Examination of the Back

It is important that the whole area of the back and legs be examined and that the shoes be removed. Unequal length of the legs or disease of the hip joints can lead to abnormal curvatures of the vertebral column. The patient should be asked to walk up and down the examination room so that the normal tilting movement of the pelvis can be observed. As one side of the pelvis is raised, a coronal lumbar convexity develops on the opposite side, with a compensatory thoracic convexity on the same side. When a person assumes the sitting position, it will be noted that the normal lumbar curvature becomes flattened, with an increase in the interval between the lumbar spines. The normal range of movements of the different parts of the vertebral column should be tested. In the cervical region, flexion, extension, lateral rotation, and lateral flexion are possible. Remember that about half of the movement referred to as flexion is carried out at the atlanto-occipital joints. In flexion, the patient should be able to touch his or her chest with the chin, and in extension he or she should be able to look directly upward. In lateral rotation, the patient should be able to place the chin nearly in line with the shoulder. Half of lateral rotation occurs between the atlas and the axis. In lateral flexion, the head can normally be tilted 45° to each shoulder. It is important that the shoulder is not raised when this movement is being tested. In the thoracic region, the movements are limited by the presence of the ribs and sternum. When testing for rotation, make sure that the patient does not rotate the pelvis. In the lumbar region, flexion, extension, lateral rotation, and lateral flexion are possible. Flexion and extension are fairly free. Lateral rotation, however, is limited by the interlocking of the articular processes. Lateral flexion in the thoracic and lumbar regions is tested by asking the patient to slide, in turn, each hand down the lateral side of the thigh.

Examination of the Back
It is important that the whole area of the back and legs be examined and that the shoes be removed. Unequal length of the legs or disease of the hip joints can lead to abnormal curvatures of the vertebral column. The patient should be asked to walk up and down the examination room so that the normal tilting movement of the pelvis can be observed. As one side of the pelvis is raised, a coronal lumbar convexity develops on the opposite side, with a compensatory thoracic convexity on the same side. When a person assumes the sitting position, it will be noted that the normal lumbar curvature

becomes flattened, with an increase in the interval between the lumbar spines. The normal range of movements of the different parts of the vertebral column should be tested. In the cervical region, flexion, extension, lateral rotation, and lateral flexion are possible. Remember that about half of the movement referred to as flexion is carried out at the atlanto-occipital joints. In flexion, the patient should be able to touch his or her chest with the chin, and in extension he or she should be able to look directly upward. In lateral rotation, the patient should be able to place the chin nearly in line with the shoulder. Half of lateral rotation occurs between the atlas and the axis. In lateral flexion, the head can normally be tilted 45° to each shoulder. It is important that the shoulder is not raised when this movement is being tested. In the thoracic region, the movements are limited by the presence of the ribs and sternum. When testing for rotation, make sure that the patient does not rotate the pelvis.In the lumbar region, flexion, extension, lateral rotation, and lateral flexion are possible. Flexion and extension are fairly free. Lateral rotation, however, is limited by the interlocking of the articular processes. Lateral flexion in the thoracic and lumbar regions is tested by asking the patient to slide, in turn, each hand down the lateral side of the thigh.increase in the weight of the abdominal contents, as with the gravid uterus or a large ovarian tumor, or it may be caused by disease of the vertebral column such as spondylolisthesis The possibility that it is a postural compensation for a kyphosis in the thoracic region or a disease of the hip joint (congenital dislocation) must not be overlooked. Scoliosis is a lateral deviation of the vertebral column. This is most commonly found in the thoracic region and may be caused by muscular or vertebral defects. Paralysis of muscles caused by poliomyelitis can cause severe scoliosis. The presence of a congenital hemivertebra can cause scoliosis. Often, scoliosis is compensatory and may be caused by a short leg or hip disease.

In unilateral dislocations, the inferior articular process of one vertebra is forced forward over the anterior margin of the superior articular process of the vertebra below. Because the articular processes normally overlap, they become locked in the dislocated position. The spinal nerve on the same side is usually nipped in the intervertebral foramen, producing severe pain. Fortunately, the large size of the vertebral canal allows the spinal cord to escape damage in most cases. Bilateral cervical dislocations are almost always associated with severe injury to the spinal cord. Death occurs immediately if the upper cervical vertebrae are involved because the respiratory muscles, including the diaphragm (phrenic nerves C3 to 5), are paralyzed.

