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CHAPTER 5 The Head, Neck and Spine
Costovertebral
Costovertebral
facet
Transverse
Spinous
process
Transverse process
notch
Spinous
141
joint
A
Costotransverse
joint
Superior articular
facet
joint
Costovertebral
joint
B
Fig. 5.31 A typical thoracic vertebra, T7. (A) Superior view. (B) Lateral view.
process
Superior
articular facet
Superior articular
facet
Costotransverse
joint
Inferior articular
A
B
Fig. 5.32 A typical lumbar vertebra, L4. (A) Superior view. (B) Lateral view.
• Each intervertebral disc consists of:
• e joints between atlas, axis and the skull are shown in
• peripheral annulus brosus, which is adherent to the
thin, cartilaginous plate on the vertebral body above
and below
• nucleus pulposus, which is gelatinous uid surrounded by the annulus brosus.
• Intervertebral discs constitute approximately one-quarter of the length of the spine, as well as accounting for its
Clinical Points
• e posterior part of the annulus brosus is relatively
secondary curvatures.
• In old age the intervertebral discs atrophy, resulting in
shrinkage and return of the curvature of the spine to the
C-shape of the newborn.
• Movement of the spine occurs particularly at the cervicodorsal and dorsolumbar junctions, which are the two
• Most posterior disc lesions pass lateral to the posterior
• Commonest site for ‘slipped disc’ is L4/5, L5/S1, or in
commonest sites of vertebral injury.
process
Inferior
vertebral
Inferior articular facet
Fig. 5.34.
thin and prone to rupture owing to degeneration or
injury; the nucleus pulposus protrudes posteriorly
into the vertebral canal or intervertebral foramen, i.e.
‘slipped disc’.
longitudinal ligament (paracentral disc), causing compression of the transiting nerve root (Fig. 5.35). Far lateral discs may compress the exiting nerve root.
the neck C5/6 or C6/7.
142
Superior
Annulus fibrosus
Intervertebral
Membrana tectoria
ligament
Anterior arch
Cut surface of
pedicle of axis
Membrana tectoria
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SECTION I Anatomy
Nucleus
pulposus
Hyaline cartilage
Annulus fibrosus
A
articular facet
Nucleus pulposus
Hyaline cartilage
Facet
joint
Intervertebral
disc
B
foramen
Inferior
articular facet
Fig. 5.33 The joints between adjacent vertebrae L3 and L4. The left half of the L2/3 disc has been cut away to
show the plate of hyaline cartilage at the upper surface of L3. This has also been cut away to the left of the
midline, exposing the upper surface of L3. (A) Superior view. (B) Lateral view.
Apical ligament
Anterior atlanto-
occipital membrane
Posterior atlantooccipital membrane
Posterior arch
of atlas
Capsule of
atlanto-occipital
joint
Cruciate
ligament
Alar ligament
Posterior longitudinal
Ligamentum
flavum
posterior arch
of atlas
Capsule of
atlanto-axial
joint
B
Cruciate
ligament
of atlas
Dens
Anterior longitudinal
A
ligament
Fig. 5.34 The ligaments joining the axis, atlas and skull. (A) Midline sagittal section. (B) Posterior surface. The
posterior arch of the atlas and the vertebral arch of the axis have been removed.
Posterior
longitudinal
ligament
Cut surface of
CHAPTER 5 The Head, Neck and Spine
Exiting
Transiting
Paracentral
S1
S1
l
143
disc
Far lateral
disc
nerve root
L3
L4
L4
L5
L5
S1
Exiting nerve
L4
Transiting
nerve
L5
L3
L4
L5
S1
nerve root
L4
L5 (L4/5 paracentral
disc prolapse causes
L5 radiculopathy)
S1 (L5/S1 paracentra
disc prolapse causes
S1 radiculopathy)
S2
Fig. 5.35 Prolapsed intervertebral disc. Radiculopathy in relation to exiting and transiting nerve roots.
Paracentral disc lesions compress the transiting nerve. Far lateral disc lesions compress the exiting nerve.
• Prolapsed L4/5 disc produces pressure on the root of L5
nerve and that of L5/S1 on S1 nerve. Pain is referred to
the back of the leg and foot along the distribution of the
sciatic nerves (sciatica).
