2 back

BACKBACK

(VERTEBRAL REGION)(VERTEBRAL REGION)

BoundariesBoundariessuperiorsuperior ：： external external

occipital protuberance and occipital protuberance and superior nuchal linesuperior nuchal line

inferior: inferior: line from the line from the coccyx apex to posterior coccyx apex to posterior iliac spineiliac spine

laterallateral ：： ant. border of trapezius, ant. border of trapezius, pos. border of deltoid,pos. border of deltoid, pos. wall of axillary fossa,pos. wall of axillary fossa, pos. axillary line pos. axillary line

Divisions:Divisions:

The napeThe nape The back of thoraxThe back of thorax

The lumberThe lumber

The sacrococcygealThe sacrococcygeal

acromionacromion

Surface Surface Anatomy Anatomy

Surface Surface Anatomy Anatomy

1.Skin incision1.Skin incision

External occipital External occipital protuberance lineprotuberance line

Acromion lineAcromion line

Inf. Angle of Inf. Angle of scapula linescapula line

Iliac crest lineIliac crest line

Dissection Dissection ProceduresProcedures

Med. vertical lineMed. vertical line

2.Reflect the skin flaps 2.Reflect the skin flaps laterallylaterally

Method of DissectionMethod of Dissection

Make out the line of Make out the line of incision by the scalpelincision by the scalpel

Hold the blade at right Hold the blade at right angle to the skin, and angle to the skin, and

drive its point through the drive its point through the skin till the superficial skin till the superficial fascia is reached. Then fascia is reached. Then incline the blade to an incline the blade to an

angle of 45angle of 450 0 to the to the surfacesurface

Only reflect the skin flaps, but not superficial fasciaOnly reflect the skin flaps, but not superficial fascia

LAYERSLAYERS

Superficial Superficial layerslayers

Deep fasciaDeep fascia MusclesMuscles

Superficial layersSuperficial layers

SkinSkin Superficial fasciaSuperficial fascia

SkinSkin

Thick Thick and highly protective and highly protective Full of hairFull of hair folliclesfollicles, , sweat glands & sebaceous glands sweat glands & sebaceous glands

Superficial fasciaSuperficial fascia

Dense, especially the Nuchal regionDense, especially the Nuchal regionFull of FatFull of FatCutaneous nerve & Superficial Cutaneous nerve & Superficial

blood vesselsblood vessels

Cutaneous nerveCutaneous nerve

Spinal Spinal nervenervePos. ramusPos. ramus

Ant. Ant. ramusramus

ganglion

Greater occipital nerveGreater occipital nerve

3rd occipital nerve3rd occipital nerve

Spinal nerve (cutaneous Spinal nerve (cutaneous branches of dorsal rami)branches of dorsal rami)Superior cluneal nerve Superior cluneal nerve (cutaneous branches of (cutaneous branches of dorsal rami L1-3)dorsal rami L1-3)

Middle cluneal nerve Middle cluneal nerve (cutaneous branches of (cutaneous branches of dorsal rami S1-3)dorsal rami S1-3)

Inferior cluneal nerve Inferior cluneal nerve ((posterior femoral posterior femoral cutaneous cutaneous

nerve(sacral plexus)nerve(sacral plexus)