Fractures of the Vertebral Column
Fractures of the Spinous Processes, Transverse Processes, or Laminae Fractures of the spinous processes, transverse processes, or laminae are caused by direct injury or, in rare cases, by severe muscular activity. Anterior and Lateral Compression Fractures Anterior compression fractures of the vertebral bodies are usually caused by an excessive flexion compression type of injury and take place at the sites of maximum mobility or at the junction of the mobile and fixed regions of the column. It is interesting to note that the body of a vertebra in such a fracture is crushed, whereas the strong posterior longitudinal ligament remains intact. The vertebral arches remain unbroken and the intervertebral ligaments remain intact so that vertebral displacement and spinal cord injury do not occur. When injury causes excessive lateral flexion in addition to excessive flexion, the lateral part of the body is also crushed. Fracture Dislocations Fracture dislocations are usually caused by a combination of a flexion and rotation type of injury; the upper vertebra is excessively flexed and twisted on the lower vertebra. Here again, the site is usually where maximum mobility occurs, as in the lumbar region, or at the junction of the mobile and fixed region of the column, as in the lower lumbar vertebrae. Because the articular processes are fractured and the ligaments are torn, the vertebrae involved are unstable, and the spinal cord is usually severely damaged or severed, with accompanying paraplegia.

Dislocations of the Vertebral Column
Dislocations without fracture occur only in the cervical region because the inclination of the articular processes of the cervical vertebrae permits dislocation to take place without fracture of the processes. In the thoracic and lumbar regions, dislocations can occur only if the vertically placed articular processes are fractured. Dislocations commonly occur between the 4th and 5th or th 5 and 6th cervical vertebrae, where mobility is greatest.

1 Back

The internal vertebral venous plexus is not subject to external pressures when the intraabdominal pressure rises. In the cervical region. particularly if the vertebral column is flexed and the disc is undergoing degenerative changes that result in herniation of the nucleus pulposus. In these areas. Central protrusions may press on the spinal cord and the anterior spinal artery and involve the various nerve tracts of the spinal cord. with the neck straight. thus. Pieces of the vertebral body are commonly forced back into the spinal cord. Cervical disc herniations are less common than herniations in the lumbar regionThe discs most susceptible to this condition are those between the fifth and sixth or the sixth and seventh vertebrae. moves forward on the body of the vertebra below and carries with it the whole of the upper portion of the vertebral column. This herniation can result either in a central protrusion in the midline under the posterior longitudinal ligament of the vertebrae or in a lateral protrusion at the side of the posterior ligament close to the intervertebral foramen The escape of the nucleus pulposus will produce narrowing of the space between the vertebral bodies. Herniated Intervertebral Discs The structure and function of the intervertebral disc are described on pages 689 and 690. Vertebral Venous Plexus and Carcinoma of the Prostate Because the longitudinal. For this reason. Lumbar disc herniations are more common than cervical disc herniations The discs usually affected are those between the fourth and fifth lumbar vertebrae and between the fifth lumbar vertebra and the sacrum. Nevertheless. Because the laminae are left behind. the vertebral canal is not narrowed. This is especially likely to occur if the intra-abdominal pressure is increased. Each spinal nerve emerges above the corresponding vertebra. its insidious onset. is the reason for the common name. Fractures of the Odontoid Process of the Axis Fractures of the odontoid process are relatively common and result from falls or blows on the head Excessive mobility of the odontoid fragment or rupture of the transverse ligament can result in compression injury to the spinal cord. the discs are vulnerable to sudden shocks. as produced by the knot of a hangman’s rope beneath the chin. is the usual cause of hangman’s fracture. A rise in pressure on the abdominal and pelvic veins would tend to force the blood backward out of the abdominal and pelvic cavities into the veins within the vertebral canal. The existence of this venous plexus explains how carcinoma of the prostate may metastasize to the vertebral column and the cranial cavity. causing disruption of the intervertebral disc and breakup of the vertebral body. as seen. In the lumbar region. It is possible for nontraumatic compression fractures to occur