Anatomy- Back

Front 1

Referred Back Pain

Back 1

AAA >4cm, Pancreatitis, Gastric/duodenal ulcer, endometriosis, Prostate CA, myeloma (primary CA and mets), kidney infection/pathology/stones, renal calculi

Front 2

Intrinsic Back Pain

Back 2

Trauma (fx, dislocation),

Pathology (compression fx d/t osteoporosis, spinal stenosis d/t osteoarthritis, ankylosing spondylitis- bone defect developed in adolescence, osteomyelitis),

IVD pathology- disc protrusion/nerve root impediment,

Postural/Structural Imbalances- overuse, misuse, occupational, recreational habits, scoliosis, spondylolisthesis, etc

Front 3

Back Pain in the Pt Exam

Back 3

identify the causes that would require emergency intervention

observe and indentify pain patterns of potential DDx for back pain

observe and identify appropriate clusters of s/s for potential ddx for back pain

palpate and identify normal/abnormal structural anatomy

observe and identify postural deviations

Front 4

Vertebral Column Structure

Back 4

33 vertebrae

7 Cervical, 12 thoracic, 5 lumbar, 5 fused sacral, 4 fused coccyx

Front 5

Gross movement of Vertebral Column

Back 5

general- F, E, LF, R

each region of the spine emphasizes and limits specific movements

Front 6

Functions of vertebral column

Back 6

protect spinal column, support wt of head/trunk, allow movement of rib cage (costovertebral joints), critical role in posture/locamotion

Front 7

Normal Curvatures of Vertebral Column

Back 7

primary- T and S (kyphotic)
secondary- L and C (lordotic)

function is to absorb shock (10x more than if straight spine)

Birth- primary curve only, when infant starts to hold head and sit up cervical curve develops, when infant begins to stand/walk lumbar curve develops

Front 8

Kyphosis

Back 8

excessive kyphosis in T spine (excessive posterior curve)
D/T comp fx, postural habits, Schuerman's disease or osteoporosis

Front 9

Lordosis

Back 9

excessive lordosis in lumbar region (excessive anterior curve), d/t anomalies, postural habits, etc
clinical- important to assess ability to "reverse the lordotic curve" during flexion of the trunk

Front 10

Scoliosis

Back 10

lateral deviation with rotary component (uneven ribs), curve named for convexity

school screenings to ID potential curves, progression and severity are key factors, depending on the above treatment ranges from observation, tx of sxs to bracing or surgical intervention

Front 11

Reversal of Cervical Curve

Back 11

reduction of normal lordosis of C spine, d/t postural habits, MVA or other trauma, etc

Front 12

Back 12

Body of typical vertebrae-

T4 and below gradually increase in size to support increasing body weight

ephyseal ring- smooth region of vertebrae along the periphery of the body, formed from annular epiphysis (2˚ ossification center during growth)

shape of body varies in each region of the spine

Front 13

Back 13

Vertebral (neural) arch= pedicles and lamina

clinically- spina bifida

Front 14

Back 14

Spina bifida- lamina fail to fuse resulting in defect of arch,

spina bifida occulta- failure of vertebral arch to fuse, bony defect

meningocele- meninges protrude through bony defect of vertebral arch

meniomyelocele- spinal cord + meninges protrude defect of vertebral arch

Front 15

Back 15

Transverse Process (2)-
project laterally from junction of pedicles and lamina
attachement and lever for spinal mm

Front 16

Back 16

Articular Process (4)- superior and inferior processes
project from junction of pedicle and lamina
adjacent articular processes from facet (zypgapophyseal) joints between vertebrae

Front 17

Back 17

Spinous Process (1)-
project posteriorly from junction of R/L lamina
attachment and lever for spinal mm

Front 18

Back 18

Vertebral Notch- superior and inferior portion of pedicle

Front 19

Back 19

Intervertebral foramen

formed between vertebrae via the vertebral notches of two adjacent segments, superior and inferior vertebral notches

Front 20

Back 20

formed by the body and vertebral arch

Front 21

Back 21

Vertebral Canal- vertebral foramina collectively form the canal

Front 22

Cervical Vertebrae

Back 22

Cervical Vertebrae (typical C3-C7, smallest vetebrae)

Body- small, wider side to side than ant-post

Vertebral foramen- LARGE, triangular

TPs- have transverse foramen, allow vertebral artery to pass through (C6-1), C7 may have small or absent

APs- superior facets face superior and posterior, inferior facets face inferior and anterior

