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Back Vertebral Column: Overview The vertebral column (spine) is divided into four regions: the cervical, thoracic, lumbar, and sacral spines. Both the cervical and lumbar spines demonstrate lordosis (inward curvature); the thoracic and sacral spines demonstrate kyphosis (outward curvature). Fig. 1.1 Vertebral column Left lateral view. O>KFL@BOSF@>IGRK@QFLK BOSF@>IPMFKB ¨ SBOQB?O>B BOSF@LQELO>@F@GRK@QFLK MFKLRP MOL@BPP ELO>@F@PMFKB ELO>@LIRJ?>OGRK@QFLK RJ?>OPMFKB RJ?LP>@O>IGRK@QFLK ¨ SBOQB?O>B LPQ>I C>@BQP OQF@RI>O MOL@BPPBP >@ORJªP>@O>IPMFKB« A Regions of the spine. KQBOSBOQB¦ ?O>ICLO>JFK> Clinical Spinal development The characteristic curvatures of the adult spine appear over the course of postnatal development, being only partially present in a newborn. The newborn has a “kyphotic” spinal curvature (A); lumbar lordosis develops later and becomes stable at puberty (C). ¨ SBOQB?O>B KQBOSBOQB¦ ?O>IAFPH ARIQPMFK>I @LIRJK >@O>I MOLJLKQLOV O>KPFQFLK>I ME>PB BOSF@>I ILOALPFP VMELQF@ PMFKB LCQEB KBT?LOK >@ORJ ª¨ SBOQB?O>B« ELO>@F@ HVMELPFP L@@VU RJ?>O ILOALPFP >@O>I HVMELPFP A 2 B C B Bony vertebral column. Left lateral view. BKPLC>UFPª« UQBOK>I >RAFQLOV@>K>I BKPLC>UFPª« LKDRB >OVKU FKBLCDO>SFQV KCIB@QFLKMLFKQP O>@EB> 1 Bones, Ligaments & Joints Fig. 1.2 Normal anatomical position of the spine MFKLRPMOL@BPPLC SBOQB?O>MOLJFKBKPª « MFK>I@LOA P@BKAFKD >LOQ> BOQB?O>I@>K>I B>OQ PLME>DRP F>MEO>DJ KQBOSBOQB?O>IAFPH MFKLRPMOL@BPP ELIB¦?LAV @BKQBOLCDO>SFQV FSBO QLJ>@E ?ALJFK>I >LOQ> A Line of gravity. The line of gravity passes through certain anatomical landmarks, including the inflection points at the cervicothoracic and thoracolumbar junctions. It continues through the center of gravity (anterior to the sacral promontory) before passing through the hip joint, knee, and ankle. LAVLC LKRPJBARII>OFP >RA>BNRFK> >@O>IMOLJLKQLOV I>AABO L@@VU B@QRJ B Midsagittal section through an adult male. 3 Back Vertebral Column: Elements Fig. 1.3 Bones of the vertebral column QI>Pª« UFPª« QI>Pª« BKPLC>UFPª« © SBOQB?O>B Fig. 1.4 Palpable spinous processes as landmarks Posterior view. The easily palpated spinous processes provide important landmarks during physical examination. BOQB?O> MOLJFKBKP ª « O>KPSBOPB MOL@BPP MFKLRP MOL@BPPBP BOSF@LQELO>@F@ GRK@QFLKª « © SBOQB?O>B O>KPSBOPB MOL@BPPBP BOQB?O>I ?LAV @>MRI>OPMFKBª« KCBOFLOP@>MRI>O >KDIBª « QEOF?ª« KSBOQB?O>I AFPH IF>@@OBPQª« © SBOQB?O>B >@ORJ ªCRPBA © SBOQB?O>B« L@@VU A Anterior view. 4 >@ORJ KQBOFLO P>@O>I CLO>JFK> L@@VU B Posterior view. LPQBOFLO P>@O>I CLO>JFK> Fig. 1.5 Structural elements of a vertebra Fig. 1.6 Typical vertebrae Left posterosuperior view. With the exception of the atlas (C1) and axis (C2), all vertebrae consist of the same structural elements. Superior view. BOQB?O>I ?LAV BOQB¦ ?O>I >O@E BOQB?O>I CLO>JBK MFKLRPMOL@BPP BOQB?O>I>O@E >JFK> RMBOFLO>OQF@RI>OC>@BQ O>KPSBOPB MOL@BPP BAF@IB >JFK> BAF@IB LPQBOFLOQR?BO@IB O>KPSBOPBMOL@BPPTFQE PRI@RPCLOPMFK>IK MFKLRP MOL@BPP O>KPSBOPBCLO>JBK LAV KCBOFLO >OQF@RI>OMOL@BPP KQBOFLO QR?BO@IB A Cervical vertebra (C4). 