THE BACK

CORTEZ GARCIA GOMEZ HUEVOS LUCAS PACASUM VILLAFUERTE

The Vertebral Column

It supports the skull, pectoral girdle, upper limbs, and thoracic cage and, by way of the pelvic girdle, transmits body weight to the lower limbs.

Within its cavity lie the spinal cord, the roots of the spinal nerves, and the covering meninges, to which the vertebral column gives great protection.

COMPOSITION
Composed of 33 vertebrae, 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused to form the sacrum), and 4 coccygeal (the lower 3 are commonly fused). Because it is segmented and made up of vertebrae, joints, and pads of fibrocartilage called intervertebral discs, it is a flexible structure.

GENERAL CHARACTERISTICS
A typical vertebra consists of a rounded body anteriorly and a vertebral arch posteriorly. These enclose a space called the vertebral foramen, through which run the spinal cord and its coverings. The vertebral arch consists of a pair of cylindrical pedicles, which form the sides of the arch, and a pair of flattened laminae, which complete the arch posteriorly.

GENERAL CHARACTERISTICS
The vertebral arch gives rise to seven processes: one spinous, two transverse, and four articular The spinous process, or spine, is directed posteriorly from the junction of the two laminae.

The transverse processes are directed laterally from the junction of the laminae and the pedicles.
Both the spinous and transverse processes serve as levers and receive attachments of muscles and ligaments. The articular processes are vertically arranged and consist of two superior and two inferior processes. They arise from the junction of the laminae and the pedicles, and their articular surfaces are covered with hyaline cartilage..

GENERAL CHARACTERISTICS
The two superior articular processes of one vertebral arch articulate with the two inferior articular processes of the arch above, forming two synovial joints. The pedicles are notched on their upper and lower borders, forming the superior and inferior vertebral notches On each side, the superior notch of one vertebra and the inferior notch of an adjacent vertebra together form an intervertebral foramen. The anterior and posterior nerve roots of a spinal nerve unite within these foramina with their coverings of dura to form the segmental spinal nerves.

TYPICAL CERVICAL VERTEBRA

A typical cervical vertebra has the following characteristics The transverse processes possess a foramen transversarium for the passage of the vertebral artery and veins

The spines are small and bifid.

The body is small and broad from side to side. The vertebral foramen is large and triangular.

The superior articular processes have facets that face backward and upward; the inferior processes have facets that face downward and forward.

ATYPICAL CERVICAL VERTEBRA

The first, second, and seventh cervical vertebrae are atypical. The first cervical vertebra, or atlas, does not possess a body or a spinous process. It has an anterior and posterior arch. The second cervical vertebra, or axis, has a peglike odontoid process that projects from the superior surface of the body The seventh cervical vertebra, or vertebra prominens, is so named because it has the longest spinous process, and the process is not bifid.

TYPICAL THORACIC VERTEBRA

The body is medium size and heart shaped. The vertebral foramen is small and circular. The spines are long and inclined downward. Costal facets are present on the sides of the bodies for articulation with the heads of the ribs. Costal facets are present on the transverse processes for articulation with the tubercles of the ribs The superior articular processes bear facets that face backward and laterally, whereas the facets on the inferior articular processes face forward and medially. The inferior articular processes of the 12th vertebra face laterally, as do those of the lumbar vertebrae.

TYPICAL LUMBAR VERTEBRA

The body is large and kidney shaped. The pedicles are strong and directed backward. The laminae are thick.

The vertebral foramina are triangular.

The transverse processes are long and slender. The spinous processes are short, flat, and quadrangular and project backward.

The articular surfaces of the superior articular processes face medially, and those of the inferior articular processes face laterally.

SACRUM
consists of five rudimentary vertebrae fused together to form a wedgeshaped bone, which is concave anteriorly. The upper border, or base, of the bone articulates with the fifth lumbar vertebra. The narrow inferior border articulates with the coccyx. Laterally, the sacrum articulates with the two iliac bones to form the sacroiliac joints

The anterior and upper margin of the first sacral vertebra bulges forward as the posterior margin of the pelvic inlet and is known as the sacral promontory The vertebral foramina are present and form the sacral canal. The laminae of the fifth sacral vertebra, and sometimes those of the fourth also, fail to meet in the midline, forming the sacral hiatus. The anterior and posterior surfaces of the sacrum each have four foramina on each side for the passage of the anterior and posterior rami of the upper four sacral nerves.

