Vertebral Column: Overview

Home , Atlas (anatomy), Cervical vertebrae, Intertransverse ligament, Lumbar, Lumbar vertebrae, Nuchal ligament

The vertebral column (spine) is divided into four regions: the and lumbar spines demonstrate lordosis (inward curvature); the thoracic cervical, thoracic, lumbar, and sacral spines. Both the cervical and sacral spines demonstrate kyphosis (outward curvature). Back

Fig. 1.1 Vertebral column Left lateral view.

¨ O>KFL@BOSF@>IGRK@QFLK SBOQB?O>B BOSF@>IPMFKB BOSF@LQELO>@F@GRK@QFLK

MFKLRP MOL@BPP ELO>@F@PMFKB

ELO>@LIRJ?>OGRK@QFLK LPQ>I RJ?>OPMFKB C>@BQP ¨ RJ?LP>@O>IGRK@QFLK SBOQB?O>B

OQF@RI>O >@ORJªP>@O>IPMFKB« MOL@BPPBP

A Regions of the spine.

KQBOSBOQB¦ ?O>ICLO>JFK> Clinical

Spinal development ¨ The characteristic curvatures of the adult spine appear over the course SBOQB?O>B of postnatal development, being only partially present in a newborn. The KQBOSBOQB¦ newborn has a “kyphotic” spinal curvature (A); lumbar lordosis develops ?O>IAFPH later and becomes stable at puberty (C).

ARIQPMFK>I @LIRJK >@O>I MOLJLKQLOV O>KPFQFLK>I ME>PB >@ORJ VMELQF@ BOSF@>I ª¨ PMFKB ILOALPFP LCQEB SBOQB?O>B« KBT?LOK ELO>@F@ HVMELPFP L@@VU

RJ?>O ILOALPFP B Bony vertebral column.

>@O>I HVMELPFP ABC

2 Fig. 1.2 Normal anatomical position of the spine 1 Bones, Ligaments & Joints Left lateral view.

UQBOK>I BKPLC>UFPª« BKPLC>UFPª« >RAFQLOV@>K>I LKDRB

>OVKU MFKLRPMOL@BPPLC SBOQB?O>MOLJFKBKPª « O>@EB> FKBLCDO>SFQV KCIB@QFLKMLFKQP MFK>I@LOA P@BKAFKD >LOQ> BOQB?O>I@>K>I B>OQ PLME>DRP KQBOSBOQB?O>IAFPH F>MEO>DJ MFKLRPMOL@BPP ELIB¦?LAV FSBO @BKQBOLCDO>SFQV

QLJ>@E LAVLC LKRPJBARII>OFP ?ALJFK>I >LOQ> A Line of gravity. The line of gravity passes through certain anatomical landmarks, >RA>BNRFK> including the inflection points at the cervi- cothoracic and thoracolumbar junctions. >@O>IMOLJLKQLOV It continues through the center of gravity (anterior to the sacral promontory) before passing through the hip joint, knee, and ankle. I>AABO L@@VU

B@QRJ

B Midsagittal section through an adult male.

3 Vertebral Column: Elements

Fig. 1.3 Bones of the vertebral column Back BKPLC>UFPª« QI>Pª« QI>Pª« UFPª«

© SBOQB?O>B Fig. 1.4 Palpable spinous processes as landmarks BOQB?O> Posterior view. The easily palpated spinous MOLJFKBKP processes provide important landmarks dur- ª « ing physical examination. O>KPSBOPB MOL@BPP MFKLRP MOL@BPPBP

BOSF@LQELO>@F@ GRK@QFLKª «

@>MRI>OPMFKBª« O>KPSBOPB © MOL@BPPBP SBOQB?O>B BOQB?O>I KCBOFLOP@>MRI>O ?LAV >KDIBª «

QEOF?ª«

KSBOQB?O>I IF>@@OBPQª « AFPH

>@ORJ LPQBOFLO ªCRPBA >@ORJ P>@O>I © CLO>JFK> SBOQB?O>B« KQBOFLO P>@O>I CLO>JFK> L@@VU L@@VU

A Anterior view. B Posterior view.

4 Fig. 1.5 Structural elements of a vertebra Fig. 1.6 Typical vertebrae Left posterosuperior view. With the exception of the atlas (C1) and axis Superior view. (C2), all vertebrae consist of the same structural elements. 1 Bones, Ligaments & Joints

RMBOFLO >OQF@RI>O BOQB?O>I MFKLRPMOL@BPP BOQB?O>I MOL@BPP CLO>JBK BOQB?O>I>O@E ?LAV >JFK> RMBOFLO>OQF@RI>OC>@BQ BAF@IB O>KPSBOPB BAF@IB BOQB¦ MOL@BPP LPQBOFLOQR?BO@IB ?O>I O>KPSBOPBMOL@BPPTFQE >O@E PRI@RPCLOPMFK>IK O>KPSBOPBCLO>JBK >JFK> MFKLRP MOL@BPP LAV KQBOFLO QR?BO@IB KCBOFLO >OQF@RI>OMOL@BPP A Cervical vertebra (C4). MFKLRPMOL@BPP LPQ>IC>@BQ >JFK>

