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The Back
 Can be defined as the posterior surface of the trunk.
 Which extends from the skull to the tip of the coccyx.

Back 

Head, neck and limbs are attached
It includes
 Skin and subcutaneous tissue
 Muscles
Yossef Teshome  Vertebral column & ribs
 Spinal cord and meninges
 Various segmental nerve & blood vessel
 Supported mainly by vertebral column

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The vertebral column

The vertebral column The vertebral column
Function
 Protects the spinal cord and spinal nerves
 Supports the weight of the body superior to the level of
the pelvis
 Provides a partly rigid and flexible axis for the body
 Provide a site on which the head is placed and pivots
 Plays an important role in posture and locomotion

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Composition of vertebral column

 The vertebral column in an adult typically consists of 26
vertebrae
 become larger as the vertebral column descends to the
sacrum and then become progressively smaller toward the
apex of the coccyx
 Intervertebral discs are pads of fibrocartilage that bind
together the vertebral bodies of adjacent vertebrae.
 Divided in to five regions:
 Cervical ……...7
 Thoracic …….12
 Lumbar ………5
 Sacral …….…. 1(five fused vertebrae)
 Coccygeal…… 1(four fused vertebrae)
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Characteristics of Typical Vertebra Characteristics of Typical Vertebra

 Consists of:- I. Vertebral body
I. Vertebral body,  More massive & roughly cylindrical; weight bearing part
II. Vertebral arch of the vertebra
and  linked to adjacent vertebral bodies by IVD and ligaments,
III. Seven processes forming the cartilaginous joints.
 Thoracic vertebrae has costal facets, which articulate
with the heads of the corresponding and subjacent (just
below) ribs.
 The size of vertebral bodies increases inferiorly as the
amount of weight supported increases.
most markedly from T4 inferiorly
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Characteristics of Typical Vertebra…

Characteristics of Typical Vertebra
II. Vertebral arch…
II. Vertebral arch  The vertebral foramina of all the vertebrae together
 is posterior to the form the vertebral canal, which contains
vertebral body and  Spinal cord, spinal nerve roots and spinal meninges
 forms the lateral and  Blood vessels
posterior parts of the  Continuous superiorly with the cranial cavity, through the
foramen magnum of the skull.
vertebral foramen.
 Consists of pedicles and laminae:
 consists of two (R&L)  two pedicles; bony pillars that attach the vertebral arch to
pedicles and laminae the vertebral body;
 has seven processes  two laminae; flat sheets of bone that extend from each
pedicle to meet in the midline and form the roof of the
vertebral arch.

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Characteristics of Typical Vertebra

7 Processes from the vertebral arch of a typical
vertebra
 One median spinous process
 Projects posteriorly (and usually inferiorly, typically
overlapping the vertebra below) from the vertebral arch
at the junction of the laminae
 Two transverse processes project posterolaterally
from the junctions of the pedicles and laminae
 The spinous and transverse processes, afford attachments
for deep back muscles and serve as levers, facilitating the
muscles that fix or change the position of the vertebrae
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Characteristics of Typical Vertebra Characteristics of Typical Vertebra

7 Processes from the vertebral arch of a typical
vertebra…
 Four articular processes (G. zygapophyses)
 two superior and two inferior also arise from the
junctions of the pedicles and laminae
 each bearing an articular surface (facet)
 Vertebral notches (sup. & inf.) are indentations on each
pedicle superiorly and inferiorly
 b/n the superior and inferior articular processes
posteriorly and the corresponding projections of the
body anteriorly

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Regional Characteristics of the

Vertebrae

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X-cs of Typical Cervical Vertebrae

Cervical Vertebrae
Transverse processes possess a foramen
 The smallest of the 24 movable vertebrae transversarium for the passage of the vertebral artery
 Their smaller size reflects the fact that they bear less and veins
weight than do the larger inferior vertebrae note that the vertebral artery passes through the
 Although the cervical IV discs are thinner than those transverse processes C1 to 6 and not through C7
of inferior regions, they are relatively thick compared The spines are small (short) and bifid
to the size of the vertebral bodies they connect
The body is small and broad from side to side
Seven cervical vertebrae form the cervical region of  has a concave superior surface & a convex inferior surface
the vertebral column & classified as
The vertebral foramen is large and triangular
Typical (3rd -6th ) and Articular processes
Atypical (1st,2nd & 7th ) Superior facets - face backward and upward;
Inferior facets are face downward and forward.
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X-cs of Typical Cervical Vertebrae X-cs of the Atypical Cervical Vertebrae

C1or Atlas:
Does not possess a body or a spinous process
Consisting of two lateral masses connected by anterior
& posterior arches.
The lateral mass has
 Concave superior articular facets articulate with the occipital
condyles (atlanto-occipital joints) and
 Inferior articular facets articulate with the axis (atlantoaxial J)

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X-cs of the Atypical Cervical Vertebrae

C2 or axis:
Has a peg like dens (odontoid) process that projects from
the superior surface of the body
 representing the body of the atlas that has fused with the
body of the axis
C7 or vertebra prominens:
Is so named because it has the longest spinous process, that
is nearly horizontal forms a visible protrusion and it is not
bifid
The transverse process is large, but the foramen
transversarium is small and transmits vertebral vein
Provides an attachment site for the ligamentum nuchae,
supraspinous ligaments, and numerous back muscles.
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Thoracic Vertebrae
 The thoracic vertebrae lie in the upper back and provide
attachment for the ribs