Dorsal Rami of Spinal NerveDorsal Rami of Spinal Nerve

The term spinal nerve generally refers to the mixed spinal nerve, which is formed from the dorsal and ventral roots that come out of the spinal cord. The spinal nerve is the bit that passes out of the vertebrae through the intervertebral foramen.There are a total of 31 bilaterally-paired spinal nerves :8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal The first to seventh cervical nerves (C1 to C7) exit from the vertebral canal above the respective cervical vertebra (that is to say, C1 exits above the first cervical vertebra; C2 exits above the second, and so forth). The C8 spinal nerve exits below the seventh cervical vertebra, and all the other spinal nerves leave below their corresponding vertebra.Formation of the spinal nervesInside the spinal cord, there is grey matter, surrounded by white matter. From out of the grey matter, two dorsal roots (one on the left side, and one on the right side) and two ventral roots emerge. The dorsal roots contain afferent sensory axons, and the ventral roots contain efferent motor axons.Dorsal means back, ventral means front. As the body is symmetrical, the same thing happens on both the left and right side of the body. This happens in each vertebra of the spine.The dorsal roots of each side continue outwards, along the way forming a dorsal root ganglion (also called a spinal ganglion).The ventral roots similarly continue out from the spinal column, and meet and mix with their corresponding dorsal nerve root at a point after the ganglion. At this point they are called a mixed spinal nerveFate of the spinal nerveAfter the dorsal and ventral roots fuse to form a spinal nerve, the nerve bifurcates into dorsal and ventral primary rami. The dorsal primary ramus supplies the muscles and sensory nerves of the back, while the ventral primary ramus supplies the rest of the body wall.Each primary ramus has two branches: from the dorsal primary ramus emerges a lateral and medial branch; from the ventral primary ramus sprout an anterior and lateral cutaneous branch. In addition, the anterior cutaneous bifurcates, forming a medial and lateral branch, while the lateral cutaneous branch splits into an anterior and posterior branch. These secondary and tertiary branches themselves typically have muscular and sensory branches that innervate the body wall.The ventral primary rami also give rise to the roots of the various nervous plexuses (e.g. the brachial plexus), which become the sensory and motor nerves of the limbs.Before forming the plexuses, the ventral rami have two branches leading to a sympathetic ganglion. These ganglia connect to the one above and below them, forming the sympathetic chain.Importance of the spinal nervesThe muscles that one particular spinal root supplies are that nerve's myotome, and the dermatomes are the areas of sensory innervation on the skin for each spinal nerve. This is of great importance in the diagnosis of neurological disorders, as lesions of one or more nerve roots result in typical patterns of neurologic defects (muscle weakness, loss of sensation) that allow localisation of the causating lesion.

Superficial Blood VesselsSuperficial Blood Vessels

NuchalNuchalOccipital arteryOccipital artery

Superficial cervical arterySuperficial cervical artery

dorsal scapular arterydorsal scapular artery

Thoracic Thoracic dorsal dorsal

Posterior intercostals arteryPosterior intercostals artery

dorsal scapular arterydorsal scapular artery

thoracodorsal arterythoracodorsal artery

Lumber Lumber Lumbar arteryLumbar artery

SacrococcygeaSacrococcygeall

Superior Cluneal arterySuperior Cluneal artery

Inferior cluneal arteryInferior cluneal artery

Deep FasciaDeep Fascia

Nuchal fasciaNuchal fascia: a deep investing : a deep investing

membrane which covers the deep membrane which covers the deep

muscles of the back of the neck.muscles of the back of the neck.

Thoracolumbar fasciaThoracolumbar fascia: a deep investing : a deep investing

membrane which covers the deep membrane which covers the deep

muscles of the back of the trunk.muscles of the back of the trunk.

ThoracolumbaThoracolumbar Fasciar Fascia

a deep investing a deep investing membrane which membrane which covers the deep covers the deep muscles of the muscles of the back of the trunkback of the trunk

3 layers in 3 layers in lumbar regionlumbar region

Q.L

Erector spinae

MUSCLESMUSCLES

intrinsic back intrinsic back musclesmuscles

movement and movement and stabilization of stabilization of the vertebral the vertebral

columncolumn

respiration and respiration and movements of movements of

the upper the upper extremityextremity

extrinsic back extrinsic back musclesmuscles

Intermediate Intermediate groupgroup

Deep Deep groupgroup

Superficial Superficial groupgroup

TrapeziusTrapezius

RhomboideusRhomboideus

Latissimus dorsiLatissimus dorsi

Semispinalis capitisSemispinalis capitisSplenius capitisSplenius capitis levator scapulaelevator scapulae

Serratus Serratus posterior posterior superiorsuperior

erector spinaeerector spinae

Serratus Serratus posterior posterior inferiorinferior

Obliquus Obliquus externus externus

abdominisabdominis

Serratus posterior Serratus posterior superiorsuperior

Serratus posterior inferiorSerratus posterior inferior

Intermediate GroupIntermediate Group

DEEP GROUPDEEP GROUP

Spinotransversales MusclesSpinotransversales Muscles

Splenius CapitisSplenius Capitis

Splenius CervicisSplenius Cervicis

ErectorErector Spine Muscles Spine Muscles

IliocostalisIliocostalis

Longissimus Longissimus

SpinalisSpinalis


Transversospinales musclesTransversospinales muscles

SemispinalisSemispinalis

RotatoresRotatores

MultifidusMultifidus

Segmental back musclesSegmental back muscles

Levatores costarumLevatores costarum

InterspinalesInterspinales

IntertransversariiIntertransversarii

P59P59


Suboccipital MusclesSuboccipital Muscles

Rectus Capitis Posterior Rectus Capitis Posterior MinorMinor

Rectus Capitis Posterior Rectus Capitis Posterior MajorMajor

Superior Oblique Superior Oblique

Inferior ObliqueInferior Oblique

Triangle Of AuscultationTriangle Of Auscultation

BoundariesBoundariesTrapeziusTrapeziusLatissimus dorsiLatissimus dorsiMedial border of scapulaMedial border of scapula

