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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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14
1 Anatomy and Surgical Approaches
a
Fi g . 1 . 7 Th e h um a n s p in e. (a) Post erior musculat ure of the spine.
1 Anatomy an d Surgical Approaches 15
b
Fi g . 1 . 7 (Continued) Th e h u m an s p in e . (b) Post e rior m usculat ure of the spine and it s innervation.
16
1 Anatomy and Surgical Approaches
ab
cd
Fi g . 1 . 8 ( a – d ) Mo rp ho lo g y o f t he C4 a nd C7 ve rt eb ra e fro m s u pe rio r a n d lat era l vie ws.
c. The posterior arch has a groove along its superior border for the vertebral
artery, which runs along it on its way to the foramen magnum of the skull.
d. Superior articular facets form the atlanto-occipital articulation with the
occipital condyles. This joint accounts for the m ajority of exion and
extension of the head.
e. The inferior articular facet contributes to the atlantoaxial joint.
f. The p on t icu lu s p ost icu s (arcu at e foram e n ) is a m alfo r m e d bony br idge
between the posterior superior articular process and the superior margin
of the posterior arch of the atlas.
(1) The arcuate foram en contains the vertebral artery and the
suboccipital nerve.
(2) It can be mistaken for a posterior arch.
(3) Lateral mass screw placem ent through the arcuate foram en can cause
vertebral artery injury.
2. Axis: odontoid process with oval articular facet anteriorly, making a synovial
joint with the anterior arch facet and large bi d spinous process (rectus
major and inferior oblique muscle attachment).
a. The synchondrosis between the dens and arch and the neurocentral cleft
between the body and arch fuse at 3 to 6 years.
b. The pedicle of t h e a xis is la rge an d p rojects m edially at 30 ° and su per iorly
at 20°.
1 Anatomy an d Surgical Approaches 17
c. The transverse ligam ent secures the dens to the anterior arch of the atlas.
Ext e n sio n o f t h is liga m en t s u p e r ior ly a n d in fe r io rly c r e a t es t h e c r u cifo r m
ligam ent.
d. Responsible for the majority of cervical rotation around the axis.
e. The alar ligaments connect the odontoid to the occipital condyles, further
stabilizing the joint.
f. The t ran s ve r se p rocesses also con t ain t h e t r a n sve rse for a m en w it h t h e
vertebral artery.
3. C3–C6 vertebrae: bi d spinous processes, pedicle, laminae, articular
processes, lateral mass (between the articular processes), transverse
processes with anterior and posterior tubercles and transverse foramen
(carotid tubercle for C6 anterior tubercle and vertebral artery in the
foram en ), u n cin at e p rocesse s (“join t s o f Lu sch ka ”), an d t rian gu lar ve r t eb ral
foram en .
a. The superior surfaces of the cervical vertebrae are concave, and the
inferior surfaces are convex.
b. The cervical vertebrae have small bodies compared with the vertebral
canal.
c. The facets gradually becom e steeper and oriented more sagittally as one
progresses down the cervical spine.
(1) The lateral m asses are bony regions betw een the cervical facets just
lateral to the lam inae.
d. The vertebral artery travels within the transverse foramina, dividing it
into posterior and anterior tubercles, bet ween which passes the exiting
nerve root.
4. C7 vertebra: large, thick spinous process and not bi d.
a. Transitional vertebra with unique characteristics.
b. Inferior surface larger than superior surface.
c. Taller and shallower lateral m asses.
d. The pedicles enlarge starting with C7 and going down the spine.
e. The spinous process is the site of attachment of the ligamentum nuchae.
f. It h a s t ra n sverse for am in a bu t t h e ve rtebra l a r ter y p asses th rou gh t h em
in only 5% of pat ien ts.
B. Liga m e n t o u s a n at o m y a n d a r t ic u la t io n .
1. Atlanto-occipital articulation: articulation between the condyles of the
occipital bone superior facets of the atlas, supported by anterior and
posterior occipital membranes (continuation of the anterior longitudinal
membranes and ligamentum avum, respectively), and capsule ( exion,
extension, and lateral motion).