O>KPSBOPBMOL@BPP BAF@IB RMBOFLO>OQF@RI>OC>@BQ KCBOFLO@LPQ>IC>@BQ RMBOFLO@LPQ>IC>@BQ LAV

B Thoracic vertebra (T6). BAF>K P>@O>I@OBPQ RMBOFLO RMBOFLO>OQF@RI>OMOL@BPP >@O>I@>K>I >OQF@RI>O MFKLRPMOL@BPP C>@BQ @@BPPLOVMOL@BPP O>KPSBOPBMOL@BPP >QBO>IM>OQ LCP>@ORJ BOQB?O>I>O@E RMBOFLO>OQF@RI>OMOL@BPP BOQB?O>ICLO>JBK RMBOFLOSBOQB?O>I LAV KLQ@E >PBLC OLJLKQLOV FKDLC P>@ORJ P>@ORJ

C Lumbar vertebra (L4). D Sacrum.

Table 1.1 Structural elements of vertebrae

Vertebrae Body Vertebral foramen Transverse processes Articular processes Spinous process

Small (may be absent in Superoposteriorly and Cervical vertebrae Small C7); anterior and posterior Short (C3–C5); bifid (C3–C6); Large (triangular) inferoanteriorly; oblique facets: C3*–C7 (kidney-shaped) tubercles enclose long (C7) most nearly horizontal transverse foramen Medium (heart- Large and strong; length Posteriorly (slightly laterally) and Long, sloping postero- Thoracic vertebrae shaped); includes Small (circular) decreases T1–T12; costal anteriorly (slightly medially); inferiorly; tip extends to level T1–T12 costal facets facets (T1–T10) facets in coronal plane of vertebral body below Posteromedially (or medially) and anterolaterally (or laterally); Long and slender; Lumbar vertebrae Large facets nearly in sagittal plane; Medium (triangular) accessory process on Short and broad L1–L5 (kidney-shaped) mammillary process on posterior posterior surface surface of each superior articular process Superoposteriorly (SI) superior Sacral vertebrae (sacrum) Decreases from Fused to rudimentary rib Sacral canal surface of lateral sacrum- Median sacral crest S1–S5 (fused) base to apex (ribs, see pp. 44–47) auricular surface *C1 (atlas) and C2 (axis) are considered atypical (see pp. 6–7).

5 Cervical Vertebrae

The seven vertebrae of the cervical spine differ most conspicu- all directions. C1 and C2 are known as the atlas and axis, respectively. ously from the common vertebral morphology. They are special- C7 is called the vertebra prominens for its long, palpable spinous process. Back ized to bear the weight of the head and allow the neck to move in

Fig. 1.7 Cervical spine Left lateral view.

LPQBOFLO >O@ELC>QI>P KQBOFLO QR?BO@IB ª>QI>P« LPQBOFLO Fig. 1.8 Atlas (C1) QR?BO@IB

RMBOFLO OLLSBCLO ª>UFP« >OQF@RI>OC>@BQ SBOQB?O>I> MFKLRP RI@RPCLO MOL@BPP LPQBOFLO KQBOFLO PMFK>IK QR?BO@IB QR?BO@IB BOQB?O>I LPQBOFLO ?LAV VD>ML¦ O>KPSBOPB O>KPSBOPB >O@ELC>QI>P KQBOFLO CLO>JBK MOL@BPP MEVPB>IGLFKQ KCBOFLO QR?BO@IB KCBOFLO>OQF@RI>O >OQF@RI>OC>@BQ LPQBOFLO MOL@BPP QR?BO@IB RMBOFLO>OQF@RI>O A Left lateral view. MOL@BPP RI@RPCLO PMFK>IK Fig. 1.9 Axis (C2) K@FK>QBMOL@BPP MFKLRP MOL@BPP KQBOFLO BKP >OQF@RI>OC>@BQ LPQBOFLO ªSBOQB?O> RMBOFLO >OQF@RI>OC>@BQ MOLJFKBKP« >OQF@RI>OC>@BQ O>KPSBOPB MFKLRP MOL@BPP O>KPSBOPB CLO>JBK MOL@BPP O>KPSBOPBCLO>JBK LAV A Bones of the cervical spine, left lateral view. O>KPSBOPB KCBOFLO BOQB?O>I MOL@BPP >OQF@RI>OC>@BQ >O@E

A Left lateral view.

Fig. 1.10 Typical cervical vertebra (C4)

O>KPSBOPB RMBOFLO CLO>JBK >OQF@RI>OMOL@BPP

O>KPSBOPBMOL@BPP RMBOFLO>OQF@RI>OC>@BQ

LAV KCBOFLO>OQF@RI>O MOL@BPP

RI@RPCLO KCBOFLO MFKLRP PMFK>IK >OQF@RI>OC>@BQ MOL@BPP

B Radiograph of the cervical spine, left lateral view. A Left lateral view.

