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Applied Anatomy of the Thorax and Abdomen

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Applied Anatomy of the Thorax and Abdomen Applied anatomy of the thorax and abdomen CHAPTER CONTENTS The posterior aspect of the vertebral body and the arch The thoracic spine e157 enclose the vertebral foramen. The spinal cord at the thoracic level is rounder and smaller than at the cervical level, and in The vertebra . e157 consequence the vertebral foramina are also smaller. The intervertebral disc . e157 Where the pedicles and laminae unite the transverse process The ligaments . e158 is found, slightly posterior to the articular process, pedicle and Facet joints . e158 intervertebral foramen. There is also an oval facet for the ribs on all the transverse processes, except for T11 and T12, to Content of the spinal canal . e158 which ribs are not attached. The thoracic cage e160 The spinous processes at mid-thorax are long and very Bony structures . e160 steeply inclined: each transverse process is at a level one Contractile structures . e161 and a half vertebrae higher than the tip of the corresponding Landmarks . e164 spinous process. In the upper and lower thorax, the spinous processes are less inclined; here, the corresponding transverse Movements of the thoracic spine and cage . e165 process is located approximately one level higher. The abdominal wall e165 The oval intervertebral foramina are located behind the vertebral bodies and between the pedicles of the adjacent vertebrae and contain the segmental nerve roots. In the tho- The thoracic spine racic spine, these are situated mainly behind the inferoposte- rior aspect of the upper vertebral body and not just behind the The vertebra disc. This makes a nerve root compression by a posterolateral displacement less likely at the thoracic level, whereas at the lumbar level nerve root compressions by posterolateral disc The thoracic spine has a primary dorsal convexity (Fig. 1) protrusions are quite common (Fig. 3, see Standring, Fig. associated with intrauterine life – a phylogenetic kyphosis – 42.27). whereas the cervical and lumbar spine have a compensatory The location of the intervertebral foramen depends on the lordosis. level. In the upper and lower thoracic area, it is level with the The 12 thoracic vertebrae are intermediate in size between tip of the spinous process of the vertebra above, i.e. level those in the cervical and lumbar regions. They are composed above. At mid-thorax there is a difference of about 11 levels. of a vertebral body – a cylindrical ventral mass of bone – con- 2 tinuing posteriorly into a vertebral arch (Fig. 2). The typical thoracic vertebral body is heart-shaped in cross-section and has The intervertebral disc on each of its lateral aspects a superior and inferior costal facet for articulations with the ribs (costovertebral joints). The arch A fibrocartilaginous disc forms the articulation between two is constructed out of two pedicles and two short laminae, the vertebral bodies. The anatomy and behaviour of discs are dis- latter uniting posteriorly to form the spinous process. Laminae cussed in Chapter 31, Applied anatomy of the lumbar spine. and spinous processes lie obliquely covering each other like the However, it is worth noting here that thoracic discs are nar- tiles of a roof, so protecting the posterior cord posteriorly. The rower and flatter than those in the cervical and lumbar spine. pedicles carry the articular and transverse processes. Disc size gradually increases from superior to inferior. The © Copyright 2013 Elsevier, Ltd. All rights reserved. The Thoracic Spine (a) 6 3 C7 C7 7 T1 T1 1 6 5 T7 (b) T7 T8 T8 1 3 6 T12 T12 2 4 5 7 L1 L1 (c) 6 7 Fig 1 • Lateral (left) and posterior (right) views of the thoracic spine. 3 5 nucleus is rather small in the thorax. Therefore protrusions are 1 usually of the annular type, and a nuclear protrusion is very 6 rare in the thoracic spine. Fig 2 • Lateral and cranial views of the sixth thoracic vertebra (a, b) and lateral view of the twelfth thoracic vertebra (c). 1, vertebral The ligaments body; 2, vertebral arch; 3, pedicle; 4, lamina; 5, spinous process; 6, articular processes; 7, transverse process. The longitudinal ligaments run anteriorly and posteriorly on the vertebral bodies (Fig. 4, see Standring, Fig. 54.10). The to each other by a joint capsule which possesses a true syn- anterior ligament covers the whole of the vertebral bodies’ ovium. The articular surface of the superior articular process anterior aspect and some of their lateral aspect. It is firmly points backwards, slightly upwards and outwards. The facet of connected to the periosteum but only loosely to the discs. The the inferior articular process faces forwards, slightly down- posterior longitudinal ligament is strongly developed at the wards and inwards. These articulations lock the vertebrae thoracic level and is wider than in the lumbar region, although together while allowing movements of flexion–extension, bilat- it covers only a part of the