Characteristic:Characteristic:Free of overlying muscleFree of overlying muscle

Clinical note:Clinical note:It is particularly suited for It is particularly suited for

auscultationauscultation

Rectus capitis Rectus capitis posterior majorposterior major

Superior Rectus Superior Rectus ObliqueOblique

Inferior Rectus Inferior Rectus ObliqueOblique

Vertebral Artery Suboccipital N

(Dorsal Ramus Of CⅠ)

Semispinalis capitisSemispinalis capitis

Splenius capitisSplenius capitis

Suboccipital Suboccipital TriangleTriangle

Vertebral ArteryVertebral Artery

Superior Lumbar TriangleSuperior Lumbar Triangle(Triangle Of Grynfeltt-Lesshaft )(Triangle Of Grynfeltt-Lesshaft )

twelfth ribtwelfth ribSerratus Serratus

posterior posterior inferior inferior

Erector spinae Erector spinae internal obliqueinternal oblique

Superior Lumbar TriangleSuperior Lumbar Triangle Covered by latissimus Covered by latissimus

dorsidorsi The depth is transverses The depth is transverses

abdominisabdominis Three nerves:Three nerves: subcostal n.subcostal n. iliohypogastric n.iliohypogastric n. ilioinguinal n.ilioinguinal n.

Clinical note:Clinical note:kidney surgical via loin : oblique surgical via loin : oblique

incision between the 12th rib incision between the 12th rib and iliac crestand iliac crest

External External Abdominal Abdominal ObliqueOblique

Latissimus DorsiLatissimus Dorsi Iliac CrestIliac Crest

Inferior Lumbar TriangleInferior Lumbar Triangle(Petit's Lumbar Triangle)(Petit's Lumbar Triangle)

Deep ArteriesDeep Arteries

Nuchal RegionNuchal Region

Occipital ArteryOccipital Artery

Superficial Cervical ArterySuperficial Cervical Artery

Dorsal Scapular ArteryDorsal Scapular Artery


Thoracic RegionThoracic Region

Posterior Intercostals ArteryPosterior Intercostals Artery

Dorsal Scapular ArteryDorsal Scapular Artery

Thoracodorsal ArteryThoracodorsal Artery

Lumber RegionLumber RegionLumbar ArteryLumbar Artery

Subcostal ArterySubcostal Artery

Sacrococcygeal Sacrococcygeal RegionRegion

Superior Cluneal ArterySuperior Cluneal Artery

Inferior Cluneal ArteryInferior Cluneal Artery


NuchalNuchalVertebral veinVertebral vein

Internal jugular veinInternal jugular vein

Subclavian veinSubclavian vein

ThoraciThoracicc

Posterior Intercostals vein – azygos Posterior Intercostals vein – azygos veinvein

