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Netter’s 4 th Edition

Clinical Anatomy
John T. Hansen, PhD
Professor of Neuroscience
Former Chair of Neurobiology and Anatomy
and Associate Dean for Admissions
University of Rochester Medical Center
Rochester, New York

Illustrations by

Frank H. Netter, MD

Contributing Illustrators
Carlos A.G. Machado, MD
John A. Craig, MD
James A. Perkins, MS, MFA
Kristen Wienandt Marzejon, MS, MFA
Tiffany S. DaVanzo, MA, CMI
1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-2899


Copyright © 2019 by Elsevier Inc.

Previous editions copyrighted 2014, 2009, 2005

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek permission,
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such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website:

his book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Permission to use Netter Art igures may be sought through the website or by emailing
Elsevier’s Licensing Department at


Knowledge and best practice in this ield are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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With respect to any drug or pharmaceutical products identiied, readers are advised to check the
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International Standard Book Number: 978-0-323-53188-7

Executive Content Strategist: Elyse O’Grady

Senior Content Development Specialist: Marybeth hiel
Publishing Services Manager: Patricia Tannian
Senior Project Manager: John Casey
Design: Patrick Ferguson
Art Manager: Karen Giacomucci

Printed in China

9 8 7 6 5 4 3 2 1
I dedicate this book to my wife

and to my children
Amy and Sean,

and to my grandchildren
Abigail, Benjamin and Jonathan.

Without their unconditional love, presence, and encouragement, little would have been
accomplished either personally or professionally. Because we’ve shared so much, this effort, like
all the others, was multiauthored.
About the Artists

he Netter illustrations are appreciated not

Frank H. Netter, MD
only for their aesthetic qualities, but, more impor-
Frank H. Netter was born in 1906, in New York tant, for their intellectual content. As Dr. Netter
City. He studied art at the Art Students’ League wrote in 1949, “. . . clariication of a subject is the
and the National Academy of Design before enter- aim and goal of illustration. No matter how beau-
ing medical school at New York University, where tifully painted, how delicately and subtly rendered
he received his medical degree in 1931. During his a subject may be, it is of little value as a medical
student years, Dr. Netter’s notebook sketches illustration if it does not serve to make clear some
attracted the attention of the medical faculty and medical point.” Dr. Netter’s planning, conception,
other physicians, allowing him to augment his point of view, and approach are what inform his
income by illustrating articles and textbooks. He paintings and what make them so intellectually
continued illustrating as a sideline after establish- valuable.
ing a surgical practice in 1933, but he ultimately Frank H. Netter, MD, physician and artist, died
opted to give up his practice in favor of a full-time in 1991.
commitment to art. After service in the United Learn more about the physician-artist whose
States Army during World War II, Dr. Netter work has inspired the Netter Reference collection:
began his long collaboration with the CIBA Phar-
maceutical Company (now Novartis Pharmaceu- .html.
ticals). his 45-year partnership resulted in the
production of the extraordinary collection of
Carlos A. G. Machado, MD
medical art so familiar to physicians and other
medical professionals worldwide. Carlos A. G. Machado was chosen by Novartis to
In 2005, Elsevier, Inc., purchased the Netter be Dr. Netter’s successor. He continues to be the
Collection and all publications from Icon Learn- main artist who contributes to the Netter collec-
ing Systems. More than 50 publications featuring tion of medical illustrations.
the art of Dr. Netter are available through Elsevier, Self-taught in medical illustration, cardiologist
Inc. (in the US: Carlos Machado has contributed meticulous
and outside the US: updates to some of Dr. Netter’s original plates and
Dr. Netter’s works are among the inest exam- has created many paintings of his own in the style
ples of the use of illustration in the teaching of of Netter as an extension of the Netter collection.
medical concepts. he 13-book Netter Collection Dr. Machado’s photorealistic expertise and his
of Medical Illustrations, which includes the greater keen insight into the physician/patient relation-
part of the more than 20,000 paintings created by ship informs his vivid and unforgettable visual
Dr. Netter, became and remains one of the most style. His dedication to researching each topic and
famous medical works ever published. he Netter subject he paints places him among the premier
Atlas of Human Anatomy, irst published in 1989, medical illustrators at work today.
presents the anatomic paintings from the Netter Learn more about his background and see
Collection. Now translated into 16 languages, it is more of his art at:
the anatomy atlas of choice among medical and -carlos-a-g-machado.html.
health professions students the world over.

About the Author

John T. Hansen, PhD, is Professor of Neuro- to nationally recognized medical educators. Dr.
science and former Associate Dean for Admissions Hansen’s investigative career encompassed the
at the University of Rochester Medical Center. Dr. study of the peripheral and central dopaminergic
Hansen served as Chair of the Department of Neu- systems, neural plasticity, and neural inflamma-
robiology and Anatomy before becoming Associ- tion. In addition to over 100 research publications,
ate Dean. Dr. Hansen is the recipient of numerous he is co-author of Netter’s Atlas of Human Physi-
teaching awards from students at three differ- ology; the lead consulting editor of Netter’s Atlas
ent medical schools. In 1999, he was the recipi- of Human Anatomy; author of Netter’s Anatomy
ent of the Alpha Omega Alpha Robert J. Glaser Flash Cards, Essential Anatomy Dissector, and
Distinguished Teacher Award given annually by Netter’s Anatomy Coloring Book; and co-author
the Association of American Medical Colleges of the TNM Staging Atlas with Oncoanatomy.


Compiling the illustrations for, researching, and Content Development Specialist, and John Casey,
writing Netter’s Clinical Anatomy, fourth edition, Senior Project Manager, both of whom kept me
has been both enjoyable and educational, con- organized, focused, and on time. Without them,
irming again the importance of lifelong learning little would have been accomplished. hanks and
in the health professions. appreciation also to Patrick Ferguson, Designer
Netter’s Clinical Anatomy is for all my students, and Karen Giacomucci, Illustration Manager. A
and I am indebted to all of them who, like many special thank you to Madelene Hyde, Publishing
others, yearn for a better view to help them learn Director, and Elyse O’Grady, Executive Content
the relevant essential anatomy that informs the Strategist, for believing in the idea and always sup-
practice of medicine. Anatomy is a visual science, porting my eforts. his competent team deines
and Netter’s illustrations are the gold standard of the word “professionalism,” and it has been an
medical illustration. honor to work with all of them.
hanks and appreciation belong to my col- Special thanks to Carlos Machado, MD, for
leagues and reviewers who provided encourage- his beautiful artistic renderings that superbly
ment and constructive comments that clariied complemented, updated, and extended the Netter
many aspects of the book. Especially, I wish to anatomy collection. Also, I wish to express my
acknowledge David Lambert, MD, Senior Associ- thanks to my faculty colleagues at Rochester for
ate Dean for Undergraduate Medical Education at their generous and constructive feedback.
Rochester, who co-authored the irst edition of Finally, I remain indebted to Frank H. Netter,
this book with me and remains a treasured col- MD, whose creative genius lives on in generations
league and friend. of biomedical professionals who have learned
At Elsevier, it has been a distinct pleasure to clinical anatomy from his rich collection of
work with dedicated, professional people who medical illustrations.
massaged, molded, and ultimately nourished the To all of these remarkable people, and others,
dream beyond even my wildest imagination. I owe “hank you.”
much to the eforts of Marybeth hiel, Senior JOHN T. HANSEN, PHD


Human anatomy is the foundation upon which to appreciate some of the clinical manifestations
the education of our medical, dental, and allied related to that anatomy. Other features of this
health science students is built. However, today’s edition include:
biomedical science curriculum must cover an
ever-increasing body of scientiic knowledge, often • An introductory chapter designed to orient

students to the body’s organ systems
in fewer hours, as competing disciplines and new
A set of end-of-chapter clinically oriented
technologies emerge. Many of these same tech-
multiple choice review questions to help
nologies, especially those in the imaging science

reinforce student learning of key concepts
ields, have made understanding the anatomy even
Basic embryology of each system that pro-
more important and have moved our discipline
vides a contextual framework for human
irmly into the realm of clinical medicine. It is fair
postnatal anatomy and several common
to say that competent clinicians and allied health

congenital defects
professionals can no longer simply view their ana-
Online access with additional Clinical Focus
tomical training in isolation from the clinical
implications related to that anatomy.
In this context, I am proud to introduce the My intent in writing this updated fourth edition
fourth edition of Netter’s Clinical Anatomy. Gen- of Netter’s Clinical Anatomy was to provide a
erations of students have used Dr. Frank H. Netter’s concise and focused introduction to clinical
elegant anatomical illustrations to learn anatomy, anatomy as a viable alternative to the more com-
and this book combines his beautiful anatomi- prehensive anatomy textbooks, which few stu-
cal and embryological renderings with numer- dents read and often ind diicult to navigate
ous clinical illustrations to help students bridge when looking for essential anatomical details.
the gap between normal anatomy and its clinical Moreover, this textbook serves as an excellent
application across each region of the human body. essential review text for students beginning their
his fourth edition provides succinct text, key clinical clerkships or elective programs, and as a
bulleted points, and ample summary tables, which reference text that clinicians will ind useful for
ofer students a concise textbook description of review and patient education.
normal human anatomy, as well as a quick refer- he text is by no means comprehensive but
ence and review guide for clinical practitioners. does provide the essential anatomy needed by the
Additionally, 215 Clinical Focus boxes represent- generalist physician-in-training that is commonly
ing some of the more commonly encountered encountered in the irst year of medical school. I
clinical conditions seen in medical practice are have intentionally focused on the anatomy that
integrated within the textbook. hese clinical cor- a irst-year student might be expected to grasp
relations are drawn from a wide variety of medical and carry forward into his or her clerkship train-
ields including emergency medicine, radiology, ing, especially in this day and age when anatomy
orthopedics, and surgery, but also include relevant courses are often streamlined and dissection exer-
clinical anatomy related to the ields of cardiol- cises abbreviated. hose students, who by choice,
ogy, endocrinology, infectious diseases, neurology, choose to enter specialties where advanced ana-
oncology, reproductive biology, and urology. By tomical training is required (e.g., surgical spe-
design, the text and clinical correlations are not cialties, radiology, physical therapy, etc.) may
exhaustive but are meant to help students focus encounter a need for additional anatomical exper-
on the essential elements of anatomy and begin tise that will be provided by their graduate medical
x Preface

or allied health education. By meeting the needs I hope that you, the health science student-
of the beginning student and providing ample in-training or the physician-in-practice, will
detail for subsequent review or handy reference, ind Netter’s Clinical Anatomy the valuable link
my hope is that Netter’s Clinical Anatomy will be you’ve searched for to enhance your understand-
the anatomy textbook of choice that will actually ing of clinical anatomy as only Frank Netter can
be read and used by students throughout their present it.
undergraduate medical or allied health careers. JOHN T. HANSEN, PHD

chapter 1 Introduction to the Human Body 1

chapter 2 Back 51

chapter 3 Thorax 93

chapter 4 Abdomen 157

chapter 5 Pelvis and Perineum 233

chapter 6 Lower Limb 291

chapter 7 Upper Limb 367

chapter 8 Head and Neck 437

Index 557


Clinical Focus Boxes

chapter 1 Introduction to the Human Body

1-1 Psoriasis, 5
1-2 Burns, 6
1-3 Langer’s Lines, 6
1-4 Fractures, 12
1-5 Degenerative Joint Disease, 13
1-6 Atherogenesis, 19
1-7 Asthma, 23
1-8 Potential Spaces, 38

Available Online
1-9 Myasthenia Gravis

chapter 2 Back
2-1 Scoliosis, 53
2-2 Cervical Fractures, 55
2-3 Osteoarthritis, 57
2-4 Osteoporosis, 60
2-5 Spondylolysis and Spondylolisthesis, 61
2-6 Intervertebral Disc Herniation, 61
2-7 Back Pain Associated with the Zygapophysial (Facet) Joints, 63
2-8 Low Back Pain, 64
2-9 Whiplash Injury, 66
2-10 Herpes Zoster, 77
2-11 Lumbar Puncture and Epidural Anesthesia, 79
2-12 Spina Bifida, 85

Available Online
2-13 Myofascial Pain
2-14 Acute Spinal Syndromes

chapter 3 Thorax
3-1 Thoracic Cage Injuries, 98
3-2 Fibrocystic Breast Disease, 102

Clinical Focus Boxes xiii

3-3 Breast Cancer, 103

3-4 Partial Mastectomy, 104
3-5 Modified Radical Mastectomy, 105
3-6 Chest Tube Thoracostomy, 109
3-7 Idiopathic Pulmonary Fibrosis, 111
3-8 Pulmonary Embolism, 112
3-9 Lung Cancer, 113
3-10 Chronic Obstructive Pulmonary Disease, 114
3-11 Cardiac Tamponade, 117
3-12 Dominant Coronary Circulation, 118
3-13 Angina Pectoris (the Referred Pain of Myocardial Ischemia), 122
3-14 Coronary Bypass, 122
3-15 Coronary Angiogenesis, 123
3-16 Myocardial Infarction, 125
3-17 Cardiac Auscultation, 126
3-18 Valvular Heart Disease, 127
3-19 Cardiac Pacemakers, 129
3-20 Cardiac Defibrillators, 130
3-21 Mediastinal Masses, 135
3-22 Ventricular Septal Defect, 144
3-23 Atrial Septal Defect, 145
3-24 Patent Ductus Arteriosus, 146
3-25 Repair of Tetralogy of Fallot, 147

Available Online
3-26 Hemothorax
3-27 Chronic Cough
3-28 Pneumonia
3-29 Cardiovascular Disease (Elderly and Women)
3-30 Saphenous Vein Graft Disease
3-31 Infective Endocarditis
3-32 Mitral Valve Prolapse
3-33 Ventricular Tachycardia
3-34 Chylothorax
3-35 Coarctation of the Aorta

chapter 4 Abdomen
4-1 Abdominal Wall Hernias, 164
4-2 Inguinal Hernias, 169
4-3 Hydrocele and Varicocele, 170
4-4 Acute Appendicitis, 175
4-5 Gastroesophageal Reflux Disease (GERD), 177
4-6 Hiatal Hernia, 178
4-7 Peptic Ulcer Disease, 179
4-8 Bariatric Surgery, 180

xiv Clinical Focus Boxes

4-9 Crohn Disease, 181

4-10 Ulcerative Colitis, 182
4-11 Diverticulosis, 183
4-12 Colorectal Cancer, 184
4-13 Volvulus, 185
4-14 Intussusception, 187
4-15 Gallstones (Cholelithiasis), 188
4-16 Pancreatic Cancer, 190
4-17 Rupture of the Spleen, 191
4-18 Cirrhosis of the Liver, 197
4-19 Portal Hypertension, 198
4-20 Renal Stones (Calculi), 206
4-21 Obstructive Uropathy, 207
4-22 Malignant Tumors of the Kidney, 208
4-23 Surgical Management of Abdominal Aortic Aneurysm, 210
4-24 Congenital Megacolon, 217
4-25 Meckel’s Diverticulum, 220
4-26 Congenital Malrotation of the Colon, 222
4-27 Pheochromocytoma, 223
4-28 Renal Fusion, 224

Available Online
4-29 Acute Abdomen: Visceral Etiology
4-30 Irritable Bowel Syndrome
4-31 Acute Pyelonephritis
4-32 Causes and Consequences of Portal Hypertension

chapter 5 Pelvis and Perineum

5-1 Pelvic Fractures, 235
5-2 Urinary Tract Infections, 241
5-3 Stress Incontinence in Women, 244
5-4 Uterine Prolapse, 245
5-5 Cervical Carcinoma, 245
5-6 Uterine Leiomyomas (Fibroids), 246
5-7 Endometriosis, 246
5-8 Uterine Endometrial Carcinoma, 247
5-9 Chronic Pelvic Inflammatory Disease, 247
5-10 Dysfunctional Uterine Bleeding, 248
5-11 Ectopic Pregnancy, 249
5-12 Assisted Reproduction, 249
5-13 Ovarian Cancer, 250
5-14 Vasectomy, 253
5-15 Testicular Cancer, 254
5-16 Hydrocele and Varicocele, 254
5-17 Transurethral Resection of the Prostate, 255

Clinical Focus Boxes xv

5-18 Prostatic Carcinoma, 256

5-19 Hemorrhoids, 269
5-20 Episiotomy, 270
5-21 Sexually Transmitted Diseases, 271
5-22 Urethral Trauma in the Male, 275
5-23 Urine Extravasation in the Male, 275
5-24 Erectile Dysfunction, 276
5-25 Hypospadias and Epispadias, 280
5-26 Uterine Anomalies, 281
5-27 Male Circumcision (Newborn), 282

Available Online
5-28 Ovarian Tumors

chapter 6 Lower Limb

6-1 Deep Venous Thrombosis, 293
6-2 Developmental Dislocation of the Hip, 296
6-3 Pelvic Fractures, 297
6-4 Intracapsular Femoral Neck Fracture, 298
6-5 Pressure (Decubitus) Ulcers, 302
6-6 Iliotibial Tract (Band) Syndrome, 303
6-7 Fractures of the Shaft and Distal Femur, 304
6-8 Thigh Muscle Injuries, 307
6-9 Diagnosis of Hip, Buttock, and Back Pain, 309
6-10 Revascularization of the Lower Limb, 311
6-11 Femoral Pulse and Vascular Access, 312
6-12 Multiple Myeloma, 318
6-13 Tibial Fractures, 319
6-14 Deep Tendon Reflexes, 319
6-15 Patellar Injuries, 320
6-16 Rupture of the Anterior Cruciate Ligament, 320
6-17 Sprains of the Knee Ligaments, 321
6-18 Tears of the Meniscus, 321
6-19 Osgood-Schlatter Lesion, 322
6-20 Osteoarthritis of the Knee, 322
6-21 Septic Bursitis and Arthritis, 323
6-22 Shin Splints, 325
6-23 Osteosarcoma of the Tibia, 325
6-24 Genu Varum and Valgum, 330
6-25 Exertional Compartment Syndromes, 330
6-26 Achilles Tendinitis and Bursitis, 331
6-27 Footdrop, 336
6-28 Ankle Sprains, 336
6-29 Ankle Fractures, 337
6-30 Rotational Fractures, 339

xvi Clinical Focus Boxes

6-31 Fractures of the Calcaneus, 340

6-32 Congenital Clubfoot, 343
6-33 Metatarsal and Phalangeal Injuries, 344
6-34 Plantar Fasciitis, 345
6-35 Deformities of the Toes, 345
6-36 Fractures of the Talar Neck, 346
6-37 Common Foot Infections, 347
6-38 Diabetic Foot Lesions, 348
6-39 Arterial Occlusive Disease, 349
6-40 Gout, 349

Available Online
6-41 Healing of Fractures

chapter 7 Upper Limb

7-1 Glenohumeral Dislocations, 370
7-2 Fracture of the Proximal Humerus, 371
7-3 Clavicular Fractures, 372
7-4 Rotator Cuff Injury, 376
7-5 Shoulder Tendinitis and Bursitis, 377
7-6 Brachial Plexopathy, 380
7-7 Axillary Lipoma, 383
7-8 Deep Tendon Reflexes, 389
7-9 Fractures of the Humerus, 389
7-10 Biceps Brachii Rupture, 392
7-11 Elbow Dislocation, 393
7-12 Fracture of the Radial Head and Neck, 397
7-13 Biomechanics of Forearm Radial Fractures, 399
7-14 Fracture of the Ulna Shaft, 404
7-15 Distal Radial (Colles’) Fracture, 404
7-16 Median Nerve Compression and Carpal Tunnel Syndrome, 409
7-17 Fracture of the Scaphoid, 410
7-18 Allen’s Test, 410
7-19 De Quervain Tenosynovitis, 411
7-20 Proximal Interphalangeal Joint Dislocations, 412
7-21 Finger Injuries, 413
7-22 Radial Nerve Compression, 419
7-23 Proximal Median Nerve Compression, 422
7-24 Ulnar Tunnel Syndrome, 423
7-25 Clinical Evaluation of Compression Neuropathy, 424
7-26 Ulnar Nerve Compression in Cubital Tunnel, 425

Available Online
7-27 Trigger Finger
7-28 Rheumatoid Arthritis
7-29 Central Venous Access

Clinical Focus Boxes xvii

chapter 8 Head and Neck

8-1 Skull Fractures, 441
8-2 Zygomatic Fractures, 441
8-3 Midface Fractures, 442
8-4 Hydrocephalus, 448
8-5 Meningitis, 449
8-6 Subarachnoid Hemorrhage, 451
8-7 Epidural Hematomas, 453
8-8 Subdural Hematomas, 454
8-9 Transient Ischemic Attack, 454
8-10 Stroke, 455
8-11 Carotid–Cavernous Sinus Fistula, 456
8-12 Collateral Circulation After Internal Carotid Artery Occlusion, 456
8-13 Vascular (Multiinfarct) Dementia, 457
8-14 Brain Tumors, 458
8-15 Metastatic Brain Tumors, 459
8-16 Trigeminal Neuralgia, 464
8-17 Herpes Zoster (Shingles), 464
8-18 Facial Nerve (Bell’s) Palsy, 465
8-19 Tetanus, 466
8-20 Orbital Blow-Out Fracture, 469
8-21 Clinical Testing of the Extraocular Muscles, 471
8-22 Horner’s Syndrome, 472
8-23 Eyelid Infections and Conjunctival Disorders, 477
8-24 Papilledema, 477
8-25 Diabetic Retinopathy, 478
8-26 Glaucoma, 479
8-27 Ocular Refractive Disorders, 480
8-28 Cataract, 481
8-29 Pupillary Light Reflex, 482
8-30 Acute Otitis Externa and Otitis Media, 486
8-31 Weber and Rinne Tests, 488
8-32 Cochlear Implant, 488
8-33 Vertigo, 489
8-34 Removal of an Acoustic Neuroma, 490
8-35 Mandibular Dislocation, 491
8-36 Mandibular Fractures, 493
8-37 Rhinosinusitis, 495
8-38 Nosebleed, 500
8-39 Common Oral Lesions, 507
8-40 Cancer of the Oral Cavity, 508
8-41 Hyperthyroidism with Diffuse Goiter (Graves’ Disease), 517
8-42 Primary Hypothyroidism, 518
8-43 Manifestations of Primary Hyperparathyroidism, 519
8-44 Emergency Airway: Cricothyrotomy, 526

xviii Clinical Focus Boxes

8-45 Manifestations of Hoarseness, 526

8-46 Nerve Lesions (CN X and CN XII), 539
8-47 Craniosynostosis, 547
8-48 Congenital Anomalies of the Oral Cavity, 547
8-49 Pharyngeal Arch and Pouch Anomalies, 548

Introduction to the
Human Body


1. TERMINOLOGY • Frontal (coronal) plane: a vertical plane that

divides the body into anterior and posterior
Anatomical Position portions (equal or unequal); this plane is at right
he study of anatomy requires a clinical vocabulary angles to the median sagittal plane.
that deines position, movements, relationships, and • Transverse (axial) plane: a horizontal plane
planes of reference, as well as the systems of the that divides the body into superior and inferior
human body. he study of anatomy can be by body portions (equal or unequal) and is at right angles
region or by body organ systems. Generally, to both the median sagittal and the frontal planes
courses of anatomy in the United States approach (sometimes called cross sections).
anatomical study by regions, integrating all applicable Key terms of relationship used in anatomy and
body systems into the study of a particular region. the clinic are summarized in Table 1.1. A structure
his textbook therefore is arranged regionally, and or feature closer to the front of the body is con-
for those studying anatomy for the irst time, this sidered anterior (ventral), and one closer to the
initial chapter introduces you to the major body back is termed posterior (dorsal). he terms medial
systems that you will encounter in your study of and lateral are used to distinguish a structure or
anatomy. You will ind it extremely helpful to refer feature in relationship to the midline; the nose is
back to this introduction as you encounter various medial to the ear, and in anatomical position, the
body systems in your study of regional anatomy. nose also is anterior to the ear. Sometimes these
By convention, anatomical descriptions of the terms of relationship are used in combination (e.g.,
human body are based on a person in the anatomi- superomedial, meaning closer to the head and nearer
cal position (Fig. 1.1), as follows: the median sagittal plane).
• Standing erect and facing forward
• Arms hanging at the sides with palms facing
forward Body movements usually occur at the joints where
• Legs placed together with feet facing forward two or more bones or cartilages articulate with
one another. Muscles act on joints to accomplish
Terms of Relationship and Body Planes these movements and may be described as
Anatomical descriptions often are referenced to follows: “he biceps muscle lexes the forearm
one or more of three distinct body planes (Fig. 1.2 at the elbow.” Fig. 1.3 summarizes the terms of
and Table 1.1), as follows: movement.
• Sagittal plane: a vertical plane that divides the
body into equal right and left halves (median Anatomical Variability
or midsagittal plane) or a plane parallel to the he human body is remarkably complex and
median sagittal plane (parasagittal) that divides remarkably consistent anatomically, but normal
the body into unequal right and left portions. variations do exist, often related to size, gender,

2 Chapter 1 Introduction to the Human Body

Frontal Parietal
Nasal Occipital
Orbital Temporal
Anterior cervical
Oral Posterior
Mental Lateral cervical
cervical Sternocleidomastoid
Sternocleidomastoid Infraclavicular fossa
Deltoid Subclavian Suprascapular Interscapular
Pectoral Deltoid
Mammary Axillary Infrascapular
Anterior Posterior brachial Posterior
Lateral thoracic Lateral
brachial brachial
Inframammary Anterior region pectoral
of elbow Hypochondriac
Cubital Posterior
Hypochondriac Posterior brachial
Epigastric of elbow
antebrachial Lumbar
Lumbar Palmar Vertebral


Trochanteric Dorsum of
Posterior Hypogastric the hand
Umbilical Medial thigh Gluteal Posterior
Anterior femoral Posterior antebrachial
femoral Sacral
Anterior region
Posterior Anal
of the knee
of the knee Popliteal
Posterior region fossa
Anterior region
Perineal of the leg
of the leg
Posterior leg
malleolar Dorsum of Calcaneal
Heel Dorsal region of the foot
the foot

FIGURE 1.1 Surface Anatomy: Regions (From Atlas of human anatomy, ed 7, Plates 2 and 3.)

Right Left
Coronal plane

Medial Lateral

Transverse plane


Caudal Distal

Posterior or dorsal

Sagittal plane

Anterior or ventral Inferior
FIGURE 1.2 Body Planes and Terms of Anatomical Relationship. (From Atlas of human anatomy,
ed 7, Plate 1.)
Chapter 1 Introduction to the Human Body 3 1
TABLE 1.1 General Terms of Anatomical Relationship
Anterior (ventral) Near the front Median plane Divides body into equal right
Posterior (dorsal) Near the back and left parts
Superior (cranial) Upward, or near the head Midsagittal plane Median plane
Inferior (caudal) Downward, or near the feet Sagittal plane Divides body into unequal
Medial Toward the midline or median right and left parts
plane Frontal (coronal) Divides body into equal
Lateral Farther from the midline or plane or unequal anterior and
median plane posterior parts
Proximal Near a reference point Transverse plane Divides body into equal or
Distal Away from a reference point unequal superior and inferior
Superficial Closer to the surface parts (cross sections)
Deep Farther from the surface

Abduction Lateral Flexion
rotation Elevation
Medial Depression
Adduction rotation

Abduction Lateral

Adduction Medial Flexion



Flexion Supination

Flexion Retrusion Protrusion



Eversion Inversion


FIGURE 1.3 Terms of Movement.

4 Chapter 1 Introduction to the Human Body

age, number, shape, and attachment. Variations are • Protection: against mechanical abrasion and in
particularly common in the following structures: immune responses, as well as prevention of
• Bones: the ine features of bones (processes, dehydration.
spines, articular surfaces) may be variable • Temperature regulation: largely through
depending on the forces working on a bone. vasodilation, vasoconstriction, fat storage, or
• Muscles: they vary with size and ine details of activation of sweat glands.
their attachments (it is better to learn their • Sensations: to touch by specialized mecha-
actions and general attachments rather than noreceptors such as pacinian and Meissner’s
focus on detailed exceptions). corpuscles; to pain by nociceptors; and to
• Organs: the size and shape of some organs will temperature by thermoreceptors.
vary depending on their normal physiology or • Endocrine regulation: by secretion of hormones,
pathophysiologic changes that have occurred cytokines, and growth factors, and by synthesis
previously. and storage of vitamin D.
• Arteries: they are surprisingly consistent, although • Exocrine secretions: by secretion of sweat and
some variation is seen in the branching patterns, oily sebum from sebaceous glands.
especially in the lower neck (subclavian branches) he skin consists of two layers (Fig. 1.4):
and in the pelvis (internal iliac branches). • Epidermis: is the outer protective layer consist-
• Veins: they are consistent, although variations, ing of a keratinized stratiied squamous epithe-
especially in size and number of veins, can lium derived from the embryonic ectoderm.
occur and often can be traced to their complex • Dermis: is the dense connective tissue layer that
embryologic development; veins generally are more gives skin most of its thickness and support, and
numerous than arteries, larger, and more variable. is derived from the embryonic mesoderm.
Fascia is a connective tissue sheet that may
2. SKIN contain variable amounts of fat. It can interconnect
structures, provide a conduit for vessels and nerves
he skin is the largest organ in the body, accounting (termed neurovascular bundles), and provide a
for about 15% to 20% of the total body mass, and sheath around structures (e.g., muscles) that permits
has the following functions: them to slide over one another easily. Supericial
Meissner’s corpuscle
Free n. endings Stratum corneum
Hair shaft Stratum lucidum

Stratum granulosum
Arrector pili m. of hair
Stratum spinosum
Stratum basale

Dermal papilla
(of papillary layer)

Sebaceous gland

Reticular layer
Subcutaneous tissue

Sweat gland

Pacinian corpuscle
Sensory nn. Subcutaneous a.

Elastic fibers Cutaneous n.

Subcutaneous v.
Skin ligs. (retinacula cutis) Somatic n.

FIGURE 1.4 Layers of the Skin.

Chapter 1 Introduction to the Human Body 5 1
Clinical Focus 1-1
Psoriasis is a chronic inflammatory skin disorder that affects approximately 1% to 3% of the population (women
and men equally). It is characterized by defined red plaques capped with a surface scale of desquamated
epidermis. Although the pathogenesis is unknown, psoriasis seems to involve a genetic predisposition.

Munro Histopathologic features

(sterile) Surface “silver” scale
Erythematous base
Persistence of nuclei stratum corneum (parakeratosis)
Increased mitotic activity indicative
of high cell turnover rate
Typical distribution
Dilation and tortuosity
of papillary vessels

Groin and

Edema and
of dermis Increased number
of Langerhans cells
pits Intergluteal
Transverse Sacrum cleft

Hand and nails

Typical appearance Nail
of cutaneous lesions Onycholysis Primarily on extension surfaces
(plaque lesion)

fascia is attached to and lies just beneath the dermis • hird-degree: burn damage that includes all
of the skin and can vary in thickness and density; the epidermis and dermis and may even involve
it acts as a cushion, contains variable amounts of the subcutaneous tissue and underlying deep
fat, and allows the skin to glide over its surface. fascia and muscle; termed a full-thickness burn,
Deep fascia usually consists of a dense connec- it causes charring.
tive tissue, is attached to the deep surface of the
supericial fascia, and often ensheathes muscles 3. SKELETAL SYSTEM
and divides them into functional groupings. Exten-
sions of the deep fascia encasing muscles also may Descriptive Regions
course inward and attach to the skeleton, dividing he human skeleton is divided into two descriptive
groups of muscles with intermuscular septa. regions (Fig. 1.5):
Common injuries to the skin include abrasions, • Axial skeleton: includes the bones of the skull,
cuts (lacerations), and burns. Burns are classiied vertebral column (spine), ribs, and sternum,
as follows: which form the “axis” or central line of the body
• First-degree: burn damage that is limited to (80 bones).
the supericial layers of the epidermis; termed • Appendicular skeleton: includes the bones of
a superficial burn, clinically it causes erythema the limbs, including the pectoral and pelvic
(redness of the skin). girdles, which attach the limbs to the body’s axis
• Second-degree: burn damage that includes all (134 bones).
of the epidermis and extends into the supericial
dermis; termed a partial-thickness burn, it causes Shapes and Function of Bones
blisters but spares the hair follicles and sweat he skeleton is composed of a living, dynamic, rigid
glands. connective tissue that forms the bones and cartilages.

6 Chapter 1 Introduction to the Human Body

Clinical Focus 1-2

Burns to the skin are classified into three degrees of severity based on the depth of the burn:

Pink or light
red. Tender.

Epidermis 1st degree

Partial thickness

2nd degree
Red, weeping, blister
2nd degree formation. Painful.
Full thickness

Dermis Deep
2nd degree
Pale, slightly moist, less red.
Diminished sensation.
3rd degree

Hair Sebaceous Sweat gland Pearly white or charred, parchmentlike,

follicle gland translucent (veins show through). Insensate.

Clinical Focus 1-3

Langer’s Lines
Collagen in the skin creates tension lines called Langer’s lines. Surgeons sometimes use these lines to make
skin incisions; other times, they may use the natural skin folds. The resulting incision wounds tend to gape
less when the incision is parallel to Langer’s lines, resulting in a smaller scar after healing. However, skin fold
incisions also may conceal the scar following healing of the incision.

Chapter 1 Introduction to the Human Body 7 1
Appendicular skeleton (134) Axial skeleton (80)
Skull (22)
Cranium (8)
Face (14)
Associated Skull and associated bones (29)
bones (7)
Clavicle (2) ossicles (6)
Pectoral girdle (4) Hyoid (1)
Scapula (2)

Sternum (1)
Thoracic cage (25)
Ribs (24)

Humerus (2)
Vertebrae (24)
Radius (2)
Sacrum (1) Vertebral column (26)
Ulna (2)
Coccyx (1)
Upper limbs (64) bones (16)
bones (10)
distal) (28)
Sesamoids (4)
Coxal bone
Pelvic girdle (2) (hip bone) (2)

Femur (2)

Patella (2)

Tibia (2)
Lower limbs (64) Fibula (2)

Tarsal bones (14)

Metatarsal bones (10)

Phalanges (28)

Sesamoids (4)

FIGURE 1.5 Axial and Appendicular Regions of Skeleton.

Generally, humans have about 214 bones, although • Long.

this number varies, particularly in the number of • Short.
small sesamoid bones that may be present. (Many • Flat.
resources claim we have only 206 bones, but they • Irregular.
have ignored the 8 sesamoid bones of the hands • Sesamoid.
and feet.) Cartilage is attached to some bones, he functions of the skeletal system include:
especially where lexibility is important, or covers • Support.
the surfaces of bones at points of articulation. About • Protection of vital organs.
99% of the body’s calcium is stored in bone, and • A mechanism, along with muscles, for
many bones possess a central cavity that contains movement.
bone marrow—a collection of hemopoietic (blood- • Storage of calcium and other salts, growth
forming) cells. Most of the bones can be classiied factors, and cytokines.
into one of the following ive shapes (Fig. 1.6): • A source of blood cells.

8 Chapter 1 Introduction to the Human Body

Markings on the Bones

Various surface features of bones (ridges, grooves,
and bumps) result from the tension placed on them
Long bone Flat bone
(humerus) (parietal)
by the attachment of tendons, ligaments, and fascia,
as well as by neurovascular bundles or other
structures that pass along the bone. Descriptively,
these features include the following:
• Condyle: a rounded articular surface covered
with articular (hyaline) cartilage.
Irregular bone • Crest: a ridge (narrow or wide) of bone.
Short bones
(vertebra) • Epicondyle: a prominent ridge or eminence
superior to a condyle.
• Facet: a lat, smooth articular surface, usually
covered with articular (hyaline) cartilage.
• Fissure: a very narrow “slitlike” opening in
Sesamoid bone a bone.
• Foramen: a round or oval “hole” in the bone
for passage of another structure (nerve or vessel).
FIGURE 1.6 Bone Classiication Based on Shape.
• Fossa: a “cuplike” depression in the bone, usually
for articulation with another bone.
• Groove: a furrow in the bone.
• Line: a ine linear ridge of bone, but less promi-
here are two types of bone: nent than a crest.
• Compact: is a relatively solid mass of bone, • Malleolus: a rounded eminence.
commonly seen as a supericial layer of bone, • Meatus: a passageway or canal in a bone.
that provides strength. • Process: a bony prominence that may be sharp
• Spongy (trabecular or cancellous): is a less dense or blunt.
trabeculated network of bone spicules making • Protuberance: a protruding eminence on an
up the substance of most bones and surrounding otherwise smooth surface.
an inner marrow cavity. • Ramus: a thin part of a bone that joins a thicker
Long bones also are divided into the following process of the same bone.
descriptive regions (Fig. 1.7): • Spine: a sharp process projecting from a bone.
• Epiphysis: the ends of long bones, which develop • Trochanter: large, blunt process for muscle
from secondary ossiication centers. tendon or ligament attachment.
• Epiphysial plate: the site of growth in length; • Tubercle: a small, elevated process.
it contains cartilage in actively growing bones. • Tuberosity: a large, rounded eminence that may
• Metaphysis: the site where the bone’s shaft joins be coarse or rough.
the epiphysis and epiphysial plate.
Bone Development
• Diaphysis: the shaft of a long bone, which
represents the primary ossiication center and Bones develop in one of the following two ways:
the site where growth in width occurs. • Intramembranous formation: most lat bones
As a living, dynamic tissue, bone receives a rich develop in this way by direct calcium deposition
blood supply from: into a mesenchymal (primitive mesoderm)
• Nutrient arteries: usually one or several larger precursor or model of the bone.
arteries that pass through the diaphysis and • Endochondral formation: most long and
supply the compact and spongy bone, as well irregularly shaped bones develop by calcium
as the bone marrow. deposition into a cartilaginous model of the bone
• Metaphysial and epiphysial arteries: usually arise that provides a scafold for the future bone.
from articular branches supplying the joint. he following sequence of events deines endo-
• Periosteal arteries: numerous small arteries chondral bone formation (Fig. 1.7, A-F):
from adjacent vessels that supply the compact • Formation of a thin collar of bone around a
bone. hyaline cartilage model.

Chapter 1 Introduction to the Human Body 9 1
Epiphysial capillaries

Perichondrium hyaline cartilage
Cancellous endochondral
Canals, containing bone laid down on spicules
Hypertrophic capillaries, periosteal
of calcified cartilage
Periosteum calcifying mesenchymal cells,
cartilage and osteoblasts
Primordial marrow cavities
Thin collar
of cancellous
A. At 8 weeks
B. At 9 weeks

C. At 10 weeks
Calcified Articular
cartilage cartilage
Epiphysial Proliferating Bone of
Epiphysial ossification growth cartilage epiphysis
(secondary) centers Hypertrophic
ossification Proximal calcifying cartilage
center epiphysial
Outer part growth
of periosteal plate
bone transforming
into compact bone Sites of growth in
Central marrow growth width occurs
cavity in length by periosteal
of bone Endochondral
bone laid down bone formation
on spicules Metaphysis
Distal of degenerating
D. At birth calcified cartilage Bone of
growth plate epiphysis
Calcified cartilage
Proliferating Articular
E. At 5 years
growth cartilage cartilage

F. At 10 years
FIGURE 1.7 Growth and Ossiication of Long Bones (Midfrontal Sections).

• Cavitation of the primary ossiication center and and surrounded by a capsule; the bony articular
invasion of vessels, nerves, lymphatics, red surfaces are covered with hyaline cartilage.
marrow elements, and osteoblasts. Fibrous joints include sutures (lat bones of
• Formation of spongy (cancellous) endochondral the skull), syndesmoses (two bones connected by
bone on calciied spicules. a ibrous membrane), and gomphoses (teeth itting
• Diaphysis elongation, formation of the central into ibrous tissue-lined sockets).
marrow cavity, and appearance of the secondary Cartilaginous joints include primary (syn-
ossiication centers in the epiphyses. chondrosis) joints between surfaces lined by hyaline
• Long bone growth during childhood. cartilage (epiphysial plate connecting the diaphysis
• Epiphysial fusion occurring from puberty into with the epiphysis), and secondary (symphysis)
maturity (early to mid-20s). joints between hyaline-lined articular surfaces and
an intervening ibrocartilaginous disc. Primary joints
Types of Joints allow for growth and some bending, whereas
Joints are the sites of union or articulation of two secondary joints allow for strength and some
or more bones or cartilages, and are classiied into lexibility.
one of the following three types (Fig. 1.8): Synovial joints generally allow for considerable
• Fibrous (synarthroses): bones joined by ibrous movement and are classiied according to their
connective tissue. shape and the type of movement that they permit
• Cartilaginous (amphiarthroses): bones joined (uniaxial, biaxial, or multiaxial movement) (Fig.
by cartilage, or by cartilage and ibrous tissue. 1.9), as follows:
• Synovial (diarthroses): in this most common • Hinge (ginglymus): are uniaxial joints for lexion
type of joint, the bones are joined by a joint and extension.
cavity illed with a small amount of synovial luid • Pivot (trochoid): are uniaxial joints for rotation.

10 Chapter 1 Introduction to the Human Body

Compact bone

Diploë Fibrous

Compact bone membrane

Joint cavity

Fibrous Synovial joint

of femur

Body of vertebra
Epiphysial Syndesmosis Intervertebral disc


Primary cartilaginous Secondary cartilaginous

FIGURE 1.8 Types of Joints.

• Saddle: are biaxial joints for lexion, extension, • Smooth: nonstriated muscle ibers that line
abduction, adduction, and circumduction. various organ systems (gastrointestinal, urogeni-
• Condyloid (ellipsoid; sometimes classiied sepa- tal, respiratory), attach to hair follicles, and line
rately): are biaxial joints for lexion, extension, the walls of most blood vessels (sometimes
abduction, adduction, and circumduction. simplistically referred to as involuntary muscle).
• Plane (gliding): are joints that only allow simple Skeletal muscle is divided into fascicles
gliding movements. (bundles), which are composed of muscle ibers
• Ball-and-socket (spheroid): are multiaxial joints (muscle cells) (Fig. 1.10). he muscle iber cells
for lexion, extension, abduction, adduction, contain longitudinally oriented myoibrils that run
mediolateral rotation, and circumduction. the full length of the cell. Each myoibril is composed
of many myoilaments, which are composed of
4. MUSCULAR SYSTEM individual myosin (thick ilaments) and actin (thin
ilaments) that slide over one another during muscle
Muscle cells (ibers) produce contractions (shorten- contraction.
ings in length) that result in movement, maintenance Skeletal muscle moves bones at their joints and
of posture, changes in shape, or the propulsion of possesses an origin (the muscle’s ixed or proximal
luids through hollow tissues or organs. here are attachment) and an insertion (the muscle’s movable
three diferent types of muscle: or distal attachment). In a few instances, the muscle’s
• Skeletal: striated muscle ibers that are attached origin moves more than its insertion. At the gross
to bone and are responsible for movements of level, anatomists classify muscle on the basis of its
the skeleton (sometimes simplistically referred shape:
to as voluntary muscle). • Flat: muscle that has parallel ibers, usually in
• Cardiac: striated muscle ibers that make up a broad lat sheet with a broad tendon of attach-
the walls of the heart and proximal portions of ment called an aponeurosis.
the great veins where they enter the heart. • Quadrate: muscle that has a four-sided appearance.

Chapter 1 Introduction to the Human Body 11 1


Axis of the
Ulna of
the elbow’s
pivot joint
hinge joint

A. Hinge B. Pivot

Metacarpal of the
thumb’s saddle joint

Tibia of
Trapezium the knee’s
C. Saddle D. Condyloid

Acromioclavicular plane joint at

the shoulder: plane joint between
the acromion of the scapula and
Acetabulum clavicle

Acromion Clavicle

Femur of the hip’s

ball-and-socket joint:
acetabulum of the
pelvis forms the
“socket” of this joint

E. Ball-and-socket F. Plane
FIGURE 1.9 Types of Synovial Joints.

12 Chapter 1 Introduction to the Human Body

Clinical Focus 1-4

Fractures are classified as either closed (the skin is intact) or open (the skin is perforated; often referred to
as a compound fracture). Additionally, the fracture may be classified with respect to its anatomical appearance
(e.g., transverse, spiral).

fracture Open
with fracture
hematoma with
fracture with

Pathologic fracture Greenstick Torus (buckle)

(tumor or bone fracture fracture
In children

Transverse Oblique
fracture fracture Spiral
fracture Comminuted


fracture Compression fracture
Avulsion (greater
tuberosity of
humerus avulsed
by supraspinatus m.)

Chapter 1 Introduction to the Human Body 13 1
Clinical Focus 1-5
Degenerative Joint Disease
Degenerative joint disease is a catch-all term for osteoarthritis, degenerative arthritis, osteoarthrosis, or
hypertrophic arthritis; it is characterized by progressive loss of articular cartilage and failure of repair. Osteo-
arthritis can affect any synovial joint but most often involves the foot, knee, hip, spine, and hand. As the
articular cartilage is lost, the joint space (the space between the two articulating bones) becomes narrowed,
and the exposed bony surfaces rub against each other, causing significant pain.

Early degenerative changes

Normal joint and articular surface
Surface fibrillation of articular cartilage
Early disruption of
matrix-molecular framework

Superficial fissures

Architecture of Sclerosis (thickening)
articular cartilage of subchondral bone,
and subchondral bone an early sign of degeneration
Advanced degenerative changes End-stage degenerative changes
Fissure penetration to subchondral bone
Release of fibrillated
cartilage into joint space Exposed articular surface
of subchondral bone
Enzymatic degradation
Subchondral sclerosis
of articular cartilage

cartilage Subchondral
Pronounced sclerosis cysts
of subchondral bone

• Circular: muscle that forms sphincters that close the muscle to maintain irmness necessary for
of tubes or openings. stability of a joint and important in maintaining
• Fusiform: muscle that has a wide center and posture.
tapered ends. • Phasic: includes two types of contraction; iso-
• Pennate: muscle that has a feathered appearance metric contraction, where no movement occurs
(unipennate, bipennate, or multipennate forms). but the muscle maintains tension to hold a
Muscle contraction shortens the muscle. Gener- position (stronger than tonic contraction), and
ally, skeletal muscle contracts in one of three ways: isotonic contraction, where the muscle shortens
• Reflexive: involuntary or through automatic to produce movement.
contraction; seen in the diaphragm during Muscle contraction that produces move-
respiration or in the relex contraction elicited by ments can act in several ways, depending on the
tapping a muscle’s tendon with a relex hammer. conditions:
• Tonic: maintains “muscle tone,” a slight contrac- • Agonist: the main muscle responsible for a
tion that may not cause movement but allows speciic movement (the “prime mover”).

14 Chapter 1 Introduction to the Human Body

• Platelets.
• White blood cells (WBCs).
• Red blood cells (RBCs).
• Plasma.
Blood is a luid connective tissue that circulates
through the arteries to reach the body’s tissues and
Tendon then returns to the heart through the veins. When
Muscle blood is “spun down” in a centrifuge tube, the RBCs
precipitate to the bottom of the tube, where they
Epimysium Muscle fiber
account for about 45% of the blood volume. his
Nuclei is called the hematocrit and normally ranges from
Satellite cell
40% to 50% in males and 35% to 45% in females.
he next layer is a “bufy coat,” which makes up
slightly less than 1% of the blood volume and
includes WBCs (leukocytes) and platelets. he
Endomysium remaining 55% of the blood volume is the plasma
and includes water, plasma proteins, clotting factors,
and various solutes (serum is plasma with the
clotting factors removed). he functions of blood
• Transport of dissolved gases, nutrients, metabolic
waste products, and hormones to and from
Myofilaments • Prevention of luid loss via clotting mechanisms.
• Immune defense.
• Regulation of pH and electrolyte balance.
FIGURE 1.10 Structure of Skeletal Muscle. • hermoregulation through blood vessel constric-
tion and dilation.

Blood Vessels
• Antagonist: the muscle that opposes the action Blood circulates through the blood vessels (Fig.
of the agonist; as an agonist muscle contracts, 1.12). Arteries carry blood away from the heart,
the antagonistic muscle relaxes. and veins carry blood back to the heart. Arteries
• Fixator: one or more muscles that steady the generally have more smooth muscle in their walls
proximal part of a limb when a more distal part than veins and are responsible for most of the
is being moved. vascular resistance, especially the small muscular
• Synergist: a muscle that complements (works arteries and arterioles. Alternatively, at any point in
synergistically with) the contraction of the time, most of the blood resides in the veins (about
agonist, either by assisting with the movement 64%) and is returned to the right side of the heart;
generated by the agonist or by reducing unneces- thus veins are the capacitance vessels, capable
sary movements that would occur as the agonist of holding most of the blood, and are far more
contracts. variable and numerous than their corresponding
5. CARDIOVASCULAR SYSTEM he major arteries are illustrated in Fig. 1.13.
At certain points along the pathway of the systemic
he cardiovascular system consists of (1) the heart, arterial circulation, large and medium-sized arteries
which pumps blood into the pulmonary circulation lie near the body’s surface and can be used to take
for gas exchange and into the systemic circulation a pulse by compressing the artery against a hard
to supply the body tissues; and (2) the vessels that underlying structure (usually a bone). he most
carry the blood, including the arteries, arterioles, distal pulse from the heart is usually taken over
capillaries, venules, and veins. he blood passing the dorsalis pedis artery on the dorsum of the foot
through the cardiovascular system consists of the or by the posterior tibial artery pulse, at the medial
following formed elements (Fig. 1.11): aspect of the ankle.

