Posterior Cervical Anatomy and Surgical

Approaches
SANJAY N. MISRA

Highlights
An understanding of the musculoskeletal anatomy of the posterior cervical spine is a requisite for successful instrumentation of
the posterior cervical spine. An understanding of the neurovascular structures encountered in posterior cervical spine
instrumentation is equally important. This chapter describes the posterior cervical anatomy from the suboccipital region to the
seventh cervical vertebrae. The description is separated into a consideration of the fascial and skeletal structural anatomy
followed by a description of the muscles and the relevant neurovascular structures of the posterior cervical spine.
Posterior Cervical Fascia
The posterior cervical fascia is contiguous with the fascial layer that forms the circumferential fascia enclosing the neck. It is
divided into superficial and deep layers. The superficial layer consists of loose connective tissue, which lies immediately below
the dermal layer. The superficial lamina of the deep cervical fascia attaches in the posterior midline to the ligamentum nuchae. It
divides to enclose the trapezius, continues forward to cover the posterior triangle of the neck, and then divides to enclose the
sternocleidomastoid muscle. The deep lamina of the deep cervical fascia is a thick fibrous layer attached superiorly to the
superior nuchal line, mastoid process, zygomatic arch, styloid process, and mandible. It is attached inferiorly to the spine and
acromion of the scapula, clavicle, and sternum. Its inferior attachment extends to the upper thoracic spinous processes and the
supraspinous ligaments. It is continuous laterally with the deep fasciae of the axillae and thorax.1
Posterior Cervical Osseous Anatomy
The osseous structures whose anatomy must be considered in approaches for the instrumentation of the posterior cervical spine
are the occipital bone, atlas, axis, and remaining five cervical vertebrae.
Occipital Bone
The squamous component of the occipital bone is located superior and posterior to the foramen magnum. The condyles of the
squamous bone are located lateral to the foramen magnum. The surface of the occipital bone is irregular and gives attachment to
the posterior muscles of the neck. The external occipital protuberance (inion) is immediately inferior to the internal occipital
protuberance and the torcular Herophili. The superior nuchal line extends laterally from this midline point. The external occipital
crest is a vertical ridge between the external occipital protuberance and the foramen magnum. The inferior nuchal line extends
laterally from the midpoint of the external occipital crest. The occipital condyles, which articulate with the atlas, are located
lateral to the foramen magnum and anterior to a line bisecting the foramen magnum.
Cervical Vertebrae
The cervical spine has a normal lordosis, which is due to perceptible anterior convexity of the cervical vertebral sagittal
alignment The spinous processes of C2, C3, and C4 are bifid. C6 is frequently bifid, but it is less prominent and narrower than
the spinous process of C7. C7 is generally not bifid and is more prominent than T1. The facet joints can be approximated two
fingerbreadths lateral to the midline spinous processes.
The Typical Cervical Vertebra
(Figs. 39–1 to 39–4)
There are four “typical” cervical vertebrae, C3–C6. The pedicle is attached on the body. The transverse process is attached to the
pedicle and body, and it possesses the foramen transversarium. A posterior bony projection of the pedicle posterior to the
foramen is the posterior tubercle. The anterior bony projection anterior to the foramen tranversarium is the anterior tubercle. The
anterior and posterior tubercles are connected by the intertubercular lamella. The vertebral artery traverses the foramen
transversarium. The laminae enclose the vertebral foramen. They are grooved for the attachment of the ligamenta flava (the deep
surface of the superior lamina and the superficial surface of the inferior lamina). At the junction of pedicle and lamina arise the
superior and inferior articular processes. The two processes form a cylindrical column for the articular facets. The superior facets
project obliquely posterosuperiorly and are both in the same horizontal plane. The lower facets project anteroinferiorly. The
articular capsule and synovial membrane of these joints are attached to the articular margins. The spinous process is bifid and
has a concavity inferiorly for the attachment of the semispinalis cervicis muscles. The anterior limit of the cervical neural
foramen, from rostral to caudal, is the posterolateral cortical margin of the superior vertebral body and the intervertebral disk.
The neural foramen is bounded posteriorly by 1 to 2 mm of the superior articular facet and the ventral surface of the inferior
articular facet. The superior and inferior limits of the neural foramen are formed by the superior and inferior vertebral pedicles.
Atypical Cervical Vertebrae
The atypical vertebrae are the C7, atlas (C1), and axis (C2).
C7 (Seventh Cervical Vertebra)
The C7 vertebra is atypical in that its spine is prominent and is not bifid, and its foramen transversarium is not traversed by the
vertebral artery. The foramen is rudimentary and contains the posterior vertebral vein. The prominence of the tip of the spinous
process gives the name vertebra prominens to C7.