COCCYX
consists of four vertebrae fused together to form a single, small triangular bone that articulates at its base with the lower end of the sacrum The first coccygeal vertebra is usually not fused or is incompletely fused with the second vertebra.

JOINTS OF THE VERTEBRAL COLUMN

Atlanto-occipital joints are synovial joints that are formed between the occipital condyles, which are found on either side of the foramen magnum above and the facets on the superior surfaces of the lateral masses of the atlas below

Atlanto-occipital joints

Atlanto-occipital joints
LIGAMENTS Anterior atlanto-occipital membrane: This is a continuation of the anterior longitudinal ligament, which runs as a band down the anterior surface of the vertebral column. The membrane connects the anterior arch of the atlas to the anterior margin of the foramen magnum. Posterior atlanto-occipital membrane: This membrane is similar to the ligamentum flavum and connects the posterior arch of the atlas to the posterior margin of the foramen magnum.

Atlanto-occipital joints
MOVEMENTS Flexion Extension Lateral flexion No rotation is possible.

JOINTS OF THE VERTEBRAL COLUMN

Atlantoaxial Joints three synovial joints: one is between the odontoid process and the anterior arch of the atlas, and the other two are between the lateral masses of the bones

Atlantoaxial Joints
Ligaments
Apical ligament: This median-placed structure connects the apex of the odontoid process to the anterior margin of the foramen magnum. Alar ligaments: These lie one on each side of the apical ligament and connect the odontoid process to the medial sides of the occipital condyles. Cruciate ligament: This ligament consists of a transverse part and a vertical part. The transverse part is attached on each side to the inner aspect of the lateral mass of the atlas and binds the odontoid process to the anterior arch of the atlas. The vertical part runs from the posterior surface of the body of the axis to the anterior margin of the foramen magnum. Membrana tectoria: This is an upward continuation of the posterior longitudinal ligament. It is attached above to the occipital bone just within the foramen magnum. It covers the posterior surface of the odontoid process and the apical, alar, and cruciate ligaments. Movements There can be extensive rotation of the atlas and thus of the head on the axis

Atlantoaxial Joints

JOINTS OF THE VERTEBRAL COLUMN

Joints of the Vertebral Column Below the Axis With the exception of the first two cervical vertebrae, the remainder of the mobile vertebrae articulate with each other by means of cartilaginous joints between their bodies and by synovial joints between their articular processes Joints Between Two Vertebral Bodies The upper and lower surfaces of the bodies of adjacent vertebrae are covered by thin plates of hyaline cartilage.

In the lower cervical region, small synovial joints are present at the sides of the intervertebral disc between the upper and lower surfaces of the bodies of the vertebrae.

JOINTS OF THE VERTEBRAL COLUMN

INTERVERTEBRAL DISCS
are responsible for one fourth of the length of the vertebral column. They are thickest in the cervical and lumbar regions, where the movements of the vertebral column are greatest. Each disc consists of a peripheral part, the anulus fibrosus, and a central part, the nucleus pulposus

INTERVERTEBRAL DISCS
Functions The semifluid nature of the nucleus pulposus allows it to change shape and permits one vertebra to rock forward or backward on another, as in flexion and extension of the vertebral column.

A sudden increase in the compression load on the vertebral column causes the semifluid nucleus pulposus to become flattened.
With advancing age, the water content of the nucleus pulposus diminishes and is replaced by fibrocartilage. The collagen fibers of the anulus degenerate and, as a result, the anulus cannot always contain the nucleus pulposus under stress. In old age the discs are thin and less elastic, and it is no longer possible to distinguish the nucleus from the anulus.

INTERVERTEBRAL DISCS
Ligaments The anterior and posterior longitudinal ligaments run as continuous bands down the anterior and posterior surfaces of the vertebral column from the skull to the sacrum.

