VERTEBRAL COLUMN RIBS STERNUM by Isabella Kung Kaan

VERTEBRAL COLUMN, RIBS & STERNUM by Isabella Kung Kaan Yücel M. D. , Ph. D. 16. October. 2012 Tuesday

VERTEBRAL COLUMN Vertebrae + intervertebtal (IV) discs Spine Omurga Onurğa Spina Wirbelsäule ������ Laf dhabar Main part of the axial skeleton

VERTEBRAL COLUMN from the cranium (skull) to the apex of the coccyx ¼ formed by the intervertebral (IV) discs. IV discs separate and bind the vertebrae together.

VERTEBRAL COLUMN Protects the spinal cord and spinal nerves. Supports the weight of the body superior to the level of the pelvis. Provides a partly rigid and flexible axis for the body and an extended base on which the head is placed and pivots. Plays an important role in posture and locomotion (the movement from one place to another).

VERTEBRAE vertebrae (singular = vertebra) separated by resilient intervertebral (IV) discs. Vertebral column flexible

VERTEBRAE 33 vertebrae arranged in 5 regions 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal

VERTEBRAE Significant motion occurs between 24 superior vertebrae. Of the 9 inferior vertebrae, 5 sacral vertebrae fused in adults to form the sacrum After ~ 30, the 4 coccygeal vertebrae fuse to form the coccyx

VERTEBRAE become larger as the vertebral column descends to the sacrum then become progressively smaller toward apex of the coccyx

Structures of the vertebrae A typical vertebra consists of A Vertebral body A Vertebral arch 7 processes

VERTEBRAL BODY Massive, cylndircal Anterior part of the bone Gives strength to the vertebral column. Supports body weight. The size of the vertebral bodies column descends most markedly from T 4 inferiorly As each bears progressively greater body weight.

VERTEBRAL ARCH Posterior to the vertebral body Consists of two (right and left) pedicles & laminae.

vertebral arch + posterior surface of the vertebral body walls of vertebral foramen

The succession of vertebral foramina in the articulated vertebral column forms the vertebral canal (spinal canal)

Vertebral notches (Incisura vertebralis) Indentations observed in lateral views of the vertebrae Superior and inferior to each pedicle Between the superior and inferior articular processes posteriorly Between the corresponding projections of the body anteriorly.

The superior and inferior vertebral notches of adjacent vertebrae and the IV discs form intervertebral foramina Intervertebral foramina Spinal (posterior root) ganglia are located Spinal nerves emerge from the vertebral column with their accompanying vessels through these foramina.

Regional Characteristics of Vertebrae vertebrae having foramina in their transverse processes are cervical vertebrae

articular facets orientation in each region different Movement needed articular facets of thoracic vertebrae nearly vertical, define an arc centered in the IV disc this arrangement permits rotation and lateral flexion of the vertebral column in this region.

Regional variations in size and shape of the vertebral canal accommodate the varying thickness of the spinal cord.

CERVICAL VERTEBRAE skeleton of the neck between the cranium & thoracic vertebrae

FEATURES TYPICAL FOR CERVICAL VERTEBRAE 1) Smallest of the 24 movable vertebrae 2) Relatively larger intervertebral discs are thin, but relative to their small size; thick.

FEATURES TYPICAL FOR CERVICAL VERTEBRAE 3) Greatest range & variety of movement of all the vertebral regions 4) foramen transversarium in the transverse process

FEATURES TYPICAL FOR CERVICAL VERTEBRAE 5) anterior tubercles of vertebra C 6 carotid tubercles Chassaignac tubercles

FEATURES TYPICAL FOR CERVICAL VERTEBRAE 6) Spinous processes of C 3 -C 6 short and usually bifid in white people

Vertebrae C 3 -C 7 typical cervical vertebrae Large vertebral foramina restricted rotation superolateral margin uncus of the body uncinate process

C 7 - vertebra prominens A long spinous process Most prominent spinous process in 70% of people

Atlas (C 1) No body No spinous process Widest of the cervical vertebrae The kidney-shaped, concave superior articular surfaces of the lateral masses articulate with occipital condyles

Anterior and posterior arches a tubercle in the center of its external aspect extend between the lateral masses forming a complete ring. Posterior arch A wide groove for the vertebral artery on its superior surface. C 1 nerve also runs in this groove.

Axis (C 2) strongest of the cervical vertebrae C 1, carrying the cranium, rotates on C 2 (e. g. , when a person turns the head to indicate “no”).

