRACHIAL PLEXUS which innervates the
upper limb.
The lumbar enlargement corresponds to the innervation of the lower limb. It
extends from the first lumbar vertebra to the third sacral segments. Most of large spinal
nerves from this lumbar enlargement composed the LUMBO-SACRAL PLEXUS.
Slide 176 Slide 177

VERTEBRAL CANAL AT THE VERTEBRAL
VERTEBRAL (NEURAL ) CANAL AND INTERVERTEBRAL DISC LEVEL
VERTEBRAL (NEURAL) CANAL
The spinal cord is strategically at the back protected by several structures notably the The vertebral (neural) canal is an osseofibrous tunnel that houses the spinal cord.
following: The boundaries of this neural canal at the vertebral level consist of: 1. the posterior
1. Osseous vertebral column border of the vertebral body; 2. the Neural Arch which consists of 2 pedicles and 2
2. Surrounding soft tissues like the muscles laminae.
3. ligaments The intervertebral levels, it is bounded by the intervertebral disks and the
4. Meninges ligamentum flava, which run between the successive laminae on either side of the
5. Cerebrospinal fluid midline.
Slide 178 In adults, the spinal cord is shorter than the vertebral column; hence there is a
progressive obliquity of the spinal nerve roots as the cord descends. Because of the
increasing distance between the spinal cord segments and the corresponding vertebra,
the length of the nerve roots increases progressively as the inferior end of the vertebral
column is approached. The lumbar and the sacral rootlets are the longest. They descend
CLINICAL ANATOMY: THE BACK until they reach the IV foramina of exit in the lumbar and sacral regions of the vertebral
column respectively. The bundle of spinal nerve roots in the lumbar cistern
THE SPINAL CORD (subarachnoid space) within the vertebral canal caudal to the termination of the spinal
cord resembles a horse’s tail, hence the name CAUDA EQUINA.
The inferior end of the spinal cord has a conical shape and tapers into the
MEDULLARY CONE(L. conus medullaris). From its inferior end, TERMINAL
FILUM(L. filum terminale) descends among the spinal nerve roots of the cauda equina.
It consists primarily of PIA MATER but its proximal end also includes vestiges of
neural tissue, connective tissue, and neuroglial tissue. The terminal filum takes on layers
of arachnoid and dura mater as it penetrates the inferior end of the dural sac and passes
through the sacral hiatus to attach ultimately to the coccyx posteriorly. The terminal
filum serves as an anchor for the end of the dural sac, the continuation of the dura
inferior to the medullary cone.
The spinal cord is enlarged in two regions for innervation of the limbs:
-The CERVICAL ENLARGEMENT extends from the C4 through the T1
segments of the spinal cord and most of the anterior rami of the spinal nerves arising
from it form the BRACHIAL PLEXUS of nerves, which innervates the upper limbs.
The BRACHIAL PLEXUS is a major network of nerves supplying the upper limb. It is
The spinal cord, spinal meninges, spinal nerve roots, and neurovascular structures formed by the union of the ANTERIOR RAMI of C1-T1 nerves, which constitute the
that supply them are in the VERTEBRAL CANAL. roots of the plexus.
In the newborn, the inferior end of the spinal cord usually is opposite the -LUMBOSACRAL (LUMBAR) ENLARGEMENT extends from the L1 through
intervertebral disc between L2 and L3 vertebrae. In adults, the spinal cord usually ends the S3 segments of the spinal cord, and the anterior rami of the spinal nerves arising
opposite the intervertebral disc between L1 and L2 vertebrae; however its tapering end, from it constitute the LUMBAR and SACRAL plexuses of nerves which innervates the
the CONUS MEDULLARIS, may terminate as high as T12 or as low as L3. lower limb. The spinal nerve roots arising from the lumbosacral enlargement and the
During the fetal stage, until the end of the third fetal month, the spinal cord is as medullary cone form the CAUDA EQUINA, the bundle of spinal nerve roots running
long as the vertebral canal and extends to the level of the of the 4th sacral vertebra. through the LUMBAR CISTERN(SUBARACHNOID SPACE).
After the 4th fetal month, the vertebral column outgrows the spinal cord. It appears A total of 31 pairs of spinal nerves are attached to the spinal cord: 8 cervical, 12
that the cord regresses to the upper lumbar levels; however, the spinal roots descend thoracic, 5 lumbar, 5 sacral and 1 coccygeal.
through the dural sac to the appropriate intervertebral foramina- the “Law of Descent”.
The resultant descending distribution of spinal roots forms the CAUDA EQUINA.
Slide 175
Slide 174

CLINICAL ANATOMY: THE BACK THE SPINAL CORD
CROSS SECTION THROUGH STRUCTURES FOUND INSIDE THE
THE SPINAL CORD THORACIC VERTEBRA VERTEBRAL CANAL
• 1. Spinal cord and its

meningeal coverings
• 2. Spinal Nerve roots
• 3. Vascular structures
-Vertebral venous
(Batson’s)plexus
-vertebral arterial vessels
4. Epidural loose fatty
connective tissues
The above slide shows the position of the spinal cord in relation to the surrounding
structures. It is almost central and being protective by the osseous vertebral column; by
The cervical enlargement is the source of the large spinal nerves that supply the the surrounding muscles; ligaments; meninges; cerebrospinal fluid.
upper limbs. It extends from the third cervical to the second thoracic segments. Most of
these spinal nerves contribute to the BRACHIAL PLEXUS which innervates the
upper limb.
The lumbar enlargement corresponds to the innervation of the lower limb. It
extends from the first lumbar vertebra to the third sacral segments. Most of large spinal
nerves from this lumbar enlargement composed the LUMBO-SACRAL PLEXUS.
Slide 176 Slide 177

VERTEBRAL CANAL AT THE VERTEBRAL
VERTEBRAL (NEURAL ) CANAL AND INTERVERTEBRAL DISC LEVEL
VERTEBRAL (NEURAL) CANAL
The spinal cord is strategically at the back protected by several structures notably the The vertebral (neural) canal is an osseofibrous tunnel that houses the spinal cord.
following: The boundaries of this neural canal at the vertebral level consist of: 1. the posterior
1. Osseous vertebral column border of the vertebral body; 2. the Neural Arch which consists of 2 pedicles and 2
2. Surrounding soft tissues like the muscles laminae.
3. ligaments The intervertebral levels, it is bounded by the intervertebral disks and the
4. Meninges ligamentum flava, which run between the successive laminae on either side of the
5. Cerebrospinal fluid midline.
Slide 178 TERMINAL FILUM. Laterally, the dural sac extends into the intervertebral foramina
and enclosing the posterior and anterior nerve roots distal to the spinal ganglia to form
the DURAL ROOT SHEATHS, or sleeves. These sheaths blend with the
epineurium(outer connective tissue covering the spinal nerves that adhere to the
periosteum lining the intervertebral foramina.
THE SPINAL CORD
Slide 179

THE SPINAL CORD
THE SPINAL MENINGES
The SPINAL MENINGES, or the THECA, are composed of the DURA MATER,
ARACHNOID MATER, AND PIA MATER. The combined arachnoid and pia can be
referred to as the LEPTOMENINGES (GREEK: delicate membrane). These membranes
and the CSF(CEREBROSPINAL FLUID) support and protect the spinal cord and spinal
nerve roots, including those in the cauda equina.
The DURA MATER is composed of tough fibrous and some elastic tissues. It is the
outermost covering membrane of the spinal cord. The dura is sometimes referred to as
the PACHYMENINX (GREEK: thick membrane). A potential space separates the dura
mater from the vertebrae. This space is called the EPIDURAL SPACE. The dura forms The DURA MATER forms a tube whose upper end is attached to the edge of the
the spinal dural sac, a long tubular sheath within the vertebral canal. This long tubular foramen magnum and to the posterior surfaces of the 2nd and 3rd cervical bodies, and
sac adheres to the margin of the FORAMEN MAGNUM, where it is continuous with also by fibrous bands to the posterior longitudinal ligament. Throughout the length to
the cranial dura mater. Along the length of the vertebral canal the dural sac is pierced by its distal portion, this attachment of the dura mater to the posterior longitudinal
the spinal nerves. At the distal end, the dural sac is anchored inferiorly by the ligament is maintained. The dural tube narrows at the lower border of the 2 nd sacral
vertebra. It invest the filum terminale, descends to the back of the coccyx, and blends The ARACHNOID MATER: This surrounds the spinal cord and is continuous with
with the periosteum. the cranial arachnoid mater. It is closely applied to the deep aspect of the dura mater.
EPIDURAL SPACE: It lies between the spinal dura mater and the tissues which At sites where vessels and nerves enter or leave the subarachnoid space, the arachnoid
line the vertebral canal. It is closed above by the fusion of the spinal dura with the mater is reflected on to the surface of these structures and forms a thin coating of
edge of the foramen magnum, and below by the posterior sacrococcygeal ligament leptomeningeal cells over the surface of both vessels and nerves. Thus a subarachnoid
closes the sacral hiatus. It contains the following: 1. loosely pack connective tissue; 2. angle is formed as nerves pass through the dura into the intervertebral foramina. At this
fat; 3. a venous plexus; 4. arterial branches; 5. lymphatics; 6. fine fibrous bands which point, the layers of leptomeninges fuse and become continuous with the perineurium.
connect the theca with the lining tissue of the vertebral canal. These fibrous band, The epineurium is in continuity of the dura. Such an arrangement seals the
known as MENINGOVERTEBRAL LIGAMENTS, are best developed anteriorly and subarachnoid space so that particulate matter does not pass directly from the
laterally. Similar bands tether the nerve root sheath or “sleeves” within their canals. subarachnoid space into nerves.
There is also a midline attachment from the posterior spinal dura to the PIA MATER: It closely invests the surface of the spinal cord and passes into the
LIGAMENTUM NUCHAE at the ATLANTO-OCCIPITAL and ATLANTO-AXIAL anterior median fissure. As in the cranial region, there is a subpial “space”, however,
levels. over the space of the spinal cord the subpial collagenous layer is thicker than in the
The venous plexus consists longitudinally arranged chains of vessels, connected by cerebral region, and it is continuous with the collagenous core of the ligamentum
circumdural venous rings. The anteriorly placed vessels receive the denticulatum.
BASIVERTEBRAL VEINS. The LIGAMENTUM DENTICULATUM is a flat, fibrous sheet which lies on each
The shape of the epidural space within each spinal segment is not uniform. In the side of the spinal cord in between the ventral and the dorsal nerve roots. Its medial
lumbar region the DURA MATER is apposed to the walls of the vertebral canal border is continuous with the subpial connective tissue of the cord and its lateral
anteriorly and attached by connective tissue in a manner that permits the displacement border forms a series of triangular processes, the apices of which are fixed at intervals
of the dural sac during movement and venous engorgement. Adipose tissue is present to the dura mater. There are usually 21 processes on each side. The first of the
posteriorly in recesses between the LIGAMENTUM FLAVUM and the DURA. denticulate ligaments crosses behind the vertebral artery where it is attached to the
The dura mater extends for a short distance through the intervertebral foramina dura mater, and is separated by the artery from the first cervical ventral root. Its site of
along the sheaths of the spinal nerves. Like the main thecal sac, the root sheaths are attachment to the dura mater is above the rim of the foramen magnum, just behind the
partially tethered to the walls of the foramina by the fine meningovertebral ligaments. hypoglossal nerve; the spinal accessory nerve ascends on it posterior aspect. The last
CLINICAL CORRELATION: Contrast media, anesthetics and other fluids injected of the denticulate ligaments lies between the exiting 12th thoracic and 1st lumbar spinal
into the epidural space at the sacral level may spread up to the cranial base. Local nerves and is a narrow, oblique bands which descends laterally from the conus
anesthetics injected near the spinal nerves, just outside the intervertebral foramina, medullaris
may spread down or up the epidural space to affect the adjacent spinal nerves or may Beyond the conus medullaris the PIA MATER continues as a coating of the filum
pass to the opposite side. terminale.
SUBDURAL SPACE: A potential space in the normal spine because the INTERMEDIATE LAYER: Aside from the well-defined 3 layers, the spinal cord
ARACHNOID and DURA are closely apposed. It does not connect with the is surrounded by an extensive INTERMEDIATE LAYER of leptomeninges. This
SUBARACHNOID SPACE, but continues for a short distance along the cranial and particular layer is concentrated on the dorsal and ventral regions and forms a highly
spinal nerves. Accidental subdural catheterization may occur during extradural perforated, almost lace-like structure which is locally compacted to form the dorsal,
injections. Injection of fluid into the subdural space may either damage the cord by dorsolateral and ventral ligaments of the spinal cord.
direct toxic effects or by compression of the vasculature. This intermediate layer of leptomeninges around the spinal cord may act as a baffle
within the subarachnoid space to dampen waves of CSF in the spinal column.
Inflammation within the spinal subarachnoid space may result in extensive fibrosis Slide 181
within the INTERMEDIATE LAYER and the complications of CHRONIC
ARACHNOIDITIS.
Slide 180 CLINICAL ANATOMY: THE BACK