1 Bones, Ligaments & Joints RMBOFLO >OQF@RI>O MOL@BPP MFKLRPMOL@BPP LPQ>IC>@BQ >JFK> O>KPSBOPBMOL@BPP BAF@IB RMBOFLO>OQF@RI>OC>@BQ KCBOFLO@LPQ>IC>@BQ RMBOFLO@LPQ>IC>@BQ LAV B Thoracic vertebra (T6). BAF>K P>@O>I@OBPQ RMBOFLO>OQF@RI>OMOL@BPP RMBOFLO >OQF@RI>O C>@BQ MFKLRPMOL@BPP @@BPPLOVMOL@BPP >@O>I@>K>I O>KPSBOPBMOL@BPP BOQB?O>I>O@E >QBO>IM>OQ LCP>@ORJ RMBOFLO>OQF@RI>OMOL@BPP BOQB?O>ICLO>JBK RMBOFLOSBOQB?O>I KLQ@E LAV >PBLC OLJLKQLOV P>@ORJ C Lumbar vertebra (L4). Table 1.1 FKDLC P>@ORJ D Sacrum. Structural elements of vertebrae Vertebrae Body Vertebral foramen Transverse processes Articular processes Spinous process Cervical vertebrae C3*–C7 Small (kidney-shaped) Large (triangular) Small (may be absent in C7); anterior and posterior tubercles enclose transverse foramen Superoposteriorly and inferoanteriorly; oblique facets: most nearly horizontal Short (C3–C5); bifid (C3–C6); long (C7) Thoracic vertebrae T1–T12 Medium (heartshaped); includes costal facets Small (circular) Large and strong; length decreases T1–T12; costal facets (T1–T10) Posteriorly (slightly laterally) and anteriorly (slightly medially); facets in coronal plane Long, sloping posteroinferiorly; tip extends to level of vertebral body below Short and broad Median sacral crest Lumbar vertebrae L1–L5 Large (kidney-shaped) Medium (triangular) Long and slender; accessory process on posterior surface Posteromedially (or medially) and anterolaterally (or laterally); facets nearly in sagittal plane; mammillary process on posterior surface of each superior articular process Sacral vertebrae (sacrum) S1–S5 (fused) Decreases from base to apex Sacral canal Fused to rudimentary rib (ribs, see pp. 44–47) Superoposteriorly (SI) superior surface of lateral sacrumauricular surface *C1 (atlas) and C2 (axis) are considered atypical (see pp. 6–7). 5 Back Cervical Vertebrae The seven vertebrae of the cervical spine differ most conspicuously from the common vertebral morphology. They are specialized to bear the weight of the head and allow the neck to move in all directions. C1 and C2 are known as the atlas and axis, respectively. C7 is called the vertebra prominens for its long, palpable spinous process. Fig. 1.7 Cervical spine Left lateral view. LPQBOFLO >O@ELC>QI>P KQBOFLO QR?BO@IB LPQBOFLO QR?BO@IB ª>QI>P« Fig. 1.8 Atlas (C1) RMBOFLO >OQF@RI>OC>@BQ ª>UFP« MFKLRP MOL@BPP RI@RPCLO PMFK>IK BOQB?O>I ?LAV VD>ML¦ MEVPB>IGLFKQ KQBOFLO QR?BO@IB RMBOFLO>OQF@RI>O MOL@BPP RI@RPCLO PMFK>IK LPQBOFLO QR?BO@IB KQBOFLO QR?BO@IB O>KPSBOPB CLO>JBK KCBOFLO>OQF@RI>O MOL@BPP LPQBOFLO QR?BO@IB OLLSBCLO SBOQB?O>I> KCBOFLO >OQF@RI>OC>@BQ O>KPSBOPB MOL@BPP LPQBOFLO >O@ELC>QI>P A Left lateral view. Fig. 1.9 Axis (C2) MFKLRP MOL@BPP K@FK>QBMOL@BPP ªSBOQB?O> MOLJFKBKP« KQBOFLO >OQF@RI>OC>@BQ RMBOFLO >OQF@RI>OC>@BQ O>KPSBOPB MOL@BPP O>KPSBOPBCLO>JBK BKP LPQBOFLO >OQF@RI>OC>@BQ MFKLRP MOL@BPP O>KPSBOPB CLO>JBK LAV A Bones of the cervical spine, left lateral view. O>KPSBOPB MOL@BPP KCBOFLO >OQF@RI>OC>@BQ BOQB?O>I >O@E A Left lateral view. Fig. 1.10 Typical cervical vertebra (C4) O>KPSBOPB CLO>JBK RMBOFLO >OQF@RI>OMOL@BPP O>KPSBOPBMOL@BPP RMBOFLO>OQF@RI>OC>@BQ LAV RI@RPCLO PMFK>IK B Radiograph of the cervical spine, left lateral view. 