Axis (C 2) The distinguishing feature blunt tooth-like dens Lies anterior to the spinal cord. Serves as the pivot about which the rotation of the head occurs.

large bifid spinous process Axis (C 2)

THORACIC VERTEBRAE The thoracic skeleton includes: 12 pairs of ribs and associated costal cartilages 12 thoracic vertebrae and the intervertebral discs between them Sternum

FEATURES TYPICAL FOR articulation with ribs. THORACIC VERTEBRAE 1) Bilateral costal demifacets on the vertebral bodies inferior and superior pairs for articulation with heads of ribs 2) Costal facets on the transverse processes for articulation with tubercles of ribs except for the inferior 2 or 3 thoracic vertebrae

FEATURES TYPICAL FOR THORACIC VERTEBRAE 3) Articular processes of thoracic vertebrae extend vertically with paired, nearly coronally oriented articular facets define an arc. greatest degree of rotation is permitted here!

FEATURES TYPICAL FOR THORACIC VERTEBRAE 4) Heart-shaped bodies 5) Long, inferiorly slanting spinous processes

T 1 -T 4 vertebrae share some features of cervical vertebrae. The middle four thoracic vertebrae (T 5 -T 8) demonstrate all the features typical of thoracic vertebrae.

T 1 atypical 1+0. 5 1. long, horizontal spinous process Vertebra prominens? No. 2. complete costal facet for the 1 st rib 3. demifacet for the 2 nd rib. Typical pattern 1+1 costal facet @ transverse processes 0. 5+0. 5 demifacet

[T 9]-T 10 vertebrae No inferior demifacet 1+1 costal facet @ transverse processes 0. 5+0. 5 demifacet T 11 -T 12 vertebrae No transverse costal facets 1 complete facet on each side 1+1 demifacet

most commonly fractured vertebra T 12 superior half thoracic in character costal facets & articular processes inferior half lumbar in character no costal facets articular processes that permit only flexion and extension.

LUMBAR VERTEBRAE in the lower back between the thorax and sacrum

FEATURES TYPICAL FOR LUMBAR VERTEBRAE 1) massive bodies 2) transverse processes project posterosuperiorly as well as laterally. 3) mammillary processes & accessory processes

Vertebra L 5 massive body and transverse processes Largest of all movable vertebrae. Carries the weight of the whole upper body. Lumbosacral angle between the long axis of the lumbar region of the vertebral column and that of the sacrum.

SACRUM L. sacred Wedged-shaped Usually composed of 5 fused sacral vertebrae in adults. Located between the hip bones Forms the roof and posterosuperior wall of the posterior half of the pelvic cavity.

Sacral canal continuation of the vertebral canal in the sacrum.

On the pelvic and posterior surfaces of the sacrum four pairs of sacral foramina

The anterior projecting edge of the body of the S 1 vertebra is the sacral promontory (L. mountain ridge), an important obstetrical landmark. The apex of the sacrum, its tapering inferior end, has an oval facet for articulation with the coccyx.

The sacrum supports the vertebral column and forms the posterior part of the bony pelvis. The sacrum is tilted so that it articulates with the L 5 vertebra at the lumbosacral angle. Eur Spine J. 2009 Feb; 18(2): 212 -7. Epub 2008 Nov 18. Assessment of lumbosacral kyphosis in spondylolisthesis: a computer-assisted reliability study of six measurement techniques. Glavas P, Mac-Thiong JM, Parent S, de Guise JA, Labelle H.

The pelvic surface of the sacrum is smooth and concave. 4 transverse lines Fusion of the sacral vertebrae starts after age 20.

The dorsal surface of the sacrum marked by five prominent longitudinal ridges. median sacral crest fused rudimentary spinous processes of the superior three or four sacral vertebra

Intermediate sacral crests fused articular processes Lateral sacral crests tips of the transverse processes of fused sacral vertebrae

Inverted U-shaped sacral hiatus Sacral cornua (L. Horns) The sacral hiatus leads into the sacral canal. The sacral cornua, representing the inferior articular processes of S 5 vertebra, project inferiorly on each side of the sacral hiatus and are a helpful guide to its location.