THE SPINAL CORD

THE SPINAL CORD
The SPINAL DURA MATER (L. tough mother) is the most external protective layer
of the spinal cord. Unlike the cranial dura mater where it is adherent to the cranial
periosteum, the spinal dura mater is not adherent to the periosteum of the vertebral
canal. It is also referred to as the PACHYMINENX (G. thick membrane). The dura
evaginates into each vertebral foramen to surround the spinal nerve and fuse with the
The dura mater of the spinal cord adheres to the margin of the foramen magnum periosteum of the vertebrae. It becomes continuous with the epineurium, the connective
where it is continuous with the cranial dura mater. The dura mater also attaches to the tissue covering each spinal nerve.
posterior surfaces of the vertebral bodies of 2nd and 3rd cervical vertebrae. Between the vertebral canal periosteum and the spinal dura mater is a space- the
The dura mater also attaches to the posterior longitudinal ligament. Throughout its EPIDURAL SPACE, which contains profuse venous plexuses (BATSON’S PLEXUS)
length, its relationship with the posterior longitudinal ligament is maintained. and fatty tissues.
CLINICAL CORRELATION: The epidural space can be infiltrated with anesthetic
agent, a procedure known as EPIDURAL (CAUDAL) ANESTHESIA. The anesthetic
agent perfuses the spinal nerves located in the epidural space taking out all the sensory Slide 182
function but not the motor function below the nerve that is blocked.
The SPINAL ARACHNOID MATER is the intermediate layer. It is a delicate
avascular membrane composed of fibrous and elastic tissue that lines the dural sac and
the dural root sheaths. It encloses the CSF-filled subarachnoid space containing the
spinal cord, spinal nerve roots, and the spinal ganglia. It is internal to the DURA CLINICAL ANATOMY: THE BACK
MATER but external to the PIA MATER. It is not attached to the dura mater but is held THE SPINAL CORD
against the inner surface of the dura by the pressure of the CSF. It is a thin membrane
that is connected to the PIA MATER by a web-like trabeculations. This web-like
trabeculation gives the name arachnoid.
Between the dura mater and the arachnoid mater is a potential space (not an actual
anatomic space) called the SUBDURAL SPACE. This space does not contain
cerebrospinal fluid (CSF).
The PIA MATER is the most interior protective layer. This tissue membrane is
intimately attached to the spinal cord and its roots. It consists of flattened cells with long
equally flattened processes that follow the surface features of the spinal cord. It also
covers the roots of the spinal nerves and the spinal blood vessels. It contains the blood
supply to the spinal cord. Distally, it continues beyond the termination of the spinal cord
as the FILUM TERMINALE, which attaches to the sacrum and the coccyx.
Between the arachnoid mater and the pia mater is actual or anatomic space called
the SUBARACHNOID SPACE, which contains cerebrospinal fluid (CSF). This space
separates the arachnoid mater from the pia mater. It extends caudally to the level of the
2nd SACRAL VERTEBRA and is wider between vertebral levels L1 and S1- the Along the length of the vertebral canal, the dural sac is pierced by the spinal nerves.
LUMBAR CISTERN.
Slide 183 nerve. Shortening or obstruction of this sleeve seen on the myelogram indicates
compression of the spinal nerve.

THE SPINAL CORD Slide 184
1. COVERINGS
AND RELATIONS
OF THE SPINAL Clinical anatomy: the back
ROOTS , SPINAL the spinal cord
NERVES IN THE
RADICULAR • CEREBROSPINAL FLUID
CANAL 1. Composition and secretion
2. CLINICAL - clear, colorless liquid
- differs from blood in its electrolyte
CORRELATION content and its very small amount of protein
- actively secreted by the
choroid plexus
- total volume: 150 ml
-25 ml in the lateral ventricles
-100 ml in the cranial subarachnoid space
- 25 ml in the spinal subarachnoid space
Tubular prolongations of the spinal dura mater, closely lined by the arachnoid,
extend around the spinal roots and nerves as they pass through the lateral zone of the
vertebral canal and through the intervertebral foramina. These prolongations called the
SPINAL NERVE SHEATHS (“root sheaths”), gradually lengthen as the spinal roots
become increasingly oblique. Each dorsal and ventral root runs in the subarachnoid
space with its own covering of pia mater. Each root penetrates the dura mater The CEREBROSPINAL FLUID is a clear, colorless fluid that is actively secreted by
separately, taking with it a sleeve of ARACHNOID MATER before joining within the the choroid plexuses in the lateral, 3rd and 4th ventricles of the brain. A total volume of
dural prolongation just distal to the distal ganglion. The dural sheaths of the spinal CSF is 150 ml, of which 25 ml is located mostly in the lateral ventricles; 100 ml in the
nerves fuse with the epineurium, within or lightly beyond the intervertebral foramina. cranial subarachnoid space; the rest is located in the spinal subarachnoid space.
The ARACHNOID prolongations within the sheaths do not extend as far distally as The CSF is secreted at a rate of 0.35-0.40 ml per minute, which means that
their dural coverings but the subarachnoid space and its contained CSF extend normally 50% of the total volume of CSF is replaced every 5 to 6 hours.
sufficiently distally to form a radiologically demonstrable ‘ROOT SLEEVE’ for each
Slide 185 An anesthetic agent can also be injected into the extradural space in the sacral canal-
A CAUDAL EPIDURAL BLOCK. The agent spreads superiorly and acts on the spinal
nerves(caudal analgesia). The distance the agent ascends( and hence the number of
nerves affected) depends on the amount injected and on the position assumed by the
patient.
CLINICAL ANATOMY: THE BACK In lumbar puncture, the needle traverses the dura and the arachnoid mater
simultaneously. Their apposition is called dura-arachnoid interface. No actual space
THE SPINAL CORD occurs naturally at this interface. It is just a potential space.
Slide 186

THE SPINAL CORD
To obtain a sample of CSf from the lumbar cistern, a lumbar puncture needle(or
spinal needle), fitted with stylet, is inserted into the subarachnoid space. Lumbar spinal
puncture is performed with the patient leaning forward or lying on the side with the
backed flexed. Flexion of the vertebral column facilitates insertion of the needle by
stretching the ligamentum flavum and spreading the laminae and spinous processes
apart. Under aseptic condition the needle is inserted between the spinous processes of
the L3 and L4 (or the L4 and L5) vertebrae. At these levels in adult, there is little danger
of damaging the spinal cord.
An anesthetic agent can be injected into the extradural(epidural) space using the
position described in Lumbar Spinal puncture. The anesthetic agent has a direct effect The introduction of contrast media (usually made up of iodinated compounds) into
on the spinal nerve roots of the cauda equina after they exit from the dural sac. The the subarachnoid space to outline the spinal cord and its components like the spinal
patient loses sensation inferior to the level of the block nerves is called myelogram. It is used to diagnosed conditions like herniated nucleus
pulposus, intravertebral canal tumors, effect of spinal fractures on the adjacent spinal Slide 188
cord.
Several years ago, these iodinated compounds are oil based and are hardly re-
absorbed and remain in the subarachnoid space for a long time. However, these oil-
based iodinated compounds cause so much inflammation of the spinal meninges CLINICAL ANATOMY: THE BACK
leading to paralysis of the patient. In other patients, these iodinated compounds rapidly
transit proximally and cause respiratory paralysis. THE SPINAL CORD
Most of these oil-based iodinated compounds are replaced by the water-based
iodinated compounds.
Slide 187

THE SPINAL CORD
The ventral rami (anterior primary) supply the limbs and the anterolateral aspects of
the trunk, and in general are larger than the dorsal rami. Thoracic ventral rami run
independently and retain a largely segmental distribution. Cervical, lumbar and sacral
ventral rami connect near the origins to form plexuses. Dorsi rami do not join these
plexuses.
Dorsal(posterior primary) rami of spinal nerves are usually smaller than the ventral
rami and are directed posteriorly. Retaining a segmental distribution, all, except for the
first cervical, 4th and 5th sacral and the coccygeal, divide into medial and lateral
branches which supply the muscles and skin of the posterior regions of the neck and
trunk.
Slide 189 The cervical nerves enlarge from the first to the 6th nerve. The 7th and 8th cervical
nerves and the 1st thoracic nerve are similar to the 6th cervical nerve in size. The
remaining thoracic nerves are relatively small. Lumbar nerves are large, increasing in
size from the 1st lumbar to the 5th. The 1st sacral nerve is the largest, thereafter the
rest of the sacral nerves decrease in size. The coccygeal nerves are the smallest spinal
CLINICAL ANATOMY: THE BACK nerves.
THE SPINAL CORD
Slide 190

THE SPINAL CORD
The spinal nerves are united ventral and dorsal spinal roots, attached in series to the
sides of the spinal cord. The term ‘spinal nerve’ strictly applies to the short segment
after union of the roots and before branching occurs. This segment, the spinal nerve
proper , lies in the intervertebral foramen.
At thoracic, lumbar, sacral and coccygeal levels the numbered nerve exits the
corresponding vertebral canal Example, L4 nerve exits the intervertebral foramen
between L4 and L5. However, in the cervical region, nerves C1 to C7 pass above their
corresponding vertebrae. C1 leaves the vertebral canal between the occipital bone and Immediately distal to the spinal ganglia, ventral and dorsal roots unite to form
atlas and hence is often termed the SUBOCCIPITAL NERVE. The last pair of cervical spinal nerves. These very soon divide into DORSAL AND VENTRAL RAMI, both of
nerves (C8) do not have a correspondingly numbered vertebra. C8 passes between the which receive fibers from both spinal roots. At all levels above the sacral, this division
7th cervical and 1st thoracic vertebrae. Each nerve is continuous with the spinal cord by occurs within the vertebral foramen. Division of the sacral spinal nerves occurs within
ventral and dorsal roots. The latter bears a spinal ganglion- the DORSAL ROOT the sacral vertebral canal, and the dorsal and ventral rami exit separately through
GANGLION. posterior and anterior sacral foramina at each level.
The dorsal, epaxial, ramus passes back lateral to the articular processes and divides At or distal to each origin each ventral ramus gives off the RECURRENT
into medial and lateral branches which penetrate the deeper muscles of the back: both MENINGEAL (or, SINUVERTEBRAL) branches. These recurrent meningeal
branches innervate the adjacent muscles, and supply a band of skin from the posterior branches, numbering 2-4 filaments or branches on each side, occur at all vertebral
median line to the scapular line. The ventral, hypaxial, ramus is connected to a levels. Each receives one or more rami from a nearby grey ramus communicans or
corresponding sympathetic ganglion by white and gray rami communicantes. It directly from a thoracic sympathetic ganglion, and most pursue a recurrent (often
innervates the prevertebral muscles and curves round in the body wall to supply the perivascular) course into the vertebral canal through the intervertebral foramen ventral
lateral muscles of the trunk. Near the midaxillary line it gives off a lateral branch to the dorsal root ganglion. Here these mixed sensory and sympathetic nerves divide
which pierces the muscles and divides into anterior and posterior cutaneous branches. into transverse, ascending and descending branches which are distributed to the dura
The main nerve advances in the body wall, where it supplies the ventral muscles and mater, the walls of the blood vessels, the periosteum, ligaments and intervertebral
terminates in branches to the skin. discs in the anterolateral region of the vertebral canal. Fine meningeal branches
occasionally pass dorsal to reach the spinal ganglia to innervate the dorsal dura,
periosteum, and ligaments, and others pass ventrally to innervate the posterior
longitudinal ligaments. Ascending branches of the upper cervical meningeal nerves are
Slide 191 large and distributed to the dura mater in the posterior cranial fossa. Meningeal nerves
are important in relation to the referred pain which is characteristic of many spinal
disorders and occipital headache.
CLINICAL ANATOMY: THE BACK Slide 192

