We finished with the bony part of the head which was the skull.

Today, we will talk about the bony framework in the neck, which is made by the cervical vertebrae and as you all know, the cervical vertebrae are part of the vertebral column. The vertebral column is made up of 33 vertebrae. They are divided into: - 7 in the cervical region - 12 thoracic - 5 lumbar - 5 sacral - 4 coccygeal The last two -the sacral and coccygeal- usually fuse with each other. The 5 sacral vertebrae fuse to form the sacrum, and the coccygeal fuse to form the coccyx. So our lecture today will be related to those 7 cervical vertebrae. Before we start we have to know some general information about the vertebral column to understand the formation and the shape of the cervical vertebrae. When we look to the vertebral column development during the fetal period, the fetus is sleeping over itself so all the vertebral column will be carved more anteriorly, this is what we refer to as the primary curvature of the vertebral column

()

<< concave anteriorly during fetal period. However

after birth some changes happen: First change when the baby starts crawling

()

he always tries to left his head up.

When he starts to left his head up the curvature in the cervical region becomes concave posteriorly instead of anteriorly. Also when the kid starts to stand up assuming hes up in the right position- and walk, the concavity in the lumbar region is changed to become posteriorly concave, so in this case we call these curvatures secondary curvatures of the vertebral column, because they change after birth from the primary curvature in which the vertebral column is concave anteriorly to become concave posteriorly. So the secondary curvatures occur in two regions : ** Cervical >> when the kid starts to left his head up. ** Lumbar>> when the kid starts to stand up on his legs.

The primary curvatures remain after birth in two regions: The thoracic region (it is still concave anteriorly) The sacral region (pelvic region sacrum + coccyx) concave anteriorly. **thoracic & sacral (pelvic) >> PRIMARY curvatures **cervical & lumbar >> SECONDARY curvatures

So the 7 cervical vertebrae are considered primary or secondary? Answer: Secondary. Those curvatures are normal because of the resilience of the vertebral column. It must be resilient to allow the movement of the trunk (rotating left, right and bowing). In addition to these normal curvatures, there could be some abnormal curvatures as well. Abnormal means it results from developmental anomalies or due to a pathological process (Anomaly genetic abnormality ) which leads to this kind of abnormal curvatures. Abnormal curvatures are mainly 3 in number: 1- Kyphosis region. **This happens because of osteoporosis (

( :) increase in the thoracic curvature (hunch

back) due

to the erosion of the anterior part of the vertebrae in the thoracic

,)which is a

pathological process that mainly happens in the geriatrics (elderly people). 2- Lordosis: increase in the lumbar curvature (secondary). When the curvature increases, its called a hollow back (hollow= empty) the back of the patient is too much concave posteriorly. **Can be seen in temporary cases as in late pregnancies in women >> weight of the fetus is very heavy producing pressure on the vertebral column increasing this kind of curvature temporary lordosis because after delivery it will be demolished.

It can also be seen in some people who suffer from muscular weakness >> especially in the anteriolateral abdominal muscles external oblique, internal oblique, transversus abdominis those muscles come from the vertebral column all the way back then turn anteriorly to reach the rectus abdominis muscle. These are the muscles that pull the vertebral column >> When those muscles become weak they will relax the vertebral column paralysis. So the vertebral column goes more anteriorly. 3- Scoliosis (curved back): Its a medical condition in which the vertebral column is curved from side to side (one side will be longer than the other). So the patients vertebral column might look like the letter S or C. Its caused by many reasons: ** Developmental anomaly: half of the vertebrae didnt develop. ** Asymmetric paralysis: in one side of the intrinsic path muscles muscles that pull the vertebral column one side is paralyzed so it curves to the opposite side. ** Difference in the lengths of the lower limbs. So the vertebral column is made up of 33 vertebrae and the joints between them are secondary cartilaginous, because there are intervertebral discs made up of fibrocartilage located between each vertebra and the other.

