Fundamental Philosophy Surgery Series | Back and Spinal Cord



Fundamental Philosophy Surgery Series
Back and Spinal Cord


Topographic Anatomy | Back


Trapezius Muscle

Spine of scapula

Deltoid muscle

Infraspinatus muscle

Long head

Lateral head

Tendon

Teres major muscle

Latissimus dorsi muscle

Lumbar (triangle of Petit)

Iliac crest

Erector spinae muscle

Posterior superior iliac spine

Intergluteal (natal) cleft

External occipital protuberance

Ligamentum nuchae

Spinous process of C7 vertebra

Deltoid muscle

Spine of scapula

Triangle of auscultation

Medial border of scapula

Inferior angle of scapula

Spinous process of T12 vertebra

Gluteus medius muscle

Sacrum

Gluteus maximus muscle

Greater trochanter of femur

Gluteal fold


Bones and Ligaments | Vertebral Column


Anterior view

Atlas (C1)

Axis (C2)

C7

T1

T12

L1

L5

Sacrum (S1-5)

Coccyx

Left lateral view

Atlas (C1)

Axis (C2)

Cervical curvature

C7

Thoracic curvature

T1

T12

L1

Lumbar curvature

L5

Sacral curvature

Sacrum (S1-5)

Coccyx

Posterior view

Cervical Vertebrae

Atlas (C1)

Axis (C2)

C7

Thoracic Vertebrae

T1

T12

Lumbar Vertebrae

L1

L5

Sacrum (S1-5)

Coccyx


Bones and Ligaments | Thoracic Vertebrae


T6 vertebra: superior view

Body

Superior costal facet

Pedicle

Transverse costal facet

Lamina

Spinous process

Superior articular facet

Superior vertebral notch (forms lower margin of intervertebral foramen)

Vertebral foramen

T6 vertebra: lateral view

Body

Superior costal facet

Superior articular process and facet

Pedicle

Transverse costal facet

Transverse process

Inferior articular process

Spinous process

Inferior vertebral notch

Inferior costal facet

T7, T8, and T9 vertebrae: posterior view

7th rib

Vertebral canal

Superior articular process and facet

T7

Spinous process of T7 vertebra

T8

T9

Transverse process of T9 vertebra

Lamina

Inferior articular process (T9)

Spinous process (T9)

T12 vertebra: lateral view

Body

Superior articular process and facet

Transverse process

Spinous process

Inferior articular process and facet

Costal facet


Bones and Ligaments | Lumbar Vertebrae


L2 vertebra: superior view

Vertebral body

Vertebral foramen

Pedicle

Transverse process

Superior articular process

Mammillary process

Lamina

Spinous process

Accessory process

Intervertebral disc

Anulus fibrosus

Nucleus pulposus

L3 and L4 vertebrae: posterior view

Vertebral body

Vertebral canal

Superior articular process

Mammillary process

Transverse process

Pars interarticularis

Accessory process

L3

Spinous process of L3 vertebra

L4

Lamina

Inferior articular process

Lumbar vertebrae, assembled: left lateral view

Vertebral Body

Intervertebral disc

Pedicle

Superior articular process

Mammillary process

Transverse process

Spinous process

Inferior articular process

Inferior vertebral notch

Intervertebral (neural) foramen

Superior vertebral notch

Lamina

Articular facet for sacrum

L1

L2

L3

L4

L5


Bones and Ligaments | Lumbar Vertebrae: Radiographs


Anteroposterior radiograph

SA, Superior articular process of L1 vertebra

IA, Inferior articular process of L1 vertebra

T, Transverse process of L3 vertebra

P, Pedicle of L3 vertebra

B, Body of L3 vertebra

L, Lamina of L4 vertebra

S, Spinous process of L4 vertebra

SF, Sacral foramen

Lateral radiograph

T12, 12th Thoracic vertebra

L1, 1st Lumbar vertebra

L2, 2nd Lumbar vertebra

IN, Inferior vertebral notch of L2 vertebra

D, Intervertebral disc space

SN, Superior vertebral notch of L3 vertebra

P, Pedicle of L3 vertebra

L3, 3rd Lumbar vertebra

I, Intervertebral foramen

IA, Inferior articular process of L3 vertebra

SA, Superior articular process of L4 vertebra

L4, 4th Lumbar vertebra

S, Spinous process of L3 vertebra

L5, 5th Lumbar vertebra

S1, 1st Sacral vertebra

S2, 2nd Sacral vertebra


Bones and Ligaments | Sacrum and Coccyx


Anterior inferior view

Base of sacrum

Lumbosacral articular surface

Superior articular process

Ala (wing)

