Chapter 39: The vertebral column

Vertebral column in general

The vertebral column usually consists of 33 vertebrae: 24 presacral vertebrae (7 cervical,
12 thoracic, and 5 lumbar) followed by the sacrum (5 fused sacral vertebrae) and the
coccyx (4 frequently fused coccygeal vertebrae). The 24 presacral vertebrae allow
movement and hence render the vertebral column flexible. Stability is provided by
ligaments, muscles, and the form of the bones. The abbreviations C., T., L., S., and Co.
are used for the regions, and these are sometimes followed by V. for vertebra or N. for
nerve.

Curvatures.
The adult vertebral column presents four anteroposterior curvatures: thoracic and
sacral, both concave anteriorly, and cervical and lumbar, both concave posteriorly (fig.
39-1). The thoracic and sacral curvatures, termed primary, appear during the embryonic
period proper, whereas the cervical and lumbar curvatures, termed secondary, appear
later (although before birth) and are accentuated in infancy by support of the head and
by the adoption of an upright posture.

Parts of a Vertebra.
A typical vertebra consists of (1) a body and (2) a vertebral arch, which has several
processes (articular, transverse, and spinous) for articular and muscular attachments.
Between the body and the arch is the vertebral foramen: the sum of the vertebral
foramina constitutes the vertebral canal, which houses the spinal cord (fig. 39-2). In
addition to the transverse and spinous processes, which serve as short levers, the 12
thoracic vertebrae are connected by joints with paired, long levers, namely the ribs.
The bodies of the vertebrae are separated from each other by intervertebral discs.
The body is mainly spongy bone and red marrow, but the margins of the upper and lower
surfaces consist of a ring of compact bone, the vertebral end-plates. The body is marked
on its sides by vascular foramina.
The vertebral arch consists of right and left pedicles (which connect it to the body)
and right and left laminae. The transverse processes emerge laterally at the junction of

the pedicles and laminae, and the spinous process proceeds posteriorly from the union of
the laminae. The superior and inferior articular processes project vertically from the
vertebral arches on each side and bear articular facets. When vertebra are in their
anatomical position, notches between adjacent pedicles form intervertebral foramina,
each of which typically transmitsneural structures including a spinal ganglion and a
ventral root of a spinal nerve.

Relationship of Spinal Nerves to Vertebrae.

The first cervical nerve emerges between the skull and the atlas, and cervical nerves C2
to 7 continue to leave the vertebral canal above the correspondingly numbered vertebrae.
C8 emerges between the C7 and T1 vertebrae, and the remaining spinal nerves leave
below the correspondingly numbered vertebrae.

Regional characteristics of vertebrae

The vertebrae of each region have special characteristics, which are now described.

Cervical Vertebrae.
The seven vertebrae of the neck are characterized by an opening in each transverse
process known as a foramen transversarium. The upper six pairs of foramina
transversaria transmit the vertebral artery. The C1 vertebra, which supports the skull, is
termed the atlas, and C2, which serves as a pivot for the atlas, is termed the axis.
Atlas (fig. 39-3).
The atlas (C1), which has neither body nor spinous process, consists of two lateral
masses connected by a short anterior and a longer posterior arch. Each lateral mass
presents upper and lower facets, for the occipital condyle of the skull and for the axis,
respectively. The transverse processes are long and are vaguely palpable in vivo
immediately below the auricle. The anterior arch presents an anterior tubercle in front
(for the anterior longitudinal ligament) and a facet posteriorly (for the dens of the axis).
The posterior arch is grooved above for the vertebral artery and the small C1 nerve on
each side, and it presents a posterior tubercle behind.
Axis (fig. 39-4).

The axis (C2) is characterized by the dens (or odontoid process), which projects upward
from the body and articulates with the anterior arch of the atlas. The dens is anchored to
the occipital bone (by apical and alar ligaments) and is limited behind by the transverse
ligament of the atlas (fig. 39-3). It is frequently claimed that the dens represents the
body of the atlas, but this is doubtful. *
Remaining cervical vertebrae (fig. 39-5).
The lower cervical vertebrae, C2 to 6 are typical and present short, bifid spinous
processes. The bodies are small and oval in shape. There are superiorly-projecting lips at
the superolateral borders of the vertebral bodies. These closely match indentations in the
lateral border of inferior aspect of the vertebral body above. Each transverse process,
pierced by a foramen transversarium, ends laterally in anterior and posterior tubercles,
which are connected by an "intertubercular lamella" or bar. # The bars are grooved by
the ventral primary rami of the spinal nerves, which pass posterior to the foramina
transversaria. The anterior tubercles of C6 vertebra are large and are termed the carotid
tubercles, because the common carotid arteries can be compressed against them. C7
vertebra has a long, non-bifid spinous process and is known as the vertebra prominens.
(The spinous processes of C6 and 7 and T1 are usually visible in vivo when the neck is
flexed.) The anterior tubercles (costal processes) of C7 vertebra may develop separately
as cervical ribs. (Lumbar ribs are less frequent.)