Intervertebral discs are very important because they function in shock

absorption. When we look at it superiorly it is made up of two parts: 1- Annulus fibrosus (fibrous): External part is very rigid fibrocartilagenous. Annulus >> circular, concentric >> rings with united centers, fibrosus >> fibrous So concentric layers of fibrocartilage strengthen the discs. 2- Nucleus pulposus (gelatinous): Internal pulp of the disc is made of gelatinous material

(.)

Nucleus pulposus is located in this area which is empty because we have an opening in the disc. It is the central core of the disc and it is more elastic because of the watery content (high water content).

So nucleus pulposus is the main part responsible for shock absorption. So the intervertebral disc is made up of 2 parts:

The Annulus fibrosus & Nucleus pulposus which is a whole space containing
the gelatinous material. Disc herniation: Tearing in annulus fibrosus >> as a result the nucleus pulposus will be drained out of the annulus fibrosus. **The disc is made of a very thick layer of annulus fibrosus anteriorly however the posterior layer is thinner. So the herniation is more prone to take place posteriorly. Then the nucleus pulposus will start to leak posteriorly where the vertebral canal

which contains the spinal cord is located.

So when the nucleus pulposus enter the vertebral canal it will press on the spinal cord producing pain in the nerve that originates from that area of the spinal cord. Herniation usually happens between L4-L5 and L5-S1 >> because they are

the last two discs and most of the weight lies on them.
The more weight applied on the disc, the greater the susceptibility of the rupture of annulus fibrosus becomes **Why are there no discs between the sacral vertebrae? Answer: Because they are fused & form the sacrum. They all work as one piece of bone. So the last disc is between L5 S1 . Sciatic nerve: originates from L4,L5,S1,S2,S3. Sciatica: ).( It happens because of pain in the sciatic nerve root. That pain usually happens because of disc herniation in the disc between L4-L5 OR L5-S1. The pain extends from the back to the lower limbs.

IV Ligaments (intervertebral ligaments):

To FIX the vertebrae and the discs in their positions, there are ligaments supporting the vertebral bodies and ligaments supporting the vertebral

arches.
Structure of the vertebra: It has a body from the front that differs from one region to another. It is rectangular in the cervical region, arch shaped in the thoracic region, kidney shaped in the lumbar region. Behind the body there is an arch composed of 2 pedicels & 2 laminae. Over them there are 7 processes: 2 transverse, 1 spinous, 2 sub articular processes and 2 inf articular processes.

Ligaments between Vertebral Bodies:

1. Ant. longitudinal ligament: From the front along the spine. Its very strong and broadband, and it extends along the anterior surface of the vertebral column from top to bottom. 2. Posterior longitudinal ligament: Very narrow ligament located posteriorly on the middle aspect of the posterior vertebral bodies. The anterior Ligament is stronger than the posterior Ligament.

Ligaments between arches & processes :

1. Ligamentum flavum: Or flavae plural. flavum means yellowish >> because it has elastic connective tissue between the laminae of the vertebra above and below. 2. Intertransverse lig. : Located between the transverse process above and the transverse process below. 3. Interspinous lig. : Between spinous processes. 4. Supraspinous lig. : On the tip of the spinous processes (between tips of the spines). 2 ligaments for the bodies and 4 ligaments for the arches **There is an additional ligament seen ONLY in the cervical region: 5. Nuchal Ligament: or ligamentum nochae.

Nucha is the French word for the back of the neck. *Occipit is the back of the head.

So this ligament as you see it here is located in the back of the neck extends from the skull (from the external occipital protuberance) a very clear point at the end of the head. Starts from the nuchal ligament and extends down along the half of the occipital bone external occipital crest OR median nuchal line. So it extends from the external occipital protuberance and median nuchal line. Descends all the way down and merges with the supraspinous ligament, only in the cervical region. So it ends at C7 *Nuchal lig. >> Supports the cervical vertebrae because they are small in size posteriorly.

