Vertebrae

Atlas (anatomy)
In anatomy, the atlas (C1) is the most superior (first) cervical vertebra of the spine.
It is named for the Atlas of Greek mythology, because it supports the globe of the head.
The atlas is the topmost vertebra, and along with the Axis forms the joint connecting the skull
and spine. The atlas and axis are specialized to allow a greater range of motion than normal
vertebrae. They are responsible for the nodding and rotation movements of the head.
The atlanto-occipital joint allows the head to nod up and down on the vertebral column. The dens
acts as a pivot that allows the atlas and attached head to rotate on the axis, side to side.
The Atlas' chief peculiarity is that it has no body, it is ring-like, and consists of an anterior and a
posterior arch and two lateral masses.
The Atlas and Axis are important neurologically because the brain stem extends down to the
Axis.
Anterior arch
The anterior arch forms about one-fifth of the ring: its anterior surface is convex, and presents at
its center the anterior tubercle for the attachment of the Longus colli muscles and the anterior
longitudinal ligament; posteriorly it is concave, and marked by a smooth, oval or circular facet
(fovea dentis), for articulation with the odontoid process (dens) of the axis.
The upper and lower borders respectively give attachment to the anterior atlantooccipital
membrane and the anterior atlantoaxial ligament; the former connects it with the occipital bone
above, and the latter with the axis below.[1]
Posterior arch
Median sagittal section through the occipital bone and first three cervical vertebr, showing
ligamentous attachments.
The posterior arch forms about two-fifths of the circumference of the ring: it ends behind in the
posterior tubercle, which is the rudiment of a spinous process and gives origin to the Recti capitis
posteriores minores and the ligamentum nuchae. The diminutive size of this process prevents any
interference with the movements between the atlas and the skull.
The posterior part of the arch presents above and behind a rounded edge for the attachment of the
posterior atlantooccipital membrane, while immediately behind each superior articular process is
a groove (sulcus arteriae vertebralis), sometimes converted into a foramen by a delicate bony
spiculum which arches backward from the posterior end of the superior articular process.
This groove represents the superior vertebral notch, and serves for the transmission of the
vertebral artery, which, after ascending through the foramen in the transverse process, winds
around the lateral mass in a direction backward and medially; it also transmits the suboccipital
nerve (first spinal nerve). In a common anatomic variant the vertebral artery passes through an
arcuate foramen.
On the under surface of the posterior arch, behind the articular facets, are two shallow grooves,
the inferior vertebral notches. The lower border gives attachment to the posterior atlantoaxial
ligament, which connects it with the axis.
Lateral masses
The lateral masses are the most bulky and solid parts of the atlas, in order to support the weight
of the head.
Each carries two articular facets, a superior and an inferior.