Subclavian veinSubclavian vein

Axillary veinAxillary vein

LumberLumber Lumbar vein – inferior vena cavaLumbar vein – inferior vena cava

SacrocoSacrococcygeal ccygeal Internal iliac veinInternal iliac vein

DEEP VEINSDEEP VEINS

Vertebral VeinsVertebral Veins

Deep NerversDeep Nervers

Dorsal rami of spinal nerveDorsal rami of spinal nerve

Accessory nerveAccessory nerve

Thoracodorsal nerveThoracodorsal nerve

Dorsal scapular nerveDorsal scapular nerve

Dorsal Rami of Spinal NerveDorsal Rami of Spinal Nerve

The term spinal nerve generally refers to the mixed spinal nerve, which is formed from the dorsal and ventral roots that come out of the spinal cord. The spinal nerve is the bit that passes out of the vertebrae through the intervertebral foramen.There are a total of 31 bilaterally-paired spinal nerves :8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal The first to seventh cervical nerves (C1 to C7) exit from the vertebral canal above the respective cervical vertebra (that is to say, C1 exits above the first cervical vertebra; C2 exits above the second, and so forth). The C8 spinal nerve exits below the seventh cervical vertebra, and all the other spinal nerves leave below their corresponding vertebra.Formation of the spinal nervesInside the spinal cord, there is grey matter, surrounded by white matter. From out of the grey matter, two dorsal roots (one on the left side, and one on the right side) and two ventral roots emerge. The dorsal roots contain afferent sensory axons, and the ventral roots contain efferent motor axons.Dorsal means back, ventral means front. As the body is symmetrical, the same thing happens on both the left and right side of the body. This happens in each vertebra of the spine.The dorsal roots of each side continue outwards, along the way forming a dorsal root ganglion (also called a spinal ganglion).The ventral roots similarly continue out from the spinal column, and meet and mix with their corresponding dorsal nerve root at a point after the ganglion. At this point they are called a mixed spinal nerveFate of the spinal nerveAfter the dorsal and ventral roots fuse to form a spinal nerve, the nerve bifurcates into dorsal and ventral primary rami. The dorsal primary ramus supplies the muscles and sensory nerves of the back, while the ventral primary ramus supplies the rest of the body wall.Each primary ramus has two branches: from the dorsal primary ramus emerges a lateral and medial branch; from the ventral primary ramus sprout an anterior and lateral cutaneous branch. In addition, the anterior cutaneous bifurcates, forming a medial and lateral branch, while the lateral cutaneous branch splits into an anterior and posterior branch. These secondary and tertiary branches themselves typically have muscular and sensory branches that innervate the body wall.The ventral primary rami also give rise to the roots of the various nervous plexuses (e.g. the brachial plexus), which become the sensory and motor nerves of the limbs.Before forming the plexuses, the ventral rami have two branches leading to a sympathetic ganglion. These ganglia connect to the one above and below them, forming the sympathetic chain.Importance of the spinal nervesThe muscles that one particular spinal root supplies are that nerve's myotome, and the dermatomes are the areas of sensory innervation on the skin for each spinal nerve. This is of great importance in the diagnosis of neurological disorders, as lesions of one or more nerve roots result in typical patterns of neurologic defects (muscle weakness, loss of sensation) that allow localisation of the causating lesion.

Accessory NerveAccessory Nerve

Thoracodorsal Nerve

Dorsal Scapular Dorsal Scapular NerveNerve

VERTEBRAL CANALVERTEBRAL CANAL

CONSTRUCTIONCONSTRUCTION Anterior Wall: Anterior Wall:

Vertebral bodides,Vertebral bodides, Posterior Border Of Posterior Border Of

Intervertebral DiscsIntervertebral Discs Posterior Longitudinal Posterior Longitudinal

Ligament Ligament Posterior Wall: Posterior Wall:

LaminaLamina Ligament Flava;Ligament Flava;

Bilateral Wall: Bilateral Wall: PediclePedicle Intervertebral ForaminaIntervertebral Foramina

Posterior Longitudinal Posterior Longitudinal LigamentLigament

Intervertebral DiscIntervertebral Disc

Vertebral bodyVertebral body

Anterior Wall:Anterior Wall:

Ligament FlavaLigament Flava

LaminaLamina

Posterior Wall:Posterior Wall:

CONTENTSCONTENTS

Spinal CordSpinal Cord

MeningesMeninges

Spinal Nerve RootSpinal Nerve Root

Cauda EquinaCauda Equina

Blood VesselsBlood Vessels

Nerves Nerves

Lymphatic VesselsLymphatic Vessels

Connective TissuesConnective Tissues

SPINAL CORDSPINAL CORD

31 spinal cord segments31 spinal cord segments8 cervical segments 8 cervical segments 12 thoracic segments 12 thoracic segments 5 lumbar segments 5 lumbar segments 5 sacral segments 5 sacral segments 1 coccygeal segment1 coccygeal segment

Two enlargementsTwo enlargementsCervical enlargement (C5-T1)Cervical enlargement (C5-T1)Lumbosacral enlargement (L2-Lumbosacral enlargement (L2-

S3)S3)

MENINGESMENINGES

Spinal dura materSpinal dura mater

Spinal arachnoid materSpinal arachnoid mater

Spinal pia materSpinal pia mater

MENINGESMENINGES

DURA MATERDURA MATER

The dura mater forms a The dura mater forms a tube whose upper end is tube whose upper end is attached to the edge of attached to the edge of the foramen magnum, the foramen magnum, The dural tube narrows The dural tube narrows at the lower border of at the lower border of the second sacral the second sacral vertebra. It invests the vertebra. It invests the thin spinal filum thin spinal filum terminale, descends to terminale, descends to the back of the coccyx, the back of the coccyx, and blends with the and blends with the periosteum. periosteum.

ARACHNOID MATERARACHNOID MATER

closely closely applied to the applied to the deep aspect deep aspect of the dura of the dura mater.mater.

