Spine Anatomy

Johns Hopkins Orthopaedic Surgery

Review Course

Physical Examination

CTQ

C6

A. Jay Khanna, MD

The Johns Hopkins Medical Institutions

Department of Orthopaedic Surgery
Baltimore, Maryland
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Key Points

Physical Examination

1. Relationship between nerve roots and:

a. Cervical Pedicle
b. Lumbar Pedicle
c. Disc

CTQ
Q

2. Cervical MRI Anatomy

3. Lumbar MRI Anatomy
4. Applied Anatomy and Surgical Approaches
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Neural Anatomy

Physical Examination

8 cervical roots
Each cervical root exits the c-spine
c spine above
the pedicle of the matching vertebrae

CTQ
Q

The remainder of the spine roots all exit

the canal under the corresponding pedicle
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

CTQ

Hoppenfeld S. 1976.

Nerve Roots

Above corresponding pedicle in cervical

spine

Below corresponding pedicle in lumbar

spine

CTQ

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.

Hoppenfeld S. 1976.

CTQ

CTQ
Hoppenfeld S. 1976.

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.

Hoppenfeld S. 1976.

CTQ

CTQ

High--Yield Fact
High
C4-5
C5 C4

Herniated C4-C5 disc

C5 nerve

C5

Herniated L4-L5 disc

Posterolateral
L5 nerve root
Far lateral

L4-5

L4 nerve root

L4

Foraminal stenosis
L4 nerve root

L5

Hoppenfeld S. 1976.

YOU MUST KNOW THIS !!

CTQ

SENSORY

REFLEX

C5

MOTOR
Deltoid/Biceps

Shoulder

Biceps

C6

Wrist Ext/Biceps

Thumb/Index

Brachioradialis

C7

Triceps/ Wrist
Flexors

Long

Triceps

C8

Intrinsics/grasp

Ring/Little

L4

Quad /Hip Add

Lat thigh / Medial Tibia

Patella Tendon

L5

EHL
Gluteus medius

Anterolateral leg
Dorsum foot

S1

Gastrocnemius

Lat malleolus/ Lat foot

Achilles

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.

Normal Axial Anatomy

Magnetic Resonance Imaging
of the Cervical Spine

Contributors to Degenerative Arthritis/Cervical

Stenosis

Intervertebral Disc
Facet Joints
Ligamentum Flavum (Hypertrophy and Ossification)
Spondylolysis
Spondylolisthesis
Congenital Stenosis

Normal Axial Anatomy

Chapman, 3rd Edition, 2001.

Neoplastic Disease

Extradural

Intradural-Extramedullary

Disc Bulge and Multilevel DJD

Intramedullary

Gonzales R. 2002

Neoplastic Disease
Narrow

I. Extradural

Normal

A.
B.
C.
D.
E.

Metastases
Myeloma
Lymphoma
Hemangioma
ABC

F. Giant Cell Tumor

G. Osteoid Osteoma
H. Osteoblastoma
I. Eosinophilic Granuloma
J. Ewings Sarcoma

K. Chordoma
L. Osteosarcoma
M. Chondrosarcoma
N. Osteochondrom

II IIntradural-Extramedullary
II.
t d lE t
d ll
A.
B.
C.

Nerve sheath tumors

(Neurofibroma > Schwannoma)
Meningiomas
Subarachnoid seeding
(Metastases)

D. Lipoma
E. Epidermoid
F. Dermoid

III. Intramedullary
A. Ependymoma
B. Astrocytoma
C. Hemangioblastoma

Neural Foraminal Narrowing

Walker HS. Radiographics 1987;7(6):1129-1152.

