sign in sign up
<<
Home , Alar ligament, Intervertebral disc, Intervertebral veins, Lumbosacral joint

1 Degenerative Disc Disease and Dynamic Stabilization . (1-3) 1). (Figure . (1-3) ent of of ent Safiye CAVDAR M.D. . and the m (1-3) elop week of the embryonal stage the mesenchi- of the embryonal week th v Region Region surounding the neurol tube Region surouunding the corpus corpus the surouunding Region Ossification Stage 3. ossification begins at this embryo- The typical nic period and continuous until 25 years of age rosus form the . Some remnents of of remnents anulus fib- fibrosus’. The nucleus pulposus’ plus the Some disc. intervertebral the form rosus the may remain within the - interverteb ral disc which can result as ‘chordoma’. This neop- and the of base the at occurs frequently lasm at lumbosacral region 1.b. The mesenchimal cells at this region gives rise to the vertebral archs. 1.c. the to rise gives region this at cells mesenchimal The rise give will porocesses costal The processes. costal to the at thoracic region 2. Stage the 6 At mal cells forms the central cartilage of the vertebrae. vertebrae. the of cartilage central the forms cells mal centers two the period embryonic this of end the At centrum. cartilage the form to unites centrum the of - the same time the centrum of the arch of the ver At - other. The elongation of the car tebra unite with each tilage centers of the arches forms the ‘spinous pro- cesses’ and ‘transvers processes’ he De he T rtebral Interve Disc the the teb ra Ver . (1-3) week the mesenchimal cells that de- week of the embryonic period. At the the At period. embryonic the of week th th week of the embryonic period the sclera-

th 1 Region Region surounding the Notchord - are closely related to the interverteb The nerves The notochord around the developing - verteb Precartilage Stage (mesenchimal stage) stage) (mesenchimal Stage Precartilage ral disc and the segmental arteies which are closely closely are which arteies segmental the and disc ral localized to the side of the body (corpus) - of the ver the dorsal intersegmen- thoracic levels the At tebrae. arteries. intercostal to converted are arteries tal toms elgine around the notochord as paired mesenc- toms elgine around the notochord as paired grouped lo- hial cells. Each of the scleratoms cells are Some levels. caudal at compact and cranial at form osely and cranially migrate group groups cell cells dens dense the the of of rest The disc. intervertebral the together with the caudal loose scleratom group uni- centrum. vertebral mesenchimal the forms and tes scleratom adjacent two by formed is centrum Each and forms an intergemental structure. end of the 4 ral body degenerates and vanishes. The notochord notochord The vanishes. and degenerates body ral the called in is between the vertebrae This expands and forms disc. jelati- intervertebral the of part nous ‘nucleus pulposus’. The nucleus pulposus is surro- ‘anulus the called fibers circular by regular unded In the 4 1.a. during the 4 The develops from the mesenchi- mal cells that accumulated around the notochord 1. 1. rive from the scleratom of the somits accumulates accumulates of the somits the scleratom from rive in 3 major regions 2 Lumbar Degenerative Disc Disease and Dynamic Stabilization each other via cartilage via other each partseachportionandconnected3posed is of to defined; one at the tip of the spinousthedefined;oftipprocessthe atone and disappears.After puberty ossification5 centers are ofage the union ofcentrum and the vertebral arch the (medulla spinalis). Betweenment of 3-6 the yearsvertebral arches enlarge- duringthe allows developmentjoints These . neurocentral of archesof the vertebrae with the centrum forms the theofupper level vertebrae fuss. Theunion theof the arches of the lumbar levels and then the lamina ous until 6 years of age. First fusion3-5 weeks. arches continu- lumbar Thefusionofthe takes place at the The arch of each half of the vertebral fusses between 5. 8 the at nent promi- more becomes arch the of ossification The cen ossification primary two of consists centrum The 4. Safiye CAVDAR M.D. hertwotheatvertebral archeachof vertebra half. ot- the and centrum at located is these of One lops. deve- centers ossification basic 3 period embryonic tersunite to form asingle center. Atcen- the ossification end of two this The dorsal). and (ventral ters Postnatal Stage Postnatal PrenatalStage Notochord, a) th Notochord week. At birth each vertebra is com- is vertebra each Atbirth week. a (1-3) b) Development1: Figure vertebrasof andembryonel disc;

(Figure 1). Nucleus pulposus and intervertebral disc, intervertebral and pulposus Nucleus Arter scleratom of Segment Nucleus pulposus and and pulposus Nucleus intervertebral disc intervertebral - b fractures epiphysis fication centers should not be mixed withossi- secondary persistentThe individuals. to according tions varia- show can age ossification The vertebrae. the fiesbythe end ofthe 25years ofage together with cular facets.Thesecondaryossificationcentersossi- arti- contains costal and arch vertebral the of centrumpresent theinbodytheofvertebrae, part betweenhysisinbonystructure.andthere is The epyp- anular by formed is vertebrae of body the tebrae ver- the of body the of surface inferior the at cated lo- is other the and superior the on located is one the epiphysis (anular epiphysis). The two epiphysis twoatthetip ofthe transverse andtwo at the number of can be 6 vertebraebe lumbar can of number the the number of can be 11,extra however vertebrae at other segment level. For example rae at one segment level can be verteb- less compensatedbecause whole evaluatedas must lumn with an vertebrae of number less approximatelyInextra or2 or there1 3%bemay cic,lumbar,5 sacral5 and3-4coccygeal vertebrae. thora- 12 contain people the of 90% Approximately 6. The variations in the number of Vertebrae of number the in variations The  . The(Figuresuperior 2). andinferior surface of fibrosus Anulus corpus vertebral Precartilage c)

Mature intervertebral disc intervertebral Mature

(1-3)

(Figure 1). disc Intervertebral . The vertebral co- vertebral The (Figure 2). c

(4,5)

