EMBRYOLOGY

Vertebral column development occurs as hyaline cartilage ossifies from primary ossification
centers. Derivatives from these ossification centers include: body (forms vertebral brody), costal
process (forms ribs and part of transverse process)
and neural arch (forms pedicle, lamina and spinous
process). The notochord forms the nucleus
pulposus, the inner portion of the vertebral disc.

Neural tube formation occurs during 3rd week of

development. The primitive streak regresses and
forms a thickened midline ectoderm, the neural
plate. Invagination of the neural plate forms the
neural groove, with neural crest forming at the
dorsal aspect. The neural crest invaginates and
fuses in midline, pinches off to form neural tube.
Neural tube derivatives include: neurons of CNS,
supporting cells of CNS, somatomotor neurons of
PNS, presynaptic autonomic neurons of PNS.
Neural crest derivatives include: sensory neurons of
PNS in dorsal root ganglia, postsynaptic autonomic neurons, schwann cells of PNS, adrenal
medullary cells, head mesenchyme and
portions of heart, melanocytes in skin, and
arachnoid and pia mater meninges (dura
from mesenchyme).
Neuroepithelium is cells in wall of neural
tube that are broken down into three zones.
Ependymal zone is the inner layer lining
central canal of spinal cord and ventricles of
brain. Mantle zone is the intermediate area
that develops into gray matter of spinal cord.
Marginal zone outer layer that becomes
white matter of spinal cord. Glial cells are
found in the mantle and marginal zones.The
neural tube is split by a longitudinal groove
called the sulcus limitans. The sulcus
limitans splits the neural tube into an alar
(dorsal) plate, which forms sensory
neurons, and a basal (ventral) plate, which
forms somatic and autonomic motor neuron.
ANATOMY

The spinal cord is part of

the central nervous
system. It extends from
the brainstem to L3 at
birth and L1 at maturity.
The spinal cord ends as
the conus medullaris at
L1, and continues as
nerve roots known as the
cauda equina. The
spinal cord is anchored
inferiorly by the terminal
filum (a pial extension
that picks up dura
mater after passing
through the dural sac at
L2), which is attached to
the coccyx. The spinal
cord, nerve roots, and
cauda equina are
surrounded by
cerebrospinal fluid (CSF)
and are all contained in
the thecal sac.

The layers of the spinal cord from outside to inside are the dura mater, arachnoid, and pia
mater. The spinal cord itself consists of ascending and descending tracts transmitting afferent
and efferent fibers of the brain, respectively. Ascending tracts include the dorsal column, which
transmits deep touch, proprioception, and vibratory sensation; the lateral spinothalamic tract
which transmits pain and
temperature sensation, and ventral
spinothalamic tract, which
transmits light touch sensation. The
descending tracts include the lateral
and ventral corticospinal tracts,
which transmit the main voluntary
motor tracts.
There are 31 pairs of spinal nerves, 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.
The nerves are formed by a dorsal and ventral root. In the cervical region, the nerve roots exit
the spinal cord above their corresponding vertebrae (e.g. C7 nerve exits above C7 vertebral
body, except for C8, which has no corresponding body). For the rest of the spine, the nerve
exits one level below the corresponding body (e.g. T4 nerve exits below T4 vertebral body, L1
nerve exits below L1 vertebral body).

The spinal cord is contained within the

bony vertebral column. There are 33
vertebral bodies, divided into the
cervical (7), thoracic (12), lumbar (5),
sacral (5), and coccyx (4) bones.

The typical vertebral is described

below. The pedicles attach the
transverse processes to the vertebral
body. The lamina are portions of the
vertebral arch that connects the
transverse process to the spinous
process. The vertebral foramen
(canal) contains the spinal cord and
meninges. The intervertebral foramen
is the opening formed by the superior
and inferior notches through which
the spinal nerve roots traverse.
Adjacent vertebrates are connected via
two superior and two inferior articular
processes (facets). Each segment of
the vertebral column (cervical, thoracic,
and lumbar) have unique anatomy.

Cervical
C1 and C2 are known as the atlas and
axis, respectively. The axis contains
the dens, through which rotation of the
head is allowed. In addition, C1-C7
contain the transverse process
through which the vertebral bodies
travel (C1-C6, do not travel through
C7). Note that the superior articular
processes are faced superiorly.
Thoracic
The 12 vertebrae of the thoracic region contain the costal facets (superior, inferior, and
transverse) onto which the 12 ribs articulate. Note the superior articular processes face
posteriorly. The spinous process projects inferiorly, and the transverse processes project
posteriorly and diagonally.

Lumbar
The 5 lumbar vertebrae are larger to allow for weight bearing. Note the superior articular
processes face medially. The spinous process projects horizontally and posteriorly, and the
transverse processes project laterally and horizontally.
Sacrum
Formed by five fused vertebrae that form a wedge-shaped bone.

Coccyx
A remnant of the embryonic tail that consists of four vertebrae.

Joints and Ligaments

Zygapophysial joints (between the superior and inferior articular processes) allow for gliding and
sliding movement. Other ligaments connect the spinous processes, lamina, and bodies of
adjacent vertebrae. The anterior longitudinal ligament prevents hyperextension, and the
posterior longitudinal ligament prevents hyperflexion. Between the vertebral bodies are the
intervertebral discs, which are formed by a central nucleus pulposus surrounded by annulus
fibrosus.
Dermatomes

Regions of the skin are innervated by

sensory nerves associated with dorsal root
ganglions at single spinal cord levels.
These levels are known as dermatomes.

CLINICAL KEYS
Lumbar Disc Herniation
- L5/S1 most common level
- 90% recover from symptoms within
3 months with nonoperative
treatment
- Due to the vertical anatomy of a
lumbar nerve root, a disc herniation
can affect different nerve roots than
the nerve root corresponding to the
vertebral body (e.g. herniation at
L4/L5 can affect L5 nerve vs in
cervical disc herniations, same
nerve root is affected)
- Symptoms include low back pain,
leg and buttock pain that is worse
with sitting, and cauda equina
syndrome
- MRI is imaging of choice
- First line treatment: rest, physical
therapy, and anti-inflammatory
pharmacological therapy
- Surgical treatment includes
laminotomy and discectomy
- Indicated for disabling pain,
progressive and significant
weakness, and cauda equina syndrome
VASCULAR SUPPLY OF SPINAL CORD

CLINICAL KEYS
Central spinal cord syndrome
- Incomplete cord injury most commonly associated with acute hyperflexion injury or
trauma
- Mostly affects the central portion, the watershed area of the spinal cord
- Signs/symptoms-weakness mostly of upper extremities, some in lower extremity
(cervical spinal cord fibers located medially), varying degree of sensation below lesion,
urinary sphincter dysfunction
Anterior cord syndrome
- Infarct of anterior spinal artery
- Signs/symptoms-Paraplegia/Quadriplegia (depends on location), sensory loss below
lesion (pain/temp with preserved proprioception and vibratory sensation)
- Diagnosis-CT, MRI to rule out surgical conditions
- Treatment-surgery for patients with evidence of cord compression or spinal instability
IMAGING

Cervical

Lateral x-ray AP x-ray

Lateral MRI
Lumbar

Lateral x-ray

Lateral MRI
 Keys to reading Spine imaging
Alignment
Vertebral bodies
Intervertebral discs
Facet joints/Arches/Spinous and Transverse processes
Spinal canal
Soft tissue