The Vertebral Column

Rene C. Catan, MD Associate Professor MHAMCM

Outline
I. General structure II. Structure of Typical Vertebra III. Regional Modifications of Vertebral Characteristics IV. Intervertebral Disks V. Ligaments

I. General Structure

A. Composition- 33 vertebrae connected by 23-24 intervertebral discs

1. Vertebrae- cervical, thoracic, lumbar, sacral, coccygeal 2. Intervertebral Discs (IVD) a. Location. Amphiarthoses (symphyses) 1) None between occiput & atlas, atlas & axis 2) Fibrocartilage- little movement b. Intervertebral ligaments. Stabilizes

I. General structure

B. Spinal curvature- terrestrial adaptation & erect stance

1. Normal curvatures- take shape of IVD
a. Sacral curve (S1-coccyx)concave anteriorly 1) Characteristic of fetuses and lower animal forms 2) Primary curve b. Lumbar curve (T12-L5)-concave posteriorly 1) Appears between 12 to 18 months 2) Pronounced in females, potential for instability 3) Adaptational curve secondary to upright posture

I. General structure

B. Spinal curvature- terrestrial adaptation & erect stance

1. Normal curvatures- take shape of IVD
c. Thoracic Curve (T2 T12) 1) Characteristic of fetus & lower animal forms 2) Primary curve d. Cervical curvature (C2-T2) 1) Appears late intrauterine, established 3-4 months after birth 2) Secondary adaptational /adaptation to quadrupedal posture

B. Spinal curvatures
1. Abnormal curvatures
a. Kyphosis (hunchback)exaggerated thoracic curve (congenital, pathologic , traumatic collapse of vertebrae)

b. Lordosis (swayback)exaggerated lumbar curve (posterior compression of IVD, late pregnancy)

Abnormal curve

c. Scoliosis- lateral curvature 1) Congenital, pathologic, unilateral paralysis of vertebral mm. a) Idiopathic (most common) b) Compensatory curve opposite direction in another region 2) Rotation of vertebra toward convex with progression. 3) Amenable to surgery in late teens or before chilbearing

Scoliosis- Lateral curvature of the spine

II. Structure of Typical Vertebra

A. Body- major support B. Structure- cylindric, function for support, increase in bulk toward sacrum 1. Articulations
a. Amphiarthoses. IVD that form symphyses b. Diarthroses. Superior & inferior articular processes by synovial joints

C. Vertebral (neural) archpedicles & laminae, forms posterior portion of vertebra 1. Pedicles- posterolaterally from vertebral body 2. Laminae- fuse in midline

II. Structure of Typical Vertebra

C. Vertebral processes
1. Spinous processes- from vertebral arch laminae fuse, attachments of vertebral muscles 2. Transverse processes- from side of v. arch pedicle laminae fuse;
a. Attachments of muscles, ligaments b. Articulate with ribs 1-10 c. Form sacral ala, articualtes with ilium

3. Costal process- side of v. body

II. Structure of Typical Vertebra

ant. to pedicle; articulate ribs of thoracic region, contribute to cervical transverse processes and alae of sacrum

4. Superior articular processesa. Form diarthrodial articulations with articular processes below b. Face posteriorly in cervical region, posteromedially in thoracic, medically in lumbar, posteriorly in sacrum

5. Inferior articular processesa. Diarthrodial joints b. Face anteriorly in cervical, anterolaterally in thoracic, laterally in lumber, but ant in 5th lumbar.

II. Structure of Typical Vertebra

D. Foramina
1. Vertebral foramen- formed by posterior surface of body and vertebral arch
a. Vertebral neural arch b. Contain spinal cord & nerve roots

2. Intervertebral foramina
a. Formed by deep notch in inferior surface of pedicle above with superior surface of notch of vertebra below b. Transmit spinal nerves, intervertebral arteries

Intervertebral foramen & notch

III. Regional modifications of vertebral

A. Cervical vertebra C1 to C7
1. Atlas C1. No body & spinous processes; consists of anterior arch, neural arch, paired transverse processes Articulations. Atlantooccipital joint
a. Nearly horizontal facets, concave receive condyles b. Flexion/extension (15 degrees) c. No IV disc d. Articulates inferiorly with axis flat, broad facets

III. Regional modifications

A.2. Axis C2
a. Structure. Dens (odontoid process), large flat superior articular facets b. Articulations. Atlantoaxial joint: dens with anterior arch of C1
1) Dens stabilized by ligaments , serves as pivot a) Cruciform ligament b) Fracture 2) Rotation (25 degrees) 3) No disc