Magnetic Resonance Imaging

of the Lumbar Spine:
p

OPLL

Disc Bulge

Disc Extrusion

Contributors to Degenerative Arthritis/Lumbar Stenosis

Intervertebral Disc
Facet Joints
Li
Ligamentum
t Flavum
Fl
(Hypertrophy
(H
t h andd Ossification)
O ifi ti )
Scoliosis
Spondylolisthesis
Congenital Stenosis

Discitis and Vertebral Osteomyelitis

Anterior Cervical

Myelomeningocele

Applied Spinal Anatomy

CTQ

Common Surgical Approaches

Anatomy
Carotid Sheath

Anterior Cervical
Posterior Cervical
Anterior Thoracic
Anterior Lumbar
Posterior Thoracolumbar

Internal and Common Carotid Arteries

Internal Jugular Vein
Vagus
g Nerve

Recurrent Laryngeal Nerve

In Tracheoesophageal Interval
Possibly more variable on right side

CTQ

Sympathetic Chain

Posterior to carotid sheath

Anterior to longus capitus muscle
Anterior to transverse process

Disruption of inferior ganglion

Horners Syndrome

CTQ

Cervical CrossCross-Sectional Anatomy

Know the SLAC-Line relationship:
Anterior
Sympathetic chain
Longus colli
Artery (vertebral)
Cervical nerve root
Lateral mass
Posterior

CTQ

Relational Anatomy: Cervical Spine

Sympathetic chain

Specific Complications
Perforation of esophagus or trachea
Recurrent laryngeal nerve palsy

Longus colli

Dysphagia
vertebral Artery

Odynophagia
Cervical nerve root

Horners Syndrome
Lateral mass

Anterior Approach CC-Spine

Recurrent laryngeal nerve
Left -- Aortic Arch
Right Subclavian artery
Supplies vocal muscles
Horners syndrome
[Inferior Ganglion of Sympathetic Chain]

Ptosis,
Miosis
Facial Anhidrosis

CTQ

Anterior Approach CC-Spine

Anterior Approach CC-Spine

C2-3 HNP

Recurrent Laryngeal Nerve

Branch off Vagus
TEG
Left more constant

Carotid Sheath
Artery anterior medial
Internal jugular vein
Vagus nerve

Relational Anatomy

Sympathetic chain
Longus coli
Vertebral artery
Lateral mass

Anterior Approach CC-Spine

Think:

Superior laryngeal nerve a risk with standard approach

A modified submandibular approach
Anterior retropharyngeal exposure
High phonation
Protect superior laryngeal nerve in Singers !!!!

Posterior Cervical

Laryngeal Nerves in ACDF

Superior laryngeal nerve

traction in upper cervical surgery

high note phonation
no vocal cord paralysis

Recurrent laryngeal nerve

vocal cord paralysis on the side of injury

hoarseness
aspiration
can compensate partially for phonation

10

Atlantoaxial
Relational Anatomy

Cross-sectional Anatomy
Relationship

Relationship # 1
Ring of C1
Dens
Transverse
Ligament

Superior articular facet

Inferior articular facet
V
Vertebral
b l artery
Nerve root
Uncovertebral joint
Neuroforamen

Transverse ligament
helps provide C1-C2 stability

The uncovertebral joint makes up the anterior wall of the

neuroforamen.
The facet joints make up the posterior wall.

CTQ

Applied
Biomechanics

Oblique Anatomy
7 cervical vertebra
8 cervical roots
C5

The lower numbered

root exits the numbered
neuroforamen
Therefore, the C5 nerve root
exits the C4-C5 neuroforamen

CTQ

Lateral C-Spine
CTQ
Normal ADI
3.5 mm in Adults
4.0 mm in
Children
Open mouth
Normal lateral mass
overhang
6.9 mm total CTQ
overhang

Atlantoaxial Relational Anatomy

Ring of C1
Dens
Transverse Ligament

Vertebral artery
Ring of C1
Greater occipital nerve
C1-C2 facet joint

Atlantoaxial
Relationship # 2

Vertebral artery
Ring of C1
Greater occipital nerve
C1 C2 facet
C1-C2
f t joint
j i t

Vertebral artery
1.0 cm lateral for superior
midline dissection
1.5 cm lateral from posterior
mid-line dissection

CTQ

11

C2 nerve root

Atlantoaxial

Applied Anatomy: Skull

Halo Application

Relationship # 3

Vertebral artery
Ring of C1
Greater occipital nerve
C1 C2 facet
C1-C2
f t joint
j i t