Promontory

Transverse ridges

Sacral part of pelvic brim (linear terminalis)

Anterior (pelvic) sacral foramina

Apex of sacrum

Transverse process of coccyx

Coccyx

Pelvic surface

Median sagittal section

Superior articular process

Sacral canal

Dorsal surface

Pelvic surface

Sacral hiatus

Posterior superior view

Facets of superior articular processes

Auricular surface

Sacral tuberosity

Lateral sacral crest

Median sacral crest

Intermediate sacral crest

Sacral hiatus

Posterior sacral foramina

Sacral cornu (horn)

Coccygeal cornu (horn)

Transverse process of coccyx

Dorsal surface

Coronal section through S2 foramina

Median sacral crest

Sacral canal

Intervertebral foramen

Posterior sacral foramen

Anterior (pelvic) sacral foramen


Bones and Ligaments | Vertebral Ligaments: Lumbar Region


Left lateral view (partially sectioned in median plane)

Anterior longitudinal ligament

Lumbar vertebral body

Intervertebral body

Anterior longitudinal ligament

Posterior longitudinal ligament

Inferior articular process

Capsule of zygapophyseal joint (partially opened)

Superior articular process

Transverse process

Spinous process

Ligamentum flavum

Interspinous ligament

Supraspinous ligament

Intervertebral foramen

Anterior vertebral segments: posterior view (pedicles sectioned)

Pedicle (cut surface)

Posterior surface of vertebral bodies

Posterior longitudinal ligament

Intervertebral disc

Posterior vertebral segments: anterior view

Pedicle (cut surface)

Ligamentum flavum

Lamina

Superior articular process

Transverse process

Inferior articular facet


Bones and Ligaments | Vertebral Ligaments: Lumbosacral Region


Left lateral view

Anterior longitudinal ligament

Body of L1 vertebra

Intervertebral discs

L2 spinal nerve

Body of L5 vertebra

L5 spinal nerve

Auricular surface of sacrum (for articulation with ilium)

Sacrum

Coccyx

Superior articular process

Transverse process

Lamina

Inferior articular process

Pedicle

Intervertebral foramen

Spinous process

Interspinous ligament

Supraspinous ligament

Posterior view

Posterior longitudinal ligament

Pedicle (cut)

Superior articular processes; facet tropism (difference in facet axis) on right side

Spinous process

Lamina

Transverse process

Inferior articular process

Ligamentum flavum

Iliolumbar ligament

Iliac crest

Posterior superior iliac spine

Posterior inferior iliac spine

Posterior sacroiliac ligaments

Greater sciatic foramen

Spine of ischium

Sacrospinous ligament

Lesser sciatic foramen

Sacrotuberous ligament

Ischial tuberosity

Lateral sacrococcygeal ligament

Posterior sacrococcygeal ligament


Spinal Cord | Spinal Cord and Ventral Rami in Situ


Base of skull

C1 spinal nerve

C2 vertebra (axis)

C8 spinal nerve

T1 spinal nerve

1st rib

Intercostal nerves

T12 spinal nerve

12th rib

Subcostal nerve

L1 spinal nerve

Conus medullaris

Cauda equina

L5 spinal nerve

S1 spinal nerve

Sacrum (cut away)

Filum terminale internum

Termination of dural sac

Filum terminale externum (coccygeal ligament)

S5 spinal nerve

Coccygeal nerve

C1 vertebra (atlas)

Cervical plexus

C7 vertebra

T1 vertebra

Brachial plexus

Spinal dura mater

Filaments of spinal nerve roots (T7 and T8)

T12 vertebra

L1 vertebra

Iliohypogastric nerve

Ilioinguinal nerve

Lumbar plexus

L5 plexus

L5 vertebra

Femoral nerve

Sacral plexus

Superior and inferior gluteal nerves

Posterior femoral cutaneous nerve

Pudendal nerve

Coccyx


Spinal Cord | Relation of Spinal Nerve Roots to Vertebrae


Base of skull

Cervical enlargement

Lumbar enlargement

Filum terminale internum

Filum terminale externum (coccygeal ligament)