The superior facets are of large size, oval, concave, and approach each other in front, but diverge
behind: they are directed upward, medially, and a little backward, each forming a cup for the
corresponding condyle of the occipital bone, and are admirably adapted to the nodding
movements of the head. Not infrequently they are partially subdivided by indentations which
encroach upon their margins.
The inferior articular facets are circular in form, flattened or slightly convex and directed
downward and medially, articulating with the axis, and permitting the rotatory movements of the
head.
Vertebral foramen
Just below the medial margin of each superior facet is a small tubercle, for the attachment of the
transverse atlantal ligament which stretches across the ring of the atlas and divides the vertebral
foramen into two unequal parts:
the anterior or smaller receiving the odontoid process of the axis
the posterior transmitting the spinal cord (medulla spinalis) and its membranes
This part of the vertebral canal is of considerable size, much greater than is required for the
accommodation of the spinal cord.
The transverse processes are large; they project laterally and downward from the lateral masses,
and serve for the attachment of muscles which assist in rotating the head. They are long, and
their anterior and posterior tubercles are fused into one mass; the foramen transversarium is
directed from below, upward and backward.
Development
The atlas ossifies from 3 centers. The atlas is usually ossified from three centers.
Of these, one appears in each lateral mass about the seventh week of fetal life, and extends
backward; at birth, these portions of bone are separated from one another behind by a narrow
interval filled with cartilage.
Between the third and fourth years they unite either directly or through the medium of a separate
center developed in the cartilage.
At birth, the anterior arch consists of cartilage; in this a separate center appears about the end of
the first year after birth, and joins the lateral masses from the sixth to the eighth year.
The lines of union extend across the anterior portions of the superior articular facets.
Occasionally there is no separate center, the anterior arch being formed by the forward extension
and ultimate junction of the two lateral masses; sometimes this arch is ossified from two centers,
one on either side of the middle line.
Injuries
A break in the first vertebra is referred to as a Jefferson fracture.
A Jefferson fracture is a bone fracture of the anterior and posterior arches of the
C1 vertebra,[1] though it may also appear as a three or two part fracture. The
fracture may result from an axial load on the back of the head or hyperextension
of the neck (e.g. caused by diving), causing a posterior break, and may be
accompanied by a break in other parts of the cervical spine.[1]
It is named after the British neurologist and neurosurgeon Sir Geoffrey Jefferson,
who reported four cases of the fracture in 1920 in addition to reviewing cases that
had been reported previously.[2]
Etiology
Jefferson fracture is often caused by an impact or load on the back of the head,
and are frequently associated with diving into shallow water, impact against the
roof of a vehicle and falls,[3] and in children may occur due to falls from
playground equipment.[4] Less frequently, strong rotation of the head may also
result in Jefferson fractures.[3]
Jefferson fractures are extremely rare in children, but recovery is usually complete
without surgery.[4]
Symptoms
Individuals with Jefferson fractures usually experience pain in the upper neck but
no neurological signs. The fracture may also cause damage to the arteries in the
neck, resulting in lateral medullary syndrome, Horner's syndrome, ataxia, and the
inability to sense pain or temperature.[1]
In rare cases, congenital abnormality may cause the same symptoms as a Jefferson
fracture.[5][6]
Treatment
The use of surgery to treat a Jefferson fracture is somewhat controversial.[7] Nonsurgical treatment varies depending on if the fracture is stable or unstable, defined
by an intact or broken transverse ligament and degree of fracture of the anterior
arch.[8][1] An intact ligament requires the use of a soft or hard collar, while a
ruptured ligament may require traction, a halo or surgery. The use of rigid halos
can lead to intracranial infections and are often uncomfortable for individuals
wearing them, and may be replaced with a more flexible alternative depending on
the stability of the injured bones, but treatment of a stable injury with a halo collar
can result in a full recovery.[9] Surgical treatment of a Jefferson fracture involves
fusion or fixation of the first three cervical vertebrae;[7][1] fusion may occur
immediately, or later during treatment in cases where non-surgical interventions
are unsuccessful.[7] A primary factor in deciding between surgical and nonsurgical intervention is the degree of stability[7][9] as well as the presence of
damage to other cervical vertebrae.[9]
Though a serious injury, the long-term consequences of a Jefferson's fracture are
uncertain and may not impact longevity or abilities, even if untreated.[10]
Conservative treatment with an immobilization device can produce excellent
long-term recovery.[11][12]
The pharyngeal and retropharyngeal inflammations may cause decalcification of atlas vertebra.
This may lead to loosening of attachments of transverse ligament which may eventually yield.
This allows the dens of axis to move and exert pressure on spinal cord causing sudden death.
[citation needed]
C1 and C2 form a unique set of articulations that provide a great degree of mobility for the skull. C1
serves as a ring or washer that the skull rests upon and articulates in a pivot joint with the dens or
odontoid process of C2. Approximately 50% of flexion extension of the neck happens between the
occiput and C1; 50% of the rotation of the neck happens between C1 and C2.
The cervical spine is much more mobile than the thoracic or lumbar regions of the spine. Unlike the other
parts of the spine, the cervical spine has transverse foramina in each vertebra for the vertebral arteries that
supply blood to the brain.
Gross Anatomy
The cervical spine is made up of the first 7 vertebrae, referred to as C1-7 (see the images below). It
functions to provide mobility and stability to the head while connecting it to the relatively immobile
thoracic spine. The cervical spine may be divided into 2 parts: upper and lower.
Upper cervical spine
The upper cervical spine consists of the atlas (C1) and the axis (C2). [1, 2, 3, 4]These first 2 vertebrae are quite
different from the rest of the cervical spine (see the image below). The atlas articulates superiorly with the
occiput (the atlanto-occipital joint) and inferiorly with the axis (the atlantoaxial joint). The atlantoaxial
joint is responsible for 50% of all cervical rotation; the atlanto-occipital joint is responsible for 50% of
flexion and extension. The unique features of C2 anatomy and its articulations complicate assessment of
its pathology.
Cervical spine. Note uniquely shaped atlas and axis (C1 and C2).
Atlas (C1)
The atlas is ring-shaped and does not have a body, unlike the rest of the vertebrae. Fused remnants of the
atlas body have become part of C2, where they are called the odontoid process, or dens. The odontoid
process is held in tight proximity to the posterior aspect of the anterior arch of the atlas by the transverse
ligament, which stabilizes the atlantoaxial joint. The apical, alar, and transverse ligaments, by allowing
spinal column rotation, provide further stabilization and prevent posterior displacement of the dens in
relation to the atlas.
The atlas is made up of a thick anterior arch, a thin posterior arch, 2 prominent lateral masses, and 2
transverse processes. The transverse foramen, through which the vertebral artery passes, is enclosed by
the transverse process.
On each lateral mass is a superior and inferior facet (zygapophyseal) joint. The superior articular facets
are kidney-shaped, concave, and face upward and inward. These superior facets articulate with the
occipital condyles, which face downward and outward. The relatively flat inferior articular facets face
downward and inward to articulate with the superior facets of the axis.
According to Steele's rule of thirds, at the level of the atlas, the odontoid process, the subarachnoid space,
and spinal cord each occupy one third of the area of the spinal canal.
Axis (C2)
The axis has a large vertebral body, which contains the odontoid process (dens). The odontoid process
articulates with the anterior arch of the atlas via its anterior articular facet and is held in place by the
transverse ligament. The axis is composed of a vertebral body, heavy pedicles, laminae, and transverse
processes, which serve as attachment points for muscles. The axis articulates with the atlas via its superior
articular facets, which are convex and face upward and outward.
Embryology
C2 has a complex embryologic development. It is derived from 4 ossification centers: 1 for the body, 1
for the odontoid process, and 2 for the neural arches. The odontoid process fuses by the seventh
gestational month.
At birth, a vestigial cartilaginous disc space called the neurocentral synchondrosis separates the odontoid
process from the body of C2. The synchondrosis is seen in virtually all children aged 3 years and is absent
in those aged 6 years. The apical portion of the dens ossifies by age 3-5 years and fuses with the rest of
the structure around age 12 years. This synchondrosis should not be confused with a fracture.
Parts of the occiput, atlas, and axis are derived from the proatlas. The hypocentrum of the fourth
sclerotome forms the anterior tubercle of the clivus. The centrum of the proatlas sclerotome becomes the
apical cap of the dens and the apical ligaments.
The neural arch components of the proatlas are divided into rostral and ventral components. The rostral
component forms the anterior portion of the foramen magnum and the occipital condyles; the caudal
component forms the superior part of the posterior arch of the atlas and the lateral atlantal masses. The
alar and cruciate ligaments are formed from the lateral portions of the proatlas.
Vasculature
There is an extensive arterial anastomotic network around the dens, fed by the paired anterior and
posterior ascending arteries arising from the vertebral arteries around the C3 level and the carotid arterial
arcade from the base of the skull. The anterior and posterior ascending arteries reach the base of the dens
via the accessory ligaments and run cephalad at the periphery to reach the tip of the process. The
anastomotic arcade also receives tributaries from the ascending pharyngeal arteries that join the arcade
after passing through the occipital condyle.
Ligaments
The craniocervical junction and the atlantoaxial joints are secured by the external and internal ligaments.
The external ligaments consist of the atlanto-occipital, anterior atlanto-occipital, and anterior longitudinal
ligaments. The internal ligaments have 5 components, as follows:
The transverse ligament holds the odontoid process in place against the posterior atlas, which
prevents anterior subluxation of C1 on C2
The accessory ligaments arise posterior to and in conjunction with the transverse ligament and
insert into the lateral aspect of the atlantoaxial joint; the apical ligament lies anterior to the lip of the
foramen magnum and inserts into the apex of the odontoid process
The paired alar ligaments secure the apex of the odontoid to the anterior foramen magnum
The tectorial membrane is a continuation of the posterior longitudinal ligament to the anterior
margin of the foramen magnum
The 3 cm 5 mm accessory atlantoaxial ligament not only connects the atlas to the axis but also
continues cephalad to the occipital bone; functionally, it becomes maximally taut with 5-8 of head
rotation, lax with cervical extension, and maximally taut with 5-10 of cervical flexion; it seems to
participate in craniocervical stability; future improvements in magnetic resonance imaging (MRI) may
lead to better appreciation of its structure and integrity of this ligament [5]
Lower cervical spine
The 5 cervical vertebrae that make up the lower cervical spine, C3-C7, are similar to each other but very
different from C1 and C2. Each has a vertebral body that is concave on its superior surface and convex on
its inferior surface (see the image below). On the superior surfaces of the bodies are raised processes or
hooks called uncinate processes, each of which articulates with a depressed area on the inferior lateral
aspect of the superior vertebral body, called the echancrure or anvil.
Normal anatomy of lower cervical spine.
These uncovertebral joints are most noticeable near the pedicles and are usually referred to as the joints of
Luschka.[6] They are believed to be the result of degenerative changes in the annulus, which lead to
fissuring in the annulus and the creation of the joint. [7] These joints can develop osteophytic spurs, which
can narrow the intervertebral foramina.
The spinous processes of C3-C6 are usually bifid, whereas the spinous process of C7 is usually nonbifid
and somewhat bulbous at its end.
Anterior and posterior columns The subaxial cervical spine can conveniently be divided into anterior