6 A Left lateral view. KCBOFLO>OQF@RI>O MOL@BPP KCBOFLO >OQF@RI>OC>@BQ MFKLRP MOL@BPP Clinical The cervical spine is prone to hyperextension injuries, such as “whiplash,” which can occur when the head extends back much farther than it normally would. The most common injuries of the cervical spine are fractures of the dens of the axis, traumatic spondylolisthesis (ventral slippage of a vertebral body), and atlas fractures. Patient prognosis is largely dependent on the spinal level of the injuries (see p. 600). RMBOFLO >OQF@RI>OC>@BQ KQBOFLO >O@E This patient hit the dashboard of his car while not wearing a seat belt. The resulting hyperextension caused the traumatic spondylolisthesis of C2 (axis) with fracture of the vertebral arch of C2, as well as tearing of the ligaments between C2 and C3. This injury is often referred to as “hangman’s fracture.” LPQBOFLO>O@E RMBOFLO >OQF@RI>O C>@BQ 1 Bones, Ligaments & Joints Injuries in the cervical spine LPQBOFLOQR?BO@IB OLLSBCLO SBOQB?O>I> >QBO>I J>PPBP O>KPSBOPBMOL@BPP O>KPSBOPBCLO>JBK O>KPSBOPB CLO>JBK KCBOFLO >OQF@RI>O C>@BQ KQBOFLO QR?BO@IB >@BQCLOABKP O>KPSBOPB MOL@BPP B Anterior view. C Superior view. KQBOFLO >OQF@RI>OC>@BQ MFKLRPMOL@BPP BKP BOQB?O>I CLO>JBK RMBOFLO >OQF@RI>OC>@BQ BOQB?O>I>O@E KCBOFLO >OQF@RI>O MOL@BPP BKP O>KPSBOPB MOL@BPP LAV O>KPSBOPB MOL@BPP RMBOFLO >OQF@RI>O C>@BQ KCBOFLO >OQF@RI>OC>@BQ B Anterior view. O>KPSBOPB CLO>JBK KQBOFLO>OQF@RI>OC>@BQ C Superior view. K@FK>QB MOL@BPP RMBOFLO >OQF@RI>O MOL@BPP LPQBOFLO QR?BO@IB RI@RPCLO PMFK>IK KQBOFLO QR?BO@IB LAV MFKLRP MOL@BPP B Anterior view. KQBOFLO>O@E KQBOFLO QR?BO@IB KCBOFLO >OQF@RI>O C>@BQ MFKLRPMOL@BPP BOQB?O>ICLO>JBK BOQB?O>I>O@E >JFK> O>KP¦ SBOPB MOL@BPP RMBOFLO >OQF@RI>OC>@BQ BAF@IB O>KPSBOPB MOL@BPPTFQE PRI@RPCLO PMFK>IK LPQBOFLOQR?BO@IB O>KPSBOPB CLO>JBK LAV KQBOFLO QR?BO@IB C Superior view. 7 Back Thoracic & Lumbar Vertebrae Fig. 1.11 Thoracic spine Fig. 1.12 Typical thoracic vertebra (T6) Left lateral view. RMBOFLO SBOQB?O>IKLQ@E RMBOFLO >OQF@RI>OC>@BQ RMBOFLO @LPQ>IC>@BQ O>KPSBOPB MOL@BPP MFKLRPMOL@BPP LPQ>IC>@BQLK QO>KPSBOPB MOL@BPP PQQELO>@F@ SBOQB?O>ª« KCBOFLO>OQF@RI>O MOL@BPP LAV KCBOFLO SBOQB?O>IKLQ@E KCBOFLO @LPQ>IC>@BQ RMBOFLO>OQF@RI>O MOL@BPP O>KPSBOPB MOL@BPP KCBOFLO @LPQ>IC>@BQ RMBOFLO @LPQ>IC>@BQ KCBOFLO >OQF@RI>OC>@BQ MFKLRP MOL@BPP A Left lateral view. LPQ>IC>@BQ LKQO>KPSBOPB MOL@BPP RMBOFLO >OQF@RI>OMOL@BPP VD>ML¦ MEVPB>IGLFKQ LAV O>KPSBOPB MOL@BPP RMBOFLO @LPQ>IC>@BQ BOQB?O>I ?LAV KCBOFLO @LPQ>IC>@BQ LPQ>IC>@BQ LKQO>KPSBOPB MOL@BPP MFKLRPMOL@BPP KQBO¦ SBOQB?O>I CLO>JBK KCBOFLO SBOQB?O>I KLQ@E B Anterior view. RMBOFLO SBOQB?O>I KLQ@E LPQ>IC>@BQLK QO>KPSBOPBMOL@BPP KCBOFLO >OQF@RI>OC>@BQ MFKLRPMOL@BPP >JFK> O>KPSBOPB MOL@BPP QEQELO>@F@ SBOQB?O>ª« BAF@IB KCBOFLO >OQF@RI>OC>@BQ KCBOFLO @LPQ>IC>@BQ RMBOFLO SBOQB?O>IKLQ@E RMBOFLO @LPQ>IC>@BQ LAV C Superior view. 8 RMBOFLO >OQF@RI>OC>@BQ Fig. 1.13 Lumbar spine Left lateral view. O>KPSBOPBMOL@BPP PQIRJ?>O SBOQB?O>ª« KQBO¦ SBOQB?O>I CLO>JBK Fig. 1.14 Typical lumbar vertebra (L4) RMBOFLO >OQF@RI>OMOL@BPP KCBOFLO SBOQB?O>I KLQ@E >JJFII>OVMOL@BPP MFKLRP MOL@BPP RMBOFLO SBOQB?O>I KLQ@E O>KPSBOPB MOL@BPP LAV MFKLRP MOL@BPP VD>MLMEVPB>I GLFKQ 1 Bones, Ligaments & Joints RMBOFLO>OQF@R¦ I>OMOL@BPP KCBOFLO SBOQB?O>IKLQ@E BOQB?O>I ?LAV KCBOFLO >OQF@RI>OMOL@BPP KCBOFLO >OQF@RI>OC>@BQ A Left lateral view. QEIRJ?