The superior part of the lateral surface of the sacrum auricular surface

COCCYX tailbone; kuyruksokumu A small triangular bone Formed by fusion of 4 rudimentary coccygeal vertebrae. Co 1 may remain separate from the fused group. Rudimentary articular processes @ post. surface

Co 1 largest & broadest coccygeal vertebra short transverse processes connected to sacrum, rudimentary articular processes form coccygeal cornua articulate with sacral cornua

Last 3 coccygeal vertebrae often fuse during middle life forming a beak-like coccyx Aging- A single bone! Muscular attachment! No contribution to support of the body weight in standing! Coccydynia

VARIATIONS IN VERTEBRAE 33 32 or 34 race, gender, and developmental factors (genetic and environmental) 32 34 Lumbar sacralization

VARIATIONS IN VERTEBRAE A • • CRANIAL SHIFT A cervical rib articulates with C 7 Rib 12 is small. L 5 partially "sacralized". S 5 partially freed B Common arrangement C CAUDAL SHIFT • Rib 12 is large. • A small lumbar rib is present. • S 1 partially "lumbarized". • Co 1 is incorporated into the sacrum

Curvatures in the Vertebral Column 1. The neck or cervical spine, curves gently inward (lordosis) 2. The mid back, or thoracic spine, curved outward (kyphosis) 3. The low back, or lumbar spine, also curves inward (lordosis) 4. Pelvic (Sacral) curvature

Scoliosis (from Greek: skoliōsis meaning from skolios, "crooked") is a medical condition in which a person's spine is curved from side to side. Scoliosis occurs in approximately 2% of women and less than 1/2% of men. It is a progressive disease whose origin is unknown (or idiopathic) , in 80% of the cases, although there is evidence for a genetic and nutritional component. Females are at 10 times more risk than males.

Scoliosis often includes a twisting of the spine, resulting in distortion of the ribs and entire thorax. It usually presents in pre-teens and adolescents. Structural scoliosis may require surgical intervention; alternatively scoliosis may be corrected using orthotics (e. g. braces).

Hyperkyphosis Kyphosis describes the natural curvatures of the thoracic spine, but hyperkyphosis a pathologically exaggerated thoracic curvature, commonly called "hunchback. " Hyperkyphos is common in aging adults, usually aided by the vertebral collapse related to osteoporosis. Other common causes may include trauma, arthritis, and endocrine or other diseases.

Hyperlordosis Lordosis describes the natural curvature of the lumbar spine, but hyperlordosis is a pathologically exaggerated lumbar curvature, commonly called "swayback. " Symptoms may include pain and numbness if the nerve trunks are compromised. Typically, the condition is attributed to weak back muscles or a habitual hyperextension, such as in pregnant women, men with excessive visceral fat, and some dance postures. Hyperlordosis is also correlated with puberty.

Ribs (L. costae) costae are curved, flat bones that form most of the thoracic cage. Remarkably light in weight yet highly resilient. Each rib has a spongy interior containing bone marrow (hematopoietic tissue), which forms blood cells.

There are three types of ribs that can be classified as typical or atypical True (vertebrocostal) ribs (1 st-7 th ribs): They attach directly to the sternum through their own costal cartilages. False (vertebrochondral) ribs (8 th, 9 th, and usually 10 th ribs): Their cartilages are connected to the cartilage of the rib above them; thus their connection with the sternum is indirect. Floating (vertebral, free) ribs (11 th, 12 th, and sometimes 10 th ribs): The rudimentary cartilages of these ribs do not connect even indirectly with the sternum; instead they end in the posterior abdominal musculature.

Typical ribs (3 rd-9 th) have the following components: Head: wedge-shaped and has two facets, facets separated by the crest of the head; one facet for articulation with the numerically corresponding vertebra and one facet for the vertebra superior to it. Neck: connects the head of the rib with the body at the level of the tubercle.

Tubercle: located at the junction of the neck and body articulates with the corresponding transverse process of the c vertebra

Body (shaft): thin, flat, and curved, most markedly at the costal angle where the rib turns anterolaterally. The angle also demarcates the lateral limit of attachment of the deep back muscles to the ribs. The concave internal surface of the body has a costal groove paralleling the inferior border of the rib, which provides some protection for the intercostal nerve and vessels.

Atypical ribs (1 st, 2 nd, and 10 th-12 th) are dissimilar: The 1 st rib is the broadest (i. e. , its body is widest and nearly horizontal), shortest, and most sharply curved of the 7 true ribs. A single facet on its head for articulation with the T 1 vertebra only 2 transversely directed grooves crossing its superior surface for the subclavian vessels; vessels the grooves are separated by a scalene tubercle and ridge, ridge to which the anterior scalene muscle is attached. .

The 2 nd rib is has a thinner, less curved body and is substantially longer than the 1 st rib. Its head has two facets for articulation with the bodies of the T 1 and T 2 vertebrae. Main atypical feature is, the tuberosity for serratus anterior a rough area on its upper surfacefrom which part of that muscle originates

10 th-12 th ribs, ribs like the 1 st rib, have only one facet on their heads and articulate with a single vertebra 11 th and 12 th ribs are short and have no neck or tubercle

Costal cartilages Prolong the ribs anteriorly Contribute to the elasticity of the thoracic wall Provide a flexible attachment for their anterior ends (tips). The cartilages increase in length through the first 7 and then gradually decrease. .

