Dr. S. Nishan Silva(MBBS)

At BirthThe spine of a newborn is C-shaped, with one curve

At About Six MonthsAs the infant lifts his or her head during the first few months, the neck (cervical) curve and its muscles develop

At About Nine Months As the infant learns to crawl and stand, the lower back (lumbar) curve and its muscles develop. Strong back muscles help give your child the strength and balance to walk and run.

The spinal column

The spinal column consists of individual bones called vertebrae, the building blocks, which provide support for the spine. These vertebrae are connected in the front of the spine by intervertebral discs.

The spinal column consists of:•seven cervical vertebrae (C1–C7) i.e. neck•twelve thoracic vertebrae (T1–T12) i.e. upper back•five lumbar vertebrae (L1–L5) i.e. lower back•five bones (that are joined, or "fused," together in adults) to form the bony sacrum • three to five bones fused together to form the coccyx or tailbone

The BackPosterior median furrow – vertical groove

along the midlineSpinous processes of vertebraeSpine of the scapula

Medial end is opposite T3

Medial border of the scapula

The BackInferior angle of the scapulaIliac crests

Supracristal line – intersects L4

Sacrum – superior to cleft in the buttocksCoccyx – posterior to the anus

Surface Anatomy of the Back

Figure 11.31a

12-8

Surface Anatomy of the Trunk Scapulae Latissimus dorsi muscle erector spinae muscle infraspinatus muscle trapezius muscle teres major muscle posterior axillary fold triangle of auscutation

Muscles of the BackTrapeziusLatissimus dorsiErector spinae

Surface Anatomy of the Back

Figure 11.31b

AnatomySpinal cord ends below lower border of L1Cauda equina is below L1Mid dorsal spinal cord & neural canal space are of

same diameter hence prone for complete lesion

Mechanical injury - early ischaemia, cord edema - cord necrosis

Neurological recovery unpredictable in cauda equina ie. peripheral nerves

General Anatomy Lecture

Anatomy Five lumbar vertebrae Five pairs (10 total)

facet joints Intricate ligamentous

support Anterior & posterior

longitudinal Interspinous &

supraspinous

Anatomy Intervertebral disks

Annulus fibrosus Outer zone (Sharpey’s fibers) Intermediate zone Inner zone 20 concentric collar like rings

criss-crossed for strength Nucleus pulposus

Fluid gradually changes to fibrocartilage

Spinal CurvesPosterior ViewSagittal View

PrimarySecondary

Bone PalpationPalpate L4/L5 junction (level of iliac crests)Palpate spinous processes superiorly and

inferiorlyS2 spinous process at level of posterior

superior iliac spineAbsence of any sacral and/or lumbar

processes suggests spina bifidaVisible or palpable step-off indicative of

spondylolisthesis

ANTERIOR PALPATION

Soft Tissue Palpation4 clinical zones

Midline rapheParaspinal musclesGluteal musclesSciatic areaAnterior abdominal wall and inguinal area

Vertebral arch7 vertebral processes arise from vertebral

arch3 lever-like processes - provide attachments

sites for ligaments and muscles Spinous process 2 Transverse processes

4 articular processes Arise from junction of pedicle and laminae

Vertebral ArchSpace enclosed by body and vertebral arch

is the vertebral foramenSuccessive vertebral foramen form the

vertebral canal

Facet JointFormed by articulation of inferior and superior

processes of subsequent vertebraeOrientation in lumbar spine is toward sagittal

plane, allowing flexion and extension but limiting rotation of the lumbar vertebrae

Helps to prevent anterior movement of superior vertebra on inferior vertebra

Articular surfaces are made up of noninnervated articular cartilage

Capsule and synovial membrane are innervated with pain receptors

Cervical spine anatomyAnterior column - Anterior longitudinal ligament+

Anterior annular ligament and anterior half of VB.

Middle column – Posterior long. Lig. + Posterior annular ligament +Posterior half of VB.

Posterior Column – Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.