6 Clinical

Injuries in the cervical spine 1 Bones, Ligaments & Joints The cervical spine is prone to hyperextension injuries, such as This patient hit the dashboard of his car while not “whiplash,” which can occur when the head extends back much farther wearing a seat belt. The resulting hyperextension than it normally would. The most common injuries of the cervical spine caused the traumatic spondylolisthesis of C2 (axis) are fractures of the dens of the axis, traumatic spondylolisthesis (ventral with fracture of the vertebral arch of C2, as well as slippage of a vertebral body), and atlas fractures. Patient prognosis is tearing of the ligaments between C2 and C3. This largely dependent on the spinal level of the injuries (see p. 600). injury is often referred to as “hangman’s fracture.”

RMBOFLO KQBOFLO >OQF@RI>OC>@BQ >O@E LPQBOFLO>O@E LPQBOFLOQR?BO@IB RMBOFLO >OQF@RI>O OLLSBCLO >QBO>I SBOQB?O>I> C>@BQ J>PPBP O>KPSBOPBMOL@BPP

O>KPSBOPBCLO>JBK

O>KPSBOPB KCBOFLO KQBOFLO O>KPSBOPB >@BQCLOABKP KQBOFLO>O@E CLO>JBK >OQF@RI>O QR?BO@IB MOL@BPP KQBOFLO C>@BQ QR?BO@IB

B Anterior view. C Superior view.

KQBOFLO MFKLRPMOL@BPP BKP >OQF@RI>OC>@BQ BOQB?O>I BOQB?O>I>O@E CLO>JBK RMBOFLO >OQF@RI>OC>@BQ BKP KCBOFLO >OQF@RI>O O>KPSBOPB O>KPSBOPB MOL@BPP MOL@BPP MOL@BPP

KCBOFLO RMBOFLO O>KPSBOPB >OQF@RI>O CLO>JBK LAV >OQF@RI>OC>@BQ C>@BQ KQBOFLO>OQF@RI>OC>@BQ

B Anterior view. C Superior view.

RMBOFLO K@FK>QB >OQF@RI>O BOQB?O>ICLO>JBK MFKLRPMOL@BPP MOL@BPP MOL@BPP BOQB?O>I>O@E LPQBOFLO >JFK> QR?BO@IB O>KP¦ RMBOFLO RI@RPCLO SBOPB >OQF@RI>OC>@BQ PMFK>IK BAF@IB KQBOFLO MOL@BPP LPQBOFLOQR?BO@IB QR?BO@IB O>KPSBOPB LAV MOL@BPPTFQE O>KPSBOPB KCBOFLO PRI@RPCLO CLO>JBK >OQF@RI>O PMFK>IK LAV MFKLRP C>@BQ KQBOFLO MOL@BPP QR?BO@IB B Anterior view. C Superior view.

7 Thoracic & Lumbar Vertebrae

Fig. 1.11 Thoracic spine Fig. 1.12 Typical thoracic vertebra (T6) Left lateral view. Back RMBOFLO RMBOFLO SBOQB?O>IKLQ@E >OQF@RI>OC>@BQ RMBOFLO O>KPSBOPB @LPQ>IC>@BQ MOL@BPP MFKLRPMOL@BPP LPQ>IC>@BQLK PQQELO>@F@ QO>KPSBOPB SBOQB?O>ª« MOL@BPP KCBOFLO>OQF@RI>O LAV MOL@BPP KCBOFLO SBOQB?O>IKLQ@E

RMBOFLO>OQF@RI>O KCBOFLO MOL@BPP @LPQ>IC>@BQ KCBOFLO MFKLRP >OQF@RI>OC>@BQ MOL@BPP O>KPSBOPB MOL@BPP A Left lateral view. KCBOFLO LPQ>IC>@BQ @LPQ>IC>@BQ LKQO>KPSBOPB MOL@BPP RMBOFLO O>KPSBOPB RMBOFLO >OQF@RI>OMOL@BPP LAV MOL@BPP @LPQ>IC>@BQ VD>ML¦ MEVPB>IGLFKQ

RMBOFLO @LPQ>IC>@BQ

BOQB?O>I ?LAV KCBOFLO LPQ>IC>@BQ @LPQ>IC>@BQ LKQO>KPSBOPB MOL@BPP KCBOFLO MFKLRPMOL@BPP >OQF@RI>OC>@BQ

KCBOFLO B Anterior view. SBOQB?O>I KQBO¦ KLQ@E SBOQB?O>I CLO>JBK RMBOFLO LPQ>IC>@BQLK MFKLRPMOL@BPP SBOQB?O>I QO>KPSBOPBMOL@BPP >JFK> KLQ@E

O>KPSBOPB MOL@BPP QEQELO>@F@ BAF@IB RMBOFLO SBOQB?O>ª« >OQF@RI>OC>@BQ KCBOFLO RMBOFLO @LPQ>IC>@BQ KCBOFLO SBOQB?O>IKLQ@E >OQF@RI>OC>@BQ RMBOFLO LAV @LPQ>IC>@BQ

C Superior view.