(Figure 2). 3 Lumbar Degenerative Disc Disease and Dynamic Stabilization

(5,6) . When . When (5,6) . In an articulated vertebral vertebral articulated an In . 3a,b). (Figure (5,6) The Development of the Vertebra and the Intervertebral Disc the Intervertebral and the Vertebra of The Development 3a,b). The inferior notch (Figure vertebral is dee-  The The of the lumbar vertebrae column the inferior vertebral notch of the vertebra vertebra of the notch vertebral inferior the column above and the superior notch of the vertebrae be- low forms a complete foramen called the exits - ‘interver nerves spinal the of roots The foramen’. tebral from these foramens the other vertebrae. The vertebral foremen of the surface which articulates with the ribs. The trans- verse processes are formed by the union of real transverse processes and costal elements we view the vertebrae from the side is between process the articular superior the and pedicle body, Similarly notch’. vertebral ‘superior a called notch articular inferior the and pedicle body, the between process is another notch called ‘inferior vertebral notch’ per than the superior 8. 5 6. to from varies vertebra lumbar of number The is vertebra lumbar the of features characteristic The the of rest the to compared large very are on they that surfaces articular an have not do They vertebrae. with for the articulation processes transverse their the ribs and do not have a foramen in their trans- vers processes. The transverse diameter of the cor- to compared larger are vertebra lumbar the of pus is located the spinal cord, meninx and the roots of roots the and meninx cord, spinal the is located the spinal nerves. Where the pedicle meets called the are la- these processes of 3 pairs are there mina ‘superior articular processes,’ inferior articular pro- cesses and ‘transverse process’. Where the extends two which la- process single a is there meets mina posteriorly called the ‘spinous processes. The supe- an has and superiorly extends process articular rior its posterior surface. This articu- articular surface on on surface articular the with articulates surface lar above. vertebrae the of process articular inferior the and inferiorly extends process articular inferior The has an articular surface on on surface its anterior articular surface the with below. articulates It 3a,b). (Figure vertebrae the of process articular superior the - joint) ca ( or zygapohysial movement The pacity of this joint is highly restricted and - variati The transvers level. to the vertebral ons according process extends horizontally and it receives the at- tachments of the muscles which produce the transverse The rota- trunk. the of flexion lateral and tion articular and has vertebra thoracic the of processes . (2,3) Bilateral segmentation defect Hemivertebrae

Figure 2: Unilateral segmentation defect Wedge vertebrae Vertebral Column Vertebral Anomalies. Development Abnormal development of the vertebral vertebral the of development Abnormal column (Spina Bifida Occulta) not develop and does not unite in the mid-line. This This In the case mid-line. of the in spina bifida unite the not vertebral does arches and total do of develop not form the in occur can abnormality congenital absence to partial absence of the vertebral arch 7. 7. The stability of the vertebral column is achieved by by achieved is column vertebral the of stability The muscles. the and disc, intervertebral the the column vertebral the of this movements the For During shocks. the absorbing of function a has discs - chan of the vertebrae the shape and volume reason ges according to the segmental A level. typical - ver tebra anteriorly is composed of a body and posteri- posteriorly extending projections The arch. an orly pedicles The ‘pedicles’. the called is body the from they and flat become posteriorly lamina further the and extending pedicle body, The ‘lamina’. called are In foramen’. ‘vertebral the called foramen a encircle an articulated vertebral column the vertebral fora- a canal form and other of the on top one pile men canal this Within 3a,b). canal’ (Figure called the ‘vertebral 4 Lumbar Degenerative Disc Disease and Dynamic Stabilization were made on the 3 the on made were (Figure process’ ‘accessory the led 3a,b). Measurements cal- spine bony small a is process transverse the of longer compared to the other vertebrae. At the base showedthebodymalewidththeofthethat inof between 20 to 90. The results of these measurementstebraeof 338 female and male subjects, age ranged verse bone. trabecular Amonoo-Kuofi to male.Thislosscanbeduetheintrans- loss in the female was more pronounced compared body of the lumbar vertebrae in relation to age. The ral column and reported loss of bone density in the cesses of the lumbar vertebrae contains a concave concave a contains vertebrae lumbar the of cesses pro- articular superior The shape. in quadrangular spinous processes are directed horizontally and are The pedicals of the lumbar vertebrae are small. The ger than thoracic but smaller than cervicalvertebraelar- lumbar is it and shape in triangular is vertebrae. Safiye CAVDAR M.D. duction tebrae showed reduction inrelationtothewidthre- ver - the of body the of height anterior the sex both In age. to relation in reduction showed vertebrae 5 the of ses facet articular vex con- a is process articular inferior the of surface ral anterolate- the On process’. ‘mamillar the located is posterior surface of the superior articular processes articularfacet onits posteromedial surface. Onthe concluded that the width of the vertebrae can show in the nigro races it was constant in the two sex. He ficant difference between male and female, Theseresultsshowedand 140femalesubjects. signi- however the vertebrae) and compared the results of 150 malethe distance between the two pedicles (the width of Superioris) Articularis (Prosesus Process Articular Superior Corpus (7) . Twomeyal. . et th lumbarvertebrae thinner(L5)isand Spinose process (Prosesus Spinosus) (Prosesus process Spinose Lamina . The transvers proces- transvers The (Figure 3a,b). rd (L3) and 4 and (L3) Anatomia of lumbar vertebrae. lumbar of Anatomia 3: Figure (8) Foramen Vertebral studied 93 adult verteb- adult 93 studied th Transversus) (Prosesus process Transverse (L4) lumbar ver- lumbar (L4) Pedicule a (9,10) measured Corpus vertebrae (3 pectof the longitudinal ligaments of upper lumbar of thediaphragmisattachedtoanterolateralas- rae is attached the ‘longitudinal ’.verteb - the of body the Theof crusaspect posterior and rior ante- the To vertebrae. lumbar the of rest the to red bar vertebrae are large and short. The spinous pro- spinous The short. and large are vertebrae bar lum- the of lamina The deep. is notch vertebral rior of thelumbar vertebrae is shallow whereas theinfe- pairedtheispedicle. superiorThe vertebral notch meninx.Extending postero-laterally from the body ris portion of the spinal cord, cauda equine and the (L1) lumbar vertebrae contains thecornus medulla- 5 in order to contribute to the sacrovertebral wasangle thethe largest among the lumbar (L5)vertebrae. lumbar vertebrae Further, was the longest and the body smallestofthelumbar vertebrae andthe tip ofthe He has reported that the transverse processes of 5 of processes transverse the that reported has He gerthan the distance between the inferior articular cular processes oftheupperlumbar vertebrae islar- arti- superior two the between distance The wards. back- directed is it and round is process spinous 5 the of process spinous The gaments. li- supraspinous and interspinalis and terspinalis in- M. multifidus, M. thoracis, spinalis M. spinalis, tebraeattaches the thoracolumbar fascia, M.erector ver - lumbar of processes spinous the To vertebrae. thoracic the like other each overlap not do cesses racial differences. Ratcliffe differences. racial all lumbar vertebrae. The vertebral canal of the 1 the of canal vertebral The vertebrae. lumbar all major muscle is attached to the sides of the body of tebrae from29 ver- the of body the of development the on studied th lumbar vertebrae is place more anteriorly compa anteriorly vertebraemore lumbar place is a) b Coronal rd ontheright,2 th prenatal week until 15 years of age. b) Lateral (11) (Prosesus Articularis Superior) Articularis (Prosesus Process Articular Superior nd (Prosesus Articularis Inferior) Articularis (Prosesus Process Articular Inferior on the left). The psoas performed detaileda (Prosesus Transversus) (Prosesus process Transverse th (L5)theis Spinosus) (Prosesus process Spinose th st -