Chapter 1 Introduction to the Human Body 15 1
Plasma composition Plasma proteins
Water 92% Albumins 60%
Transports organic and Transport lipids, steroid hormones;
Centrifuged inorganic molecules, major contributors to osmotic
blood sample cells, platelets, and heat concentration of plasma

Plasma proteins 7% Globulins 35%

Transport ions, hormones, lipids;
Other solutes 1% immune function

Fibrinogen 4%
Plasma Essential component of clotting system
Regulatory proteins <1%
Enzymes, hormones, clotting proteins

Platelets Other solutes

FIGURE 1.11 Buffy coat
<1% Normal extracellular fluid ion compo-
Composition of Blood. Blood clot formation sition essential for vital cellular
and tissue repair activities (e.g., Na+, K+, Cl )

Organic nutrients
White blood cells Used for ATP production, growth, and
maintenance of cells (e.g., fatty acids,
glucose, amino acids)

Red blood Organic wastes

cells Carried to sites of breakdown or
~45% excretion (e.g., urea, bilirubin)
Neutrophils (50-70%)

Red blood cells

Eosinophils Lymphocytes Basophils

Monocytes (2-8%) (2-4%) (20-30%) (<1%)

he major veins are illustrated in Fig. 1.14. Veins

are capacitance vessels because they are distensible Heart
and numerous and can serve as reservoirs for the he heart is a hollow muscular (cardiac muscle)
blood. Because veins carry blood at low pressure organ that is divided into four chambers (Fig. 1.15):
and often against gravity, larger veins of the limbs • Right atrium: receives the blood from the
and lower neck region have numerous valves that systemic circulation via the superior and inferior
aid in venous return to the heart (several other venae cavae.
veins throughout the body may also contain valves). • Right ventricle: receives the blood from the
Both the presence of valves and the contractions right atrium and pumps it into the pulmonary
of adjacent skeletal muscles help to “pump” the circulation via the pulmonary trunk and pul-
venous blood against gravity and toward the heart. monary arteries.
In most of the body, the veins occur as a supericial • Left atrium: receives the blood from the lungs
set of veins in the subcutaneous tissue that connects via pulmonary veins.
with a deeper set of veins that parallel the arteries. • Left ventricle: receives the blood from the left
Types of veins include: atrium and pumps it into the systemic circulation
• Venules: these are very small veins that collect via the aorta.
blood from the capillary beds. he atria and ventricles are separated by atrio-
• Veins: these are small, medium, and large veins ventricular valves (tricuspid on the right side and
that contain some smooth muscle in their walls, mitral on the left side) that prevent the blood from
but not as much as their corresponding arteries. reluxing into the atria when the ventricles contract.
• Portal venous systems: these are veins that Likewise, the two major outlow vessels, the pul-
transport blood between two capillary beds (e.g., monary trunk from the right ventricle and the
the hepatic portal system draining the GI tract). ascending aorta from the left ventricle, possess the

16 Chapter 1 Introduction to the Human Body

Volume distribution at rest Distribution of vascular resistance

Small arteries
and arterioles (47%)

Lungs (9%)

Small arteries
and arterioles (8%) Veins (64%) Veins (7%)

Capillaries (27%) Large arteries (19%)

Capillaries (5%)
Heart in diastole (7%)
Large arteries (7%)

Q = 13%
VO2 = 21%


Aortic pressure: 120/80 mm Hg

(mean pressure 95 mm Hg)
Pulmonary arterial pressure: LA
25/10 mm Hg (mean pressure 15 mm Hg) RA
LV circulation:
RV Q = 4%
VO2 = 11%

Liver and gastro-

intestinal tract:
Q = 24%
VO2 = 23%

Low-pressure system High-pressure system

(reservoir function) Skeletal m.: (supply function)
Q = 21%
VO2 = 27%

Q = 20%
VO2 = 7%

Skin and other organs

Q = 18%
VO2 = 11%

FIGURE 1.12 General Organization of Cardiovascular System. he amount of blood low per minute
(Q̇ ), as a percentage of the cardiac output, and the relative percentage of oxygen used per minute (V̇ O2)
by the various organ systems are noted.

Chapter 1 Introduction to the Human Body 17 1

Facial artery pulse

Carotid artery pulse Right and left

common carotid arteries
Aortic arch

Subclavian artery
Axillary artery

Descending thoracic aorta

Brachial artery pulse
Celiac trunk
Brachial artery
Renal artery

Superior mesenteric artery

Inferior mesenteric artery

Radial artery
Common iliac artery
Ulnar artery
Ulnar artery pulse
Internal iliac artery

Radial artery pulse

Palmar arches

iliac artery

Femoral artery pulse Deep femoral artery

Femoral artery

Popliteal artery Popliteal artery pulse

Locations for palpating arterial pulses Anterior tibial artery

(in bold)
Fibular artery

Posterior tibial artery

Posterior tibial artery pulse

Dorsalis pedis artery

Dorsalis pedis artery pulse

Plantar arch
FIGURE 1.13 Major Arteries (from Atlas of human anatomy, ed 7, Plate 4).

18 Chapter 1 Introduction to the Human Body

Major veins
Superficial vv.
Deep vv.

External jugular vein

Internal jugular vein
Brachiocephalic vein
Subclavian vein Superior vena cava

Axillary vein Azygos vein

Intercostal veins
Cephalic vein
Inferior vena cava
Brachial vein

Basilic vein
Renal vein

Common iliac vein

Radial vein
Internal iliac vein

External iliac vein

venous Deep
palmar femoral vein
arch Ulnar

Femoral vein
Palmar digital veins
Great saphenous vein

Popliteal vein

Posterior tibial vein

Anterior tibial vein

Dorsal venous arch

FIGURE 1.14 Major Veins (from Atlas of human anatomy, ed 7, Plate 5).

Chapter 1 Introduction to the Human Body 19 1
Clinical Focus 1-6
Thickening and narrowing of the arterial wall and eventual deposition of lipid into the wall can lead to one form
of atherosclerosis. The narrowed artery may not be able to meet the metabolic needs of the adjacent
tissues, which may become ischemic. Multiple factors, including focal inflammation of the arterial wall, may
result in this condition. When development of a plaque is such that it is likely to rupture and lead to thrombosis
and arterial occlusion, the atherogenic process is termed unstable plaque formation.

Fatty streak at margin Total or partial occlusion of coronary artery can cause
Lumen angina or frank myocardial infarction.
Plaque rupture Plaques likely to rupture are termed unstable. Rupture
usually occurs in lipid-rich and foam cell–rich peripheral
margins and may result in thrombosis and arterial

Fibrinogen Fibrin Platelet

Fibrous cap

Intimal disruption
and thrombus

pulmonary (pulmonic) valve and the aortic valve • Absorb fat (chylomicrons) from the small
(both semilunar valves), respectively. intestine.
Components of the lymphatic system include
6. LYMPHATIC SYSTEM the following:
• Lymph: a watery luid that resembles plasma
General Organization but contains fewer proteins and may contain
he lymphatic system is intimately associated with fat, together with cells (mainly lymphocytes and
the cardiovascular system, both in the development a few RBCs).
of its lymphatic vessels and in its immune function. • Lymphocytes: the cellular components of lymph,
he lymphatic system functions to: including T cells and B cells.
• Protect the body against infection by activating • Lymph vessels: an extensive network of vessels
defense mechanisms of the immune system. and capillaries in the peripheral tissues that
• Collect tissue luids, solutes, hormones, and transport lymph and lymphocytes.
plasma proteins and return them to the circula- • Lymphoid organs: these are collections of lym-
tory system (bloodstream). phoid tissue, including lymph nodes, aggregates

20 Chapter 1 Introduction to the Human Body

Pulmonary trunk
Left atrium Right auricle
Left pulmonary vv.
Ascending aorta
Mitral valve
Ascending aorta Aortic valve
Aortic valve
Outflow to pulmonary trunk
Superior vena cava

Right ventricle

Moderator band
Right atrium

Left ventricle
Tricuspid valve

Right posterior
papillary m. Left anterior papillary m.

Right ventricle Left ventricle

Plane of section
Muscular part of interventricular septum
FIGURE 1.15 Chambers of the Heart. (From Atlas of human anatomy, ed 7, Plate 228.)

of lymphoid tissue along the respiratory and form a key site for phagocytosis of microorganisms
gastrointestinal passageways, tonsils, thymus, and other particulate matter, and they can initiate
spleen, and bone marrow. the body’s immune responses.

Lymphatic Drainage Immune Response

he body is about 60% luid by weight, with 40% When a foreign microorganism, virus-infected cell,
located in the intracellular luid (ICF) compart- or cancer cell is detected within the body, the
ment (inside the cells) and the remaining 20% in lymphatic system mounts what is called an immune
the extracellular luid (ECF) compartment. he response. he detected pathogens are distinguished
lymphatics are essential for returning ECF, solutes, from the body’s own normal cells, and then a
and protein (lost via the capillaries into the ECF response is initiated to neutralize the pathogen.
compartment) back to the bloodstream, thus helping he human body has evolved three major responses
to maintain a normal blood volume. On average, to protect against foreign invaders:
the lymphatics return about 3.5 to 4.0 liters of luid • Nonspeciic barriers: this irst line of defense
per day back to the bloodstream. he lymphatics is composed of physical barriers to invasion.
also distribute various hormones, nutrients (fats hese include the skin and mucous membranes
from the bowel and proteins from the intersti- that line the body’s exterior (skin) or its respira-
tium), and waste products from the ECF to the tory, gastrointestinal, urinary, and reproductive
bloodstream. systems (mucosa and its secretions, which may
Lymphatic vessels transport lymph from every- include enzymes, acidic secretions, lushing
where in the body major lymphatic channels. he mechanisms such as tear secretion or the voiding
majority of lymph (about 75-80%) ultimately collects of urine, sticky mucus to sequester pathogens,
in the thoracic duct for delivery back to the venous and physical coughing and sneezing to remove
system (joins the veins at the union of the left pathogens and irritants).
internal jugular and left subclavian veins) (Fig. 1.16). • Innate immunity: this second line of defense
A much smaller right lymphatic duct drains the (if the nonspeciic barrier is breached) is com-
right upper quadrant of the body lymphatics to a posed of a variety of cells and antimicrobial
similar site on the right side. Along the route of secretions, and manifests itself by producing
these lymphatic vessels, encapsulated lymph nodes inlammation and fever.
are strategically placed to “ilter” the lymph as it • Adaptive immunity: this third line of defense
moves toward the venous system. Lymph nodes is characterized by speciic pathogen recognition,

Chapter 1 Introduction to the Human Body 21 1
Tonsils Lymphatics of upper limb

Thoracic duct lymph
Right lymphatic duct

Thymus gland

lymph nodes
Axillary lymph nodes
Thoracic duct
Lymph vessels of mammary gland
Cisterna chyli
Lymphoid nodules
of intestine
Lumbar lymph nodes

Iliac lymph nodes

Inguinal lymph nodes

Drainage of right
lymphatic duct

Bone marrow
of thoracic

Lymphatics of lower limb

FIGURE 1.16 Overview of Lymphatic System. (From Atlas of human anatomy, ed 7, Plate 7.)

immunologic memory, ampliication of immune • Trachea.

responses, and rapid response against pathogens • Bronchi, bronchioles, alveolar ducts/sacs, and
that reinvade the body. alveoli.
• Lungs (a right lung and a left lung).
7. RESPIRATORY SYSTEM Functionally, the respiratory system performs
ive basic functions:
he respiratory system provides oxygen to the body • Filters and humidiies the air and moves it in
for its metabolic needs and eliminates carbon and out of the lungs.
dioxide. Structurally, the respiratory system includes • Provides a large surface area for gas exchange
the following (Fig. 1.17): with the blood.
• Nose and paranasal sinuses. • Helps to regulate the pH of body luids.
• Pharynx and its subdivisions (nasopharynx, • Participates in vocalization.
oropharynx, and laryngopharynx). • Assists the olfactory system with the detection
• Larynx, continuous with the trachea inferiorly. of smells.

22 Chapter 1 Introduction to the Human Body


Oropharynx Superior and supreme

Laryngopharnyx Middle Nasal turbinates (conchae)
(hypopharynx) Inferior


Vocal fold (cord)


R. main bronchus
L. main bronchus
Right lung


Respiratory diaphragm

FIGURE 1.17 Respiratory System.

synapses on a selective target, usually another

8. NERVOUS SYSTEM neuron or target cell, such as muscle cells. Common
types of neurons include the following:
General Organization
• Unipolar (often called pseudounipolar): a neuron
he nervous system integrates and regulates many with one axon that divides into two long
body activities, sometimes at discrete locations processes (sensory neurons found in the spinal
(speciic targets) and sometimes more globally. he ganglia of a spinal nerve).
nervous system usually acts quite rapidly and can • Bipolar: a neuron that possesses one axon and
also modulate efects of the endocrine and immune one dendrite (rare but found in the retina and
systems. he nervous system is separated into two olfactory epithelium).
structural divisions (Fig. 1.18): • Multipolar: a neuron that possesses one axon
• Central nervous system (CNS): includes the and two or more dendrites (the most common
brain and spinal cord. type).
• Peripheral nervous system (PNS): includes the Although the human nervous system contains
somatic, autonomic, and enteric nerves in the billions of neurons, all neurons can be classiied
periphery and outside the CNS. largely into one of three functional types:
• Motor neurons: they convey eferent impulses
Neurons from the CNS or ganglia (collections of neurons
Nerve cells are called neurons, and their structure outside the CNS) to target (efector) cells;
relects the functional characteristics of an individual somatic eferent axons target skeletal muscle,
neuron (Fig. 1.19). Information comes to the neuron and visceral eferent axons target smooth muscle,
largely through treelike processes called axons, cardiac muscle, and glands.
which terminate on the neuron at specialized • Sensory neurons: they convey aferent impulses
junctions called synapses. Synapses can occur on from peripheral receptors to the CNS; somatic
neuronal processes called dendrites or on the aferent axons convey pain, temperature, touch,
neuronal cell body, called a soma or perikaryon. pressure, and proprioception (nonconscious)
Neurons convey eferent (motor or output) sensations; visceral aferent axons convey pain
information via action potentials that course along and other sensations (e.g., nausea) from organs,
a single axon arising from the soma that then glands, and blood vessels to the CNS.

Chapter 1 Introduction to the Human Body 23 1
Clinical Focus 1-7
Asthma can be intrinsic (no clearly defined environmental trigger) or extrinsic (has a defined trigger). Asthma
usually results from a hypersensitivity reaction to an allergen (dust, pollen, mold), which leads to irritation of
the respiratory passages and smooth muscle contraction (narrowing of the passages), swelling (edema) of the
epithelium, and increased production of mucus. Presenting symptoms are often wheezing, shortness of breath,
coughing, tachycardia, and feelings of chest tightness. Asthma is a pathologic inflammation of the airways
and occurs in both children and adults.

Normal bronchus
Mucosal surface

Epithelium Opening of
Basement gland

Blood vessel

Smooth m.



Increased mucus

Early asthmatic response

Smooth m. contraction
results in bronchospasm.
Increased vascular permeability
results in edema.

Allergen-IgE complex



mast cell

In early asthmatic response, release of

mediators from activated mast cells causes
smooth m. contraction, increased mucus
production, and increased vascular
permeability, resulting in airway narrowing
and airflow limitation.

24 Chapter 1 Introduction to the Human Body

Central nervous system (CNS) Receptors

Somatic sensory Visceral sensory
receptors: monitor the receptors: monitor
outside world and body internal conditions and
position organ systems
Spinal cord

Peripheral nervous Sensory information within

system (PNS) afferent division

Central processing

Motor commands within

efferent division


Somatic nervous Autonomic nervous

system system (ANS)

Parasympathetic Sympathetic Enteric nervous

division division system

Smooth muscle
Cardiac muscle GI
Skeletal muscle
Glands smooth muscle


FIGURE 1.18 General Organization of Nervous System. (From Atlas of human anatomy, ed 7,
Plate 6.)

• Interneurons: they convey impulses between are myelinated by a special glial cell called an
sensory and motor neurons in the CNS, thus oligodendrocyte, whereas in the PNS they are
forming integrated networks between cells; surrounded by a glial cell called a Schwann cell.
interneurons probably account for more than Schwann cells also myelinate many of the PNS axons
99% of all neurons in the body. they surround.
Neurons can vary considerably in size, ranging
from several micrometers to more than 100 µm in
diameter. Neurons may possess numerous branching Glia
dendrites, studded with dendritic spines that Glia are the cells that support neurons, within both
increase the receptive area of the neuron many-fold. the CNS (the neuroglia) and the PNS. Glial cells
he neuron’s axon may be quite short or over 1 far outnumber the neurons in the nervous system
meter long. he axonal diameter may vary. Axons and contribute to most of the postnatal growth,
that are larger than 1 to 2 µm in diameter are along with axonal myelination, seen in the CNS.
insulated by myelin sheaths. In the CNS, axons Functionally, glia:

Chapter 1 Introduction to the Human Body 25 1
CNS; these phagocytic cells participate in inlam-
matory reactions, remodel and remove synapses,
and respond to injury.
• Ependymal cells: these cells line the ventricles
Tanycyte cell of the brain and the central canal of the spinal
cord, which contains cerebrospinal luid.
• Schwann cells: these are the glial cells of the PNS;
Neuron Oligoden- surround all axons (myelinating many of them)
drocyte and provide trophic support, facilitate regrowth
Dendrite of PNS axons, and clean away cellular debris.

Peripheral Nerves
Axon he peripheral nerves observed grossly in the
Astrocyte foot process human body are composed of bundles of thousands
Perivascular of nerve ibers enclosed within a connective tissue
Pia mater Capillary pericyte
covering and supplied by small blood vessels. he
nerve “ibers” consist of axons (eferent and aferent)
individually separated from each other by the
cytoplasmic processes of Schwann cells or myelin-
ated by a multilayered wrapping of continuous
FIGURE 1.19 Cell Types Found in Central Nervous
Schwann cell membrane (the myelin sheath).
he peripheral nerve resembles an electrical
cable of axons that is further supported by three
• Provide structural isolation of neurons and their connective tissue sleeves or coverings (Fig. 1.20):
synapses. • Endoneurium: a thin connective tissue sleeve
• Sequester ions in the extracellular compartment. that surrounds the axons and Schwann cells.
• Provide trophic support to the neurons and their • Perineurium: a dense layer of connective tissue
processes. that encircles a bundle (fascicle) of nerve ibers.
• Support growth and secrete growth factors. • Epineurium: an outer thick connective tissue
• Support some of the signaling functions of sheath that encircles bundles of fascicles; this
neurons. is the “nerve” typically seen grossly coursing
• Myelinate axons. throughout the human body.
• Phagocytize debris and participate in inlam- Peripheral nerves include the 12 pairs of cranial
matory responses. nerves arising from the brain or brainstem and
• Play a dynamic role in pruning or preserving the 31 pairs of spinal nerves arising from the
neuronal connections. spinal cord.
• Rid the brain of metabolites and dump them
into the CSF. Meninges
• Participate in the formation of the blood-brain he brain and spinal cord are surrounded by three
barrier. membranous connective tissue layers called the
he diferent types of glial cells include the meninges. hese three layers include the following
following (see Fig. 1.19): (Fig. 1.21):
• Astrocytes: these are the most numerous of • Dura mater: the thick, outermost meningeal
the glial cells; provide physical and metabolic layer, richly innervated by sensory nerve ibers.
support for CNS neurons, can become reactive • Arachnoid mater: the ine, weblike avascular
during CNS injury, release growth factors and membrane directly beneath the dural surface.
other bioactive molecules, and contribute to the • Pia mater: the delicate membrane of connective
formation of the blood-brain barrier. tissue that intimately envelops the brain and
• Oligodendrocytes: these are smaller glial cells; spinal cord.
responsible for the formation and maintenance he space between the arachnoid and the
of myelin in the CNS. underlying pia is called the subarachnoid space
• Microglia: these are smallest and rarest of CNS and contains cerebrospinal luid (CSF), which
glia, although more numerous than neurons in bathes and protects the CNS.

26 Chapter 1 Introduction to the Human Body

Longitudinal vessels

Outer epineurium Cell body of an oligodendrocyte

(neurilemmal cells play similar
role in peripheral nervous system)
Inner epineurium

Cell membrane of
myelinated axon

Nerve fiber in cytoplasm of
bundles neuronal axon

Nerve fibers Fused layers of cell membrane of
Node of Ranvier
oligodendrocyte wrapped around
axon of a myelinated neuron of central
Endoneurium nervous system

FIGURE 1.20 Features of Typical Peripheral Nerve.

Dura mater
mater Arachnoid mater

Pia mater overlying

spinal cord

FIGURE 1.21 CNS Meninges. (From Atlas of human anatomy, ed 7, Plates 113 and 174.)

Cranial Nerves
• General somatic afferents (GSAs): they contain
Twelve pairs of cranial nerves arise from the brain, nerve ibers that are sensory from the skin, such
and they are identiied both by their names and by as those of a spinal nerve.
Roman numerals I to XII (Fig. 1.22). he cranial • General visceral efferents (GVEs): they contain
nerves are somewhat unique and can contain motor ibers to visceral structures (smooth
multiple functional components: muscle and/or glands), such as a parasympathetic
• General: same general functions as spinal nerves. iber from the sacral spinal cord (spinal cord
• Special: functions found only in cranial nerves. levels S2 to S4 give rise to parasympathetics).
• Aferent and eferent: sensory and motor • Special somatic afferents (SSAs): they contain
functions, respectively. special sensory ibers, such as those for vision
• Somatic and visceral: related to skin and skeletal and hearing.
muscle (somatic) or to smooth muscle, cardiac In general, CN I and CN II arise from the
muscle, and glands (visceral). forebrain and are really tracts of the brain for the
herefore, each cranial nerve (CN) may possess special senses of smell and sight. he other cranial
multiple functional components, such as the nerves arise from the brainstem. Cranial nerves
following: III, IV, and VI move the extraocular skeletal muscles

Chapter 1 Introduction to the Human Body 27 1
Spinal n. fibers
Efferent (motor) fibers
Afferent (sensory) fibers


I II Ciliary m., sphincter of

pupil, and all external eye ic
Olfactory Optic lm
mm. except those below htha
IV ary
Trochlear ax
Superior oblique m. V
nd ibu Motor—mm. of
Trigeminal Ma mastication
sinuses, teeth
rectus m.

Intermediate n.
VII sublingual, lacrimal glands
Facial Taste—anterior 2⁄3 of
Mm. of face tongue, sensory soft palate

Cochlear Vestibular

Taste—posterior 1⁄3 of tongue
Sensory—tonsil, pharynx, middle ear
Motor—stylopharyngeus, upper
pharyngeal mm., parotid gland

Motor—heart, lungs, palate, pharynx,
XI larynx, trachea, bronchi, GI tract
Accessory Sensory—heart, lungs, trachea,
Sternocleidomastoid, bronchi, larynx, pharynx,
trapezius mm. GI tract, external ear
Tongue mm.

FIGURE 1.22 Overview of Cranial Nerves. (From Atlas of human anatomy, ed 7, Plate 129.)

of the eyeball. CN V has three divisions: V1 and V2 Spinal Nerves

are sensory, and V3 is both motor to skeletal muscle he spinal cord gives rise to 31 pairs of spinal nerves
and sensory. Cranial nerves VII, IX, and X are both (Figs. 1.23 and 1.24), which then form two major
motor and sensory. CN VIII is the special sense of branches (rami):
hearing and balance. CN XI and CN XII are motor • Posterior (dorsal) ramus: a small ramus that
to skeletal muscle. Cranial nerves III, VII, IX, and courses dorsally to the back; it conveys motor
X also contain parasympathetic ibers of origin and sensory information to and from the skin
(visceral), although many of the autonomic ibers and intrinsic back skeletal muscles (erector
will “jump” onto the branches of CN V to reach spinae, transversospinales).
their targets. Table 1.2 summarizes the types of • Anterior (ventral) ramus: a much larger ramus
ibers in each cranial nerve. that courses laterally and ventrally; it innervates

28 Chapter 1 Introduction to the Human Body

TABLE 1.2 Cranial Nerve Fibers

I Olfactory SVA (Special sense of smell)
II Optic SSA (Special sense of sight)
III Oculomotor GSE (Motor to extraocular muscles)
GVE (Parasympathetic to smooth muscle in eye)
IV Trochlear GSE (Motor to one extraocular muscle)
V Trigeminal GSA (Sensory to face, orbit, nose, anterior tongue)
SVE (Motor to skeletal muscles)
VI Abducens GSE (Motor to one extraocular muscle)
VII Facial GSA (Sensory to skin of ear)
SVA (Special sense of taste to anterior tongue)
GVE (Motor to glands—salivary, nasal, lacrimal)
SVE (Motor to facial muscles)
VIII Vestibulocochlear SSA (Special sense of hearing and balance)
IX Glossopharyngeal GSA (Sensory to posterior tongue)
SVA (Special sense of taste—posterior tongue)
GVA (Sensory from middle ear, pharynx, carotid body, sinus)
GVE (Motor to parotid gland)
SVE (Motor to one muscle of pharynx)
X Vagus GSA (Sensory external ear)
SVA (Special sense of taste—epiglottis)
GVA (Sensory from pharynx, larynx, thoracoabdominal organs)
GVE (Motor to thoracoabdominal organs)
SVE (Motor to muscles of pharynx/larynx)
XI Accessory GSE (Motor to two muscles)
XII Hypoglossal GSE (Motor to tongue muscles)

*GSA, General somatic aferent; GSE, general somatic eferent; GVA, general visceral aferent; GVE, general visceral eferent; SSA, special somatic
aferent; SVA, special visceral aferent; SVE, special visceral eferent.

Spinal cord and anterior rami in situ all the remaining skin and skeletal muscles of
the neck, limbs, and trunk.
C1 spinal n. Cervical plexus Once nerve ibers (sensory or motor) are
beyond, or peripheral to, the spinal cord proper,
Brachial plexus the ibers (axons) then reside in nerves of the PNS.
T1 spinal n.
Components of the PNS include the following
(Fig. 1.24):
• Somatic nervous system: sensory and motor
nn. mater
ibers to skin, skeletal muscle, and joints (Fig.
1.24, left side).
• Autonomic nervous system (ANS): sensory
and motor ibers to all smooth muscle (viscera,
spinal n. vasculature), cardiac muscle (heart), and glands
(Fig. 1.24, right side).
Conus medullaris Lumbar plexus • Enteric nervous system: plexuses and ganglia
Cauda equina of the GI tract that regulate bowel secretion,
S1 spinal n. absorption, and motility (originally considered
Sacral plexus part of ANS); they are linked to the ANS for
optimal regulation.
of dural sac Features of the somatic nervous system include
the following:
• It is a one-neuron motor system.
• he motor (eferent) neuron is in the CNS, and
an axon projects to a peripheral target (e.g.,
skeletal muscle).
FIGURE 1.23 Overview of Spinal Cord and Spinal
Nerves. (From Atlas of human anatomy, ed 7, Plate 169.)
• he sensory (aferent) neuron (pseudounipolar)
resides in a peripheral ganglion called a spinal

Chapter 1 Introduction to the Human Body 29 1
Somatic components Efferent components
Pacinian Posterior root
corpuscle Spinal
Vascular smooth
m., sweat
glands, and
Posterior arrector pili
ramus mm. in skin
Skeletal m.
Anterior ramus
Gray ramus communicans
root Sympathetic chain ganglion
Free White ramus
Splanchnic n.
endings communicans
Collateral Sympathetic chain
ganglion Preganglionic sympathetic neurons
Skeletal m. passing to synapse in another
sympathetic chain ganglion
Sensory neuron of Neuroeffector junctions on
abdominal viscera smooth m., cardiac m., secretory
glands, metabolic cells, immune cells
Sensory Motor Preganglionic sympathetic Postganglionic sympathetic

FIGURE 1.24 Elements of Peripheral Nervous System. For clarity, this schematic shows the
arrangement of the eferent and aferent somatic nerve components of a typical spinal nerve on the left
side and the eferent components of the ANS of a typical spinal nerve on the right side.

ganglion and conveys sensory information from sends its axon to the target (smooth muscle, cardiac
the skin, muscle, or joint to the CNS (in this muscle, and glands). he ANS is a visceral system,
case the spinal cord). since many of the body’s organs are composed of
he unilateral area of skin innervated by the smooth muscle walls or contain secretory glandular
somatic sensory ibers from a single spinal cord tissue.
level is called a dermatome. Clinically, dermatome
maps of the body can be helpful in localizing spinal Sympathetic Division
cord or peripheral nerve lesions (see Chapter 2). he sympathetic division of the ANS is also known
Features of the ANS division of the PNS include as the thoracolumbar division because:
the following: • Its preganglionic neurons are found only in the
• It is a two-neuron motor system; the irst neuron T1-L2 spinal cord levels.
resides in the CNS and the second neuron in a • Its preganglionic neurons lie within the inter-
peripheral autonomic ganglion. mediolateral gray matter of the spinal cord, in
• he axon of the irst neuron is termed pregan- 14 spinal cord segments (T1-L2).
glionic and of the second neuron, postganglionic. Preganglionic axons exit the T1-L2 spinal cord
• he ANS has two divisions, sympathetic and in an anterior root, then enter a spinal nerve, and
parasympathetic. then via a white ramus communicans enter the
• he sensory neuron (pseudounipolar) resides sympathetic chain. he sympathetic chain is a
in a spinal ganglion (similar to the somatic bilateral chain of ganglia just lateral to the vertebral
system) and conveys sensory information from bodies that runs from the base of the skull to the
the viscera to the CNS. coccyx. Once in the sympathetic chain, the pre-
ganglionic axon may take one of three synaptic
Autonomic Nervous System routes:
he ANS is divided into sympathetic and parasym- 1. Synapse on a postganglionic sympathetic neuron
pathetic divisions. In contrast to the somatic division at the T1-L2 level, or ascend or descend to
of the PNS, the ANS is a two-neuron system with synapse on a sympathetic chain neuron at any
a preganglionic neuron in the CNS that sends its of the 31 spinal nerve levels.
axon into a peripheral nerve to synapse on a 2. Pass through the sympathetic chain, enter a
postganglionic neuron in a peripheral autonomic splanchnic (visceral) nerve, and synapse in a
ganglion (Fig. 1.25). he postganglionic neuron then collateral ganglion in the abdominopelvic cavity.

30 Chapter 1 Introduction to the Human Body

Internal carotid nerve and plexus

Superior cervical ganglion External carotid nerve and plexus
Lacrimal gland


C1– C8
Parotid gland
Innervation to arrector pili muscles,
Sublingual gland
vascular smooth muscle, and sweat
glands of skin Submandibular gland

Cardiac branches

Greater splanchnic nerve

T1– T12

Celiac ganglion
Lesser splanchnic
Aorticorenal ganglion
White ramus Liver
communicans Gallbladder

Gray ramus Pancreas

communicans Adrenal gland

Superior mesenteric
Kidneys ganglion


Lumbar splanchnic
First lumbar ganglion nerves
splanchnic Descending Inferior mesenteric
nerves colon ganglion

First sacral ganglion



Inferior hypogastric plexus

Preganglionic fibers (T1–L2)
Postganglionic fibers External genitalia

FIGURE 1.25 Sympathetic Division of Autonomic Nervous System. (From Atlas of human anatomy,
ed 7, Plate 172.)

3. Pass through the sympathetic chain, enter a hypogastric plexuses of nerves to distribute to
splanchnic nerve, pass through a collateral the head, thorax, and pelvic viscera.
ganglion, and synapse on the cells of the adrenal 3. Arise from postganglionic neurons in collateral
medulla (the central portion of the adrenal ganglia and course with blood vessels to abdomi-
gland). nopelvic viscera.
Axons of the postganglionic sympathetic neurons 4. Cells of the adrenal medulla are diferentiated
may act in one of four ways: neuroendocrine cells (paraneurons) that do not
1. Reenter the spinal nerve via a gray ramus have axons but release hormones directly into
communicans and join any one of the 31 spinal the bloodstream. hey are innervated by pre-
nerves as they distribute widely throughout the ganglionic sympathetic ibers.
body. Preganglionic axons release acetylcholine (ACh)
2. Reenter the spinal nerve but course along blood at their synapses, and norepinephrine (NE) is the
vessels in the head, or join cardiopulmonary or transmitter released by postganglionic axons (except

Chapter 1 Introduction to the Human Body 31 1
TABLE 1.3 Effects of Sympathetic Stimulation on Various Structures
Eye Dilates the pupil Liver Causes glycogen breakdown, glucose
Lacrimal glands Reduces secretion slightly synthesis and release
(vasoconstriction) Salivary glands Reduces and thickens secretion via
Skin Causes goose bumps (arrector pili vasoconstriction
muscle contraction) Genital system Causes ejaculation and orgasm, and
Sweat glands Increases secretion remission of erection
Peripheral vessels Causes vasoconstriction Constricts male internal urethral
Heart Increases heart rate and force of sphincter muscle
contraction Urinary system Decreases urine production via
Coronary arteries Vasoconstriction (metabolic vasoconstriction
vasodilation overrides this effect) Constricts male internal urethral
Lungs Assists in bronchodilation and sphincter muscle
reduced secretion Adrenal medulla Increases secretion of epinephrine or
Digestive tract Decreases peristalsis, contracts norepinephrine
internal anal sphincter muscle,
causes vasoconstriction to shunt
blood elsewhere

ACh is released on sweat glands). he cells of the 3. Exit the sacral spinal cord via an anterior root
adrenal medulla (modiied postganglionic sympa- and then enter the pelvic splanchnic nerves, to
thetic neurons) release epinephrine and some NE synapse on postganglionic neurons in terminal
into the blood, not as neurotransmitters but as ganglia located in or near the viscera to be
hormones. he sympathetic system acts globally innervated.
throughout the body to mobilize it in “fright-light- Axons of the postganglionic parasympathetic
ight” situations (Table 1.3). neurons take one of two courses:
1. Pass from the parasympathetic ganglion in the
Parasympathetic Division head on existing nerves or blood vessels, to
he parasympathetic division of the ANS also is a innervate smooth muscle and glands of the head.
two-neuron system with its preganglionic neuron 2. Pass from terminal ganglia in or near the viscera
in the CNS and postganglionic neuron in a periph- innervated and synapse on smooth muscle,
eral ganglion (Fig. 1.26). he parasympathetic cardiac muscle, or glands in the neck, thorax,
division also is known as the craniosacral division and abdominopelvic cavity.
because: As noted above, the vagus nerve (CN X) is
• Its preganglionic neurons are found in cranial unique. Its preganglionic axons exit the brainstem
nerves III, VII, IX, and X and in the sacral spinal and synapse on terminal ganglia in or near the
cord at levels S2-S4. targets in the neck, thorax (heart, lungs, glands,
• Its preganglionic neurons reside in the four smooth muscle), and abdominal cavity (proximal
cranial nuclei associated with the four cranial two thirds of the GI tract and its accessory organs).
nerves listed earlier or in the lateral gray matter Axons of the terminal ganglia neurons then synapse
of the sacral spinal cord at levels S2-S4. on their targets.
Preganglionic parasympathetic axons exit the Parasympathetic axons do not pass into the limbs
CNS in one of three ways: as do sympathetic axons. herefore, the vascular
1. Exit the brainstem in the cranial nerve (except smooth muscle, arrector pili muscles of the skin
CN X) and pass to a peripheral ganglion in the (attached to hair follicles), and sweat glands are all
head (ciliary, pterygopalatine, submandibular, innervated only by the sympathetic system. ACh
and otic ganglia) to synapse on the parasympa- is the neurotransmitter at all parasympathetic
thetic postganglionic neurons residing in these synapses, both preganglionic and postganglionic
ganglia. synapses.
2. CN X preganglionic ibers exit the brainstem he parasympathetic system is involved in
and provide preganglionic parasympathetics to feeding and sexual arousal functions and acts more
terminal ganglia (microscopically small postgan- slowly and focally than the sympathetic system.
glionic neurons) in the neck, thorax, and proximal For example, CN X can slow the heart rate without
two-thirds of the abdominal viscera. afecting input to the stomach. In general, the

32 Chapter 1 Introduction to the Human Body

Ciliary ganglion Pterygopalatine ganglion

Branch of oculomotor nerve (CN III) Lacrimal glands
Branch of facial nerve (CN VII)
Branch of glossopharyngeal
nerve (CN IX)
Parotid glands
Otic ganglion
Sublingual glands
Submandibular ganglion Submandibular glands
Vagus nerve (CN X) Lungs

Pulmonary plexus

Celiac ganglion

mesenteric Gallbladder
ganglion Bile ducts



Descending colon

Inferior hypogastric plexus Sigmoid colon

S2 Rectum
S4 Urinary bladder
Pelvic splanchnic nerves
Preganglionic fibers
Postganglionic fibers
External genitalia
FIGURE 1.26 Parasympathetic Division of Autonomic Nervous System. (From Atlas of human
anatomy, ed 7, Plate 173.)

sympathetic and parasympathetic systems maintain Enteric Nervous System

homeostasis, although as a protective measure, the he enteric nervous system was formally considered
body maintains a low level of “sympathetic tone” the third division of the ANS. he word enteric
and can activate this division on a moment’s notice. refers to the bowel. his component of the PNS
ANS function is regulated ultimately by the hypo- consists of ganglia and nerve plexuses in the walls
thalamus. Table 1.4 summarizes the speciic func- and mesenteries of the GI tract. hese ganglia
tions of the parasympathetic division of the ANS. and their neural networks include the following
Although the ANS uses classic neurotransmitters (Fig. 1.27):
such as NE and ACh at its synapses, its neurons • Myenteric (Auerbach’s) plexuses: ganglia and
also co-release a wide variety of neuroactive peptides nerves located between the circular and longi-
and other neuromodulators that “ine-tune” their tudinal smooth muscle layers of the muscularis
functions at the level of their respective targets. externa of the bowel wall.

Chapter 1 Introduction to the Human Body 33 1
TABLE 1.4 Effects of Parasympathetic Stimulation on Various Structures
Eye Constricts pupil Digestive tract Increases peristalsis, increases
Ciliary body Constricts muscle for secretion, inhibits internal anal
accommodation (near vision) sphincter for defecation
Lacrimal glands Increase secretion Liver Aids glycogen synthesis and storage
Heart Decreases heart rate and force of Salivary glands Increase secretion
contraction Genital system Promotes engorgement of erectile
Coronary arteries Vasodilation (of little importance) tissues
Lungs Cause bronchoconstriction and Urinary system Contracts bladder (detrusor muscle)
increased secretion for urination, inhibits contraction
of male internal urethral sphincter,
increases urine production

Autonomic nervous system

Parasympathetic division Sympathetic division

he endocrine system, along with the nervous and

immune systems, facilitates communication, integra-
Vagal tion, and regulation of many of the body’s functions
nuclei Sympathetic (Fig. 1.28). Speciically, the endocrine system interacts
spinal cord spinal cord

ganglia with target sites (cells and tissues), some that are

quite a distance from a gland, by releasing hormones

Vagus nn. Preganglionic
fibers into the bloodstream. Generally, endocrine glands
and hormones also share the following features:

• Secretion is controlled by feedback mechanisms.

spinal cord

• Hormones bind target receptors on cell mem-


Pelvic branes or within the cells (cytoplasmic or nuclear).

fibers • Hormone action may be slow to appear but may
have long-lasting efects.
Enteric nervous system
Myenteric Submucosal • Hormones are chemically diverse molecules
plexus plexus (amines, peptides/proteins, steroids).
Hormones can communicate through a variety
Smooth m.
of cell-to-cell interactions, including:
Blood vessels
• Autocrine: interacts on another cell as well as
on itself.
• Paracrine: interacts directly on an adjacent or
Secretory nearby cell.
• Endocrine: interacts at a great distance by travel-
FIGURE 1.27 Relationship of Enteric Nervous System to ing in the bloodstream.
Sympathetic and Parasympathetic ANS Divisions.
• Neurocrine: interacts similar to a neurotrans-
mitter, except released into the bloodstream.
• Submucosal (Meissner’s) plexuses: ganglia Table 1.5 summarizes the major hormones and
and nerves located in the submucosa of the the tissues responsible for their release.
bowel wall. Additionally, other organs have paracrine or
he enteric nervous system has important links endocrine functions. For example, the placenta
to both divisions of the ANS, which are critical for releases human chorionic gonadotropin (hCG),
optimal regulation of bowel secretion, absorption, estrogens, progesterone, and human placental
and motility. More than 20 diferent transmitter lactogen (hPL), whereas other cells release a variety
substances have been identiied in the intrinsic of growth factors. he mesenteries of the GI tract
neurons of the enteric nervous system, pointing to also release various substances, and they contain
the ine degree of regulation that occurs at the level a variable amount of fat, which itself releases the
of the bowel wall. Optimal GI functioning requires hormone leptin. Again, the endocrine system is
coordinated interactions of the ANS, the enteric widespread and critically important in regulating
nervous system, and the endocrine system. bodily functions. Each year, researchers ind

34 Chapter 1 Introduction to the Human Body

Hypothalamus TABLE 1.5 Major Hormones*

gland TISSUE/
Pituitary gland
Hypothalamus Antidiuretic hormone (ADH),
Parathyroid glands oxytocin, thyrotropin-releasing
(on posterior surface hormone (TRH), corticotropin-
of thyroid gland) Thyroid
releasing hormone (CRH), growth
hormone–releasing hormone
Thymus (GHRH), gonadotropin-releasing
hormone (GnRH), somatostatin
(SS), dopamine (DA)
Pineal gland Melatonin
Anterior pituitary Adrenocorticotropic hormone
gland (ACTH), thyroid-stimulating
hormone (TSH), growth
hormone (GH), prolactin,
follicle-stimulating hormone
(FSH), luteinizing hormone (LH),
melanocyte-stimulating hormone
Posterior pituitary Oxytocin, vasopressin (ADH)
Thyroid gland Thyroxine (T4), triiodothyronine
Digestive (T3), calcitonin
Heart Parathyroid Parathyroid hormone (PTH,
glands parathormone)
Pancreatic Thymus gland Thymopoietin, thymulin,
islets thymosin, thymic humoral factor,
Adrenal interleukins, interferons
glands Heart Atrial natriuretic peptide (ANP)
Digestive tract Gastrin, secretin, cholecystokinin
(CCK), motilin, gastric inhibitory
peptide (GIP), glucagon, SS,
Fat vasoactive intestinal peptide
(VIP), ghrelin, leptin, and many
Testes Liver Insulin-like growth factors (IGFs)
Suprarenal Cortisol, aldosterone, androgens,
(adrenal) glands epinephrine (E), norepinephrine
Ovaries (NE)
Pancreatic islets Insulin, glucagon, SS, VIP,
pancreatic polypeptide
Kidneys Erythropoietin (EPO), calcitriol,
renin, urodilatin
Fat Leptin
Ovaries Estrogens, progestins, inhibin,
Testes Testosterone, inhibin
White blood Various cytokines; interleukins,
cells and some colony-stimulating factors,
connective tissue interferons, tumor necrosis factor
cells (TNF)
FIGURE 1.28 Major Endocrine Organs.
*his list is not comprehensive; only the more commonly found
hormones are listed.

additional paracrine and endocrine substances, and

many of their regulatory functions continue to be
elucidated. • Salivary glands: three major glands and hun-
dreds of microscopic minor salivary glands
10. GASTROINTESTINAL SYSTEM scattered throughout the oral mucosa.
• Liver: the largest solid gland in the body
he GI system includes the epithelial-lined tube • Gallbladder: functions to store and concentrate
that begins with the oral cavity and extends to the bile needed for fat digestion.
anal canal, as well as GI-associated glands, including • Pancreas: crucial exocrine (digestive enzymes)
the following: and endocrine organ.

Chapter 1 Introduction to the Human Body 35 1

Pharyngeal mm. propel food into esophagus Oral cavity, teeth, tongue
Mechanical breakdown, mixing with saliva
Secretion of bile (important for lipid digestion),
storage of nutrients, production of cellular fuels,
plasma proteins, clotting factors, Salivary glands
and detoxification and phagocytosis Secretion of lubricating fluid containing enzymes
that initiate digestion

Pancreas Transport of food into the stomach
Secretion of buffers and digestive
enzymes by exocrine cells; secretion
of hormones by endocrine cells
to regulate digestion

Chemical breakdown of food by acid
and enzymes; mechanical breakdown
via muscular contractions

Storage and concentration of bile

Large intestine
Small intestine
Dehydration and compaction
Enzymatic digestion and absorption of water,
of indigestible materials for
organic substrates, vitamins, and ions; host defense
elimination; resorption of water
and electrolytes; host defense

FIGURE 1.29 Overview of Gastrointestinal System.

he epithelial-lined tube that is the GI tract the posterior abdominal wall just anterior to the
measures about 28 feet (8 m) in length (from mouth muscles of the posterior wall.
to anal canal) and includes the following cavities • Ureters: course retroperitoneally from the
and visceral structures (Fig. 1.29): kidneys to the pelvis and convey urine from the
• Oral cavity: tongue, teeth, and salivary glands. kidneys to the urinary bladder.
• Pharynx: throat, subdivided into the nasophar- • Urinary bladder: lies subperitoneally in
ynx, oropharynx, and laryngopharynx. the anterior pelvis, stores urine, and when
• Esophagus: passing from the pharynx to the appropriate, discharges the urine through the
stomach. urethra.
• Stomach: the expandable saclike portion of the • Urethra: courses from the urinary bladder to
GI tract. the exterior.
• Small intestine: subdivided into the duodenum, he kidneys function to:
jejunum, and ileum. • Filter the plasma and begin the process of urine
• Large intestine: subdivided into the cecum, formation.
ascending colon, transverse colon, descending • Reabsorb important electrolytes, organic mol-
colon, sigmoid colon, rectum, and anal canal. ecules, vitamins, and water from the iltrate.
• Excrete metabolic wastes, metabolites, and
11. URINARY SYSTEM foreign chemicals (e.g., drugs).
• Regulate luid volume, composition, and pH.
he urinary system includes the following compo- • Secrete hormones that regulate blood pressure,
nents (Fig. 1.30): erythropoiesis, and calcium metabolism.
• Kidneys: paired retroperitoneal organs that ilter • Convey urine to the ureters, which then pass
the plasma and produce urine; located high in the urine to the bladder.

36 Chapter 1 Introduction to the Human Body

• Uterine tubes (fallopian tubes): paired tubes

Adrenal that extend from the superolateral walls of the
uterus and open as imbriated funnels into the
Renal a.
pelvic cavity adjacent to the ovary, to “capture”
Renal v.
the oocyte as it is ovulated.
• Uterus: hollow, pear-shaped muscular (smooth
muscle) organ that protects and nourishes a
Ureter developing fetus.
Abdominal • Vagina: distensible ibromuscular tube (also
ureter Psoas called birth canal) approximately 8 to 9 cm long
major m. that extends from the uterine cervix (neck) to
the vestibule.
Rectum Male Reproductive System
he male reproductive system is composed of the
following structures (see Fig. 1.31):
Urethra Prostate
• Testes: the paired gonads of the male reproduc-
tive system, egg shaped and about the size of a
chestnut; produce the male germ cells, sperma-
tozoa, and reside in the scrotum (externalized
FIGURE 1.30 Urinary System.
from the abdominopelvic cavity).
• Epididymis: a convoluted tubule that receives
he kidneys ilter about 180 liters of luid each the spermatozoa and stores them as they mature.
day. Grossly, each kidney measures about 12 cm • Ductus (vas) deferens: a muscular (smooth
long × 6 cm wide × 3 cm thick and weighs about muscle) tube about 40 to 45 cm long that conveys
150 grams, although variability is common. Approxi- sperm from the epididymis to the ejaculatory
mately 20% of the blood pumped by the heart passes duct (seminal vesicle).
to the kidney each minute for plasma iltration, • Seminal vesicles: paired tubular glands that lie
although most of the luid and important plasma posterior to the prostate gland, about 15 cm
constituents are returned to the blood as the iltrate long; produce seminal luid and join the ductus
courses down the tubules of the kidney’s nephrons deferens at the ejaculatory duct.
(the nephrons are the kidney’s iltration units; they • Prostate gland: a walnut-sized gland that
are microscopically small and number about 1 surrounds the urethra as it leaves the urinary
million in each kidney). bladder; produces prostatic luid, which is
Each ureter is about 24 to 34 cm long, lies in a added to semen (sperm suspended in glandular
retroperitoneal position, and contains a thick secretions).
smooth muscle wall. he urinary bladder serves as • Urethra: a canal that passes through the prostate
a reservoir for the urine and is a smooth muscle gland, enters the penis, and conveys the semen
“bag” that expels the urine when appropriate. he for expulsion from the body during ejaculation.
female urethra is short (3-4 cm), whereas the male
urethra is long (~20 cm), coursing through the 13. BODY CAVITIES
prostate gland, external urethral sphincter, and
corpus spongiosum of the penis. Organ systems and other visceral structures are
often segregated into body cavities. hese cavities
12. REPRODUCTIVE SYSTEM can protect the viscera and also may allow for some
expansion and contraction in size. Two major col-
Female Reproductive System lections of body cavities are recognized (Fig. 1.32):
he female reproductive system is composed of • Posterior cavities: include the brain, surrounded
the following structures (Fig. 1.31): by the meninges and bony cranium, and the
• Ovaries: the paired gonads of the female spinal cord, surrounded by the same meninges
reproductive system; produce the female germ as the brain and the bony vertebral column.
cells called ova (oocytes, eggs) and secrete the • Anterior cavities: include the thoracic and abdom-
hormones estrogen and progesterone. inopelvic cavities, separated by the respiratory

Chapter 1 Introduction to the Human Body 37 1
Female: Median (sagittal) section
Suspensory lig.
of ovary
Uterine Body of uterus
Ovary Urinary bladder

Round lig.
of uterus Cervix of uterus
teres) Rectum

Fundus Vagina
of uterus

Male: Paramedian (sagittal) dissection
Crus of clitoris
Urinary bladder
Labium minus and fascia
Labium majus Ureter (cut)


Ductus (vas) deferens Rectum

Superior pubic ramus (cut)

Corpus cavernosum Prostate

by fascia)
Corpus spongiosum

ramus (cut)

FIGURE 1.31 Reproductive System. (From Atlas of human anatomy, ed 7, Plates 345 and 349.)