Thoracic Vertebrae (figs. 39-5, 39-6 and 39-7).

It should be noted that all vertebrae are dorsal, although only 12 are thoracic. The 12
vertebrae of the thorax bear the ribs. The T1 vertebra (like C.V.7) is transitional in
appearance. T2 to 8 vertebra are typical thoracic vertebrae with a kidney shaped body
(fig. 39-5). Demifacets for the heads of the ribs (see fig. 20-3) are found supeiorly and
inferiorly at the junction of the body and pedicle. The transverse processes of T1 to 10
have costal facets for the tubercles of the ribs. The spinous processes are long, slender,
and sloping: their tips lie opposite the subjacent body or even at the level of the
intervertebral disc below the subjacent body. The various facets for the ribs on T1 and on
T9 to 12 veertebral bodies are arranged differently. T11 and 12 are transitional in form,
i.e., partly resembling lumbar vertebrae. A humped back is termed kyphosis.

Lumbar Vertebrae (figs. 39-8 and 39-9).

The five vertebrae between the thorax and sacrum are large and present neither
foramina transversaria nor costal facets (fig. 39-5). The body is kidney shpaed, and the
pedicles and laminae are short and thick. The part of the lamina between the superior
and inferior articular processes is known as the pars interarticularis and is liable to
injury in some people (resulting in spondylolisthesis, i.e., a slipping forward of the body
of one vertebra on the vertebra or sacrum below it). A mamillary process projects
posteriorward from the superior articular process. The transverse process, which
corresponds to a rib, is long and thin, and an accessory process may project inferiorward
from its root. The spinous processes are quadrilateral and project horizontally backward.
The fifth lumbar vertebra, usually the largest vertebra, is mainly responsible for the
lumbosacral angle (between the lumbar part of the column and the sacrum). Excessive
"hollowing" of the back is termed lordosis.

Sacrum (figs. 39-10 and 39-11).

Five (sometimes six) vertebrae are fused in the adult to form the sacrum, which can be
felt below the "small of the back." The sacrum articulates above with L5, laterally with
the hip bones, and inferiorly with the coccyx. It has a roughly triangular appearance with
a pelvic and dorsal surface, a lateral mass on each side, and a base and apex. The pelvic
surface, concave and facing antero-inferiorly, presents four paired sacral foramina for
the ventral primary rami of sacral nerves 1 to 4. The dorsal surface, convex and facing
posterosuperiorly, presents a modified series of spinous processes termed the median
sacral crest and four paired sacral foramina for the dorsal primary rami of sacral nerves 1
to 4. Below, the sacrum shows right and left sacral cornua, which bound a variable gap
termed the sacral hiatus. An anesthetic for the spinal nerves may be injected extradurally
through the sacral hiatus (caudal analgesia). The cornua articulate with corresponding
horns on the coccyx. The lateral part or mass of the sacrum, lateral to the sacral
foramina, consists of the fused transverse processes (including their costal elements). Its
superior surface is frequently termed the ala. The superolateral part of the lateral mass
presents the auricular (ear-shaped) surface for articulation with the hip bone (sacro-iliac
joint). The surface is limited behind by an area (sacral tuberosity) for interosseous
ligaments. The base, formed by the suprior part of the first sacral vertebra, presents a
prominent anterior margin termed the promontory (fig. 39-11). Superior articular
processes articulate with the fifth lumbar vertebra. The sacral canal (which contains the
dura, cauda equina, and filum terminale) extends from the base to the sacral hiatus. The
apex of the sacrum may be fused with the coccyx.

Coccyx (fig. 39-10).

The vertebrae (usually four) below the sacrum are variably fused in the adult to form the
coccyx, which resembles a miniature sacrum in shape.

Development of vertebrae (figs. 39-12 and 39-13)

Vertebrae develop in mesenchyme and cartilage during the embryonic period proper,
and most begin to ossify during fetal life. Typically, a vertebra at birth shows three ossific
areas, one for the centrum (defined in fig. 39-14) and one for each half of the neural arch.
At about puberty, ossific centers appear in the margins of the upper and lower surfaces
of the body (ring epiphyses) and at the tips of the various processes. Developmental
failure of half a vertebra (hemivertebra) is one cause of lateral curvature (scoliosis).
Failure of fusion of the halves of one or more neural (future vertebral) arches is
termed spina bifida. The meninges alone (meningocele), or the spinal cord and meninges
(meningomyelocele), may protrude through the defect (spina bifida cystica). When the
defect is skeletal rather than neural, it may be concealed by the skin (although
sometimes marked by a tuft of hair) and is termed spina bifida occulta. In the sacrum,
this is quite common.