THE SPINAL CORD

VASCULATURE OF THE SPINE

Slide 193 Slide 194

VASCULATURE OF SPINE
Slide 195
The vertebrae are supplied by periosteal and equatorial branches of the major
cervical and segmental arteries and their spinal branches as mentioned above.
The spinal branches enter the intervertebral foramina and divide into ANTERIOR
AND POSTERIOR VERTEBRAL CANAL branches that pass to the vertebral body and
vertebral arches, respectively. The larger branches of the spinal branches continue as
terminal radicular or segmental medullary arteries distributed to the posterior and
anterior roots of the spinal nerves and their coverings and to the spinal cord.
`
Slide 196 Slide 197

VASCULATURE OF THE SPINE
• VENOUS PLEXUSES OF • VENOUS DRAINAGE
THE SPINE • Venous plexuses along the
vertebral column
• Internal vertebral
venous plexus a. Internal vertebral venous
plexus: spinal veins forming
• External vertebral venous plexuses inside the
venous plexus vertebral column
• Basivertebral veins b. External vertebral
venous plexuses: formed by
• Intervertebral veins
the spinal veins outside of
the vertebral column
Spinal veins form venous plexuses along the vertebral column both inside (Internal Spinal veins form venous plexuses along the vertebral column both inside( internal
vertebral venous plexus) and outside(external vertebral venous plexus) the vertebral vertebral venous plexus) and outside(external vertebral venous plexus) the vertebral
canal. The large tortuous BASIVERTEBRAL VEINS form within the vertebral bodies canal. The large, tortuous BASIVERTEBRAL VEINS form within the vertebral bodies
and emerge from the foramina on the surfaces of the vertebral bodies(mostly the and emerge from foramina on the surfaces of the vertebral bodies(mostly the posterior
posterior aspect) and drain into the external and especially the INTERNAL aspect) and drain into the external and especially the internal vertebral venous plexuses.
VERTEBRAL VENOUS PLEXUSES. The INTERVERTEBRAL VEINS receive veins from the spinal cord and vertebral
The INTERVERTEBRAL VEINS receive veins from the spinal cord and vertebral venous plexuses as they accompany the spinal nerves through the intervertebral
venous plexuses as they accompany the spinal nerves through the INTERVERTEBRAL foramina to drain to the vertebral veins of the neck and segmental veins of the trunk.
FORAMINA to drain into the vertebral veins of the neck and segmental veins of the
trunk.
Slide 198 Slide 199

CLINICAL ANATOMY: THE BACK THE SPINAL CORD
THE SPINAL CORD
• VASCULATURE OF SPINAL
CORD AND SPINAL NERVE
ROOTS
• BLOOD SUPPLY TO THE
POSTERIOR AND ANTERIOR
NERVE ROOTS:
-Posterior and anterior
radicular arteries
The posterior and the anterior roots of the spinal nerves and their coverings are The paired dorsal and ventral nerve roots of the spinal nerves are continuous with
supplied by POSTERIOR and ANTERIOR RADICULAR ATERIES, which run along the spinal cord. They cross the subarachnoid space and traverse the dura mater
the nerve roots. These vessels do not reach the posterior or anterior spinal arteries. separately, uniting in or close to their intervertebral foramina to form the (mixed) spinal
Segmental medullary arteries occur irregularly in the place of radicular arteries; they are nerve.
larger vessels that make it to the spinal arteries. Ventral spinal roots contain efferent somatic and, in some levels, efferent
sympathetic , nerve fibers which emerge from their spinal sources. There are also
afferent fibers in these roots. The rootlets comprising each ventral root emerge from the
anterolateral sulcus over an elongated vertical elliptical area. These rootlets come in
series of 2 to 3 irregular rows in an area 3 mm in horizontal width. The ventral roots
contain axons of neurones in the anterior and lateral spinal grey columns.
The dorsal spinal roots bear ovoid swellings, the spinal ganglia, one on each root
proximal to its junction with a corresponding ventral root in an intervertebral foramen.
Each root fans out into 6 to 8 rootlets before entering the cord in a vertical row in the
posterolateral sulcus. Dorsal roots are usually said to contain only afferent axons (both
somatic and visceral) from unipolar neurones in spinal root ganglia, but they may also
contain small (3%) of efferent fibers and autonomous vasodilator fibers. The external surface of the spinal cord is marked by the presence of fissures and
SPINAL GANGLIA (DORSAL ROOT GANGLIA): These are large groups of sulci. An anterior median fissure and a posterior median sulcus and septum almost
neurones on the dorsal spinal roots. Each is oval and reddish; its size is related to that completely separate the cord into right and left halves, but they are joined by a
of its root. A ganglion is bifid medially where the two fascicles of the dorsal root commissural band of nervous tissue which contains the central canal.
emerge to enter the cord. Ganglia are usually located in the intervertebral foramina, The anterior median fissure extends along the whole ventral surface with an
immediately lateral to the perforation of the dura mater by the roots. However, the average depth of 3 mm, although it is deeper at caudal levels. It contains a reticulum of
first and second cervical ganglia lie on the vertebral arches of the atlas and axis; the pia mater. Dorsal to it is the anterior white commissure. Perforating branches of spinal
sacral ganglion lies within the sacral vertebral canal and the coccygeal ganglion lies vessels pass from the fissure to the commissure to supply the central spinal canal.
within the dura mater. The first cervical ganglia may be absent. Small aberrant ganglia The posterior median sulcus is shallower, and from it a posterior median septum of
sometimes occur on the upper cervical dorsal roots between the spinal ganglia and the neuroglia penetrates more than halfway into the cord, almost to the central canal. The
cord. septum varies in anteroposterior extent from 4 to 6 mm, and diminishes caudally as the
canal becomes more dorsally placed and the cord contracts.
A posterolateral sulcus exists from 1.5 to 2.5 mm lateral to each side of the posterior
median sulcus. Dorsal roots(strictly rootlets)
Slide 200 Of spinal nerves enter the cord along the sulcus. The white substance between the
posterior median and posterolateral sulcus on each side is the POSTERIOR
FUNICULUS. In the cervical and upper thoracic segments a longitudinal postero-
immediate sulcus marks a septum dividing each posterior funiculus into large tracts: the
Clinical anatomy: the back FASCICULUS GRACILIS (medial) and the FASCICULUS CUNEATUS (lateral).
Between the posterolateral sulcus and the anterior median fissure is the
the spinal cord ANTEROLATERAL FUNICULUS. This is subdivided into ANTERIOR and
LATERAL FUNICULI by ventral roots which pass through its substance to issue from
the surface of the cord. The ANTERIOR FUNICULUS is medial to , and includes, the
emerging ventral roots, while the LATERAL FUNICULUS lies between the roots and
the posterolateral sulcus.
In the upper cervical cord, nerve rootlets emerge through each lateral funiculus to
form the SPINAL ACCESSORY which ascends in the vertebral canal lateral to spinal
cord and enters the posterior cranial fossa via the foramen magnum.
Slide 201 Slide 202

THE SPINAL CORD
THE SPINAL CORD
Between the posterolateral sulcus and the anterior median fissure is the anterolateral The spinal nerve roots exhibit different morphology in the different regions of the
funiculus which is subdivided into ANTERIOR and LATERAL FUNICULUS by spinal cord. In the cervical region, the first upper cervical nerve roots are small; the
ventral nerve roots. The ANTERIOR FUNICULUS is medial to, and includes, the distal 4 cervical roots the spinal roots are large. The thickness ratio of cervical dorsal
emerging ventral roots. The LATERAL FUNICULUS lies between the ventral nerve roots to the ventral roots is 3:1. However, the 1st cervical root is an exception. The
roots and the posterolateral sulcus. dorsal cervical root is smaller that the ventral root and, occasionally, is absent.
In upper cervical segments, nerve rootlets emerge through the lateral funiculus to
form the SPINAL ACCESSORY NERVE which ascends in the vertebral canal lateral
to the spinal cord and enters the posterior canial fossa via the foramen magnum.
Slide 203 Slide 204
Clinical anatomy: the back CLINICAL ANATOMY: THE BACK

the spinal cord THE SPINAL CORD
In the thoracic region, the thoracic roots are small in diameter with the exception The lower lumbar and upper sacral nerve roots have the largest diameter. The
of the 1st thoracic roots which still has the diameter same as the distal cervical rootlets that composed the roots are most numerous.
segments. The dorsal roots only slightly exceed the ventral roots in thickness. As the The coccygeal roots display the smallest diameter.
distal thoracic segments are approached, the thoracic roots successively increase in The lumbar, sacral and coccygeal roots descend with increasing obliquity to their
length. In the lower thoracic region, the roots descend in contact with the spinal cord exits.
for at least two vertebrae before emerging from the vertebral canal. The CAUDA EQUINA (Latin word meaning “horse tail”), are collection of spinal
roots of the lower lumbar, sacral and coccygeal roots as these descend to their
respective exits in increasing and obliquity.
Slide 205 Each cervical spinal dorsal ramus, except the first, divides into medial and lateral
branches which all innervate the muscles. In general, only medial branches of the 2nd
to 4th, and usually the 5th, supply the skin. Except for the 1st and 2nd, each dorsal ramus
passes back medial to a posterior intertransverse muscle, curving round the articular
THE SPINAL CORD process into the interval between semispinalis capitis and cervicis.
Slide 207

• NERVES OF VERTEBRAL
Slide 206 COLUMN
• ZYGAPOPHYSEAL
JOINTS(APOPHYSEAL or FACET
JOINTS): innervated by the
CLINICAL ANATOMY: THE BACK articular branches of the
medial branches of the
THE SPINAL CORD posterior rami
• Vertebral column
• -innervation: recurrent
meningeal branches of the
spinal branches.
The facet joints are innervated by the articular branches of the medial branches of
the posterior rami>
The vertebral column is innervated by the recurrent meningeal branches of the
spinal nerves. Most of the meningeal branches run back to the intervertebral foramina
but some remain outside of the vertebral canal. The branches outside of the canal supply
the annulus fibrosus and anterior longitudinal ligament; those inside the canal supply the
periosteum, ligamentum flavum, posterior aspect of the annulus fibrosus, posterior
longitudinal ligament, spinal dura mater, and blood vessels within the vertebral canal. Slide 209
Slide 208