 There are twelve thoracic vertebrae (T1-12), each of

which is characterized by articulations with ribs

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Thoracic Vertebrae Thoracic Vertebrae

 The middle four thoracic vertebrae (T5 - T8)  Articular processes
demonstrate all the features typical of thoracic vertebrae
 Nearly vertical articular facets;
 Vertebral body
• Superior facets directed posteriorly and slightly
Heart shaped; costal facets for articulation with head of laterally;
rib
• Inferior facets directed anteriorly and slightly medially;
 Vertebral foramen
 Spinous process
Circular and smaller than those of cervical and lumbar
vertebrae  Long; slope postero-inferiorly; tips extend to level of
vertebral body below
 Transverse processes
Long and strong and extend posterolaterally;
length diminishes from T1 to T12
T1–T10 have facets for articulation with tubercle of rib
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Thoracic Vertebrae
 The T1- T4 vertebrae share some features of cervical
vertebrae
 T1 is atypical of thoracic vertebrae in that it has a long,
almost horizontal spinous process that may be nearly as
prominent as that of the vertebra prominens (C7)
 Body of T1 has
Complete superior costal facet for the 1st rib and
Inferior demifacet that contributes to the articular surface
for the 2nd rib

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Thoracic Vertebrae
 The T9–T12 vertebrae have some features of lumbar Thoracic Vertebrae
vertebrae
e.g. Tubercles similar to the accessory processes Articulation with ribs
Mammillary processes (small tubercles) also occur on  A typical thoracic vertebra has three sites on each side
vertebra T12.
 Most of the transition in characteristics of vertebrae from
for articulation with ribs:
the thoracic to the lumbar region occurs over the length of  Two demifacets (i.e. partial facets) are located on the
a single vertebra: vertebra T12. superior and inferior aspects of the body for articulation with
 Its superior half is thoracic in character, corresponding sites on the heads of adjacent ribs
having costal facets and articular processes that permit  The superior costal facet articulates with part of the head of
primarily rotatory movement, whereas its own rib, and the inferior costal facet articulates with part
 Its inferior half is lumbar in character, of the head of the rib below
devoid of costal facets and having articular processes that
permit only flexion and extension.  An oval facet (transverse costal facet) at the end of the
 Consequently, vertebra T12 is subject to transitional stresses transverse process articulates with the tubercle of its own
that cause it to be the most commonly fractured vertebra. rib
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Thoracic Vertebrae

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Thoracic Vertebrae
Articulation with ribs
 Not all vertebrae articulate with ribs in the same
fashion
 The superior costal facets on the body of vertebra T1
are complete and articulate with a single facet on the
head of its own rib
 In other words, the head of Rib 1 does not articulate
with C7vertebra

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Thoracic Vertebrae Thoracic Vertebrae

Articulation with ribs Articulation with ribs
 T10 vertebra (and often T9) articulates only with its  T11 and T12 vertebrae articulate only with the heads
own ribs and therefore lacks inferior demifacets on of their own ribs
the body  They lack transverse costal facets
 But has transverse costal facets  Have only a single complete facet on each side of
their bodies

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Lumbar Vertebrae Lumbar Vertebrae

 Transverse processes
 Lumbar vertebrae are in the lower back between the  Long and slender;
thorax and sacrum  Accessory process on posterior surface of base of each
 The vertebral bodies are massive and progressively process; provides an attachment for the intertransversarii
increase in size from vertebra LI to LV muscles.
 Articular processes
 Note that the lumbar vertebrae have no facets for articulation
 Nearly vertical facets;
with ribs and no foramina in the transverse processes
• Superior facets directed posteromedially (or
 Vertebral body medially);
Massive; kidney shaped when viewed superiorly has mammillary process; give attachment to both
 Vertebral foramen multifidus & intertransversarii muscles of the back.
Triangular; larger than in thoracic vertebrae and • Inferior facets directed anterolaterally (or laterally);
smaller than in cervical vertebrae  Spinous process
 Short, flat, and quadrangular and project backward
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Sacrum
 A large, triangular, wedge-shaped bone
 Composed of five fused sacral vertebrae in adults.
 Is located between the hip bones and forms the roof
and posterosuperior wall of the posterior pelvic cavity
 provides strength and stability to the pelvis.
 transmits the weight of the body to the pelvic girdle,

 The sacrum is often wider in proportion to length in

female than in male, but the body of the S1 vertebra is
usually larger in males.