and posterior columns. The anterior column consists of the typical cervical vertebral body sandwiched
between supporting disks. The anterior surface is reinforced by the anterior longitudinal ligament and the
posterior body by the posterior longitudinal ligament, both of which run from the axis to the sacrum.
Articulations include disk-vertebral body articulations, uncovertebral joints, and zygapophyseal (facet)
joints. The disk is thicker anteriorly, contributing to normal cervical lordosis, and the uncovertebral joints
in the posterior aspect of the body define the lateral extent of most surgical exposures. The facet joints are
oriented at a 45 angle to the axial plane, allowing a sliding motion; the joint capsule is weakest
posteriorly. Supporting ligamentum flavum, posterior, and interspinous ligaments also strengthen the
posterior column.[8]
Nerve supply. In the neuroanatomy of the cervical spine (see the image below), the cord is enlarged, with
lateral extension of the gray matter consisting of the anterior horn cells. The lateral dimension spans 1314 mm, and the anterior-posterior extent measures 7 mm. An additional 1 mm is necessary for
cerebrospinal fluid (CSF) anteriorly and posteriorly, as well as 1 mm for the dura. A total of 11 mm is
needed for the cervical spinal cord. Exiting at each vertebral level is the spinal nerve, which is the result
of the union of the anterior and posterior nerve roots.
Cross-sectional anatomy of cervical spinal cord.
The foramina are largest at C2-C3 and progressively decrease in size down to C6-C7. The spinal nerve
and spinal ganglion occupy 25-33% of the foraminal space. The neural foramen is bordered
anteromedially by the uncovertebral joints, posterolaterally by facet joints, superiorly by the pedicle of
the vertebra above, and inferiorly by the pedicle of the lower vertebra. Medially, the foramina are formed
by the edge of the end plates and the intervertebral discs.
Interconnections are present between the sympathetic nervous system and the spinal nerve proper. The
spinal nerves exit above their correspondingly numbered vertebral body from C2-C7. Because the
numbering of the cervical spinal nerves commences above the atlas, 8 cervical spinal nerves exist, with
the first exiting between the occiput and the atlas (C1) and the eighth exiting between C7 and T1.
Vasculature
The vascular anatomy consists of a larger anterior spinal artery located in the central sulcus of the cord
and paired posterior spinal arteries located on the dorsum of the cord. It is generally accepted that the
anterior two thirds of the cord is supplied by the anterior spinal artery and that the posterior one third is
supplied by the posterior arteries.
Facet joints
The facet joints in the cervical spine are diarthrodial synovial joints with fibrous capsules. The joint
capsules are more lax in the lower cervical spine than in other areas of the spine to allow gliding
movements of the facets. The joints are inclined at an angle of 45 from the horizontal plane and 85 from
the sagittal plane. This alignment helps prevent excessive anterior translation and is important in weightbearing.[9]
Nerve supply
The fibrous capsules are innervated by mechanoreceptors (types I, II, and III), and free nerve endings
have been found in the subsynovial loose areolar and dense capsular tissues. [10] In fact, there are more
mechanoreceptors in the cervical spine than in the lumbar spine. [1] This neural input from the facets may
be important for proprioception and pain sensation and may modulate protective muscular reflexes that
are important for preventing joint instability and degeneration.
The facet joints in the cervical spine are innervated by both the anterior and posterior rami. The atlantooccipital and atlantoaxial joints are innervated by the anterior rami of the first and second cervical spinal
nerves. The C2-C3 facet joint is innervated by 2 branches of the posterior ramus of the third cervical
spinal nerve innervate, a communicating branch and a medial branch known as the third occipital nerve.
The remaining cervical facets, C3-C4 to C7-T1, are supplied by the posterior rami medial branches that
arise 1 level cephalad and caudad to the joint. [11, 12]Therefore, each joint from C3-C4 to C7-T1 is innervated
by the medial branches above and below. These medial branches send off articular branches to the facet
joints as they wrap around the waists of the articular pillars.
Intervertebral disks
Intervertebral discs are located between the vertebral bodies of C2-C7. Intervertebral disks are located
between each vertebral body caudad to the axis. These disks are composed of 4 parts: the nucleus
pulposus in the middle, the annulus fibrosis surrounding the nucleus, and 2 end plates that are attached to
the adjacent vertebral bodies. They serve as force dissipators, transmitting compressive loads throughout
a range of motion. The disks are thicker anteriorly and therefore contribute to normal cervical lordosis.
The intervertebral disks are involved in cervical spine motion, stability, and weight-bearing. The annular
fibers are composed of collagenous sheets (lamellae) that are oriented at a 65-70 angle from the vertical
and alternate in direction with each successive sheet. As a result, they are vulnerable to injury by rotation
forces because only one half of the lamellae are oriented to withstand force applied in this direction. [1]
The middle and outer one third of the annulus is innervated by nociceptors. Phospholipase A2 has been
found in the disc and may be an inflammatory mediator.[13, 14, 15]
Ligaments
Although the cervical spine consists of 7 cervical vertebrae interspaced by intervertebral disks, the
complex ligamentous network keep the individual bony elements behaving as if they were a single unit.
As noted, the cervical spine can be viewed as being made up of anterior and posterior columns. It can also
be useful to think in terms of a third (middle) column, as follows:
The anterior column consists of the anterior longitudinal ligament and the anterior two thirds of
the vertebral bodies, the annulus fibrosus, and the intervertebral disks
The middle column is composed of the posterior longitudinal ligament and the posterior one third
of the vertebral bodies, the annulus fibrosus, and the intervertebral disks
The posterior column is made up of the posterior arches, including the pedicles, transverse
processes, articulating facets, laminae, and spinous processes
The longitudinal ligaments are vital for maintaining the integrity of the spinal column. Whereas the
anterior and posterior longitudinal ligaments maintain the structural integrity of the anterior and middle
columns, the posterior column alignment is stabilized by a complex of ligaments, including the nuchal
and capsular ligaments, and the ligamentum flavum.
If 1 of the 3 columns is disrupted as a result of trauma, stability is provided by the other 2, and cord injury
is usually prevented. With disruption of 2 columns, spinal cord injury is more likely because the spine
may then move as w separate units.
Several ligaments of the cervical spine that provide stability and proprioceptive feedback are worth
mentioning and are briefly described here.[16, 17]
The transverse ligament, the major portion of the cruciate ligament, arises from tubercles on the atlas and
stretches across its anterior ring while holding the odontoid process (dens) against the anterior arch. A
synovial cavity is located between the dens and the transverse process. This ligament allows rotation of
the atlas on the dens and is responsible for stabilizing the cervical spine during flexion, extension, and
lateral bending. The transverse ligament is the most important ligament for preventing abnormal anterior
translation.[18]
The alar ligaments run from the lateral aspects of the dens to the ipsilateral medial occipital condyles and
to the ipsilateral atlas. They prevent excessive lateral and rotational motion while allowing flexion and
extension. If the alar ligaments are damaged, as in whiplash, the joint complex becomes hypermobile,
which can lead to kinking of the vertebral arteries and stimulation of nociceptors and mechanoreceptors.
This may be associated with the typical complaints of patients with whiplash injuries (eg, headache, neck
pain, and dizziness).
The anterior longitudinal ligament (ALL) and the posterior longitudinal ligament (PLL) are the major
stabilizers of the intervertebral joints. Both ligaments are found throughout the entire length of the spine;
however, the ALL adheres more closely to the disks than the PLL does, and it is not well developed in the
cervical spine. The ALL becomes the anterior atlanto-occipital membrane at the level of the atlas, whereas
the PLL merges with the tectorial membrane. Both continue onto the occiput. The PLL prevents excessive
flexion and distraction.[19]
The supraspinous ligament, the interspinous ligaments, and the ligamentum flavum maintain stability
between the vertebral arches. The supraspinous ligament runs along the tips of the spinous processes, the
interspinous ligaments run between adjacent spinous processes, and the ligamentum flavum runs from the
anterior surface of the cephalad vertebra to the posterior surface of the caudad vertebra.
The interspinous ligament and (especially) the ligamentum flavum control for excessive flexion and
anterior translation.[19, 20, 21] The ligamentum flavum also connects to and reinforces the facet joint capsules
on the ventral aspect. The ligamentum nuchae is the cephalad continuation of the supraspinous ligament
and has a prominent role in stabilizing the cervical spine
Axis (anatomy)
Second cervical vertebra, or epistropheus, from above.
In anatomy, the second cervical vertebra (C2) of the spine is named the axis (from Latin axis,
"axle") or epistropheus.
It forms the pivot upon which the first cervical vertebra (the atlas), which carries the head,
rotates.
The most distinctive characteristic of this bone is the strong odontoid process ("dens") which
rises perpendicularly from the upper surface of the body. That peculiar feature gives to the
vertebra a rarely used third name: vertebra dentata. It is the bone responsible for death in Judicial
Hanging as the odontoid process usually breaks and hits the medulla oblongata, damaging the
vital centres.
The body
The body is deeper in front than behind, and prolonged downward anteriorly so as to overlap the
upper and front part of the third vertebra.
It presents in front a median longitudinal ridge, separating two lateral depressions for the
attachment of the Longus colli muscles.
Its under surface is concave from before backward and convex from side to side.
Other features
The dens, or odontoid process, exhibits a slight constriction or neck where it joins the body.
The pedicles are broad and strong, especially in front, where they coalesce with the sides of the
body and the root of the odontoid process. They are covered above by the superior articular
surfaces.
The laminae are thick and strong, and the vertebral foramen large, but smaller than that of the
atlas.
The transverse processes are very small, and each ends in a single tubercle; each is perforated by
the transverse foramen, which is directed obliquely upward and laterally.
The superior articular surfaces are round, slightly convex, directed upward and laterally, and are
supported on the body, pedicles, and transverse processes.
The inferior articular surfaces have the same direction as those of the other cervical vertebrae.
The superior vertebral notches are very shallow, and lie behind the articular processes; the
inferior lie in front of the articular processes, as in the other cervical vertebrae.
The spinous process is large, very strong, deeply channelled on its under surface, and presents a
bifid, tuberculated extremity.
Ossification of axis
The axis is ossified from five primary and two secondary centers.
The axis is ossified from five primary and two secondary centers.
The body and vertebral arch are ossified in the same manner as the corresponding parts in the
other vertebrae, viz., one center for the body, and two for the vertebral arch.
The centers for the arch appear about the seventh or eighth week of fetal life, while the centers
for the body appear in about the fourth or fifth month.
The dens or odontoid process consists originally of a continuation upward of the cartilaginous
mass, in which the lower part of the body is formed.
About the sixth month of fetal life, two centers make their appearance in the base of this process:
they are placed laterally, and join before birth to form a conical bilobed mass deeply cleft above;
the interval between the sides of the cleft and the summit of the process is formed by a wedgeshaped piece of cartilage.
The base of the process is separated from the body by a cartilaginous disk, which gradually
becomes ossified at its circumference, but remains cartilaginous in its center until advanced age.
In this cartilage, rudiments of the lower epiphysial lamella of the atlas and the upper epiphysial
lamella of the axis may sometimes be found.
The apex of the odontoid process has a separate center which appears in the second and joins
about the twelfth year; this is the upper epiphysial lamella of the atlas.
In addition to these there is a secondary center for a thin epiphysial plate on the under surface of
the body of the bone.
The cervical vertebra 3 (C3) is a vertebra of the spinal column.