Surface anatomy
The spinous processes of the vertebrae are palpable in the median furrow of the back.
The external occipital protuberance is palpable in adults. The spines of vertebrae C6, C7,
and T1 are usually prominent and palpable, and they are made more conspicuous by
flexion of the neck and trunk. In the thoracic region, the spinous process of each vertebra
extends to the level of at least the body of the vertebra below. The inferior angle of the
scapula is frequently at the level of the spinous process of T7. A horizontal plane between
the highest points of the iliac crests (supracristal plane) is usually at the level of the
spinous process of L4, and this is used as a landmark for lumbar puncture. A needle
introduced here should enter the subarachnoid space after 4 to 6 cm. The posterior
superior iliac spine is commonly marked by a skin dimple (fig. 39-15).

Additional reading

Kohler, A., and Zimmer, E. A. Borderlands of the Normal and Early Pathologic in
Skeletal Roentgenology, 3rd ed" trans, by S. P. Wilk, Grone & Stratton, New York, 1968.
This classic study of the entire skeleton is available in a more recent edition in German.
Schmorl, G., and Junghanns, H., The Human Spine in Health and Disease, 2nd ed.,
trans. by E. F. Besemann, Grone & Stratton, New York, 1971. This well known work is an
important account of the normal and abnormal vertebral column.

Questions
39-1 How many vertebrae are movable?
39-1 The 24 "presacral" vertebrae are movable. Eighty-nine per cent of people have 24 presacral
vertebrae, 6 per cent have 23, and 5 per cent have 25 (P. E. Bomstein and R. R. Peterson, Am. J.
Phys. Anthropol., 25:139-146, 1966).

39-2 Which curvatures first appear in the vertebral column?

39-2 The thoracic and sacral curvatures are primary (appearing during embryonic life). The cervical
and lumbar curvatures are secondary (appearing during fetal life and accentuated during infancy).

39-3 How many processes characterize a vertebral arch?

39-3 A typical vertebral arch is characterized by at least seven processes: four articular, two
transverse, and one spinous. Lumbar vertebrae have small, additional (mamillary and accessory)
processes. The axis has an odontoid process (the dens) but no superior articular processes (merely
facets). The atlas has only transverse processes.

39-4 Where are the intervertebral foramina and what do they contain?
39-4 The intervertebral foramina are between adjacent pedicles, and typically each contains a
spinal ganglion and a ventral root (or rootlets) of a spinal nerve (see fig. 41-3).

39-5 Between which vertebrae does the C8 nerve emerge?

39-5 C8 nerve root emerges between C7 and T1 vertebrae. Hence the remaining spinal nerves below
leave inferior to the correspondingly numbered vertebrae.

39-6 What are the key features of the cervical, thoracic, lumbar, and sacral
vertebrae?

39-6 The key features of cervical, thoracic, lumbar, and sacral vertebrae are, respectively, foramina
transversaria, articulation with ribs, absence of both of the above features, and fusion.

39-7 How many dorsal vertebrae are present in the body?

39-7 All 33 vertebrae are dorsal. Twelve are thoracic.

39-8 What is the pars interarticularis?

39-8 The pars interarticularis, visible on oblique radiographs of the lumbar vertebrae (see fig. 39-9),
is the part of the neural arch between the superior and inferior articular processes. The slipping
forward of a vertebral body (e.g., L5) is termed spondylolisthesis (Gk, vertebral slipping) and usually
involves fracture at the pars interarticularis. Case Report. A 50-year-old nurse complained of
numbness of the right big toe, a burning pain down the lateral side of the right leg and foot, bowel
and bladder problems, and weakness of the lower limbs. She developed a marked depression over
the spinous process of L5. At operation, spondylolisthesis of L5 on S1 was found, with defective
partes interarticulares of L5 and protrusion of the L4/5 disc. The leg pains were caused by
compression of L5 nerve roots from alterations of the L5/S1 facets. Bowel and bladder difficulties
were produced by compression of the cauda equina from gross distortion of the vertebral canal.
Decompression by removal of some bone near the pedicles relieved the symptoms (G. Austin, The
Spinal Cord, Thomas, Springfield, Illinois, 1961). Numerous case studies on anatomy have been
described by E. Lachman (Case Studies in Anatomy, 3rd ed., Oxford University Press, New York, 1981)
and also by L. K. Schneider (Anatomical Case Histories, Year Book, Chicago, 1976).

39-9 What are the chief contents of the sacral canal?

39-9 The sacral canal contains the dura, cauda equina, and filum terminale. Above S2, a
subarachnoid space is also present (see fig. 41-1).