in severe cases of osteoporosis and for pathologic fractures to take place. and the nucleus pulposus is forced posteriorly like toothpaste out of a tube. Lateral protrusions cause pressure on a spinal nerve or its roots. anteriorly by the intervertebral disc and the vertebral body. Nerve Root Pain Spinal nerve roots exit from the vertebral canal through the intervertebral foramina. and a history of back pain of long duration. producing local pain and subsequent development of osteoarthritis. the largest foramen is between the first and second lumbar vertebrae and the smallest is between the fifth lumbar and first sacral vertebra. the posterior part of the anulus fibrosus ruptures. which commonly encroach on the intervertebral foramina. causing low backache and sciatica. The spine.Vertical Compression Fractures Vertical compression fractures occur in the cervical and lumbar regions. thin-walled. it is the most vulnerable. laminae. The essential defect is in the pedicles of the migrating vertebra. abdomen. the spinal cord is rarely compressed In severe cases. Pelvic venous blood enters not only the inferior vena cava. the roots of the cauda equina run posteriorly over several intervertebral discs A lateral herniation may press on one or two roots and often involves the nerve root going to the intervertebral foramen Degenerative Spondylolithesis This condition is common in the elderly and involves degeneration of the intervertebral discs in the lumbar region and osteoarthritis of the intervertebral joints. Each foramen is bounded superiorly and inferiorly by the pedicles. which may be visible on radiographs. and posteriorly by the articular processes and joints In the lumbar region. The fifth lumbar spinal nerve is the largest of the lumbar spinal nerves. with protrusion of fragments posteriorly into the spinal canal. 2 Back . whereas the remainder of the vertebra. causing pain along the distribution of the segmental nerve. and pelvis. Congenital Spondylolisthesis In congenital spondylolisthesis. This is referred to as a herniation of the nucleus pulposus. in this condition. slips forward. the pedicles are abnormally formed and accessory centers of ossification are present and fail to unite. the trunk becomes shortened. usually the fifth. the body of a lower lumbar vertebra. The discs most commonly affected are those in areas where a mobile part of the column joins a relatively immobile part—that is. protrusion of the disc between the fifth and sixth cervical vertebrae can cause compression of the C6 spinal nerve or its roots Pain is felt near the lower part of the back of the neck and shoulder and along the area in the distribution of the spinal nerve involved. the cervicothoracic junction and the lumbosacral junction. A prolapsed disc usually occurs in a younger age group and often has an acute onset. and it exits from the vertebral column through the smallest intervertebral foramen. If the neck is slightly flexed. the lower cervical vertebrae remain in a straight line and the compression load is transmitted to the lower vertebrae. Sudden overextension of the neck. having lost the restraining influence of the inferior articular processes. In the straightened lumbar region. and the lower ribs contact the iliac crest. an excessive vertical force applied from above will cause the ring of the atlas to be disrupted and the lateral masses to be displaced laterally (Jefferson’s fracture). Because the vertebral canal is enlarged by the forward displacement of the vertebral body of the axis. but the nerve roots may be pressed on. for example. Anterior slippage of the fifth lumbar vertebra often occurs. where it is possible to fully straighten the vertebral column. an excessive force from below can cause the vertebral body to break up. Slackening of the anterior and posterior longitudinal ligaments results in abnormal mobility of the vertebral bodies. The resistance of these discs to compression forces is substantial. Osteoarthritis as a cause of root pain is suggested by the patient’s age. Fracture of the Pedicles of the Axis (Hangman’s Fracture) Severe extension injury of the neck. in circus acrobats who can support four or more of their colleagues on their shoulders. it is a clinically important structure. and the lumbar nerve roots may be pressed upon causing low back pain and pain down the leg in the distribution of the involved nerve. One of the complications of osteoarthritis of the vertebral column is the growth of osteophytes. It is now generally believed that. valveless vertebral venous plexus communicates above with the intracranial venous sinuses and segmentally with the veins of the thorax. such as might occur in an automobile accident or a fall. but also the vertebral venous plexus and by this route may also enter the skull. and inferior articular processes remain in position.