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Sacrum
Base of the sacrum
 Formed by the superior surface of the S1 vertebra.
 Its superior articular processes articulate with the inferior
articular processes of the L5 vertebra.
 Sacral promontory (L. mountain ridge),
the prominent anterior edge of the S1 vertebra, an
important obstetrical landmark.
Apex of the sacrum
 tapering inferior end, has an oval facet for articulation
with the coccyx

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Sacrum
 Has four pairs of sacral foramina for the exit of the
ventral and dorsal primary rami of the first four sacral
nerves.
The anterior (pelvic) sacral foramina are larger than
the posterior (dorsal) ones.
 Sacral canal
Is the continuation of the vertebral canal
Contains the bundle of spinal nerve roots arising
inferior to the L1 vertebra, known as the cauda equina
(L. horse tail), that descend past the termination of the
spinal cord

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Sacrum
Pelvic surface of the sacrum
 It is smooth and concave
 During childhood, the individual sacral vertebrae are
connected by hyaline cartilage and separated by IV discs
 In adults there is four transverse lines indicating where
fusion of the sacral vertebrae occurred
 Fusion starts after age 20;
However, most of the IV discs remain unossified up to or
beyond middle life

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Dorsal surface of the sacrum

Sacrum
Dorsal surface of the sacrum
 It is rough, convex, and marked by five prominent
longitudinal ridges.
1. Median sacral crest (central ridge),
 represents the fused rudimentary spinous processes of the
superior three or four sacral vertebra; S5 has no spinous
process.
2. Intermediate sacral crests
 represent the fused articular processes, and
3. lateral sacral crests
 are the tips of the transverse processes of the fused sacral
vertebrae.
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Sacrum
 The clinically important features of the dorsal surface of
the sacrum are the inverted U-shaped sacral hiatus and
the sacral cornua (L. horns).
Sacral hiatus:
 Results from the absence of the laminae and spinous
process of S5 and sometimes S4.
 It is used for the administration of caudal (extradural)
anesthesia.
 Posterior sacral foramina also used for trans sacral
epidural anesthesia.
Epidural anesthesia may applied during childbirth
Sacral cornua or horn:
 Representing the inferior articular processes of S5 vertebra
 It is an important landmark for locating the sacral hiatus.
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Coccyx (tail bone) Coccyx

 Pelvic surface; It is concave and relatively smooth, and
 A small triangular bone formed by fusion of the four
rudimentary coccygeal vertebrae.  Posterior surface; has rudimentary articular
processes
 It is remnant of caudal eminence of embryonic
tail-like skeleton, Coccygeal vertebra 1 (Co1)
present in embryos from the end of the 4th wk  The largest and broadest of all the coccygeal
until the beginning of 8th wk. vertebrae.
 Provides attachment for parts of the gluteus  Its short transverse processes are connected to the
maximus and anococcygeal ligament, coccygeus and sacrum, and
levator ani muscles.  Its rudimentary articular processes form coccygeal
 Does not support body weight when standing; cornua, which articulate with the sacral cornua.
however, when sitting it is receive some weight
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Variations in the Vertebrae

 Most people have 33 vertebrae
 But developmental errors may result in 32 or 34
vertebrae
 Estimates of the frequency of abnormal numbers of
vertebrae superior to the sacrum range between 5%
and 12%
 Variations in vertebrae are affected by race, sex, and
developmental factors (genetic and environmental)
 An increased number of vertebrae occurs more often
in males and a reduced number occurs more
frequently in females
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Variations in the Vertebrae

Abnormal Fusion of Vertebrae
 Hemisacralization & sacralization of the L5 vertebra
 A condition in which L5 is partly or completely
incorporated into the sacrum, respectively
 Hemilumbarization & lumbarization of the S1
vertebra
 S1 is more or less separated from the sacrum and is
partly or completely fused with L5 vertebra,
respectively

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Curvatures of the Vertebral Column

 The vertebral column in adults has four curvatures:
cervical, thoracic, lumbar, and sacral
1. Primary Curvature
 includes thoracic & sacral curvatures
 concave anteriorly
 Develop during the fetal period in relationship to the
(flexed) fetal position
2. Secondary Curvatures
 appear after birth, result from extension from the flexed
fetal position
 includes cervical & lumbar curvatures
 Concave posteriorly

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Abnormal Curvatures of the Vertebral

Column
A. Kyphosis (hunchback or humpback) an abnormally
increased thoracic (forward) curvature resulting from
osteoporosis;
B. Lordosis (swayback or saddle back)—an abnormally
increased lumbar (backward) curvature resulting from
trunk muscular weakness or osteomalacia; and
C. Scoliosis a condition of lateral deviation resulting from
 unequal growth of the vertebral column,
 pathologic erosion of vertebral bodies, or
 asymmetric paralysis or weakness of vertebral muscles.

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Vertebral Ligaments Joints & ligaments of Vertebral Column

 Joints between vertebrae are reinforced and supported by
numerous ligaments, which interconnect components of the  The joints of the vertebral column include the:
vertebral arches.
A. Joints of the vertebral bodies
 The well known ligaments are:
B. Joints of the vertebral arches
 Anterior and posterior longitudinal ligaments,
C. Craniovertebral (atlanto-axial and atlanto-occipital)
 Ligamentum flavum,
joints
 Supraspinous ligament and
D. Costovertebral joints
 Ligamentum nuchae
 Other Ligaments
E. Sacro-iliac joints
 Interspinous (between two adjacent spinous processes) &
 Intertransverse (between two adjacent transverse
processes) ligaments.
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A. Joints of the Vertebral Bodies Intervertebral disc (IVD)

