INTRODUCTION

Heather Silverstein & Nisarg Shah (ns1251@mynsu.nova.edu)

 HOW TO BE SUCCESSFUL IN THIS
COURSE

• Go to class or watch the lectures

• Try to keep up with the material!
• Learn the basics first… Anatomy builds on itself
• If you haven’t taken anatomy before, DON’T FREAK OUT!
• Reach out for help if you need it, that’s what the fellows are for!
• COMPLETE ANATOMY IS YOUR BFF!
• Look up structures stressed in lecture to be able to visualize
 SECTIONS

• Longitudinal
• Transverse
• Oblique
 ANATOMICAL POSITION

• Standing erect or lying supine

• Head, eyes, toes directed forward
• Hands by side with palms facing forward
• Feet apart with toes facing forward
 LITHOTOMY POSITION

• Ankles in stirrups
• Hips and knees flexed
• Legs apart
• Used to examine genitalia, can see entire perineum
 ANATOMICAL PLANES

• Median (midsagittal)
• Sagittal (parallel to median)
• Coronal (frontal)
• Horizontal (transverse)
 TERMS OF RELATIONSHIP &
COMPARISONS

• Anterior vs posterior
• Inferior (caudal) vs superior (cranial)
• Medial vs lateral
• Proximal vs distal
• Superficial vs intermediate vs deep
 MOVEMENTS

• Extension, flexion (knee, wrist, hip)

• ABduction, aDduction (shoulder, hip, wrist, fingers)
• Elevation, depression (temporomandibular joint)
• Protraction, retraction (temporomandibular joint)
• Inversion, eversion (intertarsal)
• Dorsiflexion, plantar flexion (ankle)
• Pronation, supination (radioulnar joint)
• Medial, lateral (shoulder)
• Circumduction (shoulder, hip)
IMAGINARY
LINES
 SKIN – SURFACE LINES

• Tension lines aka LANGER’S lines; lines of

cleavage
• Friction lines - palms & soles
• Flexure lines – over joints
 DERMATOMES

• Area of skin supplied by the sensory fibers of a single dorsal root through the
dorsal and ventral rami of its spinal nerve
• Segmental
• Adjacent dermatomes overlap
• Helps determine whether segments of spinal cord are functioning properly
• THREE contiguous spinal nerves need to be blocked for proper anesthesia
of skin segment (block above & below)
 DERMATOMES

• T4: nipple
• T10: naval (umbilicus)
• T12: above pubis
• L5: hallux (big toe)
• C7: middle finger
• C8: little finger
 HERPES ZOSTER
ACUTE POSTERIOR GANGLIONITIS

• Acute CNS infection of DRG

• Vesicular eruption & neurologic pain in cutaneous areas supplied by
peripheral sensory nerves arising in afferent root ganglia
• Etiology: varicella-zoster virus
 FASCIA
SUPERFICIAL VS DEEP

• Superficial
• Loose connective tissue & fat
• Between dermis & deep fascia
• Contains sweat glands, blood,
lymph, cutaneous nerves
• Deep
• Dense, more organized
• Invests deep structures (muscle)
• Sends radial projections to deeper
structures & bones forming
compartmentsà compartment
syndrome
 SOME ADVICE FROM A 3 RD YEAR:

• How to succeed in Medical School:

• Take care of your mental health.
• Study ahead of time and study the RIGHT MATERIAL*** à (make smart friends/talk to mentors).
• “Grades don’t matter, but knowledge does”…… do YOUR BEST in every course and it will be less stress when reviewing for boards. Look good when getting
pimped on rotations.
• Best way to succeed in Anatomy is to MEMORIZE.
• Simple course but time consuming (6.5 credits)
• Go to Study tables/SOSA reviews and get help from Anatomy Fellows.

• Stick with the material the professor gives you. That is where the TQs come from.
• Don’t drown yourself in excess resources
• Use Complete Anatomy!

• Need 4 things for Anatomy portion of Integrated #1:

• Introduction ppt.,
• Back, Vertebral Column and Spinal Cord (Dr. Khanna) ppt.

• Radiology Folder “Spine and Vertebral Column.”