A.3. Typical cervical vertebra

III. Regional modifications

a. Structure. Transverse foramen in each transverse process

1) Hiatus represents incomplete fusion of costal and transverse processes 2) Vertebral artery except C7 3) Bifid spinous processes, angle downward except C7 which almost horizontal (vertebra prominens)

III. Regional modifications

b. Articulations.
1) Superior facets are convex 2) Rotation, flexion/extension, lateral flexion 3) Superior facets face posteriorly, inferior facets face anteriorly 4) Predisposition to dislocations

4. Movements. a. Flexion: 40 deg./ extn:90 deg. Atlantooccipital jt. b. Lateral flexion (abduction):40 deg C2-C7 c. Rotation: 45 deg at atlantooccipital joint d. Circumduction

III. Regional modifications B. Thoracic vertebrae T1-T12

1. Structure
a. Spinous processes long oriented caudally b. Costal processes developed into ribs c. Articular facets (diarthrodial joints)

2. Intervertebral articulations
a. Paired superior facets face posterolaterally, paired inferior facets face anteromedially b. Rotation at T12 facilitated by facet position c. Movement limited by ribs

III. Regional modifications

C. Lumbar vertebrae L5-S1 1. Structure. Spinous process stubby, horizontal. 2. Articulations.

a. Lie on parasagittal planes. b. Superior facets face medially, inferior face laterally 1) Flexion (60 deg), extn (35 deg) 2) Lateral flexion (20 deg) 3) Rotation (5 deg) 4) Circumduction c. L5 facets directed anteriorly

Posterior approach to the lumbar spine

III. Regional modifications

D. Sacral vertebrae
1. Structure. 4 horizontal fusion lines, rudimentary disc at S1-S2 around spinal nerves form sacral foramina Sacralization of L5 a. Median sacral crest- fused spinous processes b. Alae- fused transverse processes c. Sacral hiatus, sacral cornua.
2. Articulations. Lumbosacral joint

III. Regional modifications

F. Clinical considerations
1. Compression fractures of the vertebral bodies
a. Internal collapse result to kyphosis or scoliosis b. Spinal nerve compression, spinal cord (sc) trauma

2. Pedicle fractures result to instability

a. Misalignment of vertebral column result to nerve root compression or sc trauma b. Cervical region and lumbar region- wide canal, compression fracture may not result to sc compression c. Thoracic region fracturecommon paraplegia

IV. Intervertebral Disc

A. External structure
1. 25% total length of vertebral column 2. cervical thin, lumbar large & thick 3. Secondary vetebral curvature: differences in thickness anteriorly vs posteriroly

B. Internal structure
1. Annulus fibrosus forms central portion of disc a. composed of lamelliform connective tissue b. attached to adjacent vetebra, forming amphiarthrosis c. supports central nucleus pulposus

IV. Intervertebral Disc

2. Nucleus pulposus- forms central portion a. remnant of the notochord b. surrounded & supported by the annulus fibrosus c. cartilaginous, mucinous tissue with mucopolysaccharide- high osmotic pressure d. 70-80% water: contribute to total height C. Functions. 1. Amphiarthrosis. Bind vertebra together, allow limited movement between vertebrae 2. nucleus pulposus. distributes forces over entire surface of vertebra

Annulus fibrosus- concentric lamella of fibrocartilage forming the circumference of the IV disc. Run obliquely from one vertebra to another, thus allowing movement and strong bond

Nucleus pulposus- central core, pulpy, Catilaginous (dehydrates later). Semifluid fulcrum- flexibility and resilience. Shock absorber, avascular (diffusion) Posteriorly placed- a.f. thin post. & laterally

IV. Intervertebral Disc

D. Clinical consideration
1. Disc degeneration. Dehydration of nucleus pulposus a. leads to narrowing of iv disc, reduces disc capacity to act as cushion between vetebrae b. diminished stature, decrease size of iv foramina, nerve root compression c. osteophytes-progressive calcification of superior and inferior vertebral body margins. chronic low back, cervical pain with arm pain

IV. Intervertebral Disc

2. Disc herniation ("slipped disc")extrusion of nucleus pulposus through annulus fibrosus a. Most common: L4-L5; then L5-S1, cervical region 5-10 % b. Schmorl's node- prolapse of nucleus pulposus into vertebral body c. Commonly directed posterolaterally. Anterior and posterior longitudinal ligaments reinforce the disc. d. Nerve compression