Cranial Cranial cavity


Vertebral cavity

Posterior Thoracic Pleural
body cavity cavity
cavity Pericardial
cavity within
the mediastinum
Anterior body
Diaphragm cavity
Abdominal cavity (thoracic and
Vertebral Abdomino-
cavity pelvic
Pelvic cavity

FIGURE 1.32 Major Body Cavities.

38 Chapter 1 Introduction to the Human Body

diaphragm (a skeletal muscle important in morula enters the uterine cavity at about day 5, it
respiration). contains hundreds of cells and it develops a luid-
he CNS (brain and spinal cord) is surrounded illed cyst in its interior; it is now known as a
by three membranes (see Fig. 1.21): blastocyst. At about days 5 to 6, implantation
• Pia mater. occurs as the blastocyst literally erodes or burrows
• Arachnoid mater. its way into the uterine wall (endometrium) (see
• Dura mater. Fig. 1.33).
he thoracic cavity contains two pleural cavities
(right and left) and a single midline space called
the mediastinum (middle space) that contains the
heart and structures lying posterior to it, including Clinical Focus 1-8
the thoracic descending aorta and esophagus. he Potential Spaces
heart itself resides in the pericardial sac, which
has a parietal and a visceral layer. Each of these spaces—pleural, pericardial, and
peritoneal—is considered a “potential” space,
he abdominopelvic cavity also is lined by a
because between the parietal and visceral layers,
serous membrane, the peritoneum, which has a there is usually only a small amount of serous
parietal layer (which lines the interior abdomino- lubricating fluid, to keep organ surfaces moist and
pelvic walls) and a visceral layer (which envelopes slick and thus reduce friction from movements such
the viscera). as respiration, heartbeats, and peristalsis. However,
during inflammation or trauma (when pus or blood
14. OVERVIEW OF EARLY can accumulate), fluids can collect in these spaces
DEVELOPMENT and restrict movement of the viscera. In such situ-
ations, these “potential” spaces become real spaces,
Week 1: Fertilization and Implantation and the offending fluids may have to be removed
Fertilization occurs in the ampulla of the uterine so they do not compromise organ function or
exacerbate an ongoing infection.
tube (fallopian tube) usually within 24 hours after
ovulation (Fig. 1.33). he fertilized ovum (the union
of sperm and egg nuclei, with a diploid number of
chromosomes) is termed a zygote. Subsequent cell
division (cleavage) occurs at the two-, four-, eight-, Week 2: Formation of the Bilaminar
and 16-cell stages and results in formation of a ball Embryonic Disc
of cells that travels down the uterine tube toward As the blastocyst implants, it forms an inner cell
the uterine cavity. When the cell mass reaches days mass (future embryo, embryoblast) and a larger
3 to 4 of development, it resembles a mulberry and luid-illed cavity surrounded by an outer cell layer
is called a morula (16-cell stage). As the growing called the trophoblast (Figs. 1.33 and 1.34). he

Myometrium Four-cell stage

Early morula Zygote
(approx. 80 hr) (approx. 40 hr)
Two-cell stage (approx. 30 hr)


Advanced morula (4 days)


Blastocyst (approx. 5 days) (12 to 24 hr)

Early implantation Mature
(approx. 6 days) follicle
Embryoblast (inner cell mass)
FIGURE 1.33 Schematic of Key Events: Week 1 of Human Development.

Chapter 1 Introduction to the Human Body 39 1
Approximately 7 1/2 days Approximately 12 days Approximately 15 days
Uterine epithelium Extraembryonic
Syncytiotrophoblast Yolk sac
Cytotrophoblast Endoderm
Amniotic cavity Ectoderm
Epiblast Amniotic cavity
Hypoblast Connecting stalk
Primitive yolk sac Cytotrophoblast
Extraembryonic mesoderm Syncytiotrophoblast

FIGURE 1.34 Bilaminar Disc Formation: Week 2 of Human Development.

trophoblast undergoes diferentiation and complex during gastrulation. As you study each region of
cellular interactions with maternal tissues to initiate the body, refer to these summary pages to review
formation of the primitive uteroplacental circulation. the embryonic origins of the various tissues. Many
Simultaneously, the inner cell mass develops into the clinical problems arise during the development in
following two cell types (bilaminar disc formation): utero of these germ layer derivatives.
• Epiblast: formation of a sheet of columnar cells In general, ectodermal derivatives include the
on the dorsal surface of the embryoblast. following (Fig. 1.36):
• Hypoblast: a sheet of cuboidal cells on the • Epidermis and various appendages associated
ventral surface of the embryoblast. with the skin (hair, nails, glands).
he epiblast forms a cavity on the dorsal side • Components of the central and peripheral
that gives rise to the amniotic cavity. he blastocyst nervous systems.
cavity on the ventral side becomes the primitive • Some bones, muscles, and connective tissues of
yolk sac, which is lined by simple squamous epi- the head and neck (neural crest).
thelium derived from the hypoblast. About day 12, In general, mesodermal derivatives include the
further hypoblast cell migration forms the true yolk following (Fig. 1.37):
sac, and the old blastocyst cavity becomes coated • Notochord.
with extraembryonic mesoderm. • Skeletal, smooth, and cardiac muscle.
• Parenchyma or reticular structures and connec-
Week 3: Gastrulation tive tissues of many organ systems.
Gastrulation (development of a trilaminar embry- • Reproductive and urinary systems.
onic disc) begins with the appearance of the • Most skeletal structures.
primitive streak on the dorsal surface of the • Dermis of the skin.
epiblast (Fig. 1.35). his streak forms a groove In general, endodermal derivatives include the
demarcated at its cephalic end (head) by the primi- following (Fig. 1.38):
tive node. he node forms a midline cord of • Lining of GI tract and accessory GI organs.
mesoderm that becomes the notochord. Migrating • Lining of the airway.
epiblast cells move toward the primitive streak, • Various structures derived from the pharyngeal
invaginate, and replace the underlying hypoblast pouches.
cells to become the endoderm germ layer. Other • Embryonic blood cells.
invaginating epiblast cells develop between the • Derivatives associated with the development of
endoderm and overlying epiblast and become the the cloaca.
mesoderm. Finally, the surface epiblast cells form
the ectoderm, the third germ layer. All body tissues 15. IMAGING THE INTERNAL
are derived from one of these three embryonic germ ANATOMY
General Introduction
Embryonic Germ Layer Derivatives In 1895, Wilhelm Roentgen (Würzburg, Germany)
Figs. 1.36 to 1.38 and the accompanying tables used x-rays generated from a cathode ray tube to
provide a general overview of the adult derivatives make the irst radiographic image, for which he
of the three embryonic germ layers that are formed ultimately was awarded the irst Nobel Prize in

40 Chapter 1 Introduction to the Human Body

Formation of intraembryonic mesoderm from the primitive streak and node (knot)


Amniotic cavity Oropharyngeal membrane


Primitive knot (node)

Primitive streak

Migration of cells from the
Yolk sac cavity
primitive streak to form the
intraembryonic mesoderm
Cupola of yolk sac

Oropharyngeal membrane

Spreading of intraembryonic

Cloacal membrane
Paraxial column
= Ectoderm
Intermediate column = Mesoderm
Appearance of the neural plate
Notochord Lateral plate = Endoderm
FIGURE 1.35 Gastrulation Formation: Week 3 of Human Development.

Ectoderm of the gastrula

Primordia Derivatives or fate
Surface ectoderm Epidermis of the skin
Sweat, sebaceous, and
mammary glands
Nails and hair
Tooth enamel
Lacrimal glands
Nails External auditory meatus
(Stomodeum and Oral and nasal epithelium
Epidermis of skin nasal placodes) Anterior pituitary gland
Neural plate (Otic placodes) Inner ear
(Lens placodes) Lens of eye
Neural tube Central nervous system
Somatomotor neurons
Branchiomotor neurons
Neural tube Presynaptic autonomic
Retina/optic nerves
Posterior pituitary gland
Neural crest Peripheral sensory neurons
Surface Postsynaptic autonomic
ectoderm neurons
All ganglia
Adrenal medulla cells
Central and Melanocytes
peripheral Bone, muscle,
nervous system and connective tissue
in the head and neck
Amnion Protective bag (with
chorion) around fetus

FIGURE 1.36 Ectodermal Derivatives.

Chapter 1 Introduction to the Human Body 41 1
Primordia Derivatives or fate

Notochord Nucleus pulposus of an

intervertebral disc
Induces neurulation
Paraxial Skeletal muscle
columns Bone
(somites) Connective tissue (e.g., dorsal
dermis, meninges)
Lateral plate Intermediate Gonads
Notochord Paraxial mesoderm Kidneys and ureters
Intermediate column
column Uterus and uterine tubes
Upper vagina
Axial and appendicular
Ductus deferens, epididymis,
skeleton, 5 weeks
and related tubules
Seminal vesicles and
ejaculatory ducts
Lateral plate Dermis (ventral)
Somite sclerotome mesoderm Superficial fascia and
surrounding neural tube related tissues (ventral)
Bones and connective
tissues of limbs
Pleura and peritoneum
GI tract connective tissue
Intermediate mesoderm
forming kidneys and gonads Cardiogenic Heart
mesoderm Pericardium
Splanchnopleure mesoderm

Somatopleure mesoderm
Developing skeletal mm.,
8 weeks

FIGURE 1.37 Mesodermal Derivatives.

Primordia Epithelial derivatives or fate

Gut tube GI tract (enterocytes)

endoderm Mucosal glands of GI tract
Parenchyma of GI organs (liver,
Airway lining (larynx, trachea,
bronchial tree)
Gut tube Thyroid gland
of cylindrical Tonsils
Cloaca (part of Rectum and anal canal
hindgut) Bladder, urethra, and related glands
Lower vagina
Endoderm of Yolk sac
gastrula and yolk sac Pharyngeal Auditory tube and middle ear
pouches epithelium
(part of foregut) Palatine tonsil crypts
Thymus gland
Parathyroid glands
Stomach C cells of thyroid gland
Pharynx with Gallbladder Yolk sac Embryonic blood cell production
pharyngeal pouches (mesoderm)
Pressed into umbilical cord, then
Intestines disappears
Yolk sac Allantois (from Embryonic blood cell production
stalk yolk sac, then (mesoderm)
cloaca) Vestigial, fibrous urachus
Umbilical cord part disappears

Thyroid Esophagus Pancreas

diverticulum Trachea Allantois
Lung buds Cloaca (future urinary bladder and rectum)

FIGURE 1.38 Endodermal Derivatives.

42 Chapter 1 Introduction to the Human Body

TABLE 1.6 Attenuation of X-rays Passing

Through the Body*
Bone White Trachea
Soft tissue Light gray
Water (reference) Gray Clavicle
Fat Dark gray
Lung Very dark gray
Air Black

*Greatest to least attenuation.

Physics in 1901. As the x-rays (a form of electro- Respiratory
magnetic radiation) pass through the body, they
lose energy to the tissues, and only the photons
with suicient energy to penetrate the tissues then
expose a sheet of photographic ilm. Radiographic
images are now largely collected as digital informa-
tion (Table 1.6).

Plain (Conventional) Radiographs A. PA projection of chest.

A plain radiograph, also known as a conventional
or plain ilm radiograph, provides an image in which
the patient is positioned either anterior (antero-
posterior, AP) to or posterior (posteroanterior, PA)
to the x-ray source (Fig. 1.39, A). he x-ray tube
also may be placed in a lateral or oblique position
in reference to the patient. Contrast media (radi-
opaque luids such as barium sulfate or iodine
compounds) can be administered to study tubular
structures such as the bowel or vessels. A double
contrast study uses barium and air to image the
lumen of structures such as the distal colon (Fig.
1.39, B). X-rays now are collected digitally in real
time by producing a stream of x-rays. Techniques
are now available that can even image moving
structures in the body using angiography (contrast
medium in the heart and larger vessels) and

Computed Tomography
Computed tomography (CT) was invented in
1972 by Sir Godfrey Hounsield (at EMI Labs,
Hayes, England), who received the Nobel Prize in
Medicine or Physiology in 1979 (shared with Allen B. Double contrast radiograph of the colon.
McLeod Cormack of Tufts University, Medford, FIGURE 1.39 Plain (Conventional) Radiographs. PA,
Massachusets). A CT scanner uses x-rays generated Posteroanterior. (From Major NM: A practical approach to
by a tube that passes around the body and collects radiology, Philadelphia, 2006, Saunders.)
a series of images in the axial (transverse slices)
plane. A sophisticated computer program then as the tube rotates in a helical pattern around the
transforms the multiple images into a single slice patient, who is moving through the scanner on a
(Fig. 1.40). table. hree-dimensional (3-D) images can be
In the 1980s, multislice (multidetector) CT recreated by the computer from these slices. Bone
scanners were developed that capture many slices is well imaged by CT, and contrast media may be

Chapter 1 Introduction to the Human Body 43 1
Anterior cerebral artery

Anterior communicating artery

Middle cerebral artery

Posterior cerebral artery

Basilar artery

External carotid artery

Internal carotid artery

Liver Portal vein Inferior vena cava Aorta
Right vertebral artery B. Axial CT of epigastric region.

Left common carotid artery

Right common carotid artery

Plane of
Brachiocephalic artery section
seen in B

Aortic arch

A. CT angiogram of intracranial and extracranial arteries.

FIGURE 1.40 Computed Tomography (CT). (From Kelley LL, Petersen C: Sectional anatomy for
imaging professionals, St Louis, 2007, Mosby.)

employed to enhance the imaging of hollow viscera Magnetic Resonance Imaging

(e.g., GI tract). Additionally, CT angiography (CTA) Paul Lauterbur (Illinois) and Sir Peter Mansield
can image larger blood vessels in 2-D and 3-D after (Nottingham, England) were awarded the Nobel
intravascular administration of contrast material Prize in Medicine or Physiology in 2003 for their
(Fig. 1.40, B). contributions to the development of MRI. Since
Advantages of CT include lower costs than the irst MR image of a human subject was produced
magnetic resonance imaging (MRI), availability, 3-D in 1977, this process has become a versatile and
capabilities, ability to image bony features, and faster safe diagnostic tool. Strong magnets align hydrogen’s
speed than MRI. Disadvantages of CT include the free protons (the hydrogen in molecules of water
high dose of x-rays compared with plain ilms, present in almost all biologic tissues). hen a radio
artifacts (motion, scattering), and relatively poor wave pulse passes through the patient and delects
tissue deinition compared with MRI. the protons, which return to their aligned state but
emit small radio pulses whose strength, frequency,
Positron Emission Tomography/ and time produce distinct signals. Computers then
Computed Tomography analyze these signals and create axial, coronal, and
Glucose uptake in tissues (following 18-luorodeoxy- sagittal images (Fig. 1.41).
D-glucose administration) can be imaged by positron Advantages of MRI include the lack of ionizing
emission tomography (PET/CT), an especially useful radiation, the ability to image all planes, and the
technique for detecting tissues or structures with capability to image soft tissues at very high reso-
a higher metabolic rate, such as malignant tumors lution compared with CT. Disadvantages include
and inlammatory lesions. high cost, inability to image patients with metallic

44 Chapter 1 Introduction to the Human Body

implants or foreign bodies, inability to image bone he waves produced by the transducer are relected
well, longer procedure time than CT, potential for or refracted as they collide with the soft tissue
patients to become claustrophobic in the scanner, interfaces. he proportion of sound relected is
and the tendency for artifacts (movement). measured as acoustic impedance and represents
diferent densities of soft tissue. A computer then
Ultrasound interprets these signals and produces a real-time
Ultrasound uses very-high-frequency longitudinal image (Fig. 1.42).
sound waves that are generated by a transducer.

A viable 9-week-old fetus (black arrowheads) is seen, surrounded

by the gestational sac (white arrowheads)
FIGURE 1.42 Ultrasound. (Reprinted with permission
from Jackson S, homas R: Cross-sectional imaging made
easy, Philadelphia, 2004, Churchill Livingstone.)
Axial (transverse) MR image of the brain, T2-weighted
FIGURE 1.41 Magnetic Resonance Imaging (MRI).
(From Wicke L: Atlas of radiologic anatomy, ed 7,
Philadelphia, 2004, Saunders.)

Clinical Focus
Available Online
1-9 Myasthenia Gravis
Additional figures available online (see inside front cover for

Chapter 1 Introduction to the Human Body 44.e1 1
Clinical Focus 1-9
Myasthenia Gravis
Myasthenia gravis is a disease of the neuromuscular junction in which the postsynaptic membrane shows a
reduction in folding and a reduction in the concentration of acetylcholine (ACh) receptors. Patients present
with muscle weakness, oculomotor abnormalities, ptosis, and diplopia. The disease is generally progressive.

Pathophysiologic concepts
Nerve axon Anticholinesterase
Mitochondria Synaptic cleft
Synaptic vesicles Sarcolemmal folds acetylcholinesterase
ACh receptors Sarcolemma


A Ch h


Normal neuromuscular junction: Synaptic vesicles containing Myasthenia gravis: Marked reduction in number and length
acetylcholine (ACh) form in nerve terminal. In response to of subneural sarcolemmal folds indicates that underlying
nerve impulse, vesicles discharge ACh into synaptic cleft. ACh defect lies in neuromuscular junction. Anticholinesterase
binds to receptor sites on muscle sarcolemma to initiate drugs increase effectiveness and duration of ACh action by
muscle contraction. Acetylcholinesterase (AChE) hydrolyzes slowing its destruction by AChE.
ACh, thus limiting effect and duration of its action.

Clinical manifestations
Regional distribution
of muscle weakness




Ptosis and weakness of smile Improvement after

10% are common early signs AChE inhibitor

In early stages, patient may feel

fine in the morning but develops
diplopia and speech slurs
later in the day

Patient with chin

on chest cannot
resist when
physician pushes
head back

Challenge Yourself Questions
1. A radiologist is examining a computer-generated 5. When examining your musculoskeletal system,
series of MR scans in the frontal plane. Which the orthopedist may check the strength of a
of the following terms is synonymous with the contracting muscle at a joint. As this is done,
frontal plane? another muscle relaxes and would be designated
A. Axial by which of the following terms?
B. Coronal A. Agonist
C. Cross section B. Antagonist
D. Sagittal C. Extensor
E. Transverse D. Fixator
E. Synergist
2. Clinically, the bones can be classiied by their
shape. Which of the following shapes is used 6. During cardiac catheterization, the physician
to deine the patella (kneecap)? watches the blood low from the right ventricle
A. Flat into which of the following vessels?
B. Irregular A. Aorta
C. Long B. Coronary arteries
D. Sesamoid C. Inferior vena cava
E. Short D. Pulmonary trunk
E. Superior vena cava
3. Long bones are responsible for most of our
height. Which of the following portions of the 7. he lymphatic and immune systems are vitally
long bone is most important in lengthening important in defense of the body. Most of the
the bone? lymph ultimately drains back into the venous
A. Diaphysis system by which of the following structures?
B. Epiphysis A. Arachnoid granulations
C. Epiphysial plate B. Choroid plexus
D. Metaphysis C. Cisterna chyli
E. Shaft D. Right lymphatic duct
E. horacic duct
4. An elderly woman falls and fractures her
femoral neck (“breaks her hip”). Which of the 8. A patient experiencing a central nervous system
following type of synovial joints was involved (CNS) inlammatory process will be activating
in the fracture? which of the following phagocytic glial cells?
A. Ball-and-socket (spheroid) A. Astrocytes
B. Condyloid (ellipsoid) B. Ependymal cells
C. Hinge (ginglymus) C. Microglia
D. Plane (gliding) D. Oligodendrocytes
E. Saddle (biaxial) E. Schwann cells

Multiple-choice and short-answer review questions available online; see inside front cover for details.


46 Chapter 1 Introduction to the Human Body

9. he brain and spinal cord are surrounded by 14. A patient has diiculty digesting fats (e.g., french
membranous connective tissue layers. he pain fries) and experiences pain after a heavy meal,
associated with most CNS inlammatory which then subsides. Of the following organs
processes is mediated by sensory nerves in of the gastrointestinal tract, which would most
which of these tissue layers? likely be the culprit?
A. Arachnoid mater A. Colon
B. Dura mater B. Gallbladder
C. Endoneurium C. Pancreas
D. Ependyma D. Salivary glands
E. Pia mater E. Stomach

10. A neurologist is concerned about a patient’s 15. A patient who presents with an autoimmune
inability to walk without a distinct limp (move- disease characterized by loss of weight, rapid
ment disorder). Which of the following portions pulse, sweating, shortness of breath, bulging
of the peripheral nervous system (PNS) will eyes (exophthalmos), and muscle wasting likely
the neurologist examine irst? has oversecretion of a hormone produced and
A. Autonomic stored by which endocrine organ?
B. Enteric A. Ovary
C. Myenteric B. Pancreas
D. Somatic C. Pineal gland
E. Submucosal D. Posterior pituitary gland
E. hyroid gland
11. In response to a perceived threat of danger,
which of the following PNS components will 16. Bleeding into the pericardial sac would also
be globally activated? suggest that blood would be present in which
A. Enteric of the following cavities?
B. Parasympathetic A. Abdominal
C. Postganglionic B. Left pleural
D. Preganglionic C. Mediastinum
E. Sympathetic D. Right pleural
E. Vertebral
12. In designing a novel pharmaceutical agonist
for use in controlling blood pressure, the sci- 17. A congenital defect of the spinal cord occurs
entists must be cognizant of which of the during the third week of embryonic develop-
following distinguishing features of the auto- ment. Which of the following events character-
nomic nervous system? izes this critical period of embryonic
A. It is a one-neuron eferent system. development?
B. It is a two-neuron eferent system. A. Blastocyst formation
C. It is associated with 10 cranial nerves. B. Embryoblast formation
D. It releases only neuropeptides as C. Gastrulation
transmitters. D. Morula formation
E. It releases only norepinephrine as a E. Zygote formation
18. Malformation of the primitive heart would most
13. A kidney stone becomes lodged in the portion likely point to a problem with the development
of the urinary system between the kidney and of which embryonic tissue?
bladder. In which of the following structures A. Amnion
will the stone be found? B. Chorion
A. Bile duct C. Ectoderm
B. Oviduct D. Endoderm
C. horacic duct E. Mesoderm
D. Ureter
E. Urethra

Chapter 1 Introduction to the Human Body 47 1
19. Of the following types of medical imaging 24. When a nurse takes a patient’s pulse during a
approaches, which is the least invasive and least routine examination, the nurse will typically
expensive? feel the pulse in which of the following
A. Computed tomography arteries?
B. Magnetic resonance imaging A. Brachial artery
C. Plain radiograph B. Carotid artery
D. Positron emission tomography C. Dorsalis pedis artery
E. Ultrasound D. Femoral artery
E. Radial artery
20. As an x-ray beam passes through the human
body, which of the following is the correct order 25. When luids are lost to the extracellular space,
of attenuation of the photons, from greatest to which of the following systems or organs is
least attenuation? critical in returning the luids to the vascular
A. Bone-fat-lung–soft tissue–water-air system?
B. Bone-fat–soft tissue–lung-water-air A. Arachnoid granulations
C. Bone-lung–soft tissue–fat-water-air B. Gallbladder
D. Bone–soft tissue–lung-fat-water-air C. Lymphatic system
E. Bone–soft tissue–water-fat-lung-air D. Respiratory system
E. hyroid gland
21. A physician will know what the term dorsiflexion
of the foot means, but a patient being tested 26. In a patient with a resorption problem, the
may not be familiar with the term. herefore, physician diagnoses the problem as being
the physician might instruct a patient to do associated with the large intestine. Which of
what when she wants the patient to dorsilex the following portions of the GI system can be
the foot? excluded from further examination of the
A. Point your foot downward patient?
B. Point your foot upward A. Ascending colon
C. Stand on your toes B. Cecum
D. Turn your foot to the inside C. Ileum
E. Turn your foot to the outside D. Rectum
E. Sigmoid colon
22. Burns are typically classiied according to how
deep into the tissue the burn injury extends. 27. A patient is having diiculty becoming pregnant.
When a burn has been classiied as a second- Her physician suspects a problem associated
degree burn, how deep has the burn penetrated with the portion of her reproductive system
the tissue? that receives the ovulated oocyte. Which of
A. hrough the dermis the following structures is the focus of the
B. hrough the epidermis physician’s concern?
C. hrough the investing fascia A. Ductus deferens
D. hrough the subcutaneous tissue B. Urethra
E. Into the underlying muscle C. Uterine tube
D. Uterus
23. Notes on a patient’s chart indicate that the
E. Vagina
patient has had multiple fractures of the axial
skeleton. Which of the following bones is part 28. Following fertilization, how long does it usually
of the axial skeleton? take for the blastocyst to become implanted
A. Clavicle in the uterine wall?
B. Coxal bone A. Twenty-four hours
C. Humerus B. Forty-eight hours
D. Scapula C. hree days
E. Sternum D. Six days
E. Nine days

48 Chapter 1 Introduction to the Human Body

29. A physician diagnoses a congenital malforma- 7. E. The thoracic duct drains lymph from about
tion in a tissue that is a derivative of the three quarters of the body and returns it to
the venous system at the junction of the left
embryonic endoderm. Which of the following
internal jugular and left subclavian veins. The
tissues or structures is most likely the mal- cisterna chyli is the beginning of the thoracic
formed one? duct in the upper abdomen.
A. Biceps muscle
8. C. Microglia are the endogenous glial cells in the
B. Epidermis of the arm CNS that are phagocytic and respond to any
C. Epithelium of the trachea breach in the blood-brain barrier or to infection.
D. Dermis of the hand
9. B. The dura mater is heavily innervated by sensory
E. Femur
nerve fibers, whereas the arachnoid and pia
30. Which of the following approaches is the best mater are not innervated.
one for imaging bony structures because it 10. D. The neurologist will examine the somatic
subjects the patient to the lowest dosage of division of the PNS first to determine if the
x-rays but is still highly accurate? problem is associated with a peripheral nerve
and/or skeletal muscle. Skeletal muscle is
A. Computed tomography (CT) innervated by the somatic nervous system.
B. Magnetic resonance imaging (MRI)
C. Plain radiography 11. E. The sympathetic division of the ANS is function-
ally the “fight or flight” responder to any threat,
D. Positron emission tomography (PET)
perceived or real, and mobilizes the body
E. Ultrasound globally.

12. B. This is the only answer that accurately reflects

Answers to Challenge the ANS. It is a two-neuron efferent system,
Yourself Questions and different transmitters are co-localized and
released. Because of this, ACh, NE, and neu-
ropeptides can be targeted at different synap-
1. B. The coronal plane is named for the coronal tic sites pharmacologically to alter the response
suture on the skull and is a plane that is paral- of the system. The only exception is the
lel to that suture and synonymous with frontal neuroendocrine cells of the adrenal medulla,
plane. Axial, transverse, and cross section also which are modified postganglionic sympathetic
are synonymous terms and divide the body neurons innervated by preganglionic sympa-
into superior and inferior portions. thetic fibers.
2. D. The patella is a round bone and the largest of 13. D. The ureter is the duct connecting the kidney
the sesamoid bones. Two sesamoid bones also (renal pelvis) to the urinary bladder.
usually exist at the base of each thumb and
base of each large toe. 14. B. The gallbladder stores and concentrates bile,
which is necessary for the emulsification of
3. C. Bone growth in length occurs at the epi- fats in our diet. When fats enter the GI tract,
physial plate, where hyaline cartilage undergoes the gallbladder is stimulated, contracts, and
proliferation and ossification. Growth in width releases concentrated bile into the second
occurs at the diaphysis. portion of the duodenum.
4. A. The hip is a perfect example of a ball-and-socket 15. E. These signs and symptoms are characteristic
joint and is one of the more stable synovial of Graves’ disease (hyperthyroidism), an excess
joints in the body. The shoulder joint also is a synthesis and release of thyroid hormone,
ball-and-socket joint but is more mobile and which upregulates metabolism.
less stable than the hip joint.
16. C. The pericardium and the heart reside in the
5. B. The antagonist is the muscle that opposes the mediastinum (middle space), the region
action of the agonist, the muscle that is con- between the two pleural cavities, all of which
tracting and in this case the muscle being tested are in the thoracic cavity.
by the orthopedist.
17. C. Gastrulation is the defining event of the third
6. D. Venous blood from the body passes through week of embryonic development. This is when
the right side of the heart (right atrium and the trilaminar disc (ectoderm, mesoderm,
ventricle) and then passes into the pulmonary endoderm) develops and when the ectoderm
trunk, which divides into a right pulmonary begins to migrate medially and fold along the
artery and a left pulmonary artery carrying midline axis to form the future neural tube and
blood away from the heart and to the lungs spinal cord.
for gas exchange.

Chapter 1 Introduction to the Human Body 49 1
18. E. The heart (cardiac muscle) is a derivative largely 25. C. A considerable amount of fluid is lost to the
of the mesoderm. Later in its development, extracellular compartment at the level of the
the neural crest (neural folds of ectoderm) also capillaries. The fluid can be recaptured by
plays an important role. the lymphatic vessels and returned to the
venous system. Important proteins not easily
19. E. Ultrasound uses very-high-frequency longitu- reabsorbed by the venous system also can
dinal sound waves, is relatively safe, and is be captured by the lymphatic system. The
cost effective compared with the other imaging arachnoid granulations allow cerebrospinal
modalities. Unfortunately, it is not suitable for fluid in the nervous system to return to the
all imaging; its resolution is limited and it venous system.
cannot penetrate bone.
26. C. The ileum is part of the small intestine, and
20. E. The densest structure in the body is bone, with therefore it can be excluded by the physician.
the greatest attenuation of photons, followed All of the other listed options are part of the
by soft tissues, water (the reference medium), large intestine and must be considered in his
fat, lung (mostly air), and then air itself. On a examination.
plain radiograph, a very dense tissue like bone
appears white, while air appears black. 27. C. The ovulated oocyte is usually captured and
passes into the uterine (fallopian) tube, where
21. B. Dorsiflexion of the foot at the ankle occurs fertilization could normally occur if sperm were
when one points the foot upward. This move- present. The resulting zygote would undergo
ment is the same as extension and is the cell divisions and travel into the uterine cavity,
opposite of flexion (plantarflexion). Most where it would normally become implanted.
patients will not be familiar with the term
dorsiflexion (or extension), so the physician 28. D. Implantation of the blastocyst usually occurs
must phrase the instruction in words that are around the fifth to sixth day after fertilization
easily understood. in the uterine tube.

22. A. A second-degree burn penetrates both the 29. C. The only tissue listed that is derived from the
epidermis and the dermis, but does not go embryonic endoderm is the epithelial lining of
further. A third-degree burn includes the the trachea. The epidermis is derived from the
subcutaneous tissue below the dermis. ectoderm, and all the other options are derived
from the mesoderm.
23. E. The sternum is part of the central axis of the
body and the axial skeleton. All the other bones 30. C. Plain radiography uses the lowest dosage of
listed are part of the appendicular skeleton x-rays. CT is often a good way to image bony
(bones associated with the limbs). structures but uses a higher dosage of x-rays.
None of the other imaging modalities use
24. E. Typically, the radial artery pulse is taken at x-rays. and none are as accurate as CT or plain
the wrist and is easily felt. The dorsalis pedis radiography at delineating the fine features of
pulse is also important because it is the pulse bony structures.
farthest from the heart; it is detected on the
dorsal surface of the foot.

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1. INTRODUCTION connecting the iliac crests passes through the

spinous process of vertebra L4 and the inter-
he back forms the axis (central line) of the human vertebral disc of L4-L5, providing a useful
body and consists of the vertebral column, spinal landmark for a lumbar puncture or an epidural
cord, supporting muscles, and associated tissues block (see Clinical Focus 2-11).
(skin, connective tissues, vasculature, and nerves). • Posterior superior iliac spines: an imaginary
A hallmark of human anatomy is the concept of horizontal line connecting these two points
“segmentation,” and the back is a prime example. passes through the spinous process of S2 (second
Segmentation and bilateral symmetry of the back sacral segment).
will become obvious as you study the vertebral
column, the distribution of the spinal nerves, the 3. VERTEBRAL COLUMN
muscles of the back, and its vascular supply.
Functionally, the back is involved in three primary he vertebral column (spine) forms the central axis
tasks, as follows: of the human body, highlighting the segmental
• Support. he vertebral column forms the axis nature of all vertebrates, and usually is composed
of the body and is critical for upright posture of 33 vertebrae distributed as follows (Fig. 2.2):
(standing or sitting), as a support for the head, • Cervical: seven vertebrae; the irst two called
as an attachment point and brace for movements the atlas (C1) and axis (C2).
of the upper limbs, and as a support for transfer- • horacic: 12 vertebrae; each articulates with a
ring the weight of the trunk to the lower limbs. pair of ribs.
• Protection. he vertebral column protects the • Lumbar: ive vertebrae; large vertebrae for
spinal cord and proximal portions of the spinal support of the body’s weight.
nerves before they distribute throughout the • Sacral: ive fused vertebrae for stability in the
body. transfer of weight from the trunk to the lower
• Movements. Muscles of the back function in limbs.
movements of the head and upper limbs and in • Coccyx: four vertebrae, but variable; Co1 often
support and movements of the vertebral column. is not fused, but Co2-Co4 are fused (a remnant
of the embryonic tail).
2. SURFACE ANATOMY he actual number of vertebrae can vary, espe-
cially the number of coccygeal vertebrae.
Fig. 2.1 shows key surface landmarks of the back, Viewed from the lateral aspect (Fig. 2.2), one
including the following bony landmarks: can identify the following:
• Vertebrae prominens: the spinous process of • Cervical curvature (cervical lordosis): a second-
the C7 vertebra, usually the most prominent ary curvature acquired when the infant can
process in the midline at the posterior base of support the weight of the head.
the neck. • horacic curvature (thoracic kyphosis): a
• Scapula: a part of the pectoral girdle that sup- primary curvature present in the fetus (imagine
ports the upper limb; note its spine, inferior the spine in the “fetal position”).
angle, and medial border. • Lumbar curvature (lumbar lordosis): a second-
• Iliac crests: felt best when you place your hands ary curvature acquired when the infant assumes
“on your hips.” An imaginary horizontal line an upright posture and supports its own weight.

52 Chapter 2 Back

External occipital protuberance

Nuchal lig.

Spinous process of C7 vertebra

Trapezius m.

Spine of scapula

Deltoid m.
Infraspinatus m.

Medial border of scapula

Teres Inferior angle of scapula

major m.
Spinous process of T12 vertebra

Latissimus dorsi m.

Iliac crest

Thoracolumbar fascia

Posterior superior iliac spine


FIGURE 2.1 Key Bony and Muscular Landmarks of the Back. (From Atlas of human anatomy, ed 7
Nuchal lig. Plate 161).

Left lateral view Posterior view

Atlas (C1) C1
Axis (C2)
Cervical C2 Cervical
lordosis vertebrae Level Corresponding structure
C7 C2-3 Mandible
T1 T1
C3 Hyoid bone

C4-5 Thyroid cartilage

C6 Cricoid cartilage
Thoracic C7 Vertebra prominens
T3 Spine of scapula

T8 Level that IVC pierces respiratory diaphragm

T10 Xiphisternal junction

T10 Level that esophagus pierces respiratory diaphragm
T12 Level that aorta pierces respiratory diaphragm

L1 End of spinal cord (conus medullaris)

vertebrae L3 Subcostal plane
L5 L3-4 Umbilicus
L5 L4 Bifurcation of abdominal aorta

L4 Iliac crests
(S1-S5) S2 End of dural sac

FIGURE 2.2 Vertebral Column. (From Atlas of human anatomy, ed 7, Plate 162.)
Chapter 2 Back 53 2
Clinical Focus 2-1
Scoliosis is abnormal lateral curvature of the spine, which also includes an abnormal rotation of one vertebra
upon another. In addition to scoliosis, accentuated curvatures of the spine include kyphosis (hunchback) and
lordosis (swayback).
Pathologic anatomy of scoliosis
Spinous process
deviated to
concave side
Lamina thinner,
vertebral canal
narrower on Rib pushed
concave side posteriorly;
thoracic cage

Vertebral body
distorted toward
convex side
Rib pushed
laterally and
anteriorly Convex side
Concave side
Gauging trunk
alignment Section through scoliotic
vertebrae; decreased vertebral Characteristic distortion of vertebra
height and disc thickness on and rib in thoracic scoliosis (inferior view)
concave side

Several Common Abnormal Curvatures of the Spine

Disorder Definition Etiology

Scoliosis (illustrated) Accentuated lateral and rotational curve of Genetic, trauma, idiopathic; occurs in
thoracic or lumbar spine adolescent girls more than boys

Kyphosis Hunchback, accentuated flexion of thoracic Poor posture, osteoporosis


Lordosis Swayback, accentuated Weakened trunk muscles,

extension of lumbar spine late pregnancy, obesity

• Sacral curvature: a primary curvature present • Intervertebral foramen (foramina): the

in the fetus. opening formed by the vertebral notches that
is traversed by spinal nerve roots and associated
Typical Vertebra vessels.
A “typical” vertebra has the following features (Fig. • Lamina (laminae): paired portions of the ver-
2.3): tebral arch that connect the transverse processes
• Arch: a projection formed by paired pedicles to the spinous process.
and laminae and the spinous processes; the arch • Pedicle: paired portions of the vertebral arch
serves as the site for articulation with adjacent that attach the transverse processes to the
vertebrae and also as the attachment point for body.
ligaments and muscles. • Transverse foramina: apertures that exist in
• Articular processes (facets): two superior and transverse processes of cervical vertebrae only
two inferior facets for articulation with adjacent and transmit the vertebral vessels.
vertebrae. • Transverse processes: the lateral extensions
• Body: the weight-bearing portion of a vertebra from the union of the pedicle and lamina.
that tends to increase in size as one descends • Spinous process: a projection that extends
the spine. posteriorly from the union of two laminae.

54 Chapter 2 Back

TABLE 2.1 Key Features of the Cervical

Vertebrae (C1-C7)

Pedicle Atlas (C1) Ringlike bone; superior facet
articulates with occipital bone.
Transverse Vertebral
Two lateral masses with facets
process foramen
No body or spinous process
C1 rotates on articular facets of C2.
Vertebral artery runs in groove on
Superior posterior arch.
articular Accessory
process Axis (C2) Dens projects superiorly.
process Lamina Strongest cervical vertebra
C3 to C7 Large, triangular vertebral foramen
Spinous process
Transverse foramen through which
vertebral artery passes (except C7)
Narrow intervertebral foramina
Nerve roots at risk of compression
C3 to C5 Short, bifid spinous process
Superior articular process C6 to C7 Long spinous process
C7 Vertebra prominens; nonbifid
Interver- process
disc 1

Regional Vertebrae
articular Cervical Vertebrae
2 he cervical spine is composed of seven cervical
vertebrae. he irst two cervical vertebrae are unique
Inferior and called the atlas and axis (Fig. 2.4). he atlas
vertebral (C1) holds the head on the neck (the titan Atlas of
3 Interver-
Greek mythology held the heavens on his shoulders
tebral as punishment by Zeus). he axis (C2) is the point
(neural) of articulation where the head turns on the neck,
providing an “axis of rotation.”
4 Superior Table 2.1 summarizes key features of the cervical
vertebrae. he cervical region is a fairly mobile
portion of the spine, allowing for lexion and exten-
sion as well as rotation and lateral bending.
5 Articular Thoracic and Lumbar Vertebrae
facet for
sacrum he thoracic spine is composed of 12 thoracic
FIGURE 2.3 Features of Typical Vertebra, as Represented vertebrae (Fig. 2.5 and Table 2.2). he 12 pairs of
by L2 Vertebra (superior view) and Articulated Lumbar ribs articulate with the thoracic vertebrae. his
Vertebrae (L1-L5). (From Atlas of human anatomy, ed 7, region of the spine is more rigid and inlexible than
Plate 164.) the cervical region.
he lumbar spine is composed of ive lumbar
vertebrae (see Figs. 2.3 and 2.5 and Table 2.2). he
lumbar vertebrae are comparatively large for bearing
the weight of the trunk and are fairly mobile, but
• Vertebral foramen (canal): a foramen formed not nearly as mobile as the cervical vertebrae.
from the vertebral arch and body that contains
the spinal cord and its meningeal coverings. Sacrum and Coccyx
• Vertebral notches: superior and inferior he sacrum is composed of ive fused vertebrae
semicircular features that in articulated vertebrae that form a single, wedge-shaped bone (Fig. 2.5
form an intervertebral foramen (two semicircular and Table 2.2). he sacrum provides support for
notches form a circle). the pelvis. he coccyx is a remnant of the embryonic

Chapter 2 Back 55 2
Anterior tubercle Superior articular facet for atlas
Anterior arch Articular facet for dens Dens

Lateral mass Posterior articular facet (for

Transverse process
Vertebral transverse ligament of atlas)

Transverse foramen

Superior articular surface Transverse process

Posterior arch
of lateral mass for occipital
condyle Posterior tubercle

Atlas (C1): superior view Inferior

process Spinous process

Axis (C2): posterosuperior view

Body Transverse process Body
articular facet
Lamina Vertebral foramen
Spinous process Lamina

4th cervical vertebra: superior view

7th cervical vertebra: superior view

FIGURE 2.4 Representative Cervical Vertebrae. (From Atlas of human anatomy, ed 7, Plate 26.)

Clinical Focus 2-2

Cervical Fractures
Fractures of the axis (C2) often involve the dens and are classified as types I, II, and III. Type I fractures are
usually stable, type II fractures are unstable, and type III fractures, which extend into the body, usually reunite
well when immobilized. The hangman fracture, a pedicle fracture of the axis, can be stabilized, if survived,
with or without spinal cord damage. A Jefferson fracture is a burst fracture of the atlas (C1), often caused
by a blow to the top of the head.
Jefferson fracture of atlas (C1)
Fracture of dens Type I. Fracture of tip
Each arch may be broken Fracture of anterior arch
Type II. Fracture of in one or more places
Superior base or neck
Type III. Superior
Fracture articular
extends facet
into body
of axis Fracture of
posterior arch

Hangman Superior articular facet

neural arch
of axis
Inferior articular facet

56 Chapter 2 Back

Thoracic and lumbar vertebrae Superior articular

process and facet
Body Superior Lateral view radiograph of the
Vertebral Pedicle
foramen costal facet lower spine (with vertebral
Superior costal facet bodies numbered)
costal facet
process T12
Transverse Inferior L1
costal facet costal Inferior
Lamina facet vertebral notch
T6 vertebra: lateral view Inferior vertebral
Spinous process notch of L2 vertebra L2
Superior vertebral notch Intervertebral
T6 vertebra: superior view disc space
Superior vertebral
notch of L3 vertebra
Vertebral body L3
Pedicle of L3 vertebra
foramen Intervertebral foramen
Inferior articular
process of L3 vertebra L4
Transverse Superior articular
process Pedicle process of L4 vertebra
Spinous process
of L3 vertebra L5
Spinous process
L2 vertebra: superior view

Sacral and coccygeal vertebrae

Ala (lateral part)
Superior articular process Facets of superior articular processes
Lumbosacral articular surface
Sacral canal
Ala (wing) Auricular surface

Promontory Sacral tuberosity


Sacral part of Pe


pelvic brim Lateral sacral crest Posterior


(linea terminalis) ac sacral
Median sacral crest foramina
Anterior (pelvic) Sacral hiatus
sacral foramina Sacral cornu (horn)
ridges Sacral hiatus
Coccyx Paramedian sagittal section Coccygeal cornu (horn)

Anterior inferior view Posterior superior view

Pelvic surface Posterior surface
FIGURE 2.5 Representative Vertebrae. (From Atlas of human anatomy, ed 7, Plates 163 and 166.)

tail and usually consists of four vertebrae, with the joints that provide a relatively wide range of motion
last three often fused into a single bone. he coccyx compared with other joints of the vertebral column.
lacks vertebral arches and has no vertebral canal. he atlantooccipital joint permits one to nod the
he features and number of vertebrae can vary, head up and down (lexion and extension), as if to
and clinicians must always be aware of subtle dif- indicate “yes,” whereas the atlantoaxial joint is a
ferences, especially on radiographic imaging, that pivot joint that permits one to rotate the head from
may be variants within a normal range. side to side, as if to indicate “no” (Fig. 2.6 and
Table 2.3).
Joints and Ligaments of
Craniovertebral Spine Joints and Ligaments of Vertebral
he craniovertebral joints include the atlanto- Arches and Bodies
occipital (atlas and occipital bone of the skull) and he joints of the vertebral arches (zygapophysial
atlantoaxial (atlas and axis) joints. Both are synovial joints) occur between the superior and inferior

Chapter 2 Back 57 2
TABLE 2.2 Key Features of Thoracic, Lumbar, Sacral, and Coccygeal Vertebrae
Thoracic Heart-shaped body, with facets for rib Sacrum (S1-S5) Large, wedge-shaped bone that transmits
(T1-T12) articulation body weight to pelvis
Small circular vertebral foramen Five fused vertebrae, with fusion
Long transverse processes, with facets for complete by puberty
rib articulation in T1-T10 Four pairs of sacral foramina on dorsal
Long spinous processes, which slope and ventral (pelvic) side
posteriorly and overlap next vertebra Sacral hiatus, the opening of sacral
Lumbar Kidney-shaped body, massive for support vertebral foramen
(L1-L5) Midsized triangular vertebral foramen Coccyx Co1 often is not fused.
Facets face medial or lateral direction, (Co1-Co4) Co2 to Co4 are fused.
which permits good flexion and No pedicles, laminae, or spines
extension Remnant of our embryonic tail
Spinous process is short, strong, and
L5: largest vertebra with massive
transverse processes

Clinical Focus 2-3

Osteoarthritis is the most common form of arthritis and often involves erosion of the articular cartilage of
weight-bearing joints, such as those of the vertebral column.

Cervical spine involvement Lumbar spine involvement

Atlas (C1)

Axis (C2)

spinal nn.


Extensive thinning of cervical discs and hyperextension deformity. Narrowing

of intervertebral foramina. Lateral radiograph reveals similar changes.
Degeneration of lumbar intervertebral discs and
hypertrophic changes at vertebral margins with
spur formation. Osteophytic encroachment on
intervertebral foramina compresses spinal nerves.