8 Fig. 1.13 Lumbar spine Left lateral view. RMBOFLO>OQF@R¦

I>OMOL@BPP 1 Bones, Ligaments & Joints Fig. 1.14 Typical lumbar vertebra (L4) O>KPSBOPBMOL@BPP PQIRJ?>O SBOQB?O>ª « RMBOFLO >OQF@RI>OMOL@BPP

KCBOFLO >JJFII>OVMOL@BPP SBOQB?O>I MFKLRP KQBO¦ KLQ@E MOL@BPP O>KPSBOPB SBOQB?O>I MOL@BPP CLO>JBK RMBOFLO LAV SBOQB?O>I KLQ@E MFKLRP VD>MLMEVPB>I MOL@BPP GLFKQ KCBOFLO SBOQB?O>IKLQ@E BOQB?O>I ?LAV KCBOFLO >OQF@RI>OC>@BQ KCBOFLO >OQF@RI>OMOL@BPP A Left lateral view. QEIRJ?>O SBOQB?O>ª «

RMBOFLO >OQF@RI>O KCBOFLO KCBOFLO LAV MOL@BPP >OQF@RI>OMOL@BPP >OQF@RI>OC>@BQ O>KPSBOPB MOL@BPP Clinical

Osteoporosis The spine is the structure most affected by degenerative diseases of the skeleton, such as arthrosis and osteoporosis. In osteoporosis, more bone material gets reabsorbed than built up, resulting in a loss of bone mass. Symptoms include compression fractures and resulting back pain. KCBOFLO >OQF@RI>OC>@BQ

KCBOFLO MFKLRP >OQF@RI>OMOL@BPP MOL@BPP B Anterior view.

MFKLRPMOL@BPP RMBOFLO >OQF@RI>OC>@BQ >JJFII>OV MOL@BPP @@BPPLOV O>KPSBOPBMOL@BPP MOL@BPP

BOQB?O>I RMBOFLO>OQF@R¦ >O@E I>OMOL@BPP BOQB?O>I RMBOFLO CLO>JBK SBOQB?O>I LAV KLQ@E

A Radiograph of a normal B Radiograph of an osteoporotic spine. C Superior view. lumbar spine, left lateral The vertebral bodies are decreased in view. density, and the internal trabecular structure is coarse. Lower and upper end plates are fractured.

9 Sacrum & Coccyx

The sacrum is formed from five postnatally fused sacral verte- vertebra, and the apex articulates with the coccyx, a series of three or brae. The base of the sacrum articulates with the fifth lumbar four rudimentary vertebrae. Back

Fig. 1.15 Sacrum and coccyx

RMBOFLO >OQF@RI>O FKDLC OLJLKQLOV MOL@BPP P>@ORJ

>QBO>I M>OQ

KQBOFLOP>@O>I O>KPSBOPB CLO>JFK> IFKBP

MBULC RMBOFLO P>@ORJ >@OL@L@@VDB>I >OQF@RI>O >@O>I GLFKQ C>@BQ QR?BOLPFQV >@O>I @>K>I L@@VU

A Anterior view.

>QBO>I M>OQ ROF@RI>O PROC>@B

>QBO>I P>@O>I@OBPQ

LPQBOFLOP>@O>I BAF>K CLO>JFK> P>@O>I@OBPQ

BAF>IP>@O>I@OBPQ

>@O>IEF>QRP

>@O>I@LOKR> L@@VDB>I@LOKR >@OL@L@@VDB>I GLFKQ L@@VU

B Posterior view.

10 >PBLC P>@ORJ RMBOFLO

>OQF@RI>OMOL@BPP 1 Bones, Ligaments & Joints

OLJLK¦ QLOV

ROF@RI>O >@O>I PROC>@B QR?BOLPFQV

LPQBOFLO PROC>@B

KQBOFLOªMBISF@«PROC>@B

>QBO>I P>@O>I@OBPQ

L@@VU D Radiograph of sacrum, anteroposterior view.

C Left lateral view.

Fig. 1.16 Sacrum Superior view.

BAF>K P>@O>I@OBPQ RMBOFLO >@O>I >OQF@RI>OMOL@BPP @>K>I BAF>K P>@O>I@OBPQ >@O>I @>K>I LPQBOFLO P>@O>I >QBO>I CLO>JBK M>OQLC P>@ORJ

OLJLKQLOV FKDLC >QBO>IM>OQ P>@ORJ

A Base of sacrum, superior view. BISF@ PROC>@B KQBOFLO P>@O>ICLO>JBK

L@@VU

B Transverse section through second sacral vertebra demonstrating anterior and posterior sacral foramina, superior view.