C1, 1st Cervical spinal nerve

C1 spinal nerve exits above the C1 vertebra

C1, 1st Cervical vertebra

C2, 2nd Cervical spinal nerve

C2 spinal nerve exits above the C1 vertebra

C2, 2nd Cervical vertebra

C3, 3rd Cervical spinal nerve

C3, 3rd Cervical vertebra

C4, 4th Cervical spinal nerve

C4, 4th Cervical vertebra

C5, 5th Cervical spinal nerve

C5, 5th Cervical vertebra

C6, 6th Cervical spinal nerve

C6, 6th Cervical vertebra

C7, 7th Cervical spinal nerve

C7, 7th Cervical vertebra

C8, 8th Cervical spinal nerve exits below C7 vertebra (there are 8 cervical nerves but only 7 cervical vertebrae)

T1, 1st Thoracic vertebra

T1, 1st Thoracic spinal nerve

T2, 2nd Thoracic vertebra

T2, 2nd Thoracic spinal nerve

T3, 3rd Thoracic vertebra

T3, 3rd Thoracic spinal nerve

T4, 4th Thoracic vertebra

T4, 4th Thoracic spinal nerve

T5, 5th Thoracic vertebra

T5, 5th Thoracic spinal nerve

T6, 6th Thoracic vertebra

T6, 6th Thoracic spinal nerve

T7, 7th Thoracic vertebra

T7, 7th Thoracic spinal nerve

T8, 8th Thoracic vertebra

T8, 8th Thoracic spinal nerve

T9, 9th Thoracic vertebra

T9, 9th Thoracic spinal nerve

T10, 10th Thoracic vertebra

T10, 10th Thoracic spinal nerve

T11, 11th Thoracic vertebra

T11, 11th Thoracic spinal nerve

T12, 12th Thoracic vertebra

T12, 12th Thoracic spinal nerve

L1, 1st Lumbar vertebra

Conus medullaris (termination of spinal cord)

L1, 1st Lumbar spinal nerve

L2, 2nd Lumbar vertebra

L2, 2nd Lumbar spinal nerve

L3, 3rd Lumbar vertebra

L3, 3rd Lumbar spinal nerve

Cauda equina

L4, 4th Lumbar vertebra

L4, 4th Lumbar spinal nerve

L5, 5th Lumbar vertebra

L5, 5th Lumbar spinal nerve

Sacrum

S1, 1st Sacral spinal nerve

S2, 2nd Sacral spinal nerve

Termination of dural sac

S3, 3rd Sacral spinal nerve

S4, 4th Sacral spinal nerve

S5, 5th Sacral spinal nerve

Coccygeal nerve

Coccyx


Lumbar disc protrusion does not usually affect nerve exiting above disc. Lateral protrusion at disc level L4-5 affects L5 spinal nerve, not L4 spinal nerve. Protrusion at disc level L5-S1 affects S1 spinal nerve, not L5 spinal nerve.


L4

L4

L5

L5

S1

S2


Medial protrusion at disc level L4-5 rarely affects L4 spinal nerve but may affect L5 spinal nerve and sometimes S1-4 spinal nerves.


L4, 4th Lumbar vertebra

L4, 4th Lumbar spinal nerve

L5, 5th Lumbar vertebra

L5, 5th Lumbar spinal nerve

S1, 1st Sacral spinal nerve

S2, 2nd Sacral spinal nerve

S3, 3rd Sacral spinal nerve

S4, 4th Sacral spinal nerve

S5, 5th Sacral spinal nerve

Coccygeal nerve


Spinal Cord | Lumbar Disc Herniation: Clinical Manifestations


Schematic cross section showing compression of nerve root

Characteristic posture in left-sided lower lumbar disc herniation

Surgical exposure of lower lumbar disc

Nucleus pulposus

Nerve root

Dura

Clinical features of herniated lumbar nucleus pulposus


Level of herniation

Pain

Numbness

Weakness

Atrophy

Reflexes

L3

L4

L5

L5

S


*L4-5 disc; 5th lumbar nerve root

Over sacroiliac joint, hip, lateral thigh and leg

Lateral leg, first 3 toes

Dorsiflexion of great toe and foot; difficulty walking on heels; foot drop may occur