The cervical spinal nerve 3 (C3) passes out above it.

It is also the level at which the common carotid artery bifurcates.

C5 and C6 are the areas that see the highest amount of cervical spine trauma.

The cervical spinal nerve 6 (C6) passes out above this vertebra.
The first cricoid ring is directly opposite C6.
C6 is the vertebral level that the oesophagus becomes continuous with the laryngopharynx and
also where the larynx becomes continuous with the trachea. It is also the level where the carotid
pulse can be palpated against the transverse process of the C6 vertebrae.
Vertebra prominens is the name of the seventh cervical vertebra. The most
distinctive characteristic of this vertebra is the existence of a long and prominent spinous process
which is palpable from the skin surface, hence the name. This spinous process is thick, nearly
horizontal in direction, not bifurcated, but terminating in a tubercle to which the lower end of the
ligamentum nuchae is attached.
The seventh cervical vertebra (C7) has the most prominent spinous process only in about 70% of
people; in the remainder, either C6 or T1 (the first thoracic vertebra) is the most prominent.
The transverse processes are of considerable size, their posterior roots are large and prominent,
while the anterior are small and faintly marked; the upper surface of each has usually a shallow
sulcus for the eighth spinal nerve, and its extremity seldom presents more than a trace of
bifurcation.
The foramen transversarium may be as large as that in the other cervical vertebrae, but is
generally smaller on one or both sides; occasionally it is double, sometimes it is absent.
On the left side it occasionally gives passage to the vertebral artery; more frequently the
vertebral vein traverses it on both sides; but the usual arrangement is for both artery and vein to
pass in front of the transverse process, and not through the foramen.
Sometimes the anterior root of the transverse process attains a large size and exists as a separate
bone, which is known as a cervical rib.
Thoracic vertebrae
In vertebrates, thoracic vertebrae compose the middle segment of the vertebral column, between
the cervical vertebrae and the lumbar vertebrae.[1] In humans, they are intermediate in size
between those of the cervical and lumbar regions; they increase in size as one proceeds down the
spine, the upper vertebrae being much smaller than those in the lower part of the region. They are
distinguished by the presence of facets on the sides of the bodies for articulation with the heads
of the ribs, and facets on the transverse processes of all, except the eleventh and twelfth, for
articulation with the tubercles of the ribs.
Humans have 12, but numbers vary greatly;[2] for example, most marsupials have 13, but koalas
have only 11.[3] 12 to 15 is common among mammals, with 18 to 20 in horses, tapirs,
rhinoceroses, and elephants, and extremes in mammals are marked by certain sloths with 25 and
cetaceans with 9.[4] By convention, the human thoracic vertebrae are numbered, with the first
one (T1) located closest to the skull and higher numbered vertebrae (T2-T12) proceeding away
from the skull and down the spine.
General characteristics
These are the general characteristics of the second through eighth thoracic vertebrae. The first
and ninth through twelfth vertebrae contain certain peculiarities, and are detailed below.
The bodies in the middle of the thoracic region are heart-shaped, and as broad in the anteroposterior as in the transverse direction. At the ends of the thoracic region they resemble
respectively those of the cervical and lumbar vertebrae. They are slightly thicker behind than in
front, flat above and below, convex from side to side in front, deeply concave behind, and
slightly constricted laterally and in front. They present, on either side, two costal demi-facets,
one above, near the root of the pedicle, the other below, in front of the inferior vertebral notch;
these are covered with cartilage in the fresh state, and, when the vertebrae are articulated with
one another, form, with the intervening intervertebral fibrocartilages, oval surfaces for the
reception of the heads of the ribs.
The pedicles are directed backward and slightly upward, and the inferior vertebral notches are of
large size, and deeper than in any other region of the vertebral column.
The laminae are broad, thick, and imbricated that is to say, they overlap those of subjacent
vertebrae like tiles on a roof.
The vertebral foramen is small, and of a circular form.
The spinous process is long, triangular on coronal section, directed obliquely downward, and
ends in a tuberculated extremity. These processes overlap from the fifth to the eighth, but are less
oblique in direction above and below.
The superior articular processes are thin plates of bone projecting upward from the junctions of
the pedicles and laminae; their articular facets are practically flat, and are directed backward and
a little lateralward and upward.
The inferior articular processes are fused to a considerable extent with the laminae, and project
but slightly beyond their lower borders; their facets are directed forward and a little medialward
and downward.
The transverse processes arise from the arch behind the superior articular processes and pedicles;
they are thick, strong, and of considerable length, directed obliquely backward and lateralward,
and each ends in a clubbed extremity, on the front of which is a small, concave surface, for
articulation with the tubercle of a rib. *
Individual thoracic vertebrae

The first and ninth through twelfth thoracic vertebra have some peculiarities
First thoracic vertebra

The first thoracic vertebra has, on either side of the body, an entire articular facet for the head of
the first rib, and a demi-facet for the upper half of the head of the second rib.
The body is like that of a cervical vertebra, being broad, concave, and lipped on either side.
The superior articular surfaces are directed upward and backward; the spinous process is thick,
long, and almost horizontal.
The transverse processes are long, and the upper vertebral notches are deeper than those of the
other thoracic vertebrae.
The thoracic spinal nerve 1 (T1) passes out underneath it.
Second thoracic vertebra

The thoracic spinal nerve 2 (T2) passes out underneath it. The second thoracic vertebra is larger
than the first thoracic vertebra
Third thoracic vertebra

Fourth thoracic vertebra

The fourth thoracic vertebra, together with the fifth, is at the same level as the sternal angle.
Surface orientation of T3 and T7, at middle of spine of scapula and at inferior angle of the
scapula, respectively.
Fifth thoracic vertebra
The fifth thoracic vertebra, together with the fourth, is at the same level as the sternal angle. The
human trachea divides into two main bronchi at the level of the 5th thoracic vertebra, but may
also end higher or lower, depending on breathing.
Sixth thoracic vertebra

Seventh thoracic vertebra

Eighth thoracic vertebra

The eighth thoracic vertebra is, together with the ninth thoracic vertebra, at the same level as the
xiphoid process.
Ninth thoracic vertebra

The ninth thoracic vertebra may have no demi-facets below. In some subjects however, it has two
demi-facets on either side; when this occurs the tenth doesn't have facets but demi-facets at the
upper part.
The xiphisternum (or xiphoid process of the sternum) is at the same level in the axial plane.
Tenth thoracic vertebra

The tenth thoracic vertebra has (except in the cases just mentioned) an entire articular facet (not
demi-facet) on either side, which is placed partly on the lateral surface of the pedicle. It doesn't
have any kind of facet below, because the following ribs only have one facet on their heads.
Eleventh thoracic vertebra

In the eleventh thoracic vertebrae the body approaches in its form and size to that of the lumbar
vertebrae.
The articular facets for the heads of the ribs are of large size, and placed chiefly on the pedicles,
which are thicker and stronger in this and the next vertebrae than in any other part of the thoracic
region.
The spinous process is short, and nearly horizontal in direction.
The transverse processes are very short, tuberculated at their extremities, and do have articular
facets.
Twelfth thoracic vertebra

The twelfth thoracic vertebra has the same general characteristics as the eleventh, but may be
distinguished from it by its inferior articular surfaces being convex and directed lateralward, like
those of the lumbar vertebrae; by the general form of the body, laminae, and spinous process, in
which it resembles the lumbar vertebrae; and by each transverse process being subdivided into
three elevations, the superior, inferior, and lateral tubercles: the superior and inferior correspond
to the mammillary and accessory processes of the lumbar vertebrae. Traces of similar elevations
are found on the transverse processes of the tenth and eleventh thoracic vertebrae.
Lumbar vertebrae
In human anatomy, the lumbar vertebrae are the five vertebrae between the rib cage and the
pelvis. They are the largest segments of the vertebral column and are characterized by the
absence of the foramen transversarium within the transverse process, and by the absence of
facets on the sides of the body. They are designated L1 to L5, starting at the top. The lumbar
vertebrae help support the weight of the body, and permit movement.
General characteristics
These are the general characteristics of the first through fourth lumbar vertebrae. The fifth
vertebra contains certain peculiarities, which are detailed below.
As with other vertebrae, each lumbar vertebra consists of a vertebral body and a vertebral arch.
The vertebral arch, consisting of a pair of pedicles and a pair of laminae, encloses the vertebral
foramen (opening) and supports seven processes.
Body
The vertebral body of each lumbar vertebra is large, wider from side to side than from front to
back, and a little thicker in front than in back. It is flattened or slightly concave above and below,
concave behind, and deeply constricted in front and at the sides.[1]
Arch
The pedicles are very strong, directed backward from the upper part of the vertebral body;
consequently, the inferior vertebral notches are of considerable depth.[1] The pedicles change in
morphology from the upper lumbar to the lower lumbar. They increase in sagittal width from 9
mm to up to 18 mm at L5. They increase in angulation in the axial plane from 10 degrees to 20
degrees by L5. The pedicle is sometimes used as a portal of entrance into the vertebral body for
fixation with pedicle screws or for placement of bone cement as with kyphoplasty or
vertebroplasty.
The laminae are broad, short, and strong.[1] They form the posterior portion of the vertebral
arch. In the upper lumbar region the lamina are taller than wide but in the lower lumbar vertebra
the lamina are wider than tall. The lamina connect the spinous process to the pedicles.
The vertebral foramen within the arch is triangular, larger than in the thoracic vertebrae, but
smaller than in the cervical vertebrae.[1]
Processes
The spinous process is thick, broad, and somewhat quadrilateral; it projects backward and ends
in a rough, uneven border, thickest below where it is occasionally notched.[1]
The superior and inferior articular processes are well-defined, projecting respectively upward
and downward from the junctions of pedicles and laminae. The facets on the superior processes
are concave, and look backward and medialward; those on the inferior are convex, and are
directed forward and lateralward. The former are wider apart than the latter, since in the
articulated column the inferior articular processes are embraced by the superior processes of the
subjacent vertebra.[1]
The transverse processes are long and slender. They are horizontal in the upper three lumbar
vertebrae and incline a little upward in the lower two. In the upper three vertebrae they arise
from the junctions of the pedicles and laminae, but in the lower two they are set farther forward
and spring from the pedicles and posterior parts of the vertebral bodies. They are situated in front
of the articular processes instead of behind them as in the thoracic vertebrae, and are homologous
with the ribs.[1]
Three portions or tubercles can be noticed in a transverse process of a lower lumbar vertebrae:
the lateral or costiform process, the mammillary process, and the accessory process.[2] The
costiform is lateral, the mammillary is superior (cranial), and the accessory is inferior (caudal).
The mammillary is connected in the lumbar region with the back part of the superior articular
process.[clarification needed] The accessory process is situated at the back part of the base of the
transverse process. The tallest and thickest costiform process is usually that of L5.[2]
First and fifth lumbar vertebrae