SPs- typically bifid C3-5, C7- most prominent, common landmark for palpation

Front 23

Thoracic Vertebrae

Back 23

Body- heart shaped, costal facets

Vertebral foramen- circular and smaller than C and L

TPs- long, T1-10 have facets for articulation with ribs (transverse costal facets)

APs- superior facets face posterior and slightly lateral, inferior facets face anterior and slightly medial

SPs- long and extend inferiorly to segment below

General- upper Ts transition from C spine, mid Ts thoracic vertebrae characteristics, lower Ts begin to transition to L spine

Front 24

Lumbar Vertebrae

Back 24

Body- kidney shaped

Vertebral Foramen- triangular, larger than T, smaller than C

TPs- have accessory process- tubercles located at the base of TPs

APs- superior facets face posterior and medial, inferior facets face anterior and lateral, have mamillary process- tubercles located on superior articular pillar

SPs- sturdy, "hatchet shape"

Front 25

Sacrum

Back 25

large triangular wedged shaped bone composed of 5 fused vertebrae, 4 pairs of foramina- exit for dorsal and ventral nerve roots, provides stability to pelvis

Front 26

Promontory of Sacral Bone

Back 26

prominent anterior edge of first vertebrae (segment)

Front 27

Back 27

Ala of Sacral Bone

superior/lateral portion of sacrum (wings)

Front 28

Median Sacral Crest

Back 28

midline formed by fused SPs

Front 29

Back 29

Sacral hiatus

formed by failure of the lamina of S5 to fuse

Front 30

Back 30

Sacral cornu (horns) formed by pedicles of S5

Front 31

Back 31

Sacral Canal

contain nerve roots of cauda equina

Front 32

Apex of Sacrum

Back 32

inferior end

Front 33

Base

Back 33

superior portion of S1

Front 34

Back 34

Coccyx- wedge shaped bone of 4 fused coccygeal vertebrae (provide attachement for pelvic mm)

Front 35

Atlas (C1)

Back 35

ring shaped, no spinous process or body

consists of anterior and posterior arches with TPs

Anterior/posterior tubercles instead of spinous process

Lateral mass- superior facets articulate with occipital condyles (flexion and extension motion), inferior facets articulate with C2 (superior facets for rotation)

facet located on anterior arch- articulate with dens (odontoid process)

TPs wide- palpate inferior to mastoid process

Vertebral artery- forms large "loop" as it ascends to foramen magnum

Front is smaller than back (to orient yourself)

Front 36

Axis (C2)

Back 36

characterized by dens (odontoid process)

forms the "pivot" or axis for rotation between C1 and C2

Supported by multiple ligaments

Everything else is normal

Front 37

Back 37

Intervertebral Disc

Annulus fibrosus + nucleus pulposus

act as shock absorber, influences motion

form the secondary cartilaginous joints between vertebral bodies

composition- water, collagen fibers, proteoglycans

approximately 1/4 of overal spine length

no disc between occiput and C1, C1 and C2

Clinical- fissures develop (discogenic pain), protrusions/herniation (potential to compress nerve roots= radicular pain myatome or dermatome patterns), degenerative charges (loss of disc ht)

Front 38

Back 38

Annulus Fibrosus- concentric layers composed of collagen fibers,

bundles if collegen fibers are obliquely oriented- provides tensile strength,

direction of the fibers alternates for each layer- crosswoven effect,

anchor disc to bone or cartilaginous end plate,

outside layer will blend ALL and PLL and have innervation (can have pain)

Front 39

Back 39

Nucleus pulposus

proteoglycans attract water to this portion of the disc

gradual transition from annulus- not really a jelly donut as commonly referred to

does contain collagen fibers- finer fibers, lose random network arrangement of fibers

Front 40

Back 40

Uncovertebral (Joints of Luschka)

unique to cervical spine
formed by uncinate processes of C3 and C7

considered more of a "pseudo joint"
formed between the beveled uncinate processes of each vertebrae

the joint looks similar to a synovial joint- cartilage and capsule

research continues to debate if synovial jt or not

clinically- prone to degenerative changes (bone spur formation)

Front 41

Back 41

Facet (zygapophyseal) joints

plane synovial joints between superior and inferior facets of articular process

surrounded by loose articular capsule

permit gliding movement between vertebrae

orientation varies in each region- will both enhance and limit movement depending on motion

some wt bearing function in C and L regions

innervation- dorsal primary rami of individual segment and segment above and below

clinical- also prone to degenerative changes (result= limited movement and pain), excessive bone spurs can cause stenosis of invertebral foramen