CTQ

SAE spine 2003

Below the head equator

Adults
4 pins at 8 in-lbs

Children
8 pins at (2 to) 4 in-lbs

Greater occipital nerve

C2 nerve root
Exits between C1-C2
Posterior to C1-2 joint

Clinical Correlate

Tighten pins at 24 48 hrs

Tighten pins only once
If infected remove pin and
place adjacent to previous pin

C2 nerve root

4 at 8 or 8 at 4

Applied Anatomy
Halo Application

Dissection on the ring of C1 should

be < 1.0 cm from the midline

CTQ
Structures at Risk
SAE spine 2003

A-- insert PIN here

Atlantoaxial settling in rheumatoid

patients can compress the C2 nerve
causing base of the skull pain

B-- Supraorbital nerve

OTTO

C-- Supratrochlear nerve

C2 nerve root is at risk during
placement of the C1-2
transarticular screw

D Temporalis

CTQ
E Above the equator

Applied Spinal Anatomy

Lateral mass screws
Vertebral artery
Exiting nerve
root
Facet joint

Cervical

Exiting
Nerve
Root

Foramina in each TP
C1

No VB
No Spinous Process

C2

Dens

C7

Prominent, non-bifid SP

Vertebral
Artery
Miller, MD. Review of Orthopaedics, 3rd Edition, 2000.

12

Thoracic Spine Exposures

Anterior lateral thoracotomy

Thoracotomy: Anatomy
Dissect along SUPERIOR aspect of rib
(avoid neurovascular bundle)

Posterior

Artery
At
off Ad
Adamkiewicz
ki i (T9-T11)
(T9 T11)

CTQ
Q

Thoracic Duct
Upper thoracic spine
Left side of esophagus
Behind carotid sheath

Miller, MD. Review of Orthopaedics, 3rd Edition, 2000.

Anterolateral Thoracotomy

Anterior Lumbar

Exposure

Landmarks

13

Complications
Autonomic dysfunction-retrograde
ejaculation
Ureter injury
Vessel injury
Bowel perforation
Hernia

Lumbar Retroperitoneal Approach

Common structures at risk

Ureter lies in peritoneal cavity

Genitofemoral nerve at risk
Sympathetic chain
Iliolumbar vein at level of L5
Superior Hypogastric plexus

CTQ

Vascular anatomy of the anterior lumbar

spine
IVC to the right of descending Aorta
Bifurcation at L4/5 disc space
Segmentals at level of mid body

Surgical Approach

Anterior Lumbar: Anatomy

CTQ

Genitofemoral n/sympathetic plexus

L4-5

Ventral surface of psoas muscle

Ligation of Iliolumbar Vein often required

Superior Hypogastric Plexus

Retrograde Ejaculation
Sexual Dysfunction

CTQ

Ilioinguinal & iliohypogastric nerves

Superior
p
br. of lumbar plexus
p
Emerge upper lateral border of psoas traveling
toward the quadratus lumborum

CTQ

Obturator & femoral nerves

Deep and lateral to the psoas muscle
Not visualized during the approach

14

Applied Anatomy: Retroperitoneal Lumbar Approach

Posterior Approach

Sexual dysfunction common after extensive anterior lumbar

surgical dissection to L4-5 or L5-S1.
Erectile dysfunction
Usually nonorganic, but may be due to parasympathetic
i j
injury.
The parasympathetic nerves are deep in the pelvis at the level
of S2-3 and S3-4
Erectile function and orgasm not affected by sympathetic
injury.

Applied Anatomy: Retroperitoneal Lumbar Approach

Retrograde ejaculation
Sympathetic chain injury on the anterior surface of the major
vessels crossing the L4-5 level and at the L5-S1 interspace.