 A fibrocartilagenous ring that bind together the
 The joints of the vertebral bodies are symphyses vertebral bodies.
(secondary cartilaginous joints)  Extend from C2 to the sacrum(23 in number).
designed for weight bearing and strength  There is no IV disc between C1 and C2 vertebrae
 The superior and inferior surfaces of the bodies of  Account one quarter of the length of the vertebral
adjacent vertebrae are covered by thin plates of column below the level of C2
hyaline cartilage.  Form the inferior half of the anterior border of the
 Two adjacent vertebrae are connected by IV foramen
IV discs and  Their main function is shock absorption
Ligaments (anterior and posterior longitudinal  Thickest in the cervical and lumbar regions.
ligaments) where the movements of the vertebral column are
greatest.
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Intervertebral disc (IVD)

 Each IV disc consists of
 anulus fibrosus, an outer fibrous part, composed of
concentric lamellae of fibrocartilage, and
 nucleus pulposus; a gelatinous central mass
Which is remnant of notochord
Avascular
It receives its nourishment by diffusion from blood
vessels at the periphery of the anulus fibrosus and
vertebral body

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Anterior & posterior longitudinal ligaments

 Run as continuous bands down the anterior and posterior
surfaces of the vertebral column from the skull to the
sacrum.
Anterior longitudinal ligament;
 Attached superiorly to the base of the skull and extends
inferiorly to attach to the anterior surface of the sacrum
 Is wide and is strongly attached to the front and sides of
the vertebral bodies and to the IVDs.
Posterior longitudinal ligament:
 Is weak and narrow and is attached to the posterior
borders of the discs.
 lines the anterior surface of the vertebral canal
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B. Joints of Vertebral Arches Ligaments

 Supraspinous ligament: Connects and passes along the
 Also called zygapophysial joints (facet joints). tips of the vertebral spinous processes from vertebra
 Plane type of synovial joints between the superior and C7 to the sacrum
inferior articular processes of adjacent vertebrae.  Interspinous ligament: connects adjacent spines.
permit gliding movements between the articular  Intertransverse ligaments: run between adjacent
processes transverse processes.
 Surrounded by a thin joint capsule  Ligamentum flavum: connects the laminae of adjacent
in the cervical region, it is thin and loose reflecting the vertebrae.
wide range of movement.  In cervical region
 Accessory ligaments unite the laminae, transverse  Ligamentum nuchae: extends from the spine of the C7
processes, and spinous processes and help stabilize the vertebra to the external occipital protuberance
joints.  upward continuation of supraspinal ligament
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C. Craniovertebral Joints
 Synovial joints that have no IV discs
 Their design gives a wider range of movement than in
the rest of the vertebral column
 The articulations involve the occipital condyles, atlas,
and axis
There are two sets of craniovertebral joints
I. Atlanto-occipital joints; formed between atlas (C1) and
occipital bone of the cranium, and
II. Atlantoaxial joints: formed between atlas & axis (C2)

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Atlanto-Occipital Joints
 Articulations between the superior articular surfaces of
the lateral masses of the atlas and the occipital condyles
 Condyloid type of synovial joints.
 Movements
Flexion, extension, and lateral flexion.
Indicating approval (Yes• movement)
No rotation is possible.
 Ligaments
Anterior atlanto-occipital membrane
Posterior atlanto-occipital membrane

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Atlanto-Occipital Joints
Ligaments
 Anterior atlanto-occipital membrane:
Connects the anterior arch of the atlas to the
anterior margin of the foramen magnum.
Broader and centrally it continuous with the
anterior longitudinal ligament
 Posterior atlanto-occipital membrane:
Connects the posterior arch of the atlas to the
posterior margin of the foramen magnum
As a ligamentum flavum of lower vertebrae

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Atlanto-occipital joints ligaments Atlantoaxial Joints

 Three atlantoaxial articulations :
Two (right and left) lateral atlantoaxial joints
 b/n the inferior facets of the lateral masses of C1&
superior facets of C2
 are gliding-type synovial joints
One median atlantoaxial joint: is a pivot joint
 b/n the dens of C2 and the anterior arch of the atlas

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Atlantoaxial Joints
Ligaments: includes
 Apical ligament: median-placed structure connects
the apex of the odontoid process to the anterior margin
of the foramen magnum.
 Alar ligaments: lie one on each side of the apical
ligament and connect the odontoid process to the medial
sides of the occipital condyles.
 Cruciate ligament: has a transverse part and a
vertical part.
 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.
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Atlantoaxial joints ligaments Atlantoaxial Joints

 Cruciate ligament…
 Vertical part runs from the posterior surface of the
body of the axis to the anterior margin of the
foramen magnum.
 Membrana tectoria: an upward continuation of
the posterior longitudinal ligament.
 It runs superiorly from the body of C2 through the
foramen magnum to attach to basilar part of occipital
bone.
 Covers the posterior surface of the odontoid
process and the above three ligaments.
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Atlantoaxial Joints
Movement at all three atlantoaxial joints
 permits the head to be turned from side to side,
 as occurs when rotating the head to indicate
disapproval (the no•movement)

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Nerve Supply of Vertebral Joints Fig.

 The innervation of
Joints of the Vertebral Bodies vertebral joints.
 Innervated by the small meningeal branches of
each spinal nerve
 It arises from the spinal nerve as it exits from the
intervertebral foramen.
 re-enters the vertebral canal and supplies the
meninges, ligaments, and intervertebral discs.
 At any particular level joints receive nerve fibers
from two adjacent spinal nerves.