• Complete Anatomy Folder “Back and Spinal Cord.”
 THE BACK

Back extends from the base of the skull to the posterior aspect of the sacrococcygeal column
 OF THE 4 LAYERS OF B ACK MUSCLES, WHICH
LAYER CONTAINS THE LEVATOR SCAPULAE?

a. 1st layer
b. 2nd layer
c. 3rd layer
d. 4th layer
 LANDMARKS
POSTERIOR SUPERIOR ILIAC SPINE

• Skin dimple associated with the PSIS à common site for bone marrow biopsy
 BACK
1st Layer:
• Trapezius and latissimus dorsi
2nd layer:
• Levator Scapulae
• Rhomboids major and minor
• Serratus posterior superior and inferior
3rd Layer:
• Erector spinae (sacropinalis) & Semispinalis
4th layer:
• Suboccipital triangle and the rest
 WHICH NERVE(S) INNERVATES THE
TRAPEZIUS?

a. Accessory nerve, C4 and C5

b. Supraspinatus nerve
c. Accessory nerve, C3 and C4
d. Thoracodorsal nerve
 TRAPEZIUS

O: Ligamentum nuchae and spines of all cervical

and thoracic vertebrae. External occipital
protuberance and medial part of superior nuchal line.
I: lateral 1/3 of clavicle, medial acromion
N: Spinal part of accessory cranial nerve (CN
XI), C3 and C4.
A: shrugs (up and down) and retractions.
 TRAPEZIUS ACTIONS** à ELEVATES THE
SHOULDERS AND PULL SCAPULA BACK.

• Upper fibers: elevate the shoulder

• Middle fibers: brace back (retraction) of shoulder
• Lower fibers: depress the shoulder.
• It also, helps in raising the arm above 90° with (serratus anterior).
 LATISSIMUS DORSI

O: Thoracolumbar fascia (latissimus dorsi,

internal oblique, and transversus abdominus)
I: Floor of the bicipital groove
N: Nerve to latissimus dorsi (thoracodorsal
nerve (C6-C8).
A: PULL things close to body
• Adduction of and medial rotation of arms
• Climb (lat pull downs)
• Extension of UE
 TRUE OR FALSE: LEVATOR
SCAPULAE AND RHOMBOIDS
ALL HAVE SAME EXACT
INNERVATIONS?
WHAT’S THE DIFFERENCE
BETWEEN PARALYSIS AND
PARESIS?
 LEVATOR SCAPULAE
AND RHOMBOIDS M
&M.
Levator scapulae:
• Innervated by C3, C4, and C5.
• Origin from C1-C4 transverse process
• Action: elevate scapulae
Rhomboids M & m:
• Innervated by C4 and C5 ONLY.
• Origin from ligamentum nuchae C7-T1 for rhomboid
minor and spinous process T2-T5 for major.
• Action: retract, stabilize, and raise medial border of
scapulae.
All three muscles are inserted at medial border of
scapula and raise scapula.
 WHAT LINES THE MEDIAL BORDER OF
THE TRIANGLE OF AUSCULTATION?

a. Latissimus dorsi
b. Scapula
c. Rhomboid major
d. Lateral border of Trapezius
 SPECIAL AREAS

• Throughout this course you will encounter “Special Area” that have clinical implications
and are used for localizing neurovascular bundles.
• Triangle of Auscultation (lung sounds)
• Femoral triangle – Not on exam (central line, pulsation)
• Triangular and quadrangular spaces of upper extremity – Not on exam (injection precaution,
fracture risks).
• Best to draw them out, know the borders, and know their contents.
SPECIAL AREAS –
TRIANGLE OF
AUSCULTATION
 INTRINSIC MUSCLES =
SPINOTRANSVERSALES = SUPERFICIAL
LAYER
• Intrinsic muscle layers: (superficial to deep)
• Spinotransversales
• Erector Spinae (Sacrospinalis)
• Transversospinales

• The spinotransversales layer consists of splenius capitus and splenius cervicis.

• Extrinsic muscles: trapezius, latissimus, levator scapulae, and rhomboids
 INTRINSIC MUSCLES =
ERECTOR SPINAE
(SACROSPINALIS) =
INTERMEDIATE LAYER.
• Extrinsic muscles: trapezius, latissimus, levator scapulae, and rhomboids.
• Intrinsic muscles of the back: ”I Love Spaghetti.” From lateral to medial
• Iliocostalis – lateral column
• Longissimus – intermediate column
• Spinalis – medial column
• Each of these muscles have three parts from cephalad to caudal.
• Iliocostalis cervicis (superior), iliocostalis thoracis (middle), and iliocostalis inferior
(inferior).
• Longissimus thoracis, longissimus cervicis, and longissimus capitis.
• Spinalis thoracis, spinalis cervicis, and spinalis capitis.
A: Extends, rotates
and laterally flexes
head, neck, and trunk.

I: Posterior rami of
cervical, thoracic, and
lumbar.
 INTRINSIC MUSCLES =
TRANSVERSOSPINALIS = DEEP LAYER

• Transversospinalis are DEEP LAYER of the intrinsic muscles of the back.