CTQ
Point and Shoot

High--Yield Fact
High
Structures at risk during graft harvest?
Anterior CTQ
Lateral femoral cutaneous n.
g numbness
Anterior thigh
Posterior CTQ
Cluneal n.
8 cm lateral to PSIS
Buttock numbness

Superior gluteal artery

15

16

Lumbar

SAP: most common contributor to

osseous foraminal stenosis

Ligamentum flavum

CTQ

-Anterior surface of superior lamina to

posterior surface of inferior lamina

17

Lumbar

Spinal Cord

Iliolumbar Ligament

Connects TP of L5 with ileum

Leads to TP avulsion fractures

Brainstem to L1
Widest at Plexi

Miller, MD. Review of Orthopaedics, 3rd Edition, 2000.

Facet Joints

Cervical Spine

SAP is anterior and inferior to

IAP of level above
Nerve roots exit near SAP

Lumbar Spine

SAP is anterior and lateral to IAP

Miller, MD. Review of Orthopaedics, 3rd Edition, 2000.

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Facet Joints

Spinal Cord

Sagittal Plane Orientation

Cervical: 45 degrees
Thoracic: 60 degress
Lumbar: 90 degrees

Dorsal Columns

Deep Touch
Proprioception
Vibratory Sensation

Coronal Plane Orientation

Cervical: 0 degrees
Thoracic: 20 degrees posterior
Lumbar: 45 degrees anterior

Miller, MD. Review of Orthopaedics, 3rd Edition, 2000.

CTQ
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

18

Spinal Cord

CTQ

Lateral
Spinothalamic Tract

Vascular Supply

Artery of Adamkiewitcz

Pain and
Temperature
Site of Chordotomy
for Intractible Pain

Spinal cord

Lateral Corticospinal
Tract

Voluntary Muscle
Contraction

Through a left intervertebral

foramen in lower thoracic spine
Attempt to preserve

Anterior and posterior spinal

arteries
Segmental branches of vertebral
artery & dorsal arteries

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Key Points

Spinal Cord

1. Relationship between nerve roots and:

Ventral
Spinothalamic
Tract

a. Cervical Pedicle
b. Lumbar Pedicle
c. Disc

Li ht Touch
Light
T h
Sensation

2. Cervical MRI Anatomy

3. Lumbar MRI Anatomy
4. Applied Anatomy and Surgical Approaches
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Vascular Supply

Primary blood supply = Segmental

Arteries

Vertebral Artery

CTQ

Physical Examination

CTQ
Q

Through transverse foramina of C1-C6

Not Through C7
Posterior to Longus Coli

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

19

CTQ

CTQ

Hoppenfeld S. 1976.

Hoppenfeld S. 1976.

CTQ

CTQ

Hoppenfeld S. 1976.

Hoppenfeld S. 1976.

CTQ

CTQ

Hoppenfeld S. 1976.

Hoppenfeld S. 1976.

20

CTQ

High--Yield Fact
High
C4-5
C5 C4

Herniated C4-C5 disc

C5 nerve

C5

Herniated L4-L5 disc

Posterolateral
L5 nerve root
Far lateral

CTQ

L4-5

L4 nerve root

L4

Foraminal stenosis
L4 nerve root

L5

YOU MUST KNOW THIS !!

MOTOR

Anatomy

SENSORY

REFLEX

C5

Deltoid/Biceps

Shoulder

Biceps

C6

Wrist Ext/Biceps

Thumb/Index

Brachioradialis

C7

Triceps/ Wrist
Flexors

Long

Triceps

C8

Intrinsics/grasp

Ring/Little

L4

Quad /Hip Add

Lat thigh / Medial Tibia

Patella Tendon

L5

EHL
Gluteus medius

Anterolateral leg
Dorsum foot

S1

Gastrocnemius

Lat malleolus/ Lat foot

Achilles

Carotid Sheath
Internal and Common Carotid Arteries
Internal Jugular Vein
Vagus
g Nerve