Minor

Changes uncommon in knee and ankle jerks, but internal hamstring reflex diminished or absent

L4

L5

S

L5-S1 disc; 1st sacral nerve

Over sacroiliac joint, hip, posterolateral thigh and leg to heel

Back of calf, lateral heel, foot to toe

Plantar flexion of foot and great toe may be affected; difficulty walking on toes

Gastrocnemius and soleus

Ankle jerk diminished or absent


Spinal Cord | Lumbar Puncture and Epidural Anesthesia


Lumbar puncture

Cauda equina

Subarachnoid space

Needle entering subarachnoid space

Arrows show locations of insertion of needles

Iliac crest

Epidural anesthesia

Dural sac

Epidural space

Spinous process of L4

Ligamentum flavum

Needle entering epidural space


Epidural anesthesia and lumbar puncture are performed by inserting a needle above or below the L4 vertebral spine, which lies at the level of the iliac crest. For epidural anesthesia, the needle passes into the epidural space, and anesthetic agent bathes the nerve roots in proximity. Lumbar puncture, on the other hand, is performed in order to collect a sample of cerebrospinal fluid (CSF) or to introduce an anesthetic agent into the CSF (spinal anesthesia), so therefore the needle penetrates the dural sac to enter the subarachnoid space.


Spinal Cord | Dermatomes


Schematic demarcation of dermatomes (according to Keegan and Garrett) shown as distinct segments. There is actually considerable overlap between any two adjacent dermatomes. An alternative dermatome map is that provided by Foerster (see References).


Anterior view of full body

C2

C3

C4

C5

C5

C6

C6

C7

C8

T1

T2

T3

T4

T5

T6

T7

T8

T9

T10

T11

T12

L1

L2

L3

L4

L4

L5

L5

S1

S2

S3

Posterior view of full body

C2

C3

C4

C5

C6

C6

C6

C7

C7

C7

C8

C8

C8

T1

T2

T3

T4

T5

T6

T7

T8

T9

T10

T11

T12

L1

L2

L3

L4

L5

L5

L1

L2

L3

L4

L5

L4

Levels of principal dermatomes

C5 Clavicles

C5, 6, 7 Lateral parts of upper limbs

C8, T1 Medial sides of upper limbs

C6 Thumb

C6, 7, 8 Hand

C8 Ring and little fingers

T4 Level of nipples

T10 Level of umbilicus

L1 Inguinal or groin regions

L1, 2, 3, 4 Anterior and inner surfaces of lower limbs

L4, 5, S1 Foot

L4 Medial side of great toe

S1, 2, L5 Posterior and outer surfaces of lower limbs

S1 Lateral margin of foot and little toe

S2, 3, 4 Perineum


Spinal Cord | Sympathetic Nervous System: General Topography


Internal carotid plexus

Internal carotid nerve

Superior cervical ganglion

Gray rami communicantes

Cervical sympathetic trunk

Middle cervical ganglion

Cervicothoracic (stellate) ganglion

Thoracic visceral nerves

Pulmonary plexus

White and gray rami communicantes

Esophageal plexus

Greater thoracic splanchnic nerve

Lesser thoracic splanchnic nerve

Aorticorenal ganglion

Lumbar splanchnic nerves

Sacral splanchnic nerves

External carotid nerve

Cervical cardiac nerves

Cardiac plexus

Celiac plexus

Celiac ganglion

Superior mesenteric ganglion

Superior mesenteric plexus

Inferior mesenteric ganglion

Inferior mesenteric plexus

Hypogastric nerve

Inferior hypogastric plexus


Spinal Cord | Parasympathetic Nervous System: General Topography


Oculomotor nerve (CN III)

Facial nerve (CN VII)

Glossopharyngeal nerve (CN IX)

Vagus nerve (CN X)

Pulmonary plexus

Esophageal plexus

Pelvic splanchnic nerves (from S2-4)