• Underneath the erector spinae (sacrospinalis).
• From superficial to deep, the transversospinalis muscles are:
• Semispinalis: in the neck region (not to be confused with Splenius)
• Semispinalis capitis, semispinalis cervicis, and semispinalis thoracis.
• Multifidus: Most robust in lumbar area
• Rotatores: Short and long
• Minor DEEP intrinsic muscles: Low yield
• Interspinales
• Intertranversari
• Levatores costarum
Levator Costorum muscles:
O: From C7 – T11 “7/11”
I: Superior surface of rib immediately below vertebrae.
A: fibers contract to elevate rib cage
N: C8-T11
 WHAT ARTERY IS FOUND WITHIN THE
SUBOCCIPITAL TRIANGLE?

a. Suprorbital artery
b. Anterior cervical artery
c. Vertebral artery
d. Middle meningeal artery
 SUBOCCIPITAL TRIANGLE *TQ*

• Must know all muscles:

• Rectus capitis MINOR
• Rectus capitis MAJOR: medial border
• Obliquus capitis SUPERIOR: lateral border
• Obliquus capitis INFERIOR (only one that does rotation):
inferior border
• ROOF: Semispinalis capitis and longissimus capitis
• FLOOR: Posterior arch of atlas and posterior AO joint
membrane
• CONTENT:
• Vertebral artery
• Suboccipital nerve C1
• Greater occipital RUNS OVER the triangle and is NOT
within the triangle.
• Suboccipital venous plexus
 WHICH NERVE SUPPLIES THE
SUBOCCIPITAL TRIANGLE MUSCLES?

a. Thoracodorsal nerve
b. Accessory nerve
c. Greater occipital nerve
d. Suboccipital nerve (C1 dorsal ramus)
• Must know that the suboccipital
nerve has the vertebral artery
above and the posterior arch of
atlas below.
• Sandwich in between.

• Must know that cruciate ligament:

• Can rupture from trauma
• Can rupture during extension of neck
in patients with rheumatoid arthritis
(caution during intubation).
 CERVICAL JOINTS

• C1 = Atlas
• “T comes before X”
• C2 = Axis (odontoid process); bifid spinous process
• AO = C1 + Occipital bone
• Flexion, extension, and lateral flexion of head
• AA = C1 + C2
• ROTATION ONLY (OPP)
• C3-C7: Typical cervical vertebrae
• Bifid spinous process; C7 most prominent spinous process, attaches to ligamentous nuchae.
• ALL HAVE TRANSVERSE FORAMINAE à vertebral artery.
 WHICH VERTEBRAL CURVATURES ARE FORMED IN
FETAL PERIOD THAT PERSIST IN ADULTHOOD?

a. Thoracic only
b. Sacral only
c. Thoracic and sacral
d. Lumbar and cervical
 VERTEBRAL COLUMN

• 33 bones in infancy
• 26 bones in adulthood: Sacrum and coccyx are fused
• Curvatures: NAMED BASED ON ANTERIOR CURVE
• Lordosis: anterior convexity
• Cervical and lumbar. Seen in newborns.
• Kyphosis anterior concavity
• Thoracic (humpback) and sacral. Seen in fetal
period that persists in adulthood.
Cervical – Lordosis à anterior
Thoracic – Kyphosis à posterior
Lumbar – Lordosis (L with L) à anterior
Sacral – Kyphosis à posterior
 VERTEBRAL COLUMN

• As you go down the spine the vertebral body size increases.

• Herniation is most common at L4-L5 (L5 nerve) and C6-C7 (C7 nerve).
• Discs are typically shock absorbers; compressed with age à get shorter
• You have to know the anatomy of the vertebrae:
• Spinous process
• Transverse process and transverse foraminae (cervicals only)
• Vertebral arch: Lamina vs. pedicle
• Body
• Vertebral foramen
• FACETS: orientation changes as you go down the spine
 SUPERIOR FACET ORIENTATION

• Not sure how HY, but was mentioned in lecture.

• Orientation of superior facet changes as you go down the spine:
• Cervical: Backwards, upward, medial BUM à Horizontal plane (Rotation >
Flex/extend/sidebending)
• Thoracic: Backwards, upward, lateral BUL à Frontal plane (Rotation mostly)
• Lumbar: Backwards medial BM à Sagittal plane (Flexion and extension mostly)
 VERTEBRAL COLUMN

• C-spine: Discussed earlier Thoracic Vertebrae

• T-spine:
• T12 is the landmark for the last rib attachment.
• The first nine thoracic vertebrae (T1 through T9) contain
a pair of demi-facets, where a facet is split between two
adjacent vertebral bodies.
• Meanwhile, the first, tenth, eleventh, and twelfth (T1, T10,
T11 and T12) vertebrae all contain a pair of full facets on
their vertebral bodies to support ribs.
• Ribs 1, 10, 11, and 12 thus attach to a single vertebrae.
 VERTEBRAL COLUMN