11 Intervertebral Disks

Fig. 1.17 Intervertebral disk BOQB?O>I@>K>I in the vertebral column Back Sagittal section of T11–T12, left lateral view. BOQB?O>I?LAV RMBOFLO The intervertebral disks occupy the spaces >OQF@RI>O between vertebrae (intervertebral joints, C>@BQ see p. 14). KRIRP BOQB?O>I KQBO¦ CF?OLPRP SBOQB?O>I >O@E R@IBRP AFPH MFKLRPMOL@BPP MRIMLPRP FD>JBKQRJ CI>S> KQBOPMFKLRP IFD>JBKQ

KRIRP R@IBRP RMBOFLO O>KPSBOPB Fig. 1.18 Structure of CF?OLPRP MRIMLPRP >OQF@RI>OMOL@BPP MOL@BPP intervertebral disk Anterosuperior view with the anterior half of the disk and the right half of the end plate removed. The intervertebral disk consists of an external fibrous ring (anulus fibrosus) and a gelatinous core (nucleus pulposus). V>IFKB @>OQFI>DB BKAMI>QB

KQBOSBOQB?O>I >ODFK>IOFADB PROC>@B LAV ªBMFMEVPB>IOFKD«

Fig. 1.19 Relation of intervertebral Fig. 1.20 Outer zone of the anulus fibrosus disk to vertebral canal Anterior view of L3–L4 with intervertebral disk. Fourth lumbar vertebra, superior view.

>ODFK>IOFADB RMBOFLO ªBMFMEVPB>IOFKD« >OQF@RI>OMOL@BPP MFKLRPMOL@BPP

BOQB?O>I RMBOFLO>OQF@RI>O CLO>JBK MOL@BPP O>KPSBOPB O>KPSBOPB MOL@BPP RMBOFLO MOL@BPP SBOQB?O>I KQBOSBOQB?O>I BOQB?O>I KLQ@E CLO>JBK ?LAFBP OLPPFKDCF?BO R@IBRPMRIMLPRP PVPQBJPLCQEB >KRIRPCF?OLPRP KRIRP KKBOWLKB CF?OLPRP RQBOWLKB

KCBOFLO >OQF@RI>O MOL@BPP MFKLRPMOL@BPP

12 1 Bones, Ligaments & Joints Clinical

Disk herniation in the lumbar spine As the stress resistance of the anulus fibrosus declines with age, the tissue the spinal nerve is affected, the muscles served by that spinal nerve will show of the nucleus pulposus may protrude through weak spots under loading. weakening. It is an important diagnostic step to test the muscles innervated by If the fibrous ring of the anulus ruptures completely, the herniated material a nerve from a certain spinal segment, as well as the sensitivity in the specific may compress the contents of the intervertebral foramen (nerve roots and dermatome. Example: The first sacral nerve root innervates the gastrocnemius blood vessels). These patients often suffer from severe local back pain. Pain and soleus muscles; thus, standing or walking on toes can be affected (see is also felt in the associated dermatome (see p. 600). When the motor part of p. 398).

>RA> >QFKQEB BNRFK> BMFARO>I MFARO>I PM>@B C>Q BOKF>QBA RO>IPIBBSB KQBOSBOQB?O>I AFPH TFQEPMFK>IK CLO>JBK >RA> BNRFK>FK BKQO>I ²¦CFIIBA EBOKF>QFLK ARO>IP>@

R@IBRP >@ORJ MRIMLPRP

A Superior view. B Midsagittal T2-weighted MRI (magnetic resonance image).

Posterior herniation (A, B) In the MRI, a conspicuously herniated disk at the sac is deeply indented at that level. *CSF (cerebrospinal fluid). level of L3–L4 protrudes posteriorly (transligamentous herniation). The dural

MFK>I ARO>J>QBO RO>IP>@ MLKAVILMEVQB RO>IPIBBSB TFQEPMFK>IK LJMOBPPBA LPQBOLI>QBO>I KBOSBOLLQP EBOKF>QFLK LPQBOLI>QBO>I EBOKF>QFLK R@IBRP MRIMLPRP KQBOSBOQB?O>IAFPH

BOQB?O>I>O@E ªMBAF@IBAFSFABA« RO>IPIBBSBTFQEPMFK>IK

C Superior view. D Posterior view, vertebral arches removed.

Posterolateral herniation (C, D) A posterolateral herniation may compress medially positioned, the herniation may spare the nerve at that level, but the spinal nerve as it passes through the intervertebral foramen. If more impact nerves at inferior levels.

13 Joints of the Vertebral Column: Overview

Fig. 1.21 Joints of Table 1.2 Joints of the vertebral column the vertebral column Back Craniovertebral joints

A Atlanto-occipital joints Occiput–C1 S Atlantoaxial joints C1–C2 Joints of the vertebral bodies D Uncovertebral joints C3–C7 F Intervertebral joints C1–S1 Joints of the vertebral arch G Zygapophyseal joints C1–S1

Fig. 1.22 Zygapophyseal (intervertebral facet) joints The orientation of the zygapophyseal joints differs between the spinal regions, influencing the degree and direction of movement.

RMBOFLO>OQF@RI>O KQBOFLO MOL@BPP O>KPSBOPB QR?BO@IB MOL@BPP MFKLRPMOL@BPP LPQBOFLO QR?BO@IB VD>MLMEVPB>I GLFKQ RI@RPCLO PMFK>IK

O>KPSBOPB KCBOFLO>OQF@RI>O RMBOFLO CLO>JBK MOL@BPP >OQF@RI>OC>@BQ A Cervical region, left lateral view. The zygapophyseal joints lie LPQ>IC>@BQ 45 degrees from the horizontal.