>O SBOQB?O>ª« KCBOFLO >OQF@RI>OMOL@BPP KCBOFLO >OQF@RI>OC>@BQ LAV RMBOFLO >OQF@RI>O MOL@BPP O>KPSBOPB MOL@BPP Clinical Osteoporosis The spine is the structure most affected by degenerative diseases of the skeleton, such as arthrosis and osteoporosis. In osteoporosis, more bone material gets reabsorbed than built up, resulting in a loss of bone mass. Symptoms include compression fractures and resulting back pain. KCBOFLO >OQF@RI>OC>@BQ KCBOFLO >OQF@RI>OMOL@BPP MFKLRP MOL@BPP B Anterior view. MFKLRPMOL@BPP @@BPPLOV MOL@BPP BOQB?O>I >O@E BOQB?O>I CLO>JBK LAV A Radiograph of a normal lumbar spine, left lateral view. B Radiograph of an osteoporotic spine. The vertebral bodies are decreased in density, and the internal trabecular structure is coarse. Lower and upper end plates are fractured. RMBOFLO >OQF@RI>OC>@BQ >JJFII>OV MOL@BPP O>KPSBOPBMOL@BPP RMBOFLO>OQF@R¦ I>OMOL@BPP RMBOFLO SBOQB?O>I KLQ@E C Superior view. 9 Back Sacrum & Coccyx The sacrum is formed from five postnatally fused sacral vertebrae. The base of the sacrum articulates with the fifth lumbar vertebra, and the apex articulates with the coccyx, a series of three or four rudimentary vertebrae. Fig. 1.15 Sacrum and coccyx OLJLKQLOV RMBOFLO >OQF@RI>O MOL@BPP FKDLC P>@ORJ >QBO>I M>OQ O>KPSBOPB IFKBP KQBOFLOP>@O>I CLO>JFK> MBULC P>@ORJ RMBOFLO >OQF@RI>O C>@BQ >@OL@L@@VDB>I GLFKQ >@O>I QR?BOLPFQV >@O>I @>K>I L@@VU A Anterior view. >QBO>I M>OQ ROF@RI>O PROC>@B >QBO>I P>@O>I@OBPQ BAF>K P>@O>I@OBPQ LPQBOFLOP>@O>I CLO>JFK> BAF>IP>@O>I@OBPQ >@O>IEF>QRP >@O>I@LOKR> L@@VDB>I@LOKR L@@VU B Posterior view. 10 >@OL@L@@VDB>I GLFKQ >PBLC P>@ORJ 1 Bones, Ligaments & Joints RMBOFLO >OQF@RI>OMOL@BPP OLJLK¦ QLOV ROF@RI>O PROC>@B >@O>I QR?BOLPFQV LPQBOFLO PROC>@B KQBOFLOªMBISF@«PROC>@B >QBO>I P>@O>I@OBPQ L@@VU D Radiograph of sacrum, anteroposterior view. C Left lateral view. Fig. 1.16 Sacrum Superior view. BAF>K P>@O>I@OBPQ RMBOFLO >OQF@RI>OMOL@BPP >@O>I @>K>I BAF>K P>@O>I@OBPQ >QBO>I M>OQLC P>@ORJ OLJLKQLOV A Base of sacrum, superior view. >@O>I @>K>I LPQBOFLO P>@O>I CLO>JBK FKDLC P>@ORJ >QBO>IM>OQ BISF@ PROC>@B KQBOFLO P>@O>ICLO>JBK L@@VU B Transverse section through second sacral vertebra demonstrating anterior and posterior sacral foramina, superior view. 11 Back Intervertebral Disks Fig. 1.17 Intervertebral disk in the vertebral column BOQB?O>I@>K>I Sagittal section of T11–T12, left lateral view. The intervertebral disks occupy the spaces between vertebrae (intervertebral joints, see p. 14). BOQB?O>I?LAV KQBO¦ SBOQB?O>I AFPH RMBOFLO >OQF@RI>O C>@BQ KRIRP CF?OLPRP BOQB?O>I >O@E R@IBRP MRIMLPRP MFKLRPMOL@BPP FD>JBKQRJ CI>S> KQBOPMFKLRP IFD>JBKQ KRIRP CF?OLPRP Fig. 1.18 Structure of intervertebral disk R@IBRP MRIMLPRP RMBOFLO >OQF@RI>OMOL@BPP O>KPSBOPB MOL@BPP Anterosuperior view with the anterior half of the disk and the right half of the end plate removed. The intervertebral disk consists of an external fibrous ring (anulus fibrosus) and a gelatinous core (nucleus pulposus). V>IFKB @>OQFI>DB BKAMI>QB KQBOSBOQB?O>I PROC>@B Fig. 1.19 Relation of intervertebral disk to vertebral canal LAV >ODFK>IOFADB ªBMFMEVPB>IOFKD« Fig. 1.20 Outer zone of the anulus fibrosus Anterior view of L3–L4 with intervertebral disk. Fourth lumbar vertebra, superior view. >ODFK>IOFADB ªBMFMEVPB>IOFKD« MFKLRPMOL@BPP BOQB?O>I CLO>JBK RMBOFLO SBOQB?O>I KLQ@E RMBOFLO >OQF@RI>OMOL@BPP RMBOFLO>OQF@RI>O MOL@BPP O>KPSBOPB MOL@BPP O>KPSBOPB MOL@BPP KQBOSBOQB?O>I CLO>JBK BOQB?O>I ?LAFBP OLPPFKDCF?BO PVPQBJPLCQEB >KRIRPCF?OLPRP R@IBRPMRIMLPRP KRIRP CF?OLPRP KKBOWLKB RQBOWLKB KCBOFLO >OQF@RI>O MOL@BPP 12 MFKLRPMOL@BPP Disk herniation in the lumbar spine As the stress resistance of the anulus fibrosus declines with age, the tissue of the nucleus pulposus may protrude through weak spots under loading. If the fibrous ring of the anulus ruptures completely, the herniated material may compress the contents of the intervertebral foramen (nerve roots and blood vessels). These patients often suffer from severe local back pain. Pain is also felt in the associated dermatome (see p. 600). When the motor part of the spinal nerve is affected, the muscles served by that spinal nerve will show weakening. It is an important diagnostic step to test the muscles innervated by a nerve from a certain spinal segment, as well as the sensitivity in the specific dermatome. Example: The first sacral nerve root innervates the gastrocnemius and soleus muscles; thus, standing or walking on toes can be affected (see p. 398). >QFKQEB BMFARO>I PM>@B >RA> BNRFK> MFARO>I C>Q BOKF>QBA AFPH KQBOSBOQB?O>I CLO>JBK RO>IPIBBSB TFQEPMFK>IK 1 Bones, Ligaments & Joints Clinical >RA> BNRFK>FK ²¦CFIIBA ARO>IP>@ BKQO>I EBOKF>QFLK R@IBRP MRIMLPRP >@ORJ A Superior view. B Midsagittal T2-weighted MRI (magnetic resonance image). Posterior herniation (A, B) In the MRI, a conspicuously herniated disk at the level of L3–L4 protrudes posteriorly (transligamentous herniation). The dural MFK>I ARO>J>QBO sac is deeply indented at that level. *CSF (cerebrospinal fluid). RO>IP>@ MLKAVILMEVQB LPQBOLI>QBO>I EBOKF>QFLK R@IBRP MRIMLPRP RO>IPIBBSB TFQEPMFK>IK LJMOBPPBA KBOSBOLLQP LPQBOLI>QBO>I EBOKF>QFLK KQBOSBOQB?O>IAFPH BOQB?O>I>O@E ªMBAF@IBAFSFABA« RO>IPIBBSBTFQEPMFK>IK C Superior view. Posterolateral herniation (C, D) A posterolateral herniation may compress the spinal nerve as it passes through the intervertebral foramen. If more D Posterior view, vertebral arches removed. medially positioned, the herniation may spare the nerve at that level, but impact nerves at inferior levels. 13 Back Joints of the Vertebral Column: Overview Table 1.2 Fig. 1.21 Joints of the vertebral column Joints of the vertebral column Craniovertebral joints A Atlanto-occipital joints Occiput–C1 S Atlantoaxial joints C1–C2 Joints of the vertebral bodies D Uncovertebral joints C3–C7 F Intervertebral joints C1–S1 Joints of the vertebral arch G Zygapophyseal joints C1–S1 Fig. 1.22 Zygapophyseal (intervertebral facet) joints The orientation of the zygapophyseal joints differs between the spinal regions, influencing the degree and direction of movement. O>KPSBOPB MOL@BPP RMBOFLO>OQF@RI>O MOL@BPP KQBOFLO