• L-spine:
• Look for last rib on X-ray. That will be landmark for T12. Count
downwards for lumbar vertebrae (remember to study X-rays** (easy
points on exam)
• Sacrum: S1-S5 fused
• Sacral ala = wings
• Base of the sacrum
• Sacral promontory
• Sacral foramina on the sides bilaterally
• Sacral hiatus: Epidural anesthesia by injecting between the lumbar
laminae or the sacral hiatus
 JOINTS OF VERTEBRAL COLUMN

• Vertebral arches – all synovial, which means there is a joint cavity and bones
are united by articular capsule and ligaments (knee and hip joints)
• AO joint: Synovial as well; occipital condyle (lower part of occipital bone) and
C1. Nodding and sideways movement
• AA joint:
• Two lateral joints à plane and gliding joints
• One median joint à pivot
• Costo-vertebral: Synovial joint between head of ribs and vertebrae.
• Costo-transverse: Synovial between the ribs and transverse process.
A PATIENT 2 WEEKS POST MVA HAS A RUPTURED
INTERVERTEBRAL DISC ON MRI THAT'S
COMPRESSING A NERVE EXITING BETWEEN THE
5 TH AND 6 TH CERVICAL VERTEBRAE. WHICH
NERVE IS AFFECTED AND THROUGH WHICH
STRUCTURE DOES THIS NERVE EXIT?

a. C5; Foramen magnum

b. C6; Intervertebral foramen
c. C5; Intervertebral foramen
d. C6; Transverse foraminae
 DISC HERNIATION

• Intervertebral disc is made of central nucleus pulposus surrounded by

anulus fibrosus.
• Cervical spine compression:
• 8 nerves and 7 vertebrae.
• C1 spinal nerve is on top of C1 vertebrae. C8 spinal nerve is below C7
vertebrae.
• Cervical disc herniation compresses the one below. JUST KNOW that in C-
spine nerves comes out above the vertebrae of the same number.
 INTERVERTEBRAL DISC-
HERNIATIONS

• - Nucleus pulposus herniates out of the

anulus fibrosus
• - Most common between L4-L5, L5-S1,
and C6-C7
• - Herniations always affect the nerve
BELOW
• - Nerves exit sideways through the
intervertebral foramen
• - Herniations are most commonly
POSTERIOR and LATERAL
 A 5 0 Y / O M A L E P R E S E N T S W I T H S H O OT I N G PA I N D OW N H I S
L E F T L E G A N D C O M P L A I N S O F L E F T L OW E R B AC K PA I N . H E
WA S I N VO LV E D I N A N M VA 3 DAYS AG O W I T H I N I T I A L
I M AG I N G I N E R Y I E L D I N G N E G AT I V E R E S U LT S . YO U S E N D H I M
O U T F O R M R I A N D T H E I M P R E S S I O N S TAT E S A H E H A S A
H E R N I AT E D D I S K B E T W E E N 4 T H A N D 5 T H L U M B A R V E RT E B R A E .
W H I C H S P I N A L N E RV E D O YO U S U S P E C T I S I M P I N G E D ?

a. S1 only
b. L5 only
c. L4 only
d. L4 and possibly L5.
 LIGAMENTS

• Anterior/Posterior Longitudinal Ligaments

• Supraspinous/Interspinous Ligaments
• Ligamentum Flavum
 LIGAMENTS:
A NTERI OR/ POSTERI OR LO NG IT U DINA L LIG A M ENTS

LIGAMENTUM
FLAVUM
POSTERIOR
LONGITUDINAL
LIGAMENT

INTERVERTEBRAL
FORAMEN
SUPRASPINOUS ANTERIOR
LIGAMENT LONGITUDINAL
LIGAMENT
INTERSPINOUS
LIGAMENT
 LIGAMENTS:
SUPRASPINOUS/INTERSPINOUS LIGAMENTS
L I G A M E N T U M F L AV U M

LIGAMENTUM FLAVUM

COSTOTRANSVERSE
LIGAMENT LIGAMENTUM
FLAVUM
POSTERIOR
INTESPINOUS LONGITUDINAL
LIGAMENT
COSTOTRANSVERSE
LIGAMENT
LIGAMENT

INTERVERTEBRA
ZYGAPOHYSEAL FORAMEN
LIGAMENT SUPRASPINOUS ANTERIOR
LIGAMENT LONGITUDINAL
LIGAMENT
INTERSPINOUS
LIGAMENT
 LIGAMENTS

• Anterior Longitudinal Ligament: prevents HYPEREXTENSION

• Posterior Longitudinal Ligament: prevents forward HYPERFLEXION
• Supraspinous Ligament: prevents HYPERFLEXION

LIGAMENTUM
FLAVUM
POSTERIOR
LONGITUDINAL
LIGAMENT

INTERVERTEBRAL
FORAMEN
SUPRASPINOUS ANTERIOR
LIGAMENT LONGITUDINAL
LIGAMENT
INTERSPINOUS
LIGAMENT

ZYGAPOPHYSEAL JOINT