2. Atlantoaxial articulation (Fig. 1.9).
a. Rotational movement between the odontoid process and anterior arch of
the atlas (responsible for 50% of cervical rotation).
b. Ligaments.
(1) Anterior and posterior atlantoaxial ligam ents.
(2) Transverse ligam ent: across the arch of atlas to hold the dens against
the anterior arch of the atlas (cruciform ligament of the atlas:
transverse ligament plus superior and inferior extension).
18
1 Anatomy and Surgical Approaches
Fi g . 1 . 9 Li g a m e n t o u s a n a t o m y o f t h e u p p e r c e r v i c a l s p i n e .
(3) Alar ligam ent (sides of dens to condyles of occipital bone) and apical
ligam ent (from the apex of th e den s to the foram en m agnum as a
remnant of the notochord in this area).
(4) Tectoral m em brane: continuation of the posterior longitudinal
membrane.
3. C2–C7 articulation.
a. Flexion and extension motion.
b. Facet join t an d cap sule: h or izon tal pla n e (45° obliqu e ) of the joint and
weak capsule allow more mobility than lumbar and thoracic vertebrae.
c. Ligaments.
(1) Anterior and posterior longitudinal ligam ents.
(2) Ligam entum avum : from the posterior aspect of the lam ina below
to the anterior aspect of the lamina above with de ciency in the
midline.
(3) Interspinous ligam ent: oblique orientation from the posterior
superior aspect to the anterior inferior aspect.
(4) Supraspinous ligam ent.
(5) Ligam entum nuchae: broelastic septum from the occiput to C7.
d. Intervertebral disks: annulus brosus and nucleus pulposus.
C. M u scle s .
1. Posterior muscles.
a. Super cial: trapezius (from the external occipital protuberance and C7 to
the T12 spinous processes to insert at the lateral clavicle, acromion, and
spine of the scapula).
b. Interm ediate: splenius capitis and cervicis.
c. Deep: semispinalis capitis, sem ispinalis cervicis, and multi dus with
rotators.
1 Anatomy an d Surgical Approaches 19
2. Suboccipital muscles.
a. Rectus capitis posterior major: C2 spinous process to inferior nuchal line.
b. Rectus capitis posterior minor: C1 posterior tubercle to inferior nuchal line.
c. Obliquus capitis inferior: C2 spinous process to transverse process of C1.
d. Obliquus capitus superior: C1 transverse process to occipital bone
between superior and inferior nuchal lines.
3. Anterior muscles.
a. Platysma: from deltoid and pectoral fascia to mandible and skin,
inn er vated by facial (VII) ner ve.
b. Sternocleidomastoid: from sternum and clavicle to mastoid process.
c. Strap muscles of larynx: sternohyoid and sternothyroid muscles.
d. Omohyoid: superior and inferior bellies to depress the hyoid bone.
e. Longus colli: anterior aspect of the vertebral bodies.
II. Th o r a colu m ba r sp in e , sacr u m , an d coccyx .
A. Bo n y a n d liga m e n t o u s a n at o m y (Fig. 1.9).
1. Thoracic vertebrae (Fig. 1.10).
a. Mechanically sti er and less mobile because of rib attachment.
b. Physiological kyphosis (primary curve).
c. The upper and middle thoracic vertebrae have stabilit y against
anteroposterior translation, and the lower thoracic vertebrae have
stability against rotation due to facet joint orientation.
d. The transverse processes decrease from T1 to T10.
e. The spinal canal is circular and has less free space for the spinal cord than
the cervical and lumbar region.
f. Art icular facet s for r ibs: bod y an d t ra n sverse proce ss a n d liga m en t s
(radiate and costovertebral ligam ents between the body and rib, and
costotran sverse and intert ransverse ligam ents bet w een the transverse
process and rib).
g. Connected to the ribs at the junction between the body and the pedicle
and also at the transverse costal facet of the transverse process. The
transverse processes are posteriorly angulated to leave room for the ribs.
h. A heart-shaped body with a possible depression due to the descending
aorta on the left side. The spinous processes are long, slender, and
downward-pointing so that they overlap the vertebral arches of the
inferior vertebra.