5 Lumbar Degenerative Disc Disease and Dynamic Stabilization . At birth it is is it birth At . (5,6) The Development of the Vertebra and the Intervertebral Disc the Intervertebral and the Vertebra of The Development  The The development of the disc The The nucleus pulposus The nucleus pulposus is more developed at cervi- cal and lumbar segments. It is localized at the cent- ral and posterior surface of the disc posed of ‘anulus fibrosus’ and internally portion ‘nucleus fibrosus) (annulus external The pulposus’. of the intervertebral disc is supplied by the perip- heral vessels. However, internal portion is - avascu lar and is supplied by diffusion from the trabecu- reaction The vertebrae. of the body of the bone lar of portions avascular and vascular the of trauma to the intervertebral disc shows difference. The annu- of body the of edges the to attached is fibrosus lus the vertebrae and to the anterior and posterior lon- gitudinal ligaments. The nucleus pulposus is attac- joint cartilage. The nucleus pulpo- hed to the hyaline flattened becomes and shocks axial the absorbs sus when squeezed. During flexion, extension and late- ral flexion of the vertebral column the disc resemb- les a ball semi filled with liquid. 9.a. derived are Nucleus pulposus is derived from primitive notoc- vertebrae the and fibrosus annulus hord, by It , is formed the end plate. from and water and in anterior varying the compositions. to All attached are discs intervertebral intervertebral The ligaments. longitudinal posterior to the attached also segments at the thoracic discs of the laterally via intra-articular ligaments. intervertebral intervertebral disc is approximately 7-8 mm thick and has a diameter of 4 cm. The shape body of the the inter- of shape the to corresponds disc vertebral intervertebral the of thickness The vertebrae. the of disc varies according to the segmental levels. Furt- disc shows of the intervertebral her, the thickness regional difference thick within each anteriorly is disc. The lumbar - interver and cervical of disc tebral This structure increases the con- and posteriorly thin. vexity of the vertebral column at the cervical and lumbar regions. The thickness of the the - within interverteb even is segments thoracic the of disc ral formed is region this of concavity anterior The disc disc. intervertebral The vertebrae. the of body the by at the upper thoracic levels are surfaces thin, lower and at upper lumbar The le- thickest. the are vels hyaline with covered are discs intervertebral the of discs are com- cartilage. Externally the intervertebral