Characteristics of Osteoarthritis
Characteristic Description
Etiology Progressive erosion of cartilage in joints of spine, fingers, knee, and hip most commonly

Prevalence Significant after age 65 years

Risk factors Age, female sex, joint trauma, repetitive stress, obesity, genetic, race, previous inflammatory joint disease

Complications In spine, involves intervertebral disc and facet joints, leading to hyperextension deformity and spinal nerve

58 Chapter 2 Back

TABLE 2.3 Key Features of TABLE 2.4 Features of the Zygapophysial

Atlantooccipital and Atlantoaxial Joints and Intervertebral Joints

Atlantooccipital (Biaxial Condyloid Synovial) Joint Zygapophysial (Plane Synovial) Joints

Articular Surrounds facets and Allows flexion Articular Surrounds facets Allows gliding
capsule occipital condyles and extension capsule motion
Anterior and Anterior and Limit C5-C6 is most
posterior posterior arches movement of mobile.
membranes of C1 to foramen joint L4-L5 permits
magnum most flexion.
Atlantoaxial (Uniaxial Synovial) Joint Intervertebral (Secondary Cartilaginous
Tectorial Axis body to Is continuation [Symphyses]) Joints
membrane margin of foramen of posterior Anterior Anterior bodies Is strong and
magnum longitudinal longitudinal and intervertebral prevents
ligament (AL) discs hyperextension
Apical Dens to occipital Is very small Posterior Posterior bodies Is weaker
bone longitudinal and intervertebral than AL and
Alar Dens to occipital Limits rotation (PL) discs prevents
condyles hyperflexion
Cruciate Dens to lateral Resembles a Ligamenta Connect adjacent Limit flexion
masses cross; allows flava laminae of and are more
rotation vertebrae elastic
Interspinous Connect spines Are weak
Supraspinous Connect spinous Are stronger
tips and limit
Ligamentum C7 to occipital Is cervical
articular processes (facets) of adjacent vertebrae nuchae bone extension of
and allow for some gliding or sliding movement supraspinous
(Fig. 2.7 and Table 2.4). hese joints slope inferiorly ligament and is
in the cervical spine (facilitate lexion and exten- Intertransverse Connect transverse Are weak
sion), are more vertically oriented in the thoracic processes ligaments
region (limit lexion and extension but allow for Intervertebral Between adjacent Are secured
discs bodies by AL and PL
rotation), and are interlocking in the lumbar spine ligaments
(they do allow lexion and extension, but not to
the degree present in the cervical spine). Corre-
sponding ligaments connect the spinous processes,
laminae, and bodies of adjacent vertebrae (see Tables
2.3 and 2.4). Strong anterior and posterior longi- called the nucleus pulposus, which is surrounded
tudinal ligaments run along most of the length of by concentric lamellae of collagen ibers that
the vertebral column. Of these two ligaments, the compose the anulus ibrosus (see Clinical Focus
anterior longitudinal ligament is stronger and 2-6). he inner gelatinous nucleus pulposus
prevents hyperextension (see Figs. 2.6 and 2.7 and (remnant of the embryonic notochord) is hydrated
Table 2.4). and acts as a “shock absorber,” compressing when
he joints of the vertebral bodies (intervertebral load bearing and relaxing when the load is removed.
joints) occur between the adjacent vertebral bodies he outer ibrocartilaginous anulus ibrosus,
(see Fig. 2.7 and Table 2.4). he intervertebral joints arranged in concentric lamellae, is encircled by a
are lined by a thin layer of hyaline cartilage with thin ring of collagen and resists compression and
an intervening intervertebral disc (except between shearing forces.
the irst two cervical vertebrae). hese stable, he lumbar intervertebral discs are the thickest
weight-bearing joints also absorb pressure because and the upper thoracic ones are the thinnest
the intervertebral disc is between the bodies. intervertebral discs. he anterior and posterior
Intervertebral discs are composed of a central longitudinal ligaments help to stabilize these joints
nuclear zone of collagen and hydrated proteoglycans (see Table 2.4).

Chapter 2 Back 59 2
Capsule of Upper part of vertebral canal with spinous processes and parts of
atlantooccipital joint vertebral arches removed to expose ligaments on posterior vertebral
bodies: posterior view
Alar lig.
Tectorial membrane Atlas (C1)
Atlas (C1)
Capsule of lateral Posterior longitudinal lig.
atlantoaxial joint
Superior longitudinal band
Axis (C2) Cruciate lig. Transverse lig. of atlas
Capsule of zygapophysial Inferior longitudinal band
joint (C2–C3) Axis (C2)

Deeper (accessory) part of tectorial membrane

Principal part of tectorial membrane removed to expose deeper ligs.: posterior view

Apical lig. of dens

Alar lig.
Atlas (C1)

Axis (C2)

Cruciate lig. removed to show deepest ligs.: posterior view

Alar lig.
Synovial cavities

Transverse lig. of atlas
Normal open-mouth view of the dens of C2
Median atlantoaxial joint: superior view (arrowhead) and the lateral masses of C1(arrows).
FIGURE 2.6 Craniovertebral Joints and Ligaments. (From Atlas of human anatomy, ed 7, Plate 30;
radiograph from Major N: A practical approach to radiology, Philadelphia, 2006, Saunders-Elsevier.)

Transverse costal facet (for tubercle

of rib of same number as vertebra) Left lateral view
(partially sectioned in median plane)
Intertransverse lig. Anterior Inferior articular
longitudinal process
lig. Capsule of
Inferior costal zygapophysial
facet (for head of rib joint (partially
one number higher) opened)
Superior articular
Interarticular lig.
Intervertebral process
of head of rib
disc Ligamentum
Superior costal flavum
facet (for head of Interspinous lig.
rib of same number)
Supraspinous lig.
Radiate lig. of
head of rib

Left lateral view

costotransverse lig.
FIGURE 2.7 Joints of Vertebral Arches and Bodies. (From Atlas of human anatomy, ed 7, Plate 168.)

60 Chapter 2 Back

Clinical Focus 2-4

Osteoporosis (porous bone) is the most common bone disease and results from an imbalance in bone resorption
and formation, which places bones at a great risk for fracture.
Axial Multiple Characteristics of Osteoporosis
fractures of Characteristic Description
lower thoracic Etiology Postmenopausal
T4 and upper women, genetics,
lumbar vertebrae vitamin D synthesis
T6 in patient with deficiency, idiopathic
T8 osteoporosis Risk factors Family history, white
female, increasing
age, estrogen
T10 deficiency, vitamin
D deficiency, low
calcium intake,
smoking, excessive
alcohol use, inactive
Vertebral compression fractures lifestyle
cause continuous (acute) or Complications Vertebral compression
intermittent (chronic) back pain fractures, fracture of
from midthoracic to midlumbar L1
proximal femur or
region, occasionally to lower humerus, ribs, and
lumbar region. distal radius (Colles’
A change in backbone strength over time

Appendicular fractures
caused by minimal trauma

Proximal Proximal Distal

femur humerus radius
Osteoporosis is the thinning of the bones. Bones become fragile
and loss of height is common as the back bones begin to collapse. Most common types

Chapter 2 Back 61 2
Clinical Focus 2-5
Spondylolysis and Spondylolisthesis
Spondylolysis is a congenital defect or an acquired stress fracture of the lamina that presents with no slippage
of adjacent articulating vertebrae (most common at L5-S1). Its radiographic appearance suggests a “Scottie
dog” (terrier) with a collar (fracture site shown as red collar).
Spondylolisthesis is a bilateral defect (complete dislocation, or luxation) resulting in an anterior displacement
of the L5 body and transverse process. The posterior fragment (vertebral laminae and spinous process of L5)
remains in proper alignment over the sacrum (S1). This defect has the radiographic appearance of a dog with
a broken neck (highlighted in yellow, with the fracture in red). Pressure on spinal nerves often leads to low
back and lower limb pain.
Posterior oblique views: Scottie dog profile in yellow and fracture site in red

Superior articular process

(ear of Scottie dog)

Pedicle (eye)

Transverse process (head)

Isthmus (neck)

Spinous process
and lamina (body)

Inferior articular
process (foreleg)

Opposite inferior
articular process
In simple spondylolysis, Scottie In spondylolisthesis, Scottie dog appears
dog appears to be wearing a collar. decapitated.

Clinical Focus 2-6

Intervertebral Disc Herniation
The intervertebral discs are composed of a central nuclear zone of collagen and hydrated proteoglycans called
the nucleus pulposus, which is surrounded by concentric lamellae of collagen fibers that compose the
anulus fibrosus. The nucleus pulposus is hydrated and acts as a “shock absorber,” compressing when load
bearing and relaxing when the load is removed. Over time, the repeated compression-relaxation cycle of the
intervertebral discs can lead to peripheral tears of the anulus fibrosus that allow for the extrusion and herniation
of the more gelatinous nucleus pulposus. This often occurs with age, and the nucleus pulposus becomes
more dehydrated, thus transferring more of the compression forces to the anulus fibrosus. This added stress
may cause thickening of the anulus and tears. Most disc herniations occur in a posterolateral direction because
the anulus fibrosus tears often occur at the posterolateral margins of the disc (rim lesions). Moreover, the
posterior longitudinal ligament reinforces the anulus such that posterior herniations are much less common;
otherwise, the disc would herniate into the vertebral canal and compress the spinal cord or its nerve roots.


62 Chapter 2 Back

Clinical Focus 2-6

Intervertebral Disc Herniation—cont’d
The most common sites for disc herniation in the cervical region are the C5-C6 and C6-C7 levels, resulting in
shoulder and upper limb pain. In the lumbar region the primary sites are the L4-L5 and L5-S1 levels. Lumbar
disc herniation is much more common than cervical herniation and results in pain over the sacroiliac joint, hip,
posterior thigh, and leg.

Intervertebral disc Disc rupture and nuclear herniation

Nucleus pulposus
longitudinal lig.

Cartilage Rim Tears in Shortened Herniated
end plate lesion internal disc space
Nucleus nucleus
pulposus pulposus
of anulus
longitudinal lig.
Intervertebral disc composed of central nuclear zone Peripheral tear of anulus fibrosus and cartilage end plate (rim lesion) initiates
of collagen and hydrated proteoglycans surrounded sequence of events that weaken and tear internal anular lamellae, allowing
by concentric lamellae of collagen fibers extrusion and herniation of nucleus pulposus.
Clinical features of herniated lumbar disc Sagittal MRI of an intervertebral
Level of herniation Pain Numbness Weakness Atrophy Reflexes disc herniation

L4 uncommon
in knee and
Over Dorsiflexion Minor ankle jerks,
L5 sacro- of great toe but internal
iliac and foot; hamstring
L5 joint, difficulty reflex
S hip, walking on diminished
L4-L5 disc; lateral
Lateral leg, heels; foot- or absent
5th lumbar thigh,
first 3 toes drop may
n. root and leg occur

Over Plantar-
sacro- flexion of
iliac foot and
joint, great toe
S hip,
Herniation of L4–L5 intervertebral disc (white
may be
postero- affected; arrows) with some displacement of the posterior
Back of Ankle jerk
lateral difficulty diminished
longitudinal ligament (black arrow). The two discs
thigh, calf, lateral walking on
L5-S1 disc; above this site show the normal hydrated appear-
and leg heel, foot toes Gastrocnemi- or absent
1st sacral to toe ance of the nucleus pulposus.
to heel us and soleus
n. root Reprinted with permission from Jackson S, Thomas R: Cross-Sectional
Imaging Made Easy. Philadelphia, Churchill Livingstone, 2004.
Herniation of a lumbar disc
Portion of lamina
Herniated nucleus pulposus and facet removed
Nerve root compressed
by herniated disc

Disc material
Disc material removed to decompress nerve root

Chapter 2 Back 63 2
Clinical Focus 2-7
Back Pain Associated With the Zygapophysial (Facet) Joints
Although changes in the vertebral facet joints are not the most common cause of back pain (~15%), such
alterations can lead to chronic pain. Although the articular surfaces of the synovial facet joints are not directly
innervated, sensory nerve fibers derived from the posterior rami of spinal nerves do supply the synovial linings
of the capsules surrounding the joints. Two examples of painful conditions associated with facet joints are
degeneration of the articular cartilage and osteophyte overgrowth of the articular processes.

Facet joint
Joint capsule

Superior of synovial
articular membrane
process and capsule
Facet joint

Facet joint and

of facet joint capsule innervated
by posterior rami
Inferior from two spinal
articular levels

Joint space
Articular cartilage

Superior articular process

Inferior articular process

Innervation of synovial
membrane and capsule

Synovial membrane
Joint capsule

Degeneration of articular
cartilage with synovial
inflammation or capsular
swelling may result in
referred pain

Synovial inflammation
Cartilage Osteophytic overgrowth Osteophytes
degeneration of articular processes of
Capsular swelling
facet joint may impinge
on nerve root

64 Chapter 2 Back

Clinical Focus 2-8

Low Back Pain
Low back pain, the most common musculoskeletal disorder, can have various causes. Physical examination,
although not always revealing a definite cause, may provide clues to the level of spinal nerve involvement and
relative sensitivity to pain. The following causes are identified most often:
• Intervertebral disc rupture and herniation
• Nerve inflammation or compression
• Degenerative changes in vertebral facet joints
• Sacroiliac joint and ligament involvement
• Metabolic bone disease
• Psychosocial factors
• Abdominal aneurysm
• Metastatic cancer
• Myofascial disorders

A. Standing
Walking on heels (tests foot
Body build
and great toe dorsiflexion)
Pelvic obliquity
Spine alignment
Palpate for:
muscle spasm
trigger zones
myofascial nodes Spinal column
sciatic nerve tenderness Walking on toes
(tests calf muscles) movements:
Compress iliac crests flexion
for sacroiliac tenderness extension
side bending

B. Kneeling on C. Seated on table D. Supine

Straight leg raising: flex
thigh on pelvis and then
extend knee with foot
dorsiflexed (sciatic Palpate abdomen; listen for
nerve stretch) bruit (abdominal and inguinal)
Straight leg raising
Ankle jerk
Palpate for
Sensation on pulses and skin
calf and sole temperature Palpate for flattening
of lumbar lordosis
Knee jerk during leg raising

Measure leg lengths (anterior superior

iliac spine to medial malleolus) and thigh
Measure calf circumference circumferences
Test sensation and motor power

E. Prone
F. Rectal and/or pelvic
Test for renal tenderness examination
Palpate for local
G. MRI and/or CT and/or
extension myelogram of
tenderness or spasm
1. lumbosacral spine
2. abdomen/pelvis
H. Laboratory studies
Serum Ca2 and PO4, alkaline
phosphatase, prostate-specific
antigen (males over 40), CBC,
ESR, and urinalysis

Chapter 2 Back 65 2
pivot that permits the atlas and attached occipital
Movements of the Spine bone of the skull to rotate on the axis. Alar liga-
he essential movements of the spine are lexion, ments limit this side-to-side movement so that
extension, lateral lexion (lateral bending), and rotation of the atlantoaxial joint occurs with the
rotation (Fig. 2.8). he greatest freedom of move- skull and atlas rotating as a single unit on the axis
ment occurs in the cervical and lumbar spine, with (see Fig. 2.6).
the neck having the greatest range of motion. Movements of the spine are a function of the
Flexion is greatest in the cervical region, and exten- following features:
sion is greatest in the lumbar region. he thoracic • Size and compressibility of the intervertebral
region is relatively stable, as is the sacrum. discs.
Again, the atlantooccipital joint permits lexion • Tightness of the joint capsules.
and extension (e.g., nodding in acknowledgment), • Orientation of the articular facets (zygapophysial
and the atlantoaxial joint allows side-to-side move- joints).
ments (rotation; e.g., indicating “no”). his is • Muscle and ligament function.
accomplished by a uniaxial synovial joint between • Articulations with the thoracic cage.
the dens of the axis and its articulation with the • Limitations imposed by the adjacent tissues and
anterior arch of the atlas. he dens functions as a increasing age.


Lateral flexion


FIGURE 2.8 Movements of the Spine.

66 Chapter 2 Back

Clinical Focus 2-9

Whiplash Injury
“Whiplash” is a nonmedical term for a cervical hyperextension injury, which is usually associated with a
rear-end vehicular crash. The relaxed neck is thrown backward, or hyperextended, as the vehicle accelerates
rapidly forward. Rapid recoil of the neck into extreme flexion occurs next. Properly adjusted headrests can
greatly reduce the occurrence of this hyperextension injury, which often results in stretched or torn cervical
muscles and, in severe cases, ligament, bone, and nerve damage.

Tear of
Tear of

Headrest Vertebral fracture

and disc herniation
hyperextension Hyperflexion


spinal cord also contribute branches that supply

Blood Supply to the Spine the vertebrae.)
he spine receives blood from spinal arteries derived Radicular veins receive tributaries from the
from branches of larger arteries that serve each spinal cord and the internal vertebral veins that
midline region of the body (Fig. 2.9). hese major course within the vertebral canal; this internal
arteries include the following: venous plexus also anastomoses with a network
• Vertebral arteries: arising from the subclavian of external vertebral veins (see Fig. 2.9). he
arteries in the neck. internal vertebral venous plexus lacks valves,
• Ascending cervical arteries: arising from a whereas the external vertebral venous plexus has
branch of the subclavian arteries. recently been shown to possess some valves, direct-
• Posterior intercostal arteries: arising from the ing blood low toward the internal venous plexus.
thoracic aorta. he radicular veins then drain blood from the
• Lumbar arteries: arising from the abdominal vertebral venous plexus to segmental and interver-
aorta. tebral veins, with the blood ultimately collecting
• Lateral sacral arteries: arising from pelvic in the segmental branches of the following major
internal iliac arteries. venous channels:
Spinal arteries arise from these branches and • Superior vena cava: drains cervical vertebral
divide into small posterior branches that supply region.
the vertebral arch and small anterior branches that • Azygos venous system: drains thoracic region.
supply the vertebral body (see Fig. 2.9). Also, • Inferior vena cava: this large vein drains
longitudinal branches of radicular arteries, which lumbosacral regions of the spine.
arise from these spinal arteries, course along the
inside aspect of the vertebral canal and supply the 4. MUSCLES OF THE BACK
vertebral column. (Do not confuse these arteries
with those that supply the spinal cord, discussed Although the spine is the axis of the human body
later. In some cases, arteries that do supply the and courses down the body’s midline, dividing it

Chapter 2 Back 67 2
External Internal vertebral
vertebral Internal vertebral Basivertebral v.
(epidural) venous plexus
venous (epidural) venous
plexus plexus Anterior
Anterior spinal v. medullary/
Internal radicular v.
(epidural) Intervertebral v. Intervertebral v.
External vertebral
venous plexus

Posterior spinal v. segmental
Internal vertebral radicular v.
(epidural) venous plexus

Posterior spinal aa.

Segmental medullary a.
Anterior spinal a.

Posterior radicular a.
Anterior radicular a.
Spinal branch

Dorsal branch of posterior intercostal a.

Posterior intercostal a.

Thoracic (descending) aorta

Arteries of the spine: Section through thoracic level: anterosuperior view

FIGURE 2.9 Arteries and Veins of the Spine. (From Atlas of human anatomy, ed 7, Plates 177 and 178.)

into approximately equal right and left halves, it is Extrinsic Back Muscles
not midway between the anterior and posterior he extrinsic muscles of the back are considered
halves of the body. In fact, most of the body’s weight “extrinsic” because embryologically they arise from
lies anterior to the more posteriorly aligned vertebral hypaxial myotomes (see Fig. 2.22). he extrinsic
column. Consequently, to support the body and back muscles are divided into the following two
spine, most of the muscles associated with the spine functional groups (Fig. 2.10 and Table 2.5):
attach to its lateral and posterior processes, assisting • Supericial muscles: involved in movements
the spine in maintaining an upright posture that of the upper limb (trapezius, latissimus dorsi,
ofsets the uneven weight distribution. levator scapulae, two rhomboids), attach the
he muscles of the back are divided into two pectoral girdle (clavicle, scapula, humerus) to
major groups, as follows: the axial skeleton (skull, ribs, spine).
• Intermediate muscles: thin accessory muscles
Extrinsic back muscles: involved in movements of respiration (serratus posterior superior and
of the upper limb and with respiration. inferior) that assist with movements of the rib
Intrinsic back muscles: involved in movements cage, lie deep to the supericial muscles, and
of the spine and maintenance of posture. extend from the spine to the ribs.

68 Chapter 2 Back

TABLE 2.5 Muscles of the Back


Extrinsic Back Muscles

Trapezius Superior nuchal line, Lateral third of clavicle, Accessory nerve Elevates, retracts, and
external occipital acromion, and spine of (cranial nerve rotates scapula; lower
protuberance, nuchal scapula XI) fibers depress scapula
ligament, and spinous
processes of C7-T12
Latissimus dorsi Spinous processes Humerus (intertubercular Thoracodorsal Extends, adducts,
of T7-L5, sacrum, groove) nerve (C6-C8) and medially rotates
thoracolumbar fascia, humerus
iliac crest, and last
three ribs
Levator scapulae Transverse processes of Superior angle of scapula C3-C4 and Elevates scapula and
C1-C4 dorsal scapular tilts glenoid cavity
(C5) nerve inferiorly
Rhomboid minor Minor: nuchal ligament Medial border of scapula Dorsal scapular Retract scapula, rotate
and major and spinous processes nerve (C4-C5) it to depress glenoid
of C7-T1 cavity, and fix scapula
Major: spinous to thoracic wall
processes of T2-T5
Serratus posterior Ligamentum nuchae Superior aspect of ribs 2-5 T1-T4 anterior Elevates ribs
superior and spinous processes rami
of C7-T3
Serratus posterior Spinous processes of Inferior border of ribs T9-T12 anterior Depresses ribs
inferior T11-L3 9-12 rami
Intrinsic Back Muscles
Splenius capitis Nuchal ligament, Mastoid process of Middle cervical Bilaterally: extends head
spinous processes of temporal bone and nerves* Unilaterally: laterally
C7-T4 lateral third of superior bends (flexes) and
nuchal line rotates face to same
Splenius cervicis Spinous processes of Transverse processes of Lower cervical Bilaterally: extends neck
T3-T6 C1-C3 nerves* Unilaterally: laterally
bends (flexes) and
rotates neck toward
same side
Erector spinae Posterior sacrum, iliac Iliocostalis: angles of Respective spinal Extends and laterally
crest, sacrospinous lower ribs and cervical nerves of each bends vertebral
ligament, supraspinous transverse processes region* column and head
ligament, and spinous Longissimus: between
processes of lower tubercles and angles of
lumbar and sacral ribs, transverse processes
vertebrae of thoracic and cervical
vertebrae, mastoid
Spinalis: spinous processes
of upper thoracic and
midcervical vertebrae
Semispinalis Transverse processes of Spinous processes of Respective spinal Extends head, neck,
C4-T12 cervical and thoracic nerves of each and thorax and rotates
regions region* them to opposite side
Multifidi Sacrum, ilium, and Spinous processes Respective spinal Stabilizes spine during
transverse processes of of vertebrae above, nerves of each local movements
T1-T12 and articular spanning two to four region*
processes of C4-C7 segments
Rotatores Transverse processes of Lamina and transverse Respective spinal Stabilize, extend, and
cervical, thoracic, and process or spine above, nerves of each rotate spine
lumbar regions spanning one or two region*

*Posterior rami of spinal nerves.

Chapter 2 Back 69 2
Ligamentum nuchae Splenius capitis m.
Spinous process of C7 vertebra
Splenius cervicis m.

Trapezius m. Levator scapulae m.

Rhomboid minor m. (cut)

Spine of scapula

Serratus posterior superior m.

Latissimus dorsi m. Rhomboid major m. (cut)

Serratus posterior inferior m.

Spinous process of T12 vertebra
12th rib
Thoracolumbar fascia
Note: On the right side, the
Erector spinae m. trapezius, latissimus dorsi, and
Iliac crest
rhomboid muscles were removed
to show the intermediate muscles.

FIGURE 2.10 Extrinsic Muscles of the Back. (From Atlas of human anatomy, ed 7, Plate 180.)

extending to the lumbar transverse processes,

Intrinsic Back Muscles and iliac crest, and superiorly, forming the lateral
he intrinsic back muscles are the “true” muscles arcuate ligament for attachment of the respira-
of the back because they develop from epaxial tory diaphragm.
myotomes (see Fig. 2.22), function in movements he intrinsic back muscles also are among the
of the spine, and help maintain posture. he intrinsic few muscles of the body that are innervated by
muscles are enclosed within a deep fascial layer posterior rami of a spinal nerve. From supericial
that extends in the midline from the medial crest to deep, the intrinsic muscles include the following
of the sacrum to the ligamentum nuchae (a broad three layers (Fig. 2.11 and Table 2.5):
extension of the supraspinous ligament that extends • Supericial layer: including the splenius muscles
from the spinous process of the C7 vertebra to the that occupy the lateral and posterior neck
external occipital protuberance of the skull) (Fig. (spinotransversales muscles).
2.10) and skull, and that spreads laterally to the • Intermediate layer: including the erector spinae
transverse processes and angles of the ribs. In the muscles that mainly extend and laterally bend
thoracic and lumbar regions, the deep fascia makes the spine.
up a distinct sheath known as the thoracolumbar • Deep layer: including the transversospinales
fascia (Figs. 2.10 and 2.11; see also Fig 4.31). muscles that ill the spaces between the trans-
In the lumbar region, this fascial sheath has the verse processes and spinous processes.
following three layers (see also Fig. 4.31): he intermediate, or erector spinae, layer of
• Posterior layer: extending from the lumbar and muscles is the largest group of the intrinsic back
sacral spinous processes laterally over the surface muscles and is important for maintaining posture,
of the erector spinae muscles. extending the spine, and laterally bending the spine.
• Middle layer: extending from the lumbar hese muscles are divided into three major groups,
transverse processes to the iliac crest inferiorly as follows (Fig. 2.11 and Table 2.5):
and to the 12th rib superiorly. • Iliocostalis: most laterally located and associated
• Anterior layer: covering the quadratus lumbo- with attachments to the ribs and cervical trans-
rum muscle of the posterior abdominal wall and verse processes.

70 Chapter 2 Back

The superficial and intermediate (erecter spinae) layers of the intrinsic back muscles

Superior nuchal line of skull

Longissimus capitis m. Posterior tubercle of atlas (C1)

Semispinalis capitis m.
Spinalis cervicis m.

Splenius capitis and splenius cervicis mm.

Longissimus cervicis m.
Iliocostalis cervicis m.
Serratus posterior superior m.

Iliocostalis m.
Iliocostalis thoracis m.
Erector spinae mm. Longissimus m. Spinalis thoracis m.

Spinalis m. Longissimus thoracis m.

Iliocostalis lumborum m.
Serratus posterior inferior m.

Thoracolumbar fascia (cut edge)

The deep (transversospinal) layer of the intrinsic back muscles

Brevis Rotatores cervicis mm.
Interspinalis cervicis m.

Levator costarum m.

Brevis Rotatores thoracis mm.
Semispinalis thoracis m.

Longus Levatores costarum mm.
Multifidus thoracis mm.

Thoracolumbar fascia (anterior layer)

Interspinalis lumborum m.
Thoracolumbar fascia (posterior layer) (cut) Intertransversarius laterales lumborum m.

Multifidus lumborum mm.

Multifidus lumborum mm. (cut)

Note: Deep dissection shown on right side.

FIGURE 2.11 Intrinsic Muscles of the Back. (From Atlas of human anatomy, ed 7, Plates 181 and 182.)

Chapter 2 Back 71 2
• Longissimus: intermediate and largest column Deep to the transversospinal muscles lies a
of the erector spinae muscles. relatively small set of segmental muscles that assist
• Spinalis: most medially located and smallest of in elevating the ribs (levatores costarum) and
the erector spinae group, with attachments to stabilizing adjacent vertebrae while larger muscle
the vertebral spinous processes. groups act on the spine (interspinales, intertrans-
hese three groups are further subdivided into versarii) (Fig. 2.11).
regional divisions—lumborum, thoracis, cervicis,
and capitis—based on their attachments as one Suboccipital Muscles
proceeds superiorly (Fig. 2.11). In the back of the neck, deep to the trapezius,
he transversospinales (transversospinal) muscles splenius, and semispinalis muscles, lie several small
(deep layer) are often simply called the “paraver- muscles that move the head; they are attached to
tebral” muscles because they form a solid mass of the skull, the atlas, and the axis (Fig. 2.12 and Table
muscle tissue interposed and running obliquely 2.6). hese muscles are the suboccipital muscles,
between the transverse and spinous processes (Fig. innervated by the suboccipital nerve (posterior
2.11). he transversospinal muscles comprise the ramus of C1) and forming a (suboccipital) triangle
following three groups: with the following muscle boundaries:
• Semispinalis group: thoracis, cervicis, and • Rectus capitis posterior major.
capitis muscles; the most supericial transver- • Obliquus capitis superior (superior oblique
sospinal muscles, found in the thoracic and muscle of head).
cervical regions superior to the occipital bone. • Obliquus capitis inferior (inferior oblique
• Multiidus group: the muscles found deep to muscle of head).
the semispinalis group and in all spinal regions, Deep within the suboccipital triangle, the ver-
but most prominently in the lumbar region. tebral artery, a branch of the subclavian artery
• Rotatores group: deepest transversospinal in the lower anterior neck, passes through the
muscles; present in all spinal regions, but most transverse foramen of the atlas and loops medially
prominently in the thoracic region. to enter the foramen magnum of the skull to supply

Rectus capitis posterior minor m.

Greater occipital n. (medial branch Rectus capitis posterior major m.

of posterior ramus of C2 spinal n.)
Vertebral a.

Occipital a. Obliquus capitis superior m.

Suboccipital n. (posterior ramus of C1 spinal n.)

3rd (least) occipital n.

(medial branch of posterior Posterior arch of atlas (C1 vertebra)
ramus of C3 spinal n.)

Semispinalis capitis and

splenius capitis mm.
in posterior triangle of neck
Obliquus capitis inferior m.

Lesser occipital n. Greater occipital n. (posterior ramus of C2 spinal n.)

(cervical plexus C2, C3)

3rd (least) occipital n. (posterior ramus of C3 spinal n.)

FIGURE 2.12 Suboccipital Triangle and Associated Musculature. (From Atlas of human anatomy, ed
7, Plate 184.)

72 Chapter 2 Back

TABLE 2.6 Suboccipital Muscles

Rectus capitis Spine of axis Lateral inferior nuchal Suboccipital nerve (C1) Extends head and
posterior major line rotates to same side
Rectus capitis Tubercle of posterior Median inferior nuchal Suboccipital nerve (C1) Extends head
posterior minor arch of atlas line
Obliquus capitis Atlas transverse process Occipital bone Suboccipital nerve (C1) Extends head and
superior bends it laterally
Obliquus capitis Spine of axis Atlas transverse Suboccipital nerve (C1) Rotates head to same
inferior process side

The 31 spinal segments

and associated pairs of
spinal nerves are regionally
Cervical plexus arranged as follow:
C1 spinal n.
• 8 cervical pairs
•12 thoracic pairs
C8 spinal n.
• 5 lumbar pairs
Brachial plexus
• 5 sacral pairs
• 1 coccygeal pair
Key nerve plexuses include:
• Cervical: C1–4
• Brachial: C5–T1
• Lumbar: L1–4
Intercostal nn. • Sacral: L4–S4

T12 spinal n.

T12 vertebra
Conus medullaris

L1 spinal n. Lumbar plexus

Cauda equina

L5 spinal n.
Sacral plexus

Filum terminale internum

Sciatic n.

Termination of spinal dura mater

Filum terminale externum


FIGURE 2.13 Spinal Cord and Nerves In Situ. (From Atlas of human anatomy, ed 7, Plate 169.)

Chapter 2 Back 73 2
the brainstem. he irst three pairs of spinal nerves (gray matter) sending a myelinated axon through
are also found in this region (Fig. 2.12). an anterior (ventral) root and a spinal nerve,
and then into posterior and anterior rami of a
5. SPINAL CORD peripheral nerve, which ends at a neuromuscular
junction on a skeletal muscle (Figs. 2.14 and 2.15).
he spinal cord is a direct continuation of the Likewise, a nerve ending in the skin sends a sensory
medulla oblongata, extending below the foramen axon toward the spinal cord in a peripheral nerve.
magnum at the base of the skull and passing through (Sensory axons also arise from the muscle spindles
the vertebral (spinal) canal formed by the articulated and joints and are similarly conveyed back to the
vertebrae (Fig. 2.13). spinal cord.) hus, each peripheral nerve contains
he spinal cord has a slightly larger diameter in hundreds or thousands of motor and sensory
the cervical and lumbar regions, primarily because axons. he sensory neuron is a pseudounipolar
of increased numbers of neurons and axons in these neuron with its cell body in a spinal ganglion
regions for innervation of the muscles in the upper (a ganglion in the periphery is a collection of
and lower limbs. he spinal cord ends as a tapered neuronal cell bodies, just as a “nucleus” is in the
region called the conus medullaris, which is situ- brain) and sends its central axon into the posterior
ated at about the L1-L2 vertebral level (or L3 in horn (gray matter) of the spinal cord. At each level
neonates). From this point inferiorly, the nerve of the spinal cord, the gray matter is visible as
rootlets course to their respective levels and form a butterly-shaped central collection of neurons
a bundle called the cauda equina (“horse’s tail”). that possesses a posterior and an anterior horn
he spinal cord is anchored inferiorly by the ter- (Fig. 2.14).
minal ilum, which is attached to the coccyx. he he spinal cord gives rise to 31 pairs of spinal
terminal ilum is a pial extension that picks up a nerves, which then form two major branches (rami),
layer of dura mater after passing through the dural as follows:
sac (at the L2 vertebral level) before attaching to • Posterior ramus: a small ramus (branch) that
the coccyx (see Spinal Meninges). Features of the courses dorsally to the back and conveys motor
spinal cord include the following: and sensory information to and from the skin
• he 31 pairs of spinal nerves (8 cervical, 12 and the intrinsic back muscles and suboccipital
thoracic, 5 lumbar, and 5 sacral pairs and 1 skeletal muscles.
coccygeal pair). • Anterior ramus: a much larger ramus (branch)
• Each spinal nerve is formed by a posterior that courses laterally and ventrally and innervates
(dorsal) and anterior (ventral) root. all the remaining skin and skeletal muscles of
• Motor neurons reside in the spinal cord gray the neck, limbs, and trunk.
matter (anterior horn). Once nerve ibers (sensory or motor) are beyond,
• Sensory neurons reside in the spinal ganglia. or peripheral to, the spinal cord proper, the ibers
• Anterior rami of spinal nerves often converge then reside in nerves of the peripheral nervous
to form plexuses (mixed networks of nerve system (PNS). Components of the PNS include the
axons organized into a cervical, brachial, following (see Nervous System, Chapter 1):
lumbar, or sacral plexus) or segmental thoracic • Somatic nervous system: sensory and motor
nerves (intercostal nerves and the subcostal ibers to skin, skeletal muscle, and joints (Fig.
nerve). 2.15, left side).
• Posterior rami of spinal nerves are small and • Autonomic nervous system (ANS): sensory
only innervate the intrinsic back muscles and and motor ibers to all smooth muscle (including
the muscles of the suboccipital region (epaxial viscera and vasculature), cardiac muscle (heart),
muscles of embryo); they receive sensory ibers and glands (Fig. 2.15, right side).
from a narrow strip of skin above the intrinsic • Enteric nervous system: intrinsic plexuses and
muscles that extends down the back about 3 to ganglia of the gastrointestinal tract that regulate
4 cm lateral to the midline. bowel secretion, absorption, and motility (origi-
nally, considered part of the ANS); linked to the
Typical Spinal Nerve ANS for optimal regulation (see Fig. 1.27).
he typical scheme for a somatic (innervates hus, most peripheral nerves arising from the
skin and skeletal muscle) peripheral nerve shows spinal cord contains hundreds or thousands of three
a motor neuron in the spinal cord anterior horn types of axons (Fig. 2.15, left and right sides):

74 Chapter 2 Back

Segment of the spinal cord showing the dorsal and ventral roots, membranes removed: anterior view (greatly magnified)

Gray matter Rootlets of posterior root

White matter Posterior root of spinal n.

Rootlets of anterior root

Spinal ganglion

Anterior root
of spinal n. Anterior ramus
of spinal n.
Spinal n.

Posterior ramus
of spinal n.

Gray and white rami communicantes

Schematic of a typical peripheral nerve showing the somatic axons (autonomic axons not shown)
Posterior horn
Spinal ganglion
Sensory neuron cell body

Posterior root

Anterior horn
Motor neuron cell body root

Peripheral n.
Myelin sheath

Motor neuron Sensory neuron

Neuromuscular junction

FIGURE 2.14 Typical Spinal Nerve.

• Somatic eferent (motor) axons to skeletal Each of the 31 pairs of spinal nerves exits the
muscle. spinal cord and passes through an opening in the
• Aferent (sensory) axons from the skin, skeletal vertebral column (intervertebral foramen) to gain
muscle, and joints or viscera. access to the periphery. he C1 nerve pair passes
• Autonomic axons to smooth muscle (vascular between the skull and the atlas, with subsequent
smooth muscle and arrector pili muscles in the cervical nerve pairs exiting the intervertebral
skin), cardiac muscle, and glands. foramen above the vertebra of the same number;

Chapter 2 Back 75 2
Posterior root sympathetic
corpuscle Spinal Intermediolateral cell column
ganglion Vascular smooth
m., sweat
glands, and
Posterior arrector pili
ramus mm. in skin
Skeletal m.

Anterior ramus

Gray ramus communicans

Anterior root
Sympathetic chain ganglion
White ramus communicans
endings Splanchnic n.
Collateral Sympathetic chain
ganglion Preganglionic sympathetic neurons passing
Skeletal m. to synapse in another sympathetic chain ganglion

Sensory neuron of abdominal viscera Neuroeffector junctions on smooth m., cardiac m.,
secretory glands, metabolic cells, immune cells
Note: For simplicity, the left side of the figure only shows the somatic
components while the right side only shows the sympathetic efferent components.
FIGURE 2.15 Structural Anatomy of a horacic Spinal Nerve.

the C2 nerve exits via the intervertebral foramen and ganglia, with 31 pairs of spinal nerves, one pair
superior to the C2 vertebra, and so on, until one for each spinal cord level.) he irst cervical spinal
reaches the C8 nerve, which then exits the inter- cord level, C1, does possess sensory ibers, but these
vertebral foramen above the T1 vertebra. All the provide minimal if any contribution to the skin, so
remaining thoracic, lumbar, and sacral nerves exit at the top of the head the dermatome pattern begins
via the intervertebral foramen below the vertebra with the C2 dermatome (Fig. 2.17 and Table 2.7).
of the same number (Fig. 2.16). he dermatomes encircle the body in segmental
As it divides into its small posterior ramus and fashion, corresponding to the spinal cord level that
larger anterior ramus, the spinal nerve also gives receives sensory input from that segment of skin.
of several small recurrent meningeal branches that he sensation conveyed by touching the skin is
reenter the intervertebral foramen and innervate largely that of pressure and pain. Knowledge of
the dura mater, intervertebral discs, ligaments, and the dermatome pattern is useful in localizing
blood vessels associated with the spinal cord and speciic spinal cord segments and in assessing the
vertebral column (see Fig. 2.18). integrity of the spinal cord at that level (intact or
Dermatomes he sensory nerve ibers that innervate a segment
he region of skin innervated by the somatic sensory of skin and constitute the “dermatome” exhibit some
nerve axons associated with a single spinal ganglion overlap of nerve ibers. Consequently, a segment
at a single spinal cord level is called a dermatome. of skin is innervated primarily by ibers from a
(Likewise, over the anterolateral head, the skin is single spinal cord level, but there will be some
innervated by one of the three divisions of the overlap with sensory ibers from the level above
trigeminal cranial nerve, as discussed later.) he and below the primary cord level. For example,
neurons that give rise to these sensory ibers are dermatome T5 will have some overlap with sensory
pseudounipolar neurons that reside in the single ibers associated with the T4 and T6 spinal levels.
spinal ganglion associated with the speciic spinal hus, dermatomes provide a good approximation
cord level (Figs. 2.14 and 2.15). (Note that for each of spinal cord levels, but variation is common and
level, we are speaking of a pair of nerves, roots, overlap exists (Table 2.7).

76 Chapter 2 Back

C1 C1 spinal n. Trigeminal
C1 exits above C1 nerve (CN V)
C2 vertebra
Cervical C3 C2
enlargement C4
C5 C3
C5 C6
C8 spinal n. C4
C6 C7 exits below C7 C5
C7 C8 vertebra (there T2
T1 are 8 cervical T3
T1 nn. but only T4
T2 7 cervical T5 T1
T2 vertebrae) T6
T3 T7
T4 T8
T4 T9
T5 Cervical nn. T10
T6 Thoracic nn. T11
T7 C6
T7 Lumbar nn. T12
T8 C8
T8 Sacral and L1 C7
T9 coccygeal nn. S2, 3
T10 L2
T11 T11 L3
Conus medullaris L4
(termination of
L1 spinal cord)
enlargement L3
L3 L5
Cauda equina
terminale L5
internum L5 S1
S1 L4
S3 FIGURE 2.17 Distribution of dermatomes. (From Atlas
Termination of of human anatomy, ed 7, Plate 171.)
Filum S4 spinal dura mater
terminale S5
externum Coccygeal n.
TABLE 2.7 Key Dermatomes as Related to
Coccyx Body Surface
FIGURE 2.16 Relationship of Spinal Nerves to
Vertebrae. (From Atlas of human anatomy, ed 7, Plate
170.) C5 Clavicles
C5-C7 Lateral upper limb
C6 Thumb
C7 Middle finger
Spinal Meninges C8 Little finger
he brain and spinal cord are covered by three C8-T2 Medial upper limb
T4 Nipple
membranes called the meninges and are bathed T10 Umbilicus (navel)
in cerebrospinal luid (CSF) (Fig. 2.18). he three T12-L1 Inguinal/groin region
meningeal layers are the dura, arachnoid, and pia L1-L4 Anterior and inner surfaces of
lower limbs
mater. L4 Knee; medial side of big toe
L5 2nd to 4th toes
Dura Mater L4-S1 Foot
S1-S2 Posterior lower limb
he dura mater ("tough mother") is a thick outer S2-S4 Perineum
covering that is richly innervated by sensory nerve

Chapter 2 Back 77 2
Clinical Focus 2-10
Herpes Zoster
Herpes zoster, or shingles, is the most common infection of the peripheral nervous system. It is an acute
neuralgia confined to the dermatome distribution of a specific spinal or cranial sensory nerve root.

Painful erythematous vesicular eruption in

distribution of ophthalmic division of right
trigeminal (V) n.

Herpes zoster following course of

6th and 7th left thoracic dermatomes

Features of Shingles
Characteristic Description

Etiology Reactivation of previous infection of dorsal root or sensory ganglion by varicella-zoster virus (which causes

Presentation Vesicular rash confined to a radicular or cranial nerve sensory distribution; initial intense, burning, localized
pain; vesicles appear 72-96 hours later

Sites affected Usually one or several contiguous unilateral dermatomes (T5-L2), CN V (semilunar ganglion), or CN VII
(geniculate ganglion)

endings and that extends around the spinal cord Pia Mater
down to the level of the S2 vertebra, where the he pia mater is a delicate, transparent inner layer
dural sac ends. he epidural (extradural) space that intimately covers the spinal cord. At the cervical
lies between the vertebral canal walls and the spinal and thoracic levels, extensions of pia form approxi-
dural sac and contains fat, small nerves, and blood mately 21 pairs of triangular denticulate (“having
vessels (Fig. 2.18). small teeth”) ligaments that extend laterally and
help to anchor the spinal cord by inserting into the
dura mater. At the conus medullaris, the pia mater
Arachnoid Mater forms the terminal ilum, a single cord of thickened
he ine, weblike arachnoid membrane is avascular pia mater that pierces the dural sac at the S2
and lies directly beneath, but is not attached to, vertebral level, acquires a dural covering, and then
the dura mater. he arachnoid mater also ends at attaches to the tip of the coccyx to anchor the
the level of the S2 vertebra. Wispy threads of con- spinal cord inferiorly.
nective tissue extend from this layer to the underly-
ing pia mater and span the subarachnoid space, Subarachnoid Space and Choroid Plexus
which is illed with CSF. he subarachnoid space Cerebrospinal luid ills the subarachnoid space,
ends at the S2 vertebral level. which lies between the arachnoid and pia meningeal

78 Chapter 2 Back

Section through thoracic vertebra

Arachnoid mater Dura mater

Subarachnoid Fat in
space epidural space

Dura mater Anterior root

Pia mater

Arachnoid Anterior
mater ramus

Subarachnoid ramus

Pia mater
spinal cord
Spinal ganglion
Rootlets of

Denticulate lig. Internal vertebral (epidural) venous plexus (of Batson)

FIGURE 2.18 Spinal Meninges and Relationship to Spine. (From Atlas of human anatomy, ed 7,
Plates 174 and 175.)

layers (Figs. 2.18 and 2.19). hus, CSF circulates each midline region of the body (Fig. 2.20). hese
through the brain ventricles and then gains access major arteries include the following:
to the subarachnoid space through the lateral and • Vertebral arteries: arising from the subclavian
median apertures, where it lows around and over arteries in the neck.
the brain and inferiorly along the spinal cord to • Ascending cervical arteries: arising from a
the most caudal extent of the dural sac, which ends branch of the subclavian arteries.
at the S2 vertebral level. • Posterior intercostal arteries: arising from the
Cerebrospinal luid is secreted by the choroid thoracic aorta.
plexus, and most CSF is absorbed primarily by • Lumbar arteries: arising from the abdominal
the arachnoid granulations (associated with the aorta.
superior sagittal dural venous sinus) (Figs. 2.19 and • Lateral sacral arteries: arising from pelvic
8.8), and secondarily by small veins that also contain internal iliac arteries.
microscopic arachnoid granulations on the surface A single anterior spinal artery and two pos-
of the pia mater throughout the central nervous terior spinal arteries, originating intracranially
system (CNS) (Fig. 2.19). With about 500-700 mL from the vertebral arteries, run longitudinally along
produced daily, CSF supports and cushions the the length of the cord and are joined segmentally
spinal cord and brain, fulills some of the functions in each region by segmental arteries (Fig. 2.20).
normally provided by the lymphatic system, and he largest of these segmental branches is the major
ills the 150 mL volume of the brain’s ventricular segmental artery (of Adamkiewicz), found in the
system and the subarachnoid space. lower thoracic or upper lumbar region; it is the
It should be noted that recent microscopic major blood supply for the lower two thirds of
evidence provides support for the claim that some the spinal cord. he posterior and arterior roots
CNS regions do possess lymphatics. Future studies are supplied by segmental radicular (medullary)
may elucidate a larger role for lymphatic drainage arteries.
in some regions of the CNS. Multiple anterior and posterior spinal veins
run the length of the cord and drain into segmental
Blood Supply to Spinal Cord (medullary) radicular veins (see Fig. 2.9). Radicular
he spinal cord receives blood from spinal arteries veins receive tributaries from the internal verte-
derived from branches of larger arteries that serve bral veins that course within the vertebral canal.

Chapter 2 Back 79 2
Cerebrospinal fluid circulation
Superior sagittal sinus
Choroid plexus of lateral ventricle (phantom) Posterior arch of C1
Subarachnoid space
Dura mater C2 Posterior thecal sac
Arachnoid C3
Arachnoid mater granulations Spinal cord

C7 Spinous process of C7
T1 (vertebral prominens)
T6 Cerebrospinal fluid in
T7 subarachnoid space
Interventricular foramen (of Monro)
Choroid plexus of 3rd ventricle Midsagittal, T2-weighted MR scan
of cervical and thoracic spine
Cerebral aqueduct (of Sylvius)
Lateral aperture (foramen of Luschka)
Choroid plexus of 4th ventricle T12 Conus medullaris
Median aperture (foramen of Magendie) L1 Intervertebral disc
Spinous process of L1
Dura mater L2 CSF
Arachnoid mater L3
Subarachnoid space Cauda equina
Central canal of spinal cord

Midsagittal, T2-weighted MR scan of lumbar spine
FIGURE 2.19 Cerebrospinal Fluid Circulation. (From Atlas of human anatomy, 7th ed, Plate 120; MR
images from Kelley LL, Petersen C: Sectional anatomy for imaging professionals, St Louis, 2007,

Clinical Focus 2-11

Lumbar Puncture and Epidural Anesthesia
Cerebrospinal fluid may be sampled and examined clinically by performing a lumbar puncture (spinal tap). A
spinal needle is inserted into the subarachnoid space of the lumbar cistern, in the midline between the L3
and L4 or the L4 and L5 vertebral spinal processes. Because the spinal cord ends at approximately the L1 or
L2 vertebral level, the needle will not pierce and damage the cord. Anesthetic agents may be directly delivered
into the epidural space (above the dura mater) to anesthetize the nerve fibers of the cauda equina; this common
form of anesthesia is used during childbirth in most Western countries. The epidural anesthetic infiltrates the
dural sac to reach the nerve roots and is usually administered at the same levels as the lumbar puncture.

Epidural anesthesia Dural sac Lumbar puncture

Epidural equina
Spinous process Subarachnoid
of L4 space

Needle entering Needle entering
epidural space subarachnoid space

Arrows show locations of

insertion of needles.

80 Chapter 2 Back

Anterior view
Posterior view
Basilar a.
Posterior spinal aa.
Anterior spinal a.
Vertebral a.

Cervical vertebrae
Vertebral a. Posterior segmental medullary aa.

Segmental medullary aa.

Subclavian a. Subclavian a.
Segmental medullary aa.
Segmental medullary a.
Posterior intercostal a.
Thoracic Posterior intercostal aa.
Anterior radicular a. (great vertebrae
radicular a. of Adamkiewicz)

Lumbar a.
Lumbar aa.

Lateral (or medial) sacral aa.

Lateral (or medial) sacral aa.