Intervertebral disc herniation

IV. Intervertebral Disc

d. Nerve compression
(1) Posterolateral disc prolapse impinges on spinal nerve of the next lower vertebra causing symptoms on dermatomic and myotomic distribution

V. Ligaments

A. Supraspinous ligaments
connects tip of spinous processes. Ligamentum nuchae in cervical region

B. Interspinous ligaments
run between spinous processes 1. Limit motion on vertebrae 2. Hyper flexion trauma may result to small tears (whiplash injury)

V. Ligaments

C. Ligamentum flavum- paired,

stretches between adjacent laminae; + vetebral arch = postrerior vertebral canal 1. Elastic tissue 2. Hyperflexion - buckling result to spinal cord injury

D. Anterior longitudinal ligament- vertebral bodies & IVD

anteriorly 1. Sacrum to occipital bone 2. Resist increased lordosis 3. Reinforces annulus fibrosus, herniation posteriorly 4. Splint fractured vertebrae, trunk cast in extension

Accessory Ligaments

Anterior Longitudinal Ligament

Very dense, powerful ligament Attachments: from axis down to sacrum attaching along anterior disc and vertebral bodies of the motion segment Function: limits hyperextension of the spine restrains forward movement of one vertebrae over another

V. Ligaments

E. Posterior longitudinal ligamentconnects vertebral bodies posteriorly

1. Denticulate ligament- wide post to vertebral body, narrow post to iV dsc 2. Resist kyphosis 3. Supports annulus fibrosus posteriroly, herniation directed posterolaterally

V. Ligaments

F. Cruciform ligament- of atlas

supports dens
1. Extends to base occiput to body of axis 2. Principal: prevent atlantoaxial subluxation

I. Posterior vertebral muscles

A. Overview. Move and stabilize the vertebral
column

B. Organization. (Most superficial: upward & obliquely

outward; Middle: parallel to vertebral column; Innermost: upward & obliquely inward)

1. 2. 3. 4.

Spinotransverse group Sacrospinalis group Transversospinalis group Suboccipital muscles

I. Posterior vertebral muscles

B.1. Spinotransverse groupfrom spinous processes & nuchal lig., insert into upper cervical transverse processes & base of skull a. Divisions. 1) Splenius capitis . C7-T4, nuchal lig to sup nuchal line & mastoid process 2) Splenius cervicis. T3-T6 to transverse process C2-C7 b. Group actions.
Unilaterally rotate head, bilaterally elevate & extend neck

Splenius capitis
The splenius capitis is a broad, straplike muscle in the back of the neck. It pulls on the base of the skull from vertebrae in the neck and upper thorax.

Origin
Insertion Artery Nerve Actions

Ligamentum nuchae, spinous processof C7-T3

Mastoid process of temporal and occipital bone muscular branches of the aorta dorsal rami of C3, C4 Extend, rotate, and laterally flex the head

Splenius cervicis
Origin spinous processes of T3-T4

Insertion
Artery Nerve Actions

transverse processes of C1-C3

transverse cervical artery and occipital artery Posterior rami of the lower Cervical spinal nerves Bilaterally: Extend the head & neck, Unilaterally: Lateral flexion to the same side, Rotation to the same side.

I. Posterior vertebral muscles

B.2.Sacrospinales group (erector spinae)- middle layer;

from sacrum, iliac crest lumbar & lower thoracic spinous processses to ribs & transverse processes a. Divisions
1) Iliocostalis- Lateral segment: lumbar , thoracic, cervical 2) Longissimus- Middle segment: thoracic, cervical, capitis 3) Spinalis segment- Medial segment: poorly developed

b. Group actions- Unilaterally: flex the column on same side; bilaterally extend the vertebral column

Erector spinae
Iliocostalis:
The iliocostalis originates from the sacrum, erector spinae aponeurosis and iliac crest. The iliocostalis has three different insertions according to the parts: iliocostalis lumborum has the lumbar part(where its insertion is in the 12th to 7th ribs) iliocostalis thoracis where its insertion runs from the last 6 ribs to the first 6 ribs.

iliocostalis cervicis which runs from the first 6 ribs to the posterior tubercle of the transverse process of C6-C4

Erector spinae
Longissimus:
The longissimus muscle has three parts with different origin and insertion: longissimus thoracis originates from the sacrum,the spinous process of lumbar vertebrate and transverse process of the last thoracic vertebrate and inserts in the transverse process of the lumbar vertebrate,erector spinae aponeurosis,ribs and coastal process of thoracic vertebrate. longissimus cervicis originates from the transverse proces of T6-T1 and inserts in the transverse process of C7-C2. longissimus capitis originates from the transverse process of T3-T1 runs through C7-C3 and inserts in the mastoid process of temporal bone.