Inferior hypogastric plexus

Lacrimal gland

Ciliary ganglion

Pterygopalatine ganglion

Parotid gland

Submandibular ganglion

Sublingual and submandibular glands

Cervical cardiac branch

Cardiac plexus

Anterior and posterior vagal trunks

Celiac plexus

Superior mesenteric plexus

Cavernous nerves


Spinal Cord | Sympathetic Nervous System: Schema


Superior cervical ganglion

Gray rami communicantes

First thoracic ganglion

Innervation to arrector pili muscles, vascular smooth muscle, and sweat glands of skin

White ramus communicans

Gray ramus communicans

First lumbar ganglion

First sacral ganglion

Sacral splanchnic nerves

Internal carotid nerve and plexus

External carotid nerve and plexus

Lacrimal gland

Eye

Parotid gland

Sublingual gland

Submandibular gland

Larynx

Trachea

Bronchi

Lungs

Cardiac branches

Greater thoracic splanchnic nerve

Heart

Celiac ganglion

Lesser thoracic splanchnic nerve

Stomach

Aorticorenal ganglion

Liver

Gallbladder

Bile ducts

Pancreas

Least thoracic splanchnic

Superior mesenteric ganglion

Kidneys

Intestines

Lumbar splanchnic nerves

Descending colon

Inferior mesenteric ganglion

Sigmoid colon

Rectum

Urinary bladder

Inferior hypogastric plexus

Prostate

External genitalia

Preganglionic fibers

Postganglionic fibers


Spinal Cord | Parasympathetic Nervous System: Schema


Branch of oculomotor nerve (III)

Branch of facial nerve (VII)

Medulla oblongata

Branch of glossopharyngeal nerve (IX)

Otic ganglion

Submandibular ganglion

Ciliary ganglion

Pterygopalatine ganglion

Lacrimal glands

Eye

Parotid glands

Sublingual glands

Submandibular glands

Vagus nerve (X)

Larynx

Trachea

Bronchi

Lungs

Pulmonary plexus

Heart

Stomach

Celiac ganglion

Superior mesenteric ganglion

Liver

Gallbladder

Bile ducts

Pancreas

Kidneys

Intestines

Descending colon

Sigmoid colon

Rectum

Inferior hypogastric plexus

Urinary bladder

Prostate

Pelvic splanchnic nerves

External genitalia

Preganglionic fibers

Postganglionic fibers


Spinal Cord | Spinal Membranes and Nerve Roots


Posterior view

Ventral root of spinal nerve

Dorsal root of spinal nerve

Dorsal root (spinal) ganglion

White and gray rami communicantes to and from sympathetic trunk

Ventral ramus of spinal nerve

Dorsal ramus of spinal nerve

Dura mater

Arachnoid mater

Mesothelial septum in dorsal median sulcus

Pia mater overlying spinal cord

Filaments of dorsal root

Denticulate ligament

Membranes removed: anterior view (greatly magnified)

White matter

Gray matter

Lateral horn

Dorsal horn

Ventral horn

Filaments of dorsal root

Dorsal root of spinal nerve

Filaments of ventral root

Dorsal root (spinal) ganglion

Dorsal ramus of spinal nerve

Ventral ramus of spinal nerve

Ventral root of spinal nerve

Spinal nerve

Gray and white rami communicantes


Spinal Cord | Spinal Nerve Origin: Cross Sections


Section through thoracic vertebra

Body of vertebra

Dura mater

Arachnoid mater

Subarachnoid space

Pia mater

Recurrent meningeal branches of spinal nerve

Pleura

Lung

Aorta

Fat in epidural space

Sympathetic ganglion

Denticulate ligament

Ventral root

White and gray rami communicantes

Spinal nerve

Ventral ramus (intercostal nerve)

Dorsal ramus

Dorsal root (spinal) ganglion

Dorsal root

Lateral horn of gray matter of spinal cord

Internal vertebral (epidural) venous plexus (of Batson)

Medial branch of dorsal ramus of spinal nerve

Lateral branch of dorsal ramus of spinal nerve

Section through lumbar vertebra

Sympathetic ganglion

Gray ramus communicans

Fat in epidural space

Dorsal and ventral roots of lumbar and sacral spinal nerves forming cauda equina

Dura mater

Arachnoid mater

Ventral root

Spinal nerve

Ventral ramus (contributes to lumbar plexus)