Front 42

Back 42

Anterior Longitudinal Ligament (ALL)
runs from occiput to the sacrum along anterior portion of vertebral column

width increases as it descends down the vertebral column

function- limit extension, support anterior annulus fibrosis of disc

Front 43

Back 43

Posterior Longitudinal Ligament (PLL)- C2 to sacrum

runs along posterior vertebral column within vertebral canal (thus anterior to spinal column) along vertebral body

width decreases as it descends down the vertebral column,

narrow and much less substantial as compared to ALL

function- limits flexion, supports posterior annulus fibrosis of disc

Front 44

Back 44

Ligamentum Flavum

connects the lamina between each vertebrae, forms part of the posterior wall of vertebral canal

gradually thicken as descend from C to L regions

high elastin content

function- allow smooth flexion of vetebrae and thus reduce potential for IVD injury, elasticity assists with restoring neutral position after flexion of spine

Front 45

Back 45

Interspinous ligaments (thin membranous ligament)- connect adjacent spinous processes, attach along inferior and superior position of SP

Supraspinous ligaments (cord like ligament)- connect adjacent spinous processess, attachement of apices of each SP, C7-sacrum, merges superiorly with nuchal ligament

Front 46

Back 46

Nuchal Ligament (ligamentum nuchae)

EOP to C7, connects the EOP, posterior tubercle of C1 and SPs of C2-7, acts as septum separating muscles of R/L posterior neck

Front 47

Intratransverse Ligaments

Back 47

Connects TPs between adjacent vertebrae

Front 48

Back 48

Atlanto-occipital joints (occiput and C1)

synovial joints, orientation provides flexion/extension movement of head and neck

additional ligamentous support of atlanto occipital joints-
anterior and posterior atlanto-occipital membranes (connect arches of C1 to occiput (edges of foramen magnum), help prevent excessive movement of the joint (stability)

Front 49

Atlantoaxial Joints

Back 49

3 articulations- R/L facets and median atlantoaxial jt)

Median atlantoaxial joint- odontoid (dens) articulates with anterior arch of C1 (pivot type joint provides rotation C1 and occiput as unit on C2)

Atlanto axial membrane- attaches to anterior body of C2 and anteiror arch of C1

Facet joints of C1-C2- synovial plane type of joint- provides gliding movement, orientation allows for rotation

Front 50

Back 50

Tectorial membrane- acts as continuation of PLL, C2 to foramen magnum, runs posterior to cruciate ligament

Front 51

Back 51

Cruciate Ligament (perviously known as cruciform ligament)

cruciate ligament= transverse ligament + superior/inferior longitudinal bands

function- stabilizes dens against anterior arch of C1, acts as posterior wall and forms "socket" for dens

Front 52

Back 52

Alar Ligaments- extend from sides of dens to lateral margin of foramen magnum, limit excessive rotation

Front 53

Back 53

Apical Ligament- apex of dens to foramen magnum

Front 54

Back 54

Fascia of posterior trunk- thoracolumbar fascia

invests the deep muscles of the back, attaches to SPs and TPs of T/L regions, provides origin of lats, transverse abdominal and internal oblique mm

Front 55

Muscles of the Back Hierarchy

Back 55

Superficial layer (extrinsic, muscles that control the upper limb)- traps, lats, rhomboids and levator scapula

Intermediate layer of the back (extrinsic, assist in respiration control)- serratus posterior superior and inferior

Deep layer of the back (intrinsic, act on vertebral column)- superficial= splenius capitus and cervicis, intermediate= errector spinae (iliocostals, longissimus, spinalis), deep= transversospinal group (semispinalis, multifidi, rotatores)

Front 56

Back 56

Trapezius (extrinsic, superficial layer)

O: medial third of the superior nuchal line, external occipital protuberance, ligamentum nuchae, spinous processes of vertebrae C7-T12
I: lateral third of the clavicle, medial side of the acromion and the upper crest of the scapular spine, tubercle of the scapular spine
N: motor: spinal accessory (XI)
A: elevates and depresses the scapula (depending on which part of the muscle contracts); rotates the scapula superiorly; retracts scapula

Front 57

Back 57

Latissimus dorsi (extrinsic, superficial layer)

O: vertebral spines from T7 to the sacrum, posterior third of the iliac crest, lower 3 or 4 ribs, sometimes from the inferior angle of the scapula
I: floor of the intertubercular groove
N: thoracodorsal nerve (C7,8) from the posterior cord of the brachial plexus
A: extends the arm and rotates the arm medially