and the small size of the vertebral canal results in severe injury to the spinal cord. Thus. 4. the large size of the vertebral foramen in this region gives the roots of the cauda equina ample room. Such pressure would give rise to dermatomal pain. the whole cauda equina may be compressed. pain block procedures. considering the importance of this nervous tissue. the cord is sectioned and death occurs immediately. In this situation. the spinal canal becomes narrowed by aging. the thoracic and lumbar roots exit below the vertebra of the corresponding number. muscle weakness. This condition is often called sciatica. bodies can all result in pressure. all of which are embedded in areolar tissue. producing paraplegia. the spinal cord segments do not correspond numerically with the vertebrae that lie at the same level The following list helps determine which spinal segment is contiguous with a given vertebral body. (In the infant. in front by the lower part of the vertebral body and by the intervertebral disc. it may reach as low as the third lumbar vertebra. because of pressure on the spinal nerve root. because C8 nerve roots exist and an eighth cervical vertebral body does not. In fracture dislocations of the lumbar region. The back muscles show spasm. together with degenerative changes in the intervertebral discs and the formation of large osteophytes between the vertebral bodies. and diminished or absent reflexes. In the cervical region. Herniation of the intervertebral disc.) The subarachnoid space extends inferiorly as far as the lower border of the second sacral vertebra. However. when considerable displacement occurs.just below. pain is extreme on rotation of the vertebral column and is worst at the end of forward flexion. The longitudinally running anterior and posterior spinal arteries are of small and variable diameter. The joint is innervated by the lower lumbar and sacral nerves so that disease in the joint may produce low back pain and sciatica. displacement is often considerable. First. but the large size of the vertebral canal often results in the spinal cord escaping severe injury. Symptoms vary from mild discomfort in the lower back to severe pain radiating down the leg with the inability to walk. 12. or aortic surgery. especially on the side of the herniation. Lumbar Puncture (Spinal Tap) Lumbar puncture may be performed to withdraw a sample of cerebrospinal fluid for examination. Spinal Cord Injuries The degree of spinal cord injury at different vertebral levels is largely governed by anatomic factors. because the nerve roots move laterally as they pass toward their exit. the root corresponding to that disc space (L4 in the case of the L4 to 5 disc) is already too lateral to be pressed on by the herniated disc. the spinal nerve is vulnerable and may be pressed on or irritated by disease of the surrounding structures. It is a strong joint and is responsible for the transfer of weight from the vertebral column to the hip bones. centrally placed protrusion may give rise to bilateral pain and muscle weakness in both legs. The latter movement causes pain because the hamstring muscles hold the hip bones in position while the sacrum is rotating forward as the vertebral column is flexed. and behind by the articular processes and the joint between them. the vertebral column shows a scoliosis. Ischemia of the spinal cord can easily follow minor damage to the arterial supply as a result of regional anesthesia. 3 Back . In severe cases. The nucleus pulposus occasionally herniates directly backward. whereas pressure on the first sacral motor root causes weakness of plantar flexion. However. Pain is referred down the leg and foot in the distribution of the affected nerve. the spinal cord terminates inferiorly at the level of the lower border of the first lumbar vertebra in the adult. radiating to the sole of the foot. Pressure on the anterior motor roots causes muscle weakness. or edema of the emerging spinal nerve. the spinal cord in the adult extends only down as far as the level of the lower border of the first lumbar vertebra. even though the L5 root exits between L5 and S1 vertebrae. stretching. the sacroiliac joint is a synovial joint that has irregular elevations on one articular surface that fit into corresponding depressions on the other articular surface. and 5). and the ankle jerk may be diminished or absent A large. Moreover. Herniation of the L4 to 5 disc usually gives rise to symptoms referable to the L5 nerve roots. Disease and the Intervertebral Foramina The intervertebral foramina (Fig. As a consequence. Nerve injury may therefore be minimal in this region.5) transmit the spinal nerves and the small segmental arteries and veins. the L5 nerve root exits between the fifth lumbar and first sacral vertebrae. and the reinforcing segmental arteries vary in number and in size. and if it is a large herniation. Involvement of the fifth lumbar motor root produces weakness of dorsiflexion of the ankle. In sacroiliac disease. significant stenosis