39-10 What is the ossific status of a typical vertebra at birth?

39-10 At birth, a typical vertebra shows three primary ossific areas, one for the centrum and one for
each half of the neural arch. (The centrum does not correspond to the whole of the body: see fig.
39-14.) The three primary areas become united by bone in early childhood (3 to 6 years). A number
of secondary centers (the ring epiphyses and centers for the tips of the transverse and spinous
processes) appear at about puberty.

39-11 How is surgical access to the spinal cord achieved?

39-11 Surgical access to the spinal cord and nerve roots is achieved by sectioning the laminae
(laminectomy) on each side of several vertebrae.

39-12 What is spina bifida?

39-12 Spina bifida is a developmental anomaly in which the halves of one or more neural (future
vertebral) arches have failed to fuse. The spinal cord and meninges (myelomeningocele), or the
meninges alone (meningocele), may protrude through the defect (spina bifida cystica). When the
defect is skeletal rather than neural, it is termed spina bifida occulta; this defect is found in the
sacrum in approximately one fifth of the general population (A. C. Berry, J. Anal., 120:519,1975),
although the incidence is minute in certain peoples (J. I. Levy and C. Freed, J. Anal., 114:449,
1973).

39-13 Which Latin and Greek roots are used with reference to the vertebral column?
39-13 The Latin roots spino- and vertebro- are used with reference to the vertebral column (e.g., in
spinotransverse and vertebrocostal). Greek roots with a similar significance are spondyl- and rhachi(e.g., in spondylolisthesis and rachischisis, the latter meaning "vertebral cleft" and used for an open
spina bifida, especially one that extends along many vertebrae).

* See F. A. Jenkins, Anat. Rec., 164:173-184, 1969.

# The part of a cervical vertebra that corresponds to a rib is probably the transverse
process lateral to the foramen transversarium and including the anterior and posterior
tubercles as well as the "intertubercular lamella" (or so-called costotransverse bar). See
A. J. E. Cave, J. Zool., 177:377-393, 1975. Only the anterior tubercle is shaded in figure
39-12.

Chapter 40: Muscles, vessels, nerves and joints of the back

Muscles
The prevertebral muscles are those that are situated on the front of the column in the
neck and abdomen and supplied by ventral rami. The muscles of the back include (1)
superficially the trapezius and latissimus dorsi; (2) then the levator scapulae, rhomboids,
and serrati posteriores; and (3) the deep muscles of the back, which are mostly supplied
by dorsal rami. The fascia of the back is attached to the spines of the vertebrae, and it
proceeds laterally, as the thoracolumbar fascia, to ensheathe such muscles as the
latissimus dorsi. Two small muscles, the serratus posterior superior and serratus
posterior inferior, extend from the thoracic spines to the ribs and are supplied by ventral
rami. The serrati and the thoracolumbar fascia serve as retinacula that retain the
underlying muscles.
The deep muscles of the back (1) occupy a "gutter" on each side of the vertebral
column; (2) are practically all innervated by dorsal rami; (3) comprise longer and more
vertical bundles superficially and shorter and more oblique components deeply; (4)
produce extension and lateral flexion of the vertebral column by their longitudinal
bundles and rotation by their oblique components; and (5) may be considered, in terms
of attachments, as a spinotransverse system superficially and a transversospinal group
deeply (fig. 40-1).

The "spinotransverse system."

The "spinotransverse system" consists of the erector spinae and the splenius muscles
(fig. 40-2). The erector spinae (or sacrospinalis) is the chief extensor of the back. This
muscle group ascends from a very large common origin on the iliac crest, dorsal part of
the sacrum and lumbar spinous processes. This makes up the large muscle bulge that can
be seen lateral to the lumbar spinous processes. The muscles segregate into three
longitudinal columns: (1) the spinalis medially; (2) the longissimus; and (3) the
iliocostalis laterally. These columns of muscles appear in overlapping bands, with muscle
insertions interdigitating with origins of more supeior portions of the muscle column.
The spinalis muscles arise and insert on the spinous processes, with the most superior
muscle fibers reaching the occiput. The longissimus muscle group forms the bulk of the

erector and inserts along the transverse processes in the thoracic and cervical regions. It
also has an insertion more laterally on the occiput. The iliocostalis muscle column inserts
on the ribs, with the most superior attachment to the lower cervical transverse processes.
The vertical muscles on the posterior aspect of the neck are bandaged by the
splenius muscles, which ascend obliquely from the thoracic spinous processes and insert
into (1) the mastoid part of the temporal bone and the superior nuchal line (splenius
capitis) and (2) the cervical transverse processes (splenius cervicis). The splenius rotates
the head toward the side of contraction. The splenii of the two sides, acting together,
extend the head.

The "transversospinalis system."