QR?BO@IB MFKLRPMOL@BPP LPQBOFLO QR?BO@IB VD>MLMEVPB>I GLFKQ RI@RPCLO PMFK>IK O>KPSBOPB CLO>JBK KCBOFLO>OQF@RI>O MOL@BPP RMBOFLO >OQF@RI>OC>@BQ LPQ>IC>@BQ A Cervical region, left lateral view. The zygapophyseal joints lie 45 degrees from the horizontal. VD>MLMEVPB>IGLFKQ BOQB?O>ICLO>JBK RMBOFLO >OQF@RI>OMOL@BPP O>KSBOPB MOL@BPP O>KSBOPB MOL@BPP VD>MLMEVPB>I GLFKQ MFKLRPMOL@BPP KCBOFLO>OQF@RI>O C>@BQ B Thoracic region, left lateral view. The joints lie in the coronal plane. KCBOFLO >OQF@RI>OMOL@BPP C Lumbar region, posterior view. The joints lie in the sagittal plane. 14 Fig. 1.23 Uncovertebral joints BKP >QBO>I >QI>KQL>UF>I GLFKQ Clinical Proximity of spinal nerve and vertebral artery to the uncinate process The spinal nerve and vertebral artery pass through the intervertebral and transverse foramina, respectively. Bony outgrowths (osteophytes) resulting from uncovertebral arthrosis may compress both the nerve and the artery and can lead to chronic pain in the neck. QI>Pª« UFPª« BOQB?O>I> FKQO>KPSBOPB CLO>JBK PMFK>IK QI>Pª« UFPª« K@FK>QB MOL@BPPBP BOQB?O>I> BOQB?O>I?LAV O>KP¦ SBOPB MOL@BPP LPQBOFLO QR?BO@IB KQBOFLO QR?BO@IB 1 Bones, Ligaments & Joints Anterior view. Uncovertebral joints form during childhood between the uncinate processes of C3–C6 and the vertebral bodies immediately superior. The joints may result from fissures in the cartilage of the disks that assume an articular character. If the fissures become complete tears, the risk of pulposus herniation is increased (see p. 13). K@FK>QB MOL@BPP KQBOSBOQB?O>I AFPH O>KPSBOPB MOL@BPP RI@RPCLO PMFK>IK MFK>IK FKPRI@RP PMFK>IK KCBOFLO >OQF@RI>OC>@BQ BOQB?O>I?LAVª « A Cervical spine, anterior view. A Uncovertebral joints in the cervical spine of an 18-year-old man, anterior view. MFKLRP MOL@BPP >JFK> BOQB?O>I CLO>JBK MFK>I @LOA RMBOFLO >OQF@RI>OC>@BQ MFK>IK LPQBOFLOOLLQ ªPMFK>I«D>KDIFLK BOQB?O>I> B Uncovertebral joint (enlarged), anterior view of coronal section. O>KPSBOPB CLO>JBK O>KPSBOPB MOL@BPP BOQB?O>I ?LAV K@FK>QB MOL@BPP B Fourth cervical vertebra, superior view. C Split intervertebral disk, anterior view of coronal section. 15 Back Joints of the Vertebral Column: Craniovertebral Region Fig. 1.24 Craniovertebral joints UQBOK>IL@@FMFQ>I MOLQR?BO>K@B RMBOFLO KR@E>IIFKB @@FMFQ>I@LKAVIB >PQLFAMOL@BPP ªQBJMLO>I?LKB« BKPLC>UFPª« BAF>K >QI>KQL>UF>IGLFKQ QI>Pª« QVILFAMOL@BPP ªQBJMLO>I?LKB« UFPª« RMBOFLO>OQF@RI>O C>@BQªI>QBO>IJ>PP LC>UFP« BKPLC>UFPª« A Posterior view. OLLSBCLO SBOQB?O>I> O>KPSBOPB MOL@BPP MFKLRPMOL@BPP B Atlas and axis, posterosuperior view. Fig. 1.25 Dissection of the craniovertebral joint ligaments Posterior view. UQBOK>IL@@FMFQ>I MOLQR?BO>K@B R@E>II R@E>II QI>KQL¦L@@FMFQ>I GLFKQ QVILFAMOL@BPP LPQBOFLO>QI>KQL¦ L@@FMFQ>IJBJ?O>KB VD>MLMEVPB>I GLFKQª@>MPRIB« QI>Pª« UFPª« LPQBOFLO >QI>KQL¦ L@@FMFQ>I JBJ?O>KB MFKLRPMOL@BPP FD>JBKQ>CI>S> A Nuchal ligament and posterior atlantooccipital membrane. 