in the cauda equina area can lead to neurologic compression. can lead to narrowing of the spinal canal and intervertebral foramina. However. Since the sensory posterior roots most commonly pressed on are the fifth lumbar and the first sacral. pain is usually felt down the back and lateral side of the leg. Sacroiliac Joint Disease The clinical aspects of this joint are referred to again because disease of this joint can cause low back pain and may be confused with disease of the lumbosacral joints. Vertebrae Spinal Segment Cervical Add 1 Upper thoracic Add 2 Lower thoracic (T7 to 9) Add 3 Tenth thoracic L1 and 2 cord segments Eleventh thoracic L3 and 4 cord segments Twelfth thoracic L5 cord segment First lumbar Sacral and coccygeal cord segments Narrowing of the Spinal Canal After about the fourth decade of life. and osteoarthritis involving the joints of the articular processes or the joints between the vertebral Spinal Cord Ischemia The blood supply to the spinal cord is surprisingly meager. The sacroiliac joint is inaccessible to clinical examination. Respiration ceases if the lesion occurs above the segmental origin of the phrenic nerves (C3. An initial period of back pain is usually caused by the injury to the disc. In disease of the lumbosacral region. dislocation or fracture dislocation is common. movements of the vertebral column in any direction cause pain in the lumbosacral part of the column. Essentially. In persons in whom the spinal canal was originally small. Fortunately. Injury to the spinal cord can produce partial or complete loss of function at the level of the lesion and partial or complete loss of function of afferent and efferent nerve tracts below the level of the lesion. In fracture dislocations of the thoracic region. Second. The symptoms and signs of spinal shock and paraplegia in flexion and extension are beyond the scope of this book Relationships of Spinal Cord Segments to Vertebral Numbers Because the spinal cord is shorter than the vertebral column. fractures of the vertebral bodies. two anatomic facts aid the patient. Acute retention of urine may also occur. a small area located just medial to and below the posterosuperior iliac spine is where the joint comes closest to the surface. with its concavity on the side of the lesion. Osteoarthritic changes in the joints of the articular processes with the formation of osteophytes. paresthesia or actual sensory loss may be present. Each foramen is bounded above and below by the pedicles of adjacent vertebrae.

The average distance between the sacral hiatus and the lower end of the subarachnoid space at the second sacral vertebra is about 2 in. the lumbar puncture needle. Lumbar puncture is contraindicated in cases in which intracranial pressure is significantly raised. A needle introduced into the subarachnoid space in this region usually pushes the nerve roots to one side without causing damage. Its advantage is that. If this rise fails to occur. when the lumbar cerebrospinal fluid pressure is reduced. A distinct feeling of “give” is felt when the ligament is penetrated. which. formed by the fusion of the laminae. 12. This raises the cerebral venous pressure and inhibits the absorption of cerebrospinal fluid in the arachnoid granulations. the anesthetic does not affect the infant. areolar tissue (containing the internal vertebral venous plexus in the epidural space). and arachnoid mater. A large tumor. If the needle is pushed too far anteriorly. the lumbar and sacral nerve roots and the filum terminale. The caudal half of each sclerotome now fuses with the cephalic half of the immediately succeeding sclerotome to form the mesenchymal vertebral body 4 Back . (4 cm) above the tip of the coccyx in the upper part of the cleft between the buttocks. formed by the fusion of the bodies of the sacral vertebrae. the space between adjoining laminae in the lumbar region is opened to a maximum An imaginary line joining the highest points on the iliac crests passes over the fourth lumbar spine With a careful aseptic technique and under local anesthesia. it may hit the lamina or an articular process. including anorectal surgery and culdoscopy. The needle pierces the skin and fascia and the sacrococcygeal membrane that fills in the sacral hiatus The membrane is formed of dense fibrous tissue and represents the fused supraspinous and interspinous ligaments as well as the ligamentum flavum. and lateral mesoderm. Anatomy of Complications of Lumbar Puncture ■■ Postlumbar puncture headache This headache starts after the procedure and lasts 24 to 48 hours. (5 cm) in adults. (2. The most common bone encountered is the spinous process of the vertebra above or below the path of insertion. for example. the embryonic mesoderm becomes differentiated into three distinct regions: paraxial mesoderm. ligamentum flavum. the subarachnoid space is blocked and the patient is said to exhibit a positive Queckenstedt’s sign.19). a few drops of blood commonly escape. This fact is of great clinical significance in cases