FIGURE 39–1 Typical cervical vertebra. (A) vertebral body, (B) anterior tubercle, (C) foramen transversarium, (D) intertubercullar
lamella, (E) posterior tubercle, (F) pedicle, (G) lateral mass, (H) lamina
FIGURE 39–2 Posterior surface anatomy of typical cervical vertebra. (A) lateral mass, (B) lamina, (C) inferior articular process, (D)
superior articular process, (E) bifid spinous process, (F) transverse process of C5, (G) transverse process of C6.

FIGURE 39–3 Posterolateral view of the cervical vertebral anatomy. (A) lateral mass, (B) inferior articular process, (C) superior
articular process, (D) spinous process, (E) interlaminar space, (F) transverse process of C5, (G) transverse process of C6, (H)
nonbifid spinous process of C7. The vertebral artery (V2) passes between the transverse processes of C6 and C5 and occupies
this location up to the level of C2.
FIGURE 39–4 Articular anatomy of the cervical facet joints. (A) inferior articular facet, (B) superior articular facet, (C) central lateral
mass deep to midpoint of the lateral mass. Note the trajectory of the cervical facet joints in the sagittal plane.

Atlas (First Cervical Vertebra, C1)

(Fig. 39–5)
The atlas is ring shaped and lacks both a vertebral body and a spinous process. The lateral masses are connected posteriorly by
an arch with a median posterior tubercle and a groove on the lateral posterosuperior surface traversed by the vertebral artery.
This osseous groove may be partly or fully covered by bone from the posterior edge of the superior articular facet of the atlas to
the posterior arch. The inferior surface may also have an osseous groove for the posterior root ganglion of the C2 nerve. The
superior margin of the posterior arch gives attachment to the posterior atlanto-occipital membrane between the arterial grooves,
and the inferior margin is the attachment for the ligamentum flavum passing superiorly from the axis. The superior surface of the
lateral mass has an oval concave facet with a superomedial projection articulating with the inferolaterally projecting occipital
condyles of the squamous bone. The inferior surface of the lateral masses has a flat or slightly concave facet with a
posteroinferomedial projection for the lateral altantoaxial joint. The lateral masses project laterally as the transverse process,
which is perforated by the foramen transversarium. The C1 transverse processes are the most prominent of the cervical vertebra.

FIGURE 39–5 First cervical vertebra (C1). (A) posterior

tubercle of the posterior arch, (B) lamina (posterior arch),
(C) groove for the horizontal segment of the third segment
of the vertebral artery (V3), (D) foramen transversarium,
(E) transverse process, (F) odontoid process of C2.
FIGURE 39–6 Second cervical vertebrae (C2). (A) vertebral body, (B) foramen transversarium, (C) pedicle, (D) pars
interarticularis.

Axis (Second Cervical Vertebra, C2)

(Figs. 39–6 and 39–7)
The lateral facets extend laterally from the body onto the adjoining parts of the pedicles and articulate superiorly with the
inferior facets of the first cervical vertebra.