16 B Posterior longitudinal ligament. Removed: Spinal cord; vertebral canal windowed. LPQBOFLO>O@E LC>QI>P B@QLOF>IJBJ?O>KB ªMLPQBOFLO ILKDFQRAFK>II« BOQB?O>I>O@E The atlanto-occipital joints are the two articulations between the convex occipital condyles of the occipital bone and the slightly concave superior articular facets of the atlas (C1). The atlanto- axial joints are the two lateral and one medial articulations between the atlas (C1) and axis (C2). RMBOFLO >OQF@RI>OC>@BQ BAF>K >QI>KQL>UF>I GLFKQ KQBOFLO QR?BO@IB I>OII I>OII MF@>II LCQEBABKP O>KPSBOPBI LC>QI>P O>KPSBOPB MOL@BPP BKP >QBO>IJ>PP LCQEB>QI>P BOQB?O>ICLO>JBK LKDFQRAFK>IC>P@F@IBP LPQBOFLOQR?BO@IB LCQEB>QI>P MFKLRPMOL@BPP LC>UFP MF@>II LCQEBABKP LKDFQRAFK>I C>P@F@IBP RMBOFLO >OQF@RI>O C>@BQ B@QLOF>IJBJ?O>KB O>KPSBOPBI LC>QI>P >MPRIBLC I>QBO>I>QI>KQL¦ L@@FMFQ>IGLFKQ 1 Bones, Ligaments & Joints Fig. 1.26 Ligaments of the craniovertebral joints O>KPSBOPBMOL@BPP KQBOQO>KPSBOPBI OLLSBCLO SBOQB?O>I> LPQBOFLO >QI>KQL¦L@@FMFQ>I JBJ?O>KB LPQBOFLO>O@E LC>QI>P R@E>II MFKLRPMOL@BPP A Ligaments of the median atlantoaxial joint, superior view. The fovea of the atlas is hidden by the joint capsule. I>OII B Ligaments of the craniovertebral joints, posterosuperior view. The dens of the axis is hidden by the tectorial membrane. LKDFQRAFK>I C>P@F@IBP B@QLOF>I JBJ?O>KB QI>KQL¦ L@@FMFQ>I @>MPRIB LKDFQRAFK>I C>P@F@IBP² MF@>II LCABKP I>OI >QBO>I J>PPLC O>KPSBOPBI LC>QI>P² LKDFQRAFK>I C>P@F@IBP LPQBOFLOILKDFQRAFK>II C Cruciform ligament of atlas (*). Removed: Tectorial membrane. BKPMLPQBOFLO >OQF@RI>OPROC>@B D Alar and apical ligaments. Removed: Transverse ligament of atlas, longitudinal fascicles. 17 Vertebral Ligaments: Overview & Cervical Spine Back The ligaments of the spinal column bind the vertebrae and enable the spine to withstand high mechanical loads and shearing stresses and limit the range of motion. The ligaments are subdivided into vertebral body ligaments and vertebral arch ligaments. Fig. 1.27 Vertebral ligaments Table 1.3 Viewed obliquely from the left posterior view. Vertebral ligaments Ligament KQBOFLO O>KPSBOPB ILKDFQRAFK>IIFD>JBKQ MOL@BPP LPQBOFLOILKDFQRAFK>I IFD>JBKQ BOQB?O>I >O@E BAF@IB KQBO¦ QO>KPSBOPB IFD>JBKQ >JFK> KCBOFLO>OQF@RI>O MOL@BPP RMO>¦ PMFKLRP IFD>JBKQ RMBOFLO>OQF@RI>O MOL@BPP FD>JBKQRJCI>S> KQBOPMFKLRPIFD>JBKQ Location Vertebral body ligaments MFKLRP MOL@BPP A Anterior longitudinal ligament Along anterior surface of vertebral body P Posterior longitudinal ligament Along posterior surface of vertebral body Vertebral arch ligaments A Ligamenta flava Between laminae S Interspinous ligaments Between spinous process D Supraspinous ligaments Along posterior ridge of spinous processes F Intertransverse ligaments Nuchal ligament* Between transverse processes Between external occipital protuberance and spinous process of C7 *Corresponds to a supraspinous ligament that is broadened superiorly. Fig. 1.28 Anterior longitudinal ligament Fig. 1.29 Posterior longitudinal ligament Anterior longitudinal ligament. Anterior view with base of skull removed. Posterior view with vertebral canal windowed and spinal cord removed. The tectorial membrane is a broadened expansion of the posterior longitudinal ligament. KQBOK>I L@@FMFQ>I MOLQR?BO>K@B QI>KQL¦L@@FMFQ>I GLFKQª>QI>KQL¦ L@@FMFQ>I@>MPRIB« QI>Pª« O>KPSBOPB CLO>JFK> UFPª« KQBOFLO ILKDFQRAFK>I IFD>JBKQ RI@RPCLO PMFK>IKBOSB KQBOSBOQB?O>I AFPH 18 UQBOK>IL@@FMFQ>I MOLQR?BO>K@B @@FMFQ>I ?LKB ?