Nerve Supply of Vertebral Joints

The joints between the vertebral bodies are innervated by the small meningeal branches of each spinal nerve. The joints between the articular processes are innervated by branches from the posterior rami of the spinal nerves

Nerve Supply of Vertebral Joints

Curves of the Vertebral Column

Curves in the Sagittal Plane In the adult in the standing position, the vertebral column therefore exhibits in the sagittal plane the following regional curves:
cervical, posterior concavity; thoracic, posterior convexity; lumbar, posterior concavity; and sacral, posterior convexity.

Curves in the Coronal Plane In late childhood, it is common to find the development of minor lateral curves in the thoracic region of the vertebral column. This is normal and is usually caused by the predominant use of one of the upper limbs

Movements of the Vertebral Column

Flexion is a forward movement, and extension is a backward movement. Both are extensive in the cervical and lumbar regions but restricted in the thoracic region. Lateral flexion is the bending of the body to one or the other side. It is extensive in the cervical and lumbar regions but restricted in the thoracic region. Rotation is a twisting of the vertebral column. This is least extensive in the lumbar region. Circumduction is a combination of all these movements.

Movements of the Vertebral Column

The atlanto-occipital joints permit extensive flexion and extension of the head. The atlantoaxial joints allow a wide range of rotation of the atlas and thus of the head on the axis. In the cervical region:
flexion is produced by the longus cervicis, scalenus anterior, and sternocleidomastoid muscles. Extension is produced by the postvertebral muscles. Lateral flexion is produced by the scalenus anterior and medius and the trapezius and sternocleidomastoid muscles. Rotation is produced by the sternocleidomastoid on one side and the splenius on the other side.

Movements of the Vertebral Column

In the thoracic region, rotation is produced by the semispinalis and rotatores muscles, assisted by the oblique muscles of the anterolateral abdominal wall. In the lumbar region,
flexion is produced by the rectus abdominis and the psoas muscles. Extension is produced by the postvertebral muscles. Lateral flexion is produced by the postvertebral muscles, the quadratus lumborum, and the oblique muscles of the anterolateral abdominal wall. The psoas may also play a part in this movement. Rotation is produced by the rotatores muscles and the oblique muscles of the anterolateral abdominal wall.

MUSCLES OF THE BACK

The superficial muscles connected with the shoulder girdle. The intermediate muscles involved with movements of the thoracic cage The deep muscles or postvertebral muscles belonging to the vertebral column

Deep Muscles

Deep Muscles
Superficial Vertically Running Muscles

Intermediate Oblique Running Muscles

Deepest Muscles
Interspinales Intertransversarii

Movements of the Vertebral Column

Splenius It consists of two parts:
The splenius capitis arises from the lower part of the ligamentum nuchae and the upper four thoracic spines and is inserted into the superior nuchal line of the occipital bone and the mastoid process of the temporal bone. The splenius cervicis has a similar origin but is inserted into the transverse processes of the upper cervical vertebrae.

Nerve Supply All the deep muscles of the back are innervated by the posterior rami of the spinal nerves.

Muscular Triangle of the Back

Auscultatory Triangle the site on the back where breath sounds may be most easily heard with a stethoscope. The boundaries are the:
latissimus dorsi the trapezius medial border of the scapula.

Lumbar Triangle the site where pus may emerge from the abdominal wall. The boundaries are the:
Latissimus dorsi the posterior border of the external oblique muscle of the abdomen iliac crest.

Muscular Triangle of the Back

Deep Fascia of the Back (Thoracolumbar Fascia) The lumbar part of the deep fascia is situated in the interval between the iliac crest and the 12th rib. Medially, the lumbar part of the deep fascia splits into three lamellae.
The posterior lamella covers the deep muscles of the back and is attached to the lumbar spines. The middle lamella passes medially, to be attached to the tips of the transverse processes of the lumbar vertebrae; it lies in front of the deep muscles of the back and behind the quadratus lumborum. The anterior lamella passes medially and is attached to the anterior surface of the transverse processes of the lumbar vertebrae; it lies in front of the quadratus lumborum muscle.

Blood Supply of the Back

Arteries In the cervical region, branches arise from the occipital artery, a branch of the external carotid; from the vertebral artery, a branch of the subclavian; and from the deep cervical artery, a branch of the costocervical trunk. In the thoracic region branches arise from the posterior intercostal arteries. In the lumbar region branches arise from the subcostal and lumbar arteries. In the sacral region branches arise from the iliolumbar and lateral sacral arteries, branches of the internal iliac artery.