Dorsal ramus

Dorsal root (spinal) ganglion

Dorsal root

Conus medullaris


Spinal Cord | Arteries of Spinal Cord: Schema


Anterior view

Posterior cerebral artery

Superior cerebral artery

Basilar artery

Anterior inferior cerebellar artery (AICA)

Posterior inferior cerebellar artery (PICA)

Anterior spinal artery

Vertebral artery

Anterior segmental medullary arteries

Ascending cervical artery

Deep cervical artery

Subclavian artery

Anterior segmental medullary artery

Posterior intercostal artery

Pial plexus

Major anterior segmental medullary artery (great radicular artery of Adamkiewicz)

Posterior intercostal artery

Anterior segmental medullary artery

Lumbar

Anastomotic loops to posterior spinal arteries

Cauda equina arteries

Lateral (or medial) sacral arteries

Cervical vertebrae

Thoracic vertebrae

Lumbar vertebrae

Sacrum

Posterior view

Posterior inferior cerebellar artery

Posterior spinal arteries

Vertebral artery

Posterior segmental medullary arteries

Deep cervical artery

Ascending cervical artery

Subclavian artery

Posterior segmental medullary arteries

Posterior intercostal arteries

Posterior segmental medullary arteries

Anastomotic loops to anterior spinal artery

Lumbar arteries

Lateral (or medial) sacral arteries

Cervical vertebrae

Thoracic vertebrae

Lumbar vertebrae

Sacrum

Note: All spinal nerve roots have associated radicular or segmental medullary arteries. Most roots have radicular arteries (see Plate 172). Both types of arteries run along roots, but radicular arteries end before reaching anterior or posterior spinal arteries; larger segmental medullary arteries continue on to supply a segment of these arteries.


Spinal Cord | Arteries of Spinal Cord: Intrinsic Distribution


Section through thoracic level: anterosuperior view

Posterior spinal arteries

Anterior spinal artery

Anterior segmental medullary artery

Anterior radicular artery

Posterior radicular artery

Branch to vertebral body and dura mater

Spinal branch

Dorsal branch of posterior intercostal artery

Posterior intercostal artery

Paravertebral anastomoses

Prevertebral anastomoses

Prevertebral anastomoses

Thoracic (descending) aorta

Arterial distribution schema

Sulcal (central) branches to right side of spinal cord

Posterior radicular artery

Anterior segmental medullary artery

Pial arterial plexus

Anterior and posterior radicular arteries

Anterior spinal artery

Right posterior spinal artery

Peripheral branches from pial plexus

Sulcal (central) branches to left side of spinal cord

Left posterior spinal artery

Posterior radicular artery

Anterior segmental medullary artery

Pial arterial plexus

Note: All spinal nerve roots have associated radicular or segmental medullary arteries. Most roots have radicular arteries. Both types of arteries run along roots, but radicular arteries end before reaching anterior or posterior spinal arteries; larger segmental medullary arteries continue on to supply a segment of these arteries.


Spinal Cord | Veins of Spinal Cord and Vertebral Column


External vertebral venous plexus

Internal vertebral (epidural) venous plexus (Batson’s veins)

Internal vertebral (epidural) venous plexus

Intervertebral vein

External vertebral venous plexus

External vertebral venous plexus

Basivertebral vein

Internal vertebral (epidural) venous plexus

Segmented medullary/radicular veins

Intervertebral vein

Internal vertebral (epidural) venous plexus

External vertebral venous plexus

Anterior sulcal (central) vein

Anterior spinal vein

Basivertebral vein

Internal vertebral (epidural) venous plexus (Batson’s veins)

Intervertebral vein

Anterior segmental medullary/radicular vein

Posterior segmental medullary/radicular vein

Pial venous plexus

Posterior sulcal (central) vein

Posterior spinal vein

Internal vertebral (epidural) venous plexus


Muscles and Nerves | Muscles of Back: Superficial Layers


Gluteus maximus muscle

Gluteal aponeurosis (over gluteus medius muscle)

Iliac crest

Internal oblique muscle in lumbar triangle (of Petit)