>PFI>O M>OQ KQBOFLO >QI>KQL¦ L@@FMFQ>I JBJ?O>KB O>KPSBOPB MOL@BPP >QBO>I >QI>KQL>UF>I GLFKQª@>MPRIB« VD>MLMEVPB>I GLFKQª@>MPRIB« QI>KQL¦L@@FMFQ>I @>MPRIB LPQBOFLO>QI>KQL¦ L@@FMFQ>IJBJ?O>KB QI>KQL¦L@@FMFQ>I GLFKQ B@QLOF>IJBJ?O>KB BOQB?O>I>O@E LPQBOFLO QR?BO@IB KQBOFLO QR?BO@IB BOQB?O> MOLJFKBKP ª « LPQBOFLOILKDFQRAFK>I IFD>JBKQ Fig. 1.30 Ligaments of the cervical spine BII> QRO@F@> MF@>IIFD>JBKQ LCQEBABKP VMLDILPP>I @>K>I B@QLOF>I JBJ?O>KB @@FMFQ>I?LKB ?>PFI>OM>OQ UQBOK>I L@@FMFQ>I MOLQR?BO>K@B KQBOFLO >QI>KQL¦L@@FMFQ>I JBJ?O>KB BKPLC>UFPª« KQBOFLO>O@E LC>QI>Pª« LKDFQR¦ AFK>I C>P@F@IBP >UFII> LPQBOFLO>O@ELC>QI>P MLPQBOFLOQR?BO@IB >@BQGLFKQ @>MPRIB KQBOSBOQB?O>IAFPH KQBOFLOILKDFQRAFK>I IFD>JBKQ LPQBOFLOILKDFQRAFK>I IFD>JBKQ O>KPSBOPB IFD>JBKQLC>QI>P LPQBOFLO >QI>KQL¦L@@FMFQ>I JBJ?O>KB 1 Bones, Ligaments & Joints MEBKLFAPFKRP R@E>IIFD>JBKQ FD>JBKQ>CI>S> BOQB?O>I>O@E KQBOSBOQB?O>ICLO>JBK MFKLRPMOL@BPP KQBOPMFKLRPIFD>JBKQ RMO>PMFKLRP IFD>JBKQ SBOQB?O>I?LAV ªSBOQB?O>MOLJFKBKP« A Midsagittal section, left lateral view. The nuchal ligament is the broadened, sagittally oriented part of the supraspinous ligament that extends from the vertebra prominens (C7) to the external occipital protuberance. MBULCABKP LAVLC>UFP BOB?BIILJBARII>OV @FPQBOK LPQBOFLOQR?BO@IB LC>QI>P R@E>IIFD>JBKQ LPQBOFLOILKDFQR¦ AFK>IIFD>JBKQ BOQB?O>I?LAV KQBOSBOQB?O>I AFPH RMO>PMFKLRPIFD>JBKQ BOQB?O> MOLJFKBKPª « KQBOFLO ILKDFQRAFK>I IFD>JBKQ MFK>I@LOA R?>O>@EKLFAPM>@B B Midsagittal T2-weighted MRI, left lateral view. (From Vahlensieck, Reiser. MRT des Bewegungsapparates. 2nd ed. Stuttgart: Thieme; 2001.) 19 Back Vertebral Ligaments: Thoracolumbar Spine Fig. 1.31 Ligaments of the vertebral column: Thoracolumbar junction BOQB?O>I@>K>I Left lateral view of T11–L3, with T11–T12 sectioned in the midsagittal plane. KQBOSBOQB?O>I AFPH RMBOFLO>OQF@RI>O C>@BQ LPQBOFLOILKDFQRAFK>I IFD>JBKQ KRIRP CF?OLPRP BOQB?O>I>O@E R@IBRP MRIMLPRP FD>JBKQ>CI>S> RMBOFLO>OQF@RI>O MOL@BPP KQBOFLO ILKDFQRAFK>I IFD>JBKQ MFKLRPMOL@BPPBP KQBOPMFKLRPIFD>JBKQP O>KPSBOPBMOL@BPP BOQB?O>I?LAV KQBOQO>KPSBOPBIFD>JBKQP >@BQGLFKQ@>MPRIB RMO>PMFKLRP IFD>JBKQ KCBOFLO>OQF@RI>O C>@BQ Fig. 1.32 Anterior longitudinal ligament Anterior view of L3–L5. O>KPSBOPB MOL@BPP KQBOSBOQB?O>I AFPH BOQB?O>I?LAV KQBOFLOILKDFQRAFK>IIFD>JBKQ 20 Fig. 1.33 Ligamentum flavum and intertransverse ligament 1 Bones, Ligaments & Joints Anterior view of opened vertebral canal at level of L2–L5. Removed: L2–L4 vertebral bodies. RMBOFLO >OQF@RI>O MOL@BPP >JFK> KQBO¦ QO>KPSBOPB IFD>JBKQP FD>JBKQ> CI>S> O>KPSBOPB MOL@BPP LPQBOFLO ILKDFQRAFK>I IFD>JBKQ RMBOFLO >OQF@RI>O MOL@BPP Fig. 1.34 Posterior longitudinal ligament Posterior view of opened vertebral canal at level of L2–L5. Removed: L2–L4 vertebral arches at pedicular level. KQBOFLO ILKDFQRAFK>I IFD>JBKQ KCBOFLO>OQF@RI>O C>@BQ MFKLRPMOL@BPP RQOFBKQ CLO>JFK> BAF@IBPLC SBOQB?O>I>O@EBP LPQBOFLO ILKDFQRAFK>I IFD>JBKQ KQBOSBOQB?O>I CLO>JBK KQBOSBOQB?O>I AFPH BOQB?O>I ?LAV >MFK IFD>JBKQLRP OBFKCLO@BJBKQ LCQEBAFPH RMBOFLO >OQF@RI>OC>@BQ O>KPSBOPB MOL@BPP KCBOFLO>OQF@RI>O MOL@BPP MFKLRPMOL@BPP BOQB?O>I@>K>I 21