FIGURE 2.20 Blood Supply to Spinal Cord. (From Atlas of human anatomy, ed 7, Plates 176 and

Radicular veins then drain into segmental veins, • Primitive streak mesoderm (somites).
with the blood ultimately collecting in the following • Lateral plate mesoderm.
locations: • Difuse collections of mesenchyme.
• Superior vena cava. As the neural groove invaginates along the
• Azygos venous system of the thorax. posterior midline of the embryonic disc, it is lanked
• Inferior vena cava. on either side by masses of mesoderm called
somites. About 42 to 44 pairs of somites develop
6. EMBRYOLOGY along this central axis and subsequently develop
into the following (Fig. 2.21):
Most of the bones inferior to the skull form by • Dermomyotomes: divide further to form
endochondral bone formation, that is, from a dermatomes, which become the dermis of the
cartilaginous precursor that becomes ossiied. he skin, and myotomes, which diferentiate into
embryonic development of the musculoskeletal segmental masses of skeletal muscle.
components of the back represents a classic example • Sclerotomes: the medial part of each somite
of segmentation, with each segment corresponding that, along with the notochord, migrates around
to the distribution of peripheral nerves. his process the neural tube and forms the cartilaginous
begins around the end of the third week of embry- precursors of the axial skeleton.
onic development (day 19), during the period called Myotomes have a segmental distribution, just
gastrulation (see Chapter 1). like the somites from which they are derived. Each
segment is innervated by a pair of nerves originating
Development of Myotomes, from the spinal cord segment. A small dorsal portion
Dermatomes, and Sclerotomes of the myotome becomes an epimere (epaxial) mass
he bones, muscles, and connective tissues of the of skeletal muscle that will form the true intrinsic
embryo arise from the following sources: muscles of the back (e.g., erector spinae muscles)

Chapter 2 Back 81 2
Cross section of human embryos
At 19 days Ectoderm of At 22 days
embryonic disc Neural tube Ectoderm
groove Dermomyotome Notochord
Cut edge
of amnion Sclerotome

coelom Mesoderm
Notochord Endoderm Endoderm of gut
(roof of yolk sac) Dorsal aortas
At 27 days At 30 days
Ectoderm Spinal cord
Spinal cord
Dermomyotome (future Spinal ganglion

to neural arch Dermatome Mesenchymal

Sclerotome (future contribution to
to vertebral
contributions dermis) intervertebral disc
body (centrum)
to costal process Myotome
Notochord (future
Dorsal aortas Mesoderm Aorta nucleus pulposus)

FIGURE 2.21 Somite Formation and Diferentiation.

Segmental distribution of myotomes in fetus of 6 weeks Somatic development

Region of each trunk myotome also represents
Motor neuroblasts form
territory of dermatome into which motor and
Occipital (postotic)
primitive axons and enter
sensory fibers of segmental spinal n. extend. Epaxial mm.
skeletal m. of body wall.
Posterior ramus
Anterior ramus Posterior
Posterior division cutaneous n.
12 Anterior division
3 Epaxial mm.
4 Hypaxial mm.
2 Posterior ramus
3 (extensors of limb)
4 Cervical Anterior ramus
6 myotomes
Ventral 8 Dorsal
(hypaxial) 1 (epaxial)
2 Hypaxial
column 3 column mm. (in
of hypomeres 5 of epimeres thoracic and
6 Hypaxial mm.
7 abdominal
8 Thoracic (flexors of limb)
9 wall)
10 myotomes Hypaxial mm. Lateral
Coccygeal 2 112 (flexors of arm cutaneous n.
myotomes 54 3 2 1 543 and shoulder) Anterior cutaneous n.

Sacral myotomes
Lumbar myotomes A schematic cross section showing the body wall
and upper limb on the embryo’s right side
and the embryo body wall only on the left side
FIGURE 2.22 Myotome Segmentation into Epimeres and Hypomeres.

and are innervated by a posterior ramus of the thoracodorsal nerve, which is composed of nerves
spinal nerve (Fig. 2.22). from the anterior rami of spinal cord segments
A much larger anterior segment becomes the C6-C8.
hypomere (hypaxial) mass of skeletal muscle,
which will form the muscles of the trunk wall and Vertebral Column Development
limb muscles, all innervated by an anterior ramus Each vertebra irst appears as a hyaline cartilage
of the spinal nerve. Adjacent myotome segments model that then ossiies, beginning in a primary
often merge so that an individual skeletal muscle ossiication center (Fig. 2.23). Ossiication centers
derived from those myotomes is innervated by include the following:
more than one spinal cord segment. For example, • Body: forms the vertebral body; important for
the latissimus dorsi muscle is innervated by the support of body weight.

82 Chapter 2 Back

Fate of body, costal process, and neural arch components of vertebral

column, with sites and time of appearance of ossification centers

Cervical vertebra Thoracic vertebra

Spinous Lamina ossification
process center appears at 9th
Lamina or 10th week.
Ossification center
Vertebral appears at 9th or
foramen 10th week. Rib
Posterior Rib ossification
Transverse tubercle Superior center appears at
process Vestige of 8th or 9th week.
Body notochord
Anterior process
tubercle Pedicle
Body Ossification center
appears at 9th or
10th week.

Lumbar vertebra Sacrum

Lamina ossification Median crest Ossification center
center appears at 9th articular process Sacral appears at 10th week.
or 10th week. canal

part (ala)
Vestige of

Ossification center Body

appears at 9th or
Ossification Promontory Ossification center
10th week.
center appears appears at 6th
at 10th week. month (prenatal).
Costal process
Neural arch

FIGURE 2.23 Ossiication of Vertebral Column.

• Costal process: forms the ribs, or in vertebrae

without rib articulation, part of the transverse Neurulation and Development of
process; important for movement and muscle the Spinal Cord
attachment. Neurulation (neural tube formation) begins concur-
• Neural arch: includes the pedicle and lamina, rently with gastrulation (formation of the trilaminar
for protection of the spinal cord, and the spinous embryonic disc during the third week of develop-
process, for muscle attachment. ment). As the primitive streak recedes caudally,
he body of the vertebra does not develop from the midline surface ectoderm thickens to form the
a single sclerotome but rather from the fusion of neural plate, which then invaginates to form the
two adjacent sclerotomes (i.e., fusion of caudal half neural groove (Fig. 2.24, A). he neural crest
of sclerotome above with cranial half of sclerotome forms at the dorsal aspect of the neural groove
below). he intervertebral foramen thus lies over (Fig. 2.24, B) and fuses in the midline as the groove
this fusion and provides the opening for the spinal sinks below the surface and pinches of to form
roots that will form the spinal nerve that will the neural tube (Fig. 2.24, C). he neural tube
innervate the myotome at that particular segment. forms the following:
he notochord initially is in the central portion • Neurons of central nervous system (CNS: brain,
of each vertebral body but disappears. he noto- spinal cord).
chord persists only as the central portion (nucleus • Supporting cells of CNS.
pulposus) of each intervertebral disc, surrounded • Somatomotor neurons (innervate skeletal muscle)
by concentric lamellae of ibrocartilage. of PNS.

Chapter 2 Back 83 2
A. Embryo at 20 days (posterior view) B. Embryo at 21 days (posterior view)
Neural plate
Neural plate Level of Ectoderm Future neural crest
of forebrain of forebrain Neural crest
Neural groove Neural plate Level of
Future neural crest Neural groove

2.3 mm
2.0 mm

Neural folds Neural fold Fused neural folds

Level of section

Caudal neuropore
Primitive streak

C. Embryo at 24 days (posterior view) D. 4th week E. 6th week

The neural tube will form the brain and spinal cord (CNS). Sympathetic
Spinal trunk
Sensory neuron of
ganglion ganglion
Fused neural Neural crest Ectoderm spinal ganglion
folds Ectoderm
1st occipital Spinal cord
somite Neural crest Aorta
2.6 mm

1st cervical Level of

somite Preaortic
section Neural tube Visceral motor neuron sympathetic
1st thoracic of sympathetic ganglion
Neural tube (spinal cord) ganglion
somite Sulcus limitans
Notochord Mesonephros Dorsal
Caudal Chromaffin cell, Gut mesentery
neuropore suprarenal primordium
medulla cell of suprarenal

FIGURE 2.24 Neurulation.

• Presynaptic autonomic neurons of PNS. • Mantle: intermediate zone that develops into
he neural crest gives rise to the following (Fig. gray matter of spinal cord.
2.24, D and E): • Marginal zone: outer layer that becomes white
• Sensory neurons of PNS found in dorsal root matter of spinal cord.
ganglia. Glial cells are found primarily in the mantle and
• Postsynaptic autonomic neurons. marginal zone. he neural tube is distinguished
• Schwann cells of PNS. by a longitudinal groove on each side that forms
• Adrenal medullary cells, in each adrenal gland. the sulcus limitans and divides the tube into a
• Head mesenchyme and portions of heart. dorsal alar plate and a ventral basal plate (Fig.
• Melanocytes in skin. 2.25). he dorsal alar plate forms the sensory
• Arachnoid mater and pia mater meninges (dura derivatives of the spinal cord, and the ventral basal
mater is formed from mesenchyme). plate gives rise to the somatic and autonomic motor
he cells in the walls of the neural tube compose neurons, whose axons will leave the spinal cord
the neuroepithelium, which develops into three and pass into the peripheral tissues. he sensory
zones, as follows: neurons of the spinal ganglia are formed from
• Ependymal zone: inner layer lining central canal neural crest cells.
of spinal cord (also lines ventricles of brain).

Chapter 2 Back 83.e1 2
Clinical Focus 2-13
Myofascial Pain
Myofascial pain syndrome is pain associated with a muscle or its adjacent fascia that may be felt at a single
point or at multiple active “trigger” points, sending a signal to the central nervous system. Trauma, muscle
overuse, poor posture, and disease may precipitate the pain. The trigger site may be tender to palpation and
may initiate a muscle spasm-pain-spasm cycle. Common trigger points include the following muscles:
• Neck: levator scapulae, splenius capitis, trapezius, sternocleidomastoid
• Shoulder: infraspinatus, supraspinatus, rhomboid
• Lower back: quadratus lumborum, gluteus medius, tensor fasciae latae
• Thigh: biceps femoris, vastus lateralis, adductor longus
• Leg: gastrocnemius, soleus

Deconditioning of lumbar Stress Sympathetic

extensors, particularly Emotion pathways
longissimus and multifidus mm.
Suprasegmental centers


Injury to m.
may result in
pain and delayed
la afferent


m. fiber

Muscle spindles provide feedback mechanism for m. tension. Sensitivity of

spindles modulated by gamma efferent system and by sympathetic innervaton
of spindles. Sympathetic hyperactivity can result in painful spasm of spindles.
Deconditioning of extensor musculature
stimuli (mechanical Cortical
factors, chemical factors) processing
of pain input

Deconditioning (gating) of
of musculature pain input
due to decreased
function and
disuse results in
delayed repair
and continued

Inhibition of m. strength and

function directly related to
severity of noxious stimuli

83.e2 Chapter 2 Back

Clinical Focus 2-14

Acute Spinal Syndromes
Acute spinal cord myelopathies may be caused by several epidural (extradural) lesions, including metastatic
tumors that invade the vertebral body (top panel) or an epidural abscess resulting from a variety of infections
(lower panel). Likewise, intradural myelopathies can occur from trauma, inflammation, and vascular infarction
(shown in this image, middle panel).

Metastatic lesion Common primary sites, noted on history examination

Prostate showing
Breast extradural
caused by

Melanoma Bone
(skin or X-ray film showing
mucous destruction of
membrane) pedicle and multiple
vertebral body
Lymphoma metastases
by metastatic
(may be carcinoma

Infarction Posterior columns intact Sensory dissociation

(position sense infarct) Loss of
Lateral corticospinal tract pain and
infarcted (motor function lost) temperature
Spinothalamic tract infarcted sensation
(pain and temperature
sensation lost)
because of infarction of
anterolateral spinal cord
due to:
Thrombosis of artery
of Adamkiewicz,
central (sulcal) artery,
anterior spinal artery,
intercostal artery or to:
Aortic obstruction by Position Dissecting aortic aneurysm
dissecting aneurysm sense obstructing artery of
or clamping during retained Adamkiewicz by blocking
heart surgery intercostal artery

Sources of infection
Epidural abscess

Skin: Urinary tract: Lung: Dental: Throat:

furuncle, renal, perirenal, or pneumonia, abscess pharyngitis,
carbuncle prostatic abscess; abscess, tonsillitis,
pyelonephritis bronchiectasis abscess


Pain on percussion
of spine. Local warmth
may be noted.
Psoas Decubitus ulcer,
abscess Dermal sinus direct or hematogenous

Transverse myelitis Cause and specific pathologic process undetermined. Diagnosis by exclusion of other causes.

84 Chapter 2 Back

51/2 weeks (transverse section) Mature (transverse section)

Central Central canal
Dorsal alar Posterior gray
plate Ependymal column (horn)
(sensory and layer Sensory
coordinating) Mantle
Marginal matter)
Lateral gray
Ventral basal column (horn)
limitans Motor
plate (motor) Anterior gray
column (horn)
Tracts (white matter)

Differentiation and growth of neurons at 26 days

Neural crest

Ependymal layer
Spinal cord
(thoracic part) Mantle layer

Marginal layer

Motor neuroblasts
growing out to
terminate on
motor end plates
of skeletal m.

FIGURE 2.25 Alar and Basal Plates of Spinal Cord.

Chapter 2 Back 85 2
Clinical Focus 2-12
Spina Bifida
Spina bifida, one of several neural tube defects, is linked to low folic acid ingestion during the first trimester
of pregnancy. Spina bifida is a congenital defect in which the neural tube remains too close to the surface
such that the sclerotome cells do not migrate over the tube and form the neural arch of the vertebra (spina
bifida occulta). This defect occurs most often at the L5 or S1 vertebral level and may present with neurologic
findings. If the meninges and CSF protrude as a cyst (meningocele) or if the meninges and the cord itself
reside in the cyst (meningomyelocele), significant neurologic problems often develop.

Spina bifida occulta Types of spina bifida cystica with protrusion of spinal contents

Meningocele Meningomyelocele

Clinical Focus
Available Online

2-13 Myofascial Pain

2-14 Acute Spinal Syndromes
Additional figures available online (see inside front cover for

Challenge Yourself Questions
1. Besides his apparent mental deicits, the 4. A 19-year-old man sustained an apparent
“hunchback of Notre Dame” also sufered from cervical spine hyperextension (“whiplash”)
which of the following conditions? injury after a rear-end roller-coaster crash at
A. Halitosis a local amusement park. Radiographic examina-
B. Kyphosis tion reveals several cervical vertebral body
C. Lordosis fractures and the rupture of an adjacent ver-
D. Osmosis tebral ligament. Which of the following vertebral
E. Scoliosis ligaments was most likely ruptured during this
hyperextension injury?
2. You are asked to assist a resident with a lumbar
A. Anterior longitudinal ligament
puncture procedure to withdraw a cerebrospinal
B. Cruciate ligament
luid sample for analysis. Which of the following
C. Interspinous ligament
surface landmarks will help you determine
D. Ligamentum lavum
where along the midline of the spine you will
E. Nuchal ligament
insert the spinal needle?
A. An imaginary line crossing the two iliac 5. A 34-year-old woman presents with a spider
crests bite and a circumscribed area of inlammation
B. An imaginary line crossing the two on the back of her neck over the C4 dermatome
posterior superior iliac spines region. Which of the following types of nerve
C. At the level of the 5th lumbar spinous ibers mediate this sensation?
process A. Somatic aferents in C4 anterior root
D. At the level of the umbilicus B. Somatic aferents in C4 posterior root
E. At the level of the vertebra prominens C. Somatic aferents in C4 anterior ramus
D. Somatic eferents in C4 anterior root
3. A 56-year-old man presents with a history of
E. Somatic eferents in C4 posterior root
pain for the last 18 months over the right
F. Somatic eferents in C4 anterior ramus
buttock and radiating down the posterior aspect
of the thigh and leg. A radiographic examination 6. A newborn female presents with a congenital
reveals a herniated disc between the L5 and neural tube defect likely caused by a folic acid
the S1 vertebral levels. Which of the following deiciency and characterized by the failure of
nerves is most likely afected by this herniated the sclerotome to form the neural arch. Which
disc? of the following conditions is consistent with
A. L3 this congenital defect?
B. L4 A. Osteophyte overgrowth
C. L5 B. Osteoporosis
D. S1 C. Scoliosis
E. S2 D. Spina biida
E. Spondylolysis

Multiple-choice and short-answer review questions available online; see inside front cover for details.


Chapter 2 Back 87 2
7. After an automobile crash, a 39-year-old man For each of the following conditions (11-20), select
presents with a headache and midback pain. the muscle (A-K) most likely responsible.
A radiographic examination reveals trauma to
the thoracic spine and bleeding from the A. Erector spinae G. Rotatores
anterior and posterior internal vertebral venous B. Latissimus dorsi H. Semispinalis
plexus. In which of the following regions is the C. Levator scapulae I. Serratus posterior
blood most likely accumulating? D. Obliquus capitis superior
inferior J. Splenius capitis
A. Central spinal canal
E. Rectus capitis K. Trapezius
B. Epidural space
posterior major
C. Lumbar triangle
F. Rhomboid major
D. Subarachnoid space
E. Subdural space ____ 11. A work-related injury results in a
8. A high school football player receives a helmet- weakness against resistance in elevation of the
to-helmet blow to his head and neck and is scapula and atrophy of one of the lateral neck
brought into the emergency department. A muscles. he physician suspects damage to a
radiographic examination reveals a mild disloca- cranial nerve.
tion of the atlantoaxial joint. When you examine
____ 12. An injury results in signiicant weak-
his neck, you notice his range of motion is
ness in extension and lateral rotation along the
decreased. Which of the following movements
entire length of the spine.
of the head would most likely be afected?
A. Abduction ____ 13. After an automobile crash, a patient
B. Adduction presents with radiating pain around the shoul-
C. Extension der blades and weakness in elevating the ribs
D. Flexion on deep breathing.
E. Rotation
____ 14. An injury to the back results in a
9. A patient is admitted to the emergency depart- weakened ability to extend and medially rotate
ment with a sharp penetrating wound in the the upper limb.
upper back region just lateral to the thoracic
spine. Based on a quick examination, the physi- ____ 15. Sharp trauma to the back of the neck
cian concludes that several of the spinal ganglia damages the suboccipital nerve, resulting in a
are clearly damaged. Which of the following weakened ability to extend and rotate the head
neural elements are most likely compromised to the same side against resistance.
by this injury?
____ 16. Malformation of the craniocervical
A. Postganglionic eferents
portion of the embryonic epaxial (epimere)
B. Somatic aferents only
muscle group that attaches to the ligamentum
C. Somatic aferents and eferents
nuchae results in a weakened ability to extend
D. Somatic and visceral aferents
the neck bilaterally.
E. Somatic eferents only

10. A congenital defect that involves the neural ____ 17. Trauma to the lateral neck results in
crest cells would potentially involve the normal a lesion to the dorsal scapular nerve and a
development of which of the following weakened ability to shrug the shoulders.
____ 18. he loss of innervation to this pair
A. Anterior spinal artery of hypaxial (hypomere) muscles results in a
B. Choroid plexus bilateral weakened ability to retract the scapulae
C. Dura mater but does not afect the ability to elevate the
D. Intrinsic back muscles scapulae.
E. Schwann cells

88 Chapter 2 Back

____ 19. During spinal surgery, these small 25. A 26-year-old woman involved in an automobile
intrinsic back muscles must be retracted from crash presents with a headache and back pain.
the lamina and transverse processes of one or Imaging reveals a hematoma from rupture of
two vertebral segments. her internal vertebral venous plexus. he blood
is most likely present in which of the following
____ 20. During surgery in the neck, the areas or spaces?
vertebral artery is observed passing just deep
A. Central canal
to this muscle prior to the artery entering the
B. Epidural space
foramen magnum.
C. 4th ventricle
21. A woman presents with a painful neck. Imaging D. Subarachnoid space
reveals spinal stenosis (narrowing of the ver- E. Subdural space
tebral foramen). Hypertrophy of which of the 26. he erector spinae muscles are derived from
following ligaments would most likely result which of the following embryonic tissues?
in this syndrome?
A. Ectoderm
A. Anterior longitudinal ligament B. Endoderm
B. Interspinous ligament C. Epimeres
C. Ligamentum lavum D. Hypomeres
D. Nuchal ligament E. Neural crest
E. Supraspinous ligament
27. During surgery involving the posterior abdomi-
22. A 51-year-old man is admitted to the emergency nal wall, it is important to not damage the
department following a bicycle accident. His primary blood supply to the lower two thirds
physical examination reveals weakened medial of the spinal cord, which usually is supplied by
rotation, extension, and adduction of an upper which of the following arteries?
limb. Which of the following nerves is most
A. Lateral sacral arteries
likely injured?
B. Lumbar arteries
A. Accessory nerve (CN XI) C. Major anterior segmental medullary
B. Axillary nerve arteries
C. Dorsal scapular nerve D. Posterior intercostal arteries
D. Radial nerve E. Vertebral arteries
E. horacodorsal nerve
28. Extreme exercise and/or physical trauma may
23. A 54-year-old woman presents with a case of easily damage the spinal cord. However, it is
shingles (herpes zoster infection) that afects tethered laterally by several important struc-
the sensory spinal nerve roots innervating the tures that prevent side-to-side excursions of
skin on her back overlying the inferior angle the cord. Which of the following structures is
of her scapula. Which of the following derma- responsible for this stabilization of the cord?
tomes is most likely involved?
A. Denticulate ligaments
A. C5-C6 B. Interspinous ligament
B. T1-T2 C. Ligamentum lavum
C. T6-T7 D. Supraspinous ligament
D. T10-T11 E. Terminal ilum
E. L1-L2

24. During a routine lumbar puncture to sample

the CSF, which of the following ligaments
normally would be penetrated by the spinal
A. Anterior longitudinal ligament
B. Denticulate ligament
C. Nuchal ligament
D. Posterior longitudinal ligament
E. Supraspinous ligament

Chapter 2 Back 89 2
29. Trauma involving the intervertebral foramen
Answers to Challenge
between the C3 and C4 vertebrae results in
Yourself Questions
damage to the anterior root of a spinal nerve.
Which of the following nerve ibers are
1. B. Kyphosis, or “humpback (hunchback),” is one
damaged? of several accentuated spinal curvatures. It is
A. Motor ibers of the C3 spinal cord level commonly observed in the thoracic spine.
B. Motor ibers of the C4 spinal cord level Halitosis refers to bad breath, and lordosis to
the lumbar curvature, either the normal cur-
C. Sensory ibers of the C3 spinal cord level
vature or an accentuated lordosis similar to
D. Sensory ibers of the C4 spinal cord level that observed in women during the third tri-
E. Motor and sensory ibers of the C3 spinal mester of pregnancy. Osmosis is the passage
cord level of a solvent through a semipermeable mem-
F. Motor and sensory ibers of the C4 spinal brane based on solute concentration, and
scoliosis is an abnormal lateral curvature of
cord level the spine.
For questions 30 to 35, refer to the midsagittal MRI 2. A. An imaginary line connecting the two iliac crests
of the lumbar spine and provide the letter that demarcates the space between the L3 and L4
correctly answers the question or identiies the spinous processes with patients on their side
structure described. and the spine flexed. Lumbar punctures are
usually performed between the L3-L4 or L4-L5
30. Which letter points to the cauda equina? levels to avoid injury to the spinal cord proper,
which usually ends as the conus medullaris at
31. Where is the nucleus pulposus? the L1-L2 vertebral levels. Below the L2 verte-
bral level, the nerve roots comprise the cauda
equina, and are suspended in the CSF-filled
32. Where is the CSF located?
subarachnoid space.
33. Where is the spinous process of the L3 vertebra 3. D. The nucleus pulposus of the intervertebral discs
located? usually herniates in a posterolateral direction,
where it can impinge on the nerve roots passing
34. Identify the supraspinous ligament. through the intervertebral foramen. A disc
herniating at the L4-L5 level usually impinges
35. Identify the ligamentum lavum. on the L5 roots, and herniation at the L5-S1
level involves the S1 roots.

T11 4. A. Hyperextension-hyperflexion (whiplash) of the

C cervical spine can occur when the relaxed neck
D is thrown backward (hyperextension), tearing
the anterior longitudinal ligament. Hyperflex-
E ion is usually limited when one’s chin hits the
F sternum. Properly adjusted car seat headrests
A can limit the hyperextension.
G 5. B. Sensation from the skin is mediated by somatic
H afferents (fibers in the posterior root), and the
L4 cell bodies of these sensory neurons (pseu-
dounipolar neurons) associated with the T4
dermatome reside in the T4 spinal ganglion.

6. D. Mesoderm derived from the sclerotome nor-

mally contributes to the formation of the neural
From Kelley LL, Petersen C: Sectional anatomy for imaging arch (pedicle, lamina, and spinous process),
and a folic acid deficiency in the first trimester
professionals, ed 3, St Louis, 2012, Elsevier.
of pregnancy may contribute to this congenital
malformation (spina bifida occulta).

7. B. The internal vertebral venous plexus (Batson’s

plexus) resides in the epidural fat surrounding
the meningeal-encased spinal cord. The epidural
space lies between the bony vertebral spinal
canal and the dura mater surrounding the spinal

90 Chapter 2 Back

8. E. The atlantoaxial joint (atlas and axis) functions 18. F. Hypaxial muscles are innervated by the ante-
in the axial rotational movements of the head. rior rami of spinal nerves, and the rhomboid
The cranium and atlas move as a unit and rotate major muscle is a hypaxial muscle that retracts
side to side on the uniaxial synovial pivot joint the scapulae.
between the axis (C2) and atlas (C1).
19. G. The rotatores muscles are part of the trans-
9. D. The spinal ganglia between T1 and L2 contain versospinales group of muscles that largely
sensory neurons for both somatic and visceral fill the spaces between the transverse processes
(autonomic) afferent fibers, so both of these and the spinal processes. Specifically, the
modalities would be compromised. Efferent rotatores muscles extend between the lamina
(motor) fibers are not associated with the spinal and transverse processes and stabilize, extend,
ganglia. and rotate the spine.

10. E. Of the options, only Schwann cells are derived 20. E. The vertebral arteries ascend in the neck by
from the neural crest. While the arachnoid passing through the transverse foramina of
mater and pia mater are derived from neural the C6-C1 vertebrae, then loop medially and
crest cells (neither of these choices are options), superiorly to the posterior arch of the atlas
the dura mater is derived from mesoderm. (C1), pass deep (anterior) to the rectus capitis
posterior major muscle, and enter the foramen
11. K. The only muscle of this group innervated by magnum to supply the posterior portion of the
a cranial nerve is the trapezius muscle by the brainstem and brain, and the cerebellum by
accessory nerve (CN XI). The other neck muscle forming the basilar artery and its branches.
innervated by CN XI is the sternocleidomastoid
muscle in the lateral neck. 21. C. Of all the ligaments listed, only the ligamentum
flavum is found in the vertebral foramen, where
12. A. The major extensors along the entire length it connects adjacent laminae of two vertebrae.
of the spine, also involved in lateral rotation
or bending when unilaterally contracted, are 22. E. The thoracodorsal nerve innervates the latis-
the erector spinae group of muscles (spinalis, simus dorsi muscle. This muscle can medially
longissimus, and iliocostalis muscles). rotate, adduct, and extend the humerus;
extension of the humerus is its primary action.
13. I. The only muscles in the list that are associated It is a muscle well developed in competitive
with the shoulder blade (scapula), attach to swimmers.
the ribs, and elevate them during inspiration
are the serratus posterior superior group. These 23. C. Herpes zoster infection affects the sensory
muscles are considered respiratory muscles distribution of spinal and cranial nerves in a
because they assist in respiratory movements pattern generally following a dermatome. In
of the ribs. this instance, it affects the dermatomes asso-
ciated with the skin overlying the inferior angle
14. B. The latissimus dorsi muscle extends and medi- of the scapula, or, approximately, the derma-
ally rotates the upper limb at the shoulder and tomes of T6-T7. See Clinical Focus 2-10.
is the only muscle in this list with these
combined actions on the upper limb. 24. E. As the spinal needle descends in the midline
of the back, it would normally encounter the
15. E. The suboccipital nerve (posterior ramus of C1) supraspinous ligament and ligament flavum
innervates the suboccipital muscles in the before it enters the vertebral foramen. It would
posterior neck, and the rectus capitis posterior then pierce the dura mater and arachnoid mater
major muscle is the only one in the list that before reaching the CSF in the subarachnoid
extends and rotates the head to the same side. space.

16. J. The splenius capitis muscle is the only epaxial 25. B. The internal vertebral plexus (of Batson) of
muscle (intrinsic back muscles innervated by veins lies within the vertebral foramen and
posterior rami of the spinal nerves) in this list just outside the dura mater and epidural fat.
that has significant attachment to the ligamen- The other spaces lie beneath the dura mater
tum nuchae (origin) and exclusively extends (subdural or subarachnoid space). The central
the neck when it contracts bilaterally. canal is within the spinal cord itself.

17. C. The levator scapulae muscle is innervated 26. C. The erector spinae muscles are true intrinsic
by the posterior scapular nerve (C5) and assists back muscles innervated by posterior rami
the superior portion of the trapezius muscle of the spinal nerves. They are derived from
in shrugging the shoulders. myotomes (mesoderm) forming the epimeres.
Hypomeres give rise to skeletal muscle inner-
vated by the anterior rami of spinal nerves.

Chapter 2 Back 91 2
27. C. The major anterior segmental medullary artery 30. B. See Fig. 2.19.
(of Adamkiewicz) is in the lower thoracic or
upper lumbar region. It usually provides the 31. E. The nucleus pulposus lies within the center of
major blood supply to the lower two thirds of the intervertebral disc. See Clinical Focus 2-6.
the spinal cord. The other options include
32. A. The CSF is located in the subarachnoid space,
arteries that provide blood to more discrete
seen here surrounding the cauda equina.
regions of the spinal cord or to the brainstem
and cerebellum (the vertebral arteries). 33. G. The spinous process of the L3 vertebra is slanted
slightly posteroinferior to the more anterior
28. A. The spinal cord is anchored cranially by its
L3 vertebral body.
continuation intracranially as the brainstem
and caudally by the terminal filum, which 34. D. The supraspinous ligament is stretching
attaches to the coccyx. However, its lateral between adjacent spines of the vertebrae.
movement is limited by approximately 21 pairs
of triangular-shaped pia mater extensions that 35. H. The ligamentum flavum is connecting adjacent
pierce the arachnoid mater and insert into the laminae of the vertebrae. The ligament also
dura mater. These attachments limit side-to- contains some elastic fibers.
side movements of the cord.

29. B. The anterior root of a spinal nerve contains

only motor (efferent) nerve fibers. The first
spinal nerve exits the spinal cord between the
C1 vertebra (the atlas) and the skull, and each
subsequent spinal nerve exits the vertebral
canal above the vertebra of the same number.
So the anterior root of the C4 spinal nerve
exits between the C3 and C4 vertebrae.
However, because there are eight cervical
nerves and only seven cervical vertebrae, the
C8 spinal nerve exits above the T1 vertebra;
hence, all remaining thoracic, lumbar, and sacral
nerves exit via the intervertebral foramen below
the vertebra of the same number (e.g., the T1
nerve exits the intervertebral foramen between
the T1 and T2 vertebrae). See Fig. 2.16.

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1. INTRODUCTION and the esophagus between the neck and thorax.

Clinicians often refer to “thoracic outlet syndrome,”
he thorax lies between the neck and abdomen, which describes symptoms associated with com-
encasing the great vessels, heart, and lungs, and pression of the brachial plexus as it passes over
provides a conduit for structures passing between the irst rib (speciically, the T1 anterior ramus).
the head and neck superiorly and the abdomen, he inferior thoracic aperture (the anatomical
pelvis, and lower limbs inferiorly. Functionally, the thoracic outlet) conveys the inferior vena cava (IVC),
thorax and its encased visceral structures are aorta, esophagus, nerves, and thoracic lymphatic
involved in the following: duct between the thorax and the abdominal cavity.
• Protection: the thoracic cage and its muscles Additionally, the thorax contains two pleural
protect the vital structures in the thorax. cavities laterally and a central “middle space” called
• Support: the thoracic cage provides muscular the mediastinum, which is divided as follows
support for the upper limb. (Fig. 3.1):
• Conduit: the thorax provides for a superior and • Superior mediastinum: a midline compart-
an inferior thoracic aperture and a central ment that lies above an imaginary horizontal
mediastinum. transverse thoracic plane that passes through
• Segmentation: the thorax provides an excellent the manubrium of the sternum (sternal angle
example of segmentation, a hallmark of the of Louis) and the intervertebral disc between
vertebrate body plan. the T4 and T5 vertebrae
• Breathing: the movements of the respiratory • Inferior mediastinum: the midline com-
diaphragm and intercostal muscles are essential partment below this same horizontal plane,
for expanding the thoracic cavity to facilitate which is further subdivided into an anterior,
the entry of air into the lungs in the process of middle (contains the heart), and posterior
breathing. mediastinum
• Pumping blood: the thorax contains the heart,
which pumps blood through the pulmonary and 2. SURFACE ANATOMY
systemic circulations.
he sternum, ribs (12 pairs), and thoracic ver- Key Landmarks
tebrae (12 vertebrae) encircle the thoracic contents Key surface landmarks for thoracic structures
and provide a stable thoracic cage that both protects include the following (Fig. 3.2):
the visceral structures of the thorax and ofers • Jugular (suprasternal) notch: a notch marking
assistance with breathing. Because of the lower the level of the second thoracic vertebra, the
extent of the rib cage, the thorax also ofers protec- top of the manubrium, and the midpoint between
tion for some of the abdominal viscera, including the articulation of the two clavicles. he trachea
the liver and gallbladder on the right side, the is palpable in the suprasternal notch.
stomach and spleen on the left side, and the adrenal • Sternal angle (of Louis): marks the articulation
(suprarenal) glands and upper poles of the kidneys between the manubrium and body of the
on both sides. sternum, the dividing line between the superior
he superior thoracic aperture (the anatomi- and the inferior mediastinum, and the site of
cal thoracic inlet) conveys large vessels, important articulation of the second ribs (a useful landmark
nerves, the thoracic lymphatic duct, the trachea, for counting ribs and intercostal spaces).

94 Chapter 3 Thorax

Sternal angle
Rib 1

Superior mediastinum
Anterior mediastinum

Middle mediastinum

Inferior mediastinum
Posterior mediastinum

Respiratory T12

FIGURE 3.1 Subdivisions of the Mediastinum.

Sternocleidomastoid m. Sternal head

Clavicular head
Clavicle Axilla

Jugular notch Anterior axillary fold

Posterior axillary fold
Deltoid m.
Clavicular head
Pectoralis major m.
Body of sternum Sternal head

Latissimus dorsi m.

Serratus anterior m.
Xiphoid process of sternum

Linea alba

Serratus anterior m.
FIGURE 3.2 Surface Anatomy Landmarks of horax. (From Atlas of human anatomy, ed 7, Plate 187.)

• Nipple: marks the T4 dermatome and approxi- vertical planes of reference include the following
mate level of the dome of the respiratory dia- (Fig. 3.3):
phragm on the right side. • Midclavicular line: passing just medial to the
• Xiphoid process: marks the inferior extent of nipple.
the sternum and the anterior attachment point • Anterior axillary line: inferolateral margin of the
of the diaphragm. pectoralis major muscle; demarcates the anterior
axillary fold.
Planes of Reference
• Midaxillary line: a descending line from the
In addition to the sternal angle of Louis, physi- midpoint of the axilla.
cians often use other imaginary planes of refer- • Posterior axillary line: along the margin of
ence to assist in locating underlying visceral the latissimus dorsi and teres major muscles;
structures of clinical importance. Important demarcates the posterior axillary fold.

Chapter 3 Thorax 95 3
• Scapular line: intersects the inferior angles of
the scapula. 3. THORACIC WALL
• Midvertebral line (also called the “posterior
median” line): vertically bisects the vertebral Thoracic Cage
column. he thoracic cage, which is part of the axial skeleton,
includes the thoracic vertebrae, the midline sternum,
the 12 pairs of ribs (each with a head, neck,

Left anterior axillary line

Right midclavicular line
tubercle, and body; floating ribs 11 and 12 are

Left midclavicular line

short and do not have a neck or tubercle), and the
Transumbilical plane
costal cartilages (Fig. 3.4). he head of each rib

Midsternal line
Median plane
typically articulates with the superior costal facet
of the vertebra of the same number, the inferior
costal facet of the vertebra above its number, and
Right upper Left upper the intervertebral disc between the two vertebrae
quadrant quadrant (these costovertebral articulations are plane synovial
(RUQ) (LUQ) 1
2 joints). he rib’s tubercle articulates with the
Right lower Left lower 3 transverse process of the vertebra of the same
quadrant quadrant 4
(RLQ) (LLQ) 5 number. However, ribs 1, 10, 11, and 12 usually
6 articulate only with the vertebra of the same number
7 T12
Subcostal 8 L1 (Fig. 3.4). his bony framework provides the scaf-
plane 9 L2
10 folding for attachment of the chest wall muscles
FIGURE 3.3 Planes of Reference for Visceral Structures. and the pectoral girdle, which includes the clavicle,
(From Atlas of human anatomy, ed 7, Plate 251.) scapula, and humerus, and forms the attachment


Coracoid process 1
Glenoid fossa (cavity) Jugular notch
2 Manubrium
Subscapular fossa Neck Head
Angle Tubercle
Body Sternum Angle
True ribs (1–7) 5 Superior Inferior
process Articular facets
Costal cartilages for vertebral
7 11 Articular facet
for transverse
False ribs (8–12) 12 process of
9 vertebra
10 Costal groove
Floating ribs (11-12) Middle rib: posterior view

Anterior longitudinal ligament Transverse costal facet (for tubercle

of rib of same number as vertebra)
Inferior costal facet (for head Lateral costotransverse ligament
of rib one number greater)
Intertransverse ligament
Intraarticular ligament of head of rib
Superior costal facet (for Superior costotransverse ligament
head of rib of same number)

Radiate ligament of head of rib

Left anterolateral view

FIGURE 3.4 horacic Cage. (From Atlas of human anatomy, ed 7, Plates 192 and 193.)

96 Chapter 3 Thorax

of the upper limb to the thoracic cage at the he true anterior thoracic wall muscles fill
shoulder joint (Table 3.1). the intercostal spaces or support the ribs, act on
Rib fractures can be a relatively common and the ribs (elevate or depress the ribs), and keep the
very painful injury (we must continue to breathe) intercostal spaces rigid, thereby preventing them
but are less common in children because their from bulging out during expiration and being drawn
thoracic wall is still fairly elastic. he weakest part in during inspiration (Fig. 3.6 and Table 3.3). Note
of the rib is close to the angle (Fig. 3.4). that the external intercostal muscles are replaced
by the anterior intercostal membrane at the costo-
Joints of Thoracic Cage chondral junction anteriorly, and that the internal
Joints of the thoracic cage include articulations intercostal muscles extend posteriorly to the angle
between the ribs and the thoracic vertebrae (dis- of the ribs and then are replaced by the posterior
cussed in the preceding section), and between the intercostal membrane. he innermost intercostal
ribs and the sternum. he clavicle also articulates muscles lie deep to the internal intercostals and
with the manubrium of the sternum and the first
rib. hese articulations are summarized in Figure Manubrium Interclavicular
Clavicle lig.
3.5 and Table 3.2. Articular Costoclavicular lig.
Muscles of Anterior Thoracic Wall
he musculature of the anterior thoracic wall Rib
includes several muscles that attach to the thoracic Manubriosternal joint
cage but that actually are muscles that act on the 2 Intraarticular
upper limb (Fig. 3.6). hese muscles include the Articular sternocostal lig.
Costal cartilages cavities
following (for a review, see Chapter 7):
• Pectoralis major. Radiate Costochondral joints
• Pectoralis minor. sternocostal ligs.
• Serratus anterior.
TABLE 3.1 Features of the Thoracic Cage 5

Sternum Long, flat bone composed of the 6

manubrium, body, and xiphoid Xiphoid
process 7 8 process
True ribs Ribs 1-7: articulate with the sternum Sternocostal articulations: anterior view
Note: On left side of the rib cage, the sternum and proximal
False ribs Ribs 8-10: articulate to costal ribs have been shaved down and the ligaments removed to
cartilages of the ribs above show the bone marrow and articular cavities.
Floating ribs Ribs 11 and 12: articulate with
vertebrae only FIGURE 3.5 Sternocostal Articulations of horacic
Cage. (From Atlas of human anatomy, ed 7, Plate 193.)

TABLE 3.2 Joints of the Thoracic Cage

Sternoclavicular (Saddle-Type Synovial) Joint With an Articular Disc
Capsule Clavicle and manubrium Allows elevation, depression, protraction, retraction, circumduction
Sternoclavicular Clavicle and manubrium Consists of anterior and posterior ligaments
Interclavicular Between both clavicles Connects two sternoclavicular joints
Costoclavicular Clavicle to first rib Anchors clavicle to first rib
Sternocostal (Primary Cartilaginous [Synchondroses]) Joints
First sternocostal First rib to manubrium Allows no movement at this joint
Radiate sternocostal Ribs 2-7 with sternum Permit some gliding or sliding movement at these synovial plane
Costochondral (Primary Cartilaginous) Joints
Cartilage Costal cartilage to rib Allow no movement at these joints
Interchondral (Synovial Plane) Joints
Interchondral Between costal cartilages Allow some gliding movement

Chapter 3 Thorax 97 3
Sternalis m. (inconstant) Clavicle
Pectoralis major m.
Coracoid process
Thoracoacromial a. (pectoral
Cephalic v. branch) and lateral pectoral n.
Pectoralis minor m. invested by
2 Clavipectoral fascia
4 External intercostal
membranes anterior to
5 internal intercostal mm.
Rectus abdominis m.
Digitations of serratus anterior m.

External abdominal External intercostal mm.
oblique m.
Note: A deeper dissection is shown 10
on the left side of the thoracic wall.

Clavicle (cut)
Subclavian a. and v.
Subclavian a. and v.

Internal thoracic a. and v. Internal intercostal mm.

Innermost intercostal mm.

Body of sternum

Transversus thoracis m.

Respiratory diaphragm Xiphoid process

Transversus abdominis m.

Note: Diaphragm has been

removed on the right side.

FIGURE 3.6 Muscles of Anterior horacic Wall. (From Atlas of human anatomy, ed 7, Plates 194
and 196.)

TABLE 3.3 Muscles of the Anterior Thoracic Wall

External Inferior border of rib Superior border of rib Intercostal nerves Elevate ribs, support
intercostal above below intercostal space
Internal Inferior border of rib Superior border of rib Intercostal nerves Elevate ribs (upper
intercostal above below four and five); others
depress ribs
Innermost Inferior border of rib Superior border of rib Intercostal nerves Act with internal
intercostal above below intercostals
Transversus Posterior surface of Internal surface of Intercostal nerves Depress ribs
thoracis lower sternum costal cartilages 2-6
Subcostal Internal surface of lower Superior borders of Intercostal nerves Depress ribs
rib near their angles second or third ribs
Levator Transverse processes of Subjacent ribs between Posterior rami of Elevate ribs and costal
costarum C7 and T1-T11 tubercle and angle C8-T11 cartilages

98 Chapter 3 Thorax

Clinical Focus 3-1

Thoracic Cage Injuries
Thoracic injuries are responsible for about 25% of trauma deaths. These injuries can involve the heart, great
vessels, tracheobronchial tree, and/or thoracic cage. Cage injuries often involve rib fractures (ribs 1 and 2 and
11 and 12 are more protected and often escape being fractured), crush injuries with rib fractures, and penetrating
chest wounds such as gunshot and stab wounds. The pain caused by rib fractures can be intense because
of the expansion and contraction of the rib cage during respiration; it sometimes requires palliation by anesthetizing
the intercostal nerve (nerve block).

Simple Complicated

Costovertebral Traumatization of pleura

dislocation (any level) and of lung (pneumothorax,
lung contusion, subcutaneous
Transverse rib fracture emphysema)
Multiple rib fractures
Oblique rib fracture
Intercostal nerve block to
Tear of blood vessels
relieve pain of fractured ribs
Overriding rib fracture (hemothorax) 1
Chondral fracture
Compound by missile
or by puncture wound
separation 2
Injury to heart
or to great vessels
Sternal fracture

1 Sites for injection
Needle introduced to contact lower border 1. Angle of rib (preferred)
of rib (1), withdrawn slightly, directed caudad, 2. Posterior axillary line
advanced 1/8 inch to slip under rib and enter 3. Anterior axillary line 5
intercostal space (2). To avoid pneumothorax, 4. Infiltration of fracture site
aspirate before injecting anesthetic. 5. Parasternal

extend from the midclavicular line to about the

TABLE 3.4 Arteries of the Internal
angles of the ribs posteriorly. Thoracic Wall

Intercostal Vessels and Nerves ARTERY COURSE

he intercostal neurovascular bundles (vein, Internal thoracic Arises from subclavian artery
and terminates by dividing
artery, and nerve) lie inferior to each rib, running into superior epigastric and
in the costal groove deep to the internal intercostal musculophrenic arteries.
muscles (Fig. 3.7 and Table 3.4). he veins largely Intercostals First two posterior branches
derived from superior
correspond to the arteries and drain into the azygos intercostal branch of
system of veins posteriorly or the internal thoracic costocervical trunk and lower
veins anteriorly. he intercostal arteries form an nine from thoracic aorta; these
anastomose with anterior
anastomotic loop between the internal thoracic branches derived from internal
artery (branches of anterior intercostal arteries arise thoracic artery (1st-6th spaces)
here) and the thoracic aorta posteriorly. Posterior or its musculophrenic branch
(7th-9th spaces); the lowest
intercostal arteries arise from the aorta, except for two spaces only have posterior
the first two, which arise from the supreme inter- branches.
costal artery, a branch of the costocervical trunk Subcostal From aorta, courses inferior to
the 12th rib.
of the subclavian artery. Pericardiacophrenic From internal thoracic artery and
he intercostal nerves are the anterior rami accompanies phrenic nerve.
of the first 11 thoracic spinal nerves. he 12th

Chapter 3 Thorax 99 3
Arteries of the internal thoracic wall

Subclavian a. and v.

Phrenic n. and Subclavian a. and v.

a. and v. Internal thoracic a. and v.

Internal thoracic a. and v. Anterior intercostal vv. and n. and intercostal n.

Perforating branches
of internal thoracic
a. and v. and
anterior cutaneous
branch of intercostal n.

Transversus thoracis m.
Veins of the thoracic wall
Respiratory diaphragm

Right brachiocephalic vein

a. and v. Left superior
intercostal vein
Superior epigastric a. and vv. Left brachiocephalic
Internal thoracic a. and vv. vein
Right superior
intercostal vein



Anterior intercostal vein

Distribution of intercostal nerves and arteries

Spinal ganglion

Posterior ramus of thoracic n.

Intercostal n. (anterior
ramus of thoracic spinal n.) Dorsal branch of posterior
intercostal a.
Internal intercostal membrane Posterior intercostal a.
deep to external intercostal mm.
Lateral cutaneous branch
of posterior intercostal a.
Innermost intercostal mm. Sympathetic
trunk and ganglia Innermost intercostal mm.
Internal intercostal mm. Internal intercostal mm.
Right posterior Thoracic aorta
Lateral cutaneous intercostal External intercostal mm.
branch of intercostal n. aa.(cut) Sternum
Internal thoracic a.
External intercostal mm.
Note: The nerves are shown on
the right side and the arteries
on the left side. The posterior
ramus of each nerve innervates the
Transversus thoracis m. intrinsic muscles of the back and
the overlying skin. Note the muscle
Anterior cutaneous branch of intercostal n. Anterior intercostal aa. layers and other features of the thoracic
Superior epigastric a. wall in this cross-sectional view.
FIGURE 3.7 Intercostal Vessels and Nerves. (From Atlas of human anatomy, ed 7, Plates 196, 197,
and 198.)

100 Chapter 3 Thorax

thoracic nerve gives rise to the subcostal nerve, about 15 to 20 lobes, which are supported and
which courses inferior to the 12th rib. he nerves separated from each other by fibrous connec-
give rise to lateral and anterior cutaneous branches tive tissue septae (the suspensory ligaments of
and branches innervating the intercostal muscles Cooper) and fat. Each lobe is divided in lobules
(Fig. 3.7). of secretory acini and their ducts. Features of the
breast include the following (Fig. 3.8):
• Breast: fatty tissue containing glands that
Female Breast produce milk; lies in the superficial fascia above
he female breast, a modified sweat gland, extends the retromammary space, which lies above the
from approximately the second rib to the sixth rib deep pectoral fascia enveloping the pectoralis
and from the sternum medially to the midaxillary major muscle.
line laterally. Mammary tissue is composed of • Areola: circular pigmented skin surrounding
compound tubuloacinar glands organized into the nipple; it contains modified sebaceous and

Anterolateral dissection

Pectoralis major m.
(deep to
pectoral fascia) Suspensory
retinacula of

Serratus glands (of
anterior m. Montgomery)


2nd rib External abdominal Nipple

oblique m. Lactiferous ducts
major m. Gland lobules Fat Lactiferous sinus

mm. Suspensory retinacula of breast (Cooper’s)

vessels Lactiferous ducts
and n.
Lactiferous sinus
Gland lobules

Fat (superficial fascia)

6th rib

Sagittal section
FIGURE 3.8 Anterolateral and Sagittal Views of Female Breast. (From Atlas of human anatomy, ed 7,
Plate 188.)

