Far Eastern University – Nicanor Reyes Medical Foundation
Gross B – Back and Suboccipital Region
James Taclin Banez, M.D.
BACK
 Extends from the skull to the tip of the coccyx
 Posterior surface of the trunk
 Superimposed on the upper part of the posterior surface of the
thorax are the scapula and the muscles that connect that scapula
to the trunk
There are three layers of muscles on the back: the superficial,
intermediate and deep muscle layers. It is covered posteriorly by the
superficial fascia and skin. The primary muscles of the back, collectively
known as the erector spinae muscles, are covered by the deep fascia
called the thoracolumbar fascia.
The lumbar portion of the thoracolumbar fascia can be divided into
three: posterior, middle and anterior. The posterior portion covers the
erector spinae; the middle portion is anterior to the erector spinae
thereby ensheathing the whole muscle. The latter is posterior to the
quadratus lumborum, and together with the anterior portion of the
fascia, ensheaths the muscle. However, the psoas major is not covered
by any part of the thoracolumbar fascia.
Boundaries of the Back:
 Superiorly: external occipital protuberance
 An imaginary line from the superior nuchal line down to the
sacrum (and coccyx), passing through the vertebral spines,
divides the back into the right and left
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 Lateral: acromion process
 Lateral extension of the spine of the scapula. Making an
imaginary line from this point down to the iliac crest forms
the posterior axillary line
Deep Fascia of the Back:
The erector spinae is considered the primary muscles of the back
because it arises and inserts to the bones of the back (the vertebrae
and the ribs)
 Ensheaths the superficial and intermediate muscles of the back
 Thoracolumbar fascia – a thicker portion of the deep fascia that
ensheaths the erector spinae. It has a thoracic and lumbar part
 The thoracic part is attached medially to the vertebral spines
and laterally to the angles of ribs. It covers the posterior surface
of the deep muscles of the back
The anterior portion of the erector spinae muscles is primarily covered
by the ribs and intercostals muscles, specifically the internal
intercostals muscles
 The lumbar part lies in the interval between the iliac crest and
the 12th rib. Medially, it splits into three lamellae:
 Posterior – attached to the spinous process of the lumbar
vertebrae and covers the deep muscles (erector spinae)
 Middle – anterior to the deep muscles but posterior to the
quadratus lumborum. It is attached to the tips of the
transverse process of lumbar vertebra
 Anterior – anterior to the quadratus lumborum and
attached to the anterior surface of the transverse process
of lumbar spines
The quadratus lumborum is the muscle of the posterior abdominal wall
where the kidney is lying on.
Bloody Supply of the Back:
A. Cervical Region
Because of the rich blood supply of the back of the neck, chances of
ischemia are very small.
 Occipital artery – branch of the external carotid artery;
instead of going inside the cranial cavity, this artery supplies
the back
 Vertebral artery – second branch of the subclavian artery
(first branch is the internal thoracic / internal mammary
artery)
 Deep Cervical artery – branch of the costocervical trunk
 Ascending Cervical artery – deepest and most posterior
branch of the thyrocervical trunk
The thyrocervical trunk is a branch of the subclavian artery. One of its
branches is the ascending cervical artery, a small artery that sends
muscular branches to the lateral muscles of the upper neck and spinal
branches into the intervertebral foramina.
B. Thoracic Region Skin:
 Posterior Intercostal arteries – composed of 11 pairs and are  Although the skin in the back is considered thin, the dermal layer
branches of the thoracic aorta is thicker in this area
 The subcutaneous layer is relatively thinner in the back as
C. Lumbar Region compared to that of the anterior because of the greater
 Subcostal arteries – last pair of artery that supplies the last deposition of of adipose tissue
pair rib. Branch of the thoracic aorta
 Lumbar arteries – branches of the abdominal aorta Muscles of the Back:
A. SUPERFICIAL MUSCLES
These are the branches supplying the back muscles, the vertebra, spinal
cord and the cauda equina.

D. Sacral Region
 Iliolumbar artery – from the posterior division of the
internal iliac
 Lateral Sacral artery – arises from the posterior division of
the internal iliac

Venous Drainage of the Back:

 Forms communicating plexuses extending along the vertebral
column from the skull to the coccyx
 External Vertebral venous plexus
 Internal Vertebral venous plexus

Nerve Supply of the Back:

 Posterior rami of the 31 pairs of spinal nerves, supplies the skin
and muscles of the back
 Dorsal (posterior) rami will supply the back and does not form
plexuses like the ventral (anterior) rami. This is important
because it entails that the rami will be in the same level as the
spinal cord. This is useful for determining which part of the
spinal cord is resected. There will be no sensation beyond the
resected part. These are the muscles that are inserted to the bones of the upper
extremities (shoulder bones) but arise from the vertebra, hence they
assist in the movement of the upper extremities