Recurrent Laryngeal Nerve

In Tracheoesophageal Interval
Possibly more variable on right side

CTQ

Relational Anatomy: Cervical Spine

Neoplastic Disease

Sympathetic chain
Longus colli
vertebral Artery
Extradural

Intradural-Extramedullary

Intramedullary

Cervical nerve root

Lateral mass

Gonzales R. 2002

21

Applied
Biomechanics

Anterior Approach CC-Spine

Recurrent laryngeal nerve
Left -- Aortic Arch
Right Subclavian artery
Supplies vocal muscles

Lateral C-Spine
CTQ
Normal ADI
3.5 mm in Adults
4.0 mm in
Children

Horners syndrome
Open mouth
Normal lateral mass
overhang
6.9 mm total CTQ
overhang

[Inferior Ganglion of Sympathetic Chain]

CTQ

Ptosis,
Miosis
Facial Anhidrosis

C2 nerve root

Clinical Correlate

Oblique Anatomy

Dissection on the ring of C1 should

be < 1.0 cm from the midline

7 cervical vertebra
8 cervical roots
C5

The lower numbered

root exits the numbered
neuroforamen

Atlantoaxial settling in rheumatoid

patients can compress the C2 nerve
causing base of the skull pain
C2 nerve root is at risk during
placement of the C1-2
transarticular screw

CTQ

Therefore, the C5 nerve root

exits the C4-C5 neuroforamen

Atlantoaxial
Relational Anatomy

CTQ

Applied Anatomy
Halo Application

Relationship # 1
Ring of C1
Dens
Transverse
Ligament

CTQ
Structures at Risk
SAE spine 2003

A-- insert PIN here

B-- Supraorbital nerve

OTTO

C-- Supratrochlear nerve

D Temporalis

Transverse ligament
helps provide C1-C2 stability

E Above the equator

CTQ

22

Surgical Approach

Thoracotomy: Anatomy

CTQ

Genitofemoral n/sympathetic plexus

Ventral surface of psoas muscle

Dissect along SUPERIOR aspect of rib

(avoid neurovascular bundle)

CTQ
Q

Artery
At
off Ad
Adamkiewicz
ki i (T9-T11)
(T9 T11)
Thoracic Duct
Upper thoracic spine

Deep and lateral to the psoas muscle

Not visualized during the approach

Behind carotid sheath

Applied Anatomy: Retroperitoneal Lumbar Approach

Anterior Lumbar: Anatomy

L4-5
Ligation of Iliolumbar Vein often required

Retrograde Ejaculation

Superior
p
br. of lumbar plexus
p
Emerge upper lateral border of psoas traveling
toward the quadratus lumborum

Obturator & femoral nerves

Left side of esophagus

Superior Hypogastric Plexus

Ilioinguinal & iliohypogastric nerves

CTQ

Retrograde ejaculation
Sympathetic chain injury on the anterior surface of the major
vessels crossing the L4-5 level and at the L5-S1 interspace.

CTQ
CTQ

Point and Shoot

Sexual Dysfunction

Lumbar Retroperitoneal Approach

Structures at risk during graft harvest?

Common structures at risk

Ureter lies in peritoneal cavity

Genitofemoral nerve at risk
Sympathetic chain
Iliolumbar vein at level of L5
Superior Hypogastric plexus

CTQ

Vascular anatomy of the anterior lumbar

spine
IVC to the right of descending Aorta
Bifurcation at L4/5 disc space
Segmentals at level of mid body

High--Yield Fact
High
Anterior CTQ
Lateral femoral cutaneous n.
g numbness
Anterior thigh
Posterior CTQ
Cluneal n.
8 cm lateral to PSIS
Buttock numbness

Superior gluteal artery

23

Lumbar

SAP: most common contributor to

osseous foraminal stenosis

Ligamentum flavum

CTQ

Thank You
-Anterior surface of superior lamina to
posterior surface of inferior lamina

Spinal Cord

Dorsal Columns

Deep Touch
Proprioception
Vibratory Sensation

CTQ
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Spinal Cord

CTQ

Lateral
Spinothalamic Tract

Pain and
Temperature
Site of Chordotomy
for Intractible Pain

Lateral Corticospinal
Tract

Voluntary Muscle
Contraction

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

24