The "transversospinalis system" consists of the semispinalis and a number of small
underlying muscles (multifidus and rotatores), deep to which are interspinous and
intertransverse muscles. This name derives from the origin of these muscles from
transverse processes (mamillary processes in the lumbar region) and insertion on the
spinous processes. The more superficial muscles are more oblique, inserting on
vertebrae up to six levels above their origin. The deeper muscles are more transverse in
orientation, skipping fewer veertebrae between their origin and insertion.
The semispinalis, so called because it extends chiefly along the upper half of the
vertebral column, is responsible for the longitudinal bulges on the posterior side of the
neck on either side of the median plane. This part (semispinalis capitis) ascends from
cervical and thoracic transverse processes to reach the occipital bone. This muscle is
necessary to hold the head up and when it contracts bilaterally, it is the chief extensor of
the neck. The semispinalis capitus muscle covers the suboccipital triangle and a deeper
muscle, the semispinalis cervicis, that is attaching heavily to cervical spinous processes
(fig. 40-2). The splenius, semispinalis capitis, and sternomastoid are the chief rotators of
the head.
The multifidi are prominent in the lumbar region, arising from the mamillary
processes and inserting on spinous processes several segements superior to the origin.
Multifidi are quite poorly developed in thoracic and cervical regions. The rotators are
found at all spinal levels, arising from transverse processes and inserting on spinous

process of the immediately suprajacent (rotator brevis) or skipping one vertebra before
inserting on the spinous (rotator longus).
There are also small intersegmental muscles between spinous processes
(interspinous) or between the transverse processes (intertransverse). These small
muscles and the rotators are very small and contribute little to directly moving the spine.
However, they are heavily endowed with receptors that contribute important sensory
feedback for control of spine motions.

The suboccipital triangle.

The suboccipital triangle (fig. 40-3) is delimited by three points: the spinous process of
the axis, the transverse process of the atlas, and the lateral part of the occipital bone. The
boundaries of the triangle are the muscles attached to these three points: the obliquus
capitis inferior, obliquus capitis superior, and rectus capitis posterior major. The
muscles, supplied chiefly by the suboccipital nerve, are mainly postural. They also have
receptors that detect head position. The triangle is roofed by the semispinalis capitis, and
its floor is the posterior atlanto-occipital membrane. The suboccipital triangle contains
the vertebral artery and the suboccipital nerve, both lying in a groove on the upper
surface of the posterior arch of the atlas. The subarachnoid space can be tapped by
inserting a needle at the back of the neck and piercing the posterior atlanto-occipital
membrane. This rarely performed procedure is termed cisternal puncture (see fig. 41-1).

Blood vessels
The vertebral artery.
The vertebral artery is one of the main vessels to the brain. It arises from the subclavian
artery, and its course comprises four parts: cervical, vertebral, suboccipital, and
intracranial. The vertebral portion courses through the transverse foramina of the upper
six cervical vertebrae. After passing the transverse formen of the axis, the artery follows a
tortuous course to reach the laterally-positioned transverse formen of the atlas. The
suboccipital part courses from lateral to medial, passing posterior to the lateral mass of
the atlas and lying in a groove on the superior side of the posterior arch of the atlas (see
fig. 39-3). Within the suboccipital triangle, it enters the vertebral canal by passing a

hiatus in the posterior atlantoaxial membrane. It then perforates the dura and arachnoid
and traverses the foramen magnum to become intracranial.

The vertebral venous system.

The vertebral venous system is a valveless network that extends between the cranial
dural sinuses and the pelvic veins and is connected with the azygos and caval systems
(see fig. 24-2A). It allows a flow of blood in either direction, depending on intrathoracic
and intra-abdominal pressure, and it permits the spread of carcinoma, emboli, and
infections. The divisions of the network (see fig. 41-3) are as follows: (1) the internal
vertebral plexus, which surrounds the dura and is drained by veins in the intervertebral
foramina; (2) the basivertebral veins on the back of the vertebral bodies, which drain a
network in the marrow spaces of the vertebrae; and (3) the external vertebral plexus,
which lies on the anterior and lateral sides of the vertebral bodies and on the vertebral
arches. The suboccipital plexus is an extensive and complicated part of the external
plexus. It lies on and in the suboccipital triangle and drains the scalp. The suboccipital
plexus receives the occipital vein. and sends tributaries to the vertebral vein, which
descends through the foramina transversaria to end in the brachiocephalic vein.