Cervical Vertebrae:
There are 7 cervical vertebrae. We classify them to typical and atypical, depending on specific characteristics such as the ribs. The typical vertebrae have 4 main charecteristics. If we miss one of them it will be considered atypical. Atypical vertebrae: C1 the Atlas C2 the Axis C7 Typical vertebrae: C3, C4, C5, C6 **Because they have a: 1-rectangular shaped body. 2-transverse foramina Holes in transverse Processes 3-Bifid: (2 heads) ONLY exception is C7 it has a Long process and a unifid (1 head) process.
Transverse processes of cervical vertebrae have foramina that dont exist in the other vertebrae of the body, because of a very important artery ascending from the root of the neck up into the skull to provide blood supply to the post. inf. part of the brain especially the cerebellum, which is called the vertebral artery inside the vertebral column within the cervical vertebrae. Its a direct branch of the subclavian artery that enters the transverse foramina and after passing the first one it goes to foramen magnum of the brain.

This vertebral artery passes through cervical transverse foramina except C7. Although C7 has transverse foramen, the artery passes anterior to the transverse process, and then it enters C6 foramen up to the brain. The cause of that >> If the artery is going to pass in the transverse foramen of C7 it has to make a sharp angle, so it will block the blood supply to the brain <<< and thats the first reason why the C7 is atypical.

4- Large triangular vertebral foramen. The spinal cord passes through the vertebral foramen between the body and the arch of the vertebrae. The vertebral foramen is biggest in the neck cervical vertebrae then it becomes narrower as you go down the thoracic, lumbar then sacrum, because of tapering of the spinal cord.

Because C7 has a long spinous process the physicians count the vertebrae from the spinous processes of C7. In the root of the neck theres a very clear area (bony prominent palpated easily) which is the tip of the spinous process of C7. **So C7 has a long spinous process with one head. It is very easily palpated (bulging beneath the skin) and thats why we depend on this spinous process in counting the vertebrae.

Four main characteristics of the typical cervical vertebrae: 1- Rectangular body 2- Transverse foramina 3- Bifid spinous process and short 4- Triangular and large vertebral foramen Exception C7 >> long unifid spinous process and has a foramen but the vertebral artery doesnt pass in this foramen.

Atlas C1: The first cervical vertebra: Atypical >> It has no body. It is a ring shaped bone

( .)So it has no body and no

spinous process. Instead it has only an anterior arch and a posterior arch and two lateral masses of bone to allow articulation up and down. So its a ring with 2 small masses of bone for articulation.
Why do they call it Atlas? In the Greek mythology, theres a Greek gad called ATLAS whos holding the whole earth in his hands. So referring to this kind of mythology or resembling, the Atlas is the first vertebra holding the whole skull up.

Atlas communicates superiorly by 2 joints (the most important 2 joints in the cervical region). The first one with the skull superiorly with the occipital condyles occipital bone forming atlanto occipital >> it allows the head to move in anterior posterior directions flexion and extension signifying yes. This is between the atlas and the skull. The other joint which is inferior to the atlas (atlanto axial joint) is for the rotational movement of the head signifying no. It has nothing to do with the skull; it takes place inside the cervical vertebrae. There is no movement for the skull there (between atlas and axis).

Most two important joint in the cervical vertebrae: 1- Atlanto_occipital 2- Atlanto_axial >> flexion & extension. >> lateral movement.

Axis C2: It is Atypical because of one reason >> on its body it has a dense, tooth, axis, Odontoid process. It is thought by some anatomists that the dense of axis actually used to be the body of atlas but with development and with time it has lost its communication and fusion with atlas to go and fuse with the axis to allow the rotational movement. Atlas is a ring shape and this is the axis, and the dense extending from it. The atlas is connected to the dense and it wraps around it. So the dense or the odontoid process acts as an axis for the atlas producing rotational movement saying NO >> so atlas rotates over the dense of the axis on the atlanto-axial joint .

Atlanto-Occipital Joint: You have to know the type, articulation, supporting ligaments and the movement. **NOTE: The special characteristics of it are not included.