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Joints of Vertebral Arches Movements of the Vertebral Column

Innervation:
 The range of movement of the vertebral column varies
 Posterior rami divide into
according to the region and the individual
 Medial and
 Lateral branches.
 The vertebral column is capable of
 The medial branch gives rise Flexion & Extension; occurring primarily in the
to articular branches that cervical and lumbar regions
innervate the zygapophysial Lateral flexion and extension; occurring mostly in
joint at that level, and to the the cervical and lumbar regions
joint one level inferior to its
Rotation; occurs primarily at the craniovertebral
exit.
joints and thoracic region
therefore, each joint is
supplied by two nerves.

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Movements of the Vertebral Column Movements of the Vertebral Column

 Movements of the vertebral column are more free The range of vertebral column movement is limited by:
in the cervical and lumbar regions than elsewhere
 Thickness, elasticity and compressibility of IVDs
 Note:Vertebral column in thoracic region is relative  Shape and orientation of zygapophysial joints
stabile because  Tension of the joint capsules of zygapophysial joints
 It’s IV discs are thin relative to the size of the  Resistance of the back muscles and ligaments
vertebral bodies e.g., ligamenta flava and post. longitudinal ligament
 It connected to the sternum by the ribs and costal  Attachment to the thoracic (rib) cage
cartilages.  Bulk of surrounding tissue

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Movements of the Vertebral Column Movements of the Vertebral Column

 The sagittally oriented joint planes of the lumbar region
Flexion, extension, lateral flexion, and rotation
are conducive to flexion and extension
of the neck are especially free because the:
however, the interlocking articular processes here
 IV discs are thick relative to the size of the vertebral
prevent rotation
bodies at this level
 Lateral flexion of the vertebral column is greatest in the
 Surfaces of zygapophysial facet are relatively large and
cervical and lumbar regions
the joint planes are almost horizontal
 In the thoracic region the joint planes lie on an arc that is
 Joint capsules of the zygapophysial joints are loose
centered on the vertebral body, permitting rotation
 Neck is relatively slender (less surrounding soft
But flexion and lateral flexion are limited
tissue).

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Movements of the Vertebral Column

Vasculature of the Vertebral

Column

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Vasculature of the Vertebral Column

 Vertebrae are supplied by

 Periosteal and equatorial branches of the major
 Cervical arteries and
 Segmental arteries of the trunk
 These branches occur at all levels of the vertebral
column, and from the following arteries:

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Vasculature of the Vertebral Column Vasculature of the Vertebral Column

Arteries includes Venous drainage
 Spinal veins form venous plexuses;
Neck Thoracic Abdominal Pelvic
 Internal vertebral venous plexus (epidural venous
region region region region
plexuses); inside the vertebral canal
 External vertebral venous plexuses, outside the
 Vertebral  Posterior  Subcostal  Iliolumbar vertebral canal
 Ascending intercostal  Lumbar  Lateral
 These plexuses communicate through the
cervical sacral
 Medial intervertebral foramina
sacral  Drain into the vertebral veins of the neck and
segmental (intercostal, lumbar, and sacral) veins of the
trunk
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Con’t
Intervertebral veins
 Receive veins from the spinal cord and vertebral
venous plexuses pass through IV foramina to
 Drain into the vertebral veins of the neck and
segmental (intercostal, lumbar, and sacral) veins of the
trunk

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Vasculature of the Vertebral Column Nerves of the Vertebral Column

 Zygapophysial joints
 Innervated by articular branches of the medial
branches of the posterior rami
 Other part of vertebral column
 Innervated by recurrent meningeal branches of
the spinal nerves
arise from the mixed spinal nerve, or from the
anterior ramus.

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Nerves of the Vertebral Column Nerves of the Vertebral Column

 Inside the canal,
Recurrent meningeal of spinal nerve give branches
 transverse, ascending, and descending branches distribute
outside and inside the vertebral canal
nerve fibers to the:
 Outside the canal
 Periosteum (covering the surface of the posterior
anterolateral aspect of the vertebral bodies and IV vertebral bodies, pedicles, and laminae).
discs.  Ligamenta flava.
periosteum and especially the anuli fibrosi and  Anuli fibrosi of the posterior and posterolateral aspect of
anterior longitudinal ligament. the IV discs.
 Posterior longitudinal ligament.
 Spinal dura mater.
 Blood vessels within the vertebral canal.
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Muscles of the Back

Two major groups of muscles in the back
 The extrinsic back muscles include
 Superficial muscles: produce and control limb movements
 Intermediate muscles: produce and control respiratory
movements.
 The intrinsic (deep) back muscles
 Specifically act on the vertebral column, producing its
movements and maintaining posture

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Superficial extrinsic back muscles

 are posterior axio- appendicular muscles
 Connect the pectoral girdle and humerus to the
trunk and produce and control limb movements
 Includes: trapezius, latissimus dorsi, levator scapulae,
and rhomboids mm
 Most part these muscles receive their nerve supply
from the anterior rami of cervical nerves and act on
the upper limb
 The trapezius receives its motor fibers from a cranial
nerve, the spinal accessory nerve (CN XI)

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Trapezius
 Large, triangular muscle covering the posterior
aspect of the neck and the superior half of the trunk
 The two sides of the muscle form a trapezium
 Attaches the pectoral girdle to the cranium and
vertebral column
 Its fibers are divided into three parts:
1. Superior fibers- elevate the scapula
2. Middle fibers-retract the scapula
3. Inferior fibers- depress the scapula