Cervical Alignment

Anterior vertebral body

Posterior vertebral body

Spinolaminal line

Spinous process tips

General Vertebral AnatomyBodyVertebral Arch

Pedicles Laminae

Vertebral ForamenSpinous ProcessFacets

Superior Articulating Surface

Inferior Articulating Surface

Transverse Process Intervertebral Foramen

Distinguishing Features of Cervical Vertebrae

Transverse foramina

C1 transverse process

Spinous ProcessesC6 and C7C3-C6 = bifurcateNone for C1

Articulating Facets

Atlas1st Cervical

VertabraeLack of BodySuperior Articular

FoveaeInferior

Articulating Foveae

Fovea Dentis

AxisC2Dens

Rotation between skull and atlas

C7BodySpinous processTransverse

ForaminaAnterior element

Articulations within cervical regionLateral Atlantoaxial

JointsSuperior facets and

inferior facets of atlasFlat and in transverse

planeRotation

Side toward rotation Side away from rotation

Median Atlantoaxial JointsDens of axis and

anterior arch of atlasTectorial membraneCruciform ligament

Articulation within cervical spineAtlanto-occipital

Occipital condyles of skull and superior articulating surface of atlas

Rotation

Articulations within cervical spineBody-to-body

articulationFibrocartilogenous

Intervertebral Disk Annulos fibrosis Nucleus puplosis

Articulations within cervical spineCervical facet

jointsParallel to frontal

plane45 degrees to

transverse planeRotation

Ligaments within cervical spine

Ligamentum Nuchae

Interspinous Ligament

Ligamentum FlavaPosterior Atlanto-

occipital membraneIntertransverse

Ligament

Curvature of cervical spineLordotic Curve

Cervical spine movement

Flexion/ExtensionAtlanto-occipital

RotationAtlanto-axial joint

Brachial PlexusNerve Roots

C5,6,7,8,T1Trunks

Upper Middle Lower

Divisions Anterior Posterior

Cords Lateral Posterior Medial

Throat Anatomy1. Thyroid gland 2. Trachea 3. Brachiocephalic

artery 4. Common carotid

artery 5. Internal jugular

vein 6. Superior vena

cava

Thoracic VertebraeBodiesPediclesLaminaeSpinous ProcessesTransverse ProcessesInferior & Superior

FacetsDistinguishing Feature

Costal Fovea T1 T2-T8 T9-12

Thoracic Vertebrae and Rib JunctionFunctions of

Thoracic SpineCostovertebral JointCostotransverse

JointMotions

All availableFlexion and

extension limitedT7-T12

Lumbar Spine BodiesPediclesLaminaeTransverse

ProcessSpinous ProcessArticular Facets

Lumbar Spine Thoracolumbar

Fascia

Lumbar SpineIliolumbar

LigamentsFunctions of

Lumbar SpineResistance of

anterior translationResisting RotationWeight SupportMotion

Spinal LigamentsAnterior

LongitudinalPosterior

LongitudinalLigamentum FlavumInterspinous

LigamentsSupraspinous

LigamentsIntertransverse

Ligaments

Intervertebral DisksRatio between

disk thickness and vertebral body height

Disk CompositionNucleus pulposisAnnulus Fibrosis

Vertebral venous plexus

Deep Muscles of the Back (Erector

Spinae)

Iliocostalis

Iliocostalis lumborumIliocostalis ThoracisIliocostalisCervicis

Iliocostalis LumborumO

Common tendon origin in sacrum, iliac crest, lumber vertebrae

I Lower borders ribs 6-12

N Dorsal rami of spinal nerves

F Bilateral

Spinal extension Maintenance of erect

posture Stabilization of spine during

flexion Unilateral

Lateral flexion Ipsilateral rotation

Iliocostalis Thoracis

OUpper borders rib 6-12

ILower borders ribs 1-6

NDorsal rami of spinal

nervesF

Bilateral Same as above

Unilateral Same as above

Iliocostalis CervicisO

Angles ribs 1-6I

C4-6 transverse processes

NDorsal rami of spinal

nervesF

Same as above

Longissimus

Longissimus ThoracisLongissimus CervicisLongissimus Capitus

Longissimus ThoracisO

Common tendon origin in sacrum, iliac crest, lumber vertebrae

IT1-12 transverse

processesN

Dorsal rami of spinal nerves

FSame as above

Longissimus CervicisO

T1-5 transverse processes

IC2-6 transverse

processesN

Dorsal rami of spinal nerves

FSame as above

Longissimus CapitusOT1-5 transverse

processesC5-7 articular processes

IPosterior mastoid process

NDorsal rami of spinal

nervesF

Extends and rotates head

Spinalis Spinalis ThoracisSpinalis Cervicis Spinalis Capitus

Spinalis ThoracisO

Common tendon origin in sacrum, iliac crest, lumber vertebrae

IT3-8 spinous

processesN

Dorsal rami pf spinal nerves

FSame as above

Spinalis CervicisO

C6-T12 spinous processes

IC2 spinous process

NDorsal rami of

spinal nervesF

Same as above

Spinalis CapitisO

Spinous processes of lower cervical and upper thoracic

I Between superiior and

inferior nuchal line on occiput

N Dorsal rami of spinal

nervesF

Same as above

Transversospinal MusclesSemispinalis thoracisSemispinalis CervicisSemispinalis Capitus