posterior aspect of each vertebral eral side flexion and rotation. body. It has some lateral expansions, which are firmly attached to the discs. Content of the spinal canal The ligamentum flavum, interposed between the laminae, extends laterally as far as the medial part of the inferior articu- The spinal canal is formed by the vertebral foraminae of lar process. At each level the ligamentum flavum has lateral the successive vertebrae, the posterior aspects of the discs, the extensions to both sides to form the capsules of the facet joints posterior longitudinal ligament, the ligamenta flava and the (see Standring, Fig. 42.42). The transverse processes are con- anterior capsules of the facet joints. In contrast to the cervical nected to each other by the intertransverse ligaments. The and lumbar regions, where the canal is triangular in cross- supra- and interspinal ligaments bridge the gap between the section and offers a large lateral extension to the nerve roots, spinous processes. the thoracic spinal canal is small and circular. It can be divided into three zones: the upper (T1–T3), and lower (T10–T12) Facet joints zones are transitional, respectively, the cervical and the tho- racic spine, and the thoracic and the lumbar spine. Between Each facet joint is composed of a superior and an inferior these is the mid-thoracic zone (T4–T9), where the spinal canal articular process, covered by hyaline cartilage and connected is at its narrowest (Fig. 5). © Copyright 2013 Elsevier, Ltd. All rights reserved. e158 Applied anatomy of the thorax and abdomen Spinal cord The dura mater contains the spinal cord, which ends approxi- mately at the L1 level. The spinal cord occupies the space of the spinal canal maximally at the thoracic level. This, together with its poor vascularization renders the thoracic spine very vulnerable to damage by extradural processes and vertebral trauma. The cord depends for its blood supply on these arterial circles. The inner circle is of three longitudinal arterial chan- nels, which run from the medulla oblongata to the conus med- ullaris. Their perforating arteries to the spinal cord are larger and more numerous at the cervical and lumbar level than at the thoracic level. Moreover, the inner arterial circle is charac- Thoracic motion segment terized in the thoracic spine by a lack of anastomoses. One of the two outer arterial circles is located in the extra- dural space, the other in the extravertebral tissues. These give rise to the ‘medullary feeders’, which arise at the cervical spine mainly from the vertebral arteries and in the thoracic and lumbar spine from the intercostal and lumbar arteries, which are segmental branches of the aorta. It is at mid and lower thorax that the spinal cord has the least profuse blood supply: the so-called critical vascular zone. When surgery is contemplated here, strict care must be taken not to impede blood flow. Nerve roots and innervation As at the cervical and lumbar levels, the thoracic spinal nerves emerge from the cord as a ventral and a posterior ramus, which join together to form the short spinal nerve root. The lateral part of the spinal canal that envelops the nerve root is the radicular canal. It is formed anteriorly by the posteroinferior aspect of the upper vertebra and a small part of the interver- Lumbar motion segment tebral disc, both covered by the posterior longitudinal liga- ment. The posterior boundary is formed by the lamina and the superior articular facet. The intraspinal course of the upper Fig 3 • Thoracic discs are smaller and flatter than lumbar discs. thoracic nerve roots is almost horizontal, as in the cervical The intervertebral foramen is located behind the vertebral body spine. Therefore, a nerve root can only become compressed by instead of behind the disc. its corresponding disc. However, the more caudal it is in the spine, the more oblique is the nerve root’s course. The T12 nerve root within the spinal canal is at the height of the elev- enth vertebral body, and therefore courses downwards, out- The spinal canal contains the dural tube, within which are wards and slightly anteriorly behind the T11 disc and the T12 the spinal cord, the spinal nerves and the epidural tissue (see vertebral body, to leave the foramen at the inferior margin of Standring, Fig. 43.3). body T12. As a consequence, the lowest thoracic nerve roots can be compressed by disc lesions of two consecutive levels (T12 root by T11 or T12 disc). Dura mater The nerve leaves the spinal canal through the intervertebral The dura mater, a blind-ended membraneous sack arising from foramen just behind the inferior vertebral margin and the the occiput and ending at S2 level, has similar characteristics costovertebral joints. Because the intervertebral foramina are at all levels. It is free within the spinal canal, where it is only quite large at these levels, osseous interference with the nerve loosely attached to the adjacent posterior longitudinal ligament roots is seldom encountered in the thoracic spine.
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