Nerves
The innervation of the back is from the meningeal branches and dorsal rami of the spinal
nerves.
Each spinal nerve gives off a meningeal branch (or sinuvertebral nerve), which
reenters the vertebral canal and supplies vasomotor and sensory fibers to dura,
ligaments, periosteum, and blood vessels.
The dorsal primary rami of the spinal nerves contain motor, sensory, and
sympathetic fibers. They supply the muscles, bones, joints, and skin of the back. Most
dorsal rami divide into medial and lateral branches.
The dorsal primary ramus of the C1 nerve root, known as the suboccipital nerve,
usually has no cutaneous distribution. The medial branch of the dorsal primary ramus of
C2 nerve root, termed the greater occipital nerve, supplies a large region of the scalp,
usually extending at least to the vertex. The cutaneous division of the medial branch of
the dorsal primary ramus of C3 is known as the third occipital nerve. The dorsal primary

rami of the C1 and C6 to 8 nerve roots usually give no cutaneous branches, so that the C5
and T1 dermatomes are adjacent over the posterior neck. Through most of the trunk, the
sensory distribution of dorsal primary rami appear in regular bands. However, the
lumbar and sacral dorsal primary rami overlap the skin of the buttocks as a series of
clunial nerves.

Joints
The joints of the vertebral column are (1) those between the bodies of adjacent vertebrae
(intervertebral discs), (2) those of the vertebral arches (between articular processes), (3)
the atlanto-occipital and atlanto-axial joints, (4) the costovertebral joints, and (5) the
sacro-iliac joint.

Joints Between Bodies of Adjacent Vertebrae.

The bodies of adjacent vertebrae are united by longitudinal ligaments and intervertebral
discs. The anterior longitudinal ligament extends from the anterior tubercle of the atlas
to the sacrum and is attached to the anterior aspect of the vertebral bodies and discs. The
posterior longitudinal ligament is a continuation of the tectorial membrane, extending
from the occipital bone to the sacrum. It lies within the vertebral canal, and is loosely
attached to the back of the vertebral bodies while expanding and attaching firmly to the
posteiror part of the discs (fig. 40-4).
The intervertebral discs.
The intervertebral discs account for about a quarter of the length of the vertebral
column. They are shock-absorbing, fibrocartilaginous joints between adjacent vertebrae.
In young adults, each disc consists of a semigelatinous nucleus pulposus surrounded
peripherally by an anulus fibrosus. Each disc is separated from the bone above and below
by two growth plates of hyaline cartilage (fig. 40-4). The anulus fibrosis consists of
fibrocartilage containing concentric layers of dense, regular connective tissue. The
collagen in these layers is not vertically arranged. Instead, each layer is obliquely
oriented, with adjacent layers having an opposite obliquity. Therefore, the collagenous
fibers in an anular layer is oriented nearly at right angles to the adjacent layers. The
anulus fibrosis surrounds and contains the nucleus.

The nucleus develops from the notochord in the embryo. The discs contain much
water, diminution of which (temporarily during the day and permanently in advanced
age) results in a slight decrease in stature. The fluid nature of the nucleus acts as a
hydraulic spacer to maintain the height of disc. With advancing age, the entire disc tends
to become fibrocartilaginous, and the distinction between nucleus and anulus becomes
lost. The forces of body weight are then transmitted more directly to the anular fibers
which can degenerate. Additionally, as the discs wear out, more forces can be
transmitted to the posterior joints, which can also degenerate. Pathological change in an
intervertebral disc may be followed by herniation of the nucleus pulposus, which then
compresses adjacent nerves. In the lumbar region, herniated discs usually compress the
nerve exiting at the level below the herniation. This is because the lumbar pedicles attach
to the superior part of the vertebral bodies, meaning that discs are at the inferior aspect
of the intervertebral formen. Since nerve roots tend to occupy the supeiror part of the
intervertebral formen, disc herniation does not usually affect the nerve exiting at that
spinal level. However, the subjacent nerve root must pass the herniated disc and can be
involved (see fig. 41-4). For example, herniation of the disc between the L4 and 5
vertebra often irritates the L5 nerve root (which exits at the intervertebral formen
between the L5 vertebra and the sacrum).
The cervical discs may develop fissures at the lateral edges that have been dubiously
called uncovertebral joints. They are situated laterally between lips on the adjacent upper
and lower surfaces of the vertebral bodies and can undergo degenerative changes similar
to other joints.

Joints of Vertebral Arches.