VD>MLMEVPB>IGLFKQ BOQB?O>ICLO>JBK

RMBOFLO >OQF@RI>OMOL@BPP O>KSBOPB MOL@BPP

O>KSBOPB VD>MLMEVPB>I MOL@BPP GLFKQ

KCBOFLO>OQF@RI>O MFKLRPMOL@BPP C>@BQ

B Thoracic region, left lateral view. The joints lie in the coronal plane. KCBOFLO >OQF@RI>OMOL@BPP

C Lumbar region, posterior view. The joints lie in the sagittal plane.

14 Fig. 1.23 Uncovertebral joints Clinical Anterior view. Uncovertebral joints form during childhood between the uncinate processes of C3–C6 and the vertebral bodies immediately supe- Proximity of spinal nerve and vertebral artery 1 Bones, Ligaments & Joints rior. The joints may result from fissures in the cartilage of the disks that to the uncinate process assume an articular character. If the fissures become complete tears, The spinal nerve and vertebral artery pass through the intervertebral and the risk of pulposus herniation is increased (see p. 13). transverse foramina, respectively. Bony outgrowths (osteophytes) resulting from uncovertebral arthrosis may compress both the nerve and the artery and can lead to chronic pain in the neck. BKP QI>Pª«

BOQB?O>I> FKQO>KPSBOPB >QBO>I UFPª« CLO>JBK >QI>KQL>UF>I GLFKQ PMFK>IK QI>Pª«

UFPª« K@FK>QB MOL@BPPBP BOQB?O>I> BOQB?O>I?LAV K@FK>QB MOL@BPP LPQBOFLO KQBOSBOQB?O>I O>KP¦ QR?BO@IB AFPH SBOPB O>KPSBOPB MOL@BPP KQBOFLO MOL@BPP QR?BO@IB RI@RPCLO PMFK>IK MFK>IK FKPRI@RP PMFK>IK

BOQB?O>I?LAVª « KCBOFLO >OQF@RI>OC>@BQ A Cervical spine, anterior view. A Uncovertebral joints in the cervical spine of an 18-year-old man, anterior view. MFKLRP MOL@BPP

>JFK> BOQB?O>I CLO>JBK MFK>I @LOA

RMBOFLO >OQF@RI>OC>@BQ

LPQBOFLOOLLQ MFK>IK ªPMFK>I«D>KDIFLK

BOQB?O>I> BOQB?O>I O>KPSBOPB ?LAV MOL@BPP B Uncovertebral joint (enlarged), anterior view of coronal section. O>KPSBOPB K@FK>QB CLO>JBK MOL@BPP

B Fourth cervical vertebra, superior view.

C Split intervertebral disk, anterior view of coronal section.

15 Joints of the Vertebral Column: Craniovertebral Region

Fig. 1.24 Craniovertebral joints Back RMBOFLO UQBOK>IL@@FMFQ>I KR@E>IIFKB MOLQR?BO>K@B

@@FMFQ>I@LKAVIB >PQLFAMOL@BPP ªQBJMLO>I?LKB« BKPLC>UFPª« BAF>K QVILFAMOL@BPP QI>Pª« >QI>KQL>UF>IGLFKQ ªQBJMLO>I?LKB« BKPLC>UFPª« RMBOFLO>OQF@RI>O UFPª« C>@BQªI>QBO>IJ>PP LC>UFP« A Posterior view.

OLLSBCLO O>KPSBOPB SBOQB?O>I> MOL@BPP

MFKLRPMOL@BPP

B Atlas and axis, posterosuperior view.

Fig. 1.25 Dissection of the craniovertebral joint ligaments Posterior view.

UQBOK>IL@@FMFQ>I MOLQR?BO>K@B R@E>II R@E>II

QI>KQL¦L@@FMFQ>I QVILFAMOL@BPP GLFKQ LPQBOFLO LPQBOFLO>O@E LPQBOFLO>QI>KQL¦ >QI>KQL¦ QI>Pª« LC>QI>P L@@FMFQ>IJBJ?O>KB L@@FMFQ>I JBJ?O>KB B@QLOF>IJBJ?O>KB VD>MLMEVPB>I ªMLPQBOFLO GLFKQª@>MPRIB« UFPª« ILKDFQRAFK>II« MFKLRPMOL@BPP BOQB?O>I>O@E FD>JBKQ>CI>S>

A Nuchal ligament and posterior atlanto- B Posterior longitudinal ligament. Removed: occipital membrane. Spinal cord; vertebral canal windowed.