Type: condyloid synovial joint >> condyloid because of occipital condyles are part of the articulation. Articulations: atlas with occipital condyles. Movement: flexion and extension, also helps in Lateral flexion. (Distinguish from the rotational flexion). **Lateral flexion: atlas wraps around the axis, and the axis wraps around the C3, the C3 wraps around the C4 together. It starts with the atlanto-occipital and continues within the cervical vertebrae in the bending of your head. Ligaments: Two important membranes: 1. Ant. atlanto-occipital membrane: Starts from the anterior arch of atlas to the anterior margin of foramen magnum. 2. Post. atlanto-occipital membrane: From the posterior arch of atlas to the posterior margin of foramen magnum occipital bone It protects the joint posteriorly. ***So both of them extend from the arches of atlas to the margins of foramen magnum. Atlanto-Axial Joints: 3 Atlas articulates with the axis in the 3 joints. **First 2 lateral atlanto_axial They are Laterally located between the lateral masses of atlas with the superior articular facets of axis. Type >> they are synovial gliding joints. *Atlas with lateral masses and Axis with facets .
Condyle: is a smooth round surface that helps in articulation of the joint. Its always present in the joints e.g: tempromandebular joint there is a condyler process in the mandible

**Median atlanto-axial joint: It is located in the middle and it is the most important. Its classified as a pivot synovial joint. Pivot means axial, so the movement is rotational. The rotation starts between the anterior arch of atlas along with the dense of axis. Articulation: Anterior arch of atlas, the dense of axis and posterior there is a ligament >> transverse ligament of atlas. The transverse ligament of atlas begins from the lateral mass of atlas in one side to the lateral mass of atlas in the other side. So its the stick that keeps the dense attached firmly against the anterior arch of atlas, and thats why it considered a part of articulation. So: 1- Anterior arch of atlas 2- The dense of axis 3- Transverse ligament of atlas Imagine this ligament is ruptured. If there is a tearing in this ligament, this means the dense will leave the anterior arch of atlas, so there will be a posterior displacement of the dense of axis and that is the dangerous situation. If it was posteriorly displaced this is what we call Atlanto-axial dislocation sometimes if its minor, we call it subluxation (Again dense of axis goes posteriorly away from the atlas) Behind the dense of axis there is the spinal cord, and above the atlas directly theres the skull (foramen magnum). At the level of foramen magnum, the last part of the brain is usually found medulla oblongata

( .) It ends at the foramen magnum and the

spinal cord starts. So if that tearing happens the dense will go more posterior and it will either hit the medulla oblongata or it will injure the spinal cord. Medulla oblongata has very important centers >> the cardiovascular center and the respiratory center. If the tear hits those two centers that will result in direct death.

Quadriplegia

(:)

luckier situation if the dense goes backwards and hit the spinal cord only, that will

result in paralysis in all the nerves that the spinal cord supplies. All the limbs become paralyzed. 80% of car accidents death happens because of tearing in transverse ligament of atlas. Web lash injuries

( :) If the driver is driving in a very high speed

and he

suddenly hits the breaks, his head will go ant. and post. web lashing when the head comes back, huge force is gathered causing a tearing in the transverse ligament and the dense hit the medulla oblongata .

Supporting Ligaments of atlanto_axial joint: 1- Cruciate Lig Or cross ligament is located posteriorly. The horizontal part of it is the transverse ligament of atlas. But in order to strengthen it, 2 vertical branches extend from it (2 lig. Attach to the skull, the ant. Margin of foramen magnum). One of them descends to attach to the body of the dense post. So one from above and the other from below. Just remember that this ligament mainly is an expansion of transverse ligament of atlas. 2- Apical Lig You cant see it here. You have to cut the cruciate lig. Its at the apex of the axis, attached to the tip of the dense along with the ant. border of foramen magnum. 3-Alar Ligaments They go to the sides. A ligament extends from the tip of the dense of axis and goes to the top, called apical. 2 ligaments extend from it, one to the right and one to the left. Those are called the Alars. So we have 1 apical and 2 alars.

4- Tectorial Membrane Covers all the ligaments. So if you cut it you will see posteriorly the cruciate lig. and when you cut the cruciate you will see the alars and the apical. **The Tectorial membrane is a continuation of the posterior longitudinal ligament of the vertebral column. When the posterior longitudinal ligament reaches the back of C2 and C1, it will be named tectorial. ***NOTE: The Tectorial ligament is the posterior longitudinal ligament itself.

Your colleague :) Malak abuaqulah