• With L5 lesion there will be weakness of ankle dorsiexion and big toe extension. ere will be numbness over
the lower and lateral part of the leg and medial side of
the foot.
• With S1 lesion ankle jerk may be diminished or
absent, there will be weakness of the evertors of the
foot and there will be numbness over the lateral side
of the foot.
• Direct posterior prolapse of the disc (central disc prolapse) may compress the cauda equina, giving rise to
cauda equina syndrome.
• Cauda equina syndrome causes compression of the
sacral outow, saddle paraesthesia, reduced anal
sphincter tone, reduced bladder coordination, painless
retention and overow, loss of anal reex and bilateral
leg symptoms. It is a surgical emergency.
OSCE SCENARIOS
OSCE Scenario 5.1
A 55-year-old female undergoes a right supercial parotidectomy for a pleomorphic adenoma of the parotid
gland.
1. What is the order of structures traversing the gland
from without in?
2. Name the divisions of the facial nerve within the gland.
3. How would you test the integrity of the individual
branches of the facial nerve in the postoperative period
to exclude intraoperative damage?
4. What is Frey’s syndrome? Explain its anatomical basis.
OSCE Scenario 5.2
A 50-year-old male presents to a general surgery clinic with
a lump in the right side of his neck.
1. What are the boundaries of the anterior and posterior
triangles of the neck? Examination reveals that the lump
is in the right posterior triangle.
2. What are the possible dierential diagnoses? On further
examination you suspect lymphoma and discuss the
case with a haematologist. e haematologist requests
an excision biopsy. e lump lies centrally in the posterior triangle.
3. What structure do you need to avoid at surgery and
what is the eect of injury to this structure?
OSCE Scenario 5.3
A 40-year-old female is to undergo a subtotal thyroidectomy for a multinodular goitre.
1. Describe the gross anatomy of the thyroid gland.
144
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SECTION I Anatomy
2. When exposing the gland at surgery, which structures
are encountered?
3. Describe the arterial blood supply of the thyroid gland.
3. How would you go about draining the maxillary sinus
surgically?
4. How can carcinoma of the maxillary sinus present?
4. Where are the nerves situated in relation to the gland
and when are they in danger of damage?
OSCE Scenario 5.5
A 29-year-old male presented to Accident and Emergency
OSCE Scenario 5.4
A 35-year-old female is referred to the ENT clinic aer
recurrent episodes of nasal congestion, nasal discharge,
fever, headache, tiredness, and facial pain in the right
cheek. COVID-19 swabs were negative on several occasions and the GP is seeking advice for management of possible chronic sinusitis and is concerned that the symptoms
are unilateral.
1. What are the paranasal sinuses and where are they
with mandibular pain and inability to occlude the teeth following a bout of excessive laughter while watching a comic
movie in the cinema. Examination of the temporomandibular
joint (TMJ) revealed prominent mandibular head anteriorly.
1. What is the likely diagnosis and what other events can
cause it?
2. What would you nd on examination?
3. What type of joint is TMJ?
4. How would you treat the patient?
located?
2. Where do they drain into?
Answers in Appendix pages 440–442
Please check your eBook at https://studentconsult.inkling.com/ for more self-assessment questions. See inside cover for
registration details.
6
Parieto-occipital
Occipital lobe
Frontal pole
Central sulcus
The Nervous System
THE BRAIN
e brain is divided into the:
• forebrain
• midbrain
• hindbrain.
ese are further subdivided as shown in Box 6.1.
Cerebral Hemispheres (Figs. 6.1 and 6.2)
• Frontal lobe lies in anterior cranial fossa with the frontal
pole at its anterior extremity.
• Temporal lobe lies in middle cranial fossa with the temporal pole at its anterior extremity and an upturned projection on its medial surface, the uncus.
• Parietal lobe lies above temporal lobe between frontal
and occipital lobes.
• Occipital lobe lies above tentorium cerebelli with the
occipital pole at its posterior extremity.