Chapter 3 Thorax 101 3
sweat glands (glands of Montgomery) that • Lateral mammary branches of the lateral thoracic
lubricate the nipple and keep it supple. artery (a branch of the axillary artery).
• Nipple: site of opening for the lactiferous ducts, • horacoacromial artery (branch of the axillary
which at their distal ends are dilated into lactifer- artery).
ous sinuses; the nipple usually lies at about the he venous drainage (Fig. 3.9) largely parallels
level of the fourth intercostal space. the arterial supply, finally draining into the internal
• Axillary tail (of Spence): extension of mammary thoracic, axillary, and adjacent intercostal veins.
tissue superolaterally toward the axilla.
• Lymphatic system: lymph is drained from breast
tissues; about 75% of lymphatic drainage is to 4. PLEURA AND LUNGS
the axillary lymph nodes (Fig. 3.9; see also Fig.
7.11), and the remainder drains to infraclavicular, Pleural Spaces (Cavities)
pectoral, or parasternal nodes. he thorax is divided into the following three
he primary arterial supply to the breast compartments:
includes the following: • Right pleural space.
• Anterior intercostal branches of the internal • Left pleural space.
thoracic (mammary) arteries (from the subcla- • Mediastinum: a “middle space” lying between
vian artery). the pleural spaces.

Confluence of lymphatic trunks Thoracic duct

Pectoralis major m.
Subclavian lymphatic trunks

Central lymph
Superficial vv. of
node group
breast and thorax

Areolar venous


External mammary
lymph node group
Main lymphatic
collecting trunks

Lateral thoracic

Intercostal vessels plexus

of breast

Internal thoracic (mammary) Thoracic duct

vessels and lymphatics Azygos v.
FIGURE 3.9 Veins and Lymphatics of Female Breast.

102 Chapter 3 Thorax

Clinical Focus 3-2

Fibrocystic Breast Disease
Fibrocystic change is a nonspecific term covering a large group of benign conditions occurring in about
80% of women that are often related to cyclic changes in maturation and involution of glandular tissue.
Fibroadenoma, the second most common form of breast disease and the most common breast mass, has
a peak incidence in patients between 20 and 25 years of age, with most below the age of 30 years. The
tumors are benign neoplasms of the glandular epithelium and usually are accompanied by a significant increase
in periductal connective tissue. They usually present as firm, painless, mobile, solitary palpable masses that
may grow rapidly during adolescence and warrant follow-up evaluation.

Fibrocystic disease

Sagittal section

Schema of clinical
syndrome: tender,
granular swelling

Tumor being excised
from breast


Fibrous stalk

Papilloma within
Discharge breast tissue
from nipple

Chapter 3 Thorax 103 3
Clinical Focus 3-3
Breast Cancer
Breast cancer is the most common malignancy in women, and women in the United States have the highest
incidence in the world. Well over two thirds of all cases occur in postmenopausal women. The most common
type (occurring in about 75% of cases) is an infiltrating ductal carcinoma, which may involve the suspensory
ligaments, causing retraction of the ligaments and dimpling of the overlying skin. Invasion and obstruction of
the subcutaneous lymphatics can result in dilation and skin edema, creating an “orange peel” appearance
(peau d’orange). About 60% of the palpable tumors are located in the upper outer breast quadrant (the quadrant
closest to the axilla, which includes the axillary tail). About 5-10% of breast cancers have a familial or genetic
link (mutations of the BRCA1 and 2 tumor suppressor genes). Distant sites of metastasis include the lungs
and pleura, liver, bones, and brain.

Nipple retraction
Carcinomatous involvement of Retraction of nipple
mammary ducts may cause duct
shortening and retraction or
inversion of nipple.

Carcinoma involving
mammary ducts
of nipple

Skin edema
Subcutaneous lymphatics
Skin edema with peau
d’orange appearance
Lymph Involvement and obstruction of subcutaneous
accumulation lymphatic by tumor result in lymphatic dilatation
Skin gland and lymph accumulation in the skin. Resultant
orifices edema creates “orange peel” appearance owing to
prominence of skin gland orifices.

Skin dimpling
Dimpling of skin
over a carcinoma
is caused by Skin dimple over carcinoma
involvement and Connective tissue shadows
retraction of
suspensory Edema of skin

Suspensory (Cooper’s) lig.

Suspensory (Cooper’s) lig.
Pectoralis fascia

104 Chapter 3 Thorax

Clinical Focus 3-4

Partial Mastectomy
Several clinical options are available to treat breast cancer, including systemic approaches (chemotherapy,
hormonal therapy, immunotherapy) and “local” approaches (radiation therapy, surgery). In a partial mastectomy,
also called “lumpectomy” or “quadrantectomy,” the surgeon performs a breast-conserving surgery that removes
the portion of the breast that harbors the tumor along with a surrounding halo of normal breast tissue. Because
of the possibility of lymphatic spread, especially to the axillary nodes, an incision also may be made for a
sentinel node biopsy to examine the first axillary node, which is likely to be invaded by metastatic cancer cells
from the breast.

A. Breast nodes and carcinoma

Central axillary nodes
Posterior axillary
(subscapular) nodes

Lateral axillary
Apical axillary
(humeral) nodes
(subclavian) nodes
jugular vein
B. Incision for mastectomy
Right lymphatic
duct Incision for axillary
Pectoralis exploration and
minor sentinel lymph
muscle node biopsy

(Rotter’s) nodes Parasternal
Anterior axillary
(pectoral) nodes

lymph nodes

With aesthetic in mind, the incisions of choice

are circumareolar, curvilinear that parallel
Langer’s lines (upper half of the breast), and
radial (inferior half of the breast).

Infiltrating carcinoma
(seen in
cross section C. Dissection of breast
of breast)

Axillary vein and

lymph nodes

mass D. Removed specimen oriented
with a suture
Pectoral fascia

Chapter 3 Thorax 105 3
Clinical Focus 3-5
Modified Radical Mastectomy
In addition to breast-conserving surgery, several more invasive mastectomy approaches may be indicated,
depending on a variety of factors:
• Total (simple) mastectomy: the whole breast is removed, with or without some axillary lymph
nodes if indicated, down to the retromammary space.
• Modified radical mastectomy (illustrated here): the whole breast is removed along with most of
the axillary and pectoral lymph nodes, the axillary fat, and the investing fascia over the chest wall
muscles. Care is taken to preserve the pectoralis, serratus anterior, and latissimus dorsi muscles and the
long thoracic and thoracodorsal nerves to the latter two muscles, respectively. Damage to the long
thoracic nerve results in “winging” of the scapula, and damage to the thoracodorsal nerve weakens
extension at the shoulder.
• Radical mastectomy: the whole breast is removed along with the axillary lymph nodes, fat, and
chest wall muscles (pectoralis major and minor); use of the radical surgical approach is much less
common now.


During development of the skin flaps,

the breast tissue is retracted downward
while the flaps, superior and inferior,
are retracted perpendicularly Superior
to the chest wall. skin flap

skin flap

Incision site

Rotter’s (interpectoral)
lymph nodes

Pectoralis major muscle

Pectoralis minor muscle

Serratus anterior muscle

Pectoral fascia
partially dissected

Breast tissue
partially dissected


Postoperative appearance

Axillary vessels

Long thoracic nerve

Latissimus dorsi muscle

106 Chapter 3 Thorax

he lungs lie within the pleural cavity (right pleura is richly innervated with aferent ibers that
and left) (Fig. 3.10). his “potential space” is between course in the somatic intercostal nerves. Over most
the investing visceral pleura, which closely envel- of the surface of the diaphragm and in the parietal
ops each lung, and the parietal pleura, which pleura facing the mediastinum, the aferent pain
relects of each lung and lines the inner aspect of ibers course in the phrenic nerve (C3-C5). he
the thoracic wall, the superior surface of the dia- visceral pleura has few, if any, pain ibers.
phragm, and the sides of the pericardial sac (Table Clinically, it is important for physicians to be
3.5). Normally, the pleural cavity contains a small able to “visualize” the extent of the lungs and pleural
amount of serous luid, which lubricates the surfaces cavities topographically on the surface of their
and reduces friction during respiration. he parietal patients (Fig. 3.10). he lungs lie adjacent to the

Cervical parietal pleura Trachea

Apex of lung

Right border of heart 1

Cardiac notch of left lung
Horizontal fissure of right lung
Oblique fissure of left lung
(often incomplete) 3

Right dome of 4
respiratory diaphragm Inferior border of left lung
Oblique fissure of right lung
6 Costodiaphragmatic recess
of pleural cavity
Inferior border of right lung
recess of pleural cavity 8
Pleural reflection

C3 Cervical parietal pleura

Apex of left lung 4
5 Oblique fissure of right lung
1 T1
Horizontal fissure
3 2
of right lung (often
Oblique fissure of left lung 4 3 incomplete)
5 4
6 Right dome
of respiratory
Left dome of 7 diaphragm
respiratory diaphragm 8 7
9 8 Inferior border of right lung
Inferior border of left lung 9
11 11 Costodiaphragmatic
Costodiaphragmatic recess of pleural cavity 12 recess of pleural cavity
Pleural reflection
Pleural reflection 2
Right kidney

FIGURE 3.10 Anterior and Posterior Topography of the Pleura and Lungs. (From Atlas of human
anatomy, ed 7, Plates 202 and 203.)

Chapter 3 Thorax 107 3
TABLE 3.5 Pleural Features and Recesses he right lung has three lobes and is slightly
larger than the left lung, which has two lobes. Both
lungs are composed of spongy and elastic tissue,
Cupula Dome of cervical parietal pleura which readily expands and contracts to conform
extending above the first rib
Parietal pleura Membrane that in descriptive to the internal contours of the thoracic cage (Fig.
terms includes costal, mediastinal, 3.11 and Table 3.7).
diaphragmatic, and cervical (cupula) he lung’s parenchyma is supplied by several
Pleural Points at which parietal pleurae small bronchial arteries that arise from the
reflections reflect off one surface and extend proximal portion of the descending thoracic aorta.
onto another (e.g., costal to Usually, one small right bronchial artery and a pair
Pleural recesses Reflection points where the lung does of left bronchial arteries (superior and inferior) can
not fully extend into the pleural be found on the posterior aspect of the main
space (e.g., costodiaphragmatic, bronchi. Although much of this blood returns to
the heart via the pulmonary veins, some also collects
into small bronchial veins that drain into the azygos
system of veins (see Fig. 3.25).
TABLE 3.6 Surface Landmarks of the
he lymphatic drainage of both lungs is to
Pleura and Lungs
pulmonary (intrapulmonary) and bronchopul-
MARGIN MARGIN monary (hilar) nodes (i.e., from distal lung tissue
sites to the proximal hilum). Lymph then drains
Midclavicular line 6th rib 8th rib into tracheobronchial nodes at the tracheal
Midaxillary line 8th rib 10th rib
Paravertebral line 10th rib 12th rib bifurcation and into right and left paratracheal
nodes (Fig. 3.12). Clinicians often use diferent
names to identify these nodes (intrapulmonary,
parietal pleura inferiorly to the sixth costal cartilage. hilar, carinal, and scalene), so these clinical terms
(Note the presence of the cardiac notch on the left are listed in parentheses after the corresponding
side.) Beyond this point, the lungs do not occupy anatomical labels in Fig. 3.12.
the full extent of the pleural cavity during quiet As visceral structures, the lungs are innervated by
respiration. hese points are important to know if the autonomic nervous system. Sympathetic bron-
one needs access to the pleural cavity without chodilator ibers relax smooth muscle, vasoconstrict
injuring the lungs, for example, to drain inlamma- pulmonary vessels, and inhibit the bronchial tree
tory exudate (pleural efusion), blood (hemotho- alveolar glands. hese ibers arise from upper
rax), or air (pneumothorax) that collects in the thoracic spinal cord segments (about T1-T4). Para-
pleural cavity. In quiet respiration, the lung margins sympathetic bronchoconstrictor ibers contract
reside two ribs above the extent of the pleural cavity bronchial smooth muscle, vasodilate pulmonary
at the midclavicular, midaxillary, and paravertebral vessels, and initiate secretion of alveolar glands.
lines (Table 3.6). hey arise from the vagus nerve(CN X).
Visceral aferent ibers that course back to the
The Lungs CNS in the vagus nerve are largely relexive and
he paired lungs are invested in the visceral pleura convey impulses from the bronchial mucosa,
and are attached to mediastinal structures (trachea muscles and connective tissue stretch receptors
and heart) at their hilum. Each lung possesses the (the Hering-Breuer relex), pressor receptors on
following surfaces: arteries, and chemoreceptors sensitive to blood gas
• Apex: superior part of the upper lobe that levels and pH. Pain (nociceptive) aferents from
extends into the root of the neck (above the the visceral pleura and bronchi pass back via the
clavicles). sympathetic ibers, through the sympathetic trunk,
• Hilum: area located on the medial aspect and to the sensory spinal ganglia of the upper
through which structures enter and leave the thoracic spinal cord levels.
• Costal: anterior, lateral, and posterior aspects
of the lung in contact with the costal elements During quiet inspiration the contraction of the
of the internal thoracic cage. respiratory diaphragm alone accounts for most of
• Diaphragmatic: inferior part of the lung in the decrease in intrapleural pressure, allowing air to
contact with the underlying diaphragm. expand the lungs. Active inspiration occurs when

108 Chapter 3 Thorax

Right lung Apex

Groove for Groove for azygos v.

vena cava Oblique fissure
Pleura (cut edge)

Superior lobe Right superior lobar (eparterial) bronchus

Right pulmonary a.

Hilum Right bronchial a.

Right intermediate bronchus
Right superior pulmonary vv.
Horizontal fissure
Bronchopulmonary (hilar) lymph nodes
Cardiac impression Right inferior pulmonary vv.
Inferior lobe
Middle lobe
Groove for esophagus
Oblique fissure
Pulmonary lig.
Diaphragmatic surface


Left lung
Area for trachea and esophagus

Oblique fissure
Groove for arch of aorta

Pleura (cut edge) Hilum

Left pulmonary a.

Left bronchial aa. Superior lobe

Left main bronchus
Cardiac impression
Left superior pulmonary vv.
Pulmonary lig.
Bronchopulmonary (hilar) lymph nodes
Cardiac notch
Inferior lobe Oblique fissure

Left inferior pulmonary v. Groove for esophagus

Groove for descending aorta

Diaphragmatic surface
FIGURE 3.11 Features of Medial Aspect of the Lungs. (From Atlas of human anatomy, ed 7, Plate 205.)

TABLE 3.7 External Features of the Lungs

Lobes Three lobes (superior, middle, Lingula Tongue-shaped feature of
inferior) in right lung; two in left left lung
lung (superior and inferior) Cardiac notch Indentation for the heart, in left
Horizontal fissure Only on right lung, extends along lung
line of fourth rib Pulmonary Double layer of parietal pleura
Oblique fissure On both lungs, extends from T2-T3 ligament hanging from the hilum that marks
vertebra spine to sixth costal reflection of visceral pleura to
cartilage anteriorly parietal pleura
Impressions Made by adjacent structures, in Bronchopulmonary 10 functional segments in each lung
fixed lungs segment supplied by a segmental bronchus
Hilum Points at which structures and a segmental artery from the
(bronchus, vessels, nerves, pulmonary artery
lymphatics) enter or leave lungs

Chapter 3 Thorax 109 3
Clinical Focus 3-6
Chest Tube Thoracostomy

1–3. Monitor patient’s vital signs. Place patient in supine

position. Abduct the patient’s arm and flex elbow to 4–7. Use ultrasonography to locate the 4th
position the hand over the patient’s head. and 5th intercostal spaces in the anterior
axillary line at the level of the nipple.
Cleanse the area with antiseptic and drape
the patient.
4th rib
5th rib

Anterior axillary line

8. Administer anesthetic to a 2- to
3-cm area of the skin and 10. Advance the needle until a flash of
subcutaneous tissue at incision pleural fluid or air enters the syringe,
site (A). Continue to anesthetize confirming entry into the pleural
deeper subcutaneous A space.
tissues and intercostal B
muscles (B). 11. Use a scalpel to make a
9. Identify the rib inferior to the 1- to 2-cm incision parallel to
intercostal space where tube will be the rib.
inserted and anesthetize the
periosteal surface (C).

12–14. Dissect a tract through

subcutaneous tissue and intercostal
muscles. Gently enter the pleural

Open the clamp while inside the

pleural space and then withdraw so
that all layers of the dissected tract 15. Insert a finger into the pleural
are enlarged. space and rotate 360 degress to feel
for adhesions.

17. Use sutures to close

incision. Secure chest tube
to chest wall using suture’s
loose ends to wrap around
16. Use a Kelly clamp to
grab fenestrated portion of
the tube and introduce it
through the insertion site.

18–20. Wrap petroleum-based gauze around tube and cover

with regular gauze. Secure the site with dressings and
adhesive tape. Connect chest tube to drainage device.
Obtain a chest radiograph to confirm proper tube placement.

110 Chapter 3 Thorax

Right superior tracheobronchial nodes Right paratracheal nodes

Bronchomediastinal lymphatic trunk Left paratracheal nodes
Brachiocephalic v. Bronchomediastinal lymphatic trunk

Thoracic duct
Right lymphatic duct
Left superior
tracheobronchial nodes
Subclavian v. and subclavian
lymphatic trunk

Bronchopulmonary (hilar) nodes
(hilar) nodes
Pulmonary (intrapulmonary)
(intrapulmonary) nodes

Drainage lymph
follows bronchi, vessels
aa., and vv.

(carinal) nodes

Drainage routes
Right lung: All lobes drain to pulmonary and Left lung: Superior lobe drains to pulmonary and
bronchopulmonary (hilar) nodes, and then to bronchopulmonary (hilar) nodes and inferior tracheo-
inferior tracheobronchial (carinal) nodes. bronchial (carinal) nodes. Left inferior lobe drains
also to pulmonary and bronchopulmonary (hilar) nodes
and to inferior tracheobronchial (carinal) nodes, but then
mostly to right superior tracheobronchial nodes, where
it follows same route as lymph from right lung.
FIGURE 3.12 Lymphatic Drainage Routes of the Lungs. (From Atlas of human anatomy, ed 7,
Plate 212.)

the diaphragm and intercostal muscles together diaphragm upward. Having the “wind knocked out
increase the diameter of the thoracic wall, decreasing of you” shows how forceful this maneuver can be.
intrapleural pressure even more. Although the first
rib is stationary, ribs 2 to 6 tend to increase the Trachea and Bronchi
anteroposterior diameter of the chest wall, and the he trachea is a single midline airway that extends
lower ribs mainly increase the transverse diameter. from the cricoid cartilage to its bifurcation at
Accessory muscles of inspiration that attach to the the sternal angle of Louis. It lies anterior to the
thoracic cage may also assist in very deep inspiration. esophagus and is rigidly supported by 16 to 20
During quiet expiration the elastic recoil of the C-shaped cartilaginous rings (Fig. 3.13 and Table
lungs, relaxation of the diaphragm, and relaxation 3.8). he trachea may be displaced if adjacent
of the thoracic cage muscles expel the air. In forced structures become enlarged (usually the thyroid
expiration the abdominal muscles contract and, gland or aortic arch).
by compressing the abdominal viscera superiorly, he trachea bifurcates inferiorly into a right
raise the intraabdominal pressure and force the main bronchus and a left main bronchus, which

Chapter 3 Thorax 111 3
enter the hilum of the right lung and the left lung,
respectively, and immediately divide into lobar Clinical Focus 3-7
(secondary) bronchi (Fig. 3.13). he right main Idiopathic Pulmonary Fibrosis
bronchus often gives rise to the superior lobar
(eparterial) bronchus just before entering the hilum Idiopathic pulmonary fibrosis (IPF) is a chronic
restrictive lung disease. Chronic restrictive lung
of the right lung. Each lobar bronchus then divides
diseases account for approximately 15% of noninfec-
again into tertiary bronchi supplying the 10
tious lung diseases and include a diverse group of
bronchopulmonary segments of each lung (some disorders with reduced compliance that cause chronic
clinicians identify 8 to 10 segments in the left lung, inflammation, fibrosis, and the need for more pres-
whereas anatomists identify 10 in each lung) (Fig. sure to inflate the stiffened lungs. IPF is a specific
3.13 and Tables 3.7 and 3.8). he bronchopulmo- form of fibrosing interstitial pneumonia that mainly
nary segments are lung segments that are supplied affects people over the age of 50 years. Cigarette
by a tertiary bronchus and a segmental artery of smoking is a major risk factor.
the pulmonary artery that passes to each lung. he
tertiary bronchus and artery course together, but
the segmental veins draining the segment are at
the periphery of each segment. Additionally, each
bronchopulmonary segment is surrounded by
connective tissue that is continuous with the visceral Dyspnea
pleura on the lung’s surface, thus forming a func- Cyanosis Clubbing
of fingers
tionally independent respiratory unit. he bronchi Nonproductive
and respiratory airways continue to divide into hacking cough

smaller and smaller passageways until they terminate Diffuse pulmonary

in alveolar sacs (about 25 divisional generations fibrosis on x-ray
from the right and left main bronchi). Gas exchange
occurs only in these most distal respiratory regions.
he right main bronchus is shorter, more
vertical, and wider than the left main bronchus.
herefore, aspirated objects often pass more easily
into the right main bronchus and right lung. Basilar inspiratory
("Velcro") crackles


Cor pulmonale (late)
Elevated diaphragm
The Pericardium
he pericardium and heart lie within the middle
mediastinum. he heart is enclosed within a
fibroserous pericardial pouch that extends and
blends into the adventitia of the great vessels that
enter or leave the heart. he pericardium has a
ibrous outer layer that is lined internally by a
serous layer, the parietal serous layer, which then
reflects onto the heart and becomes the visceral
serous layer, which is the outer covering of the
heart itself, also known as the epicardium (Fig.
3.14 and Table 3.9). hese two serous layers form
a potential space known as the pericardial sac
Diffuse bilateral fibrosis of lungs with multiple
The Heart small cysts giving honeycomb appearance
he heart is essentially two muscular pumps in
series. he two atria contract in unison, followed
by contraction of the two ventricles. he right side
of the heart receives the blood from the systemic

112 Chapter 3 Thorax

Clinical Focus 3-8

Pulmonary Embolism
The lungs naturally filter venous clots larger than circulating blood cells and can usually accommodate small
clots because of their fibrinolytic (“clot buster”) mechanisms. However, pulmonary embolism (PE) is the cause
of death in 10% to 15% of hospitalized patients. Thromboemboli originate from deep leg veins in approximately
90% of cases. Major causes are called Virchow’s triad and include the following:
• Venous stasis (e.g., caused by extended bed rest)
• Trauma (e.g., fracture, tissue injury)
• Coagulation disorders (inherited or acquired)
Other contributors to PE include postoperative and postpartum immobility and some hormone medications
that increase the risk of blood clots. Most PEs are “silent” because they are small; larger emboli may obstruct
medium-sized vessels and lead to infarction or even obstruction of a vessel as large as the pulmonary trunk
(saddle embolus). PE without infarction is common and presents as tachypnea, anxiety, dyspnea, syncope,
and vague substernal pressure. Saddle embolus, on the other hand, is an emergency that can precipitate acute
cor pulmonale (right-sided heart failure) and circulatory collapse.

Sources of pulmonary emboli Massive embolization

Most Common Less Common
Sources of Sources of
Pulmonary Emboli Pulmonary Emboli

Right side of heart

Gonadal (ovarian
or testicular) v.
External Uterine v.
iliac v. Pelvic venous plexus Saddle embolus completely occluding right pulmonary
Femoral v. a. and partially obstructing trunk and left aa.
Great saphenous v. Embolism of lesser degree without infarction
femoral v.
Popliteal v.
Small saphenous v.
tibial v. Multiple small
Soleal plexus emboli of lungs
of v.

Sudden onset of dyspnea and

tachycardia in a predisposed
individual is a cardinal clue


Auscultation may be normal

or with few rales, and CT shows multiple
diminished breath sounds emboli in right upper
may be noted lobe pulmonary
aa. (arrow)

Chapter 3 Thorax 113 3
Clinical Focus 3-9
Lung Cancer
Lung cancer is the leading cause of cancer-related deaths worldwide. Cigarette smoking is the cause in about
85-90% of all cases. Lung cancer arises either from alveolar lining cells of the lung parenchyma or from the
epithelium of the tracheobronchial tree. Although there are a number of types, squamous cell (bronchiogenic)
carcinoma (about 20% of lung cancers in the United States) and adenocarcinoma (from intrapulmonary
bronchi; about 37% of lung cancers in the United States) are the most common types. Bronchiogenic carcinoma
may impinge on adjacent anatomical structures. For example, in Pancoast syndrome, this apical lung tumor
may spread to involve the sympathetic trunk, affect the lower portion of the brachial plexus (C8, T1, and T2),
and compromise the sympathetic tone to the head. This may lead to Horner’s syndrome on the
affected side:
• Miosis: constricted pupil
• Ptosis: minor drooping of the upper eyelid
• Anhidrosis: lack of sweating
• Flushing: subcutaneous vasodilation
Additionally, involvement of the neurovascular components passing into the upper limb (trunks of the brachial
plexus and subclavian artery) may be affected, resulting in pain and paresthesia in the neck, shoulder, and
limb and paresis (incomplete paralysis) of the arm and hand.

Bronchogenic carcinoma: epidermoid (squamous cell) type Horner’s syndrome and wasting, pain,
paresthesias, and paresis of arm and hand

Tumor typically located

near hilus, projecting
into bronchi


Bronchoscopic view

Pancoast syndrome: bronchogenic carcinoma of the apex of the lung

Brachial plexus Vagus n.

Subclavian a. and v.
Carotid a.


Combined CT/PET images of Pancoast tumor

(bright area) seen in axial view

114 Chapter 3 Thorax

Clinical Focus 3-10

Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a broad classification of obstructive lung diseases, the most
familiar being chronic bronchitis, asthma, and emphysema. Emphysema is characterized by permanent
enlargement of air spaces at and distal to the respiratory bronchioles, with destruction of the bronchiole walls
by chronic inflammation. As a result, lung compliance increases because the elastic recoil of the lung decreases,
causing collapse of the airways during expiration. This increases the work of expiration as patients try to force
air from their diseased lungs and can lead to a “barrel-chested” appearance caused by hypertrophy of the
intercostal muscles. Smoking is a major risk factor for COPD.

Gross specimen. Involvement tends to

be most marked in upper part of lung.

The typical patient with COPD has clinical, physiological, and

radiographic features of both chronic bronchitis and emphysema.
She may have chronic cough and sputum production, and need
accessory muscles and pursed lips to help her breathe. Pulmonary
function testing may reveal variable degrees of airflow limitation,
hyperinflation, and reduction in the diffusing capacity, and
arterial blood gases may show variable decreases in PO2 and
Magnified section. Distended, intercommunicating, increases in PCO2. Radiographic imaging often shows components
saclike spaces in central area of acini. of airway wall thickening, excessive mucus, and emphysema.

Chapter 3 Thorax 115 3
Connective tissue sheath (visceral layer of pretracheal fascia)
Thyroid cartilage Tracheal cartilage (ring)
Cricoid cartilage Elastic fibers
Small a.
Connective tissue Lymph vessels
sheath (visceral Nerve
layer of pretracheal Epithelium
erior wal
A nt

Tracheal cartilages
Cross section Trachealis (smooth) m.
Mucosa of posterior through trachea
tracheal wall
shows longitudinal Posterior wall
folds formed by
dense collections
of elastic fibers
Superior lobar
Esophageal m.
(eparterial) bronchus
Upper lobe
Upper lobe
To Superior
superior division of
lobe bronchus To
Middle lobar bronchus Lingular bronchus superior Middle lobe Lingula
Right and left
To To lingula
main bronchi
middle Lower lobe
lobe Lower lobe
To Inferior lobar
inferior bronchus To inferior lobe
Inferior lobar bronchus

Intrapulmonary Extrapulmonary Intrapulmonary Normal chest x-ray with superimposed drawing of

primary and secondary bronchi.
FIGURE 3.13 Trachea and Bronchi. (From Atlas of human anatomy, ed 7, Plate 208; chest radiograph
from Major NM: A practical approach to radiology, Philadelphia, 2006, Saunders.)

circulation and pumps it into the pulmonary circula-

TABLE 3.8 Features of the Trachea
and Bronchi tion of the lungs. he left side of the heart receives
the blood from the pulmonary circulation and
pumps it into the systemic circulation, thus perfus-
Trachea Approximately 5 inches (10 cm) ing the organs and tissues of the entire body,
long and 1 inch in diameter;
courses inferiorly anterior to including the heart itself. In situ, the heart is oriented
esophagus and posterior to in the middle mediastinum and has the following
aortic arch descriptive relationships (Fig. 3.15):
Cartilaginous rings Are 16-20 C-shaped rings
Bronchus Divides into right and left main • Anterior (sternocostal): the right atrium, right
(primary) bronchi at level of ventricle, and part of the left ventricle.
sternal angle of Louis
Right bronchus Shorter, wider, and more vertical
• Posterior (base): the left atrium.
than left bronchus; aspirated • Inferior (diaphragmatic): some of the right
foreign objects more likely to ventricle and most of the left ventricle.
pass into right bronchus
Carina Internal, keel-like cartilage at
• Acute angle: the sharp right ventricular margin
bifurcation of trachea of the heart, largely the right atrium.
Secondary bronchi Supply lobes of each lung (three • Obtuse angle: the more rounded left margin
on right, two on left) of the heart, largely the left ventricle.
Tertiary bronchi Supply bronchopulmonary
segments (10 for each lung) • Apex: the inferolateral part of the left ventricle
at the fourth to fifth intercostal space.
he atrioventricular groove (coronary sulcus)
separates the two atria from the ventricles and
marks the locations of the right coronary artery

116 Chapter 3 Thorax

Left common carotid a.

Internal jugular v.
Vagus n. (CN X)
Right brachiocephalic v.
Left brachiocephalic v.
Subclavian a. and v. Thymus
1st rib Arch of aorta
Superior vena cava
Phrenic n. and
a. and v.
Phrenic n.
and pericardia-
Mediastinal part of parietal pleura
a. and v.

Pericardium (fibrous layer)

Respiratory diaphragm

Heart drawn out of Superior vena cava Arch of aorta

opened pericardial
sac: left lateral view Pulmonary trunk
Ascending aorta

Left auricle (atrial appendage) Transverse pericardial sinus

Left ventricle Left pulmonary vv.

Coronary sinus

Inferior (posterior)
interventricular sulcus Oblique pericardial sinus

Right ventricle
Left atrium
Diaphragmatic part of pericardium
Inferior vena cava
Sternocostal part of pericardium (cut edge)

FIGURE 3.14 Pericardium and Pericardial Sac. (From Atlas of human anatomy, ed 6, Plates 215
and 219.)

TABLE 3.9 Features of the Pericardium

Fibrous pericardium Tough, outer layer that reflects Transverse sinus Space posterior to aorta and
onto great vessels pulmonary trunk; can clamp
Serous pericardium Layer that lines inner aspect of vessels with fingers in this sinus
fibrous pericardium (parietal and above
layer); reflects onto heart as Oblique sinus Pericardial space posterior to
epicardium (visceral layer) heart
Innervation Phrenic nerve (C3-C5) for
conveying pain; vasomotor
innervation via postganglionic

Chapter 3 Thorax 117 3
Clinical Focus 3-11
Cardiac Tamponade
Cardiac tamponade can result from fluid accumulation or bleeding into the pericardial sac. Bleeding may be
caused by a ruptured aortic aneurysm, a ruptured myocardial infarct, or a penetrating injury (most common
cause) that compromises the beating heart and decreases venous return and cardiac output. The fluid can be
removed by a pericardial tap (i.e., withdrawn by a needle and syringe).

Patient in variable
degrees of shock
or in extremis Neck veins distended
Heart sounds distant

Venous pressure
Decreased arterial (pathognomonic)
and pulse pressures
often exist but not

Pericardial tap
at Larrey’s point
(diagnostic and

and the circumflex branch of the left coronary itself. Although variations in the coronary artery
artery. he anterior and posterior interven- blood supply to the various chambers of the heart
tricular grooves mark the locations of the left are common, in general, the right coronary artery
anterior descending (anterior interventricular) supplies the:
branch of the left coronary artery and the inferior • Right atrium.
(posterior) interventricular branch of right coronary, • Right ventricle (most of it).
respectively. • SA and AV nodes (usually).
• Interatrial septum.
Coronary Arteries and Cardiac Veins
• Left ventricle (a small portion).
he right and left coronary arteries arise immediately • Posteroinferior one third of the interventricular
superior to the right and left cusps, respectively, septum.
of the aortic semilunar valve (Fig. 3.16). he right In general, the left coronary artery supplies:
coronary artery courses in the right atrioventricular • Most of the left atrium.
groove and passes around the acute angle (right • Most of the left ventricle.
side) of the heart. he left coronary artery passes • Most of the interventricular septum.
between the left auricle and the pulmonary trunk, • Right and left bundle branches (conduction
reaches the left atrioventricular groove, and divides system).
into the anterior interventricular (left anterior • Small portion of the right ventricle.
descending [LAD]) and circumflex branches. he he corresponding great cardiac vein, middle
LAD descends in the anterior interventricular cardiac vein, and small cardiac vein parallel
sulcus between the right and left ventricles, and the LAD branch of the left coronary artery, the
the circumflex branch courses around the obtuse posterior descending artery (PDA) of the right
margin (left side) of the heart. During ventricular coronary artery, and the marginal branch of the right
diastole, blood enters the coronary arteries to coronary artery, respectively. Each of these cardiac
supply the myocardium of each chamber. About veins then empties into the coronary sinus on
5% of the total cardiac output goes to the heart the posterior aspect of the atrioventricular groove

118 Chapter 3 Thorax

Left brachiocephalic vein

Brachiocephalic trunk
Left vagus nerve (CN X)
Subclavian artery and vein
Arch of aorta
Right brachiocephalic vein
Ligamentum arteriosum
Phrenic nerve and
artery and vein Pulmonary trunk

Superior vena cava

Hilum of left lung
Left auricle
(atrial appendage)
Mediastinal pleura
(cut edge) Anterior interventricular
Right auricle sulcus and anterior inter-
(atrial appendage) ventricular branch of
left coronary artery

Right atrium
Pericardium (cut edge)
Coronary sulcus and
right coronary artery Left ventricle

Right ventricle Apex of heart




Clinical Focus 3-12

Dominant Coronary
D A Circulation
About 67% of individuals have a “right dominant”
coronary circulation. This means that the right coro-
nary artery gives rise to the inferior interventricular
A Apex of heart PA Pulmonary artery (left)
branch and the posterolateral artery, as shown in
AA Aortic arch RA Right atrium
Fig. 3.16. In about 15% of cases, the left coronary
C Clavicle S Spine of scapula artery’s circumflex branch gives rise to the branch.
CP Coracoid process of scapula SV Superior vena cava In the remaining cases, both the right and the left
D Dome of diaphragm (right) T Trachea (air) coronary arteries may contribute to this branch or
IV Inferior vena cava V Left ventricle it may be absent and branches from both coronaries
FIGURE 3.15 Anterior In Situ Exposure of the may supply this region.
Heart. (From Atlas of human anatomy, ed 7, Plate 216.)

Chapter 3 Thorax 119 3
Sinuatrial (SA) nodal branch Aorta (cut)

Left coronary a.
Atrial branch of right coronary a.
Circumflex branch of left coronary a.

Right coronary a.
Great cardiac v.
Anterior cardiac vv.
Anterior interventricular branch (left anterior
Small cardiac v. descending) of left coronary a.
Right (acute) marginal branch of
right coronary a.
Interventricular septal branches

Sternocostal surface
Sinuatrial (SA) nodal branch

Oblique v. of left atrium (of Marshall)

Great cardiac v.

Circumflex branch of left coronary a.

Left marginal branch

Coronary sinus Small cardiac v.

Posterolateral a. Right coronary a.

Middle cardiac v. Inferior (posterior) interventricular

(posterior descending) branch of right
coronary a.
Interventricular septal branches
Right marginal branch

Diaphragmatic surface
FIGURE 3.16 Coronary Arteries and Cardiac Veins. (From Atlas of human anatomy, ed 7, Plate 222.)

TABLE 3.10 Coronary Arteries and Cardiac Veins

Right coronary Consists of major branches: sinuatrial Middle cardiac Parallels inferior (posterior) interventricular
artery (SA) nodal, right marginal, inferior vein branch and drains into coronary sinus
(posterior) interventricular, Small cardiac Parallels right marginal artery and
atrioventricular (AV) nodal vein drains into coronary sinus
Left coronary Consists of major branches: circumflex, Anterior cardiac Several small veins that drain directly
artery anterior interventricular (left anterior veins into right atrium
descending [LAD]), left marginal Smallest cardiac Drain through the cardiac wall directly
Great cardiac Parallels LAD artery and drains into veins into all four heart chambers, but
vein coronary sinus mostly the right atrium

(Table 3.10). he coronary sinus empties into he left atrium and left ventricle receive
the right atrium. Additionally, numerous smallest blood from the pulmonary circulation and pump
cardiac veins (thebesian veins) empty venous blood it to the systemic circulation (Fig. 3.18 and
into all four chambers of the heart, but mostly into Table 3.12).
the right atrium. In both ventricles the papillary muscles and
their chordae tendineae provide a structural
Chambers of the Heart mechanism that prevents the atrioventricular
he human heart has four chambers, each with valves (tricuspid and mitral) from everting
unique internal features related to their function (prolapsing) during ventricular systole. he papillary
(Fig. 3.17 and Table 3.11). he right side of the muscles (actually part of the ventricular muscle)
heart is composed of the right atrium and right contract as the ventricles contract (ventricular
ventricle. hese chambers receive blood from the systole) and pull the valve leaflets into alignment.
systemic circulation and pump it to the pulmonary his prevents them from prolapsing into the atrial
circulation for gas exchange. chamber above as the pressure in the ventricle

120 Chapter 3 Thorax

Opened right atrium: right lateral view Ascending aorta

Superior vena cava

Right auricle (atrial appendage)
Right pulmonary a. Crista terminalis

Pericardial reflection Septal leaflet (cusp) of

right atrioventricular
(tricuspid) valve

Interatrial septum Pectinate mm.

Fossa ovalis Opening of coronary

Inferior vena cava

Valve of coronary sinus

Valve (eustachian) of inferior vena cava

Pulmonary trunk
Nonadjacent semilunar leaflet
(anterior semilunar cusp)
Right adjacent semilunar
leaflet (cusp) Pulmonary valve
Right atrium Left adjacent semilunar
leaflet (cusp)
leaflet (anterior Conus arteriosus
Right cusp)
atrioven- Septal papillary m.
tricular Septal leaflet
(tricuspid) (cusp)
Interventricular septum (muscular part)
valve Inferior leaflet
cusp) Septomarginal trabecula
(moderator band)
Chordae tendineae
(anterior) papillary m.
Apical trabeculations Opened right ventricle: anterior view
FIGURE 3.17 Right Atrium and Ventricle Opened. (From Atlas of human anatomy, ed 7, Plate 224.)

TABLE 3.11 General Features of Right Atrium and Right Ventricle

Right Atrium Right Ventricle
Auricle Pouchlike appendage of atrium; Trabeculae carneae Irregular ridges of ventricular
embryonic heart tube derivative myocardium
Pectinate muscles Ridges of myocardium inside Papillary muscles Superoposterior, inferior, and
auricle septal projections of myocardium
Crista terminalis Ridge that runs from inferior vena extending into ventricular cavity;
cava (IVC) to superior vena cava prevent valve leaflet prolapse
(SVC) openings; its superior Chordae tendineae Fibrous cords that connect papillary
extent marks site of SA node muscles to valve leaflets
and it conveys an internodal Moderator band Muscular band that conveys AV
conduction pathway to the AV bundle from septum to base
node of ventricle at site of anterior
Fossa ovalis Depression in interatrial septum; papillary muscle
former site of foramen ovale Ventricular openings One to pulmonary trunk through
Atrial openings One each for SVC, IVC, and pulmonary valve; one to receive
coronary sinus (venous return blood from right atrium through
from cardiac veins) tricuspid valve

Chapter 3 Thorax 121 3
Flap opened in posterolateral wall of left ventricle
Oblique v. of left Left auricle (atrial
atrium (of Marshall) appendage) Arch of aorta
atriove- Mural leaflet
Ligamentum arteriosum
ntricular- (posterior cusp)
(mitral) Aortic Left pulmonary a.
valve leaflet
(anterior Right pulmonary a.
Left pulmonary vv.
(anterior) Left atrium
papillary m. Pericardium
Epicardial fat
Coronary sinus
Tricuspid valve RV
Inferior vena cava RA LV
Inferior (posterior) papillary m.

Mitral valve
Section through left atrium and ventricle
with mitral valve cut away
Left coronary leaflet
(semilunar cusp)
Right coronary leaflet Axial, T1-weighted MR scan of heart with pericardium
(semilunar cusp)
Nonadjacent leaflet
semilunar cusp)
Membranous septum Right pulmonary vv.

Valve of foramen ovale

Left atrium

Inferior vena cava

Muscular part of interventricular septum Left atrioventricular (mitral) valve (cut away)
FIGURE 3.18 Left Atrium and Ventricle Opened. (From Atlas of human anatomy, ed 7, Plate 225;
MR image from Kelley LL, Petersen C: Sectional anatomy for imaging professionals, St Louis, 2007,

TABLE 3.12 General Features of Left Atrium and Left Ventricle

Left Atrium Chordae tendineae Fibrous cords that connect
Auricle Small appendage representing papillary muscles to valve leaflets
primitive embryonic atrium Ventricular wall Wall much thicker than that of
whose wall has pectinate muscle right ventricle
Atrial wall Wall slightly thicker than thin- Membranous Very thin superior portion of IVS
walled right atrium septum and site of most ventricular septal
Atrial openings Usually four openings for four defects (VSDs)
pulmonary veins Ventricular One to aorta through aortic valve;
openings one to receive blood from left
Left Ventricle atrium through mitral valve
Papillary muscles Superoposterior and inferior muscles,
larger than those of right ventricle

122 Chapter 3 Thorax

Clinical Focus 3-13

Angina Pectoris (the Referred Pain of Myocardial Ischemia)
Angina pectoris (“strangling of the chest”) is usually described as pressure, discomfort, or a feeling of choking
or breathlessness in the left chest or substernal region that radiates to the left shoulder and arm, as well as
the neck, jaw and teeth, abdomen, and back. The discomfort also may radiate to the right arm. This radiating
pattern is an example of referred pain, in which visceral pain afferents from the heart enter the upper
thoracic spinal cord along with somatic afferents, both converging in the spinal cord’s posterior horn. The
higher brain center’s interpretation of this visceral pain may initially be confused with somatic sensations from
the same spinal cord levels. Somatic pain is “mapped” on the brain’s sensory cortex, but a similar symptomatic
mapping of visceral sensations does not occur. This may explain why pain from visceral structures is often
mistakenly perceived as somatic pain.

Pain of myocardial ischemia

Common descriptions of pain

Most commonly radiates
to left shoulder and/or ulnar
aspect of left arm and hand
Constricting Crushing weight
May also radiate to neck, jaw, and/or pressure
teeth, back, abdomen, or right
arm Fear
Other manifestations Perspiration
of myocardial ischemia Shortness
of breath Nausea;

Weakness, collapse, coma

Chiefly retrosternal and intense

Clinical Focus 3-14

Coronary Bypass
A coronary artery bypass graft (CABG), also called “the cabbage procedure,” offers a surgical approach
for revascularization. Veins or arteries from elsewhere in the patient’s body are grafted to the coronary arteries
to improve the blood supply. In a saphenous vein graft a portion of the great saphenous vein is harvested
from the patient’s lower limb. Alternatives include internal thoracic artery and radial artery grafts.

If indicated the physician may prefer

to use coronary angioplasty to widen
the partially occluded artery, which
may include using a stent to keep the Coronary artery
artery open. bypass grafts (CABGs)

Chapter 3 Thorax 123 3
Clinical Focus 3-15
Coronary Angiogenesis
Angiogenesis occurs by the budding of new blood vessels from small sprouts of existing vessels, thereby
expanding the capillary network. Hypoxia and inflammation are the two major stimuli for new vessel growth.
Revascularization of the myocardium after an ischemic episode by angiogenesis, bypass surgery, or percutaneous
coronary intervention is vital for establishing blood flow to the ischemic myocardium.

(capillary formation)

Myocardial m. cells VEGF

↓Tissue O2 tension promotes release of hypoxia-inducible factor 1 (HIF-1).

Fibroblasts and VEGF HIF-1 HIF-1 binds to the DNA sequence of the gene responsible for the expression of
extracellular matrix vascular endothelial growth factor (VEGF), which induces mitosis of endothelial
cells that, in turn, activates pathways to break down the extracellular matrix,
opening space for the sprouting vessel to grow.
Lasting myocardial ischemia leads to an inflammatory reaction. Macrophages
Sprouting capillary (transformed monocytes) produce cytokines such as basic fibroblast growth
factor (bFGF), VEGF, and transforming growth factor  (TGF-).
Recruited pericytes contribute to stabilize the three-dimensional
structure of the new vessel.

Newly formed blood vessels connect to each other,
forming loops and expanding the capillary network.


Obstructed coronary a.

Ischemic myocardium (shaded area)

124 Chapter 3 Thorax

increases. During ventricular diastole, the muscle (of His) conveys electrical impulses between the
relaxes and the tricuspid and mitral valves open atria and the ventricles. he following normal heart
normally to facilitate blood flow into the ventricles. sounds result from valve closure:
Toward the end of ventricular diastole, the atria • First heart sound (S1): results from the closing
contract and “top of ” the ventricles, just prior to of the mitral and tricuspid valves.
ventricular systole. • Second heart sound (S2): results from the
closing of the aortic and pulmonary valves.
Cardiac Skeleton and Cardiac Valves
he heart has four valves that, along with the Conduction System of the Heart
myocardium, are attached to ibrous rings of dense he heart’s conduction system is formed by special-
collagen that make up the ibrous skeleton of the ized cardiac muscle cells that form nodes and by
heart (Fig. 3.19 and Table 3.13). In addition to pro- unidirectional conduction pathways that initiate
viding attachment points for the valves, the cardiac and coordinate excitation and contraction of the
skeleton separates the atrial myocardium from the myocardium (Fig 3.20). he system includes the
ventricular myocardium (which originate from the following four elements:
ibrous skeleton) and electrically isolates the atria • Sinuatrial (SA) node: the “pacemaker” of the
from the ventricles. Only the atrioventricular bundle heart, where initiation of the action potential
occurs; located at the superior end of the crista
terminalis near the opening of the superior vena
TABLE 3.13 Features of the Heart Valves cava (SVC).
VALVE CHARACTERISTIC • Atrioventricular (AV) node: the area of the
Tricuspid (Right AV) Between right atrium and right heart that receives impulses from the SA node
ventricle; has three cusps and conveys them to the common atrioven-
Pulmonary (Semilunar) Between right ventricle and tricular bundle (of His); located between the
pulmonary trunk; has three semilunar
cusps (leaflets) opening of the coronary sinus and the origin of
Mitral (Bicuspid) Between left atrium and left the septal cusp of the tricuspid valve.
ventricle; has two cusps
Aortic (Semilunar) Between left ventricle and • Common atrioventricular bundle and bundle
aorta; has three semilunar cusps branches: a collection of specialized heart
muscle cells; the AV bundle divides into right

Left fibrous trigone

Nonadjacent semilunar
leaflet (anterior
Interventricular part
semilunar cusp) Membranous
Pulmonary valve (broken line)
Right adjacent septum
Atrioventricular part
semilunar leaflet (cusp)
Left adjacent
semilunar leaflet (cusp) Anterosuperior
Right coronary leaflet (anterior tricular
(semilunar cusp) cusp)
Aortic (tricuspid)
Left coronary leaflet Septal
valve valve
(semilunar cusp) leaflet
Nonadjacent leaflet (cusp)
(posterior [noncoronary] Inferior
semilunar cusp) leaflet
Aortic leaflet cusp)
(anterior cusp)
Left atrioven-
Commissural Right fibrous ring
(mitral) leaflet (cusp) (of right atrioven-
valve Mural leaflet tricular [tricuspid]
(posterior cusp) valve)
Right fibrous trigone
Left fibrous ring (of
left atrioventricular
[mitral] valve)
FIGURE 3.19 Heart in Ventricular Diastole Viewed From Above With Atrial Chambers
Removed. (From Atlas of human anatomy, ed 7, Plate 226.)

Chapter 3 Thorax 125 3
Clinical Focus 3-16
Myocardial Infarction
Myocardial infarction (MI) is a major cause of death. Coronary artery atherosclerosis and thrombosis, the
major causes of MI, precipitate local ischemia and necrosis of a defined myocardial area. Necrosis usually
occurs approximately 20 to 30 minutes after coronary artery occlusion. Usually, MI begins in the subendocardium
because this region is the most poorly perfused part of the ventricular wall.

Anterior infarct Anterolateral infarct

Occlusion of
Occlusion left circumflex
of proximal coronary a.,
left anterior marginal branch
descending of left circumflex a.,
a. (LAD) or diagonal
branch of
left anterior
descending a.



True posterior infarct Diaphragmatic or inferior infarct

of distal
circumflex a.

of inferior
branch or
distal right
coronary aa.