The first lumbar vertebra is level with the anterior end of the ninth rib. This level is also called
the important transpyloric plane, since the pylorus of the stomach is at this level.
The fifth lumbar vertebra is characterized by its body being much deeper in front than behind,
which accords with the prominence of the sacrovertebral articulation; by the smaller size of its
spinous process; by the wide interval between the inferior articular processes, and by the
thickness of its transverse processes, which spring from the body as well as from the pedicles.[1]
The fifth lumbar vertebra is by far the most common site of spondylolysis and spondylolisthesis.
[3]
Most individuals have five lumbar vertebrae, while some have four or six. Lumbar disorders that
normally affect L5 will affect L4 or L6 in these latter individuals.
[edit]Segmental movements
The range of segmental movements in a single segment is difficult to measure clinically, not only
because of variations between individuals, but also because it is age and gender dependent.
Furthermore, flexion and extension in the lumbal spine is the product of a combination of
rotation and translation in the sagittal plane between each vertebra.[4]
Ranges of segmental movements in the lumbal spine (White and Panjabi, 1990) are (in degrees):
[5]
L1-L2 L2-L3 L3-L4 L4-L5 L5-S1

Flexion/
Extension
12
14
15
16
17
Lateral
flexion
Axial
rotation
Evolutionary variation
Extant African apes have three and four lumbar vertebrae (Bonobos have different spines with an
additional vertebra) and modern humans normally five. This difference, and because the lumbar
spines of Nacholapithecus (a Miocene hominoid with six lumbar vertebrae and no tail) are
similar to those of early Australopithecus and early Homo, it can be assumed that the
Chimpanzee-human last common ancestor (PHLCA) also had a long axial column with a long
lumbar region, and that the reduction in the number of lumbar vertebrae occurred independently
in each ape clade. [6] The limited number of lumbar vertebrae in chimpanzees and gorillas result
in an inability to lordose their lumbar spines, in contrast to the spines of Old World monkeys and
Nacholapithecus and Proconsul, which suggests that the PHLCA was not "short-backed" as
previously believed. [7]
Sacrum
In humans, the sacrum (plural: sacrums or sacra) is a large, triangular bone at the base of the
spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge
between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part
with the coccyx (tailbone). It consists of usually five initially unfused vertebrae which begin to
fuse between ages 1618 and are usually completely fused into a single bone by age 34.
It is curved upon itself and placed obliquely (that is, tilted forward). It is kyphotic that is,
concave facing forwards. The base projects forward as the sacral promontory internally, and
articulates with the last lumbar vertebra to form the prominent sacrovertebral angle. The central
part is curved outward towards the posterior, allowing greater room for the pelvic cavity. The
two lateral projections of the sacrum are called ala (wings), and articulate with the ilium at the Lshaped sacroiliac joints.
Etymology
The name is derived from the Latin (os) sacrum, (sacer, sacra, sacrum, "sacred"), a translation of
the Greek hieron (osteon), meaning sacred or strong bone.[1] Since the sacrum is the seat of the
organs of procreation, animal sacra were offered in sacrifices. In Slavic languages and in German
this bone is called the 'cross bone' (Kreuzbein),[2] in Dutch 'holy bone' (Heiligbeen).
Parts
The pelvic surface of the sacrum is concave from above downward, and slightly so from side to
side.
The dorsal surface of the sacrum is convex and narrower than the pelvic.
The lateral surface of the sacrum is broad above, but narrowed into a thin edge below.
The base of the sacrum, which is broad and expanded, is directed upward and forward.
The apex (apex oss. sacri) is directed downward, and presents an oval facet for articulation with
the coccyx.
The vertebral canal (canalis sacralis; sacral canal) runs throughout the greater part of the bone;
above, it is triangular in form; below, its posterior wall is incomplete, from the non-development
of the laminae and spinous processes. It lodges the sacral nerves, and its walls are perforated by
the anterior and posterior sacral foramina through which these nerves pass out.
Articulations
The sacrum articulates with four bones:
the last lumbar vertebra above
the coccyx (tailbone) below
the illium portion of the hip bone on either side

Rotation of the sacrum forward a few degrees vis--vis the ilia is sometimes called "nutation"
(from the Latin term nutatio which means "nodding"), and the reverse (posterior) motion
"counter-nutation."[3] In upright vertebrates, the sacrum is capable of slight independent
movement along the sagittal plane. When you bend backward the top (base) of the sacrum moves
forward relative to the ilium; when you bend forward the top moves back.[4]
The sacrum is called so when referred to all of the parts combined. Its parts are called sacral
vertebrae when referred individually.
Sexual dimorphism
The sacrum is noticeably sexually dimorphic (differently-shaped in males and females).
In the female the sacrum is shorter and wider than in the male; the lower half forms a greater
angle with the upper; the upper half is nearly straight, the lower half presenting the greatest
amount of curvature. The bone is also directed more obliquely backward; this increases the size
of the pelvic cavity and renders the sacrovertebral angle more prominent.
In the male the curvature is more evenly distributed over the whole length of the bone, and is
altogether larger than in the female.
Variations
In some cases the sacrum will consist of six pieces [1] or be reduced in number to four [2]. The
bodies of the first and second vertebrae may fail to unite.
Sometimes the uppermost transverse tubercles are not joined to the rest of the ala on one or both
sides, or the sacral canal may be open throughout a considerable part of its length, in
consequence of the imperfect development of the laminae and spinous processes.
The sacrum also varies considerably with respect to its degree of curvature.
Coccyx
The coccyx ( /kksks/ kok-siks; plural: coccyges), commonly referred to as the tailbone, is the
final segment of the vertebral column in tailless primates. Comprising three to five separate or
fused vertebrae (the coccygeal vertebrae) below the sacrum, it is attached to the sacrum by a
fibrocartilaginous joint, the sacrococcygeal symphysis, which permits limited movement
between the sacrum and the coccyx.
The term coccyx comes originally from the Greek and means "cuckoo",[1] referring to
the curved shape of a cuckoo's beak when viewed from the side.[2][3]
Function
In humans and other tailless primates (e.g., great apes) since Nacholapithecus (a Miocene
hominoid),[4][5] the coccyx is the remnant of a vestigial tail, but still not entirely useless;[6] it is
an important attachment for various muscles, tendons and ligamentswhich makes it necessary
for physicians and patients to pay special attention to these attachments when considering
surgical removal of the coccyx.[2] Additionally, it is also a part of the weight-bearing tripod
structure which acts as a support for a sitting person. When a person sits leaning forward, the
ischial tuberosities and inferior rami of the ischium take most of the weight, but as the sitting
person leans backward, more weight is transferred to the coccyx.[2]
The anterior side of the coccyx serves for the attachment of a group of muscles important for
many functions of the pelvic floor (i.e., defecation, continence, etc.): The levator ani muscle,
which include coccygeus, iliococcygeus, and pubococcygeus. Through the anococcygeal raph,
the coccyx supports the position of the anus. Attached to the posterior side is gluteus maximus
which extend the thigh during ambulation.[2]
Many important ligaments attach to the coccyx: The anterior and posterior sacrococcygeal
ligaments are the continuations of the anterior and posterior longitudinal ligaments that stretches
along the entire spine.[2] Additionally, the lateral sacrococcygeal ligaments complete the
foramina for the last sacral nerve.[7] And, lastly, some fibers of the sacrospinous and
sacrotuberous ligaments (arising from the spine of the ischium and the ischial tuberosity
respectively) also attach to the coccyx.[2]
An extension of the pia mater, the filum terminale, extends from the apex of the conus, and
inserts on the coccyx.
Structure
The coccyx is usually formed of four rudimentary vertebrae (sometimes five or three). It
articulates superiorly with the sacrum. In each of the first three segments may be traced a
rudimentary body and articular and transverse processes; the last piece (sometimes the third) is a
mere nodule of bone. The transverse processes are most prominent and noticeable on the first
coccygeal segment. All the segments are destitute of pedicles, laminae and spinous processes.
The first is the largest; it resembles the lowest sacral vertebra, and often exists as a separate
piece; the last three diminish in size from above downward.
Most anatomy books wrongly state that the coccyx is normally fused in adults. In fact it has been
shown[8][9] that the coccyx may consist of up to five separate bony segments, the most common
configuration being two or three segments.
Surfaces
The anterior surface is slightly concave and marked with three transverse grooves that indicate
the junctions of the different segments. It gives attachment to the anterior sacrococcygeal
ligament and the Levatores ani and supports part of the rectum. The posterior surface is convex
marked by transverse grooves similar to those on the anterior surface, and presents on either side
a linear row of tubercles, the rudimentary articular processes of the coccygeal vertebrae. Of
these, the superior pair are large, and are called the coccygeal cornua; they project upward, and
articulate with the cornua of the sacrum, and on either side complete the foramen for the
transmission of the posterior division of the fifth sacral nerve.
Borders
The lateral borders are thin and exhibit a series of small eminences, which represent the
transverse processes of the coccygeal vertebrae. Of these, the first is the largest; it is flattened
from before backward, and often ascends to join the lower part of the thin lateral edge of the
sacrum, thus completing the foramen for the transmission of the anterior division of the fifth
sacral nerve; the others diminish in size from above downward, and are often wanting. The
borders of the coccyx are narrow, and give attachment on either side to the sacrotuberous and
sacrospinous ligaments, to the coccygeus in front of the ligaments, and to the gluteus maximus
behind them.
Apex
The apex is rounded, and has attached to it the tendon of the Sphincter ani externus. It may be
bifid.
Sacrococcygeal and intercoccygeal joints