Precentral gyrus
Frontal lobe
BOX 6.1 Major Subdivisions and Parts of
the Brain
Major subdivisions Parts
Forebrain Cerebral hemisphere or
telencephalon (lateral
ventricle)
Diencephalon containing
thalamus and hypothalamus
(third ventricle)
Midbrain Mesencephalon
(cerebral
aqueduct)
Hindbrain Pons, medulla
and cerebellum
(fourth ventricle)
The parts of the ventricular system are shown in
brackets
Postcentral gyrus
Parietal lobe
B
sulcus
Brainstem
A
Temporal pole
Lateral sulcus
Temporal lobe
Fig. 6.1 The brain, lateral view. Line A indicates the posterior border of the temporal lobe and Line B indicates
the superior border of the temporal lobe (along with the lateral sulcus).
Occipital pole
Cerebellum
Preoccipital notch
145
146
Central sulcus
Uncus
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SECTION I Anatomy
Motor area
a
e
r
a
y
r
o
s
n
e
S
Visual
area
A
Auditory area
B
Fig. 6.2 The major areas of the cortex. (A) Lateral view. (B) Medial view.
e cerebral hemisphere:
• has a layer of grey matter on its external surface, the
cerebral cortex
• has white matter internal to this, in which are the nuclei
of the basal ganglia
• has a cavity in each hemisphere, i.e. the lateral ventricles.
Parietal Lobe
Important areas of the parietal lobe are:
• sensory cortex in the postcentral gyrus, which receives
aerents from the thalamus and is concerned with all
forms of somatic sensation
• parietal association cortex, the remainder of the lobe,
which is concerned with recognition of somatic sensory
Cerebral Cortex (Figs. 6.1 and 6.2)
• Composed of a large number of sulci (cles) and gyri
stimuli and their integration with other forms of sensory
information. It receives aerents from the thalamus.
(folds).
• e large lateral sulcus on the superolateral surface separates the temporal lobe from the parietal and frontal
lobes.
• e central sulcus separates the precentral gyrus (motor
area) from the postcentral gyrus (sensory area).
• e parieto-occipital sulcus on the medial surface of the
hemisphere separates the occipital from the parietal lobe.
• e calcarine and postcalcarine sulci lie on the medial
aspect of the occipital lobe and are concerned with
visual centres.
• e corpus callosum lies between the two hemispheres
Temporal Lobe
Important areas of the temporal lobe are:
• the auditory cortex lying on the superior temporal
gyrus, which receives aerents from the medial geniculate body and is concerned with auditory stimuli
• the temporal association cortex, which surrounds the
auditory cortex and is responsible for the perception of
auditory stimuli and their integration with other sensory modalities
• the uncus on the medial surface of the temporal lobe,
which is concerned with olfactory stimuli.
and links them.
Occipital Lobe
Frontal Lobe
Important areas of the frontal lobe are:
• motor cortex situated in the precentral gyrus, from
which bres pass through the internal capsule to motor
nuclei of the cranial and spinal nerves. Receives aerents from the thalamus and cerebellum and is concerned with voluntary movement
Important areas of the occipital lobe are:
• the visual cortex, surrounding the calcarine and postcalcarine sulci, which is concerned with vision of the
opposite half-eld of sight
• the occipital association cortex, lying anterior to the
visual cortex, which is concerned with recognition and
integration of visual stimuli.
• Broca’s area, in the posterior part of the inferior frontal
gyrus of the dominant hemisphere, which controls the
motor elements of speech
• frontal cortex, which comprises a considerable part of
the frontal lobe. e lateral part of the frontal lobe is
related to ‘intellect’; the medial and orbital surfaces to
aective behaviour.
Clinical Points
• Frontal cortex: damage results in impairment of emotions and intellect.
• Motor cortex: damage results in weakness of the opposite side of the body. Lesions low down on the cortex
aect the face; higher up they aect the arm; and higher
Fig. 6.3 The motor homunculus, showing propor-
tional somatotopic representation in the precentral
gyrus.
lesions aect the leg. Both precentral and postcentral
gyri have somatotopic representation (Fig. 6.3).
• Sensory cortex: damage results in contralateral hemianaesthesia (same pattern as motor cortex distribution)
aecting sensory modalities such as stereognosis and
two-point position sense. Astereognosis is inability to
recognize sensory stimuli: put an object in a patient’s
hand; they are aware of the object but cannot identify it.
• Temporal association cortex: damage results in auditory
agnosia, i.e. inability to recognize or understand the signicance of meaningful sounds.
• Occipital cortex: damage results in contralateral homonymous hemianopia.
