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Lippincott Williams & Wilkins atlas of ANATOMY THE BACK CHAPTER 1

Plate 1-01 Palpable Structures of the Back ...... 5 Plate 1-02 Vertebral Column, Lateral View ...... 6 Plate 1-03 Cervical Vertebrae ...... 7 Plate 1-04 Articulated Cervical Vertebrae ...... 8 Plate 1-05 Thoracic and Lumbar Vertebrae ...... 9 Plate 1-06 Articulated Thoracic Vertebrae ...... 10 Plate 1-07 Articulated Lumbar Vertebrae ...... 11 Plate 1-08 Sacrum and Coccyx ...... 12 Plate 1-09 Ligaments of the Cervical Vertebrae ...... 13 Plate 1-10 Ligaments of the Thoracic Vertebrae ...... 14 Plate 1-11 Ligaments of the Lumbar Vertebrae and Sacrum ...... 15 Plate 1-12 Cutaneous Innervation of the Back ...... 16 Plate 1-13 Superficial Muscles of the Back ...... 17 Plate 1-14 Deep Back Muscles, Superficial Dissection ...... 18 Plate 1-15 Deep Back Muscles, Deeper Dissection ...... 19 Plate 1-16 Suboccipital Region...... 20 Plate 1-17 Pattern of a Typical Spinal Nerve ...... 21 Plate 1-18 Spinal Cord, Posterior View ...... 22 Plate 1-19 Superior Portion of the Spinal Cord ...... 23 Plate 1-20 Inferior Portion of the Spinal Cord ...... 24 Plate 1-21 Blood Supply of the Spinal Cord, Anterior View...... 25 Plate 1-22 Venous Drainage of the Vertebral Column and Spinal Cord ...... 26 Plate 1-23 Dermatomes ...... 27 10752-01_CH01redo.qxd 9/24/07 3:07 PM Page 4

Palpable Structures of the Back PLATE 1-01

Palpable bony structures

Superior nuchal line

External occipital protuberance

Superior border of trapezius muscle

Vertebra prominens (C7) Clavicle

Acromioclavicular Acromion of scapula joint Spine of scapula

Greater tubercle Posterior axillary of humerus fold

Inferior angle of scapula Spinous processes of vertebrae in vertebral furrow

Rib

Bulge of erector spinae muscles Iliac crest

Hip bone Posterior superior iliac spine

Sacrum

Coccyx Greater trochanter of femur

Ischial tuberosity

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PLATE 1-02 Vertebral Column, Lateral View Cervical Vertebrae PLATE 1-03

Vertebral Column, Lateral View A. Atlas (C1), superior view B. Atlas (C1), inferior view Posterior Anterior arch Anterior tubercle tubercle rch Vertebral PosteriorAnterior archa Articular facet foramen Transverse for dens process Transverse process

Atlas (C1)

Axis (C2) Transverse foramen Vertebral Transverse Cervical curvature foramen foramen

Superior articular Posterior arch Inferior articular facet for occipital facet for axis Articular facet C7 condyle Posterior for dens T1 tubercle Anterior arch Groove for vertebral artery Anterior and C1 ventral ramus tubercle

C. Axis (C2), superior view

Anterior articular facet Anterior archDens for arch of atlas

Thoracic curvature Superior articular facet Transverse process Inferior articular process

T12 Lamina Posterior articular facet for L1 transverse ligament of atlas Spinous process

Lumbar curvature D. Cervical vertebra (C4), superior view E. Cervical vertebra (C4), lateral view Body

Transverse process: Uncinate Superior articular Uncinate L5 process process facet and process Anterior tubercle Pedicle Transverse foramen Transverse process:

Sacral curvature Anterior Sacrum Posterior tubercle tubercle Transverse Superior foramen articular Posterior facet tubercle Vertebral Spinous Inferior Body foramen process articular process Lamina Spinous process Coccyx

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PLATE 1-04 Articulated Cervical Vertebrae Thoracic and Lumbar Vertebrae PLATE 1-05

A. Lateral view B. Radiograph of cervical vertebrae, lateral view A. Thoracic vertebra (T6), superior view B. Thoracic vertebra (T6), lateral view Body

Superior Superior articular vertebral Occipital bone facet and process Vertebral notch Superior foramen costal facet Body Anterior arch Pedicle of atlas (C1) Superior C1 C1 Superior costal facet Transverse Posterior arch vertebral costal facet of atlas (C1) notch Pedicle C2 C2 Transverse Transverse process Intervertebral disc costal facet C3 C3 Inferior articular C4 Lamina process Inferior C4 Superior Inferior Zygapophyseal joint Transverse articular vertebral costal facet process facet notch Spinous Spinous C5 C5 process process Intervertebral foramen