th (L5) lumbar lumbar (L5) th thoracic vertebrae, vertebrae, thoracic th . (L4) and 5 (5,6) (L3) lumbar vertebrae be- th . There are no - interverteb rd (5,6) (L5) vertebrae is angulated, it it angulated, is vertebrae (L5) th . The lower border of the - trans (5,6) (L1) to 3 lumbar vertebrae (L5). The articular articular The (L5). vertebrae lumbar st th lumbar vertebrae (L4), and almost di- th superior tubercle of the 12  The anatomy of the lumbar vertebrae disc disc vertebrae lumbar the of anatomy The th verse verse processes of 5 to which the multifidus the and the define medial to intertrans- hard is It attached. are muscles versus accessory process, if present the medial intertrans- versus muscle is attached sappears at 5 ral disc between (C1), (C2) and between and between (C2) axis (C1), atlas between ral disc disc intervertebral lumbar The vertebrae. coccygeal fourth one approximately forms subjects human in The lumbar column. of of the vertebral the length There are totally 23 intervertebral disc, 6 cervical, 12 thoracic,5 lumbar 9. 9. hed. To the lower intertransversus and upper lateral border the of attaches the trans- processes the verse to homolog is process mammillary The muscles. 12 are attaches to the tips of the transverse processes processes to of the tips the transverse are attaches the of surface posterior the To vertebrae. deep lumbar of the of fibers muscular the processes transverse back muscles and the longisimus muscles are attac- (lumbocostal arch) and the iliolumbar ligaments is a vertical line which attaches the anterior layer of the thoracolumbar fascia. muscle major To psoas the the medial aspect attaches line vertical this of and to its lateral aspect attaches the quadratus lum- of the thoracolum- borum muscle. The middle layer ligaments arcuate medial and lateral the fascia, bar extends laterally then superolaterally. The angle at angle The superolaterally. then laterally extends the lower border of the transverse processes repre- sents the costal elements and its lateral ends repre- The transverse processes. the transverse real sents processes of 1 flat vertebrae extends dorsoventrally and - elonga ted dorsolateraly cesses are opposite (concave on the superior arti- cular process and amount convex the inferior small articular pro- allows joint This another. one to cess) of rotation, flexion and extension. Except for the 5 processes. This difference between the distances is distances the between difference This processes. reduces at 4 surfaces on the superior and inferior articular pro- (L5) lumbar vertebrae the transverse processes are processes transverse the vertebrae lumbar (L5) vertebrae are smaller. On the anterior surface of the the of surface anterior the On smaller. are vertebrae vertebrae lumbar of processes transverse the of tip come larger from above downwards. However, the the However, downwards. above from larger come transverse processes of 4 6 Lumbar Degenerative Disc Disease and Dynamic Stabilization high pressure and holds it in its appropriate posi- appropriate its in it holds and pressure high surroundsIt thenucleus pulposus whichunderis water and more thannucleus pulposus less possess and fibrous more is fibrosus Anulus fibrosus Anulus together. vertebrae the hold to ligament like it acts as movement axis. The third function is toin act an axial direction and in lower body movements ting position. It has a functionsit- in pressure high under is it and structure tinous of transferring the load (Figure 4). Thenucleuspulposusisintheformofgela - becomes more hard and more vulnerable to trauma reduces the water holding capacity of the discs and medbetween collagen andtheproteoglycan. for- Also are bandings Cross structure. in fibrous more therest ofthe disc and becomes less hydrated and age the nucleus pulposus cannot be separated from terial develops the hyaline cartilage. Withtochord cellsdisappearandintimethemucoidma- increasing no- the development the in Later fibrosus. annulus canposses few notochord cells and fibers from the composed of soft gelatinous and mucoid material. It Safiye CAVDAR M.D. during bending. These lamellar fibers are aligned aligned are fibers lamellar These bending. during elastinfibers.These elastin fibers support discthe mella’.Between this lamellar ‘la- structurescalled are areand located rings collagen 15-25 roximately tion . Anulus fibrosus is composed of app- of composed is fibrosus Anulus (Figure 4). Nucleus pulposus Nucleus Anatomia of intervertebral disc. intervertebral of Anatomia 4: Figure Annulus fibrosus inner lamella inner fibrosus Annulus transition area transition fibrosus Annulus (5,6) lamella outer fibrosus Annulus . ons to trauma are different are trauma to ons rent structuresoftheintervertebral disctheirreacti- vessels.from peripheralblood diffe- two the Dueto tebrae and the second source is by way ofver diffusion- the of body the overlying cartilage hyaline the marrowdiffusion fromsmall foramens located on suppliedisIt sources:2by First waybyisbone of 9.b. column ral verteb- the of levels all in present be not may rosus fib - annulus the of structure standard This trauma. looseontheposterior aspect maybevulnerable to 65 parallel to each other and aligned vertically forming that the cranium can move freely move can cranium the that so loose quite are ligaments These (C2). axis and Theseligaments connects cranium to the atlas (C1) 10.a. ligaments. vertebral and niocervical into 3groupsasexternalcraniocervical,internalcra- Theligaments ofthevertebral column aredivided 10.

0 between vertebrae. The vertical fibers may be be may fibers vertical The vertebrae. between The arterial supply of the intervertebral disc intervertebral the of supply arterial The The ligaments of the vertebral column vertebral the of ligaments The   External craniocervical ligaments craniocervical External and for the exit of the the 1 the the of exit the for and atlas the towards artery vertebral the of teryandforms anopening forthe course ar- vertebral the over arches side each on ofthe . This membrane archtheofatlas andtheposterior border posterior the of borders upper the ween bet- extends It membrane. lantooccipital It islargerandthinnerthattheanteriorat- membrane atlantooccipital posterior The spinal nerves spinal anterior longitudinal ligament longitudinal anterior mentis strengthened by the course of the liga- this Anteriorly joint. atlantooccipital ligament continuous with the capsulethick fibroelastic of the membrane. Laterally this rior border of the foramen magnum. It isante- the and a atlas the of arch anterior the of borders upper the between extends It membrane atlantooccipital anterior The (Figure 5). (5,6) . (11) . (5,6) . st (C1) cervical (5,6) . 7 Lumbar Degenerative Disc Disease and Dynamic Stabilization 6). (Figure