• STRUCTURES INSIDE THE
THE SPINAL CORD SUBOCCIPITAL TRIANGLE
The SUBOCCIPITAL REGION is the area found at the superior part of the neck. It
involves a triangular area known as the SUBOCCIPITAL TRIANGLE inferior to the
The first cervical dorsal ramus, the SUBOCCIPITAL NERVE, is larger than the occipital region of the head including the posterior aspects of C1 and C2 vertebrae. The
ventral ramus. It emerges superior to the posterior arch of the atlas and inferior to the SUBOCCIPITAL TRIANGLE lies deep to the trapezius and semispinalis capitis
vertebral artery and enters the SUBOCCIPITAL TRIANGLE to supply the rectus muscle. The boundaries and contents of the SUBOCCIPITAL TRIANGLE are:
capitis major and minor, obliquus capitis superior and inferior, and semispinalis capitis. a. Superomedially, rectus capitis posterior major
A filament from the branch to the inferior oblique joins the second cervical dorsal b. Superolaterally, superior oblique
ramus. The SUBOCCIPITAL NERVE occasionally has a cutaneous branch which c. Inferolaterally, inferior oblique
accompanies the occipital artery to the scalp, and connects with the greater and lesser d. Floor, posterior atlanto-occipital membrane and posterior arch of C1
occipital nerves. It may also communicates with the spinal accessory nerve. e. Roof, semispinalis capitis
CONTENTS OF THE SUBOCCIPITAL TRIANGLE: VERTEBRAL ARTERY AND
SUBOCCIPITAL NERVE(C1)
There are 4 small muscles in this region, namely: Rectus capitis posterior major, The 2nd cervical dorsal ramus is slightly larger than its ventral pair. It is even larger
rectus capitis posterior minor, inferior oblique of head, superior oblique of head. than all the other cervical dorsal rami.
A. Rectus capitis posterior major arises from the spinous process of C2 vertebra It emerges between the posterior arch of the atlas and the lamina of the axis below
and inserts into the lateral part of the inferior nuchal line of the occipital bone. inferior oblique, which it supplies. It receives connection from the first cervical dorsal
B. Rectus capitis posterior minor arises from the posterior tubercle on the posterior ramus and divides into a large medial and smaller lateral branches. The medial branch,
arch of the C1 vertebra and inserts into the medial third of the inferior nuchal line. termed “GREATER OCCIPITAL NERVE” ascends between the inferior oblique
C. Inferior oblique of head arises from the spinous process of the C2 vertebra and muscle and the semispinalis capitis, pierces the latter and trapezius near their occipital
inserts into the transverse process of the C1 vertebra. The name of this muscle is attachments, and joined by a filament from the medial branch of the 3rd dorsal ramus.
somewhat misleading because it is the “capitis” muscle that has no attachment to the It ascends with the occipital artery, divides into branches which connect with the lesser
cranium. occipital nerve, and supplies the skin of the scalp as far as forward as the vertex. It
D. Superior oblique of head arises from the transverse process of C1 and inserts supplies the semispinalis capitis and, occasionally, the back of the ear.
into the occipital bone between the superior and inferior nuchal lines. The lateral branch supplies the following:
The actions of the SUBOCCIPITAL GROUP of muscles is to extend the head on C1 -splenius capitis
and rotate the head and the C1 on C2 vertebrae. -longissimus capitis
-semispinalis capitis
Slide 210 It is often joined by the corresponding third cervical branch.
CLINICAL CORRELATION: GREATER OCCIPITAL NEURALGIA: refers to a
syndrome of pain and paresthesia felt in the distribution of the greater occipital nerve.
It is usually due to an entrapment neuropathy of the nerve as it pierces the attachment
CLINICAL ANATOMY: THE BACK of the neck extensor to the occiput. A similar syndrome may be caused by upper facet
THE SPINAL CORD joint arthritis involving the 2nd cervical root.
The third cervical dorsal ramus is intermediate in size between the 2nd and the 4th.
It comes around the articular pillar of the 3rd cervical vertebra, medial to the posterior
intertransverse muscle, and divides into medial and lateral branches. Its medial branch
runs between spinalis capitis and semispinalis cervicis, and pierces the splenius and the
trapezius to end in the skin. Deep to the trapezius it gives rise to a branch, the THIRD
OCCIPITAL NERVE, which pierces to end in the skin of the lower occipital region,
medial to the greater occipital nerve and connected to it. The lateral branch often joins
a branch of the 2nd cervical dorsal ramus. The dorsal ramus of the suboccipital nerve
and the medial branches of the dorsal rami of the 2nd and 3rd cervical nerves are
sometimes joined by loops to form the POSTERIOR CERVICAL PLEXUS
Slide 211 Slide 212
Clinical anatomy: the back CLINICAL ANATOMY: THE BACK

the spinal cord THE SPINAL CORD
The third cervical dorsal ramus is intermediate in size between the 2nd an 4th . It The dorsal rami of the lower five cervical nerves (C4-C8) curve back round the
courses back round the articular pillar of the 3rd cervical vertebra, medial to the vertebral articular pillars and divide into medial and lateral branches. Medial branches
posterior intertransverse muscle, and divides into medial and lateral branches. Its medial of the 4th and 5th run between the semispinalis cervicis and semispinalis capitis, reach
branch runs between spinalis capitis and semispinalis cervicis, and pierces the the vertebral spines and pierce the splenius and trapezius to end in the skin. The
splenius and trapezius to end in the skin. Deep to the trapezius, it gives rise to a medial branch of the 5th cervical ramus may not reach the skin. The medial branches
branch, the THIRD OCCIPITAL NERVE, which pierces trapezius to end in the skin of of the lowest 3 cervical nerves are small and end in the semispinalis cervicis,
the lower occipital region, medial to the greater occipital nerve and connected to it. semispinalis capitis, multifidus, and interspinales.
The lateral branch often joins a branch of the 2nd cervical dorsal ramus. The lateral branches supply the iliocostalis cervicis, longissimus cervicis and
The dorsal ramus of the SUBOCCIPITAL NERVE and the medial branches of the longissimus capitis.
dorsal rami of the 2nd and 3rd cervical nerves are sometimes joined by loops to form the
posterior cervical plexus.
Slide 213 The lower five or six also have cutaneous branches, and pierce serratus posterior
inferior and latissimus dorsi in line with the costal angles. Some upper thoracic lateral
branches supply the skin. The 12th thoracic lateral branch sends a filament medially
along the iliac crest, then passes down to the anterior gluteal skin. Medial cutaneous
branches of the thoracic dorsal rami descend close to the vertebral spines before
CLINICAL ANATOMY: THE BACK reaching the skin; the lateral branches descend across as many as four ribs before
THE SPINAL CORD becoming superficial. The branch of the 12th thoracic reaches the skin a little above
2
the iliac crest.
Slide 214

THE SPINAL CORD
Thoracic dorsal rami pass backwards close to the vertebral facet joints to divide
into medial and lateral branches. Each medial branch emerges between a joint and the
medial edges of the costotransverse ligament and intertransverse muscle. Each lateral .
branch runs in the interval between the ligament and the muscle before inclining
posteriorly on the medial side of the levator costae.
Medial branches of the upper six thoracic dorsal rami pass between and supply the
semispinalis thoracis and multifidus, then pierce the rhomboids and trapezius, and
reach the skin near the vertebral spines.
Medial branches of the lower six thoracic dorsal rami mainly supply multifidus and
longissimus thoracis and occasionally the skin the median region. Lateral branches Lumbar dorsal rami pass back medial to the medial intertransverse muscles, and
increase inferiorly in size, and run through, or deep to, longissimus thoracis to the divide into medial and lateral branches.
interval between it and iliocostalis cervicis, supplying these muscles and the levatores Medial branches run near the vertebral articular processes to end in the multifidus.
costarum. They are related to the bone between the accessory and mamillary processes and
groove it, crossing a distinct notch or even a foramen. Lateral branches supply the Slide 216
erector spinae. In addition, the upper three rami give rise to cutaneous nerves which
pierce the aponeurosis of latissimus dorsi at the lateral border of the erector spinae and CLINICAL ANATOMY: THE BACK
cross the iliac crest posteriorly to reach the gluteal skin, some reaching as far as the
level of the greater trochanter. THE SPINAL CORD
Sacral dorsi rami are small, diminishing downwards, and other than the fifth, all
emerge through the dorsal sacral foramina. The upper three are covered at their exit by
multifidus, and divide into medial and lateral branches. Medial branches are small and
end in multifidus. Lateral branches join together and with lateral branches of the last
lumbar and 4th sacral dorsal rami to form loops dorsal to the sacrum. Branches from
these loops run dorsal to the sacrotuberous ligament and form a second series of loops
under gluteus maximum. From these, 2 or 3 gluteal branches pierce the gluteus
maximus (along a line from the posterior iliac spine to the coccygeal apex) to supply
the posterior gluteal skin.
The dorsal rami of the 4th and 5th sacral nerves are small and lie below multifidus.
They unite with each other and with the coccygeal dorsal ramus to form loops dorsal to
the sacrum: filaments from these supply the skin over the coccyx.
COCCYGEAL DORSAL SPINAL RAMUS: does not divide into medical and
lateral branches.
Slide 217
Slide 215

INNERVATION TO THE SPINE

Slide 218 parallel to and in the same direction as every other part of the body. Translation can
occur in either straight line(RECTILINEAR) or a curved line (CURVILINEAR).
ROTATION, in contrast, describes a motion in which an assumed rigid body moves
in a circular path about some pivot point. As a result, all points in the body
simultaneously rotate in the same angular process (e.g., clockwise and
counterclockwise) across the same number of degrees. The pivot point for the angular
motion is called the axis of rotation. The axis is at the point where motion of the rotating
body is zero. For most of the movements of the body, the axis of rotation is located
within or very near the structure of the joint.
Movement of the human body, as a whole, is often described as a translation of the
body’s center of mass, located generally just anterior to the sacrum. Although a person’s
center of mass translate through space, it is powered by muscles that rotate the limbs.
Slide 219
The origins of the word KINESIOLOGY are from the Greek kinesis, to move and ology,
to study. The study of kinesiology is dependent on 3 bodies of knowledge: ANATOMY,
BIOMECHANICS, and PHYSIOLOGY. ANATOMY is the science of the shape and
structure. BIOMECHANICS is a discipline that uses the principles of physics to
quantitatively study how forces interact within a living body. PHYSIOLOGY is the
biologic study of living organisms.
KINESIOLOGY is a branch of mechanics that describes the motion of a body,
without regard to the forces or torques that may produce the motion. In biomechanics
the term body is used rather loosely to describe the entire body, or any of its parts or
segments. Such as individual bones or regions.
In general, there are 2 types of motions: TRANSLATION and ROTATION.
TRANSLATION describes a linear motion in which all parts of a rigid body move
OSTEOKINEMATICS describes the motion of bones relative to the three cardinal flexion, ulnar and radial deviation, eversion and inversion. In the HORIZONTAL
planes of the body with reference to the anatomic position. The SAGITTAL PLANE PLANE, the movements allowed are external and internal rotation, axial rotation.
runs parallel to the sagittal suture of the skull dividing the body into right and left
sections. The FRONTAL PLANE runs parallel to the coronal suture of the skull,
dividing the body in FRONT and BACK. The HORIZONTAL( or TRANSVERSE
PLANE) courses parallel to the horizon and divides the body into upper and lower Slide 221
section.
Slide 220
• OSTEOKINEMATICS
• DEGREES OF FREEDOM
-refers to the number of independent
movements allowed at a joint.
- 3 degrees of freedom
-sagittal
-frontal
-horizontal
Example of movements in different body
planes:
A. SAGITTAL PLANE
-flexion and extension
-dorsiflexion and plantar flexion
-forward and backward bending
In general, the articulations of two body segments constitute a joint. Movement at a

joint can therefore be considered from 2 perspective: 1. the proximal segment rotating a
fixed distal segment, or, 2. the distal segment rotating against a fixed proximal segment.
DEGREES OF FREEDOM refers to the number of independent movements allowed The term knee flexion describes only the relative motion between the thigh and leg.
at a joint. Again the reference planes are the three cardinal planes of the body based on It does not describe which of the two segments is actually rotating. To be exact, it does
the anatomic position. In SAGITTAL PLANE, the movements allowed can be flexion not describe the segment that is rotating and the segment that acts as the fixed segment.
and extension, dorsiflexion and plantarflexion, forward and backward bending. In Terms such as tibial-on –femoral movement or femoral-on tibial movement adequately
FRONTAL PLANE, the movements allowed can be abduction and adduction, lateral describe the OSTEOKINETICS.
Slide 222 Regional kinematics of the spine refers to the range and predominant direction of
movements at the various regions of the vertebral column. The ZERO or the
REFERENCE POINT used to describe the motion is the resting posture of the region
while standing.
The illustration above shows the normal sagittal plane curvatures across the regions
of the vertebral column. The curvatures represent the normal resting posture of the
region.
At the cervical region, the normal cervical lordosis is 30-35 degrees; the thoracic
kyphosis is 40 degrees, the lumbar lordosis 45 degrees.
REGIONAL KINEMATICS OF
THE SPINE Slide 224
Slide 223
THE CRANIOCERVICAL REGION

• REGIONAL KINEMATICS OF THE SPINE
• DEFINITION:
-Refers to the range and
predominant direction of movements
at the various regions of the vertebral
column
-ZERO or REFERENCE POINT:
Resting posture of the region while
standing
-resting curvature:
- cervical lordosis- 30-
35 degrees
- thoracic kyphosis- 40
degrees
- lumbar lordosis- 45 degrees The CRANIOCERVICAL REGION, or, the NECK, includes the structures involved
in the articulation of the cranium to the cervical spine and the structures involved in the
articulation of the C7 to T1.
Slide 225 Slide 226
• FUNCTIONAL ANATOMY OF THE • THE ATLANTO-OCCIPITAL