with prolapse of an intervertebral disc Caudal Anesthesia Solutions of anesthetics may be injected into the sacral canal through the sacral hiatus. Each somite becomes differentiated into a ventromedial part (the sclerotome) and a dorsolateral part (the dermatomyotome). the needle should be withdrawn as far as the subcutaneous tissue. The paraxial mesoderm is a column of tissue situated on either side of the midline of the embryo.The lower lumbar part of the vertebral canal is thus occupied by the subarachnoid space. supraspinous ligament. dura mater. Note that the sacral canal is curved and follows the general curve of the sacrum . The depth to which the needle will have to pass varies from 1 in. The sacral hiatus is palpated as a distinct depression in the midline about 1. The solutions pass superiorly in the loose connective tissue and bathe the spinal nerves as they emerge from the dural sheath. It is interesting to note that the cerebrospinal fluid pressure normally fluctuates slightly with the heart beat and with each phase of respiration. the patient will experience a fleeting discomfort in one of the dermatomes. and at about the fourth week. can be detected by compressing the internal jugular veins in the neck. The common arrangement is for the hiatus to be formed by the Development of the Vertebral Column Early in development. the normal pressure is about 60 to 150 mm H2O. which may be caused by a tumor of the spinal cord or the meninges. it may hit the body of the third or fourth lumbar vertebra The cerebrospinal fluid pressure can be measured by attaching a manometer to the needle. fitted with a stylet. The dermatomyotome now further differentiates into the myotome and the dermatome The mesenchymal cells of the sclerotome rapidly divide and migrate medially during the fourth week of development and surround the notochord (Fig. which is tethered to the coccyx by the filum terminale. The headache is relieved by assuming the recumbent position. above the tentorium cerebelli with a high intracranial pressure may result in a caudal displacement of the uncus through the tentorial notch or a dangerous displacement of the medulla through the foramen magnum. superficial fascia. (10 cm) in obese adults. and the thin-walled veins of the internal vertebral venous plexus. Anatomy of “Not Getting In” If bone is encountered. is passed into the vertebral canal above or below the fourth lumbar spine The needle will pass through the following anatomic structures before it enters the subarachnoid space: skin. it becomes divided into blocks of tissue called somites. The hiatus is triangular or U shaped and is bounded laterally by the sacral cornua The size and shape of the hiatus depend on the number of laminae that fail to fuse in the midline posteriorly.The anterior wall.5 cm) or less in a child to as much as 4 in. depending on whether a sensory or a motor root was impaled. Using smallgauge styletted needles and avoiding multiple dural holes reduce the incidence of headache. This usually indicates that the point of the needle is situated in one of the veins of the internal vertebral plexus and has not yet reached the subarachnoid space. If the entering needle should stimulate one of the nerve roots of the cauda equina. is smooth. Note also that the sacral canal contains the dural sac (containing the cauda equina). With the patient lying on the side with the vertebral column well flexed. intermediate mesoderm. ■■ Brain herniation. the needle. The posterior wall. nonfusion of the fifth and sometimes the fourth sacral vertebrae. The leak reduces the volume of cerebrospinal fluid. Relationship of the Vertebral Body to the Spinal Nerve Since the fully developed vertebral body is intersegmental in position. or a muscle will twitch. administered by this method. and it usually follows the use of a wide-bore needle. interspinous ligament. in turn. the sacral and coccygeal nerves as they emerge from the dural sac surrounded by their dural sheath. If the needle is directed laterally rather than in the midline. and the angle of insertion should be changed.6 in. Block of the Subarachnoid Space A block of the subarachnoid space in the vertebral canal. Obstetricians use this method of nerve block to relieve the pain during the first and second stages of labor. is passed into the vertebral (sacral) canal through the sacral hiatus. thus producing a rise in the manometric reading of the cerebrospinal fluid pressure. In the recumbent position. is rough and ridged. With a careful aseptic technique and under local anesthesia. Caudal anesthesia is used in operations in the sacral region. As the stylet is withdrawn. The cause is a leak of cerebrospinal fluid through the dural puncture. each spinal nerve leaves the vertebral canal through the intervertebral foramen and is closely related to the intervertebral disc. fitted with a stylet. causes a downward displacement of the brain and stretches the nervesensitive meninges—a headache follows. which contains the cauda equina—that is.