(5,6) . (5,6) . (5,6) The Development of the Vertebra and the Intervertebral Disc the Intervertebral and the Vertebra of The Development Internal Internal cranoicervical ligaments strengthen the cranoicervical region and restrict preventsThey head. the of movements extensive the around head of the rotation lateral and medial the the atlantoaxial joint membrane Tectorial vertebral the within is located membrane Tectorial of the posterior It continuation is the canal. upper bone and the posterior tubercle ligament of This atlas and vertebrae. spi- cervical of processes nous muscle provides and midline the in septum a forms attachments Ligamentum flavum It is a yellowish elastic membrane that extends bet- the of arch ween lamina of posterior the the vertebrae of between two neighboringextens It vertebrae. between absent is It axis. the of lamina the and atlas the atlas and the 10.b. at the located are ligaments cranoicervical Internal They vertebrae. the of body the of surface posterior Figure 5: Intervertebral disc herniation. . The upper 6). (Figure The upper Disc Disc herniation Spinal nerve It is a fibroelastic membrane which extends between Nuchael ligament between extends which membrane fibroelastic a is It of the occipital protuberance occipital the external extension called the ‘atlantoaxial’ ligament (epist- ligament). rophic part of this ligament, medially The supports midline. the the in ante- membrane atlantooccipital rior and of atlas the tubercle anterior the between part on ridge the lateral have axis median the anterior The anterior longitudinal ligament extends from the the from extends ligament longitudinal anterior The base of the skull to the Anterior Anterior longitudinal ligament The joint capsule extends between the condyles of condyles the between extends capsule joint The the occipital bone and superior articular the facets allows and of loose quite is capsule The atlas. the at is thin capsule joint The head. of the movement on thickening The sides. the on thick and center the liga- are also called ‘lateral atlantooccipital the sides restricts ligament atlantooccipital lateral The ment’. head. the of flexion lateral the Joint capsule 8 Lumbar Degenerative Disc Disease and Dynamic Stabilization lectively called ‘cruciform ligament’ ‘cruciform called lectively cicles. Thetransverse andthevertical bandsarecol- fas- longitudinal inferior and superior the axis- the dens and the posterior surface of the of the body of tectorialmembrane andtheapical ligament theof tothe basilar part of the occipital bone between the tothebase oftheoccipital tobefixed respectively, int of the dens extending upwards and downwards pect ofthelateralmassatlas.Frommidpo- each sideitattachestothetubercleonmedialas- sing transversely posterior to the densTransverse pas- ligament isastrong ligamentofatlas of the axis. On atlas of Transverseligament oblongate dulla me- and cord spinal the to functions supportive a has ligaments other the to addition membrane periorlyblendsduramater.withthetectorial The su- and magnum, foramen the of edge lateral and anteriortheaxisriortosurfacethebody ofthe of poste- the from extends It ligament. longitudinal Safiye CAVDAR M.D. toaxialjoint. atlan- the arround the siveof rotation - exces the restricts It atlas. ofthe he of tachments of the transverseat- the ligament)to (close masses lateral the to extendsdenstheItbaseoffrom the ligament Accessory arroundthe atlantooccipital joint. It controls the excessive rotation of thetheofcondyles theofoccipital bone. surface medial the to dens of aspect superolateral the from laterally and upwards extends ligament alar The ligament . cruciform the and the superior longitudinal fibers of between the atlantooccipitaltion membrane of the foramen magnum. Extends apex ofthedenstoanteriormidpor- The apical ligament extends from the ligament Apical (5,6) . (5,6) . ligament capsule Facet ligament Supraspinal Ligaments of vertebral column. vertebral of Ligaments 6: Figure Posterior Longitudinal Ligament LongitudinalPosterior column mentprevents hyperextensionthe vertebraltheof liga- This segments. thoracic at thickest is ligament connect several vertebrae. The anterior longitudinalraeand the intervertebral verteb- disc, the whereas of long body fibers two neighboring the connects superficialsedof anddeepfibers. Theshort fibers vertebrae andtotheintervertebral disc.Itiscompo- attachedanteriortheto surface thebodytheof of longitudinalligament duringcloselycauseitsis it anterior The downwards. above from wider mes beco- It sacrum. and atlas the of tubercle anterior bandItisa shape ligament extending between the ligament longitudinal Anterior 10.c. pect of the body of the vertebrae withinthe vertebral column.Itislocatedattheposterioras- the vertebral vertebral levels and narrow at the lowerThe segmentsposterior of longitudinal ligament is wide at upper Ligamentum flavum Ligamentum Vertebral ligaments Vertebral  (Figure 6). ligament Intertransvers ligament longitudinal Posterior ligament longitudinal Anterior 9 Lumbar Degenerative Disc Disease and Dynamic Stabilization - sacral vertebrae. The The vertebrae. sacral nd and 2 st of sacral segments. The fibers of this The fibers segments. of sacral th The Development of the Vertebra and the Intervertebral Disc the Intervertebral and the Vertebra of The Development and 4 Facet Facet (Zygopophysial) joint  The The joint between the body of the vertebrae Joins of the vertebral column rd ses and spinous processes are fibrous type. type. fibrous are processes spinous and ses 11.a. The bodies of the vertebrae articulates with the an- terior, posterior longitudinal ligament and the fib- rocartiaginous intervertebral discs. 11.b. This joint takes place between the superior and inferior articular process. This joint is also called Interosseous Interosseous sacroiliac ligament It is composed of short thick fiber bundles. a Forms It of the ileum. ex- the tubercles between tends deep located is It bones. two the between band firm to the dorsal sacroiliac ligament and is one of the strongest ligament within the body. Sacrotuberal and sacrospinal ligaments Sacrotuberal ligaments and Both sacrospinal joint. ligaments are acces- sacroiliac the of ligaments sory dorsal Anterior, joint. this of movements the assists and lateral sacroccocygeal ligament binds the sac- rum to the coccyx. 11. between vertebrae the of bodies the between joint The arti- C2 and S1 is cartilaginous. The joint is between (zygapophyses) type synovial of are processes cular proces transverse the lamina, between the joint and - a function of streng in structure and has and fibrous capsule. joint the thening Dorsal ligament) sacroiliac ligament sacroiliac (posterior It extends on the dorsal surface. Superficially it is composed of long and deeply composed of liga- mentous bundles. The long superficial bundles posterior the of from aspects extends ligaments lateral sacroiliac the the to attaches and spine iliac superior of 3 ligament which are externally located fusses with the . The deep short fibers of the dorsal sacroiliac ligament extends from the medial surface of the ileum and attaches to the la- teral surface of the 1 deep short fibers of the dorsal sacroiliac ligament are also called interosseus ligament. 6). (Figure