External oblique muscle

Thoracolumbar fascia

Spinous process of T12 vertebra

Latissimus dorsi muscle

Teres major muscle

Teres minor muscle

Infraspinatus fascia

Deltoid muscle

Spine of scapula

Trapezius muscle

Posterior triangle of neck

Sternocleidomastoid muscle

Spinous process of C2 vertebra

Superior nuchal line of skull

Semispinalis capitis muscle

Splenius capitis muscle

Spinous process of C7 vertebra

Splenius cervicis muscle

Levator scapulae muscle

Rhomboid minor muscle (cut)

Supraspinatus muscle

Serratus posterior superior muscle

Rhomboid major muscle (cut)

Infraspinatus fascia (over infraspinatus muscle)

Teres minor and major muscles

Latissimus dorsi muscle (cut)

Serratus anterior muscle

Serratus posterior inferior muscle

12th rib

Erector spinae muscle

External oblique muscle

Internal oblique muscle


Muscles and Nerves | Muscles of Back: Intermediate Layers


Superior nuchal line of skull

Posterior tubercle of atlas (C1)

Longissimus capitis

Semispinalis capitis muscle

Splenius capitis and splenius cervicis muscles

Iliocostalis muscle of Erector spinae muscle

Longissimus muscle of Erector spinae muscle

Spinalis muscle of Erector spinae muscle

Serratus posterior inferior muscle

Tendon of origin of transversus abdominis muscle

Internal  oblique muscle

External oblique muscle (cut)

Iliac crest

Rectus capitis posterior minor muscle

Obliquus capitis superior muscle

Rectus capitis posterior major muscle

Obliquus capitis inferior muscle

Longissimus capitis muscle

Semispinalis capitis muscle (cut)

Spinalis cervicis muscle

Spinous process of C7 vertebra

Longissimus cervicis muscle

Iliocostalis cervicis muscle

Iliocostalis thoracis muscle

Hook

Spinalis thoracis muscle

Longissimus thoracis muscle

Iliocostalis lumborum muscle

Spinous process of T12 vertebra

Transversus abdominis muscle and tendon of origin

Thoracolumbar fascia (posterior layer) (cut)


Muscles and Nerves | Muscles of Back: Deep Layers


Superior nuchal line of skull

Mastoid process

Posterior tubercle of atlas (C1 vertebra)

Spinous process of axis (C2 vertebra)

Semispinalis capitis muscle

Spinous process of C7 vertebra

External intercostal muscles

Semispinalis thoracis muscles

Multifidus muscles

Thoracolumbar fascia (anterior layer)

Thoracolumbar fascia (posterior layer) (cut)

Transversus abdominis muscle and tendon of origin

Multifidus muscles

Erector spinae muscle (cut)

Rectus capitis posterior minor muscle

Obliquus capitis superior muscle

Rectus capitis posterior major muscle

Transverse process of atlas (C1)

Obliquus capitis inferior muscle

Longus of Rotatores cervicis muscles

Brevis of Rotatores cervicis muscles

Interspinalis cervicis muscle

Levator costae muscle

Longus of Rotatores thoracis muscles

Brevis of Rotatores thoracis muscles

Brevis of Levatores costarum muscles

Longus of Levatores costarum muscles

Interspinalis lumborum muscle

Intertransversarius muscle

Quadratus lumborum muscle

Iliac crest

Multifidus muscles (cut)


Muscles and Nerves | Nerves of Back


Accessory nerve (XI)

Trapezius muscle (reflected)

Levator scapulae muscle

Transverse cervical artery and vein

Subtrapezial plexus

Supraspinatus

Spine of scapula

Infraspinatus fascia

Rhomboid minor muscle

Rhomboid major muscle

Latissimus dorsi muscle

Spinous process of T12 vertebra

Thoracolumbar fascia

Gluteus maximus muscle

Greater occipital nerve (dorsal ramus of C2 spinal nerve)

3rd occipital nerve (dorsal ramus of C3 spinal nerve)

Lesser occipital nerve of Cervical plexus (ventral rami of C2, 3 spinal nerves)

Great auricular nerve of Cervical plexus (ventral rami of C2, 3 spinal nerves)

Trapezius muscle

Posterior cutaneous branches (from medial branches of dorsal rami of C4-T6 spinal nerves; C7, 8 are minimal)

Deltoid muscle

Infraspinatus fascia

Teres minor and major muscles

Superior lateral brachial cutaneous nerve (from axillary nerve C5, 6)