Intercostal spaces Separate the ribs and their costal cartilages from one another. Named according to the rib forming the superior border of the space. 4 th intercostal space lies between ribs 4 and 5. 11 intercostal spaces and 11 intercostal nerves intercostal muscles and membranes, and two sets (main and collateral) of intercostal blood vessels and nerves identified by the same number assigned to the space.

The space below the 12 th rib subcostal space Anterior ramus (branch) of spinal nerve T 12 subcostal nerve.

The intercostal spaces widest anterolaterally widen further with inspiration further widened by extension and/or lateral flexion of the thoracic vertebral column to the contralateral side.

Rib Fractures • The short, broad 1 st rib, rarely fractured • When broken ---structures crossing its superior aspect injured, including the brachial plexus of nerves and subclavian vessels. • The middle ribs most commonly fractured. • The weakest part of a rib is just anterior to its angle. 79

Supernumerary Ribs The number of ribs is increased by the presence of cervical and/or lumbar ribs, or decreased by failure of the 12 th pair to form. Cervical ribs relatively common (0. 5 -2%) and may interfere with neurovascular structures exiting the superior thoracic aperture. Supernumerary (extra) ribs Clinical significance confusion in radiological diagnosis Supernumerary ribs in a neonate 14 pairs of ribs in the chest X-ray 80

STERNUM G. sternon, chest Flat, elongated bone Forms the middle of the anterior part of the thoracic cage. Affords protection for mediastinal viscera in general and much of the heart in particular.

STERNUM G. sternon, chest 1) 2) 3) Manubrium Body Xiphoid process

Manubrium L. handle, as in the handle of a sword, with the sternal body forming the blade A roughly trapezoidal bone. Widest and thickest of the three parts of the sternum

jugular notch (suprasternal notch) The easily palpated concave center of superior border of manubrium Deepened by the medial (sternal) ends of the clavicles, which are much larger than the relatively small clavicular notches in the manubrium that receive them, forming the sternoclavicular (SC) joints.

Inferolateral to the clavicular notch, the costal cartilage of the 1 st rib is tightly attached to the lateral border of the manubrium. synchondrosis of the first rib

sternal angle The manubrium and body of the sternum in slightly different planes manubriosternal joint sternal angle (of Louis)

Body of the sternum (Corpus sterni) Longer, narrower, and thinner than the manubrium. Located at the level of the T 5 -T 9 vertebrae. Its width varies because of the scalloping of its lateral borders by the costal notches. . Gladiolus

Xiphoid process Smallest and most variable part of the sternum Thin and elongated Inferior end lies at the level of T 10 vertebra.

Surface Anatomy: Key Landmarks Jugular (suprasternal)notch: T 2 vertebra in male, T 4 in female Sternal angle (of Louis) Th 4 vertebra • The border between superior and inferior mediastinum • Overlies the tracheal bifurcation and aortic arch • Useful for counting intercostal spaces (2 nd ribs articulate here). 90

Xiphoid process an important landmark in the median plane Its junction with the sternal body at the xiphisternal joint inferior limit of the central part of the thoracic cavity Xiphisternal joint site of the infrasternal angle (subcostal angle) formed by the right and left costal margins Midline marker for superior limit of the liver, central tendon of the diaphragm, diaphragm inferior border of the heart

Sternal Fractures • Despite the subcutaneous location of the sternum, sternal fractures are not common. Airbag • A fracture of the sternal body is usually a comminuted fracture (a break resulting in several pieces). • The most common site in elderly people @ the sternal angle • The concern in sternal injuries heart injury or lung injury. http: //www. sciencephoto. com/media/393330/enlarge 96

Median Sternotomy • To gain access to the thoracic cavity for surgical operations in the mediastinum—e. g. , coronary artery bypass grafting—the sternum is divided (split) in the median plane and retracted. • A good exposure for removal of tumors in the superior lobes of the lungs. • After surgery, the halves of the sternum are joined using wire sutures. 97

Sternal Anomalies Complete sternal cleft is an uncommon anomaly through which the heart may protrude ectopia cordis Partial clefts Sternal foramen A receding (pectus excavatum, or funnel chest) or projecting (pectus carinatum, carinatum or pigeon breast) breast sternum 98

TYPICAL CERVICAL VERTEBRA

ATLAS

AXIS

TYPICAL THORACIC VERTEBRA