The joints are variable and may be: (1) synovial joints; (2) thin discs of fibrocartilage; (3)
intermediate between these two; (4) ossified.[10][11]
Pathology
Injuring the coccyx can give rise to a condition called coccydynia.[12] [13] A number of tumors
are known to involve the coccyx; of these, the most common is sacrococcygeal teratoma. Both
coccydynia and coccygeal tumors may require surgical removal of the coccyx (coccygectomy).
One complication of cocygectomy is a coccygeal hernia.[14] Fortunately, most cases of coccyx
pain respond well to nonsurgical treatment, such as medications given by local injection (often
done under fluoroscopic guidance).
Sacralization of the fifth lumbar vertebra (or sacralization) is a

congenital anomaly, in which the transverse process of the last lumbar vertebra (L5) fuses to the
sacrum on one side or both, or to ilium, or both. These anomalies are observed at about 3.5
percent of people, and it is usually bilateral. Although sacralization may be a cause of low back
pain, it is asymptomatic in many cases (especially bilateral type). Low back pain in these cases
most likely occurs due to chronic faulty biomechanics. In sacralization, the L5-S1 intervertebral
disc may be thin and narrow. This abnormality is found by X-ray.
Bertolotti's syndrome is a form of back pain associated with lumbosacral

transitional vertebrae. It can be treated surgically with posterolateral fusion or resection of the
transitional articulation. Non surgical treatments include steroid injections in the lower back or
radiofrequency sensory ablation. It is named for Mario Bertolotti, an Italian physician [1]
Bertolotti's syndrome is defined by a transitional 5th lumbar vertebrae resulting in partial
sacralization. Of importance is that this syndrome will result in a pain generating 4th lumbar disc
resulting in a "sciatic" type of a pain correlating to the 5th lumbar nerve root. Usually the
transitional vertebra will have a "spatulated" transverse process on one side resulting in
articulation or partial articulation with the sacrum or at time the illium and in some cases with
both. This results in limited / altered motion at the lumbo-sacral articulation. This loss of motion
will then be compensated for at segments superior to the transitional vertebra resulting in
accelerated degeneration and strain through the L4 disc level which can become symptomatic
and inflame the adjacent L5 nerve root resulting in "sciatic" or radicular pain patterns. This is a
congenital condition and is usually not symptomatic until one's later twenties or early thirties, yet
there are cases found where Bertolotti's is symptomatic at a much earlier age. MRI help to detect
this syndrome.
Lumbarization is a term that refers to an anatomic anomaly in the human spine. It is

defined by the nonfusion of the first and second segments of the sacrum. The lumbar spine
subsequently appears to have six vertebrae or segments, not five. Conversely the sacrum appears
to have only four segments instead of its designated five segments.[1]
Spinal disc herniation

A spinal disc herniation (prolapsus disci intervertebralis) is a medical condition affecting the
spine due to trauma, lifting injuries, or idiopathic (unknown) causes, in which a tear in the outer,
fibrous ring (annulus fibrosus) of an intervertebral disc (discus intervertebralis) allows the soft,
central portion (nucleus pulposus) to bulge out beyond the damaged outer rings. Tears are almost
always postero-lateral in nature owing to the presence of the posterior longitudinal ligament in
the spinal canal. This tear in the disc ring may result in the release of inflammatory chemical
mediators which may directly cause severe pain, even in the absence of nerve root compression.
Disc herniations are normally a further development of a previously existing disc "protrusion", a
condition in which the outermost layers of the annulus fibrosus are still intact, but can bulge
when the disc is under pressure. In contrast to a herniation, none of the nucleus pulposus escapes
beyond the outer layers.
Most minor herniations heal within several weeks. Anti-inflammatory treatments for pain
associated with disc herniation, protrusion, bulge, or disc tear are generally effective. Severe
herniations may not heal of their own accord and may require surgical intervention.
The condition is widely referred to as a slipped disc, but this term is not medically accurate as
the spinal discs are fixed in position between the vertebrae and cannot "slip".
Terminology
Normal situation and spinal disc herniation in cervical vertebrae.
Some of the terms commonly used to describe the condition include herniated disc, prolapsed
disc, ruptured disc and slipped disc. Other phenomena that are closely related include disc
protrusion, pinched nerves, sciatica, disc disease, disc degeneration, degenerative disc disease,
and black disc.
The popular term slipped disc is a misnomer, as the intervertebral discs are tightly sandwiched
between two vertebrae to which they are attached, and cannot actually "slip", or even get out of
place. The disc is actually grown together with the adjacent vertebrae and can be squeezed,
stretched and twisted, all in small degrees. It can also be torn, ripped, herniated, and degenerated,
but it cannot "slip".[1] Some authors consider that the term "slipped disc" is harmful, as it leads
to an incorrect idea of what has occurred and thus of the likely outcome.[2][3] However, one
vertebral body can slip relative to an adjacent vertebral body. This is called spondylolisthesis and
can damage the disc between the two vertebrae.
Signs and symptoms