Veins The veins draining the structures of the back form plexuses extending along the vertebral column from the skull to the coccyx. The external vertebral venous plexus lies external and surrounds the vertebral column. The internal vertebral venous plexus lies within the vertebral canal but outside the dura mater of the spinal cord

Lymph Drainage of the Back

The deep lymph vessels follow the veins and drain into the deep cervical, posterior mediastinal, lateral aortic, and sacral nodes. The lymph vessels from the skin of the neck drain into the cervical nodes, those from the trunk above the iliac crests drain into the axillary nodes, and those from below the level of the iliac crests drain into the superficial inguinal nodes.

Nerve Supply of the Back

The skin and muscles of the back are supplied in a segmental manner by the posterior rami of the 31 pairs of spinal nerves. The posterior rami run downward and laterally and supply a band of skin at a lower level than the intervertebral foramen from which they emerge.

Spinal Cord
The spinal cord is a cylindrical, grayish white structure that begins above at the foramen magnum, where it is continuous with the medulla oblongata of the brain. It terminates below in the adult at the level of the lower border of the first lumbar vertebra. In the young child,. Inferiorly, the spinal cord tapers off into the conus medullaris, from the apex of which a prolongation of the pia mater, the filum terminale, descends to be attached to the back of the coccyx. The cord possesses in the midline anteriorly a deep longitudinal fissure, the anterior median fissure, and on the posterior surface a shallow furrow, the posterior median sulcus.

Roots of Spinal Cord

Along the whole length of the spinal cord are attached 31 pairs of spinal nerves by the anterior, or motor, roots and the posterior, or sensory, roots. Each root is attached to the cord by a series of rootlets, which extend the whole length of the corresponding segment of the cord. Each posterior nerve root possesses a posterior root ganglion, the cells of which give rise to peripheral and central nerve fibers.

Roots of Spinal Cord

The spinal nerve roots pass laterally from each spinal cord segment to the level of their respective intervertebral foramina, where they unite to form a spinal nerve.

In the upper cervical region the spinal nerve roots are short and run almost horizontally, but the roots of the lumbar and sacral nerves below the level of the termination of the cord (lower border of the first lumbar vertebra in the adult) form a vertical leash of nerves around the filum terminale. The lower nerve roots together are called the cauda equina

Blood Supply of the Spinal Cord

The spinal cord receives its arterial supply from three small, longitudinally running arteries:
the two posterior spinal arteries one anterior spinal artery.

Composition of Spinal Cord

Dura Mater The dura mater is the most external membrane and is a dense, strong, fibrous sheet that encloses the spinal cord and cauda equina.I The dural sheath lies loosely in the vertebral canal and is separated from the walls of the canal by the extradural space (epidural space). The dura mater extends along each nerve root and becomes continuous with connective tissue surrounding each spinal nerve (epineurium) at the intervertebral foramen. The inner surface of the dura mater is separated from the arachnoid mater by the potential subdural space.

Composition of Spinal Cord

Arachnoid Mater The arachnoid mater is a delicate impermeable membrane covering the spinal cord and lying between the pia mater internally and the dura mater externally It is separated from the dura by the subdural space that contains a thin film of tissue fluid. The arachnoid is separated from the pia mater by a wide space, the subarachnoid space, which is filled with cerebrospinal fluid.

Composition of Spinal Cord

Pia Mater The pia mater is a vascular membrane that closely covers the spinal cord. The pia mater is thickened on either side between the nerve roots to form the ligamentum denticulatum, which passes laterally to be attached to the dura. It extends along each nerve root and becomes continuous with the connective tissue surrounding each spinal nerve

Cerebrospinal Fluid
The cerebrospinal fluid is a clear, colorless fluid formed mainly by the choroid plexuses, within the lateral, third, and fourth ventricles of the brain. The fluid circulates through the ventricular system and enters the subarachnoid space through the three foramina in the roof of the fourth ventricle. It circulates both upward over the surface of the cerebral hemispheres and downward around the spinal cord. Eventually, the fluid enters the bloodstream by passing through the arachnoid villi into the dural venous sinuses, in particular the superior sagittal venous sinus.