Spinous process of C6 C6 C6 C. Intervertebral disc, superior view Transverse process Anulus C7 C7 fibrosus

T1 Nucleus pulposus

C. Posterior view D. Radiograph of cervical vertebrae, posterior view

D. Lumbar vertebra (L3), superior view Mandible E. Lumbar vertebra (L3), lateral view C1 Body Superior C2 articular Superior process vertebral notch Pedicle C3 C3 Transverse process Transverse C4 C4 process of C4 Pedicle Spinous processes C5 Vertebral Spinous C5 Transverse foramen process process

C6 C6 Lamina of C6 Inferior Superior vertebral articular Body C7 C7 Inferior notch process articular Spinous process and facet Lamina process Inferior of C7 Mammillary T1 process articular Spinous facet process

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PLATE 1-06 Articulated Thoracic Vertebrae Articulated Lumbar Vertebrae PLATE 1-07

A. Lateral view B. Radiograph of lumbar vertebrae, lateral view A. Lateral view B. Posterior view

Inferior articular T12 T12 process Superior articular C7 process L1 Pedicle T1 L1 Intervertebral disc Spinous processes L2 L2 Spinous process

Inferior vertebral notch Intervertebral foramina L3 L3 Transverse costal facets Intervertebral foramen

L4 Superior vertebral notch L4 Transverse Inferior costal facets process of L4

Laminae L5 Body L5

Sacrum

Superior costal facets Transverse processes C. Posterior view D. Radiograph of lumbar vertebrae, posterior view

T12 T12

Pedicles Transverse process L1 L1 Zygapophyseal joint L2 Inferior articular process Intervertebral discs L2 Superior articular process

Pedicle L3 L3 Spinous process

L4 L4 Lamina T12

L5 L5 L1

Sacrum

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PLATE 1-08 Sacrum and Coccyx Ligaments of the Cervical Vertebrae PLATE 1-09

Base of sacrum A. Lateral view A. Anterior view

Anterior atlanto-occipital membrane Capsule of atlanto-occipital joint Posterior atlanto-occipital membrane Ala (lateral part) Anterior arch of atlas (C1) Superior articular process Body of axis (C2) Lumbosacral articular surface Promontory Vertebral artery

Capsules of zygapophyseal joints Anterior (pelvic) Ligamenta flava (C3–C4 and C4–C5) sacral foramina Transverse ridges Anterior longitudinal ligament Ligamentum nuchae

Apex of sacrum Interspinous ligament Intervertebral discs (C4–C5 and C6–C7) Coccyx Spinous process of C7 vertebra (vertebra prominens)

T1

B. Posterior view B. Posterior view

Occipital bone

Capsule of atlanto-occipital joint Posterior atlanto-occipital membrane Superior articular facet Transverse process of atlas (C1) Capsule of lateral atlantoaxial joint Atlas (C1) Auricular surface Axis (C2)

Median sacral crest Ligamenta flava Posterior sacral Ligamentum nuchae Lateral sacral crest foramina

Vertebral artery Capsules of zygapophyseal joints

Sacral hiatus

Coccyx

T1 Supraspinous ligament

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PLATE 1-10 Ligaments of the Thoracic Vertebrae Ligaments of the Lumbar Vertebrae and Sacrum PLATE 1-11

A. Lateral view Body of T12

Ligamenta Body of L1 flava Posterior longitudinal ligament A. Lateral view Anulus fibrosus Nucleus pulposus Intervertebral Supraspinous Tip of conus medullaris (cut) foramen surrounded by nerve roots ligament C7 Interspinous T1 L2 spinal nerve ligament Zygapophyseal joint capsules Anterior longitudinal ligament Intervertebral foramen Posterior longitudinal B. Posterior view Supraspinous ligament ligament Intertransverse Intervertebral disc ligaments Anterior longitudinal C7 ligament Interspinous ligament Pedicle Superior costotransverse T1 Spinous ligaments Transverse process process

Dorsal rami: Ventral rami: Radiate L4 L4 ligaments L5 L5 Ribs B. Posterior view Superior costotransverse ligament Ribs Supraspinous Lamina ligament Sacrum Lateral Intervertebral costotransverse discs ligament Intertransverse Posterior Pedicle ligament longitudinal (cut) ligament