CRANIOCERVICAL JOINTS JOINT
KINESIOLOGY • THE ATLANTO-OCCIPITAL JOINT
• -provides independent movement of
the cranium relative to the atlas
• -structures that go into the formation
of the joint
• -stability of the joint
• -ligaments of the joint
• -degrees of freedom
• -primary motions
• -sagittal flexion
• -sagittal extension
• - slight lateral flexion
• - axial rotation: not a degree of
freedom
The atlanto-occipital joints provide independent movement of the cranium relative

to the atlas. The joints are formed by the protruding convex condyles of the occipital
bone fitting into the reciprocally concave superior articular facets of the atlas. The
congruent convex-concave relationship provides inherent stability to the articulation.
The concave-convex configuration of the atlanto-occipital joints permits angular
The terms “craniocervical region” and “neck” are used interchangeably. Both terms rotation in 2 degrees of freedom. The primary motions are FLEXION and
refer to the combined set of 3 articulations: 1. ATLANTO-OCCIPITAL JOINT, 2. EXTENSION. Lateral rotation is slight. Axial rotation is restricted and not considered
ATLANTO-AXIAL JOINT COMPLEX, 3. INTRACERVICAL APOPHYSEAL as a degree of freedom.
JOINTS (C2-C3). Intra-articular fat pads are commonly found between the joint capsule and the
The craniocervical region is the most mobile area within the entire vertebral column. margins of the articular cartilage. Anteriorly, the capsule of each atlanto-occipital joint
Highly specialized joints facilitate the positioning of the head, involving vision, hearing, blends with the anterior atlanto-occipital membrane and the anterior longitudinal
smell, and equilibrium. The individual joints within the craniocervical region interact in ligament. Posteriorly, the capsule is covered by a thin, broad posterior atlanto-occipital
a highly coordinated manner. membrane. The vertebral artery pierces the posterior atlanto-occipital membrane to
enter the foramen magnum. This artery supplies blood to the brain.
Slide 227 axial joint complex. The second degree of freedom is flexion and extension. Lateral
flexion is very limited and not considered a degree of freedom.
Two important connective tissues stabilizing the craniocervical junction deserve
attention. These are the ff: 1. TECTORIAL MEMBRANE, 2. ALAR LIGAMENTS.
The tectorial membrane is a broad, firm sheet of connective tissue just posterior to the
• FUNCTIONAL ANATOMY OF THE
transverse ligament. As the continuation of the posterior longitudinal ligament, the
CRANIOCERVICAL JOINTS
• THE ATLANTO-AXIAL JOINT COMPLEX
tectorial membrane attaches to the basilar part of the occipital bone, just anterior to the
-Structures that go into the formation of
the joint complex
rim of the foramen magnum. It strengthens the attachment between the cranium and the
a. median joint cervical column by limiting the extremes of flexion and extension.
b. 2 apophyseal joints
-degrees of freedom The ALAR LIGAMENTS are tough fibrous cords that pass obliquely upward and
1. axial rotation
2. flexion and extension laterally from the apex of the dens to the medial sides of the occipital condyles.
- Lateral flexion: very limited and not
considered a degree of freedom Clinically referred to as “check ligaments”, the alar ligaments limit axial rotation of the
-Stabilizing connective tissues
-tectorial membrane head and atlas relative to the axis. Evident by their position, the alar ligament also limit
-alar ligaments
lateral flexion.
Slide 228
The atlanto-axial joint complex consists of two joint structures: a median joint and a
pair of laterally positioned apophyseal joints. The median joint is formed by the dens of
C2 projecting through a ring created by the transverse ligament and the anterior arch of
the atlas. The joint complex has two synovial cavities. The smaller anterior cavity
consists of a synovial membrane that surrounds the articulation between the anterior CLINICAL ANATOMY: THE BACK
side of the dens and the posterior border of the anterior arch of the atlas. A small KINESIOLOGY
anterior facet on the anterior side of the dens marks this articulation. The much larger CERVICAL REGION
INTRACERVICAL APOPHYSEAL
JOINTS
posterior cavity has a synovial membrane that separates the posterior side of the dens
and the a cartilage-lined section of the transverse ligament of the atlas. Because the dens APOPHYSEAL JOINTS
acts as a vertical axis, the atlanto-axial joint is often described as a PIVOT JOINT. -occurring in the entire
cervical region (from C1 to
The 2 apophyseal joints of the atlanto-axial joint are formed by the articulation of C7)
the inferior facets of the atlas and the superior facets of the axis. The surfaces of these -Facet (or joint surface)
apophyseal joints are nearly flat and oriented close to the horizontal plane, a design that orientation (C2-C7): 45
degrees
maximizes the freedom of AXIAL ROTATION. -freedom of motion: great
The atlanto-axial joint complex allows 2 degrees of freedom. About 50% of the total freedom of movement in all
horizontal plane (axial) rotation within the craniocervical region occurs at the atlanto- 3 planes
The facet surfaces within the apophyseal joints of C2-C7 are oriented like shingles Slide 230
on a 45-degree sloped roof, approximately halfway between the frontal and horizontal
planes. This orientation provides great freedom of movement in all three planes, a
characteristic, or hallmark, of the cervical articulation.
Slide 229
• REGIONAL KINEMATICS OF THE SPINE
• SAGITTAL PLANE KINEMATICS AT THE CRANIOCERVICAL REGION-
FLEXION and EXTENSION
• SAGITTAL PLANE KINEMATICS AT THE CRANIOCERVICAL REGION
• Flexion- extension occuring in the following

craniocervical joints: • Flexion-extension arc: 130- 135 degrees
• 1 atlanto-occipital • Resting neutral posture: 30-35 degrees of
extension
• 2. atlanto-axial complex
• -from resting neutral posture: additional
• 3. Intracervical region (C2-C7) 85 degrees on active extension
• -20 to 25% of the total sagittal plane motion • - from resting neutral posture: 45-50
occurs over the atlanto-occipital and atlanto-
axial joint complex
degrees on active flexion
Although highly variable, about 130 to 135 degrees of flexion and extension occur at
• - remainder of motion: intracervical region (C2-
C7)
the craniocervical region. The neutral resting posture of the craniocervical region is
about 30 to 35 degrees. From the extended position , the craniocervical region extends
an additional 85 degrees and flexes 45 to 50 degrees. In general, flexion and extension
sequentially from cranial to caudal direction.
About 20 to 25% of the total sagittal plane motion at the craniocervical region
Above illustration shows the kinematics of craniocervical flexion as it occurs at the occurs over the atlanto-occipital joint complex, and the remainder over the appophyseal
atlanto-occipital joint, the atlanto-axial joint complex, and along the intracervical region joints of C2- C7. The axis of rotation for flexion and rotation extends approximately in
from C2-C7. Note that flexion slackens the anterior longitudinal ligament and increases medial-lateral direction through each of the 3 joint regions: the occipital condyles at the
the space between the adjacent laminae and spinous processes. On the other hand, the atlanto-occipital joint, the dens at the atlanto-axial joint complex, and the bodies of C2-
vertebral arch ligaments, the supraspinous, interspinous ligaments, ligamentum flava, C7.
are elongated and taut. The extremes of flexion and extension are limited primarily by tension in tissues
located either posteriorly or anteriorly to the various axes of rotation. Flexion is also
limited by the compresssion forces from the anterior margin of the annulus fibrosus, B. ATLANTO-AXIAL JOINT COMPLEX
whereas extension is limited by the compression forces from the posterior margin of Although the primary motion at the atlanto-axial joint complex is axial rotation,
annulus fibrosus. the joint structure does allow about 15 degrees of flexion and extension. As a spacer
between the cranium and axis, the ring-shaped atlas pivots forward during flexion and
backward during extension. The extent of the pivot motion is limited in part by the dens
that contacts the median joint of the atlanto-axial articulation.
Slide 231 C. INTRACERVICAL ARTICULATION (C2-C7)
Flexion and extension throughout the C2-C7 occur about an arc of motion
that follows the oblique plane set by the articular facets of the apophyseal joints. During
extension, which is initiated at the lower cervical spine(C4-C7), the inferior articular
facets of superior vertebrae slide inferiorly and posteriorly, relative to the superior
articular facets of the inferior vertebrae. These movement produce approximately 70
• ARTHROKINEMATICS OF FLEXION AND EXTENSION degrees of extension. Full extension is considered the close-packed position at the
cervical apophyseal joints, as well as the other regions throughout the vertebral column.
This position results in maximal joint contact and load-bearing. The inferior sliding of
the articular facets of superior vertebrae tends to slacken the joint capsule. The close-
packed position of most synovial joints increases the tension in the surrounding capsule
and associated ligaments. The apophyseal joints are one of the few exception to this
general rule.
Flexion is also initiated at the lower cervical spine (C4-C7). The movements are the
reverse of extension. The inferior facets of the superior vertebrae slide superiorly and
anteriorly, relative to the superior facets of the inferior vertebrae. The sliding
movements between the articular facets produces approximately 35 degrees of flexion.
Flexion stretches the capsule of the apophyseal joints and reduces the area for joint
contact.
Overall, approximately 105 degrees of cervical flexion and extension occur as a
result of the sliding between the apophyseal joint surfaces. This extensive range of
motion is due in part to the relatively long and unobstructed arc of motion provided by
Like the rockers on a rocking chair, the convex occipital condyles roll forward in the oblique plane of the facet surfaces. On average, about 20 degrees of sagittal plane
flexion and backward in extension within the concave superior articular facets of the motion occur at each intervertebral junction between C2-C3 and C6-C7. This is
atlas. Based on traditional convex-on-concave arthrokinematics, the condyles considerably greater angular motion than at the thoracic region. The largest angular
simultaneously slide slightly in the direction opposite to the roll. Tension on the tectorial displacement tends to occur between C5-C6, possibly accounting for the relatively high
membrane, articular capsules, and atlanto-occipital membranes limits the extent of the incidence of spondylosis, and hyperflexion-related fractures at this level.
roll of the condyles.
Slide 232 In addition to flexion and extension in the craniocervical region, the head can also
translate forward(PROTRACTION) and backward(RETRACTION) within the sagittal
plane.
PROTRACTION of the head flexes the lower-to-mid cervical spine and extends the
upper craniocervical region. RETRACTION of the head, in contrast, extends or
• KINEMATICS OF CRANIOCERVICAL EXTENSION
straigthens the lower-to-mid cervical spine and flexes the upper craniocervical region.
• ATLANTO-AXIAL JOINT: In both movements, the lower-to-mid cervical spine follows the translation of the head.
Although protraction and retraction of the head are physiologically normal useful
• -degrees of freedom:
• -primarily axial rotation
• - 15 degrees flexion-extension
motions, they may be associated with faulty posture. Prolonged periods of protraction
• - osteokinematics:: backward pivot of atlas
• - restraint to pivot motion of atlas: contact of dens
may lead to a chronic forward head posture, causing increased strain on the
against the median joint of atlanto-axial articulation
•
craniocervical extensor muscles.