• Lesions aecting the lower region of the sensory cortex
and the auditory association cortex will cause dysphasia.
Basal Ganglia
• Consists of corpus striatum (caudate nucleus, putamen,
globus pallidus), claustrum, amygdaloid nucleus and
thalamus.
CHAPTER 6 The Nervous System
147
Pons
• Lies between medulla and midbrain.
• Connected to cerebellum by middle cerebellar peduncle.
• Dorsal surface of lower pons forms oor of fourth
ventricle.
• Contains nuclei of cranial nerves VI, VII and VIII.
• Sensory nucleus of cranial nerve V extends from midbrain through pons and medulla to upper cervical cord.
• Motor nucleus of cranial nerve V lies in pons.
• Corticospinal tracts cross in lower pons.
Medulla
• Continuous above with pons and below through the
foramen magnum with the spinal cord.
• Connected to cerebellum by inferior cerebellar peduncle.
• Contains nucleus ambiguus (motor to cranial nerves IX
and X).
• Contains nucleus of tractus solitarius (sensory for cranial nerves VIII, IX and X).
• Contains cranial nerve nuclei IX, X, XI and XII.
• Dorsal column nuclei cross to form the medial lemniscus.
• Sensory decussation contains some uncrossed bres.
Cerebellum
• Largest part of hindbrain.
• Made up of two lateral cerebellar hemispheres separated
by the vermis.
• Connected to brainstem by three pairs of cerebellar
peduncles.
• e bulge of the lateral lobe that projects inferiorly posterolateral to the medulla is the tonsil.
• e structural organization of the cerebellum is uniform and similar to that of the cerebral hemisphere, i.e.
a thin layer of cortex outside and deeper white matter
containing the various cerebellar nuclei.
• Blood supply is derived from three pairs of arteries:
• posterior inferior cerebellar branches of vertebral
arteries
• anterior inferior cerebellar branches of the basilar
artery
• superior cerebellar branches of basilar artery.
Midbrain
• Connects pons and cerebellum to diencephalon (thalamus and hypothalamus).
• Contains cerebral peduncles (corticobulbar and corticospinal tract), red nucleus, substantia nigra, nuclei of
cranial nerves III and IV, and portion of sensory nucleus
of cranial nerve V.
• Ascending bres travel in medial and lateral lemniscus.
• Descending motor bres pass through to reach pons
and spinal cord.
Clinical Points
• Cerebellum is concerned with balance, regulation
of posture, muscle tone and muscle coordination.
Cerebellar lesions give rise to symptoms and signs on
the same side of the body. Cerebellar lesions may cause
unsteady gait, tremor, nystagmus, dysarthria.
• In cases where there is raised intracranial pressure the
cerebellar tonsil can herniate into the foramen magnum
and compress the medulla oblongata, e.g. following
lumbar puncture.
Subarachnoid
5
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148
SECTION I Anatomy
SPINAL CORD
• Extends from foramen magnum (continuous with
medulla oblongata to lower border of rst or upper border of the second lumbar vertebra.
• Approximately 45 cm long.
• Tapers inferiorly into the conus medullaris from which
a prolongation of pia mater, the lum terminale, extends
downwards to be attached to the coccyx (Fig. 6.4).
• Dura mater fuses with lum terminale at S2 and obliterates the subarachnoid space at this level.
• Spinal cord lls the whole of vertebral canal during the
rst 3 months of intrauterine life.
• Vertebral column grows more rapidly than cord, such
that at birth the cord extends as far as the third lumbar vertebra; it then gradually reaches its adult level
(between rst and second lumbar vertebrae).
• A total of 31 pair of nerves originate from the cord:
• eight cervical
• twelve thoracic
• ve lumbar
• ve sacral
• one coccygeal.
• e lumbar and sacral nerve roots below the termination of the cord form the cauda equina.
Figs 6.5 and 6.6 show the relationships of the spinal cord
to the meninges and vertebral column.
Clinical Points
• Lumbar puncture should be carried out at L3/4,
L4/5 or L5/S1 interspace. e L4/5 or L5/S1 interspace
should be used in children as the spinal cord ends
at L3.
• As a landmark a line joining the iliac crests passes
through the fourth lumbar vertebra.
• e spine should be fully exed to increase the space
between the spinous processes.