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Trapezius
 Origin: -Medial third of superior nuchal line
- External occipital protuberance
- Nuchal ligament & Spinous processes of
C7 - T12 vertebrae
 Insertion: Lateral third of clavicle; acromion and spine of
scapula
 Nerve Supply: Accessory nerve (CN XI)
 Main Action:
 Descending part elevates;
 Ascending part depresses; and
 Middle part (or all parts together) retracts scapula
 Descending and ascending parts act together to rotate
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Latissimus dorsi
 Latissimus dorsi(L. widest of the back)
 Large, fan-shaped muscle passing from the trunk
to the humerus
 In combination with the pectoralis major:
– is a powerful adductor of the humerus
– is also useful in climbing a tree, as it raises the
trunk to the arm(thus Climbing muscle)

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Latissimus dorsi Levator scapulae

 Origin  Lies deep to the SCM & Trapezius
 Spinous processes of inferior 6 thoracic vertebrae,  True to its name, it acts to elevate the scapula
 Thoracolumbar fascia, Iliac crest, and  Origin: Posterior tubercles of transverse processes
 Inferior 3 or 4 ribs of C1 - C4 vertebrae
 Insertion: intertubercular groove of humerus  Insertion: Medial border of scapula superior to spine
 Innervation:Thoracodorsal nerve  Nerve Supply: Dorsal scapular (C4 & C5) and
 Action: Extends, adducts, and medially rotates cervical (C3, C4) nerves
humerus; raises body toward arms during climbing  Main Action:
 Elevates scapula and tilts its glenoid cavity inferiorly by
rotating scapula
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Rhomboids (major and minor)

 Have a rhomboid appearance
 They lie deep to the trapezius and form broad parallel
bands that pass inferolaterally from the vertebrae to the
medial border of the scapula
 Origin:
 Minor: nuchal ligament; spinous processes of C7 and T1
vertebrae
 Major: spinous processes of T2 to T5 vertebrae
 Insertion:
 Minor: medial end of scapular spine
 Major: medial border of scapula from level of spine to
inferior angle
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Rhomboids (major and minor)

 Rhomboid Major: THINNER, ~2x wider than
rhomboid minor
 Rhomboid minor-THICKER, superior in position
 Innervation:
 Dorsal scapular nerve
 Action:
 Retract scapula and rotate it to depress glenoid cavity
 fix scapula to thoracic wall during movements of
upper limb

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Muscular Triangles of the Back Muscular Triangles of the Back

 Auscultatory Triangle
 The site on the back where
 Lumbar Triangle
breath sounds may be most  It may be the site of
easily heard with a an abdominal hernia and
stethoscope.
pus may emerge from the abdominal wall.
 Formed by the
 Boundaries
 Inferior: Superior border of
latissimus dorsi,  Posterior: latissimus dorsi,
 Lateral: Medial border of  Anterior: Posterior border of the external oblique
scapula, and muscle of the abdomen, and
 Medial: Inferolateral border  Inferior: Iliac crest
of trapezius  Floor: Internal oblique muscle
 Floor: Rhomboid major
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Intermediate extrinsic back muscles

Serratus posterior muscles;
 are thin muscles, commonly designated as superficial
respiratory muscles.
 Serratus posterior superior lies deep to the
rhomboid muscles, and
 Serratus posterior inferior lies deep to the
latissimus dorsi.
 Both are innervated by intercostal nerves

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Intermediate extrinsic back muscles

 Serratus posterior superior
 Origin: Nuchal ligament, spinous processes of C7 to T3
vertebrae
 Insertion: Superior borders of 2nd to 4th ribs
 Action: elevate ribs
 Innervation: 2nd to 5th intercostal nerves
 Serratus posterior inferior
 Origin: Spinous processes of T11 to L2 vertebrae
 Insertion: Inferior borders of 8th to12th ribs near their
angles
 Action: depress ribs
 Innervation: T9 to T12 thoracic spinal nerves
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Intrinsic Back Muscles

 Also called muscles of back proper, deep back
muscles
 Because:
 Act to maintain posture and control movements of
the vertebral column &
 Innervated by the posterior rami of spinal nerves
 These muscles extend from the pelvis to the cranium
& enclosed by deep fascia

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Intrinsic Back Muscles

Deep fascia
 Medially; attaches to the
 nuchal ligament,
 tips of the spinous processes of the vertebrae,
 supraspinous ligament, and
 median crest of the sacrum
 Laterally; attaches to the
 cervical and lumbar transverse processes and to the angles
of the ribs
 In thoracic and lumbar regions it is called thoracolumbar
fascia

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Thoracolumbar fascia
 Invests the deep muscles of the back,
 Have
I. Anterior layer: lies anterior to the quadratus
lumborum and attaches to the vertebral transverse
process, and
II. Middle layer: lies b/n quadratus lumborum and erector
spinae attaches to the vertebral transverse process
III. Posterior layer that lies posterior to the erector
spinae and attaches to the spinous processes.
B. Location of the intrinsic back muscles and the layers of
 Provides the origins for the latissimus dorsi and the fascia associated with them.
internal oblique and transverse abdominis muscles.
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Superficial Layer of Intrinsic Back Muscles

Intrinsic Back Muscles
(Spinotransverse Group)
 According to their relationship to the surface, Splenius muscles (L. musculi splenii)
intrinsic (deep) back muscles are grouped in to three  lie on the lateral and posterior aspects of the neck,
layers covering the vertical muscles like a bandage
o Superficial,  Cover & hold the deep neck muscles in position.
o Intermediate, and  Consisting of
o Deep layers  Splenius cervicis
 Splenius capitis
Arise from the midline and extend superolaterally to the
cervical vertebrae and cranium respectively.