1. Trapezius
Origin: Occipital protuberance of the occipital bone,
ligamentum nuchae, C7 to T12 spines
Insertion: Upper fibers: inserted to the later third of the
clavicle
Middle fibers: to the acromion process
Lower fibers: to the spine of the scapula
Action: Upper fibers: elevates the scapula
Middle fibers: pull the scapula medially
Lower fibers: pulls the scapula down
Nerve: Accessory Nerve (CN XI) – does not solely arise
from the medulla oblongata, but there is also
contribution from spinal nerves C2-C3

Almost as soon as they are formed by the merging posterior and The ligamentum nuchae is a triangular membrane that forms a median
anterior roots, spinal nerves divide into the anterior and posterior rami fibrous septum between the muscles of the neck
making it only 1 – 1.15cm in length.

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 2. Latissimus Dorsi B. INTERMEDIATE MUSCLES
Origin: Iliac crest, middle and lateral sacral, lumbar
fascia, T7-T12 spines, inferior angle of scapula
Insertion: Intertubercular groove of the bicipital groove of
humerus
Action: Extend, adduct and medially rotate arm
Nerve: Thoracodorsal nerve

3. Levator Scapula
Origin: Transverse process of C1-C4
Insertion: Medial border of scapula
Action: Raise medial border of scapula
Nerve: Dorsal scapular nerve

4. Rhomboid Minor
Origin: Ligamentum nuchae, spines of C7 and T1
Insertion: Medial border of the scapula
Action: Raise the medial border of scapula upward and
medially
Nerve: Dorsal scapular nerve

5. Rhomboid Major
Origin: T2-T5 spines
Insertion: Medial border of scapula
These are the muscles that assist in forceful inspiration. These arise
Action: Raise medial border of scapula upward and from the vertebral column and are attached to move the ribs.
medially
Nerve: Dorsal scapular nerve
1. Serratus Posterior Superior
Origin: Lower cervical and upper thoracic spines
Insertion: Upper ribs
Action: Raise ribs
Nerve: Intercostal nerves

2. Serratus Posterior Inferior

Origin: Lower thoracic and upper lumbar spines
Insertion: Lower ribs
Action: Depress ribs – to increase the size of the
Triangle of Auscultation thoracic cavity in concert with the action of the
serratus posterior superior
Nerve: Intercostal nerves

3. Levatores Costarum - This muscle is deeper than the rest of

the intermediate muscles, however it is classified as such
Triangle of Petit
because of its similar action as the others
Origin: Tip of transverse process
Insertion: Rib below
Action: Raise ribs
Nerve: Posterior rami of thoracic spinal nerves

The triangle of auscultation is the site where breath sounds are best
heard. Its boundaries are the latissimus dorsi inferiorly, trapezius
medially, and the medial border of the scapula laterally. The lumbar
triangle of Petit is a usual site of lumbar hernia and is bounded by the
external oblique abdominal muscles laterally, the latissimus dorsi
medially and the iliac crest inferiorly.

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C. DEEP MUSCLES Iliocostalis cervicis:
rd th
Origin: Angles of 3 and 6 ribs
Insertion: Transverse process of C4-C6
Action: Extension and lateral flexion of vertebra
Nerve: Posterior rami of spinal nerves

3. Longissimus – the largest of the three muscles of the

erector spinae

Longissimus thoracis:
Origin: Mid crest of sacrum
Insertion: Transverse process of lumbar and thoracic
vertebra, thoracolumbar fascia and lower 9-10
ribs
Action: Bend the vertebral column backwards and
laterally
Nerve: Posterior rami of spinal nerves

Longissimus cervicis:
Origin: Transverse process of T1-T5
These are concerned with the posture and movement of vertebral Insertion: Transverse process of C2-C6
column. It has three sublayers: superficial, intermediate and deep Action: Bend the vertebral column backwards and
laterally
a. SUPERFICIAL LAYER OF THE DEEP MUSCLES OF THE BACK:
Nerve: Posterior rami of spinal nerves
1. Splenius capitis:
Origin: Ligamentum nuchae, spinous process of C7- T3
Longissimus capitis:
Insertion: Mastoid process and lateral part of occipital
Origin: Transverse process of T1-T5, articulation
bone
process of C5-C7
Splenius cervicis:
Insertion: Posterior margin of mastoid process
Origin: Spinous process of T3-T7
Action: Extend the head and turns the face towards the
Insertion: Transverse process of C1-C4
same side
Nerve: Posterior rami of spinal nerves
Action: Together, they extend the neck, individually,
laterally bends and rotate to the same side
Nerve: Posterior rami of the cervical spinal nerve
4. Spinalis – smallest of the three muscles of the erector
spinae and usually unseen.