(5,6) 6). (Figure

(5,6) 6). (Figure

(C7) to the sac- th (5,6) 6). (Figure

(5,6) 6). (Figure

(5,6) Ligaments of the coccyx and sacrum It arises from the thin pelvic and is alar surface of the sac- ligament This ileum. the to attaches and rum 10.d. 10.d. ligament) sacroiliac ligament (anterior sacroiliac Ventral transverse transverse processes. This ligament is in the form of filamentous thick structure dense at of lumbar form the levels, in is - howe it levels thoracic at ver, bands Intertransvere Intertransvere ligaments two between space the fills ligaments Intertransvere Interspinous ligaments fills the space between two two between space the fills ligaments Interspinous spinous processes. The interspinous ligaments is most developed at lumbar levels Interspinous Interspinous ligaments nuous with the ligamentum nuchae, anteriorly with with anteriorly nuchae, ligamentum the with nuous of thickness The ligaments. interspinal to anterior the cervical from increases ligaments supraspinal the lumbar levels Supraspinal ligaments extends between the spinous spinous the between extends ligaments Supraspinal processes of 7 rum. The supraspinal ligaments superiorly conti- Supraspinal ligaments above and the posterosuperior border of the lamina teroinferior border lamina the of of the lamina border of the vertebrae posterosuperior the and above of the vertebrae below. The medial aspect of the li- the gament of contains openings for the thickness exit The of the exter- plexus. venous internal and nal ligamentum flavum increases from cervical to lum- bar levels Ligamentum flavum Ligamentum flavum connects two neighboring la- mina of the vertebrae. It extends between the an- canal. It extends between the axis and the sacrum. sacrum. the and axis the between It extends canal. - longitudinal liga portion of the posterior The upper The membrane. tectorial the with specially continuous ment ligament longitudinal posterior the of and sides laterally extends regions lumbar and thoracic at fusses with the annulus fibrosus fibers of the inter- longitudinal li- the posterior disc. Between vertebral the of body the of surface posterior the and gament vertebrae is located the vein. The basivertebral pos- terior longitudinal ligament prevents the hyperfle- xion of the vertebral column 10 Lumbar Degenerative Disc Disease and Dynamic Stabilization and posterior atlantooccipital membrane. atlantooccipital posterior and sule enclosing the two bone fussescap- joint withThe two. theinto divided anterioris surface articular surfaceconcaveatlastheisof sometimes and this andthe condyle of the occipital bone. The articular Itis the joint between the lateral masses of the atlas 11.c. nerves. spinal the of mus ra- dorsal the of branches medial the innervatedby thecervical andlumbar levels. Thefacetjoints are of movements rotation and extension flexion, the functiona ofcarrying the weight. Further, controls vertebraetogether withintervertebralthe dischas tension.Thefacet ex- ofthe cervical and flexion andlumbar of amount large produce to levels cervical the enables This levels. lumbar and racic tho- to compared region cervical at loose and long haveinsthinarticular capsule. Thesecapsules arejo- facet The cartilage. hyaline with covered and zygopophysialjoint.articularThe surfaces flatare Safiye CAVDAR M.D. of the axis. The medial atlantoaxial joint takes place superioratlasthetheandfaceof articular surface - betweensur place articular takes It inferior axis. the joint,located between the atlas and the body of the axis.The lateral atlantoaxial joint isplanea type of Therearetwo between theatlas and 11.d. vedby this joint. The nodding movement of the head is achie- is head the of movement nodding The Atlanooccipital joint Atlanooccipital Atlantoaxial joint Atlantoaxial a) Figure 7: Figure Vertebral column curves. Vertebralcolumn b) rum by the . iliolumbar the by rum lumbar vertebrae isconnectedtotheileumandsac- lumbar and the 1 the and lumbar posed of lateral, dorsal and ventral ligaments. ventral and dorsal lateral, of posed com- is It coccyx. the of base the and sacrum the of Sacrococcygealljoint takes place between theapex 11.f. 5 the between place takes joint Lumbosacral 11.e. joint. of type pivot a is it and axis the of betweenthe anterior arch ofthe atlas and the dens and lumbar curvatures starts developing at fatal fatal at developing starts curvatures lumbar and curvatures’ ‘primary called period racicsacralandcurvatures develops embryonicat tho - The convex. are segments lumbar and cervical at and concave are segments sacral and and racic tho- the anterior from viewed is column vertebral the When curvatures. 4 of consists teroposteriorly an- column vertebral The coccygeal. and sacral is cervical, 28 cm is thoracic, 18 cm lumbar and 12 cm femalelength.andinincmcm60 isis cm The 12 Thevertebral columnmaleapproximately inis 70 12. rior longitudinalligament. Additionally, the5 poste- and anterior the by posteriorly and teriorly tervertebral disc.Lumbosacraljointissupportedan- The curvatures of the vertebral column vertebral the of curvatures The  Sacrococcygeal joint Sacrococcygeal Lumbosacral Koksigeal st (S1) sacral vertebrae and the in- the and vertebrae sacral (S1) c) Lumbar (Figure 7).Cervical Sacral Cervical Thoracic th th (L5) (L5) 11 Lumbar Degenerative Disc Disease and Dynamic Stabilization 9). (Figure Thoracic seg-