The superior facets do not form an articular pillar with the inferior facets but are anterior to the latter. The laminae are thicker
than those of other cervical vertebrae, the pedicles are stout, and the spinous process is large and bifid. The transverse processes
are small. The foramen transversarium is directed superolaterally to accommodate a lateral deviation of the vertebral artery on its
path to the foramen transversarium of the atlas. The inferior articular facets are situated at the junction of the pedicles and
laminae and project anteroinferiorly as in typical cervical vertebrae. The inferior articulation of the axis with C3 is identical to
the articulations of typical cervical vertebrae. The pars articularis is the area of bone intervening between the superior and
inferior facets of the axis. The pedicle of C2 connects the pars to the vertebral body and has a trajectory parallel to its spinous
process. The pair of semispinalis cervicis muscles are inserted into the concavity of the spinous process, whereas the rectus
capitis posterior major and the inferior oblique diverge widely from the outer surface on either side. The superior and inferior
margins of the laminae are the attachment for the ligamentum flavum. Multifidus and longissimus muscles attach to the posterior
surface of the laminae. The atlanto-occipital and the atlantoaxial joints provide a wide range for head motion, the former for
forward and lateral flexion, the latter for rotation. The articular surfaces determine the direction of motion. 2–5
Atlantoaxial Joints (Fig. 39–8)
The atlantoaxial facet joints are horizontal and do not possess an intervertebral disk. Stability is provided by the ligaments of the
articulation, the ligamentum flavum, and the supraspinous ligament. The capsule attaches into the ligamentum flavum.
The atlas and the occipital bone are connected by then articular capsules surrounding the atlanto-occipital joints and by the
anterior and posterior atlanto-occipital membranes.
The posterior atlanto-occipital membrane is attached to the posterior margin of the foramen magnum and to the superior margin
of the posterior arch of the atlas. The lateral border of the membrane is unattached and arches behind the vertebral artery and the
first cervical nerve root. The lateral edge of this membrane may be ossified in the area where it arches over the posterior aspect
of the vertebral artery, forming a partial or complete osseous foramen for the artery on the medial aspect of the atlanto-occipital
joint. Joints between vertebral articular processes (zygapophyses) are synovial, and the laminae, spines, and transverse processes
are connected through syndesmoses consisting of the ligamenta flava; interspinous, supraspinous, and intertransverse ligaments;
and the ligamentum nuchae.
FIGURE 39–7 Sagittal suboccipital articular anatomy. (A) occipital condyle of squamous part of the occipital bone, (B) articular
mass of C1, (C) atlanto-occipital joint, (D) vertebral artery, (E) articular surface of C2, (F) pars interarticularis.

FIGURE 39–8 Anterior view of the atlantoaxial articulations.

(A) transverse process of C1 with its foramen transversarium,
(B) superior articular facet of C1, (C) inferior articular facet of C1, (D) transverse process of C2. This demonstrates the relatively
lateral portion of the foramen transversarium of C1 relative to C2 and the lateral location of the vertical segment of V3.

Zygapophyseal Joints
These joints are simple synovial articulations. They are the articulations between adjacent cervical vertebrae below C2 (between
the articular facets of the interior articular processes of one vertebra and the superior articular facets of the inferior vertebra). The
articular surfaces are covered by hyaline cartilage. The articular capsules are thin and loose and attached to the articular facets of
the adjacent zygapophyseal joints.
Syndesmoses
The lateral spinal canal is covered posteriorly by the superior and inferior vertebral lamina. The ligamentum flavum is attached
to two thirds of the ventral surface of the superior lamina, and inferiorly it is attached to the superior edge of the lower lamina.
The ligamentum flavum ends laterally 1 to 2 mm before the neural foramen. The ligamentum flavum connects the adjacent
vertebral laminae and lies deep to the laminae. It attaches to the zygapophyseal joint capsule and extends medially to the
spinolaminar junction. The ligamentum nuchae is a bilaminar, fibroelastic, intermuscular septum separated by areolar tissue. It is
attached to the external occipital crest and extends laterally to a variable extent. Its other attachments are to the posterior atlantal
tubercle and the medial aspects of the bifid spines of cervical vertebrae. It also acts as a septum for the bilateral attachment of
cervical muscles. The ligamentum nuchae is relatively avascular. The supraspinous ligament is a strong ligament connecting the
spinous processes. Interspinous ligaments connect adjoining spinous processes. They attach to the ligaments flava anteriorly and
the supraspinous ligament posteriorly. Intertransverse ligaments pass between the vertebral transverse processes.