Occlusion of right coronary a. Infarct

Artery and Area Affected by MI

Artery occluded Frequency and affected area
40–50%; affects anterior and apical left ventricle and anterior two thirds of interventricular septum (IVS)

Right coronary 30–40%; affects posterior wall of left ventricle, posterior one third of IVS (if right-dominant coronary circulation)

Left circumflex 15–20%; affects lateral wall of left ventricle (can also affect posterior wall if left dominant coronary circulation)

126 Chapter 3 Thorax

Clinical Focus 3-17

Cardiac Auscultation
Auscultation of the heart requires not only an understanding of normal and abnormal heart sounds but also
knowledge of the optimal location to detect the sounds. Sounds are best heard by auscultating the area where
turbulent blood flow radiates (i.e., distal to the valve through which the blood has just passed). The
areas indicated on the image below are approximate, and one must expand the area of auscultation depending
on the size of the patient’s heart, other normal variations, or pathological conditions that may be present, such
as patent ductus arteriosus or ventricular hypertrophy.

Diagrams of several murmurs

Innocent murmur Systolic murmur from
increased pulmonic flow Holosystolic murmur Continuous murmur
followed by fixed, widely (IVSD or mitral or (patent ductus arteriosus)
split S2 (atrial septal defect) tricuspid regurgitation)
A2 P2 S1 S2 S1 S2
S1 S2 S1 ES

Murmur and ejection Systolic murmur (chronic Diastolic murmur Long diastolic murmur
click (pulmonary mitral regurgitation) with (aortic or pulmonary following opening snap
hypertension) S3 and S4 (dilated regurgitation) (mitral stenosis)
S2 cardiomyopathy) S1 S2
S1 EC S1 S2 OS
S4 S1 S2 S3

Precordial areas of auscultation

Pulmonic area (pulmonary trunk)

Tricuspid area (right ventricular area)
Aortic area
(aortic root and ascending aorta) 1
Pulmonic valve
Aortic valve 5
Mitral valve 6
Tricuspid valve

Mitral area (left ventricular area)

Features of Various Heart Sounds
Area Comment
Aortic Upper right sternal border; aortic stenosis
Pulmonary Upper left sternal border to below left clavicle; second heart sound, pulmonary valve murmurs, VSD
murmur, continuous murmur of patent ductus arteriosus (PDA)
Tricuspid Left fourth intercostal space; or sternal border of 5th rib; tricuspid and aortic regurgitation
Mitral Left fifth intercostal space in midclavicular line; apex; first heart sound, murmurs of mitral or aortic
valves, third and fourth heart sounds

Chapter 3 Thorax 127 3
Clinical Focus 3-18
Valvular Heart Disease
Although any of the valves may be involved in disease, the mitral and aortic valves are most frequently involved.
Major problems include stenosis (narrowing) or insufficiency (compromised valve function, often leading
to regurgitation). Several examples of aortic stenosis are shown (lower right images).

Left atrium
Great hypertrophy
of left ventricle
Aorta in aortic stenosis

Jet lesion

Thickened stenotic mitral valve: aortic leaflet (anterior Elongation of left ventricle with tension on
cusp) has typical convexity; enlarged left atrium; chordae tendineae, which may prevent full
“jet lesion” on left ventricular wall closure of mitral valve

Condition Comment
Aortic stenosis Leads to left ventricular
overload and hypertrophy;
caused by rheumatic heart
disease (RHD), calcific
stenosis, congenital
bicuspid valve (1–2%)
Stenosis and insufficiency
Aortic Caused by congenitally (fusion of all commissures)
regurgitation malformed leaflets, RHD,
(insufficiency) IE, ankylosing spondylitis,
Marfan’s syndrome,
aortic root dilation

Mitral stenosis Leads to left atrial dilation;

usually caused by RHD

Mitral Caused by abnormalities

regurgitation of valve leaflets, rupture
(insufficiency) of papillary muscle or
chordae tendineae,
papillary muscle fibrosis,
IE, left ventricular Calcific stenosis

IE, infective endocarditis (infection of cardiac valves)

128 Chapter 3 Thorax

Action potentials
SA node

Atrial m.

AV node

Common bundle

Bundle branches

Purkinje fibers

Ventricular m.

0.2 0.4 0.6
FIGURE 3.20 Conduction System and Electrocardiogram.

and left bundle branches, which course down • Minimally vasoconstricts the coronary resistance
the interventricular septum. vessels (via alpha adrenoceptors).
• Subendocardial (Purkinje) system: the rami- his coronary artery vasoconstriction, however,
fication of bundle branches in the ventricles of is masked by a powerful metabolic coronary
the heart’s conduction system; this system vasodilation (mediated by adenosine release from
includes a subendocardial network of conduction myocytes), which is important because coronary
cells that supply the ventricular walls and papil- arteries must dilate to supply blood to the heart as
lary muscles. it increases its workload.
In the posterior mediastinum, a bilateral thoracic
Autonomic Innervation of the Heart sympathetic chain of ganglia (sympathetic trunk)
Parasympathetic ibers from the vagus nerve (CN passes across the neck of the upper thoracic ribs
X) course as preganglionic nerves that synapse on and, as it proceeds inferiorly, aligns itself closer to
postganglionic neurons in the cardiac plexus or the lateral bodies of the lower thoracic vertebrae
within the heart wall itself (Fig. 3.21). Parasympa- (Fig. 3.22). Each of the 11 or 12 pairs of ganglia
thetic stimulation: (number varies) is connected to the anterior ramus
• Decreases heart rate. of the corresponding spinal nerve by a white ramus
• Decreases the force of contraction. communicans (the white ramus conveys pregan-
• Vasodilates coronary resistance vessels (although glionic sympathetic fibers from the spinal nerve).
most vagal efects are restricted directly to the A gray ramus communicans then conveys post-
SA nodal region). ganglionic sympathetic fibers back into the spinal
Sympathetic ibers arise from the upper tho- nerve and its anterior or posterior rami (see Chapter
racic cord levels (intermediolateral cell column of 1, Nervous System). Additionally, the upper thoracic
T1-T4/T5) and enter the sympathetic trunk (Fig. sympathetic trunk conveys small thoracic cardiac
3.21). hese preganglionic ibers synapse in the branches (postganglionic sympathetic fibers from
upper cervical and thoracic sympathetic chain the upper thoracic ganglia, T1-T4 or T5) to the
ganglia, and then send postganglionic ibers to the cardiac plexus, where they mix with preganglionic
cardiac plexus on and around the aorta and pul- parasympathetic fibers from the vagus nerve (Figs.
monary trunk. Sympathetic stimulation: 3.21 and 3.22). hree other pairs of thoracic
• Increases the heart rate. splanchnic nerves arise from the lower seven or
• Increases the force of contraction. eight thoracic ganglia and send their preganglionic

Chapter 3 Thorax 129 3
Superior cervical ganglion Superior cervical ganglion
Right vagus n. (CN X) Left vagus n. (CN X)
Superior cervical (sympathetic) cardiac n.
Middle cervical ganglion

Phrenic n. Middle cervical ganglion

Cervicothoracic (stellate) ganglion Vertebral ganglion

Ansa subclavia

Thoracic cardiac branch of vagus n. Thoracic (sympathetic) cardiac branches

Thoracic (sympathetic) cardiac branches Thoracic cardiac branches of vagus n.
(CN X)
Left recurrent laryngeal n.
Cardiac plexus (deep)

FIGURE 3.21 Autonomic Innervation of the Heart. (From Atlas of human anatomy, ed 7, Plate 230.)

Clinical Focus 3-19

Cardiac Pacemakers
Cardiac pacemakers consist of a pulse generator and one to three endocardial electrode leads. Pacemakers
can pace one heart chamber, dual chambers, or (the right atrial appendage [auricle] and right ventricle), or
can provide biventricular pacing, with leads in the right atrium and ventricle and one introduced into the
coronary sinus and advanced until it is over the surface of the left ventricular wall near the left (obtuse) marginal
artery. Depending upon the device, its programming, and its positioning, it can pace the heart chamber (SA
node or correct atrial fibrillation), pace the atrium and ventricle sequentially (dual-chamber pacemaker), or
provide normal AV pacing and enable pacing of the left ventricular wall (biventricular pacing).

Implantable cardiac pacemaker (dual-chamber cardiac pacing)

The endocardial leads are usually introduced via Subclavian vein

the subclavian or the brachiocephalic vein (left Clavicle
or right side), then positioned and tested.
Border of pectoralis
major m.
A pocket for the pulse generator is commonly made Border of deltoid m.
below the midclavicle adjacent to the venous access
for the pacing leads. The incision is parallel to the Coracoid process
inferior clavicular border, approximately 1 inch below it.

The pulse generator is placed either into the deep

subcutaneous tissue just above the prepectoralis fascia
or into the submuscular region of the pectoralis major.

Atrial and ventricular leads

130 Chapter 3 Thorax

Clinical Focus 3-20

Cardiac Defibrillators
An implantable cardioverter defibrillator is used for survivors of sudden cardiac death, patients with
sustained ventricular tachycardia (a dysrhythmia originating from a ventricular focus with a heart rate
typically greater than 120 beats/min), those at high risk for developing ventricular arrhythmias (ischemic dilated
cardiomyopathy), and other indications. In addition to sensing arrhythmias and providing defibrillation to stop
them, the device can function as a pacemaker for postdefibrillation bradycardia or atrioventricular dissociation.

Implantable cardiac defibrillator (dual-chamber leads)

Due to the number of functions the ICD can perform

In all aspects, the surgical procedure for implantable (cardioverter, defibrillator, and pacemaker), the ICD
cardioverter defibrillator (ICD) implantation is very is usually slightly larger than a pacemaker. The surface
similar to that of cardiac pacemaker implantation. of the ICD functions as one of the electrodes of the
defibrillation system.

Lead in the right atrium/auricle

Lead with two defibrillation coils.

The distal coil is in the right ventricle,
and the proximal one is in the superior
vena cava/right atrial position.

sympathetic fibers inferiorly to abdominal ganglia. superior and an inferior mediastinum by an imagi-
he thoracic splanchnic nerves (spinal levels can nary horizontal line extending from the sternal angle
vary) (see Chapter 4) contain preganglionic sym- of Louis to the intervertebral disc between the T4
pathetic fibers and are named as follows: and T5 vertebrae (Fig. 3.23; see also Fig. 3.1). he
• Greater splanchnic nerve: preganglionic fibers superior mediastinum lies behind the manubrium
usually arise from the T5-T9 spinal cord levels. of the sternum, anterior to the irst four thoracic
• Lesser splanchnic nerve: preganglionic fibers vertebrae, and contains the following:
usually arise from the T10-T11 spinal cord levels. • hymus gland (largely involuted and replaced
• Least splanchnic nerve: preganglionic fibers by fat in older adults).
usually arise from the T12 spinal cord level. • Brachiocephalic veins (right and left).
Visceral aferents for pain or ischemia from • Superior vena cava.
the heart are conveyed back to the upper thoracic • Aortic arch and its three arterial branches
spinal cord, usually levels T1-T4 or T5, via the (brachiocephalic trunk, left common carotid
sympathetic fiber pathways (see Clinical Focus 3-13). artery, and left subclavian artery) and pulmonary
Visceral aferents mediating cardiopulmonary trunk.
relexes (stretch receptors, barorelexes, and che- • Trachea.
morelexes) are conveyed back to the brainstem • Esophagus.
via the vagus nerve (CN X). • Phrenic and vagus nerves.
• horacic duct and lymphatics.
6. MEDIASTINUM he inferior mediastinum is further subdivided
as follows (Figs. 3.23 and 3.24):
he mediastinum (“middle space”) is the middle • Anterior mediastinum: the region posterior
region of the thoracic cavity and is divided into a to the body of the sternum and anterior to the

Chapter 3 Thorax 131 3
Cervicothoracic (stellate) ganglion Cervical cardiac nn.
Ansa subclavia (sympathetic and vagal)
Cervical cardiac nn. Vagus n. (CN X) (cut)
(sympathetic and vagal)
Thoracic (sympathetic)
cardiac branches Left recurrent laryngeal n.
Sympathetic trunk Thoracic cardiac branch of vagus n.
Vagus n. (CN X) (cut) and branches Cardiac plexus
to cardiac and pulmonary plexuses
Anterior pulmonary plexus
Thoracic (sympathetic)
cardiac branches
Sympathetic trunk
Gray and white rami communicantes
Thoracic aortic plexus
6th thoracic ganglion
Esophageal plexus

Greater thoracic splanchnic n.

Greater thoracic splanchnic n.

Lesser thoracic splanchnic n.

Thoracic duct
Anterior vagal trunk
Lesser thoracic splanchnic n.
Least thoracic splanchnic n. Respiratory diaphragm (pulled down)
Azygos v. (cut)
Inferior vena cava (cut)

FIGURE 3.22 Autonomic Nerves in the horax (From Atlas of human anatomy, ed 6, Plate 213.)

pericardium (substernal region); contains a (3) at the point where it is crossed by the left main
variable amount of fat. bronchus, and (4) distally at the point where it
• Middle mediastinum: the region containing passes through the diaphragm at the level of the
the pericardium and heart. T10 vertebra. he esophagus receives its blood
• Posterior mediastinum: the region posterior supply from the inferior thyroid artery, esophageal
to the heart and anterior to the bodies of the branches of the thoracic aorta, and branches of the
T5-T12 vertebrae; contains the esophagus and left gastric artery (a branch of the celiac trunk in
its nerve plexus, thoracic aorta, azygos system the abdomen).
of veins, sympathetic trunks and thoracic he thoracic aorta descends alongside and
splanchnic nerves, lymphatics, and thoracic duct. slightly to the left of the esophagus (Fig. 3.25) and
gives rise to the following arteries before piercing
Esophagus and Thoracic Aorta the diaphragm at the T12 vertebral level:
he esophagus extends from the pharynx (throat) • Pericardial arteries: small arteries that branch
to the stomach and enters the thorax posterior to from the thoracic aorta and supply the posterior
the trachea. As it descends, the esophagus gradually pericardium; variable in number.
slopes to the left of the median plane, lying anterior • Bronchial arteries: arteries that supply blood
to the thoracic aorta (Fig. 3.25); it pierces the to the lungs; usually one artery to the right lung
diaphragm at the T10 vertebral level. he esophagus and two to the left lung, but variable in number.
is about 10 cm (4 inches) long and has four points • Esophageal arteries: arteries that supply the
along its course where foreign bodies may become esophagus; variable in number.
lodged: (1) at its most proximal site at the level of • Mediastinal arteries: small branches that supply
the C6 vertebra (level of the cricoid cartilage), (2) the lymph nodes, nerves, and connective tissue
at the point where it is crossed by the aortic arch, of the posterior mediastinum.

132 Chapter 3 Thorax

Superior mediastinum and lungs

Right agus n. (CN X)

Anterior scalene m. Phrenic n. (cut)

Thoracic duct
Brachiocephalic trunk
Left brachiocephalic v.
Right brachiocephalic v.
Arch of aorta
Superior vena cava Left vagus n. (CN X)
Left recurrent laryngeal n.
Ligamentum arteriosum

Pulmonary trunk
Left main bronchus

Sternal angle

Superior mediastinum

Anterior mediastinum

Middle mediastinum

Inferior mediastinum

Posterior mediastinum

Respiratory diaphragm

Left superior lobe of lung
Ascending aorta
Pulmonary trunk
Right superior lobe of lung
Trachea (bifurcation)
Superior vena cava Descending aorta
Azygos vein
Body of vertebra

Spinal cord
Spinous process of vertebra

FIGURE 3.23 Mediastinum. (From Atlas of human anatomy, ed 7, Plates 210.)

Chapter 3 Thorax 133 3
Transverse section: level of T7, 3rd interchondral space

Sternum (body)
Right atrium
Right ventricle

Apex of heart
Superior vena cava
Interatrial septum
Left ventricle
Esophagus Leaflet of
(mitral) valve
Azygos v.
Left atrium
Serratus Descending
anterior m. thoracic
Body of
T7 vertebra Thoracic duct

FIGURE 3.24 Inferior Mediastinum. (From Atlas of human anatomy, ed 7, Plate 248.)

Esophageal branch of
Inferior thyroid a.
Thyrocervical trunk
Subclavian a.
Subclavian a.

Brachiocephalic trunk Common carotid a.

Arch of aorta

Right bronchial a.

Esophageal branch of Superior left bronchial a.

right bronchial a.
Inferior left bronchial a.
and esophageal branch

Thoracic (descending) aorta

Esophageal branches of
descending thoracic aorta

Thoracic part of esophagus

Respiratory diaphragm

Abdominal part of esophagus


Esophageal branch of
left gastric a.
Celiac trunk

FIGURE 3.25 Esophagus and horacic Aorta. (From Atlas of human anatomy, ed 7, Plate 240.)

134 Chapter 3 Thorax

• Posterior intercostal arteries: paired arteries IVC before the ascending lumbar and subcostal
that supply blood to the lower nine intercostal tributaries join it), the hemiazygos vein, and the
spaces. accessory hemiazygos vein (if present, it usually
• Superior phrenic arteries: small arteries to the begins at the fourth intercostal space). A small left
superior surface of the respiratory diaphragm; superior intercostal vein (a tributary of the left
anastomose with the musculophrenic and brachiocephalic vein) may also connect with the
pericardiacophrenic arteries (which arise from hemiazygos vein. Ultimately, most of the thoracic
the internal thoracic artery). venous drainage passes into the azygos vein, which
• Subcostal arteries: paired arteries that lie below ascends right of the midline to empty into the SVC.
the inferior margin of the last rib; anastomose
Arteriovenous Overview
with superior epigastric, lower intercostal, and
lumbar arteries. Arteries of the Thoracic Aorta (Fig. 3.27)
he heart (1) gives rise to the ascending aorta
Azygos System of Veins (2), which receives blood from the left ventricle.
he azygos venous system drains the posterior he right and left coronary arteries immediately
thorax and forms an important venous conduit arise from the aorta and supply the heart itself.
between the inferior vena cava (IVC) and superior he aortic arch (3) connects the ascending aorta
vena cava (SVC) (Fig. 3.26). his system represents and the descending aorta (4) and is found in the
the deep venous drainage characteristic of veins superior mediastinum. he descending aorta then
throughout the body. Its branches, although variable, continues inferiorly as the thoracic aorta (5). he
largely drain the same regions supplied by the thoracic aorta gives rise to branches to the lungs,
thoracic aorta’s branches described earlier. he key esophagus, pericardium, mediastinum, and dia-
veins include the azygos vein, with its right ascend- phragm, and also gives rise to posterior intercostal
ing lumbar, subcostal, and intercostal tributaries branches to the thoracic wall. he posterior
(sometimes the azygos vein also arises from the intercostal arteries course along the inferior aspect

Internal jugular v. Subclavian v.

External jugular v.

Thoracic duct
Right brachiocephalic v.
Left brachiocephalic v.

Superior vena cava

Esophageal vv. (plexus)

Accessory hemiazygos v.

Azygos v.

Junction of accessory
Hemiazygos v.
hemiazygos and azygos vv.
Left inferior phrenic v.
Short gastric vv.
Hepatic vv.

Inferior vena cava

Esophageal branches of left gastric v. Splenic v.

Hepatic portal v. Left renal v.

Left gastric v.
Inferior mesenteric v.
Right gastric v.
Superior mesenteric v.

FIGURE 3.26 Azygos System of Veins. (From Atlas of human anatomy, ed 7, Plate 241.)

Chapter 3 Thorax 135 3
of each rib (in the costal groove) and supply spinal arteries are shorter than the right intercostal arter-
branches (to the thoracic vertebrae and thoracic ies. As it approaches the diaphragm, the aorta shifts
spinal cord), lateral branches, and branches to the closer to the midline of the lower thoracic vertebrae.
mammary glands. he intercostal arteries anasto- he lower portion of the esophagus passes anterior
mose with the anterior intercostal branches from to the lower portion of the thoracic aorta (5) on
the internal thoracic artery, a branch of the sub- its way to the diaphragm and stomach. he thoracic
clavian artery (see Figs. 8.50 and 8.65). he thoracic aorta pierces the diaphragm at the level of the T12
aorta lies to the left of the thoracic vertebral bodies vertebra and passes through the aortic hiatus to
as it descends in the thorax, so the left intercostal enter the abdominal cavity. he aortic arch gives

Clinical Focus 3-21

Mediastinal Masses
Some of the more common mediastinal masses and their signs and symptoms are noted here.

Anterior mediastinum Posterior mediastinum

Substernal thyroid gland

Thymoma Neurilemoma
Teratoma Neurofibroma
Schwann cell tumor

Middle Bronchogenic
mediastinum or pericardial cyst
Lymph nodes; Vascular; aneurysm, Bronchogenic
lymphoma enlarged heart Lymph nodes; or pericardial cyst
lymphoma, Esophageal; achalasia,
metastatic cancer diverticula

Types of Mediastinal Masses

Type of mass Comment
Anterior Mediastinum (retrosternal pain, cough, dyspnea, SVC syndrome, choking sensation)
Thymoma Thymus tumors (<50% malignant), often associated with myasthenia gravis
Thyroid mass Mass that may cause enlarged gland to extend inferiorly and displace trachea
Teratoma Benign and malignant tumors of totipotent cells, often containing all three germ cell types (ectoderm,
mesoderm, and endoderm)
Lymphoma Hodgkin’s, non-Hodgkin’s, and primary mediastinal B-cell tumors
Middle Mediastinum (signs and symptoms similar to those of anterior masses)
Lymph nodes Enlarged nodes resulting from infections or malignancy
Aortic aneurysm Aneurysm that is atherosclerotic in origin, may rupture, and can be in any part of the mediastinum
Vascular dilatation Enlarged pulmonary trunk or cardiomegaly
Cysts Bronchogenic (at tracheal bifurcation) cysts, pericardial cysts
Posterior Mediastinum (pain, neurologic symptoms, or swallowing difficulty)
Neurogenic tumors Tumors of peripheral nerves or sheath cells (e.g., schwannomas)
Esophageal lesions Diverticula and tumors

136 Chapter 3 Thorax

Thyrocervical trunk Common carotid a.

Vertebral a.
Superior thoracic a.
Subclavian a.
Thoracoacromial a.
Axillary a. thoracic a.
1. Heart (Left Ventricle)* aorta
2. Ascending Aorta 2nd
intercostal a.
3. Aortic Arch
4. Descending Aorta
5. Thoracic Aorta intercostal a.
Bronchial arteries (branches) Collateral
Esophageal arteries branch
Pericardial arteries
Mediastinal arteries Lateral
Superior phrenic arteries Lateral
thoracic a.
Posterior intercostal arteries (lower 9 spaces)
Dorsal branch
Medial cutaneous branch Anterior mammary
intercostal aa. branch
Lateral cutaneous branch
Spinal branches Anterior
Superior intercostal a.
Postcentral branch
epigastric a.
Prelaminar branch Abdominal
Posterior radicular artery Musculophrenic a. aorta

Anterior radicular artery

Segmental medullary artery Subcostal a.

Posterior intercostal arteries (cont’d)

Collateral branch
2nd and 3rd
Lateral cutaneous branch lumbar aa.
Lateral mammary branches Aortic bifurcation
Subcostal artery (inferior to rib 12)
Dorsal branch
Spinal branch

*Direction of blood flow from proximal to distal

FIGURE 3.27 Arteries of the horacic Aorta.

of very small branches to the aortic body chemo- course in the costal groove at the inferior margin
receptors (not listed in the outline; they function of each rib. he intercostal veins drain largely into
similarly to the carotid body chemoreceptors and hemiazygos vein (2) and azygos vein (3) in the
are important receptors that monitor blood gas posterior mediastinum. An ascending lumbar vein
levels and the pH). from the upper abdominal cavity collects venous
blood segmentally and often from the left renal
Veins of the Thorax (Fig. 3.28) vein; it is an important connection between these
he venous drainage begins with the vertebral abdominal caval veins and the azygos system in the
venous plexus draining the vertebral column and thorax. A number of mediastinal veins exist in the
spinal cord. his plexus includes both an internal posterior mediastinum and drain the diaphragm,
and an external vertebral venous plexus. While most pericardium, esophagus, and main bronchi. hese
of these veins are valveless, recent evidence suggests veins ultimately drain into the accessory hemia-
that some valves do exist in variable numbers in zygos vein (1) and hemiazygos vein (2) just to
some of these veins. he posterior intercostal the left of the thoracic vertebral bodies or into the
veins parallel the posterior intercostal arteries and azygos vein (3) just to the right of the vertebral

Chapter 3 Thorax 137 3
Posterior internal vertebral venous plexus*
External jugular v.
Internal jugular v.
Post. and ant. spinal veins
Right brachiocephalic v. Internal thoracic vv.
Veins of spinal cord
Basivertebral veins Subclavian v. Posterior intercostal vv.
Anterior internal vertebral venous plexus Internal thoracic v. Anterior intercostal vv.
Ant. and post. external vertebral venous plexus Cephalic v.
Superior vena cava Superior
Posterior intercostal veins (left 4–8th) epigastric vv.

Bronchial veins (left) Axillary v.

1. Accessory Hemiazygos Vein
hemiazygos v. Areolar
Azygos v. plexus
Ascending lumbar vein (left)
Posterior intercostal veins (left 8–12th)
Esophageal veins
Mediastinal veins Thoraco-
epigastric v.
Superior phrenic veins (left)
Subcostal v.
2. Hemiazygos Vein Hemiazygos v. (12th intercostal v.)
1st lumbar v.
Inferior vena cava
lumbar v.
Ascending lumbar vein (right) Common iliac v.
Posterior intercostal veins (right 5–11th) Tributaries of
periumbilical vv.
Esophageal veins
Mediastinal veins External iliac v.
epigastric v.
Pericardial veins Superficial
Bronchial veins (right) circumflex
iliac v.
Right superior intercostal vein
Femoral v. Inferior
3. Azygos Vein epigastric v.
4. Superior Vena Cava External
5. Heart (Right Atrium) pudendal v.
*Distal (vertebral and intercostal veins)
saphenous v.
to Heart (right atrium)

FIGURE 3.28 Veins of the horax.

bodies. About midway in the thorax, the hemiazygos direction. As with other regional veins, the number
vein crosses the midline and drains into the azygos of veins of the azygos system can be variable.
vein (3), although the hemiazygos usually maintains
its connection with the accessory hemiazygos vein Thoracic Lymphatics
as well. Veins tend to connect with one another he thoracic lymphatic duct begins in the abdomen
where possible, and many connections are small, at the cisterna chyli (found between the abdominal
variable, and not readily recognizable. he azygos aorta and the right crus of the diaphragm), ascends
vein delivers venous blood to the superior vena through the posterior mediastinum posterior to
cava (4) just before the SVC enters the right atrium the esophagus, crosses to the left of the median
of the heart (5). he accessory hemiazygos vein also plane at approximately the T5-T6 vertebral level,
often has connections with the left brachiocephalic and empties into the venous system at the junc-
vein, providing another venous pathway back to the tion of the left internal jugular and left subclavian
right side of the heart. Flow in the azygos system veins (Figs. 3.29 and 4.41). Lymph from the left
of veins is pressure dependent; because the veins hemithorax and left lung generally drains into
are essentially valveless, the flow can go in either tributaries that empty into the thoracic duct. Lymph

138 Chapter 3 Thorax

Inferior deep cervical mesoderm forms the stroma of each lung. By 6

(internal jugular) nodes months of gestation, the alveoli are mature enough
for gas exchange, but the production of surfactant,
Thoracic duct
which reduces surface tension and helps prevent
nodes alveolar collapse, may not be suicient to support
Superior Posterior respiration. A premature infant’s ability to keep its
and inferior mediastinal airways open often is the limiting factor if the
tracheo- nodes
premature birth occurs before functional surfactant
nodes nodes cells (type II pneumocytes) are present.
Posterior Early Embryonic Vasculature
nodes Toward the end of the third week of development,
the embryo establishes a primitive vascular system
to meet its growing needs for oxygen and nutrients
(Fig. 3.31). Blood leaving the embryonic heart
phrenic enters a series of paired arteries called the aortic
nodes arches, which are associated with the pharyngeal
Left gastric arches. he blood then flows from these arches
Juxtaesophageal (cardiac
into the single midline aorta (formed by the
and superior nodes of fusion of two dorsal aortas), coursing along the
phrenic nodes stomach)
length of the embryo. Some of the blood enters
Celiac nodes the vitelline arteries to supply the future bowel
(still the yolk sac at this stage), and some passes
FIGURE 3.29 Mediastinal Lymphatics. (From Atlas of to the placenta via a pair of umbilical arteries,
human anatomy, ed 7, Plate 242.) where gases, nutrients, and metabolic wastes are
Blood returning from the placenta is oxygenated
from the right hemithorax and right lung usually and carries nutrients back to the heart through the
drains into the right lymphatic duct, which empties single umbilical vein. Blood also returns to the
into the venous system at the junction of the right heart through the following veins:
subclavian and right internal jugular veins (see • Vitelline veins: drain blood from yolk sac;
Fig. 1.16). will become the portal system draining the
gastrointestinal tract through the liver.
7. EMBRYOLOGY • Cardinal veins: form SVC and IVC (and azygos
system of veins) and their tributaries; will become
Respiratory System the caval system of venous return.
he airway and lungs begin developing during the
fourth week of gestation. Key features of this Aortic Arches
development include the following (Fig. 3.30): Blood pumped from the primitive embryonic heart
• Formation of the endodermal laryngotracheal passes into aortic arches that are associated with
diverticulum from the ventral foregut, just the pharyngeal arches (Fig. 3.32). he right and
inferior to the last pair of pharyngeal pouches left dorsal aortas caudal to the pharyngeal arches
• Division of the laryngotracheal diverticulum into fuse to form the single midline aorta, while the
the left and right lung (bronchial) buds, each aortic arches give rise to the arteries summarized
with a primary bronchus in Table 3.14. Note that the third, fourth, and sixth
• Division of the lung buds to form the definitive pairs of embryonic aortic arches are the major
lobes of the lungs (three lobes in the right lung, contributors to arteries that will persist in the fetus
two lobes in the left lung) and neonate.
• Formation of segmental bronchi and 10 bron-
chopulmonary segments in each lung (by weeks Development of Embryonic Heart Tube
6 to 7) and Heart Chambers
he airway passages are lined by epithelium he primitive heart begins its development as a
derived from the endoderm of the foregut, while single unfolded tube, much like an artery develops

Chapter 3 Thorax 139 3
Upper foregut
at 4 to 5 weeks Oropharyngeal membrane
Sagittal section 1st pharyngeal pouch (ventral view) (disintegrating)
(disintegrating) I
Pharynx Thyroid diverticulum
Pharyngeal pouches
Splanchnic mesoderm Left lung (bronchial) bud
Laryngotracheal of ventral foregut
Stomodeum ridge or groove (lung stroma)
1st pharyngeal arch Esophagus Esophagus
Bronchial (lung) bud Right lung (bronchial) bud
Thyroid diverticulum

Respiratory system at 6 to 7 weeks

Pharyngeal cavity

1st pharyngeal pouch (auditory tube and middle ear)

2nd pharyngeal pouch (supratonsillar fossa)
Tongue 3rd pharyngeal pouch
Parathyroid III (future inferior parathyroid gland)
Thyroid gland
4th pharyngeal pouch
Parathyroid IV (future superior parathyroid gland)
Trachea Postbranchial (ultimobranchial) body

Upper lobe Upper lobe

Middle lobe
Lower lobe
Lower lobe

FIGURE 3.30 Embryology of the Respiratory System.

TABLE 3.14 Aortic Arch Derivatives • Atrium: early on it is a single chamber that
receives blood from the sinus venosus and passes
it to the ventricle.
1 Largely disappears (part of maxillary artery
in head) • Ventricle: early on it is a single chamber that
2 Largely disappears (stapedial artery in receives atrial blood and passes it to the bulbus
middle ear) cordis.
3 Common carotid and proximal internal
carotid arteries • Bulbus cordis: receives ventricular blood and
4 Brachiocephalic artery and proximal right passes it to the truncus arteriosus.
subclavian artery and on the left side a • Truncus arteriosus: receives blood from the
small portion of the aortic arch bulbus cordis and passes it to the aortic arch
5 Disappears
6 Ductus arteriosus and proximal portions of system for distribution to the lungs and body.
both pulmonary arteries his primitive heart tube soon begins to fold on
itself in an “S-bend.” he single ventricular chamber
folds downward and to the right, and the single
atrium and sinus venosus fold upward, posteriorly
(Fig. 3.33). he heart tube receives blood from the and to the left, thus forming the definitive positions
embryonic body, which passes through its heart of the heart’s future chambers (atria superior to the
tube segments in the following sequence: ventricles) (Fig. 3.33 and Table 3.15).
• Sinus venosus: receives all the venous return he four chambers of the heart (two atria and
from the embryonic body and placenta. two ventricles) are formed by the internal septation

140 Chapter 3 Thorax

Aortic arches


Sinus venosus

Aortic sac
Vitelline v. Anterior, common, and posterior cardinal vv.

Dorsal intersegmental aa.

Yolk sac
Dorsal aorta

Umbilical v.

Vitelline a.

Left umbilical a. (right not shown)

Umbilical cord

Vascular systems Chorion

Chorionic villi of placenta

FIGURE 3.31 Early Embryonic Vasculature.

Internal carotid aa.

R. aortic arch I L. aortic arch I External carotid aa.
R. dorsal aorta III
L. dorsal aorta
Aortic sac IV
III VI (ductus arteriosus)
R. primitive pulmonary a. L. primitive pulmonary a.
Pulmonary trunk L. pulmonary a.
L. dorsal aorta R. pulmonary a.
R. dorsal aorta
4 mm 14 mm
External carotid aa.
Common Internal carotid aa.
carotid aa.
Common carotid aa.
Brachiocephalic trunk
R. subclavian a. L. subclavian a.
Arch of aorta
R. subclavian a. Ductus arteriosus

Brachiocephalic trunk L. pulmonary a.

Ascending aorta L. subclavian a. R. pulmonary a.
Arch of aorta
Pulmonary trunk
Pulmonary trunk Descending aorta

17 mm At term
FIGURE 3.32 Sequential Development of Aortic Arch Derivatives (Color-Coded).

Chapter 3 Thorax 141 3
Heart tube derivatives

Heart tube primordia

Aortic arches (AA)

Ascending aorta
Truncus arteriosus (TA)
Pulmonary trunk

Bulbus cordis (BC) Aortic vestibule of left ventricle

Conus arteriosus of right ventricle

Adult heart, anterior view

Ventricle (V) Trabecular walls of left and right ventricles

Atrium (A) Auricles/pectinate muscle walls of left

and right atria (smooth wall of left
atrium from pulmonary veins)

Coronary sinus
Sinus venosus (SV) Smooth wall of right atrium

Adult heart, posterior view

FIGURE 3.33 Primitive Heart Tube Formation.

TABLE 3.15 Adult Heart Derivatives of

of the single atrium and ventricle of the primitive
Embryonic Heart Tube heart tube. Because most of the blood does not
perfuse the lungs in utero (the lungs are filled with
amniotic fluid and are partially collapsed), most of
Truncus arteriosus Aorta the blood in the right atrium passes directly to the
Pulmonary trunk
Bulbus cordis Smooth part of right ventricle left atrium via a small opening in the interatrial
(conus arteriosus) septum called the foramen ovale. he interatrial
Smooth part of left ventricle (aortic septum is formed by the fusion of a septum primum
Primitive ventricle Trabeculated part of right ventricle and a septum secundum (the septum secundum
Trabeculated part of left ventricle develops on the right atrial side of the septum
Primitive atrium Pectinate wall of right atrium primum) (Fig. 3.34). Shortly after birth, when the
Pectinate wall of left atrium
Sinus venosus Smooth part of right atrium (sinus pressure of the left atrium exceeds that of the right
venarum)* atrium (blood now passes into the lungs and returns
Coronary sinus to the left atrium, raising the pressure on the left
Oblique vein of left atrium
side), the two septae are pushed together and fuse,
From Dudek R: High-yield embryology: a collaborative project of thus forming the fossa ovalis of the postnatal
medical students and faculty, Philadelphia, 2006, Lippincott Williams
& Wilkins.
heart. While the interatrial septum is forming,
*he smooth part of the left atrium is formed by incorporation of the ventricular septum forms from the superior
parts of the pulmonary veins into the atrial wall. he junction of the
pectinated and smooth parts of the right atrium is called the crista
growth of the muscular interventricular septum
terminalis. from the base of the heart’s common ventricle
toward the downward growth of a thin membranous
septum from the endocardial cushion (Fig. 3.35).

142 Chapter 3 Thorax

Left atrium Foramen secundum appears

Septum secundum
Right atrium

Foramen primum
Foramen primum Septum primum diminishes

vena cava
Septum primum
with foramen

Foramen ovale

Fossa ovalis

Septum secundum
Inferior vena cava
Prenatal Foramen ovale closed after birth
with increased pulmonary flow
FIGURE 3.34 Atrial Septation.

Without the spiral septum With the spiral septum

No exit for blood in left ventricle Blood can exit both ventricles

The three structures that must fuse
to complete ventricular separation: Pulmonary trunk
Truncus arteriosus
Endocardial cushions
Interventricular septum
Bulbus cordis
Spiral septum

Endocardial Spiral septum


Right Left atrioventricular canal

canal Interventricular (IV) septum
FIGURE 3.35 Ventricular Septation.

Chapter 3 Thorax 143 3
Prenatal circulation

Pulmonary trunk Ductus arteriosus arteriosum
Superior vena cava Left pulmonary artery ductus
Right pulmonary artery Left pulmonary vein arteriosus)
Right pulmonary vein
Foramen ovale Inferior vena cava

Hepatic vein Aorta

Ductus venosus Celiac trunk
Liver Superior mesenteric artery
Hepatic portal vein
Fossa ovalis
Umbilical vein
Kidney (obliterated
foramen ovale)
Ligamentum venosum
Intestine (obliterated ductus venosus)
Umbilical arteries Ligamentum teres
(round ligament) of liver
(obliterated umbilical vein)
Medial umbilical ligaments
(fibrous part of umbilical arteries)
Postnatal circulation

Ductus arteriosus Umbilical arteries

Common carotid arteries Umbilical vein

Spiral arteries
Middle cerebral arteries
Uterine radial arteries

Uterine arcuate arteries

Uterine arteries
and ascendant branches

FIGURE 3.36 Fetal Circulation Pattern and Changes at Birth. (From Atlas of human anatomy, ed 7,
Plate 233.)

Simultaneously, the bulbus cordis and truncus (Fig. 3.36). Various shunts allow fetal blood to largely
arteriosus form the outflow tracts of the ventricles, bypass the liver (not needed for metabolic process-
pulmonary trunk, and aorta. he neural crest plays ing in utero) and lungs (not needed for gas exchange
a key role in the septation and development of the in utero) so that the blood may gain direct access
truncus arteriosus as it becomes the pulmonary to the left side of the heart and be pumped into
trunk and ascending aorta. the fetal arterial system. At or shortly after birth,
these shunts close, resulting in the normal pattern
Fetal Circulation of pulmonary and systemic circulation observed
he pattern of fetal circulation is one of gas exchange postnatally. Figure 3.36 highlights these changes
and nutrient/metabolic waste exchange across the and the adult “reminders” that persist in us of our
placenta with the maternal blood (but not the prenatal existence (see the labels associated with
exchange of blood cells), and distribution of oxygen “Postnatal circulation” in the right image of the
and nutrient-rich blood to the tissues of the fetus figure).

144 Chapter 3 Thorax

Clinical Focus 3-22

Ventricular Septal Defect
Ventricular septal defect (VSD) is the most common congenital heart defect, representing about 30% of all
heart defects. Approximately 80% of cases are perimembranous (occur where the muscular septum and
membranous septum of the endocardial cushion should fuse). This results in a left-to-right shunt, which may
precipitate congestive heart failure. The repair illustrated in the figure is through the right atrial approach.

Transatrial repair of ventricular septal defect


Cannula in
superior vena cava


Right ventricle
VSD with
Retracted left-to-right
septal leaflet Perimembranous VSD shunt

Right atriotomy and retraction

of the tricuspid valve leaflets
Cannula in provide excellent exposure of
inferior vena cava the perimembranous VSD.

Left ventricle
septal Synthetic
leaflet patch

Region of conduction Posterior

nerve bundle on wall leaflet
of left ventricle

The septal leaflet of the tricuspid valve may need to be bisected to The VSD is closed with a synthetic patch and pledgetted sutures.
permit placement of pledgetted sutures at its junction with the VSD. The septal leaflet, if detached, is then repaired with a running suture.
Superficial sutures are placed along the inferior border of the VSD to
prevent injury to the conduction system.

Chapter 3 Thorax 145 3
Clinical Focus 3-23
Atrial Septal Defect
Atrial septal defects make up approximately 10% to 15% of congenital cardiac anomalies. Most of these
defects are ostium secundum defects from incomplete closure of the foramen ovale. Larger defects may
require a patch that is sutured into place. For smaller atrial septal defects, a percutaneous transcatheter
approach using a septal occluder can be deployed and secured. By threading the catheter through the IVC,
the catheter is positioned to pass directly into the atrial defect, as shown below, and is then deployed.

The Amplatzer Septal Occluder is deployed from its delivery sheath, forming two discs, one for either side
of the septum, and a central waist available in varying diameters to seat on the rims of the atrial septal defect.

Atrial septum Pulmonary vv.

Inferior vena cava
After sizing the defect,
Right atrium the delivery sheath is
used to insert the device
into the left atrium and
deploy it at the defect. The left atrial disc of
the occluder is deployed
in the left atrium.



Tricuspid valve
Right ventricle Left ventricle

Once the left atrial disc and part of

the connecting waist are deployed,
the device is carefully pulled back
until the left atrial disc touches the
septum and the waist is in the septal

The right atrial disc is deployed

and the placement of the occluder
is checked by echocardiography. Occluder in place
Then, the device is released.

146 Chapter 3 Thorax

Clinical Focus 3-24

Patent Ductus Arteriosus
Patent ductus arteriosus (PDA) is failure of the ductus arteriosus to close shortly after birth. This results in a
postnatal shunt of blood from the aorta into the pulmonary trunk, which may lead to congestive heart
failure. PDA accounts for approximately 10% of congenital heart defects and can be treated medically (or
surgically if necessary). Surgical treatment is by direct ligation or a less invasive, catheter-based device that
is threaded through the vasculature and positioned to occlude the PDA. Often, children with a PDA may be
fine until they become more active and then experience trouble breathing when exercising and demonstrate
a failure to thrive. A continuous murmur usually is evident over the left sternal border to just below the clavicle
(see Clinical Focus 3-17).

Patent ductus arteriosus


Ductus arteriosus

Left pulmonary a.

Right pulmonary a.

Pulmonary trunk

Pathophysiology of patent ductus arteriosus

Decreased systemic flow

Left-to-right shunt through

patent ductus arteriosus

Increased pulmonary flow

(pulmonary volume overload)

Left ventricular hypertrophy

Chapter 3 Thorax 147 3
Clinical Focus 3-25
Repair of Tetralogy of Fallot
Tetralogy of Fallot usually results from a maldevelopment of the spiral septum that normally divides the truncus
arteriosus into the pulmonary trunk and aorta. This defect involves the following:
• Pulmonary stenosis or narrowing of the right ventricular outflow tract
• Overriding (transposed) aorta
• Right ventricular hypertrophy
• Ventricular septal defect (VSD)
Surgical repair is done on cardiopulmonary bypass to close the VSD and provide unobstructed flow into the
pulmonary trunk. The stenotic pulmonary outflow tract is widened by inserting a patch into the wall (pericardial),
thus increasing the volume of the subpulmonic stenosis and/or the pulmonary artery stenosis.

Deoxygenated Patent ductus

blood arteriosus

pulmonary a. Ligated ductus arteriosus

Stenotic pulmonary trunk


VSD with
right-to-left Stenotic
shunt pulmonary valve

Aortic and mitral

valve seen
through VSD
Right ventricular

GORE-TEX graft Hypertrophied

with pledgets right ventricle

followed by
patch to

Retracted patch to
tricuspid valve reduce

148 Chapter 3 Thorax

Clinical Focus
Available Online

3-26 Hemothorax 3-31 Infective Endocarditis

3-27 Chronic Cough 3-32 Mitral Valve Prolapse
3-28 Pneumonia 3-33 Ventricular Tachycardia
3-29 Cardiovascular Disease 3-34 Chylothorax
3-30 Saphenous Vein Graft Disease 3-35 Coarctation of the Aorta

Additional figures available online (see inside front cover for details).

Chapter 3 Thorax 148.e1 3
Clinical Focus 3-26
Accumulation of blood in the pleural cavity transforms this potential space into a real space capable of accom-
modating a large volume. Blood in this space does not clot well because of the smooth pleural surfaces and
the defibrinating action of respiratory movements.

4 1

5 7

1. Lung
2. Intercostal vv.
3. Internal thoracic
(internal mammary) a. 8
4. Thoracoacromial a. via wound 8
5. Lateral thoracic a. track
6. Mediastinal great vessels
7. Heart
8. Abdominal structures (liver,
spleen) via diaphragm

Degrees and management

Minimal Moderate Massive

(up to 350 mL) (350 to 1500 mL) (over 1500 mL)

Blood usually resorbs spontaneously Thoracentesis and tube drainage Two drainage tubes inserted since
with conservative management. with underwater-seal drainage one may clog, but immediate or early
Thoracentesis is rarely necessary. usually suffices. thoracotomy may be necessary to
arrest bleeding.

148.e2 Chapter 3 Thorax

Clinical Focus 3-27

Chronic Cough
Although an acute cough often signals an upper respiratory viral infection, a chronic cough may indicate a
more serious underlying illness. Chronic cough can cause conjunctival bleeding, epistaxis, vomiting, stress
urinary incontinence, rib fractures, disc herniation, hernias, esophageal rupture, and cardiac arrhythmias.

Causes of Chronic Cough

Medication (particulary
ACE inhibitors) (<1%)
Postnasal drip (28–41%)
(vagal irritation)
Post URI

Chronic bronchitis (5–10%)


GERD (mediated via

vagal irritation) (10–21%)

Causes of Chronic Cough

with Abnormal Chest X-ray
Involved Ectatic
nodes mucus-filled

Cystic fibrosis and bronchiectasis

Pulmonary tuberculosis

air sacs

of lung
Left ventricular
COPD (pulmonary emphysema) and dilation
Left-sided congestive heart failure
and pulmonary hypertension

Chapter 3 Thorax 148.e3 3
Clinical Focus 3-28
Lungs are continually exposed to infectious agents. Infections in the form of pneumonia account for one sixth
of all deaths in the United States.

Staphylococcal pneumonia

Severe staphylococcal pneumonia

complicating endocarditis, with
abscess formation, empyema,
vegetations on tricuspid valve,
and emboli in branches of
pulmonary artery

Pneumococcal pneumonia

Lobar pneumonia;
right upper lobe

Right upper lobe and segment of

right lower lobe pneumonia

148.e4 Chapter 3 Thorax

Clinical Focus 3-29

Cardiovascular Disease (Elderly and Women)
Cardiovascular disease is a major health problem, especially with the notable increase in obesity and diabetes
in the population. The incidence has decreased in elderly men but remains unchanged in women. Some of
the more common manifestations of cardiovascular disease are illustrated.

Cardiovascular disease in the elderly

Clinical signs

Signs of
Stroke failure
(CAD) Clinical presentation of CAD in
elderly is often atypical with dyspnea or
heart failure as initial symptom and may delay diagnosis
Increased incidence
of comorbidities
Aggressive management
contributes to
of hypertension
polypharmacy, and
(systolic or diastolic)
risk of adverse drug Significant decrease in
effects is high morbidity and mortality
Primary and from cardiovascular event
prevention by
Absolute risk of cardiovascular event (mainly stroke and CAD with MI) LDL reduction
increases incrementally as population ages and is greatest in elderly
population (65 years). Approximately 85% of cardiovascular deaths occur Management goals
after age 65.
Cardiovascular disease in women
Risk factors Clinical presentation
Women may present with
X “heartburn” type
symptoms due to CHD

Back pain is a
Insulin common “anginal
Diabetes in women more powerful risk factor equivalent” in
than in men, associated with 3-7 times women
increase in CHD development

Smoking stronger risk factor for MI in middle-

aged women than men Cardiovascular disease is leading
cause of death in both men and
Hormone replacement contraindicated as women. More women die of
cardioprotection in postmenopausal women cardiovascular disease than of
breast cancer. Fatigue and dyspnea on
exertion with decreased
exercise tolerance are
common complaints
CHD symptoms reported by women often differ
Treatment of dyslipidemias ( LDL, HDL, from those reported by men. These vague or
triglycerides) offers reduction in confusing symptoms may contribute to a delayed
or missed diagnosis.
cardiovascular event risk

Chapter 3 Thorax 148.e5 3
Clinical Focus 3-30
Saphenous Vein Graft Disease
Saphenous vein graft disease is a long-term complication of grafting. Percutaneous coronary intervention
provides access to the vein graft, often through the femoral artery. By this method, one may introduce distal
protection and thrombectomy devices, such as balloons for expansion or stents, which reduce the incidence
of occlusion, embolization, and infarction in these patients with ischemia.

Percutaneous coronary
intervention: vascular access

Distal protection device

Guidewire in left
Aorta coronary a.