• INTRACERVICAL ARTICULATION (C2-C7)
• Initiation of motion
A. Atlanto-occipital joint:
• -low cervical spine(C4-C7)
B. - backward roll of convex occipital condyles within
the concave superior facets of the atlas. • -70 degrees of extension
C. -simultaneous slide slightly in the direction opposite • -full extension: close packed position of
to the roll cervical apophyseal jonts.
D. - tension in tectorial membrane, articular capsules, • -slackening of joint capsule with inferior
and atlanto-occipital membrane limits the extent of
the roll and slide of the occipital condyles.
sliding motion of the inferior facets of the Slide 234
superior vertebrae
E. -
Slide 233
• ARTHROKINEMATICS OF FLEXION AND EXTENSION
• OSTEOKINEMATICS OF PROTRACTION AND RETRACTION

The bar graph above is an in vitro cervical flexion and extension motion study surfaces have also been described as lightly convex when considering the thickness of
involving over 10 cadaveric specimen. The bar is expressed as a percent of the total the articular cartilage. Because of the limited axial rotation permitted at the atlanto-
range of sagittal plane motion in the cervical spine. It is lowest at the C2-C3 junction occipital joint, the cranium follows the rotation of the atlas, essentially degree for
gradually increasing with the greatest motion at C5-C6 intervertebral junction. degree. The axis of rotation of the head and atlas is through the vertical projected dens.
Horizontal plane rotation of the atlas is coupled with slight lateral flexion to the
opposite side.
Tension in the alar ligaments increases with rotation at the atlanto-axial joint
Slide 235 complex especially in the ligament located opposite to the direction of the rotation.
Tension of the alar ligaments and capsules of the lateral apophyseal joints, plus the
many muscles about the neck limit axial rotation.
KINESIOLOGY OF THE SPINE

CRANIOCERVICAL REGION Slide 236
ARTHROKINEMATICS OF AXIAL ROTATION AT THE CRANIOCERVICAL REGION
• HORIZONTAL PLANE KINEMATICS AT THE CRANIOCERVICAL REGION

• OSTEOKINEMATICS OF AXIAL ROTATION
The atlanto-axial joint complex is designed for maximal rotation within the
horizontal plane. The design is most evident by the structure of the axis (C2), with its
vertical dens and nearly horizontal superior articular facets. The ring-shaped atlas
“twists” about the dens, producing about 40 to 45 degrees of axial rotation in each
direction. The flat to slightly concave inferior articular facets of the atlas slide in a
circular path across the broad “shoulders” of the superior facets of the axis. These
Axial rotation of the head and neck is a very important function, intimately related side over the C2-c7 region, nearly equal to that permitted at the atlanto-axial joint
to vision and hearing. As shown above, the craniocervical region rotates about 90 complex. Rotation is greatest in the more cranial vertebral segments.
degrees to each side, for a total range of nearly 180 degrees. With an additional 150 to
160 degrees of total horizontal plane movement of the eyes, the visual field approaches
360 degrees, with little or no movement of the trunk. Other factors, of course, influence
this wide visual fields. These are the range of motion and sight. Slide 238
About 50% of axial rotation of the craniocervical region occurs at the atlanto-axial
joint complex, with the remaining throughout C2-C7. Rotation of the atlanto-occipital
joint is restricted due to the deep-seated placement of the occipital condyles within the
articular facets of the atlas.
Slide 237 • FRONTAL PLANE KINEMATICS AT • LATERAL FLEXION

THE CRANIOCERVICAL REGION
• OSTEOKINEMATICS OF LATERAL
FLEXION
• -approximately 40 degrees of
lateral flexion
• -most movement occurs at the
• ARTHROKINEMATICS OF AXIAL ROTATION AT THE CRANIOCERVICAL REGION
C2-C7 region
• AXIAL ROTATION AT THE INTRACERVICAL ARTICULATIONS (C2-C7)
• -5 degrees occur at the atlanto-
occipital joint
• - negligible lateral flexion at the
atlanto-occipital joint
Approximately 40 degrees of lateral flexion is available to each side throughout the

craniocervical region. The extremes of movement can be demonstrated by attempting to
touch the ear to the tip of the shoulder. Most of this movement occurs at the C2-C7
Rotation throughout C2-C7 is guided primarily by the spatial orientation of the facet
region; however about 5 degrees may occur at the atlanto-occipital joint. Lateral flexion
surface within the apophyseal joints. The facet surfaces are oriented 45 degrees between
at the atlanto-axial joint complex is negligible.
the horizontal and frontal planes. The inferior facets slide posteriorly and somewhat
inferiorly on the same side of the rotation, and anteriorly and somewhat superiorly on
the side opposite the rotation. Approximately 45 degrees of axial rotation occur to each
Slide 239
The inferior articular facets on the side of lateral flexion slide inferiorly and slightly
posteriorly, and the inferior articular facets on the side opposite the lateral flexion slide
superiorly and slightly anteriorly.
The approximate 45 degree inclination of the articular facets of C2-C7 dictates the
• ARTHROKINEMATICS OF LATERAL • LATERAL FLEXION
FLEXION mechanical coupling between movements in the frontal and horizontal plane. Because
• ATLANTO-OCCIPITAL JOINT an upper vertebra follows the plane of the articular facet of the lower vertebra,
• -small amount of side-to-side rolling
of the occipital condyles over the component of lateral flexion and axial rotation must occur simultaneously. For this
superior facet of the atlas reason, lateral flexion and axial rotation in the mid-to-low cervical region are
• -extremes of lateral flexion:
• -slight unilateral joint
mechanically coupled in an ipsilateral fashion; for example, lateral flexion to the right
approxiimation on the side of lateral occurs with slight axial rotation to the right, and vice versa.
flexion
• -slight joint separation on the side
opposite the lateral flexion Slide 241
Slide 240 KINEMATICS OF THE THORACIC SPINE

REGION
• Sliding of the articular

facets at the side of flexion
• Sliding of the articular
facets opposite the lateral
flexion
• Mechanical coupling: lateral
flexion plus ipsilateral slight
axial rotation
ARTHROKINEMATICS AT THE
INTRACERVICAL
ARTICULATION C2-C7
Slide 242 Slide 243
THORACIC REGION
THORAX:
-formed by:
-ribs
-sternum • FUNCTIONAL ANATOMY
-thoracic vertebrae
-the rigidity of the region provides the ff. functions: OF THORACIC ARTICULAR
1-a stable base for muscles to control the STRUCTURES
craniocervical region
2-protection of the intrathoracic region • THORACIC SPINE:
3 -mechanical bellows for breathing
-24 apophyseal
joints(12 pairs)
-bilateral articular
facets
The thoracic region of the vertebral column has peculiar characteristics that make it -restricted
distinct from the cervical and the lumbar regions. It is the longest part of the vertebral movements
column that is relatively rigid and is interposed between 2 mobile spinal regions. Its
relative rigidity is due to the presence of the rib cage which is formed by the ribs,
sternum and the thoracic vertebrae. This relative rigidity of the thoracic region provides
3 functions: 1. a stable base for muscles to control the craniocervical region and the
upper extremities, 2. protection of the intrathoracic region, 3. mechanical bellows for
breathing. The thoracic spine has 24 apophyseal joints, 12 on each side and these provide the
The thoracic vertebrae are well stabilized by the ribs and associated costovertebral primary mechanism for thoracic mobility. However, their potential for mobility is
and costotransverse joints. Stability protects the spinal cord from trauma. During a fall, restricted by the adjacent COSTOVERTEBRAL AND COSTOTRANSVERSE joints
for example, the impact to the thoracic spine is partially absorbed and dissipated by the which tie mechanicaly most of the thoracic region anteriorly to the sternum.
ribs and the associated muscles and connective tissues.
Slide 244 costotransverse ligament is stabilized by a superior costotransverse ligament. This
strong ligament attaches between the superior margin of the neck of one rib and the
inferior margin of the transverse process of the vertebra located above. Ribs 11 and 12
usually lack costotransverse joints.
Slide 245
• KEY ANATOMIC ASPECTS OF THE

COSTOVERTEBRAL JOINT KINEMATICS OF THORACOLUMBAR
KINESIOLOGY OF THE SPINE FLEXION
• Each costovertebral joint THE THORACIC REGION
• -connects the head of a typical Approx. 30-40 degrees of
rib with a pair of costal facets and flexion
the adjacent margin of an -extremes of flexion
intervening intervertebral disc. limited by: 1. the
• -is stabilized by radiate and posterior arch ligaments
like the supraspinous and
capsular ligament
interspinous ligaments
2. capsules of the
apophyseal joints
3. posterior annulus
fibrosus
4. posterior longitudinal
lig.
Most COSTOVERTEBRAL joints connect the head of a rib with a pair of costal Range of motion at each thoracic intervertebral junction is small. However,
facets and the adjacent margin of an intervening intervertebral disc. The articular cumulative motion over the entire thoracic spine is considerable. Approximately 30 to
surfaces of the costovertebral joints are highly ovoid held together primarily by capsular 40 degrees of flexion occurs throughout the thoracic vertebral region alone. However, in
and radiate ligaments. situation like shown above where there is involvement of the thoracolumbar regions, the
COSTOTRANSVERSE joints connect the articular tubercle of a typical rib to the range of flexion goes higher to 85 degrees- a sum of 35 degrees of thoracic flexion and
costal facet on the transverse process of a corresponding thoracic vertebra. The 50 degrees of lumbar flexion
extensive (nearly 2 cm long) costotransverse ligament firmly anchors the neck of the rib The movement of the articular surfaces at the apophyseal joints are essentially
to the entire length of a corresponding transverse process. In addition, each similar to that of the C2-C7 apophyseal joints. If there are subtle differences, these are
attributed primarily to the different shapes of the vertebrae and the spatial orientation of
the facets. For example, flexion between T5-T6 occurs by superior and slightly anterior
sliding of the inferior facet surfaces of T5 on the superior facet surfaces of T6.
Extension occurs by a reverse process- that is inferior and slightly posterior sliding of
the inferior facet surfaces of T5 on the superior facet surfaces of T6.
Slide 246 Slide 247
• KINEMATICS OF • KINEMATICS OF AXIAL

EXTENSION AT THE ROTATION AT THE
THORACIC REGION THORACIC REGION
• Approx. 20-25 degrees of • Approx. 30 degrees of
extension horizontal plane(axial) to
each side
• With thoracolumbar
coupling: 35 to 40 • Freedom of axial rotation
degrees of extension (a decreases in a cranial-to-
sum of 20 to 25 degrees caudal direction
of thoracic extension and • Mid to lower thoracic
15 degrees of lumbar spine, the greater
extension) vertically oriented
apophyseal joints tend to
block horizontal plane
motion.
Approximately 20-25 degrees of extension is available over the entire thoracic Approximately 30 degrees of horizontal plane(axial) rotation occurs to each side
region. However, in thoracolumbar coupling as shown above, 35-40 degrees of flexion throughout the thoracic region. In general, the degree of axial rotation decreases in the
is available. Note that the amount of extension contributed by the lumbar region is less thoracic region in a cranial-to-caudal direction. In the mid to lower thoracic spine, the
compared to the thoracic region as far as thoracolumbar coupling is concerned. Unlike greater vertically oriented apophyseal joints tend to block horizontal plane motion.
in thoracolumbar flexion, the amount of flexion contributed by the lumbar region is In the thoracolumbar region however, axial rotation has 35 degree-arc- a sum of 30
much greater than the thoracic region by as much as 15 degrees. degrees of thoracic region and 5 degrees of lumbar rotation.
The extremes of extension in the thoracic region are limited by the potential
impingement between adjacent downward-sloping spinous process especially at the
midthoracic vertebrae.
In general the magnitude of flexion and extension increases in a cranial-to-caudal.
Slide 248 lateral flexion. Note that the ribs slightly drop on the side of the lateral flexion, and rise
slightly on the side opposite the lateral flexion.
As in the cervical spine, lateral flexion and axial rotation are mechanically coupled
in an ipsilateral manner. Coupling is most evident in the upper thoracic spine where the
articular facets possess a closer orientation to those in the lower cervical region. The
influence of coupling decreases and is inconsistent in the middle and lower thoracic
regions.
• KINEMATICS OF
THORACIC LATERAL
FLEXION
Slide 249
• Approx. 25 degrees to
each side
• Magnitude of this
motion relatively
constant
• Mechanical coupling in
ipsilateral manner
KINEMATICS AT THE LUMBAR