Semispinalis ThoracisO

T6-10 transverse processes

IC6 – T4 spinous

processesN

Sorsal rami of spinal nerves

FSame as above

Semispinalis CervicisO

T1-T6 spinous processes

IC2-5 spinous

processesN

Dorsal rami of spinal nerves

FSame as above

Semispinalis CapitisO

C4-7 transverse processes

T1-7 vertebraeI

Between superior and inferior nuchal lines of occiput

NDorsal rami of spinal

nervesF

Same as above

MultifidusO

Transverse processes C4-L5

SacrumPSIS

ISpinous process of vert

above originN

Spinal nerve rootsF

Extend and lateral flexion of vertebral column

Quadratus LumborumO

Iliolumbar Ligament Iliac crest

I Lower border 12th rib L1-L4 transverse

processesN

ventral branches of T12 and L1 to L4.

F Pelvis elevation Trunk extension Trunk lateral flexion Pulls down rib 12 to fix

origin of diaphragm

RotatoresO

Transverse processes from axis to sacrum

ILaminae of vert above

NDirect branches over

spinal nerve rootsF

Spine extensionRotation to opposite

side

Range of Motion

FlexionExtension

Lateral BendingRotation

Flexion - 80º

Extension - 35º

Side bending - 40º each side

Twisting - 3-18º

Neurologic Exam: Sensory Sensory dermatomes C2-C3: Occipital area and angle of

jaw C4: Supraclavicular area Axillary Nerve Patch: Lateral aspect

of shoulder C5: Lateral upper arm C6: Lateral forearm, thumb, and

index finger C7: Middle finger and palmar aspect

of hand C8: Small finger, ring finger, and

medial portion of palmar surface

Neurologic Exam: Sensory Sensory dermatomes T1: Medial side of forearm and elbow T2: Medial aspect of upper arm T3: Medial aspect of upper arm T10: Umbilicus L2: Medial mid-thigh L3: Superior aspect of medial knee

(vastus medialis) L4: Knee and medial arch L5: Dorsum of the foot S1: Lateral border and lateral aspect

of foot S2: Popliteal fossa

Neurologic Exam: Motor C1-C2: Neck flexion C1-C2: Neck extension C3: Neck lateral flexion C4: Shoulder elevation C5: Shoulder abduction and external rotation C6: Elbow flexion and wrist extension C7: Elbow extension and wrist flexion C8: Thumb abduction and ulnar deviation

Neurologic Exam: Motor T1: Finger approximation L2: Hip flexion L3: Knee extension L4: Dorsiflexion L5: Great toe extension, ankle dorsiflexion,

ankle eversion S1: Plantarflexion S2: Knee flexion

Neurologic Exam: Reflexes Biceps (C5-C6) Supinator (C5-C6) Triceps (C7-C8) Upper abdominal (T8-T10) Lower abdominal (T11-T12) Patella (L3-L4) Achilles tendon (S1-S2) Babinski

Myotomes

Map of Dermatomes – Anterior View

Figure 14.17a

Map of Dermatomes – Posterior View

Figure 14.17b

Cervical

Read

Back Pain

Common Sources of LBP

Somatic dysfunction

Muscle in “spasm”

Nerve root

In somatic dysfunction, some muscles become overactive (“spasm”)and other muscles become inactive.

Joint receptors

vasculature

viscera

Connectivetissues

Muscles

Internal organs

Blood vessels

Bones and ligaments

Joint Receptors

Muscle Spindles

NocioceptorsPressure, temperaturechemical

Humoral Factors circulating hormones (gender-specific response)

immune proteins cortisol

Disc Diseases

Radicular SignsPain radiation to

buttocks – SciaticaPosterior thigh painParasthesia – nerve

root impringement

Lower Spinal conditions

Spondylolysthesis

Spondylolysthesis

Spondylolysis

Spinal injuriesWatch video

Atlas Fractures

Type Odontoid Treated with external orthrosis

Spinal Column InjurySubaxial (C3-C7) #

Whiplash injury:Traumatic injury to

the soft tissue in the cervical region

Hyperflexion, hyperextention

No fractures or dislocations

Most common automobile injury

Recover 3-6 months

Hangman’s Fracture