• e lumbar puncture needle passes through the following structures:
• skin
• supraspinous ligament
• interspinous ligament
• ligamentum avum—there is a sudden ‘give’ as it is
penetrated
• dura mater—there is another ‘give’ as the needle pen-
etrates the dura mater and enters the subarachnoid
space.
Internal Structure of Spinal Cord (Fig. 6.7)
• Divided into grey and white matter.
• In transverse section the central canal is seen surrounded by the H-shaped grey matter.
T12
Epidural space
Adult cord
Dural sheath
space
Filum terminale
L1
2
3
4
5
S1
2
3
4
5
C1
2
3
4
Fig. 6.4 The termination of the spinal cord in the adult
showing its variations (solid black to dashed line). The
figure also shows the termination of the dural sheath.
• is is surrounded in turn by white matter containing
the long ascending and descending tracts.
• Dorsal horn of grey matter (posterior horn) is capped
by the substantia gelatinosa and contains the sensory
bres entering via the posterior nerve roots.
• Ventral horn of grey matter (anterior horn) contains
motor cells giving rise to bres of ventral roots.
• Lateral horns are found in the thoracic and upper lumbar cord; they contain the cells of origin of preganglionic sympathetic system.
• White matter is divided into dorsal, lateral and ventral
columns, each containing a number of ascending and
descending tracts.
The Tracts of the Spinal Cord (Fig. 6.8)
Descending Tracts
• Lateral corticospinal tract (crossed pyramidal):
• commences in motor cortex
• decussates in the medulla
Subarachnoid space
Supraspinous ligament
posterior longitudinal
Dura mater
Epidural space
Ligamentum flavum
CHAPTER 6 The Nervous System
Spinal cord
Anterior longitudinal
ligament
Dura mater and
ligament
Vertebral body
Intervertebral disc
149
Fig. 6.5 Sagittal MRI of the thoracic spine. (From Jacob S: Atlas of Human Anatomy. Churchill Livingstone
2002, with permission.) MRI, Magnetic resonance imaging.
• Anterior corticospinal tract (direct pyramidal tract):
Spinous process
• descends in the pyramidal tract on the contralateral
side of the cord
• at each spinal segment, bres enter the anterior horn
and synapse with motor nuclei—the tracts therefore
get progressively smaller as they descend
• bres are somatotopically arranged in the tract, bres
for the lower part of the cord laterally, and those for
the upper half medially.
• bres do not cross in the decussation in the medulla
• bres eventually cross the midline at segmental levels and terminate close to those in the lateral corticospinal tract.
Ascending Tracts
• Lateral and anterior spinothalamic tracts:
• conduct pain and temperature as well as some tactile
sensations
• bres enter the posterior roots, ascend a few segments and relay in the substantia gelatinosa
150
Supraspinous ligament
posterior longitudinal
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SECTION I Anatomy
Ligamentum flavum
Dura mater
Conus medullaris
Intervertebral disc
Body of L1 vertebra
Subarachnoid space
Fig. 6.6 Sagittal MRI of the lumbar spine. (From Jacob S: Atlas of Human Anatomy. Churchill Livingstone 2002,
with permission.) MRI, Magnetic resonance imaging.
• they then cross to the opposite side in the ventral
• they ascend in spinothalamic tracts to the thalamus,
• bres are somatotopically arranged in the lateral spi-
• Anterior and posterior spinocerebellar tracts:
• ascend on the same side of the cord
• enter the cerebellum through the superior and infe-
Epidural space
Spinous process
grey commissure close to the central canal
whence they are relayed to the sensory cortex
nothalamic tract, those for the lower limb supercial
and those for the upper limb deepest.
rior cerebellar peduncles, respectively
Dura mater and
ligament
Anterior longitudinal
ligament
Cauda equina
Sacral promontory
• concerned with the maintenance of equilibrium.
• Posterior (dorsal) columns:
• composed of the medial fasciculus gracilis (of Goll)
and the lateral fasciculus cuneatus (of Burdach)
• contain bres subserving ne and discriminative
tactile sensation, proprioception (position sense)
and vibration sense
• as cord is ascended, bres are added to lateral part
of posterior columns—hence the fasciculus gracilis
deals mostly with the lower limb and the fasciculus
cuneatus with the upper limb
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