REGION
The predominant frontal plane orientation of the thoracic facet surfaces suggests a
relative freedom of lateral flexion. This potential for movement is never fully expressed,
however, because of the stabilization provided by the attachment to the ribs. Lateral
flexion in the thoracic region is, most of the time, coupled with lateral flexion of the
thoracolumbar region as illustrated above. However, pure flexion of the thoracic region
has approximately 25 degrees to each side. This magnitude of this intervertebral motion
remains relatively constant throughout the entire thoracic region.
Lateral flexion occurs as the inferior facet of the superior vertebra slides superiorly
on the side contralateral to the lateral flexion and inferiorly on the side ipsilateral to the
Slide 250 Slide 251
• FUNCTIONAL ANATOMY
• FUNCTIONAL ANATOMY OF THE
ARTICULAR STRUCTURES WITHIN • -Abrupt change in the facet
THE LUMBAR SPINE(L1-S5) orientation at or near the
• Facet articular thoracolumbar junction
surfaces: 25 degree • - high incidence of
from the sagittal plane traumatic paraplegia in
• Favors sagittal plane injuries involving the
motion at the expense thoracolumbar region
of axial rotation.
The facet surfaces of lumbar apophyseal joints are oriented nearly vertical, with The facet surfaces change their orientation rather abruptly at or near the
moderate-to-strong sagittal plane bias. The orientation of the superior articular facet of thoracolumbar junction. The sharp frontal-to-sagittal plane transition may help to
L2, as shown by the above illustration, is 25 degrees. This orientation favors sagittal explain the relatively high incidence of traumatic paraplegia at this junction. The thorax,
plane motion at the expense of axial rotation. This trend is evident even in the mid-to- being held relatively rigid by the rib cage, is free to flex as a unit over the lumbar
lower thoracic regions. region. A large flexion torque delivered to the thorax may concentrate an excessive
hyperflexion stress at the extreme upper lumbar region. If severe enough, the stress may
fracture or dislocate the bony elements and possibly injure the caudal end of the spinal
cord or the cauda equina.
Surgical fixation devices implanted to immobilize an unstable thoracolumbar
junction are particularly susceptible to stress failure compared with other regions of the
vertebral column.
Slide 252 Tilting of the pelvis is defined as a short-arc sagittal plane rotation of the pelvis
relative to the femurs. The direction of the tilt is indicated by the direction of rotation of
the iliac crests of the pelvis.
Several structures stabilize the anterior-posterior alignment of the L5-S1 junction,
especially the anterior longitudinal ligament and the iliolumbar ligament.
• L5-S1 JUNCTION
• Typical intervertebral junction Slide 253
with an interbody joint
anteriorly and a pair of
apophyseal joints posteriorly
• Facet surfaces of L5-S1
apophyses oriented in a more
frontal plane
• Sacrohorizontal angle =40
degrees
• connective tissues stabilizing
the L5-S1 junction
• 1. Anterior longitudinal
ligament
• 2. Iliolumbar ligaments
• L5-S1 apophyseal joints resist
anterior shear force.
LIGAMENTS THAT STABILIZE THE

As any intervertebral junction, the L5-S1 junction has an interbody joint anteriorly The wide and sturdy articular facets of
L5-S1 JUNCTION: 1. ANTERIOR
and a pair of apophyseal joint posteriorly. The facet surfaces of the L5-S1 apophyseal the L5-S1 apophyseal joints provide
bony stabilization to L5-S1 junction
LONGITUDINAL LIGAMENT 2.
THE ILIOLUMBAR LIGAMENTS
those of other lumbar regions.
The base(top) of the sacrum is naturally inclined anteriorly and inferiorly, forming
an approximate 40-degree sacrohorizontal angle while standing. Given this angle, the
resultant force due to body weight (BW) creates an anterior shear (BWs) and a
compressive force (BWn) acting perpendicular to the superior surface of the sacrum. A
typical sacrohorizontal angle of 40 degrees has a magnitude anterior shear force acting
at L5-S1 junction equal to 64% of body weight. Increasing the sacrohorizontal angle The ANTERIOR LONGITUDINAL LIGAMENT crosses anterior to the L5-S1
also increases the anterior shear. For example, increasing the sacrohorizontal angle to 55 junction. The ILIOLUMBAR LIGAMENT arises from the inferior aspect of the
degrees increases the anterior shear force to about 82% of superimposed body weight. transverse process of L5 and adjacent fibers of the QUADRATUS LUMBORUM
While standing or sitting, lumbar lordosis can be increased by anterior tilting of the muscle. The ligament attaches inferiorly to the ilium, just anterior to the sacroiliac joint,
pelvis. and to the lateral aspect of the sacrum. As a bilateral pair, the iliolumbar ligaments
provide a firm anchor between the lower lumbar vertebrae and the underlying ilium and
sacrum.
The wide, sturdy articular facets of the L5-S1 apophyseal joints provide bony While standing the lumbar region in the healthy adult typically exhibits about 40-45
stabilization to the L5-S1 junction. The near frontal plane inclination of the facet degrees of lordosis. Lumbar lordosis is greater in women than in men, with the greatest
surfaces can resist part of the anterior shear at this region. This blockage creates a force differences appearing after the 5th decade. Compared with standing, sitting reduces the
within the apophyseal joint. lordosis by about 20 to 35 degrees.
Without adequate stabilization, the lower end of the lumbar region can slip forward About 50 degrees of flexion and 15 degrees of extension occur at the healthy lumbar
relative to the sacrum. This abnormal, potentially serious condition is known as spine. This is a substantial range of motion considering it occurs across only 5
SPONDYLOLISTHESIS. intervertebral junctions. This predominance of sagittal plane motion is largely due to the
prevailing sagittal plane bias of the facet surfaces in the lumbar apophyseal joints. As a
general principle, the amount of lumbar intervertebral flexion and extension gradually
increases in a cranial-to-caudal directions.
There is also a strong kinematic relationships between the lumbar region, the trunk
as a whole and the lower extremities. Pelvic-on-femoral(hip) flexion increases the
Slide 254 passive tension in the stretched hamstring muscles. With the lower end of the vertebral
column fixed by te sacroiliac joints, continued flexion of the middle and upper lumbar
region reverses the natural lordosis of the back.
During flexion, between L2-L3 for example, the inferior facets of L2 slide
superiorly and anteriorly, relative to the superior facets of L3. As a consequence,
muscular and gravitational forces are transferred away from the apophyseal joints,
which generally support about 20% of the total spinal load in erect standing, and toward
the discs and posterior spinal segments. Discs are compressed while the posterior
• KINEMATICS AT THE LUMBAR
REGION ligaments are tensed. In extreme flexion, the fully stretched articular capsule of the
• APPROX. RANGE OF MOTION FOR apophyseal joints restrains additional forward migration of the superior vertebra.
THE 3 PLANES OF MOVEMENT FOR
THE LUMBAR REGION The extreme flexed position significantly reduces the contact area within the facet
• FLEXION AN D EXTENSION
(SAGITTAL PLANE)
surfaces of the apophyseal joints. Paradoxically, although a fully flexed lumbar reduces
-FLEXION: 50 DEGREES ---- the total force on a given apophyseal joint, the pressure (force per unit area) increases
•
EXTENSION: 15 DEGREES
-TOTAL: 65 DEGREES
on the decreased surface area under contact. High pressure may damage joints that have
• AXIAL ROTATION: 5 DEGREES abnormally developed articular surfaces.
• LATERAL FLEXION (FRONTAL
PLANE): 20 DEGREES
The kinematics of flexion of the lumbar region, as shown by the above illustration,
is taken in context with flexion of the trunk and hips. P
Slide 255
Slide 256
THORACOLUMBAR EXTENSION: 20-25 DEGREES OF

THORACIC EXTENSION AND 15 DEGREES OF LUMBAR
EXTENSION
• RELATIVE RESISTANCE PROVIDED BY THE

LOCAL CONNECTIVE TISSUES TO
EXTREME FLEXION IN THE LUMBAR
REGION
• CAPSULE OF THE APOPHYSEAL JOINT:
LARGEST RESISTANCE
• DISC: FOLLOWS 2ND
• SUPRASPINOUS AND INTERSPINOUS
THORACOLUMBAR LATERAL FLEXION: 25
LIGAMENTS-3RD
DEGREES THORACIC LATERAL FLEXION; 20
DEGREES OF LUMBAR LATERAL FLEXION • LIGAMENTUM FLAVUM: THE LEAST
RESISTANCE.
• CLINICAL SIGNIFICANCE: IN HEALTHY
LOWER BACK, PASSIVE RESISTANCE
OFFERED BY THE APOPHYSEAL CAPSULE
REDUCES COMPRESSION LOAD ON THE
INTERVERTEBRAL DISC.
The bar graph shows the results from cadaveric experiments on the relative
resistance provided by nonmuscular tissues against a flexion torque at the lumbar
spines. There is relatively large resistance provided by the stretched articular capsule of
the apophyseal joints. This is followed by the intervertebral discs. The ligamentum
flavum offering the least resistance.
Of clinical interest is the relatively large resistance provided by the stretched Extension of the lumbar spine is essentially the reverse of flexion. Extension
articular capsule that surrounds the flexed apophyseal joints. In the healthy lower back, between L2-L3, for example, occurs as the inferior articular facets of L2 slide inferiorly
the passive tension within the capsule of flexed apophyseal joints reduces the and slightly posteriorly relative to the superior facets of L3. Full extension increases
compression load on the intervertebral discs. A weakened or overstretched articular both the amount of load and area of contact at the apophyseal joints.
capsule, however, may not be able to generate sufficient tension to protect the discs When lumbar extension is combined with full hip extension, passive tension in the
from injury. This might be true in a chronic, slumped sitting posture where the capsules stretched hip flexors helps maintain lordosis by anteriorly tilting the pelvis.
of the apophyseal joints are overstretched. In the neutral standing posture, the healthy disc is the primary load-bearing structure
in the lumbar region. As such, healthy discs reduce the load imposed apophyseal joints
and thereby protect them from excessive wear. In diseased or severely dehydrated disc,
Slide 257 however, a greater portion of the total load is shifted to the apophyseal joints. It is not
uncommon, therefore, for a person with severe disc disease to develop osteoarthritis in
the lumbar apophyseal joints.
Slide 258
• EXTENSION OF THE
LUMBAR REGION
• Essentially reverse of
lumbar flexion
• Increases lumbar
lordosis
• Full extension
increases both the
amount of load and
area of contact at the
apophyseal joints.
Flexion and extension of the lumbar spine can occur by two fundamentally different A second movement strategy involves a relatively short-arc tilt of the pelvis. As
movement strategies. The first strategy is typically used to maximally displace the upper shown above, an anterior or a posterior pelvic tilt accentuates or reduces lumbar
trunk and upper extremities relative to the thighs, such as when lifting or reaching. This lordosis. The change in lordosis alters the position of the nucleus pulposus within the
strategy combines maximal flexion and extension of the lumbar spine with a wide arc of disc and alters the diameter of the intervertebral foramina.
pelvic-on-femoral(hip) and trunk motion. The axis of rotation for pelvic tilting is through both hip joints. This mechanical
association strongly links the movement(pelvic-on-femoral) of the hip joints with that of
the lumbar spine.
Slide 259 THERAPEUTIC AND KINESIOLOGIC CORRELATIONS BETWEEN ANTERIOR

PELVIC TILT AND INCREASED LUMBAR LORDOSIS:
Active anterior tilt of the pelvis is caused by the hip flexor and back extensor
muscles. Strengthening and increasing the control of these muscles, in theory, favors a
more lordotic posture of the lumbar spine. Although this idea is intriguing, whether a
EFFECT IF PELVC TILT ON THE LUMBAR person can subconsciouslly adopt and maintain a newly learned pelvic posture is
SPINE uncertain. Nevertheless, maintaining the natural lordotic posture in the lumbar spine is a
fundamental principle espoused by Mckenzie for persons with a herniated disc.
Increased lumbar extension reduces the pressure within the disc and, in some cases,
reduces the contact pressure between the displaced nuclear material and the neural
elements. Evidence of the latter is often described as “CENTRALIZATION” of low
• ANTERIOR AND POSTERIOR PELVIC TILT back pain, meaning that discogenic pain(formerly in the lower extremities due to nerve
root impingement) migrates toward the back. Centralization, therefore, suggests reduced
disc pressure on the nerve root.
Slide 260
LUMBAR FLEXION: ITS EFFECT ON THE DIAMETER OF THE
INTERVERTEBRAL FORAMEN AND MIGRATION AND MIGRATION OF THE
NUCLEUS PULPOSUS
Relative to a neutral position, full flexion of the lumbar spine increases the diameter
Illustration A and C show of the intervertebral foramina by 195 and increases the volume of the vertebral canal by
anterior pelvic tilt or
Intervertebral lumbar 11%. Therapeutically, flexion of the lumbar region is often used to temporarily reduce
extension the pressure on a lumbar nerve root that is impinged by an obstructed foramen. In
Illustration B and D show certain circumstances, however, this potential therapeutic advantage can be associated
posterior pelvic tilt or with a potential therapeutic disadvantage. For example, flexion of the lumbar region
intervertebral lumbar flexion
generates compression forces on the anterior side of the disc, which tend to migrate the
nucleus pulposus posteriorly. The magnitude of the migration is small in a healthy spine.
In a person with a weakened posterior annulus, however, posterior migration of the
nucleus pulposus increases pressure on the spinal cord or nerve roots.
THERAPEUTIC AND KINESIOLOGIC CORRELATIONS BETWEEN POSTERIOR
PELVIC TILT AND DECREASED LUMBAR LORDOSIS:
Active posterior tilting of the pelvis is produced by hip extensors and abdominal
muscles. Strengthening and increasing the patient’s conscious control over these
muscles theoretically favors a reduced lumbar lordosis. This concept was the trademark
of the “WILLIAMS FLEXION EXERCISES,” a therapeutic approach that stressed
stretching the hip flexors and back extensor muscles and strengthening the abdominal
and hip extenor muscles. In principle, these exercises are most appropriate for persons
with back pain related to excessive lordosis and significantly increased lumbohorizontal
angle. This posture, according to Williams, was associated with degenerative disc
Extension of the lumbar spine and its effect on the diameter of the intervertebral disease, stenosis of the lumbar intervertebral foramen, osteophyte formation with nerve
foramen and migration of the annulus pulposus: root irritation, and anterior spondylolisthesis.
Relative to the neutral position, full lumbar extension reduces the volume within the
vertebral canal by 15%. For this reason, clinicians often suggest that a person with nerve Slide 261
root impingement, from a stenosed intervertebral foramen, limit acitivities that involved
hyperextension. Extension, however, tends to migrate the annulus fibrosus anteriorly.
Person with nuclear protrusion or prolapsed may find, therefore, that extension reduces
pain associated with pressure on the spinal cord or nerve roots. The normal lumbar
lordotic posture may restrict the migration of the nucleus pulposus within a weakened
disc from approaching the neural elements. It is uncertain whether the nucleus pulposus
migrates in a similar manner in both healthy and degenerated discs.
be considered when planning an exercise program for a person with generalized low
back pain.
• LUMBAR FLEXION: Its Effect on the Diameter of