16 The atlanto-occipital joints are the two articulations between the axial joints are the two lateral and one medial articulations between the convex occipital condyles of the occipital bone and the slightly atlas (C1) and axis (C2). concave superior articular facets of the atlas (C1). The atlanto- 1 Bones, Ligaments & Joints

Fig. 1.26 Ligaments of the craniovertebral joints

BAF>K KQBOFLO MF@>II LKDFQRAFK>I >QI>KQL>UF>I QR?BO@IB I>OII I>OII LCQEBABKP C>P@F@IBP GLFKQ RMBOFLO MF@>II RMBOFLO B@QLOF>IJBJ?O>KB >OQF@RI>OC>@BQ LCQEBABKP >OQF@RI>O C>@BQ O>KPSBOPBI O>KPSBOPB O>KPSBOPBI >MPRIBLC LC>QI>P MOL@BPP LC>QI>P I>QBO>I>QI>KQL¦ O>KPSBOPBMOL@BPP L@@FMFQ>IGLFKQ BKP KQBOQO>KPSBOPBI OLLSBCLO >QBO>IJ>PP BOQB?O>ICLO>JBK SBOQB?O>I> LCQEB>QI>P LPQBOFLO>O@E LKDFQRAFK>IC>P@F@IBP LPQBOFLO LC>QI>P LPQBOFLOQR?BO@IB >QI>KQL¦L@@FMFQ>I R@E>II MFKLRPMOL@BPP JBJ?O>KB LCQEB>QI>P LC>UFP MFKLRPMOL@BPP A Ligaments of the median atlantoaxial joint, superior view. The fovea of the atlas is hid- B Ligaments of the craniovertebral joints, den by the joint capsule. posterosuperior view. The dens of the axis is hidden by the tectorial membrane.

B@QLOF>I LKDFQRAFK>I MF@>II I>OII JBJ?O>KB C>P@F@IBP LCABKP

QI>KQL¦ L@@FMFQ>I @>MPRIB LKDFQRAFK>I I>OI C>P@F@IBP² >QBO>I J>PPLC O>KPSBOPBI BKPMLPQBOFLO LC>QI>P² >OQF@RI>OPROC>@B

LKDFQRAFK>I LPQBOFLOILKDFQRAFK>II C>P@F@IBP

C Cruciform ligament of atlas (*). Removed: D Alar and apical ligaments. Removed: Transverse Tectorial membrane. ligament of atlas, longitudinal fascicles.

17 Vertebral Ligaments: Overview & Cervical Spine

The ligaments of the spinal column bind the vertebrae and enable stresses and limit the range of motion. The ligaments are subdivided the spine to withstand high mechanical loads and shearing into vertebral body ligaments and vertebral arch ligaments. Back

Fig. 1.27 Vertebral ligaments Table 1.3 Vertebral ligaments Viewed obliquely from the left posterior view. Ligament Location KQBOFLO O>KPSBOPB Vertebral body ligaments ILKDFQRAFK>IIFD>JBKQ MOL@BPP Along anterior surface of A Anterior longitudinal ligament vertebral body LPQBOFLOILKDFQRAFK>I Along posterior surface of IFD>JBKQ P Posterior longitudinal ligament vertebral body BAF@IB KQBO¦ BOQB?O>I Vertebral arch ligaments QO>KPSBOPB >O@E >JFK> IFD>JBKQ A Ligamenta flava Between laminae KCBOFLO>OQF@RI>O S Interspinous ligaments Between spinous process MOL@BPP RMO>¦ Along posterior ridge of D Supraspinous ligaments RMBOFLO>OQF@RI>O PMFKLRP spinous processes MOL@BPP IFD>JBKQ F Intertransverse ligaments Between transverse processes FD>JBKQRJCI>S> MFKLRP KQBOPMFKLRPIFD>JBKQ MOL@BPP Between external occipital Nuchal ligament* protuberance and spinous process of C7 *Corresponds to a supraspinous ligament that is broadened superiorly.

Fig. 1.28 Anterior longitudinal ligament Fig. 1.29 Posterior longitudinal ligament Anterior longitudinal ligament. Anterior view with base of skull removed. Posterior view with vertebral canal windowed and spinal cord removed. The tectorial membrane is a broadened expansion of the posterior longitudinal ligament.

KQBOK>I @@FMFQ>I UQBOK>IL@@FMFQ>I L@@FMFQ>I ?LKB MOLQR?BO>K@B MOLQR?BO>K@B ?>PFI>O M>OQ QI>KQL¦L@@FMFQ>I GLFKQª>QI>KQL¦ KQBOFLO L@@FMFQ>I@>MPRIB« >QI>KQL¦ L@@FMFQ>I JBJ?O>KB QI>Pª« O>KPSBOPB O>KPSBOPB MOL@BPP CLO>JFK> >QBO>I QI>KQL¦L@@FMFQ>I QI>KQL¦L@@FMFQ>I UFPª« >QI>KQL>UF>I @>MPRIB GLFKQ GLFKQª@>MPRIB« LPQBOFLO>QI>KQL¦ B@QLOF>IJBJ?O>KB KQBOFLO VD>MLMEVPB>I L@@FMFQ>IJBJ?O>KB ILKDFQRAFK>I GLFKQª@>MPRIB« IFD>JBKQ BOQB?O>I>O@E LPQBOFLO RI@RPCLO QR?BO@IB PMFK>IKBOSB KQBOFLO QR?BO@IB

KQBOSBOQB?O>I LPQBOFLOILKDFQRAFK>I AFPH BOQB?O> IFD>JBKQ MOLJFKBKP ª «

18 Fig. 1.30 Ligaments of the cervical spine BII> MF@>IIFD>JBKQ VMLDILPP>I B@QLOF>I QRO@F@> LCQEBABKP @>K>I JBJ?O>KB 1 Bones, Ligaments & Joints