Spinalis thoracis: - from spines of T11-L2 to spines of

2. Iliocostalis – most lateral of the three muscles comprising
upper thoracic vertebra; biggest of the spinalis muscles,
the erector spinae
therefore the most important among the three.

Iliocostalis lumborum:
Spinalis cervicis: - from ligamentum nuchae and C7 to
Origin: Mid crest sacrum, spines of T11-L5, posterior
spine of axis (may be absent)
iliac crest, lateral crest of sacrum
Insertion: Angles of lower 6 ribs
Spinalis capitis: - usually blends with the semispinalis
Action: Extension and lateral flexion of vertebra
capitis
Nerve: Posterior rami of spinal nerves
Action: Extend vertebral column – the spinalis muscles
cannot rotate the body because its origin and
Iliocostalis thoracis:
insertions are on the same plane, unlike the
Origin: Angles of lower 6 ribs
iliocostalis and longissimus muscle
Insertion: Angle of upper ribs 1-6 and transverse process
Nerve: Posterior rami, cervical and thoracic spinal
of C7
nerves
Action: Extension and lateral flexion of vertebra
Nerve: Posterior rami of spinal nerves

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 b. INTERMEDIATE LAYER OF THE DEEP MUSCLES OF THE BACK: c. DEEP LAYER OF THE DEEP MUSCLES OF THE BACK:
1. Semispinalis 1. Interspinalis – short, paired muscles attached to the
apices of the contiguous spines of the vertebra. Most
Semispinalis capitis: distance in the cervical region
Origin: Transverse process of C7-T7, articular process 2. Intertransversarii – small muscles between the
of C4-C6 transverse process of the vertebra, best developed in the
Insertion: Occipital bone between superior and inferior cervical region
nuchal line
Muscles of the Suboccipital Region:
Semispinalis cervicis:
Origin: Transverse process of T1-T6
Insertion: C2-C5 spine

Semispinalis thoracis:
Origin: Transverse process of T6-T10
Insertion: C6-T4 spines

Action: S. thoracis and cervicis extend cervical and

thoracic regions of vertebra and rotate to the
opposite side. S. capitis extend the head and
turns face towards the opposite side.
1. Rectus Capitis Posterior Major
Nerve: Posterior rami of thoracic and cervical
Origin: Spine of axis
spinal nerve
Insertion: Lateral part of inferior nuchal line of occipital
Action: Extends the head, rotates the head towards the
same side
2. Multifidus – primarily located in the lumbar and lower
Nerve: Suboccipital nerve (posterior ramus of C1)
thoracic areas
Origin: Back of sacrum; aponeurosis of erector spinal
2. Rectus Capitis Posterior Minor
posterior superior iliac spine; mammillary
Origin: Tubercle of the posterior part of the atlas
process of lumbar vertebra; transverse process
Insertion: Medial part of inferior nuchal line of occipital
of thoracic, lower four cervical vertebrae
Action: extends the head
Insertion: Spine of vertebra above it
Nerve: Suboccipital nerve
Action: Rotates vertebra slightly towards the opposite
side
3. Oblique Capitis Inferior
Nerve: Posterior rami of spinal nerves
Origin: Lateral surface of the spine and lamina of axis
Insertion: Transverse process of atlas
Action: Rotate face to same side
3. Rotatores – fully developed only in the thoracic region.
Nerve: Suboccipital nerve
Has a short and long belly. The short belly inserts to the
same vertebra it arises from, while the long belly inserts to
4. Oblique Capitis Superior
the vertebra above it. (R. thoracis (11 pairs), R. cervicis
Origin: Upper surface of transverse process of atlas
and R. lumborum)
Insertion: Occipital bone between the superior and
inferior nuchal lines
Origin: Transverse process of vertebra
Action: Flex head backwards and to the same side
Insertion: Lamina of the vertebra immediately above
Nerve: Suboccipital nerve
Action: Rotates the vertebral column to the other side
Nerve: Posterior rami of spinal nerves

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 The suboccipital muscles, except the rectus capitis minor, form the
suboccipital triangle. The suboccipital triangle is bounded
superomedially by the rectus capitis posterior major, superolaterally by
the oblique capitis superior and inferolaterally by the oblique capitis
superior.

Boundaries of the Suboccipital Triangle:

 Above and medially: Rectus capitis posterior major
 Above and lateral: Oblique capitis superior
 Below and lateral: Oblique capitis inferior

Contents of the Suboccipital Triangle:

 Vertebral Artery
 Suboccipital nerve

Kostoba nedenka!
“Be Strong and Brave!”

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