Erector spinae
Spinalis:
The spinalis muscle, as usual, has three parts: spinalis thoracis which originates from the spinous process of L3-T10 and inserts in the spinous process of T8-T2. spinalis cervicis originates from the spinous process of T2-C6 and inserts in the spinous process of C4-C2. spinalis capitis is an inconstant muscles fibres that runs from the cervical and upper thoracic which then inserts in the external occipital protuberance.

Transversopinales group
1. Semispinalis (superficial)
a. Capitis b. Cervicis c. Dorsi

2. Multifidus (middle) 3. Rotatores (deepest)

I. Posterior vertebral muscles

B.3. Transversospinalis groupInnermost; from tranverse processes, inserts into spinous processes a. Divisions
1) Semispinalis- thoracic, cervical capitis portions beneath erector spinae passes over 5 > vertebrae

Semispinalis capitis
Origin Transversal process of lower cervical and higher thoracal columna Area between superior and inferior nuchal line Greater occipital nerve Extend the head

Insertion Artery Nerve Actions

Semispinalis cervicis
Origin transverse processes of the upper five or six thoracic vertebr cervical spinous processes, from the axis to the fifth

Insertion

Artery
Nerve Actions

Semispinalis dorsi
Origin transverse processes of the sixth to the tenth thoracic vertebr spinous processes of the upper four thoracic and lower two cervical vertebrae

Insertion

Artery Nerve Actions

I. Posterior vertebral muscles

B.3. Transversospinalis groupInnermost; from tranverse processes, inserts into spinous processes
2) Multifidus- deep into semispinalis, pass over 3 vertebrae a) Extinguishable from E.S. except short bundles b) Best developed in lumbar & cervical regions

Multifidus
Origin Sacrum, Erector spinae Aponeurosis,PSIS, and Iliac crest spinous process Posterior branches Stabilizes vertebrae in local movements of vertebral column

Insertion Nerve Actions

I. Posterior vertebral muscles

3) Long rotators. From transverse processes to spinous processes above 4) Segmental muscles run between adjacent vertebra
a) Short rotators mm run between transverse & spinous processes of adjacent vertebra b) Interspinales mm run between spinous processes, well developed in lumbar and cervical c) Intertransversarii mm run between transverse processes

 b. Group actions. Unilaterally rotate the neck & trunk to opposite side, bilaterally extend vertebral column

II. Anterior vertebral muscles

A. Overview. Incomplete, primarily flex, rotate, & stabilize vertebral column B. Lateral Group
1. Scalene mm from cervical transvers process to 2nd ribs; elevate 1st & 2nd ribs , lateral flexion of cervical column 2. Levator scapulae mm from C1-C4 transverse processes to scapular notch

II. Anterior vertebral muscles

C. Anterior group
1. Longus colli m. runs from C4-C6 to occiput. Flexes cervical column

2. Lateral rectus capitis m. runs between C1 transverse process to jugular notch of occiput. Flexes and rotate the head

II. Anterior vertebral muscles

3. Anterior rectus capitis m runs between C1 transverse process to basal part of occipital bone. Flexes head at atlantooccipital joint 4. Quadratus lumborum runs from iliac crest to inferior borders of 12th ribs. Stabilize rib cage during ventilation

III. Functional considerations

A. Normal function. Major movements, keep center of gravity over the first sacral vertebra B. Adjustments
1. Standing erect and holding a weight. Weight is distributed evenly over each vertebral disk 2. Lifting a weight 3. Bending forward to lift a weight

Kozanek M., Wang S. et al, Spine 2009, Sept 1: 34 (19)

Range of motion and orientation of the lumbar facet joints in vivo. Flexion/extension of trunk, facet joints rotated along M-L axis (2 to 6 degrees) and translated cephalad/caudad direction (2-4 mm) Lateral and twisting: coupling of rotation and translation (<5 deg. & 3 mm)

Low Back Strain Low Back Pain Syndrome

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