Front 58

Back 58

Both are extrinsic superficial
Rhomboid minor
O: inferior end of the ligamentum nuchae, spines of vertebrae C7 and T1
I: medial border of the scapula at the root of the spine of the scapula
N: dorsal scapular nerve (C5)
A: retracts, elevates and rotates the scapula inferiorly

Rhomboid major
O: spines of vertebrae T2-T5
I: medial border of the scapula inferior to the spine of the scapula
N: dorsal scapular nerve (C5)
A: retracts, elevates and rotates the scapula inferiorly

Front 59

Back 59

Levator Scapula (extrinsic, superficial)
O: transverse processes of C1-C4 vertebrae
I: medial border of the scapula from the superior angle to the spine
N: dorsal scapular nerve (C5); the upper part of the muscle receives branches of C3 & C4
A: elevates the scapula

Front 60

Back 60

Intermediate Layer of Back Muscles – EXTRINSICS

Serratus posterior superior
O: ligamentum nuchae, spines of vertebrae C7 -T3
I: superior borders of ribs 2-4
N: intercostals nerves 2-5 (branches of the ventral primary rami)
A: elevates the upper ribs

Front 61

Back 61

Intermediate Layer of Back Muscles – EXTRINSICS

Serratus posterior inferior
O: thoracolumbar fascia, SP’s of vertebrae T11-L2
I: ribs 8-12 (inferior borders near their angles)
N: branches of the ventral primary rami of spinal nerves T9-T12
A: pulls down lower ribs

Front 62

Back 62

Deep Layer of Back Muscles– INTRINSICS (true back muscles) – innervated by DPR
Superficial layer of the deep back muscles = Splenius muscles – fiber direction is superolateral, cover vertical mm like a bandage (L. splenion)

Splenius capitis
O: ligamentum nuchae and spines of C7-T4 vertebrae
I: mastoid process and lateral end of the superior nuchal line
N: dorsal primary rami of spinal nerves C2-C6
A: Bilateral: extends neck/head
Unilateral: lateral flex and rotate head/neck to same side

Front 63

Back 63

Deep Layer of Back Muscles– INTRINSICS (true back muscles) – innervated by DPR
Superficial layer of the deep back muscles = Splenius muscles – fiber direction is superolateral, cover vertical mm like a bandage (L. splenion)

Splenius cervicis
O: ligamentum nuchae and spines of C7-T4 vertebrae
I: posterior tubercles of the transverse processes of C1-C3 or 4 vertebrae
N: dorsal primary rami of spinal nerves C2-C6
A: Bilateral: extends neck/head
Unilateral: lateral flex and rotate head/neck to same side

Front 64

Back 64

Intermediate layer of the deep back muscles
Collectively known as …Erector Spinae muscles…3 ”columns” of muscle, act as chief EXTENSOR of the vertebral column, each column shares common origin of broad tendon

Iliocostalis – lateral column
Longissimus – intermediate column
Spinalis – medial column

Front 65

Iliocostalis

Back 65

lliocostalis – lumborum, thoracis, and cervicis
O: broad tendon from posterior part iliac crest and sacrum, SP’s of lower L and S, supraspinus ligament
I: angles of the ribs and cervical TP’s
N: dorsal primary rami of spinal nerves
A: Bilaterally: extends the vertebral column, assist with flexion (eccentric contraction)
Unilateral: laterally bends the vertebral column

Front 66

Longissimus

Back 66

Longissimus – thoracis, cervics, and capitis
O: broad tendon from posterior part iliac crest and sacrum, SP’s of lower L and S, supraspinus ligament
I: ribs, TP’s at superior vertebral levels, mastoid process
N: dorsal primary rami of spinal nerves
A: Bilaterally: extends the vertebral column, assist with flexion (eccentric contraction)
Unilateral: laterally bends the vertebral column

Front 67

Spinalis

Back 67

Spinalis – spinalis thoracis, spinalis cervicis
O: broad tendon from posterior part iliac crest and sacrum, SP’s of lower L and S, supraspinus ligament
I: spinous processes at superior vertebral levels and base of the skull
N: dorsal primary rami of spinal nerves
A: Bilaterally: extends the vertebral column, assist with flexion (eccentric contraction)
Unilateral: laterally bends the vertebral column

Front 68

Back 68

Deep Layer of the deep back muscles
a. Collectively known as Transversospinalis muscle group, all originate from TP’s and insert into SP’s