Symptoms of a herniated disc can vary depending on the location of the herniation and the types
of soft tissue that become involved. They can range from little or no pain if the disc is the only
tissue injured, to severe and unrelenting neck or low back pain that will radiate into the regions
served by affected nerve roots that are irritated or impinged by the herniated material. Often,
herniated discs are not diagnosed immediately, as the patients come with undefined pains in the
thighs, knees, or feet. Other symptoms may include sensory changes such as numbness, tingling,
muscular weakness, paralysis, paresthesia, and affection of reflexes. If the herniated disc is in the
lumbar region the patient may also experience sciatica due to irritation of one of the nerve roots
of the sciatic nerve. Patients with L3 or L5 herniated disc (usually affecting the knee and leg)
also have a high chance of experiencing decreased sexual performance ( erectile dysfunction )
due to the tissue involved with the penile muscle tissue. If the extruded nucleus pulposus
material doesn't press on the p tissues or muscles, patients may not experience any reduced
sexual function symptoms. Unlike a pulsating pain or pain that comes and goes, which can be
caused by muscle spasm, pain from a herniated disc is usually continuous or at least is
continuous in a specific position of the body.
It is possible to have a herniated disc without any pain or noticeable symptoms, depending on its
location. If the extruded nucleus pulposus material doesn't press on soft tissues or nerves, it may
not cause any symptoms. A small-sample study examining the cervical spine in symptom-free
volunteers has found focal disc protrusions in 50% of participants, which suggests that a
considerable part of the population can have focal herniated discs in their cervical region that do
not cause noticeable symptoms.[4][5]
Typically, symptoms are experienced only on one side of the body. If the prolapse is very large
and presses on the spinal cord or the cauda equina in the lumbar region, affection of both sides of
the body may occur, often with serious consequences. Compression of the cauda equina can
cause permanent nerve damage or paralysis. The nerve damage can result in loss of bowel and
bladder control as well as sexual dysfunction. This disorder is called cauda equina syndrome.
Cause
Disc herniations can result from general wear and tear, such as when performing jobs that require
constant sitting and squatting. However, herniations often result from jobs that require lifting.
Traumatic injury to lumbar discs commonly occurs when lifting while bent at the waist, rather
than lifting with the legs while the back is straight. Minor back pain and chronic back tiredness
are indicators of general wear and tear that make one susceptible to herniation on the occurrence
of a traumatic event, such as bending to pick up a pencil or falling. When the spine is straight,
such as in standing or lying down, internal pressure is equalized on all parts of the discs. While
sitting or bending to lift, internal pressure on a disc can move from 17 psi (lying down) to over
300 psi (lifting with a rounded back).[citation needed]
Herniation of the contents of the disc into the spinal canal often occurs when the anterior side
(stomach side) of the disc is compressed while sitting or bending forward, and the contents
(nucleus pulposus) get pressed against the tightly stretched and thinned membrane (annulus
fibrosis) on the posterior side (back side) of the disc. The combination of membrane thinning
from stretching and increased internal pressure (200 to 300 psi) results in the rupture of the
confining membrane. The jelly-like contents of the disc then move into the spinal canal, pressing
against the spinal nerves, thus producing intense and usually disabling pain and other symptoms.
[citation needed]
There is also a strong genetic component. Mutation in genes coding for proteins involved in the
regulation of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to
contribute to lumbar disc herniation.[6]
Location
The majority of spinal disc herniation cases occur in lumbar region (95% in L4-L5 or L5-S1).[7]
The second most common site is the cervical region (C5-C6, C6-C7). The thoracic region
accounts for only 0.15% to 4.0% of cases.
Herniations usually occur posterolaterally, where the annulus fibrosis is relatively thin and is not
reinforced by the posterior or anterior longitudinal ligament.[7] In the cervical spinal cord, a
symptomatic posterolateral herniation between two vertebrae will impinge on the nerve which
exits the spinal canal between those two vertebrae on that side.[7] So for example, a right
posterolateral herniation of the disc between vertebrae C5 and C6 will impinge on the right C6
spinal nerve. The rest of the spinal cord, however, is oriented differently, so a symptomatic
posterolateral herniation between two vertebrae will actually impinge on the nerve exiting at the
next intervertebral foramen down.[7] So for example, a herniation of the disc between the L5 and
S1 vertebrae will impinge on the S1 spinal nerve, which exits between the S1 and S2 vertebrae.
Cervical
Cervical disc herniations occur in the neck, most often between the fifth & sixth (C5/6) and the
sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the
neck, shoulder girdle, scapula,[8] shoulder, arm, and hand. The nerves of the cervical plexus and
brachial plexus can be affected.[9]
Thoracic
Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the
uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs
can mimic lumbar herniations.[10]
Lumbar
Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar
vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back,
buttocks, thigh, anal/genital region (via the Perineal nerve), and may radiate into the foot and/or
toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The
femoral nerve can also be affected[11] and cause the patient to experience a numb, tingling
feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs.
Pathophysiology
There is now recognition of the importance of chemical radiculitis in the generation of back
pain.[12] A primary focus of surgery is to remove pressure or reduce mechanical compression
on a neural element: either the spinal cord, or a nerve root. But it is increasingly recognized that
back pain, rather than being solely due to compression, may also be due to chemical
inflammation.[12][13][14][15] There is evidence that points to a specific inflammatory mediator
of this pain.[16][17] This inflammatory molecule, called tumor necrosis factor-alpha (TNF), is
released not only by the herniated disc, but also in cases of disc tear (annular tear), by facet
joints, and in spinal stenosis.[12][18][19][20] In addition to causing pain and inflammation, TNF
may also contribute to disc degeneration.[21]
Diagnosis
Diagnosis is made by a practitioner based on the history, symptoms, and physical examination.
At some point in the evaluation, tests may be performed to confirm or rule out other causes of
symptoms such as spondylolisthesis, degeneration, tumors, metastases and space-occupying
lesions, as well as to evaluate the efficacy of potential treatment options.
Physical examination
Main article: Straight leg raise
The Straight leg raise may be positive, as this finding has low specificity; however, it has high
sensitivity. Thus the finding of a negative SLR sign is important in helping to "rule out" the
possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is
sitting.[22] However, this reduces the sensitivity of the test.[23]
Imaging
X-ray: Although traditional plain X-rays are limited in their ability to image soft tissues such as
discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as
tumors, infections, fractures, etc. In spite of these limitations, X-ray can still play a relatively
inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is
thus strengthened, other methods may be used to provide final confirmation.
Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer
reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures
around it, including soft tissues. However, visual confirmation of a disc herniation can be
difficult with a CT.
Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of
body structures using powerful magnets and computer technology. It can show the spinal cord,
nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows
soft tissues even better than CAT scans. An MRI performed with a high magnetic field strength
usually provides the most conclusive evidence for diagnosis of a disc herniation. T2-weighted
images allow for clear visualization of protruded disc material in the spinal canal.
Myelogram: An x-ray of the spinal canal following injection of a contrast material into the
surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can
show the presence of structures that can cause pressure on the spinal cord or nerves, such as
herniated discs, tumors, or bone spurs. Because it involves the injection of foreign substances,
MRI scans are now preferred for most patients. Myelograms still provide excellent outlines of
space-occupying lesions, especially when combined with CT scanning (CT myelography).
Electromyogram and Nerve conduction studies (EMG/NCS): These tests measure the electrical
impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there
is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether
there is another site of nerve compression. EMG/NCS studies are typically used to pinpoint the
sources of nerve dysfunction distal to the spine.
The presence and severity of myelopathy can be evaluated by means of Transcranial Magnetic
Stimulation (TMS), a neurophysiological method that allows the measurement of the time
required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and
ending at the anterior horn cells of the cervical, thoracic or lumbar spinal cord. This
measurement is called Central Conduction Time (CCT). TMS can aid physicians to:
determine whether myelopathy exists

identify the level of the spinal cord where myelopathy is located. This is especially useful
in cases where more that two lesions may be responsible for the clinical symptoms and
signs, such as in patients with two or more cervical disc hernias [24]
follow-up the progression of myelopathy in time, for example before and after cervical
spine surgery
TMS can also help in the differential diagnosis of different causes of pyramidal tract
damage.[25]
Lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and
compresses the spinal cord and nerves at the level of the lumbar vertebra. This is usually due to
the common occurrence of spinal degeneration that occurs with ageing. It can also sometimes be
caused by spinal disc herniation, osteoporosis or a tumor. In the cervical (neck) and lumbar (low
back) region it can be a congenital condition to varying degrees.
Spinal stenosis may affect the cervical or thoracic region in which case it is known as cervical
spinal stenosis or thoracic spinal stenosis. In some cases, it may be present in all three places in
the same patient. Lumbar spinal stenosis results in low back pain as well as pain or abnormal
sensations in the legs, thighs, feet or buttocks, or loss of bladder and bowel control.
Signs and symptoms

Understanding the meaning of signs and symptoms for the clinical syndrome of lumbar stenosis
requires an understanding of what the syndrome is, and the prevalence of the condition. A recent
review on lumbar stenosis in the Journal of the American Medical Association's "Rational
Clinical Examination Series"[1] emphasized that the syndrome can be considered when lower
extremity pain occurs in combination with back pain. This syndrome occurs in 12% of older
community dwelling men[2] and up to 21% of those in retirement communities.[3]
The leg symptoms in lumbar spinal stenosis (LSS) are similar to those found with vascular
claudication giving rise to the term pseudoclaudication.[4] These symptoms include pain,
weakness, and tingling of the legs,[4] and "radiation down the posterior part of the leg to the
feet".[5] Additional symptoms in the legs may be fatigue, heaviness, weakness, a sensation of
tingling, pricking, or numbness and leg cramps, as well as bladder symptoms.[5] Symptoms are
most commonly bilateral and symmetrical, but they may be unilateral; leg pain is usually more
troubling than back pain.[5]
Pseudoclaudication, now referred to as neurogenic claudication, typically worsen with standing
or walking and improve with sitting. The occurrence is often related to posture and lumbar
extension. Lying on the side is often more comfortable than lying flat, since it permits greater
lumbar flexion. Vascular claudication "can mimic spinal stenosis" and some individuals
experience unilateral or bilateral symptoms radiating down the legs "rather than true
claudication".[6] "In contrast to those with vascular claudication, sitting but not standing will
relieve symptoms; walking uphill will be better tolerated than downhill walking; and exercise on
a stationary bicycle in a seated flexed position will be better tolerated than walking in the erect
position."[5]
The first symptoms of stenosis include bouts of low back or neck pain. After a few months or
years, this may progress to claudication. The pain may be radicular, following the classic
neurologic pathways. This occurs as the spinal nerves or spinal cord become increasingly trapped
in a smaller space within the canal. It can be difficult to determine whether pain in the elderly is
caused by lack of blood supply or stenosis; testing can usually differentiate between them but
patients can have both vascular disease in the legs and spinal stenosis.[citation needed]
Among people with lower extremity pain in combination with back pain, lumbar stenosis as the
cause is two times more likely[clarification needed] in those older than 70 years of age while
those younger than 60 years it is 0.40 as likely. The character of the pain is also useful. When the
discomfort does not occur while seated, the likelihood of LSS increases considerably around 7.4
times. Other features increasing the likelihood of lumbar stenosis are improvement in symptoms
on bending forward 6.4 times, pain that occurs in both buttocks or legs 6.3 times, and the
presence of neurogenic claudication 3.7 times.[1] Alternately, the absence of neurogenic