Spinous process

Anterior Lamina longitudinal ligament T12 Transverse process

Lamina Ligamenta flava L1 Intertransverse ligament

Zygopophyseal joint capsule

Iliolumbar ligament

Supraspinous ligament

T12

Posterior sacroiliac L1 ligament

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PLATE 1-12 Cutaneous Innervation of the Back Superficial Muscles of the Back PLATE 1-13

Superior nuchal line

Greater occipital nerve Sternocleidomastoid muscle (dorsal ramus of C2) Splenius capitis muscle Accessory nerve (CN XI) Third occipital nerve Spinous process of C7 (dorsal ramus of C3) Splenius cervicis muscle Transverse cervical artery Trapezius muscle Levator scapulae muscle Trapezius muscle Skin Rhomboid minor muscle Spine of scapula Rhomboid major muscle Posterior cutaneous branches (dorsal rami of C4–T6) Trapezius muscle Deltoid muscle Deltoid muscle Infraspinatus fascia Infraspinatus Teres major muscle fascia

Thoracodorsal Teres major artery and nerve muscle

Latissimus dorsi muscle

Posterior cutaneous branches Triangle of (dorsal rami of T7–T12) auscultation

Erector spinae muscles External abdominal oblique muscle Superficial (deep to thoracolumbar fascia) fascia Latissimus dorsi Latissimus dorsi muscle muscle (cut)

Lateral cutaneous branches of ventral rami (intercostal nerves) External abdominal oblique muscle Serratus anterior muscle Spinous process of T12 Serratus posterior Lumbar triangle inferior muscle 12th rib Iliac crest Superior cluneal nerves (dorsal rami of L1–L3) Thoracolumbar fascia

Iliac crest

Middle cluneal nerves (dorsal rami of S1–S3)

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PLATE 1-14 Deep Back Muscles, Superficial Dissection Deep Back Muscles, Deeper Dissection PLATE 1-15

Superior nuchal line Rectus capitis posterior muscles: External occipital protuberance External occipital protuberance Minor Major

Superior nuchal line Obliquus capitis superior muscle Transverse process of altas (C1) Posterior tubercle of atlas (C1) Posterior tubercle of atlas Obliquus capitis inferior muscle Spinous process of axis (C2) Interspinalis cervicis muscle Splenius capitis and Semispinalis capitis muscle cervicis muscles Semispinalis muscles: Capitis Rotatores cervicis muscles: Longissimus cervicis muscle Thoracis Longus Brevis Spinous process of C7 Iliocostalis cervicis muscle

Iliocostalis thoracis muscle Spinous process of C7 (retracted)

Serratus posterior superior muscle

Rotatores thoracis muscles: Longus Brevis

External intercostal muscles

Interspinalis thoracis muscle Erector spinae muscle: Spinalis thoracis muscle Iliocostalis muscle Longissimus muscle Levatores costarum muscles: Spinalis muscle Longissimus thoracis muscle Multifidus muscles Longus Brevis Iliocostalis lumborum muscle

Serratus posterior inferior muscle Interspinalis lumborum muscle

External abdominal Internal abdominal Lateral oblique muscle oblique muscle intertransversarius muscle

Iliac crest Iliac crest

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PLATE 1-16 Suboccipital Region Pattern of a Typical Spinal Nerve PLATE 1-17

A. Orientation

B. Oblique section

Anterior cutaneous branch of 6th intercostal nerve: Medial branch Lateral branch

Parietal pleura Trapezius muscles (cut) Occipital artery Greater occipital nerve Superficial fascia Rectus capitis posterior minor muscle Skin

Rectus capitis posterior major muscle Sternum

Vertebral artery External intercostal membrane External intercostal muscle Obliquus capitis Transversus thoracis muscle superior muscle Internal intercostal muscle Innermost intercostal muscle Sternocleidomastoid muscle (cut)

Suboccipital nerve Lateral cutaneous branch Sternocleidomastoid (dorsal ramus of C1 spinal nerve) of 6th intercostal nerve: muscle (cut) Anterior branch Posterior branch Obliquus capitis inferior muscle Body of 6th thoracic vertebra

Lesser occipital nerve Splenius capitis muscle (cut and reflected) Sympathetic ganglion

Semispinalis capitis muscle Greater occipital nerve White and gray rami (dorsal ramus of C2 communicantes spinal nerve) Splenius capitis muscle Ventral root