the Intervertebral Foramen and Migration of the
Annulus Pulposus
• full lumbar flexion: increases the volume of the
vertebral canal by 11%
• -increases the diameter of the intervertebral
foramen by 19%
• -generates compression force on the anterior
side of the disc, which tend to migrate the disc
posteriorly
Relative to a neutral position, full flexion of the lumbar spine increases the diameter
of the intervertebral foramina by 19% and increases the volume of the vertebral canal by
11%. Therapeutically, flexion of the lumbar region is often used to temporarily reduce
the pressure on a lumbar nerve root that is impinged by an obstructed intervertebral
foramen. In certain circumstances, this potential therapeutic advantage may be
associated with a potential therapeutic disadvantage. For example, flexion of the lumbar
region generates compression forces on the anterior side of the disc, which tend to
migrate the nucleus pulposus posteriorly. The magnitude of the migration is small in the
healthy spine. In a person with a weakened posterior annulus fibrosus, however,
posterior migration of the nucleus pulposus increases pressure on the spinal cord or
nerve roots. These contrasting therapeutic effects of flexion in the lumbar regionare to
Slide 262
• UNDESIRABLE EFFECTS OF EXAGGERATED

LUMBAR LORDOSIS
• -Ex. In residuals of poliomyelitis involving
hip flexion contracture
• -increased compression force on the
apophyseal joints
• -increased anterior shear at the
lumbosacral junction leading to
spondylolisthesis.
The lumbar region may demonstrate greatly exaggerated lordosis that is undesirable
from a medical perspective. Such structure may be found in residuals of postpolio
infection where there is severe hip flexion contracture and increased passive tension in
the hip flexor muscles. The possible negative results of this exaggerated lumbar lordosis
are increased compression force on the apophyseal joints and increased anterior shear at
the lumbosacral junction leading to spondylolisthesis.
Slide 263 region . In both B and C, the amount of overall trunk flexion is reduced. If greater trunk
flexion is required, the hip joints or lumbar region may mutually compensate for the
other’s limited mobility. This situation may increase the stress on the compensating
region. As depicted in fig. B, with limited hip flexion due to restricted hamstring
extensibility, for example, bending the trunk toward the floor requires greater flexion in
• LUMBOPELVIC RHYTHM the lumbar and lower thoracic spine. Eventually, exaggerated flexion may overstretch
DURING TRUNK FLEXION posterior connective tissues, such as the interspinous ligaments, posterior annulus
fibrosus, posterior longitudinal ligament, apophyseal joint capsules and thoracolumbar
LUMBOPELVIC
fascia, or increase stress on the discs and apophyseal joints.
RHYTHM
In contrast, as shown in fig. C, limited mobility in the lumbar spine may require
greater flexion of the hip joints. Greater forces may be required from the hip extensor
muscles which as a consequence, increase the compression force at the hips. In persons
with healthy hips, this relatively low-level increase in compression force is usually
tolerated without cartilage degeneration or discomfort. In a person with a preexisting
hip condition like osteoarthritis, or, gross joint asymmetry, the increased compression
force may accelerate degenerative changes.
Slide 264
• LUMBOPELVIC RHYTHM
In conjunction with the hip joints, the lumbar region provides the major flexion and DURING TRUNK EXTENSION
extension pivot point for the trunk, especially during activities such as forward bending,
climbing and lifting.
LUMBOPELVIC RHYTHM is the kinematic relationship between the lumbar spine
and hip joints during sagittal plane movements.
An understanding of the normal lumbopelvic rhythm during flexion and extension of
the trunk can help distinguish pathology affecting the spine and that affecting the hips. LUMBOPELVIC
Consider the common action of bending forward and toward the ground while RHYTHM
keeping the knees straight. This motion is measured as combination of about 40 degrees
of lumbar flexion and 70 degrees of hip (pelvic-on femoral) flexion. The hips and
lumbar spine flex simultaneously throughout the arc of trunk flexion but this motion is
initiated at the lumbar spine. Figures B and C show obvious abnormal lumbopelvic
rhythms associated with marked restriction in mobility at the hip joints (B) or lumbar
The typical lumbopelvic rhythm used to extend the trunk from a forward bent
position is shown in the above illustration. Extension of the trunk with knees extended
is normally initiated by extension of the hips, then followed by extension of the lumbar For many persons, a lot , a time is spent sitting, either at work, school, or home, or
spine. This normal lumbopelvic rhythm reduces the demands on the lumbar extensor in a vehicle. The posture of the pelvis and lumbar spine has a large influence on the
muscles and underlying apophyseal joints and discs, thereby protecting the region posture in other areas of the vertebral column particularly the lumbar and
against high stress. Delay in lumbar extension shifts the extensor torque demand to the craniocercervical regions.
powerful hip extensors(hamstrings and gluteus maximus), at the time when the external In the illustration depicting two classical postures- the slouching or “poor” posture
flexion torque on the lumbar region is greatest(external moment arm depicted as dark and the “ideal” sitting posture. In the poor slouched posture, the pelvis is posteriorly
black line). In this scenario, the demand on the lumbar extensor muscles increases only tilted with a lightly flexed (flattened) lumbar spine. Eventually, this posture may lead to
after the trunk is sufficiently raised and the external moment arm, relative to the body adaptive shortening in tissues that maintain this posture. Tissues that, if shortened,
weight, is minimal. Persons with severe low back pain may purposely delay contraction predispose a person to slouched sitting posture with a posterior tilted pelvis:
of the lumbar extensor muscles until the trunk is nearly vertical. After standing 1. Hamstring muscles
completely upright, hip and back muscles are typically inactive, as long as the vector 2. Anterior longitudinal ligament
due to the body weight falls posterior to the hip joints. 3. Anterior fibers of the annulus fibrosus
A habitually slouched sitting posture may, in time, overstretch and weaken the
posterior annular fibrosus, reducing its ability to block a protruding nucleus pulposus.
Slide 265 A slouched sitting posture typically increases the external moment arm between the
line-of-force of the upper body weight and lumbar vertebrae. As a consequence, the
greater flexor torque increases the compression force on the anterior margin of the
lumbar discs. In vivo pressure measurements typically demonstrate larger pressures
within the lumbar discs in slouched sitting position compared with the erect sitting.
SITTING POSTURE AND ITS EFFECTS ON

ALIGNMENT OF THE LUMBAR AND
CRANIOCERVICAL REGIONS
Slide 266 Sitting posture may be improved by a combination of awareness, strengthening and
stretching appropriate muscles; eyeglasses; and ergonomically designed seating, which
includes adequate lumbar support
Slide 267
The sitting posture of the pelvis and the lumbar spine strongly influences the posture
of the entire skeletal axial skeleton including the craniocervical region. A flat posture of
the low back is associated with a more protracted head (i.e., a “ forward head”) posture.
Sitting with the lumbar spine flexed tips the thoracic and lower cervical regions
forward into excessive flexion. In order to maintain a horizontal visual gaze- such as The ideal sitting posture with natural lordosis and increased anterior pelvic tilt
that typically required to view a computer monitor- the upper craniocervical region must extends the lumbar spine. The change in posture at the base (inferior aspect) of the spine
compensate by extending slightly. Over time, this posture may result in adaptive has an optimizing influence on the posture
shortening in the small posterior suboccipital muscles.
A prolonged slouched sitting posture may be an occupational hazard. It may increase
the muscular stress at the base of the cervical spine. The forward –head posture
increases the external flexion torque on the cervical column as a whole, requiring
greater force production from the extensor muscles and local connective tissues.
Slide 268
FLEXION: Bilateral action of : Rectus abdominis. Psoas major, Gravity

EXTENSION: Erector spinae , Multifidus, semispinalis thoracis
Rhomboids, Serratus Anterior
ROTATION: Unilateral action of : Rotatores, Multifidus, Iliocostalis, Longissimus,
External oblique acting synchronously with opposite oblique, Splenius thoracis.
Slide 269 the vertebral arteries, and therefore, reduces the blood flow to the brainstem. This
ischemic condition of the brainstem may manifest in situation of prolong turining of the
head-as occurs when backing up a motor vehicle. Signs and symptoms may include
lightheadedness, dizziness, or vertigo.
One of the most common medical complaints that bring patients to clinic is BACK
PAIN, and the most common cause of this is BACK STRAIN. Back strain results from
extreme movements of the vertebral column such as extension or rotation. Such extreme
movements result in stretching or microscopic tearing of muscle fibers and/or ligaments
of the back. The muscles involved are usually those producing movements of the
lumbar intervertebral joints, especially the ERECTOR SPINAE muscles. If the weight is
not properly balanced on the vertebral column, strain is exerted on the muscles. As a
protective mechanism, the back muscles go into SPASM after an injury or in response to
inflammation of structures such as the ligaments.
The anatomic significance of the SUBOCCIPITAL TRIANGLE is that it is where
the vertebral arteries pass to supply parts of the brain. The vertebral arteries have
winding course as these pass through the SUBOCCIPITAL TRIANGLE. Medical
condtion like arteriosclerosis reduces blood flow in this anatomical part of the course of

The Back

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

The Back

Загружено:

Авторское право:

Доступные форматы

Slide 118 Slide 119

The MEDIAL ATLANTOAXIAL JOINT (or, the ATLANTO-DENS articulation)

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK Slide 127

THE VERTEBRAL COLUMN

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

-Wide area of coverage of the

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

The anterior longitudinal ligament is a long, straplike structure attaching between

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

The APOPHYSEAL JOINTS are primarily responsible for guiding intervertebral

Acting as mechanical barricades, the apophyseal joints permit certain movements

CLINICAL ANATOMY: THE BACK:

As shown in the above illustration lumbar extension generates compression force in

• THE SPINAL CORD

CLINICAL ANATOMY: THE BACK CLINICAL ANATOMY: THE BACK

• 1. Spinal cord and its

CLINICAL ANATOMY: THE BACK CLINICAL ANATOMY: THE BACK

VERTEBRAL (NEURAL) CANAL

CLINICAL ANATOMY: THE BACK

• 1. Spinal cord and its

CLINICAL ANATOMY: THE BACK CLINICAL ANATOMY: THE BACK

VERTEBRAL (NEURAL) CANAL

CLINICAL ANATOMY: THE BACK

Slide 180 CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK Slide 192

CLINICAL ANATOMY: THE BACK

VASCULATURE OF THE SPINE

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

Clinical anatomy: the back CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

Clinical anatomy: the back CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

CLINICAL ANATOMY: THE BACK

INNERVATION TO THE SPINE

In general, the articulations of two body segments constitute a joint. Movement at a

CLINICAL ANATOMY: THE BACK

THE CRANIOCERVICAL REGION

• FUNCTIONAL ANATOMY OF THE • THE ATLANTO-OCCIPITAL

The atlanto-occipital joints provide independent movement of the cranium relative