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Superficial Layer of Intrinsic Back Muscles Superficial Layer of Intrinsic Back Muscles
Splenius muscles
 Origin: Nuchal ligament and spinous processes of
C7–T6 vertebrae
 Insertion
 Splenius capitis: fibers run superolaterally to mastoid
process of temporal bone and lateral third of superior
nuchal line of occipital bone
 Splenius cervicis: tubercles of transverse processes of
C1–C3 or C4 vertebrae
 Innervation: Posterior rami of spinal nerves

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Intermediate Layer of Intrinsic Back Muscles Intermediate of Intrinsic Back Muscles

Grouped as erector spinae muscles
(Sacrospinalis Group)
 Lie in a groove•
on each side of the vertebral column
between the spinous processes centrally and the angles
of the ribs laterally
 Chief extensor of the vertebral column
 Divided into three columns:
 Lateral Iliocostalis
 Intermediate  Longissimus and
 Medial Spinalis
 Each column is divided regionally into three parts
according to the superior attachments
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Intermediate Layer of Intrinsic Back Muscles

Erector spinae
(Intermediate intrinsic back muscles)
A. Iliocostalis forms the lateral column,
 Iliocostalis lumborum  Origin
 Iliocostalis thoracis  Iliac crest, posterior surface of sacrum, sacro-iliac
 Iliocostalis cervicis ligaments,
B. Longissimus forms the intermediate column, and  Sacral and inferior lumbar spinous processes, and
 Longissmus thoracis
supraspinous ligament
 Longissmus cervicis
 Insertion
 Longissmus capitis
 Iliocostalis: lumborum, thoracis, cervicis;
fibers run superiorly to angles of lower ribs and cervical
C. Spinalis forms the medial column.
transverse processes
 Spinalis thoracis
 Spinalis cervicis
 Spinalis capitis
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Erector spinae
(Intermediate intrinsic back muscles)
 Insertion
 Longissimus: thoracis, cervicis, capitis;
Fibers run superiorly to ribs between tubercles and
angles to transverse processes in thoracic and
cervical regions, and
to mastoid process of temporal bone
 Spinalis: thoracis, cervicis, capitis;
Fibers run superiorly to spinous processes in the
upper thoracic region and to cranium
 Innervation: Posterior rami of spinal nerves

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Deep layer of intrinsic back muscles

Transversospinalis group
 Deep to the erector spinae & an obliquely disposed group
of much shorter muscles
 Occupy the ―gutter‖ b/n the transverse & the spinous
processes.
 Consisting of
 Semispinalis,
 Multifidus, and
 Rotatores
 Originate from transverse processes of vertebrae and pass to
spinous processes of more superior vertebrae.

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Deep layer of intrinsic back muscles Deep layer of intrinsic back muscles
(Transversospinalis) (Transversospinalis)
Semispinalis Multifidus
 Superficial member of the group.  Middle layer of the group
 It is divided into three parts according to the superior  Consists of short, triangular muscular bundles that are
attachments: thickest in the lumbar region.
 Semispinalis capitis, Rotatores or rotator muscles
 Semispinalis thoracis, and
 Deepest of the three layers of transversospinal muscles
 Semispinalis cervicis
 Best developed in the thoracic region.
 Fibers run from transverse processes of vertebrae to
 Fibers arises from transverse processes of C4–T12
junction of lamina and transverse process or spinous
vertebrae to occipital bone and spinous processes in
process of vertebra
thoracic and cervical regions
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Transversospinalis (rotator muscles)

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Intrinsic Back Muscles Suboccipital & Deep Neck Muscles

IV. Other segmental deep back muscles Suboccipital region
 Are innervated by the dorsal primary rami of the spinal  is a muscle ―compartment‖ deep to the superior part of the
nerves. posterior cervical region,
 Consist of the following  underlying the trapezius, sternocleidomastoid, splenius, and
A. Interspinales: Run between adjacent spinous semispinalis muscles.
processes and aid in extension of the vertebral  It is a pyramidal space inferior to the external occipital
column. prominence of the head that includes the posterior aspects of
B. Intertransversarii: Run between adjacent vertebrae C1 and C2.
transverse processes and aid in lateral flexion of the  Consist of four small muscles;
vertebral column  Two rectus capitis posterior (major and minor) and
C. levatores costarum: Extend from the transverse  Superior and inferior obliquus capitis muscles.
processes to ribs, elevate the ribs, and are innervated
by the intercostal nerves.
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Suboccipital M Origin Insertion

Rectus capitis Spinous process Lateral part of inferior Suboccipital & Deep Neck Muscles
posterior major of vertebra C2 nuchal line of occipital bone
 All four muscles are innervated by suboccipital nerve
Rectus capitis Spinous process Lateral part of inferior (posterior ramus of C1)
posterior major of vertebra C2 nuchal line of occipital bone  The nerve emerges within the suboccipital triangle.
 b/n vertebral artery above and posterior arch of atlas
Rectus capitis Post tubercle of Medial part of infer nuchal
below
posterior minor post arch of C1 line of occipital bone