A delicate A delicate avascular avascular membrane membrane

PIA MATERPIA MATER

The spinal pia mater closely invests the The spinal pia mater closely invests the surface of the spinal cord and passes into surface of the spinal cord and passes into the anterior median fissure. the anterior median fissure.

C1

T1

T12

L5

S1

Conus medullaris

terminale filum

Cauda equina

coccyxcoccyx

Denticulate Denticulate LigamentLigament

Average 21 pairsAverage 21 pairs Attach pia mater Attach pia mater

to the arachnoid to the arachnoid and dura matersand dura maters

Provide stability Provide stability for the spinal for the spinal cord cord

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SPACES SPACES

Epidural spaceEpidural space

Subdural spaceSubdural space

Subarachnoid spaceSubarachnoid space


Arachnoid materArachnoid mater

Dura materDura mater

subarachnoid subarachnoid spacsspacs

Pia materPia mater


The epidural space lies between the spinal dura The epidural space lies between the spinal dura mater and the tissues which line the vertebral mater and the tissues which line the vertebral canal. canal.

It is closed above by fusion of the spinal dura It is closed above by fusion of the spinal dura with the edge of the foramen magnum, and with the edge of the foramen magnum, and below by the posterior sacrococcygeal ligament below by the posterior sacrococcygeal ligament which closes the sacral hiatus. which closes the sacral hiatus.

It contains loosely packed connective tissue, fat, It contains loosely packed connective tissue, fat, venous plexus, small arterial branches, venous plexus, small arterial branches, lymphatic vesselslymphatic vessels

Clinical anaesthetics injected in the space can Clinical anaesthetics injected in the space can block the conduction of spinal nerves.block the conduction of spinal nerves.

Subdural spaceSubdural space

The subdural space is a potential space in the The subdural space is a potential space in the normal spine because the arachnoid and dura normal spine because the arachnoid and dura are closely apposed. It does not connect with are closely apposed. It does not connect with the subarachnoid space, but continues for a the subarachnoid space, but continues for a short distance along the cranial and spinal short distance along the cranial and spinal nerves. Accidental subdural catheterization may nerves. Accidental subdural catheterization may occur during extradural injections. Injection of occur during extradural injections. Injection of fluid into the subdural space may either damage fluid into the subdural space may either damage the cord by direct toxic effects or by the cord by direct toxic effects or by compression of the vasculature.compression of the vasculature.

Subarachnoid spaceSubarachnoid space

The subarachnoid space lies between the The subarachnoid space lies between the arachnoid and the pia mater. It contains arachnoid and the pia mater. It contains cerebrospinal fluid (CSF)cerebrospinal fluid (CSF)

The terminal cistern is more expansive The terminal cistern is more expansive spaces from Lspaces from L11 to S to S2 .2 .and it is the best site and it is the best site for puncture to obtain CSF or spinal for puncture to obtain CSF or spinal anaesthesiaanaesthesia

Epidural AnaesthesiaEpidural Anaesthesia

L4

Epidural Venous Epidural Venous PlexusPlexus

Lumbar CisternLumbar Cistern

LUMBAR PUNCTURE

SPINAL NERVE ROOTSSPINAL NERVE ROOTS

Cisterna MagnaCisterna Magna(Cerebellomedulla(Cerebellomedulla

ry Cistern)ry Cistern)

Relationship Relationship with intervertebral with intervertebral

foramen & discforamen & disc

OPERATING DECOMPRESSIONOPERATING DECOMPRESSION

Segmental Artery

VEINSVEINS

Spinal CordSpinal Cord VertebraVertebra

C1-4C1-4 C1-4C1-4

C5-8, T1-4C5-8, T1-4 Cn-1Cn-1

T5-8T5-8 Tn-2Tn-2

T9-12T9-12 Tn-3Tn-3

L1-5L1-5 T10-11T10-11

S1-5, S1-5, CoccygealCoccygeal

T12, L1T12, L1

Segments of Spinal Segments of Spinal CordCord

C1-C4C1-C4 head and neck.head and neck.

C3-C5C3-C5 diaphragm (chest and breathing)diaphragm (chest and breathing)

C5-T1C5-T1 shoulders, arms and handsshoulders, arms and hands

T2-T12T2-T12chest and abdomenchest and abdomen

(excluding internal organs)(excluding internal organs)

L1-L4L1-L4abdomen (excluding internal abdomen (excluding internal

organs), buttocks, genitals, and organs), buttocks, genitals, and upper legsupper legs

L4-S1L4-S1 legslegs

S2-S4S2-S4 genitals and muscles of the genitals and muscles of the perineumperineum

DISTRIBUTION DISTRIBUTION

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