Guide catheter

Saphenous v. graft
Stenotic lesion catheter


Brachial a.

Femoral a.

Stent delivery
catheter with its
balloon inflated
and the
stent expanded
Stenotic Stent in
lesion place

Aspiration catheter
Native vessel debris

Occlusion balloon

148.e6 Chapter 3 Thorax

Clinical Focus 3-31

Infective Endocarditis
Infective endocarditis (IE) is an infection of the cardiac valves (often previously damaged) or the endocardial
surface that results in an infectious colonization and formation of a thrombotic mass, termed vegetation. Any
microorganism may cause IE, although most cases are caused by bacteria, usually streptococci. The mitral
and aortic valves are most often involved. Some common predisposing factors are illustrated.

Common portals of bacterial entry in bacterial endocarditis

Dental infections Genitourinary infections Cutaneous infections Pulmonary infections


Bicuspid aortic
valve (congenital
or acquired)
Mild residual changes of
rheumatic mitral valve disease

Early vegetations of
bacterial endocarditis on
bicuspid aortic valve
Early vegetations of bacterial endocarditis at
contact line of mitral valve

Common predisposing lesions

Chapter 3 Thorax 148.e7 3
Clinical Focus 3-32
Mitral Valve Prolapse
Mitral valve prolapse is the most common type of congenital heart disease in adults (about 5%) and is often
asymptomatic. Cardiac auscultation is the key to clinical diagnosis.

Normal mitral valve Posterior

Thickened, Anterior leaflet
redundant anulus
valve leaflets
and chordae

Papillary m.

Mitral valve prolapse


papillary m.
dysfunction Elongated
Middle scallop lax chordae
of posterior leaflet tendineae
most involved
Increased anulus length, leaflet area, and elongated
chordae tendineae allow “buckling” or prolapse of
valve leaflets into left atrium during systole.


Late systolic murmur following

midsystolic click (mitral prolapse)
Plane of
S1 A2 P2 Normal systole mitral valves coapt mitral valve
on ventricular side of mitral valve. anulus

Click Left

Plane of
mitral valve
In mitral valve prolapse, anulus
mitral valve leaflets coapt on
atrial side of the plane of the
mitral anulus. Some mitral
regurgitation may be present.

148.e8 Chapter 3 Thorax

Clinical Focus 3-33

Ventricular Tachycardia
Ventricular tachycardia is a dysrhythmia originating from a ventricular focus with a heart rate typically greater
than 120 beats/min. It is usually associated with coronary artery disease.

Acute management
Patient status
Patient assessment Ventricular tachycardia Presyncope, hypotension,
Presyncopal well tolerated pulmonary edema
IV antiarrhythmic DC cardioversion
Dyspnea also utilized in

cases refractory
to medical
If medical
Hypotension response poor,
pacing with
ventricular lead
Urgent blood studies
(including magnesium)
BUN, creatinine,
cardiac enzymes
Glucose, VT DC Sinus
toxicology screen cardioversion rhythm
Blood gases if indicated
(Follow-up studies to rule Primary acute management goal after stabilization of patient is
out myocardial infarction) termination of ventricular tachycardia.

Long-term management
Myocardial revascularization
is indicated in many cases of
ventricular tachycardia when
coronary artery disease is the
underlying cause or a
Long-term management with cofactor.
antiarrhythmics and other pharmacologic
agents is often dictated by diagnosis.

Coronary artery
bypass grafts (CABGs)

Implantable cardioverter
defibrillator (ICD)
indicated, particularly
when rate and
rhythm are refractory Sinus
to other therapies VT Pacing burst rhythm
ECG demonstrating pacing effect on

Chapter 3 Thorax 148.e9 3
Clinical Focus 3-34
Chylothorax usually arises from a complication of surgery (laceration of the thoracic duct) in the mediastinum,
especially when performing vascular surgery on the great vessels.

Aspiration of milky (chylous) fluid from

thoracic cavity (may be reintroduced
into body by way of nasogastric tube or
by well-monitored intravenous infusion)

(innominate) vv.
vena cava
Thoracic duct

Esophagus (cut away)

Azygos vein

thoracic aorta


Cisterna chyli
Normal course of thoracic duct
Azygos v.

Ligation of thoracic duct

after identification of
rupture site by escape of
intraabdominally injected dye

Thoracic duct

148.e10 Chapter 3 Thorax

Clinical Focus 3-35

Coarctation of the Aorta
This coarctation is a congenital narrowing of the aorta, usually near the ligamentum (ductus) arteriosum
(preductal, juxtaductal, or postductal). Blood flows via collateral arterial routes to gain access to structures
distal to the defect. The increased blood flow in some arteries may lead to enlargement of those vessels.

Vertebral aa.

R. transverse scapular a. L. common carotid a.

R. transverse cervical a.
L. costocervical trunk
L. transverse scapular a.

L. internal thoracic
(int. mammary) a.
L. axillary a.
L. subclavian a.
R. subscapular a.
R. circumflex Ligamentum
IV arteriosum
scapular a.



aberrans VII

R. 4th intercostal

Internal IX
thoracic (int.
mammary) aa.

To superior and
inferior epigastric and L. intercostal arteries
external iliac aa.

Postductal type Intercostal a. retracted from rib,
demonstrating erosion of costal
(Infant; 1 month) groove by the tortuous vessel
Preductal type

Challenge Yourself Questions
1. During open-heart surgery, the pericardial sac 5. A coronary artery angiogram for a patient about
is cut open by a longitudinal incision. If a to undergo coronary bypass surgery shows
horizontal incision is used, which of the fol- significant blockage of a vessel that supplies
lowing structures might be transected? the right and left bundle branches of the heart’s
A. Azygos vein conduction system. Which of the following
B. Inferior vena cava arteries is most likely involved?
C. Internal thoracic artery A. Anterior interventricular
D. Phrenic nerves B. Circumflex
E. Vagus nerves C. Posterior interventricular
D. Right marginal
2. A small, thin, 4-year-old boy presents with an
E. Sinuatrial nodal branch
audible continuous murmur that is heard near
the left proximal clavicle and is present through- 6. An infant presents with left-to-right shunting
out the cardiac cycle. he murmur is louder of blood and evidence of pulmonary hyperten-
in systole than diastole. Which of the following sion. Which of the following conditions is most
conditions is most likely the cause of this likely responsible for this condition?
murmur? A. Atrial septal defect
A. Atrial septal defect B. Mitral stenosis
B. Mitral stenosis C. Patent ductus arteriosus
C. Patent ductus arteriosus D. Patent ductus venosus
D. Right ventricular hypertrophy E. Ventricular septal defect
E. Ventricular septal defect
7. An elderly woman presents with valvular
3. A 61-year-old man presents with severe chest stenosis and a particularly loud first heart sound
pain and a rhythmic pulsation over the left (S1). Which of the following heart valves are
midclavicular, fifth intercostal space. Which responsible for the S1 sound?
portion of the heart is most likely responsible A. Aortic and mitral
for this pulsation? B. Mitral and tricuspid
A. Aortic arch C. Tricuspid and pulmonary
B. Apex of the heart D. Pulmonary and aortic
C. Mitral valve E. Aortic and tricuspid
D Pulmonary valve
8. Endoscopic examination of a 52-year-old man
E. Right atrium
with a history of smoking reveals a malignancy
4. After a boating accident, a young child needs in the right main bronchus. Which of the
a tracheotomy because of injuries to his upper following lymph structures will most likely be
body. Which of the following structures is most infiltrated first by cancerous cells emanating
at risk for injury during this procedure? from this malignancy?
A. Left brachiocephalic vein A. Bronchomediastinal trunk
B. Phrenic nerve B. Bronchopulmonary (hilar) nodes
C. horacic duct C. Inferior tracheobronchial (carinal) nodes
D. hymus gland D. Pulmonary (intrapulmonary) nodes
E. Vagus nerve E. Right paratracheal nodes

Multiple-choice and short-answer review questions available online; see inside front cover for details.


150 Chapter 3 Thorax

9. Auscultation of the lungs of a 31-year-old ____ 15. Radiographic contrast imaging of the
woman reveals crackles heard on the back along heart highlights this roughened internal feature
the right medial border of the scapula, just of each ventricular wall.
above the inferior scapular angle, during late
inspiration. Which of the following lobes are ____ 16. his feature is the postnatal manifesta-
most likely involved in this pathology? tion of the primitive embryonic atrial cardiac
A. Lower lobe of the right lung
B. Lower lobes of both lungs 17. A 67-year-old man experiences chest pain
C. Middle lobe of the right lung indicative of angina pectoris and myocardial
D. Upper lobe of the right lung ischemia. he visceral sensory neurons mediat-
E. Upper lobes of both lungs ing this pain would most likely be found in
10. A penetrating injury in the lower left neck which of the following locations?
just superior to the medial third of the clavicle A. Intermediolateral gray matter of the
results in the collapse of the left lung. Which of upper thorax spinal cord
the following respiratory structures was most B. Medial brachial cutaneous nerve
likely injured, resulting in this pneumothorax? C. Spinal root ganglion of T1-T2
A. Costal pleura D. Sympathetic chain ganglia
B. Cupula E. Vagal sensory ganglion
C. Left main bronchus 18. Cardiomyopathy results in the enlargement of
D. Left posterior lobe the left atrium. Which of the following struc-
E. Mediastinal parietal pleura tures is most likely to be compressed by this
For each condition described below (11-16), select expansion?
the cardiac feature from the list (A-O) that is most A. Azygos vein
likely responsible. B. Esophagus
C. Left pulmonary artery
(A) Aortic valve (I) Opening of D. Superior vena cava
(B) Chordae tendineae coronary sinus E. Sympathetic trunk
(C) Conus arteriosus (J) Papillary muscles
(D) Crista terminalis (K) Pectinate muscle 19. A woman is diagnosed with metastatic breast
(E) Fossa ovalis (L) Pulmonary valve cancer with lymph node involvement. Most of
(F) Membranous (M) Sinuatrial node the lymphatic drainage of the breast passes to
ventricular septum (N) Trabeculae carneae which of the following lymph nodes?
(G) Mitral valve (O) Tricuspid valve A. Abdominal
(H) Moderator band B. Axillary
C. Infraclavicular
____ 11. During strenuous exercise, this feature D. Parasternal
of the right ventricle ensures coordinated E. Pulmonary
contraction of the anterior papillary muscle.
20. he sternal angle (of Louis) is an important
____ 12. An implantable cardiac defibrillator clinical surface landmark on the anterior chest
can function as a pacemaker should this wall, dividing the thorax into the superior and
structure be unable to initiate the normal inferior mediastinum. Which of the following
cardiac rhythm. features also is found at the level of the sternal
____ 13. Most atrial septal defects occur at this
A. Articulation of first rib
B. Azygos vein
____ 14. Some of the venous blood returning C. Descending aorta
to the right atrium gains access through this D. Sinuatrial node
feature. E. Tracheal bifurcation

Chapter 3 Thorax 151 3
21. A 6-year-old boy is diagnosed with decreased 25. A 63-year-old man is admitted to the hospital
blood low into the proximal descending with a myocardial infarction and cardiac
thoracic aorta. His brachial arterial pressure is tamponade. An emergency pericardiocentesis
signiicantly increased and his femoral pressure is ordered to draw of the blood in the peri-
is decreased. Which of the following embryonic cardial cavity. At which of the following loca-
structures has failed to develop normally? tions will a needle be inserted to perform this
A. 2nd aortic arch procedure?
B. 3rd aortic arch A. Left fourth intercostal space in the
C. 4th aortic arch midaxillary line
D. 5th aortic arch B. Left ifth intercostal space just lateral to
E. 6th aortic arch the sternum
C. Just to the right of the xiphoid process
22. A 27-year-old comatose anorexic woman is
D. Right third intercostal space 1 inch from
admitted to the emergency department. A
the sternum
nasogastric tube is inserted and passed into
E. Right seventh intercostal space 1 inch
her esophagus. What will be the last resistance
from the sternum
point felt by the physician as the tube passes
from the nose into the stomach? 26. A robbery victim receives a stab injury to the
A. Esophageal hiatus of the diaphragm thoracic wall in the area of the right fourth
B. Level of the superior thoracic aperture costal cartilage. Which of the following pul-
C. Posterior to the aortic arch monary structures is present at the site of this
D. Posterior to the left atrium injury?
E. Posterior to the left main bronchus A. Apex of the lung
B. Horizontal issure of the lung
23. A 68-year-old man is scheduled to have coro-
C. Lingula
nary bypass surgery to the inferior (posterior
D. Oblique issure of the lung
descending) interventricular artery. As this
E. Pulmonary ligament
procedure is performed, which of the following
vessels is most at risk of injury? 27. A 37-year-old man is admitted to the hospital
A. Anterior cardiac vein with a blood pressure measurement of
B. Coronary sinus 84/46 mm Hg. A central venous line is placed,
C. Great cardiac vein and subsequent radiographic imaging detects
D. Middle cardiac vein a chylothorax. Which of the following structures
E. Small cardiac vein was most likely accidently damaged during this
24. A 3-year-old girl undergoes corrective surgery
A. Anterior jugular vein
to repair a small ventricular septal defect (VSD).
B. Left proximal external jugular vein
To gain access to the site, an incision is made
C. Origin of left brachiocephalic vein
in the anterior surface of the right atrium so
D. Right external jugular vein
instruments may be inserted through the tri-
E. Right subclavian vein
cuspid valve to repair the VSD. Which of the
following structures is the most important to 28. A 24-year-old distance runner is admitted to
protect as the incision is made in the right the hospital with severe dyspnea and an acute
atrium? asthma attack. A bronchodilating drug is
A. Anterior papillary muscle administered. Which of the following compo-
B. Crista terminalis nents of the nervous system must be inhibited
C. Coronary sinus by this drug to achieve relaxation of the tra-
D. Pectinate muscles cheobronchial smooth muscle?
E. Valve of the inferior vena cava A. Postganglionic parasympathetic ibers
B. Postganglionic sympathetic ibers
C. Preganglionic sympathetic ibers
D. Somatic eferent ibers
E. Visceral aferent ibers

152 Chapter 3 Thorax

29. A 3-year-old girl aspirates a small peanut and For each statement below (33 to 37), select the
begins coughing and choking. In which com- nerve or nerve fibers that are most likely responsible
ponent of the tracheobronchial tree is the for the function described or the disorder caused
peanut most likely lodged? (i.e., the single best answer).
A. Carina of the trachea
(A) Greater splanchnic (F) Right recurrent
B. Left main bronchus
nerve laryngeal nerve
C. Left tertiary bronchus
(B) Left recurrent (G) Somatic aferent
D. Proximal trachea
laryngeal nerve ibers
E. Right main bronchus
(C) Phrenic nerve (H) Somatic eferent
30. An examination of a 51-year-old woman shows (D) Posterior ramus ibers
an orange-peel appearance of her skin on her of a spinal nerve (I) Sympathetic trunk
breast, a tumor in the right upper outer quad- (E) Postganglionic (J) Vagus nerve
rant of her breast, and several deep dimples in sympathetic fibers
the skin over the site of the tumor. Which of
the following breast structures is responsible ____ 33. Causes contraction of the internal
for the deep dimpling of her skin? intercostal muscles.
A. Inflammation of her lactiferous ducts ____ 34. Carries nerve ibers that monitor
B. Intraductal obstruction from the cancer barorelexes and chemorelexes.
C. Invasion of the tumor into her
retromammary space ____ 35. Travels to the heart in cervical cardiac
D. Obstruction of her cutaneous lymphatics nerves.
E. Retraction of her suspensory ligaments
____ 36. A hoarse voice caused by a tumor
31. A 58-year-old man presents with dyspnea. pressing on the aortic arch.
Examination reveals a mitral valve prolapse.
At which of the following locations is ausculta- ____ 37. Carries referred pain from the respira-
tion of this valve best performed? tory diaphragm.
A. Above the medial third of the left clavicle
For questions 38 to 40, select the feature shown in
B. Directly over the sternal angle
the chest radiograph that best satisies the condition
C. At the left fifth intercostal space, just
below the nipple
D. At the left second intercostal space, just
lateral to the sternum
E. At the right second intercostal space, just
lateral to the sternum
32. A 56-year-old woman undergoes an aortic valve
replacement and is connected to a heart-lung
machine. he surgeon explores her oblique
pericardial sinus and is able to palpate each of
the following structures except one. Which
structure is not routinely palpable from this
perspective? F
A. Inferior left pulmonary vein C
B. Inferior right pulmonary vein G
C. Inferior vena cava
D. Right atrium
E. Superior vena cava

Chapter 3 Thorax 153 3
____ 38. Blood from this heart chamber next 8. C. The “carinal” nodes are located at the inferior
passes through the tricuspid valve. aspect of the tracheal bifurcation and would
be the first nodes involved as lymph moves
____ 39. Proximal narrowing of this structure from the hilar nodes to the carinal nodes.
can reduce the blood flow to the left subclavian 9. A. At this position on the right side of the back,
artery. the inferior lobe of the right lung would be the
location of the crackles. The oblique fissure
____ 40. he mitral valve can best be auscul- dividing the right lung into superior and
tated over this structure. inferior lobes begins posteriorly at the level of
the T2-T3 vertebral spine, well above this level.

10. B. The cupula is the dome of cervical pleura

Chapter 3: Thorax surrounding the apex of the lung and it extends
above the medial portion of the clavicle and
the first rib.
1. D. The phrenic nerves course from superior to
inferior along the lateral sides of the pericar- 11. H. The moderator band (septomarginal trabecula)
dium, anterior to the root structures entering extends from the lower interventricular septum
or leaving the lungs. A longitudinal incision to the base of the anterior papillary muscle in
would run parallel to these nerves while a the right ventricle. It conveys the right AV
horizontal incision might potentially run across bundle to this distal papillary muscle and
the nerves, unless the surgeon is very careful. probably assists in its coordinated contraction.
2. C. This continuous murmur is caused by the sound 12. M. The “pacemaker” of the heart is the sinuatrial
of blood rushing through a patent ductus or SA node. It initiates the action potential
arteriosus from the aorta into the pulmonary that will pass through the atria and down into
trunk (higher-pressure to lower-pressure the AV node and then the ventricles.
vessel). This is best heard over the left proxi-
mal clavicular area. Normally, the ductus 13. E. Most atrial septal defects (ASDs) occur at the
narrows and closes shortly after birth to form site of the foramen ovale in the fetal heart
the ligamentum arteriosum. (fossa ovalis). If the foramen ovale (foramen
secundum) remains open after birth, blood can
3. B. The apex (lower left ventricle) of the heart lies pass from the left atrium into the right atrium.
in the left midclavicular line at the fifth inter-
costal space. Its forceful contraction as it pumps 14. I. Venous blood returning from the coronary
blood into the aorta and systemic circulation circulation returns to the right atrium via the
is easily heard over this area. coronary sinus. Obviously, the SVC and IVC
also return venous blood to the right atrium,
4. A. The left brachiocephalic vein passes across the but these two vessels are not listed as options.
trachea and is very near the sixth cervical
vertebra; moreover, in a young child it can lie 15. N. The roughened appearance of the muscular
above the level of the manubrium of the bundles of the ventricular walls is called the
sternum. A tracheotomy is made below the trabeculae carneae (fleshy woody beams).
cricoid cartilage and thyroid gland and just
superior to this vein at about the level of the 16. K. The roughened muscular walls of the atria
C6 vertebra. (pectinate muscle) represent the “true” embry-
onic atrium; the smooth portion of each atrium
5. A. The major blood supply to the interventricular is derived from the embryonic sinus venosus.
septum and the right and left bundle branches
is by the left anterior descending (LAD, or 17. A. Sensory nerve cell bodies conveying somatic
anterior interventricular) coronary artery. The or visceral pain are found in the spinal ganglia.
posterior interventricular branch supplies the Those sensory pain fibers (visceral pain) from
remainder of the interventricular septum. myocardial ischemia are conveyed to the upper
portion of the sympathetic component of the
6. E. Ventricular septal defects (VSDs) are the most ANS and reside in the spinal ganglia of T1-T2.
common congenital heart defect. The shunting
of blood from the left to right ventricle results 18. B. The esophagus lies directly posterior to the
in right ventricular hypertrophy and pulmonary left atrium and may be compressed by enlarge-
hypertension. ment of this heart chamber.

7. B. The first heart sound is made by the closing 19. B. About three quarters of all the lymph from the
of the two atrioventricular valves (tricuspid and breast passes to the axillary lymph nodes.
mitral valves). The stenosis (narrowing) most Lymph can also pass laterally, inferiorly, and
likely involves the mitral valve. superiorly, but most passes to the axilla.

154 Chapter 3 Thorax

20. E. The sternal angle is a good landmark for 29. E. The right main bronchus is more vertical and
determining the level of the tracheal bifurcation, shorter and wider than the left main bronchus,
the location of the aortic arch, and the articu- so most (but not all!) aspirated objects pass
lation of the second ribs with the sternum. into this bronchus. The tertiary bronchus is
usually too small for an object as large as a
21. C. The arch of the aorta develops from the left peanut to be aspirated into it.
fourth aortic arch. The second pair of arches
largely disappears (it forms the small stapedial 30. E. Deep dimpling of the skin results from the
artery of the middle ear); the third pair forms tension and retraction of the suspensory
the common carotid arteries and a small ligaments of the breast. The peau d’orange
proximal portion of the internal carotid artery; (orange peel) appearance of her skin results
the right fourth arch forms the brachiocephalic from obstruction of subcutaneous lymphatics,
trunk and proximal right subclavian artery; the causing edema and the accumulation of lymph
fifth pair disappears; and the sixth pair forms in dilated lymphatics near the surface of the
the proximal pulmonary arteries and, on the skin.
left, the ductus arteriosus.
31. C. The mitral valve is heard downstream from
22. A. The esophageal hiatus is the last resistance the valve as the turbulent flow of blood carries
point. It is located at the T10 vertebral level the sound into the left ventricle. The valve is
as the esophagus passes through the dia- best heard near the apex of the left ventricle,
phragm. Other resistance points include the which is at about the fifth intercostal space
pharyngoesophageal junction, the area poste- and to the left of the sternum. In males, this
rior to the aortic arch, and the area posterior is usually just below the left nipple; in females,
to the left main bronchus. the nipple location can vary, depending on the
size of the breast.
23. D. The middle cardiac vein parallels the inferior
(posterior) interventricular coronary artery and 32. E. Although each of the other structures can be
drains into the large coronary sinus, which palpated by the physician’s fingertips, the SVC
drains into the right atrium. The great cardiac cannot be felt in the oblique sinus, which is a
vein parallels the LAD branch of the left coro- cul-de-sac lying beneath the atria, IVC, portions
nary artery. of both ventricles, and pulmonary veins.

24. B. The crista terminalis, because at its superior 33. H. The intercostal muscles are skeletal muscles
margin lies the SA node and beneath its length and are innervated by anterior rami of the spinal
lies the posterior internodal pathway of conduc- nerves, which contain three types of nerve
tion fibers between the SA and AV nodes. It fibers: somatic efferents, somatic afferents, and
also is the site of origin of the atrium’s pecti- postganglionic sympathetics. Only the somatic
nate muscles. efferent nerve fibers cause contraction of the
skeletal muscle, however.
25. B. The needle usually is inserted, with ultrasound
guidance, in the left fifth intercostal space just 34. J. Baroreceptors and chemoreceptors associated
to the left of the sternum. In emergencies, if with the heart are found primarily on the aortic
echocardiography is not available, a subxiphoid arch. Their sensory modalities are conveyed
approach is used just between the xiphisternum back to the brainstem by the vagus nerve (CN
and the left costal margin. X). Similar receptors also exist at the common
carotid bifurcation in the neck, but these
26. B. The horizontal fissure of the right lung courses afferents are carried by the glossopharyngeal
along the path of the fourth rib. Both lungs nerve (CN IX). These specialized receptors
possess an oblique fissure, but only the right monitor the blood pressure (baroreceptors),
lung has a horizontal fissure and three lobes; blood pH, and partial pressure of oxygen and
the left lung has two lobes. carbon dioxide in the blood (chemoreceptors).

27. C. The thoracic lymphatic duct has been damaged, 35. E. Cervical and thoracic cardiac nerves contain
producing a chylothorax. This duct returns postganglionic sympathetic fibers that travel
lymph from three quarters of the body to the to the heart and increase the heart rate
venous system at the junction of the left inter- and force of contraction. Their preganglionic
nal jugular vein and left subclavian vein where sympathetic neurons arise in the upper thoracic
they form the proximal left brachiocephalic vein. (T1-T4) intermediate (intermediolateral) gray
matter of the spinal cord, and the postgangli-
28. A. Although sympathetic fibers relax the smooth onic cell neurons are in the sympathetic trunk
muscle of the tracheobronchial tree (allowing ganglia (cervical and upper thoracic regions).
for increased respiration associated with the
fight-or-flight response), postganglionic para-
sympathetic fibers constrict this smooth muscle
and, therefore, must be inhibited.

Chapter 3 Thorax 155 3
36. B. A hoarse voice can be indicative of swollen 38. C. Blood from the right atrium next passes through
vocal cords (caused by overuse, which leads the tricuspid (right atrioventricular) valve to
to swollen mucosa) or paralysis of one of the enter the right ventricle of the heart. Remem-
vocal folds, which are innervated by the recur- ber, when viewing a radiographic image, that
rent laryngeal nerves from the vagus nerve “right” and “left” refer to the patient’s right
(CN X). A tumor pressing on the aortic arch and left, not the right and left side of the image!
could involve the left vagus nerve as it courses
over the arch and gives rise to the left recurrent 39. E. Narrowing of the aortic arch (which can happen
laryngeal nerve. with coarctation of the proximal aortic arch;
see online Clinical Focus 3-35) may reduce blood
37. C. The diaphragm is a skeletal muscle and somatic flow to the left common carotid and subclavian
afferents from it would travel in the phrenic arteries, as well as the descending thoracic
nerve (C3-C5), which innervates the diaphragm. aorta.
A general answer would be the somatic affer-
ent fibers, but a more specific, and the best, 40. G. The mitral valve is best heard over the fifth
answer is the phrenic nerve. Pain can be intercostal space, about 3 inches to the left of
referred to the shoulder and lower neck region. the sternum (apex of the heart).

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1. INTRODUCTION hepatic portal systems and the key anastomoses

between these two systems that facilitate venous
he abdomen is the region between the thorax return to the heart.
superiorly and the pelvis inferiorly. he abdomen Lastly, study the posterior abdominal wall
is composed of the following: musculature, and identify the components and
• Layers of skeletal muscle that line the abdominal distribution of the lumbar plexus of somatic
walls and assist in respiration and, by increasing nerves.
intraabdominal pressure, facilitate micturition
(urination), defecation (bowel movement), and 2. SURFACE ANATOMY
Key Landmarks
• he abdominal cavity is a peritoneal lined cavity
that is continuous with the pelvic cavity inferiorly Key surface anatomy features of the anterolateral
and contains the abdominal viscera (organs). abdominal wall include the following (Fig. 4.1):
• Visceral structures that lie within the abdominal • Rectus sheath: a fascial sheath containing the
peritoneal cavity (intraperitoneal) include the rectus abdominis muscle, which runs from the
gastrointestinal (GI) tract and its associated pubic symphysis and crests to the xiphoid process
organs (the liver, gallbladder, and pancreas), and ifth to seventh costal cartilages.
the spleen, and the urinary system (kidneys • Linea alba: literally the “white line”; a relatively
and ureters), which is located retroperitone- avascular midline subcutaneous band of ibrous
ally behind and outside the peritoneal cavity tissue where the fascial aponeuroses of the
but anterior to the posterior abdominal wall rectus sheath from each side interdigitate in
muscles. the midline.
In your study of the abdomen, irst focus on the • Semilunar line: the lateral border of the rectus
abdominal wall and note the continuation of the abdominis muscle in the rectus sheath.
three muscle layers of the thorax (intercostal • Tendinous intersections: transverse skin
muscles) as they blend into the abdominal lank grooves that demarcate transverse ibrous attach-
musculature. ment points of the rectus sheath to the underly-
Next, note the disposition of the abdominal ing rectus abdominis muscle.
organs. For example, you should know the region • Umbilicus: the site that marks the T10 derma-
or quadrant of the abdominal cavity in which the tome, lying at the level of the intervertebral disc
organs reside; whether an organ is suspended in a between L3 and L4; the former attachment site
mesentery or lies retroperitoneally (refer to embry- of the umbilical cord.
ology of abdominal viscera, i.e., foregut, midgut, • Iliac crest: the rim of the ilium, which lies at
or hindgut derivatives); the blood supply and about the level of the L4 vertebra.
autonomic innervation pattern to the organs; and • Inguinal ligament: a ligament composed of the
features of the organs that will allow you to readily aponeurotic ibers of the external abdominal
identify which organ or part of an organ you are oblique muscle, which lies deep to a skin crease
viewing (particularly important in laparoscopic that marks the division between the lower
surgery). Also, you should understand the dual abdominal wall and upper thigh of the lower
venous drainage of the abdomen by the caval and limb.

158 Chapter 4 Abdomen

Tendinous intersection
Rectus abdominis m. External abdominal oblique m.
Linea alba
Semilunar line
Anterior superior iliac spine Iliac crest
Superficial epigastric vv.
Superficial circumflex iliac v.
Inguinal lig.

Pubic symphysis Pubic tubercle

FIGURE 4.1 Key Landmarks in Surface Anatomy of Anterolateral Abdominal Wall. (From Atlas of
human anatomy, ed 7, Plate 249.)

Median plane
Right midclavicular line

Left midclavicular line

Right upper Left upper

quadrant quadrant Transumbilical plane
Right lower Left lower 1
quadrant quadrant
(RLQ) (LLQ) 2

Epigastric region 5
A. 6
7 T12
Right hypochondriac region
8 L1 Left hypochondriac
9 region
Subcostal plane 10 L2

Umbilical region L3
Left lateral region
Right lateral region
Intertubercular plane

Right inguinal region Left inguinal region

Pubic (hypogastric) region

FIGURE 4.2 Four-Quadrant (A) and Nine-Region (B) Abdominal Planes. (From Atlas of human
anatomy, ed 7, Plate 251.)

Chapter 4 Abdomen 159 4
TABLE 4.1 Clinical Planes of Reference • Extraperitoneal (fascia) fat: connective tissue
for Abdomen that is variable in thickness and contains a vari-
PLANE OF able amount of fat.
REFERENCE DEFINITION • Peritoneum: thin serous membrane that lines
Median Vertical plane from xiphoid process to
the inner aspect of the abdominal wall (parietal
pubic symphysis peritoneum) and occasionally relects of the
Transumbilical Horizontal plane across umbilicus at walls as a mesentery to invest partially or
the L4 disc; these planes divide the
abdomen into quadrants.
completely various visceral structures. It then
Subcostal Horizontal plane across inferior encircles the viscus as visceral peritoneum.
margin of 10th costal cartilage
Intertubercular Horizontal plane across tubercles of Muscles
Midclavicular Two vertical planes through midpoint he muscles of the anterolateral abdominal wall
of clavicles; these planes divide the include three lat layers that are continuations of
abdomen into nine regions.
the three layers in the thoracic wall (Fig. 4.3). hese
include two abdominal oblique muscles and the
transversus abdominis muscle (Table 4.2). In the
Surface Topography midregion a vertically oriented pair of rectus
Clinically, the abdominal wall is divided descriptively abdominis muscles lies within the rectus sheath
into quadrants or regions so that both the underly- and extends from the pubic symphysis and crest
ing visceral structures and the pain or pathology to the xiphoid process and costal cartilages 5 to 7
associated with these structures can be localized superiorly. he small pyramidalis muscle just
and topographically described. Common clinical superior to the pubis (Fig. 4.3, B) is inconsistent
descriptions use either quadrants or the nine and clinically less signiicant.
descriptive regions, demarcated by two vertical
midclavicular lines and two horizontal lines: the Rectus Sheath
subcostal and intertubercular planes (Fig. 4.2 and he rectus sheath encloses the vertically running
Table 4.1). rectus abdominis muscle (and inconsistent pyrami-
dalis), the superior and inferior epigastric vessels,
3. ANTEROLATERAL the lymphatics, and the anterior rami of the T7-L1
ABDOMINAL WALL nerves, which enter the sheath along its lateral
margins (Fig. 4.3, C). he superior three quarters
Layers of the rectus abdominis is completely enveloped
he layers of the abdominal wall include the within the rectus sheath, and the inferior one quarter
following: is supported posteriorly only by the transversalis
• Skin: epidermis and dermis. fascia, extraperitoneal fat, and peritoneum; the site
• Supericial fascia (subcutaneous tissue): a single, of this transition is called the arcuate line (Figs.
fatty connective tissue layer below the level of 4.4, 4.5, and 4.6 and Table 4.3).
the umbilicus that divides into a more supericial
fatty layer (Camper’s fascia) and a deeper Innervation and Blood Supply
membranous layer (Scarpa’s fascia; see Fig. 4.11). he segmental innervation of the anterolateral
• Investing fascia: connective tissue that covers abdominal skin and muscles is by anterior rami
the muscle layers. of T7-L1. he blood supply includes the following
• Abdominal muscles: three lat layers, similar arteries (Figs. 4.3, C, and 4.5):
to the thoracic wall musculature, except in the • Musculophrenic: a terminal branch of the
anterior midregion where the vertically oriented internal thoracic artery that courses along the
rectus abdominis muscle lies in the rectus sheath. costal margin.
• Endoabdominal fascia: tissue that is unremark- • Superior epigastric: arises from the terminal
able except for a thicker portion called the trans- end of the internal thoracic artery and anasto-
versalis fascia, which lines the inner aspect of moses with the inferior epigastric artery at the
the transversus abdominis muscle; it is continuous level of the umbilicus.
with fascia on the underside of the respiratory • Inferior epigastric: arises from the external
diaphragm, fascia of the posterior abdominal iliac artery and anastomoses with the superior
muscles, and fascia of the pelvic muscles. epigastric artery.

160 Chapter 4 Abdomen

major muscle
Xiphoid process
Pectoralis major muscles

Anterior layer of rectus

sheath (cut edges)
Linea alba

Rectus abdominis muscle

Serratus anterior muscle
Latissimus dorsi muscle External abdominal oblique
muscle (cut away)
External Muscular part
abdominal Tendinous intersection
oblique Aponeurotic part
muscle Internal abdominal
oblique muscle

Rectus sheath Anterior superior iliac spine

Linea alba
External oblique aponeurosis
(cut and turned down)
Anterior superior iliac spine

Inguinal ligament (Poupart’s)

Inguinal ligament (Poupart’s)

Pyramidalis muscle
Superficial inguinal ring

A. The external abdominal oblique muscle is B. The internal abdominal oblique muscle is shown on the left
shown in this image of the right side of the body. side of the body and the rectus abdominis muscle is exposed.

Superior epigastric vessels Anterior layer of

rectus sheath (cut)
External abdominal oblique
muscle (cut away) Anterior layer of
rectus sheath
Rectus abdominis muscle
External oblique 7 Transversus abdominis
aponeurosis (cut) muscle (cut)

Internal oblique 8 Transversalis fascia

aponeurosis (cut) (opened on left)
Transversus Extraperitoneal fascia
abdominis muscle 10 (areolar tissue)

Internal abdominal Medial umbilical ligament

oblique muscle (cut) (fibrous part of umbilical artery)

Posterior layer
of rectus sheath
Inferior epigastric artery
Arcuate line and vein (cut)

Inferior epigastric vessels

Anterior superior iliac spine

Inguinal ligament (Poupart’s)

Inguinal ligament (Poupart’s)

C. The transversus abdominis muscle is shown on the right side of the body
and is partially reflected on the left side to reveal the underlying transversalis fascia.
FIGURE 4.3 Muscles of Anterolateral Abdominal Wall. (From Atlas of human anatomy, ed 7, Plates
252 to 254.)

Chapter 4 Abdomen 161 4
TABLE 4.2 Principal Muscles of Anterolateral Abdominal Wall
External oblique External surfaces of 5th Linea alba, pubic Inferior six thoracic Compresses and
to 12th ribs tubercle, and nerves and supports abdominal
anterior half of iliac subcostal nerve viscera; flexes and
crest rotates trunk
Internal oblique Thoracolumbar fascia, Inferior borders of Anterior rami Compresses and
anterior two thirds 10th to 12th ribs, of inferior six supports abdominal
of iliac crest, and linea alba, and thoracic nerves viscera; flexes and
lateral half of inguinal pubis via conjoint and 1st lumbar rotates trunk
ligament tendon nerve
Transversus Internal surfaces of Linea alba with Anterior rami Compresses and
abdominis costal cartilages 7-12, aponeurosis of of inferior six supports abdominal
thoracolumbar fascia, internal oblique, thoracic nerves viscera
iliac crest, and lateral pubic crest, and and 1st lumbar
third of inguinal pecten pubis via nerve
ligament conjoint tendon
Rectus abdominis Pubic symphysis and Xiphoid process and Anterior rami Compresses abdominal
pubic crest costal cartilages 5-7 of inferior six viscera and flexes
thoracic nerves trunk

Section above arcuate line

Anterior layer of rectus sheath Internal abdominal
Aponeurosis of external abdominal oblique m. Rectus abdominis m.
Skin Transversus oblique m.
Aponeurosis of internal abdominal oblique m. abdominis m.
Linea alba External abdominal
Aponeurosis of transversus abdominis m. oblique m.

Falciform lig.
Peritoneum Posterior layer of rectus sheath Superficial
Transversalis fascia fascia (fatty layer)
Extraperitoneal fascia
Section below arcuate line
Superficial fascia (fatty
Aponeurosis of external abdominal oblique m. Anterior layer of rectus sheath and membranous layers)
Aponeurosis of internal abdominal oblique m. Rectus abdominis m. Transversus abdominis m.
Aponeurosis of transversus abdominis m. Internal abdominal oblique m.
External abdominal
oblique m.

Transversalis fascia
Extraperitoneal fascia Medial umbilical lig. and fold
Peritoneum Median umbilical lig. (obliterated urachus)
in median umbilical fold

FIGURE 4.4 Features of Rectus Sheath. (From Atlas of human anatomy, ed 7, Plate 255.)

TABLE 4.3 Aponeuroses and Layers Forming Rectus Sheath

Anterior lamina Formed by fused aponeuroses of Below arcuate line All three muscle aponeuroses fuse to
above arcuate line external and internal abdominal form anterior lamina, with rectus
oblique muscles abdominis in contact only with
Posterior lamina Formed by fused aponeuroses of transversalis fascia posteriorly
above arcuate line internal abdominal oblique and
transversus abdominis muscles

162 Chapter 4 Abdomen

Axillary a. Subclavian a.
Internal thoracic aa.
Lateral thoracic a.

Anterior intercostal aa.

Musculophrenic aa.

Superior epigastric aa.


Transversus abdominis m.
and aponeurosis
Anastomoses with lower intercostal, Rectus abdominis mm.
subcostal, and lumbar aa.

External abdominal oblique m.

Transversus abdominis m.
Posterior layer of rectus sheath

Ascending branch of deep circumflex iliac a.

Arcuate line

Inferior epigastric a.
Superficial circumflex iliac a.
Superficial epigastric a.

Superficial circumflex iliac a.

FIGURE 4.5 Arteries of Anterolateral Abdominal Wall. (From Atlas of human anatomy, ed 7,
Plate 258.)

• Supericial circumlex iliac: arises from the • Lumbar nodes: deep drainage internally to the
femoral artery and anastomoses with the deep nodes along the abdominal aorta.
circumlex iliac artery. • External iliac nodes: deep drainage along the
• Supericial epigastric: arises from the femoral external iliac vessels.
artery and courses toward the umbilicus.
• External pudendal: arises from the femoral 4. INGUINAL REGION
artery and courses toward the pubis.
Supericial and deeper veins accompany these he inguinal region, or groin, is the transition zone
arteries, but, as elsewhere in the body, they form between the lower abdomen and the upper thigh.
extensive anastomoses with each other to facilitate his region, especially in males, is characterized
venous return to the heart (Fig. 4.6 and Table 4.4). by a weakened area of the lower abdominal wall
Lymphatic drainage of the abdominal wall paral- that renders this region particularly susceptible to
lels the venous drainage, with the lymph ultimately inguinal hernias. Although occurring in either
coursing to the following lymph node collections: gender, inguinal hernias are much more common
(see Fig. 4.41). in males because of the descent of the testes into
• Axillary nodes: supericial drainage above the the scrotum, which occurs along this boundary
umbilicus. region.
• Supericial inguinal nodes: supericial drainage he inguinal region is demarcated by the ingui-
below the umbilicus. nal ligament, the inferior border of the external
• Parasternal nodes: deep drainage along the abdominal oblique aponeurosis, which is folded
internal thoracic vessels. under on itself and attaches to the anterior superior

Chapter 4 Abdomen 163 4
Subclavian v. Cephalic v.

Axillary v.

Lateral thoracic v. Axillary v.

Anterior intercostal vv. Lateral thoracic v.

Internal thoracic v.

Superior epigastric vv.

Thoracoepigastric v.
Note: The left side of the body Thoracoepigastric v.
shows the veins in the superficial
fascia while the right side shows
a deeper dissection.
Paraumbilical vv. in round ligament of liver Tributaries of paraumbilical vv.
Inferior epigastric vv.

Tributaries to deep circumflex iliac vv.

Superficial epigastric v.
Superficial circumflex iliac v.
Superficial circumflex iliac v.

Superficial epigastric v.

FIGURE 4.6 Veins of Anterolateral Abdominal Wall. (From Atlas of human anatomy, ed 7, Plate 259.)

TABLE 4.4 Principal Veins of ligament but deep to it and reinforces the medial
Anterolateral Abdominal Wall portion of the inguinal canal.
Inguinal Canal
Superficial epigastric Drains into femoral vein
Superficial Drains into femoral vein and he gonads in both genders initially develop retro-
circumflex iliac parallels inguinal ligament peritoneally from a mass of intermediate mesoderm
Inferior epigastric Drains into external iliac called the urogenital ridge. As the gonads begin
Superior epigastric Drains into internal thoracic to descend toward the pelvis, a peritoneal pouch
vein called the processus vaginalis extends through
Thoracoepigastric Anastomoses between the various layers of the anterior abdominal wall
superficial epigastric and
lateral thoracic and acquires a covering from each layer, except
Lateral thoracic Drains into axillary vein for the transversus abdominis muscle because
the pouch passes beneath this muscle layer. he
processus vaginalis and its coverings form the fetal
iliac spine and extends inferomedially to attach to inguinal canal, a tunnel or passageway through
the pubic tubercle (see Figs. 4.1 and 4.3, B and C). the anterior abdominal wall. In females the ovaries
Medially, the inguinal ligament lares into the are attached to the gubernaculum, the other end
crescent-shaped lacunar ligament that attaches of which terminates in the labioscrotal swellings
to the pecten pubis of the pubic bone (Fig. 4.7). (which will form the labia majora in females or
Fibers from the lacunar ligament also course the scrotum in males). he ovaries descend into
internally along the pelvic brim as the pectineal the pelvis, where they remain, tethered between the
ligament (see Clinical Focus 4-2). A thickened lateral pelvic wall and the uterus medially (by the
inferior margin of the transversalis fascia, called ovarian ligament, a derivative of the gubernaculum).
the iliopubic tract, runs parallel to the inguinal he gubernaculum then relects of the uterus

164 Chapter 4 Abdomen

Clinical Focus 4-1

Abdominal Wall Hernias
Abdominal wall hernias often are called ventral hernias to distinguish them from inguinal hernias. However,
all are technically abdominal wall hernias. Other than inguinal hernias, which are discussed separately, the
most common types of abdominal hernias include:
• Umbilical hernia: usually seen up to age 3 years and after 40.
• Linea alba hernia: often seen in the epigastric region and more common in males; rarely contains
visceral structures (e.g., bowel).
• Linea semilunaris (spigelian) hernia: usually occurs in midlife and develops slowly.
• Incisional hernia: occurs at the site of a previous laparotomy scar.

Hernia of linea alba

Umbilical hernia

Hernia at linea semilunaris

(spigelian hernia)

Incisional hernia (postoperative scar hernia)

External abdominal oblique muscle

and aponeurosis
Anterior superior iliac spine Transversalis fascia within
Internal abdominal oblique inguinal triangle (site of direct
muscle (cut and reflected) inguinal hernia)
Transversus abdominis muscle
Inguinal falx (conjoint tendon)
Deep inguinal ring (in transversalis fascia)
Cremaster muscle (lateral origin)
Inferior epigastric vessels Reflected inguinal ligament
(deep to transversalis fascia)
Inguinal ligament (Poupart’s) Intercrural fibers

Lacunar ligament (Gimbernat’s) External spermatic fascia on

spermatic cord exiting
Superficial inguinal ring
Superficial inguinal ring

Pubic crest
Anterior view
FIGURE 4.7 Adult Inguinal Canal and Retracted Spermatic Cord. (From Atlas of human anatomy,
ed 7, Plate 262.)

Chapter 4 Abdomen 165 4
11 weeks
(43-mm crown-rump)
Suprarenal gland

8-9 lunar months
Suspensory (26-cm crown-rump)
ligament (atrophic)


Gubernaculum Superficial inguinal ring

Deep inguinal ring Ductus deferens

Urinary bladder Scrotum (cut open)


Cavity of tunica
vaginalis (cut open)
FIGURE 4.8 Fetal Descent of Testes.

as the round ligament of the uterus, passes suspends the testis. In females the only structure
through the inguinal canal, and ends as a ibrofatty in the inguinal canal is the ibrofatty remnant of
mass in the future labia majora. the round ligament of the uterus, which terminates
In males the testes descend into the pelvis but in the labia majora. he contents in the spermatic
then continue their descent through the inguinal cord include the following (Fig. 4.9):
canal (formed by the processus vaginalis) and into • Ductus (vas) deferens.
the scrotum, which is the male homologue of the • Testicular artery, artery of the ductus deferens,
female labia majora (Fig. 4.8). his descent through and cremasteric artery.
the inguinal canal occurs around the 26th week • Pampiniform plexus of veins (testicular veins).
of development, usually over several days. he • Autonomic nerve ibers (sympathetic eferents
gubernaculum, which guides the descent of the and visceral aferents) coursing on the arteries
testis into the scrotum, terminates in the scrotum and ductus deferens.
and anchors the testis to the loor of the scrotum. • Genital branch of the genitofemoral nerve
A small pouch of the processus vaginalis called (innervates the cremaster muscle via L1-L2).
the tunica vaginalis persists and partially envelops • Lymphatics.
the testis. In both genders the processus vaginalis Layers of the spermatic cord include the follow-
normally seals itself and is obliterated. Sometimes ing (see Fig. 4.9):
this fusion does not occur or is incomplete, espe- • External spermatic fascia: derived from the
cially in males, probably caused by descent of the external abdominal oblique aponeurosis.
testes through the inguinal canal. Consequently, a • Cremasteric (middle spermatic) fascia: derived
weakness may persist in the abdominal wall that from the internal abdominal oblique muscle.
can lead to inguinal hernias (see Clinical Focus 4-2). • Internal spermatic fascia: derived from the
As the testes descend, they bring their accom- transversalis fascia.
panying spermatic cord along with them and, as he features of the inguinal canal include its
these structures pass through the inguinal canal, anatomical boundaries, as shown in Fig. 4.10 and
they too become ensheathed within the layers of summarized in Table 4.5. Note that the deep
the anterior abdominal wall (Fig. 4.9). he spermatic inguinal ring begins internally as an outpouching
cord enters the inguinal canal at the deep inguinal of the transversalis fascia lateral to the inferior
ring (an outpouching in the transversalis fascia epigastric vessels, and that the supericial inguinal
lateral to the inferior epigastric vessels) and exits ring is the opening in the aponeurosis of the
the 4-cm-long canal via the supericial inguinal external abdominal oblique muscle. Aponeurotic
ring before passing into the scrotum, where it ibers at the supericial ring envelop the emerging

166 Chapter 4 Abdomen

Superficial inguinal ring

Testicular a.

Ductus deferens
External spermatic fascia Artery to ductus deferens

Genital branch of genitofemoral n.

Cremaster m. and fascia
Pampiniform (venous) plexus
Septum of scrotum (formed by dartos fascia)
Epididymis (head)
Dartos fascia of scrotum

Skin of scrotum
Testis (covered by visceral
Note: The dissection on the right side of layer of tunica vaginalis testis)
the body shows the external and cremasteric
fascial coverings of the cord and testis, while
Parietal layer of tunica vaginalis testis
the dissection on the left shows the contents
of the spermatic cord once its layers have
been opened.

FIGURE 4.9 Layers of Spermatic Cord and Contents. (From Atlas of human anatomy, ed 7, Plate 369.)

Testicular vessels covered by peritoneum

Extraperitoneal fascia
External iliac vessels covered by peritoneum Peritoneum (loose connective tissue)

External abdominal
oblique m.
Ductus deferens covered by peritoneum Internal abdominal
Ductus deferens oblique m.
Transversalis fascia
Inferior epigastric vessels
Transversus abdominis m.

Urinary bladder Anterior superior iliac spine

Testicular vessels and genital

branch of genitofemoral n.

Origin of internal spermatic fascia from

transversalis fascia at deep inguinal ring

Inguinal falx