Obliquus capitis Post tubercle of Transverse process of C1

inferior post arch of C2

Obliquus capitis inferior is the only ―capitis‖ muscle that

has no attachment to the cranium
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Suboccipital & Deep Neck Muscles

Suboccipital triangle
 Bounderies
 Medially: rectus capitis posterior major muscle,
 Laterally: obliquus capitis superior muscle, and
 Inferiorly: obliquus capitis inferior muscle.
 Roof: semispinalis capitis and longissimus capitis.
 Floor: posterior arch of the atlas and posterior atlanto-
occipital membrane.
 Contains: vertebral artery and suboccipital nerve & vessels.

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Suboccipital and Deep Neck Muscles

Suboccipital region
 is a muscle ―compartment‖ deep to the superior part of the
posterior cervical region, Clinical Correlation
 underlying the trapezius, sterno cleidomastoid, splenius, and
semispinalis muscles. of
 It is a pyramidal space inferior to the external occipital
prominence of the head that includes the posterior aspects of Vertebral Column
vertebrae C1 and C2.
 The four small muscles of the suboccipital region lie deep
(anterior) to the semispinalis capitis muscles and consist of
two rectus capitis posterior (major and minor) and two
obliquus muscles.

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Fracture and Dislocation of C2

Fracture and Dislocation of C2 Fractures of the dens are
 Fractures of the vertebral arch  The transverse ligament of atlas is stronger than dens of the C2.
of the axis are one of the  Fractures of the dens make up about 40% of fractures of the axis.
most common injuries of  Commonly dens fracture occurs at
the cervical Vertebrae
 Its base: do not reunite because
Hangman’s fracture:
 the transverse ligament of the atlas becomes interposed
 Fracture at the pars
between fragments and
interarticularis of the axis
(C2),  the separated fragment (the dens) no longer has a blood
 Due to hyperextension of supply.
the head over the neck.  Vertebral body inferior to the base of the dens.
 In this fracture, the  heals more readily because the fragments retain their blood
cruciform ligament is torn supply.
and the spinal cord is
crushed, causing death.  Other dens fractures result from abnormal ossification patterns.
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Fractures of the dens at Cervical Ribs

 A cervical rib is a relatively common anomaly.
 Supernumerary (extra) rib: place pressure on
structures that emerge from the superior thoracic
aperture,
 notably the subclavian artery or inferior trunk of the
brachial plexus, and
 may cause thoracic outlet syndrome.

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Anomalies of the Vertebrae Anomalies of the Vertebrae

Spina bifida Spina bifida occulta
 Defective closure of the vertebral arch associated  A common congenital anomaly of the vertebral
with maternal folic acid deficiency column
 Usually occurs in the vertebral arch of L5 and/or S1  The laminae (neural arches) of L5 and/or S1 fail to
 It may be classified as fuse posterior to the vertebral canal
I. Spina bifida occulta  The defect is concealed by the overlying skin
II. Spina bifida cystica but its location is often indicated by a tuft of hair

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Anomalies of the Vertebrae

Spina bifida cystica
 Severe types of spina bifida, one or more vertebral
arches may fail to develop completely
 Associated with herniation of
I. Meninges called meningocele, and
II. Meninges and/or spinal cord called
meningomyelocele
A. Spina bifida occulta
B. Meningocele
C. Meningomyelocele

Infant with spina bifida cystica

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Anomalies of the Vertebrae Herniation of the Nucleus Pulposus

II. Meningomyelocele  Herniation or protrusion of the gelatinous nucleus

pulposus into or through the anulus fibrosus is a well-
 Neurological symptoms are usually present
recognized cause of low back and lower limb pain
e.g., paralysis of the limbs and
 It commonly occurs posterolaterally,
disturbances in bladder and bowel control
 where the anulus fibrosus is relatively thin and
 Result from neural tube defects, such as the defective
closure of the neural tube during the 4th week of  does not receive support from either the posterior or
embryonic development the anterior longitudinal ligaments
 It is associated with maternal folic acid deficiency

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Herniation of the Nucleus Pulposus Herniated IVD

 Posterolateral herniations of the nucleus pulposus are
most common in the lumbar and lumbosacral regions
 Because the IV discs are largest in these regions and
movements are consequently greater,
 Approximately 95% of lumbar disc protrusions occur at
the L4-L5 or L5- S1 levels
Note:
 The general rule is that when an IV disc protrudes, it
usually compresses the nerve root numbered one
inferior to the herniated disc;
e.g. An L4-L5 IV disc herniation would likely
compress the L5 nerve ( not L4 nerve roots)
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Lumbar Spinal Puncture

 Is the tapping of the subarachnoid space in the lumbar
region (lumbar cistern),
 Usually between the laminae of vertebrae L3 and L4 or
vertebrae L4 and L5.
 LP is performed with the patient lying on the side with
the back and hips flexed (knee-chest position)
 It allows withdrawal of a sample of CSF for microbial or knee-chest position
chemical analysis and also allows introduction of
anesthesia, drugs, or radiopaque material into the
subarachnoid space.

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Thank you

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