The atlanto-occipital and atlanto-axial joints are special cases that are discussed below.
The articular processes of adjacent vertebrae are united by plane synovial joints often
called facet joints. The facet joints are rather typical joints with hyaline cartilage covering
the joint surface and a fibrous articular capsule. *
Facet joints guide the types of movement that can occur at the segment. The
articular surfaces have different orientations in the various vertebral regions (see fig. 395). In the cervical region below the axis, the joint surface on the superior articular
process faces more superior than posterior. This joint permits some rotation, but this
must be coupled with with lateral flexion. This is due to the fact that, when the

suprajacent vertebra moves anterior on one side, that side is also forced superior by the
obliquity of the facet joint. Therfore, the lower cervical spine with laterally flex toward
the side of rotation. In the thoracic region, the superior articular process faces mostly
posterior, with a slight supeior and lateral direction. This pattern permits the greatest
degree of rotation of the spine, with the axis of rotation centered on the disc. Of course,
this rotation is limited by the attachemnt of ribs. In the lumbar region, the superior
articular processes face posterior and medial and are concave. This orientation permits
flexion and extension, but little rotation. Of course, since there are large numbers of
vertebral segments, small motions between any two segements can add up to significant
overall mobility when summed over the entire spinal column.
The vertebral arches are connected by ligaments, particularly strong in the lumbar
region, e.g., the ligamenta flava between the laminae. The spinous processes are united
by the interspinous and supraspinous ligaments, which merges in the neck with the
ligamentum nuchae. This latter ligament is a median partition between the muscles of
the two sides of the neck and is attached to the occipital bone.

Atlanto-occipital and Atlanto-axial Joints.

The atlanto-occipital joints are between the concave articular surface on the supereior
side of the lateral masses of the atlas and the convex occipital condyles. Synovial in type,
the right and left joints allow nodding of the head around a transverse axis and sideways
tilting of the head around an anteroposterior axis. Anterior and posterior atlantooccipital membranes connect the respective arches of the atlas to the margins of the
foramen magnum (figs. 40-5 and 40-6).
The atlanto-axial joints, synovial in type, unite the first two vertebrae. The two
lateral joints are between the articular processes. These joints are in a mostly horizontal
plane, although the lateral part of the joint is inferrior to the medial part. This joint
permits anterior and posterior motion of the atlas on the axis. The median atlanto-axial
joint is between (1) the anterior arch and transverse ligament of the atlas and (2) the
pivot formed by the dens of the axis (fig. 40-5).
The transverse ligament of the atlas unites the medial aspects of the lateral masses
(fig. 40-6) and, together with longitudinal bands attaching to the foramen magnum and
the body of the axis, constitutes the cruciform ligament of the atlas (fig. 40-6B). This

ligament holds the anterior part of the dens against the posterior side of the anterior
arch of the atlas and is designed to prevent posterior motion of the dens (which would
damage the upper spinal cord). Since the lateral joints between the atlas and axis permit
anterior and posterior motion, the dens provides a pivot around which the atlas can
rotate. In fact, there is nearly 45 degrees of rotation permitted to each side between these
two segments, an enormous contribution to the overall rotation of the spine. The apex of
the dens is connected to the occipital bone by a median apical ligament and two lateral
alar ligaments. The alar ligaments are the principal restriction to rotation since they
become tight on the side that moves anterior during rotation. Finally, the tectorial
membrane, the upward continuation of the posterior longitudinal ligament, is anchored
to the basilar part of the occipital bone (fig. 40-5).

Costovertebral Joints.
The costovertebral joints (see fig. 20-6) are those between 1) the heads of the ribs and
the vertebral bodies and (2) the tubercles of the ribs and the transverse processes
(costotransverse joints).

Sacro-iliac Joint.
The sacro-iliac joint (see fig. 31-7) is a plane synovial joint formed by the union of the
auricular surfaces of the sacrum and ilium. There are ligaments surrounding this joint on
all sides, however, the strongest of these are located posteriorly since the body weight is
transmitted through the posterosuperior part of the sacrum. The ilium is connected to
the transverse process of the L5 vertebra by various strong bands collectively known as
the iliolumbar ligaments. The weight of the head, upper limbs, and trunk is transmitted
through the sacrum and ilia to the femora when one is standing and to the ischial
tuberosities when one is sitting.

Movements.
The movements of the vertebral column are flexion (forward bending), extension
(backward bending), lateral flexion to the right or left (bending to the side), and rotation
(around a longitudinal axis). The axis of each type of movement runs through the
nucleus pulposus. The cervical and lumbar regions are the most mobile and are frequent
sites of degeneration and of aches and pains. Flexion and extension of the head occur

mainly at the atlanto-occipital and atlanto-axial joints. The skull and the atlas rotate on
the axis at the three atlanto-axial joints, pivoting on the dens like a ball-and-socket joint.
The chief flexors of the vertebral column are the prevertebral muscles, recti
abdominis, iliopsoas, scaleni, and stemomastoids. Gravity may also be important, and
the movement is controlled by the erector spinae muscles. The chief extensors are the
erector spinae. Lateral flexion is carried out mainly by the oblique muscles of one side of
the abdominal wall. The muscles of the back are relatively inactive when one is standing
at ease. Injury or inflammation may easily result in reflex spasm of the muscles of the
back.

Additional reading
De Palma, A. F., and Rothman, R. R., The Intervertebral Disc, W. B. Saunders
Company, Philadelphia, 1970. An account of disc disease.