When the child begins to raise his or her head.Two centers of chondrification appear in the middle of each mesenchymal vertebral body. segmental fusion also takes place. it enlarges to form the nucleus pulposus of the intervertebral discs The surrounding fibrocartilage. each costal process forms a cartilaginous rib. Usually by the 13 year. In the thoracic region. At about the 18th year. During adolescence. Later. the costal processes fuse together to form the lateral mass of the sacrum. in the sacral region. The notochord degenerates completely in the region of the vertebral body. or primordia of the ribs. which is convex anteriorly. the mesenchymal vertebral body gives rise to dorsal and lateral outgrowths on each side. A hemivertebra is caused by a failure in development of one of the two ossification centers that appear in the centrum of the body of each vertebra Spina Bifida In spina bifida. In the coccygeal region. These centers also extend anteriorly to fuse with the cartilaginous centrum and laterally into the costal processes. the costal process forms part of the transverse process. A secondary center also appears at the tip of each transverse process and at the tip of the spinous process. This leaves only the neural arch for the atlas. Development of the Curves of the Vertebral Column The embryonic vertebral column shows one continuous anterior (ventral) concavity. and the epiphyseal plates are formed. which grows anteriorly and finally fuses in the midline to form the characteristic ring shape of the atlas vertebra. all the secondary centers have fused with the rest of the vertebra. the meninges and spinal cord may or may not be involved in varying degrees. this process starts th caudally. the cervical curve. which is convex anteriorly. the spines and arches of one or more adjacent vertebrae fail to develop. The atlas and axis develop somewhat differently. of the intervertebral disc is derived from sclerotomic mesenchyme situated between adjacent vertebral bodies Meanwhile. the lumbar curve. when the child stands up. the anulus fibrosus. and in later life the coccyx often fuses with the sacrum. but the complete union of all the primary centers does not occur until several years after birth.Each vertebral body is thus an intersegmental structure. 5 Back . By the 25th year. The dorsal outgrowths grow around the neural tube between the segmental nerves to fuse with their fellows of the opposite side and form the mesenchymal neural arch The lateral outgrowths pass between the myotomes to form the mesenchymal costal processes. to form the vertebral arches in the affected region. The costal processes in the cervical region remain short and form the lateral and anterior boundaries of the foramen transversarium of each vertebra. This condition is a result of failure of the mesenchyme. At birth. Toward the end of the first year. Beneath this defect. and sacral regions. secondary centers appear in the cartilage covering the superior and inferior ends of the vertebral body. the cervical. In the lumbar region. all the sacral vertebrae are united. the sacrovertebral angle develops. These quickly fuse to form a cartilaginous centrum A chondrification center forms in each half of the mesenchymal neural arch and sreads dorsally to fuse behind the neural tube with its fellow of the opposite side. The condition occurs most frequently in the lower thoracic. lumbar. Scoliosis Scoliosis results from a congenital hemivertebra. In the sacral region. Development of the Muscles of the Vertebral Column The prevertebral and postvertebral muscles develop from the segmental myotomes. the bodies of the individual vertebrae are separated from each other in early life by intervertebral discs. which grows in between the neural tube and the surface ectoderm. but in the intervertebral region. The centrum of the atlas fuses with that of the axis and becomes the part of the axis vertebra known as the odontoid process. The condensed mesenchymal or membranous vertebra has thus been converted into a cartilaginous vertebra. At about the ninth week of development. thoracic. primary ossification centers appear: two for each centum and one for each half of the neural arch The two centers for the centrum usually unite quickly. develops. the bodies start to become united by bone. develops. and lumbar regions show one continuous anterior (ventral) concavity.

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