Trapezius muscle (cut) 3rd occipital nerve Spinal cord (dorsal ramus of C3 spinal nerve) Dorsal root Dorsal root ganglion Longissimus capitis muscle 6th thoracic spinal nerve Scapula Ventral ramus (intercostal nerve) Dorsal ramus

Posterior cutaneous branch of dorsal ramus of 6th thoracic spinal nerve: Lateral branch Medial branch

Deep back muscles

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PLATE 1-18 Spinal Cord, Posterior View Superior Portion of the Spinal Cord PLATE 1-19

Occipital bone A. Orientation

C1 vertebra (atlas, cut) C1 spinal nerve B. Dissection C2 vertebra (axis, cut) Splenius capitis and splenius cervicis muscles Denticulate ligament (cut and reflected) C7 vertebra (cut) Dorsal root ganglion T1 vertebra (cut) Serratus posterior C5 pedicle (cut) superior muscle (cut and reflected) T1 spinal nerve

Dura mater

Dura and arachnoid mater Arachnoid mater (cut and reflected) Pia mater on surface of spinal cord

Erector spinae muscle: Roots of spinal nerves T2–T11 Iliocostalis muscle Dorsal median sulcus Longissimus muscle (spinalis muscle removed) Ventral ramus Dorsal ramus Serratus posterior inferior muscle (cut and reflected) Dorsal rootlets Conus medullaris

L1 spinal nerve T12 vertebra Posterior radicular artery (cut) Dorsal root of spinal nerve Termination of spinal cord L1 vertebra at intervertebral disc L1/L2 (cut) Denticulate ligament Cauda equina

Posterior spinal arteries Filum terminale internum Ventral root of spinal nerve L5 vertebra (cut) L5 spinal nerve Sacrum Dorsal root ganglion (cut) S1 spinal nerve Hip bone Spinal branches Termination of dural sac of posterior intercostal artery at S2 vertebral level

T3 pedicle (cut) S5 spinal nerve Filum terminale externum Coccygeal nerve Coccyx

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PLATE 1-20 Inferior Portion of the Spinal Cord Blood Supply of the Spinal Cord, Anterior View PLATE 1-21

A. Orientation B. Dissection

Posterior spinal arteries Thoracic vertebrae Anterior spinal Spinal cord artery

Arachnoid mater Dura mater Dura and arachnoid mater Denticulate ligament (cut) Arachnoid mater (cut and reflected) Posterior radicular artery Conus medullaris Posterior Branch to vertebral body Anterior radicular artery intercostal and dura mater artery Spinal branch Radicular arteries Lumbar vertebrae

Cauda equina

Pedicles (cut)

Filum terminale internum

Dorsal root ganglia

Sacrum

Filum terminale externum

C. MRI (T2 weighted), sagittal view Intercostal nerves Basivertebral Dorsal branch veins of posterior Accessory Conus medullaris intercostal artery hemiazygos vein Descending Vertebral bodies (L2 and L3) Sympathetic trunk thoracic aorta and ganglion Spinous process Thoracic duct Cerebrospinal fluid in lumbar cistern Posterior intercostal arteries Intervertebral disc

Cauda equina Accessory hemiazygos vein

Azygos vein

Sacrum

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PLATE 1-22 Venous Drainage of the Vertebral Column and Spinal Cord Dermatomes PLATE 1-23

A. Sagittal view A. Anterior view B. Posterior view

CN V Anterior external C2 vertebral venous plexus C3 C2 C4 C5 Basivertebral vein C6 Internal vertebral C3 venous plexus C7 C4 C8 T1 T1 T2 C6 T2 T3 T4 C5 T3 Cutaway sections of: T5 T6 Epidural fat L1 vertebral body T4 Dura mater T7 Arachnoid mater T5 T8 Spinal cord T6 T9 T10 T1 T7 T11 T12 T8 L1 C6 T9 L2 L3 T10 L4 C8 Posterior external vertebral venous plexus L1 T11 L5 S1 T12 L2 S2 S3 S4 C6 S2–S3 S5 C7 C7 C8

L3

B. Superior view External vertebral venous plexus L4

S1

Basivertebral vein Anterior median spinal vein Internal vertebral venous plexus Anterior lateral spinal vein Anterior radicular vein Intervertebral vein Posterior radicular vein L5

S2

Epidural fat Posterior lateral External vertebral venous plexus spinal vein

Posterior median spinal vein S1 L5

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