Posterior cutaneous branches (from lateral branches of dorsal rami of T7-12 spinal nerves)

Lateral cutaneous branches of ventral rami (intercostal nerves)

External oblique muscle

Iliac crest

Iliohypogastric nerve (ventral ramus of L1 spinal nerve)

Superior clunial nerves (dorsal rami of L1, 2, 3 spinal nerves)

Medial clunial nerves (dorsal rami of S1, 2, 3 spinal nerves)

Inferior clunial nerves from posterior femoral cutaneous nerve (sacral plexus S1, 2, 3)


Muscles and Nerves | Suboccipital Triangle


Epicranial aponeurosis (galea aponeurotica)

Occipital belly (occipitalis) of occipitofrontalis muscle

Greater occipital nerve (dorsal ramus of C2 spinal nerve)

Occipital artery

Third occipital nerve (dorsal ramus of C3 spinal nerve)

Semispinalis capitis and splenius capitis muscles in posterior triangle of neck

Posterior auricular artery

Great auricular nerve (cervical plexus C2, 3)

Lesser occipital nerve (cervical plexus C2)

Sternocleidomastoid muscle

Trapezius muscle

Posterior cutaneous branches of dorsal rami of C4, 5, 6 spinal nerves

Rectus capitis posterior minor muscle

Rectus capitis posterior major muscle

Semispinalis capitis muscle (cut and reflected)

Vertebral artery (atlantic part)

Obliquus capitis superior muscle

Suboccipital nerve (dorsal ramus of C1 spinal nerve)

Posterior arch of atlas (C1 vertebra)

Occipital artery

Obliquus capitis inferior muscle

Greater occipital nerve (dorsal ramus of C2 spinal nerve)

Splenius capitis muscle (cut and reflected)

Third occipital nerve (dorsal ramus of C3 spinal nerve)

Longissimus capitis muscle

Splenius cervicis muscle

Semispinalis cervicis muscle

Semispinalis capitis muscle (cut)

Splenius capitis muscle (cut)


Muscles and Nerves | Lumbar Region of Back: Cross Section


Quadratus lumborum muscle

Latissimus dorsi muscle

Serratus posterior inferior muscle

Tendon of origin of transversus abdominis and internal oblique muscles

Transversus abdominis muscle

Internal oblique muscle

External oblique muscle

Transversalis fascia

Extraperitoneal (subserous) fascia (areolar tissue)

Peritoneum

Pararenal fat

Perirenal fat

Renal (Gerota’s) fascia (anterior and posterior layers

Kidney

Descending (2nd) part of duodenum

Inferior vena cava

Pancreas

Anterior longitudinal ligament

Crura of diaphragm

Superior mesenteric artery and vein

Mesentery

Abdominal aorta

Duodenojejunal

Body of L2 vertebra

Psoas major muscle and fascia

Lumbar spinal nerve

Transverse process

Spinal dura mater

Cauda equina

Spinous process of L1 vertebra

Supraspinous ligament

Erector spinae muscle

Thoracolumbar fascia (posterior layer)

Thoracolumbar fascia (middle layer)

Thoracolumbar fascia (anterior layer-quadratus lumborum fascia)


Muscles and Nerves | Typical Thoracic Spinal Nerve


Anterior cutaneous branch

Lateral cutaneous branch

Posterior cutaneous branch

Dorsal ramus

Ventral ramus (intercostal nerve)

Spinal nerve

Dorsal root

Ventral root

Sternum

External intercostal membrane

Medial branch

Transversus thoracis muscle

Lateral branch

External intercostal muscle

Internal intercostal muscle

Innermost intercostal muscle

Anterior branch

Posterior branch

Serratus anterior muscle

Latissimus dorsi muscle

Subscapularis muscle

Teres major muscle

Scapula

Infraspinatus muscle

Trapezius muscle

Rhomboid major muscle

Erector spinae muscle

Internal intercostal membrane

Lateral branch

Medial branch

Intervertebral foramen

Dorsal root (spinal) ganglion

Sympathetic ganglion

Gray and white rami communicantes

Note: In lower thoracic region, lateral branch of dorsal ramus is longer, motor, and cutaneous; medial branch is shorter and motor only.

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