MEBKLFAPFKRP

@@FMFQ>I?LKB ?>PFI>OM>OQ UQBOK>I KQBOFLO L@@FMFQ>I >QI>KQL¦L@@FMFQ>I MOLQR?BO>K@B JBJ?O>KB BKPLC>UFPª« KQBOFLO>O@E LC>QI>Pª« O>KPSBOPB LKDFQR¦ IFD>JBKQLC>QI>P >UFII> AFK>I LPQBOFLO C>P@F@IBP >QI>KQL¦L@@FMFQ>I JBJ?O>KB LPQBOFLO>O@ELC>QI>P MLPQBOFLOQR?BO@IB R@E>IIFD>JBKQ FD>JBKQ>CI>S> >@BQGLFKQ @>MPRIB BOQB?O>I>O@E

KQBOSBOQB?O>IAFPH KQBOSBOQB?O>ICLO>JBK

MFKLRPMOL@BPP KQBOFLOILKDFQRAFK>I IFD>JBKQ KQBOPMFKLRPIFD>JBKQ

LPQBOFLOILKDFQRAFK>I RMO>PMFKLRP IFD>JBKQ IFD>JBKQ

SBOQB?O>I?LAV ªSBOQB?O>MOLJFKBKP«

A Midsagittal section, left lateral view. The nuchal ligament is the broadened, sagittally oriented part of the supraspinous ligament that extends from the vertebra prominens (C7) to the external occipital protuberance.

BOB?BIILJBARII>OV MBULCABKP @FPQBOK

LPQBOFLOQR?BO@IB LAVLC>UFP LC>QI>P

R@E>IIFD>JBKQ

LPQBOFLOILKDFQR¦ AFK>IIFD>JBKQ

BOQB?O>I?LAV

KQBOSBOQB?O>I AFPH RMO>PMFKLRPIFD>JBKQ BOQB?O> MOLJFKBKPª « MFK>I@LOA

KQBOFLO R?>O>@EKLFAPM>@B ILKDFQRAFK>I IFD>JBKQ

B Midsagittal T2-weighted MRI, left lateral view. (From Vahlensieck, Rei- ser. MRT des Bewegungsapparates. 2nd ed. Stuttgart: Thieme; 2001.)

19 Vertebral Ligaments: Thoracolumbar Spine

Fig. 1.31 Ligaments of the vertebral BOQB?O>I@>K>I column: Thoracolumbar junction Back Left lateral view of T11–L3, with T11–T12 RMBOFLO>OQF@RI>O sectioned in the midsagittal plane. C>@BQ

LPQBOFLOILKDFQRAFK>I KRIRP IFD>JBKQ KQBOSBOQB?O>I CF?OLPRP BOQB?O>I>O@E AFPH R@IBRP MRIMLPRP

FD>JBKQ>CI>S>

RMBOFLO>OQF@RI>O KQBOFLO MOL@BPP ILKDFQRAFK>I IFD>JBKQ MFKLRPMOL@BPPBP

KQBOPMFKLRPIFD>JBKQP

O>KPSBOPBMOL@BPP

BOQB?O>I?LAV KQBOQO>KPSBOPBIFD>JBKQP

>@BQGLFKQ@>MPRIB

RMO>PMFKLRP IFD>JBKQ

KCBOFLO>OQF@RI>O C>@BQ

Fig. 1.32 Anterior longitudinal ligament Anterior view of L3–L5.

KQBOSBOQB?O>I O>KPSBOPB AFPH MOL@BPP BOQB?O>I?LAV

KQBOFLOILKDFQRAFK>IIFD>JBKQ

20 Fig. 1.33 Ligamentum flavum and intertransverse ligament Anterior view of opened vertebral canal at 1 Bones, Ligaments & Joints level of L2–L5. Removed: L2–L4 vertebral bodies.

RMBOFLO >OQF@RI>O MOL@BPP

>JFK>

KQBO¦ QO>KPSBOPB FD>JBKQ> IFD>JBKQP CI>S>

O>KPSBOPB MOL@BPP

LPQBOFLO RMBOFLO ILKDFQRAFK>I >OQF@RI>O Fig. 1.34 Posterior longitudinal IFD>JBKQ MOL@BPP ligament Posterior view of opened vertebral canal at KQBOFLO level of L2–L5. Removed: L2–L4 vertebral ILKDFQRAFK>I arches at pedicular level. IFD>JBKQ KCBOFLO>OQF@RI>O C>@BQ

MFKLRPMOL@BPP

RQOFBKQ CLO>JFK>

BAF@IBPLC LPQBOFLO SBOQB?O>I>O@EBP ILKDFQRAFK>I IFD>JBKQ

KQBOSBOQB?O>I KQBOSBOQB?O>I CLO>JBK AFPH BOQB?O>I >MFK ?LAV IFD>JBKQLRP OBFKCLO@BJBKQ RMBOFLO LCQEBAFPH >OQF@RI>OC>@BQ

O>KPSBOPB MOL@BPP

KCBOFLO>OQF@RI>O MOL@BPP MFKLRPMOL@BPP BOQB?O>I@>K>I