claudication makes lumbar stenosis much less likely as the explanation for the pain.[7]
Causes
Spinal stenosis may be congenital (rarely) or acquired (degenerative), overlapping changes
normally seen in the aging spine, "resulting from degenerative changes or as consequences of
local infection, trauma or surgery".[5][6] "Degeneration is believed to begin in the intervertebral
disk where biochemical changes such as cell death and loss of proteoglycan and water content
lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to
the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and
osteophyte formation; this is associated with thickening and buckling of the ligamentum flavum.
The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and
ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the
space available for the neural elements. This compression of the nerve roots of the cauda equina
leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis."[6]
Degenerative spondylolisthesis
Forward displacement of a proximal vertebra in relation to its adjacent vertebra in association
with an intact neural arch, and in the presence of degenerative changes is known as degenerative
spondylolisthesis.[8][9] Degenerative spondylolisthesis narrows the spinal canal and symptoms
of spinal stenosis are common. Of these, neural claudication is most common. Any forward
slipping of one vertebra on another can cause spinal stenosis by narrowing the canal. If this
forward slipping narrows the canal sufficiently, and impinges on the contents of the spinal
column, it is spinal stenosis by definition. If there are associated symptoms of narrowing, the
diagnosis of spinal stenosis is confirmed. With increasing age, the occurrence of degenerative
spondylolisthesis becomes more common. The most common spondylolisthesis occurs with
slipping of L4 on L5. Frymoyer showed that spondylolisthesis with canal stenosis is more
common in diabetic women who have undergone oophorectomy (removal of ovaries). The cause
of symptoms in the legs can be difficult to determine. A peripheral neuropathy secondary to
diabetes can have the same symptoms as spinal stenosis.[10]
Ankylosing spondylitis
Main article: Ankylosing spondylitis
Drawing of a lumbar disc herniation which can cause a localized stenosis. Thoracic discs though
rare are similar.
Diagnosis
The diagnosis is based on clinical findings; "neurologic findings on physical examination are
unusual".[6] Some patients can have a narrowed canal without symptoms, and do not require
therapy. Stenosis can occur as either central stenosis (the narrowing of the entire canal) or
foraminal stenosis (the narrowing of the foramen through which the nerve root exits the spinal
canal). Severe narrowing of the lateral portion of the canal is called lateral recess stenosis". The
ligamentum flavum (yellow ligament), an important structural component intimately adjacent to
the posterior portion of the dural sac (nerve sac) can become thickened and cause stenosis. The
articular facets, also in the posterior portion of the bony spine can become thickened and
enlarged causing stenosis. These changes are often called trophic changes or facet trophism
in radiology reports. As the canal becomes smaller, resembling a triangular shape, it is called a
"trefoil" canal.[citation needed]
The normal lumbar central canal has a midsagittal diameter (front to back) greater than 13 mm.,
with an area of 1.45 square cm. Relative stenosis is said to exist when the anterior-posterior canal
diameter between 10 and 13 mm. Absolute stenosis of the lumbar canal exists anatomically when
the anterior-posterior measurement is 10 mm. or less.[11][12][13]
Plain x-rays of the lumbar or cervical spine may or may not show spinal stenosis. The definitive
diagnosis is established by either CT (computerized tomography) or MRI scanning. Identifying
the presence of a narrowed canal makes the diagnosis of spinal stenosis.[14][15][16]
Bicycle test of van Gelderen

In 1977, Dyck and Doyle[17] reported on the bicycle test of van Gelderen. The bicycle test is a
simple procedure in which the patient is asked to pedal on a stationary bicycle. If the symptoms
are caused by peripheral vascular disease, the patient will experience claudication (def: limping;
experienced as a sensation of not getting enough blood to the legs); if the symptoms are caused
by lumbar stenosis, symptoms will be relieved when the patient is leaning forward while
bicycling. Despite the fact that diagnostic progress has been made with newer technical
advances, the bicycle test remains an inexpensive and easy way to distinguish between
claudication caused by vascular disease and spinal stenosis. Dyck and Doyle wrote in their 1977
article:
The authors describe a simple clinical adjunct to the routine neurological examination of patients
with intermittent cauda equina compression syndrome. The "bicycle test" helps exclude
intermittent claudication due to vascular insufficiency and frequently confirms the relationship of
posture to radicular pain.
Magnetic resonance imaging

MRI is the preferred method of diagnosing and evaluating spinal stenosis of all areas of the
spine, including cervical, thoracic and lumbar.[18][19] MRI is useful to diagnose cervical
spondylotic myelopathy (degenerative arthritis of the cervical spine with associated damage to
the spinal cord).[20] The finding of degeneration of the cervical spinal cord on MRI can be
ominous; the condition is called myelomalacia or cord degeneration. It is seen as an increased
signal on the MRI. In myelopathy (pathology of the spinal cord) from degenerative changes, the
findings are usually permanent and decompressive laminectomy will not reverse the pathology.
Surgery can stop the progression of the condition. In cases where the MRI changes are due to
Vitamin B-12 deficiency, a brighter prospect for recovery can be expected.[21][22][23]
The detection of spinal stenosis in the cervical, thoracic or lumbar spine confirms only the
anatomic presence of a stenotic condition. This may or may not correlate with the diagnosis of
spinal stenosis which is based on clinical findings of radiculopathy, neurogenic claudication,
weakness, bowel and bladder dysfunction, spasticity, motor weakness, hyperreflexia and
muscular atrophy. These findings, taken from the history and physical examination of the patient
(along with the anatomic demonstration of stenosis with an MRI or CT scan), establish the
diagnosis.[citation needed]
Management
Nonoperative therapies and laminectomy are the standard treatment for LSS;[24] little "evidence
is available to recommend specific nonsurgical treatments".[6]
A trial of conservative treatment including "activity modification, medications, physical therapy,
home exercise therapy, and spinal injections" is recommended.[6] Individuals are generally
advised to avoid stressing the lower back, particularly with the spine extended. A physical
therapy program to provide core strengthening and aerobic conditioning may be recommended
and is considered useful, although "high-level evidence is lacking for the direct benefit of
physical therapy or exercise".[6]
Medication
The evidence for the use of medical interventions for lumbar spinal stenosis is poor.[25]
Injectable but not nasal calcitonin may be useful for short term pain relief.[25] Epidural blocks
may also transiently decrease pain, but there is no evidence of long-term effect.[25] Adding
steroids to these injections does not improve the result;[25][26] the use of epidural steroid
injections (ESIs) is controversial and evidence of their efficacy is contradictory.[6]
Non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and opioid analgesics are
often used to treat low back pain, but evidence of their efficacy is lacking and they should have a
limited role in treatment.[6]
Surgery
Surgery appears to lead to better outcomes if there are ongoing symptoms after three to six
months of conservative treatment.[27] Laminectomy is the most effective of the surgical
treatments.[24] In those who worsen despite conservative treatments surgery leads to
improvement in 6070% of cases.[6] Another procedure using an interspinous distraction device
known as X-STOP was less effective and more expensive when more than one spinal level is
repaired.[24] Both surgical procedures are more expensive than medical management.[24]
Prognosis
See also: Failed back syndrome
Most people with mild to moderate symptoms do not get worse.[6] While many improve in the
short term after surgery this improvement decreases somewhat with time.[6] A number of factors
present before surgery are able to predict the outcome after surgery, with people with depression,
cardiovascular disease and scoliosis doing in general worse while those with more severe
stenosis beforehand and better overall health doing better.[5]
The natural evolution of disc disease and degeneration leads to stiffening of the intervertebral
joint. This leads to osteophyte formationa bony overgrowth about the joint. This process is
called spondylosis, and is part of the normal aging of the spine. This has been seen in studies of
normal and diseased spines. Degenerative changes begin to occur without symptoms as early as
age 2530 years. It is not uncommon for people to experience at least one severe case of low
back pain by the age of 35 years. This can be expected to improve and become less prevalent as
the individual develops osteophyte formation around the discs.[28]
In the US workers' compensation system, once the threshold of two major spinal surgeries is
reached, the vast majority of workers will never return to any form of gainful employment.
Beyond two spinal surgeries, any more are likely to make the patient worse, not better. Very few
studies in the worldwide surgical literature actually document return to work after spinal surgery,
or lack thereof.[29]

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Atlas (anatomy)

Each carries two articular facets, a superior and an inferior.

Normal anatomy of lower cervical spine.

Cross-sectional anatomy of cervical spinal cord.

and has a prominent role in stabilizing the cervical spine

The cervical vertebra 3 (C3) is a vertebra of the spinal column.

The cervical vertebra 4 (C4) is a vertebra of the spinal column.

The cervical vertebra 5 (C5) is a vertebra of the spinal column.

The cervical vertebra 6 (C6) is a vertebra of the spinal column.

Individual thoracic vertebrae

First thoracic vertebra

Second thoracic vertebra

Third thoracic vertebra

Fourth thoracic vertebra

Fifth thoracic vertebra

Sixth thoracic vertebra

Seventh thoracic vertebra

Eighth thoracic vertebra

Ninth thoracic vertebra

Tenth thoracic vertebra

Eleventh thoracic vertebra

Twelfth thoracic vertebra

First and fifth lumbar vertebrae

L1-L2 L2-L3 L3-L4 L4-L5 L5-S1

the illium portion of the hip bone on either side

Sacrococcygeal and intercoccygeal joints

Sacralization of the fifth lumbar vertebra (or sacralization) is a

Bertolotti's syndrome is a form of back pain associated with lumbosacral

Lumbarization is a term that refers to an anatomic anomaly in the human spine. It is

Spinal disc herniation

Signs and symptoms

determine whether myelopathy exists

Lumbar spinal stenosis

Signs and symptoms

presence of neurogenic claudication 3.7 times.[1] Alternately, the absence of neurogenic

Bicycle test of van Gelderen

Magnetic resonance imaging

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