8). (Figure

(11,12) (4,5) . (5,6) The Development of the Vertebra and the Intervertebral Disc the Intervertebral and the Vertebra of The Development Rotation Rotation movement  The The arterial supply Circumdiction movement drainage of the lumbar vertebrae Muscles producing movements of the the of movements producing Muscles vertebral column  The arterial supply and the venous venous the and supply arterial The The flexion movement is achieved by M. longus longus M. by achieved is movement flexion The mental somatic arteries arteries intercostal posterior by supplied are ments segments The abdominal . of the descending are supplied by lumbar arteries from the abdomi- body the surround arteries lumbar Both aorta. nal of the vertebrae and give the periosteal and equa- the dorsal give also arteries These branches. torial 14. 14. produce is column vertebral the of movements The muscles of group vertebral first The the to muscles. of 2 groups by directly attached second are The that ones the muscles’. are ‘intrinsic called are they column group of muscles are attached to the bony structu- muscles these column, vertebral the than other res indirectly assist the movements of the vertebral co- lumn and are called ‘extrinsic muscles’. abdominus rectus M. sternocleidomastoid, M. coli, M. by achived is movement extension The muscles. erector spinalis, M. splenius, M. semispinalis capi- tis, M. trapezius muscle 15. 15.a. The vertebral column and the soft tissue is supp- lied by the dorsal ramus of the embryonic interseg- antagonist antagonist muscles and ligaments limit the lateral flexion. Lateral flexion can occur together with ro- - at cervical and lum flexion can occur tation. Lateral bar levels. 13.d. This movement occurs by the rotation of the - ver tebrae body one on top of the other. Most of the ro- rotation least levels thoracic at upper occurs tation occurs at the cervical and lumbar level. 13.e. It column. of the vertebral It movement is limited is the combination of flexion, lateral flexion and ex- tension movements - . 7) (Figure The cer- Extension Extension movement Flexion Flexion movement Lateral Lateral flexion movement  The The movements of the vertebral column 13.c. one of disc intervertebral the flexion lateral During side compresses while the other side tenses. The spinous processes decreases. The extension - move ment is disc present at cervical intervertebral and thin the lumbar to due segments. levels thoracic At structure skeletal and muscular inappropriate and limited amount of extension occurs. ral disc are compressed, the distance between the 13.b. 13.b. Exactly the opposite events occur in the case of ex- tension movement. The anterior longitudinal liga- ment contracts, posterior borders of the interverteb duces flexion as much as these ligaments allows. At vum, At interspinous and allows. subspinous ligaments ligaments pro- these as much as flexion duces - interverteb the same time the anterior border of the the between distance the and compressed is disc ral lamina increases and the superior articular proces- The ten- ses glides on the inferior articular processes. sion of the extensor muscles are important in limi- can segments Cervical movement. the flexion ting flexion. extensive produce 13.a. the and relaxes ligament longitudinal anterior The posterior longitudinal ligaments, ligamentum fla- produce flexion, extension, lateral flexion, rotation rotation flexion, lateral extension, flexion, produce and circumduction. ments do occurs around these the is joints. column The cervicalvertebral the of portions lumbar and most mobile portions. The vertebral column can ral disc and the facet joints. Although the capacity capacity the Although joints. facet the and disc ral of the movements of the vertebrae are highly rest- ricted by the ligaments, however, various - move The movements of the vertebral column are achi- eved by the nucleus pulposus of the - interverteb 13. period and becomes prominent at childhood and are called ‘secondary curvatures’ the keeps child the when develops when curvature vical develops curvature lumbar the and erect head development abnormal The walking. starts child the of the curvature results in excessive xphosis, lordo- . and sis 12 Lumbar Degenerative Disc Disease and Dynamic Stabilization Safiye CAVDAR M.D. throughout the vertebral column vertebral the throughout externaland internal venous plexus which extends Thevenous drainage of the vertebral column is via 15.b. branches anastomotic and laminar pre- by supplied are flavum ligamentum and canal epidural tissue, dura, posterior wall of the vertebraldura artery also supplies the anterior epidural tissue and similarwiththearteries oppositethe of side.This rae body and the intervertebral disc and anastomoisvertebthe of surface the supply branch postcentral - postcentral,prelaminar andradicular arteries. The spinalarteries entering vertebral canal divides into nerves spinal the of roots and cord nal spi- the supplies arteries radicular the ditionally, and subcutaneous tissue ints,posterior surfacelamina,the of muscles, skin the intervertebral foramenandsuppliesthefacetjo- through enters branches spinal The branches. nal spi- arises branches dorsal the from and branches bony vertebrae, dura and epidural structures. Ad- structures. epidural and dura vertebrae, bony ted spinal arteries. These orien- spinallongitudinally are arteriesthere segments sacral suppliesthe the Venous drainage of lumbar vertebrae lumbar of drainage Venous  (Figure 9). The posterior vertebral arch, posterior Figure 8: Figure vertebral column in three planes. Movements of vertebral column:Flexion, extension, rotation. extension, column:Flexion, vertebral of Movements planes. three in column vertebral Flexion movementFlexion Themuscles theofvertebral bodyand theposterior elements, allows movement theof (11-14)

(Figure 9). At cervical and (11-14) (11-14) .There are no . (Figure 9).The Disk Vertebral body Vertebral theinternal venous plexus. kind of congestions by the small veinsHowever, that thedrain spinal into cord can protect itself fromto the this cerebrospinal fluid (CSF) via the venoussure difference plexi. in the body cavities can pres- beThe areas. large to spread can conveyedsepsis or seases pathways. Because therearenovalves themaligndi- abdominalveinsdevelopcan alternative drainage her, patients with major obstruction of the thoracic,Furt- capacity. dilatation of amount large has lumn rior and posterior groups. These have free free have veins These groups. posterior and rior ante- into divided are plexi vertebral external The plexus vertebral external The 16. and tedto the cranial venous sinuses, deep veins of the lumbar azygossystem.Theseveins arealsoconnec- developmenttheseplexi drains into cavalthe and thelongitudinal veins. After thecompletion theof nal and internalexter- the venousperiod fetal early plexusthe In haveveins. vertebral connection inter- withthe into drains and other each with tomosis venousBoth externalandinternal plexushave anas- valvesin both external and internal venous plexus. Extension movement Extension (11-14) . The veins of the vertebral co- vertebral the of veins The . Rotation movementRotation 13 Lumbar Degenerative Disc Disease and Dynamic Stabilization