2. Lumbar vertebrae (Fig. 1.11).
a. Strong facet joint and capsule for rotational stability and superior
articular processes (mammillary process) are lateral and anterior to the
inferior articular process below.
b. Pedicles: strong and directed posteriorly 1 m m inferior to the tip of the
inferior articular process in the m iddle of the tran sverse processes. They
arise from the upper part of the vertebral body.
c. Triangular spinal canal.
d. Ligaments:
(1) Supraspinous ligam ent: ends around L3.
(2) Interspinous ligam ent: oriented obliquely from cephalad to caudad
from post erior to anterior.
20
1 Anatomy and Surgical Approaches
a
b
Fi g . 1 . 1 0 ( a – c ) Bo n y a n a t o m y o f
c
the thoracic spine.
(3) Posterior longitudinal ligam ent.
(4) Anterior longitudinal ligam ent.
(5) Ligam entum avum : from the posterior aspect of the lam ina below
to the anterior aspect of the lamina above.
e. Kidney-shaped vertebral bodies that are widest transversely.
f. Th e facet s a r e in a sagit t al o r ie n t at ion , lim it ing t h e a xia l r ot at ion .
Th e e xce pt io n is t h e L5 – S1 fa cet b e ca u s e it is m or e cor o n al t o re s ist
anteroposterior translation.
g. More prom inent pars interarticularis.
h. Broad and tall spinous process.
1 Anatomy an d Surgical Approaches 21
Fi g . 1 . 1 1 Bo n y a n a t o m y o f t h e lu m b a r s p i n e .
i. Sm aller transverse process:
(1) The L5 transverse process attaches to the iliolum bar ligam ent.
(2) The accessory process is on the medial aspect of the transverse
process where it joins the posterior bony arch.
3. Sacrum and coccyx (Fig. 1.12).
a. Bony structures of the sacrum: ala, promontory, median sacral crest,
sacral foramina, articular surface (Fig. 1.13).
b. Coccyx: three or four elements and the last two to three segments are
fused.
(1) Attachment site for the muscles of the pelvic oor.
c. Sacroiliac joint.
(1) Articular process: sacral hyaline cartilage and iliac brocartilage.
(2) Ligam ents: interosseous sacroiliac ligam ent, posterior sacroiliac
ligam ent, and anterior sacroiliac ligam en t .
d. Connecting ligaments.
(1) Sacrotuberous ligam ent: sacrum to ischial tuberosity.
(2) Sacrospinous ligam ent: divides pelvis into greater and lesser sciatic
notches.
(3) Iliolum bar ligaments: L5 transverse processes to ala of sacrum.
22
1 Anatomy and Surgical Approaches
a
b
Fi g . 1 . 1 2 ( a ) Ant e rior a nd (b) po ste rior anatom y of the sacrum .
1 Anatomy an d Surgical Approaches 23
b
a
cd
Fi g . 1 . 1 3 ( a – d ) Bo n y a n a t o m y o f t h e s a c r u m .
B. So ft t iss u e s t r u ct u re s .
1. Muscles.
a. Super cial.
(1) Latissimus dorsi: origin from T6 to T12, lum bar spine, sacrum , and
posterior iliac crest and lower four ribs to insert at the bottom of the
intertubercular groove of the hum erus.
(2) Levator scapulae: origin from C1 to C4 transverse processes to insert
at the medial border of the scapula above the spine.
(3) Rhom boid minor: origin from C7 to T1 to insert at medial border of
the scapula at the root of the spine.
(4) Rhom boid major: origin from T2 to T5 and insertion at the medial
border of the scapula below the spine.
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