Questions
40-1 What are the prevertebral muscles?
40-1 The pre vertebral muscles lie on the front of the column in the neck (longus capitis and longus
colli, rectus capitis anterior and rectus capitis lateralis) and abdomen (psoas major and minor).
Although they produce flexion, the main antagonists of the dorsal muscles are the abdominal
muscles, such as the recti abdominis.

40-2 Which muscles of the back can be most readily identified in vivo?
40-2 The most readily identifiable muscles of the back in vivo are the trapezius, latissimus dorsi,
erector spinae, and semispinalis capitis.

40-3 What are the main actions of the deep muscles of the back?
40-3 The deep muscles of the back produce extension and lateral flexion of the vertebral column,
according to circumstances. They are important antigravity muscles in the erect posture and in
sitting. They control bending forward and enable the erect position to be regained. At the end of
flexion, the muscles are quiet and the column is supported by ligaments and intervertebral discs.
Hence the danger to these structures is in lifting "with the back" rather than with the muscles of the
lower limbs.

40-4 Which muscles are included in the "spinotransverse system"?

40-4 The "spinotransverse system" consists of the erector spinae and the splenius.

40-5 Which is the most prominent muscle of the "transversospinalis system"?

40-5 The most prominent component of the "transversospinalis system" is the semispinalis.

40-6 What is the most important structure in the suboccipital triangle?

40-6 The most important structure in the suboccipital triangle is the vertebral artery.

40-7 How is the vertebral venous system arranged?

40-7 The vertebral venous system, which is important physiologically and pathologically, comprises
1) an internal plexus around the dura, (2) basivertebral veins on the back of the vertebral bodies,
and (3) an external plexus on the front of the vertebral bodies and on the vertebral arches. For
details see H. J. Clemens, Die Venensysteme der menschlichen Wirbelsiiule, de Gruyter, Berlin,
1961. A classic article is that by O. V. Batson, Am. J. Roentgenol., 78:195, 1957.

40-8 How many intervertebral discs are present in the body?

40-8 The 24 presacral vertebrae are separated by 23 intervertebral discs. A variable disc is present
between the dens and the body of the axis, and another variable one between the sacrum and
coccyx. In addition, depending on age, remains of four discs may be found within the sacrum, and
perhaps a further one may be found within the coccyx.

40-9 What is an intervertebral disc?

40-9 An intervertebral disc is a fibrocartilaginous joint between two adjacent vertebral bodies. The
disc continually changes in structure, "notochordal tissue appears to be absent after 10 years of
age," and "in advanced age, macroscopic distinction between nucleus and annulus is lost" (A.
Peacock, J. Anat., 86:162, 1952).

40-10 What is a "slipped disc"?

40-10 A "slipped disc" is a herniation of the nucleus pulposus into or through the anulus fibrosus,
usually in a posterolateral direction. Pressure on the "lower" nerve roots (the "upper" roots having
already left the vertebral canal) may result in sensory and motor deficits, but it is important to
appreciate that variations of signs and symptoms are considerable.

40-11 On which nerve would herniation of the disc between the L4 and L5 vertebra
be likely to press?

40-11 Herniation of the disc between L4 and L5 would be likely to press on the roots of the L5 nerve
because the L4 nerve root would have already made its exit from the vertebral canal. The pain and
sensory loss would be mainly along the lateral side of the leg and on the dorsum of the foot (L5
dermatome), and motor deficiency might include weak dorsiflexion of the great toe (extensor
hallucis longus) and atrophy of the tibialis anterior. Similarly, the disc between L5 and S1 would be
likely to press on the S1 nerve root, resulting in pain and sensory loss on the back of the leg, ankle,
and sole; weak plantar flexion (gastrocnemius); atrophy of the calf; and diminished or absent ankle
jerk.

40-12 Which joints are involved in (a) nodding in approval and (b) shaking the head
in disapproval?
40-12 Nodding affirmatively involves the atlanto-occipital joints. Shaking the head negatively
involves the atlanto-axial joints.

40-13 Which are the most mobile regions of the vertebral column?
40-13 The cervical and lumbar regions are the most mobile, and they are frequent sites of aches.
Fracture-dislocations occur chiefly in these regions. Prognosis is governed by the presence or
absence of injury to the spinal cord and nerve roots.

*Yu SW, Sether L, Haughton VM. Facet joint menisci of the cervical spine:
correlative MR imaging and cryomicrotomy study. Radiology. 164:79-82, 1987. This
combined radiographic and anatomical study defined 3 types of intraarticular extensions
from the joint capsule that they termed "menisci" in the cervical spine. One arrangement
appears to be mainly in childhood and one appears only associated with joint
degeneration. The function of these "menisci" is not known.