Lumbar Lumbar vein Basivertebral vein Lumbar vein vein Lumbar ascending branch Anterior external external Anterior venous plexus Intervertebral vein . They exit through . through exit They Anterior-posterior Anterior-posterior longitudinal sinus (11-14) Posterior external external Posterior venous plexus . (11-14) The Development of the Vertebra and the Intervertebral Disc the Intervertebral and the Vertebra of The Development Intervertebral veins Basivertebral Basivertebral veins the vertebrae and anastomosis with each other. It is is It other. each with anastomosis and vertebrae the foramen the around vein vertebral the to conneted magnum, occipital and sigmoid sinus, basilar plex- ons at elderly ages. ages. elderly at ons 17.b. The intervertebral veins accompany the spinal ner- collect They foramen. intervertebral the within ves - internal and external ver blood from the the venous intercostal posterior the into drain and plexi tebral 9). The up- (Figure lateral sacral vein lumbar vein, vein, into drain veins intercostal posterior the levels per system, caval the the to then veins into drain brachiocephalic the levels lower the of veins intercostal the sus, venous plexus around the hypoglossal canal and emissary veins 17.a. bone the within located are veins basivertebral The cranium of the veins diploic to the similar are and having a tortious structure the small foramen located at the body of the - ver tebrae and drain into the anterior external - verteb ral plexus located within the vertebral foramen connects that trunks two or one form They 9). (Figure the posterior transverse and anterior internal - ver tebral plexus. The basivertebral veins show dilati- Anterior vertebral vertebral Anterior canal branch Posterior branch of branch Posterior lumbar artery Feeder Feeder branches Aort Radicular/Segmental Radicular/Segmental meduller artery Arterial feeding and venous drenage of lumbar vertebrae Figure 9: Posterior branch Posterior Lumbar artery arch, arch, artery Lumbar and meningeal canal, spinal branch Lomber Lomber artery . The anterior external vertebral plexi plexi vertebral external . 9) (Figure The anterior . The external plexi forms more dense dense more forms plexi 9). (Figure The external Spinal branch of branch Spinal lumbar artery  The The internal vertebral plexus plexi. There are 4 vertical coursing longitudinal - ve ins (2 anterior and 2 posterior), which external have anterior The inter- other. each with connections the on located are that plexi venous large are plexi and of of the body the vertebrae surface posterior drain into the ba- disc. These veins the intervertebral sivertebral veins via the transverse veins. The pos- the with external anastomosis plexi around internal terior ring a forms plexi venous internal The plexi. The internal vertebral plexus are located between the dura mater and the vertebrae. It collects the - ve and the spinal marrow the bone from blood nous cord 17. connections with the vertebral veins, posterior in- tercostal vein, and lumbar vein. are located at the anterior aspect of the body of the the of body the of aspect anterior the at located are to the basivertebral are They connected vertebrae. and intervertebral veins. Drains the venous blood from the body of the The vertebrae. posterior - exter nal vertebral plexus are located at the posterior - as have processes.They trans- lamina, spinal processes, pect of the vertebral articular the and processes verse has It plexus. venous internal the with anastamosis anastomosis and are mostly developed at cervical at cervical developed and are mostly anastomosis levels 14 Lumbar Degenerative Disc Disease and Dynamic Stabilization ral sacral and internal iliac lymph nodes lymph iliac internal and sacral ral late- the into vertebraldrains the column of portion lateral aortic or retroaortic lymph nodes. The pelvic posteriorintercostal lymphnodes, lumbar portion deepcervical lymph nodes, thoracic portion tothe calportion theofvertebral column drains intothe tic vessels whichaccompany thearteries. The cervi- lympha- deep the into drain vessels lymphatic The 17.c. spreadof the cancer cells. causemayreverse bloodtheflowofresultand in pressure intraabdominal the in increase an or ges chan- postural to Due veins. pelvic the with plexus spreadthebyconnections theofinternal vertebral sis to the body of themetasta- vertebrae.cause can neoplasm The cancerpelvic or cellscancer cantate pros- how explains This direction. backwards a in talresearches haveshown thattheblood canflow veins have anactive functioningvalves. Experimen- knownthat the basivertebral and the intervertebral tebrae and drain into thever- inferiorthe of body venathe encircle cava.sometimes may ItThey is not ontheanterior surface ofthetransverse processes. cendinglumbar veins which course longitudinally as- the into veins,drain lumbar The system. azygos Safiye CAVDAR M.D. novertebralnerves. si from and branches meningeal the from branches dorsallumnarespinalramus of nerves, recurrent nerveImportant innervatingfibers vertebralthe co- hetic ganglia suppliessympat- thethoracic sympathaticthe of communicans innervations.ramus gray the from branches Also, nerves. spinal segmental via is levels lumbar at it surrounding tissue soft the and column vertebral the of innervation The 17.d. Lymphatic drainage Lymphatic Innervation of the vertebral column vertebral the of Innervation (11-14) . - 13- 13- References 14- 10- 12- 12- 11- 9- 9- 8- 7- 6- 5- 3- 1- 4- 2- 2- Amonoo-Kuofi HS:Maximumandminimumlum- Afifi AD, BergmanRA:Basicneuroscience.(2 Amonoo-Kuofi HS: The sagittal diameter of the the of diameter sagittal The HS: Amonoo-Kuofi  1983. 136:15-25, Anat J column. bone density and structure of the lumbar vertebral TwomeyL, Taylor J, Furniss B: Agechanges in the 1976. 45:575-580, Anthropol Phys J Am spine. EricksenMF: Some aspects of aging in the lumbar pp:11-20. 1983 1, Vol Pharma, CIBA tions. illustra- medical of collection Ciba The FH: Netter Longmann Group, 1989, pp 315-489, 919-948. 315-489, pp 1989, Group, Longmann Wendel CP, Williams PL, Treadgold S: Basic hu- Basic S: Treadgold PL, Williams CP, Wendel Gray’s anatomy. (37 anatomy. Gray’s WilliamsWarwickP,BannisterDyson M,R, LH: 723-728. pp 2008, ton, ders, 1988, pp 334-340, 364-401. 334-340, pp 1988, ders, (4 HamiltonWJ, Mossman HW: Human embryoloji. man embryology. (3 embryology. man sis of clinical practice. (2 practice. clinical of sis ba- anatomical The anatomy: Gray’s S: Standring 102-143. pp Moore K:Thedeveloping human.(4  53-95. pp 1985, Wilkins, Williams Snell RS: Clinical neuroanatomy for medical stu- medical for neuroanatomy Clinical RS: Snell  dents. (2 dents. Carpenter MB: Core text of neuroanatomy. (3 ofneuroanatomy. MB:Coretext Carpenter 1981. 133:625-638, Anat J study. teriographic man dorsalandlumbarvertebral body: A microar- Ratcliffe FF: ofthedeveloping anatomy Arterial hu- rians. J Anat 135:225-233, 1982. 135:225-233, Anat J rians. Nige - adult normal in distance interpeducular bar Urban, Schwarzenberg Inc, 1986, pp 43-91. pp 1986, Inc, Schwarzenberg Urban, ans. J Anat 140:69-78, 1985. 140:69-78, Anat J ans. Nigeri - adult normal the in vertebralcanal lumbar th

ed), Williams and Wilkans 1972, pp 437, 526. 437, pp 1972, Wilkans and Williams ed), nd

ed), Boston, Little, Brown and Brown Little, Boston, ed), th rd

ed),Chur-Chill Livingstone ed),PitmanLtd,1984,Pub nd

ed), Churchill Livings- Churchill ed), th

ed), WBSaun- nd rd

ed), ed),