Semispinalis – thoracics, cervicis, and capitis
O: TPs of C4-T12
I: capitis: back of skull between nuchal lines; cervicis & thoracis: SP’s 4-6 vertebrae above origin
N: dorsal primary rami of spinal nerves
A: Bilaterally: extends the head and vertebral column in C and T region, stabilize vertebrae during local or isolated movements of vertebral column, assit with extension of vertebral column
Unilateral: rotates the vertebral column to opposite side (contralateral rotation)
May have proprioceptive function

Front 69

Back 69

Deep Layer of the deep back muscles
a. Collectively known as Transversospinalis muscle group, all originate from TP’s and insert into SP’s

Multifidus
O: sacrum,TPs of T1-L5 and articular pillars (AP’s) of C4-7
I: spinous processes 2-4 vertebral levels superior to their origin
N: dorsal primary rami of spinal nerves
A: Bilaterally: extends the head and vertebral column in C and T region, stabilize vertebrae during local or isolated movements of vertebral column, assit with extension of vertebral column
Unilateral: rotates the vertebral column to opposite side (contralateral rotation)
May have proprioceptive function

Front 70

Back 70

Deep Layer of the deep back muscles
a. Collectively known as Transversospinalis muscle group, all originate from TP’s and insert into SP’s

Rotatores
O: TPs of vertebral column
I: long rotatores: SP’s (lamina) 2 vertebrae above origin
short rotatores: SP’s (lamina) 1 vertebrae above origin
N: dorsal primary rami of spinal nerves
A: Bilaterally: extends the head and vertebral column in C and T region, stabilize vertebrae during local or isolated movements of vertebral column, assit with extension of vertebral column
Unilateral: rotates the vertebral column to opposite side (contralateral rotation)
May have proprioceptive function

Front 71

Minor deep intrinsics (not sure if need to know)

Back 71

Levatores costarum (sometimes thought as analogous to intertransverse m in C and L regions)
O: Tips of C7 – T11 vertebrae
I: pass inferolaterally and insert on rib between it’s tubercle and angle
N: dorsal rami of C8-T11
A: elevate ribs, assisting with inspiration, assist with LF of spinal column

Front 72

Back 72

Suboccipital Triangle
1. Boundaries
a. medial – rectus capitus posterior major
b. lateral – obliquus capitus superior muscle
c. inferior – obliquus capitus inferior

2. Floor – posterior arch of the atlas and posterior atlanto-occipital membrane
3. Roof – semispinalis capitis and longissimus capitis
4. Contents of suboccipital triangle– contains vertebral artery, suboccipital nerve (C1) and blood vessels

Front 73

Back 73

Rectus capitis posterior major
O: SP of C2 (axis)
I: inferior nuchal line (lateral portion)
N: suboccipital nerve (DPR of C1)
A: extends the head, rotate head to same side (ipsilateral rotation)

Front 74

Back 74

Rectus capitis posterior minor
O: posterior tubercle of C1 (atlas)
I: inferior nuchal line (medial portion)
N: suboccipital nerve (DPR of C1)
A: extends the head, rotate head to same side (ipslateral rotation)

Front 75

Back 75

Obliquus capitis superior
O: TP of C1 (atlas)
I: occipital bone above inferior nuchal line
N: suboccipital nerve (DPR of C1)
A: extends the head, rotates the head to the same side

Front 76

Back 76

Obliquus capitis inferior
O: SP of the C2 (axis)
I: TP of C1 (atlas)
N: suboccipital nerve (DPR of C1)
A: rotates the head to the same side (ipslateral rotation)

Front 77

Dura Matter

Back 77

a. Dural sac extends from foramen magnum (continuatiuon of cranial dura)
b. Distal end of dural sac – filum terminale attaches to coccyx bone
c. Spinal nerve roots pierce dura sac and form dural sleeves
d. Epidural or extradural space = space between vertebral bone and dura, contains - adipose tissue, venous plexus
• Epidural block – inject anesthesia direct effect on the spinal nerve roots of the cauda equina after they exit the dural sac

Front 78

Arachnoid ("spider")

Back 78

a. middle layer between dura and pia
b. does not adhere to pia – creates a space known as subarachnoid space
c. subarachnoid space is filled with CSF (cerebrospinal fluid)
d. enlarged areas of the subarchnoid space = cisterns
• lumbar cistern used for lumber puncture – sample CSF, inject contrast for myelogram, measure CSF pressure

Front 79

Pia Matter

Back 79

a. inner most layer
b. in spinal cord – small extensions form dentate ligaments
c. dentate ligaments anchor the spinal cord to the dura
d. distal end – pia filament extends from conus medullaris to end of dural sac