Posterior Cervical Musculature Layers

The posterior cervical musculature can be considered to comprise three layers. The ligamentum nuchae in the midline separates
the two sides, and the splenius separates the deep cervical extensor muscles and the more superficial trapezius and
sternocleidomastoid. When all these are removed, deeper muscles of the back of the neck are seen to be divided into upper and
lower portions by the prominent backward projection of the prominent large spinous process of the C2. The most superficial
layer is that of the trapezius and sternocleidomastoid. The intermediate layer is the semispinalis and splenius.
Superficial Layer
The trapezius extends from the medial half of the superior nuchal line, external occipital protuberance, and spinous processes of
the cervical and thoracic vertebrae and attaches to the scapula and the lateral third of the clavicle. The sternocleidomastoid has
its origin from the lateral half of the superior nuchal line and mastoid process. Its attachment is to the manubrium of the sternum
and the medial third of the clavicle.
Intermediate Layer
The splenius capitis is deep to and partly covered by the trapezius and sternocleidomastoid. It is attached to the occipital bone
inferior to the lateral third of the superior nuchal line and extends to attach to the spinous processes of the lower cervical and
upper thoracic vertebrae, intervening supraspinous ligament, and lower half of the ligamentum nuchae. The semispinalis capitis
is deep to the splenius capitis, taking origin from the upper six thoracic transverse processes and lower cervical articular pillars
and attaching to the occipital bone between the superior and inferior nuchal lines. The longissimus capitis is also deep to the
splenius capitis and is lateral to the semispinalis capitis, taking origin from the mastoid process and attaching to the spinous
processes of the lower cervical and upper thoracic vertebrae. The splenius cervicis ascends from the third to the sixth thoracic
spines to the upper two or three cervical posterior transverse tubercles, anterior to the attachments of the levator scapulae. It is
inconsistent in its degree of development.
Deep Layer (Fig. 39–9)

The deep posterior cervical muscles are a muscle complex including extensors and short segmental muscle rotators (erector
spinae and transversospinalis, the latter comprising semispinales, rotatores, and multifidus). The spinous process of the C2
divides the deep muscles into a superior group (the suboccipital muscles). Inferior to the C2 spinous process, the semispinalis
cervicis is seen converging almost vertically upward to the bifid axial spine.
The Erector Spinae
The semispinalis cervicis is attached inferiorly to the upper five or six thoracic transverse processes and extends
superiorly to the C1–C5 spinous processes.
The spinalis cervicis, an inconstant muscle, ascends
from the lower ligamentum nuchae, the seventh cervical
spine, and the first and second thoracic spinous processes
to the spinous process of the axis.
The iliocostalis cervicis ascends from the third to the
sixth costal angles to the posterior tubercles of the
fourth to sixth cervical transverse processes.
Transversospinalis
This muscle group consists of the multifidus, semispinalis
cervicis, rotatores cervicis, and semispinalis capitis. These
muscles ascend obliquely and medially from the transverse processes to adjacent and distant vertebral spinous
processes.
The multifidus is deep in the groove lateral to the vertebral spinous process. It extends along the entire length
of the spinous process, passing to the spine of the vertebra above, its superficial fibers passing from one vertebra
to the third or fourth vertebra above. The deep fibers
connect only adjacent vertebral spinous processes.
The interspinales are paired between adjacent vertebral spines, flanking the interspinous ligament and
spanning more than two vertebrae.
The intertransversarii, small muscles between the
transverse processes, are best developed at the cervical
level, consisting of anterior and posterior divisions, separated by the ventral rami of the spinal nerves. The intertranversii may be
absent between the atlas and axis.
Suboccipital Muscles
The suboccipital muscles, located in the next layer, are
situated deep to the splenius, semispinalis, and longissimus capitis in the suboccipital area.
The rectus capitis posterior major extends from the
lateral surface of the spinous process of the axis and
broadens laterally to the inferior nuchal line and
occipital bone. The two diverging recti capitis posterior major muscles expose an intervening triangular
space that is partly covered by the rectus capitis posterior minor.
The rectus capitis posterior minor is medial to and
partially covered by the rectus capitis posterior major,
has a tendinous attachment to the posterior tubercle on
the posterior arch of the atlas, and ascends to the medial
part of the inferior nuchal line and occipital bone between the line and the foramen magnum. The rectus
capitis posterior minor is the only muscle attached to
the posterior arch of the atlas.
The inferior oblique (obliquus capitis inferior) is
attached between the outer surface of the bifid spine
(inferior to the rectus capitis posterior major) and the
posterior aspect of the lateral mass of the atlas.

FIGURE 39–9 Posterior cervical deep muscles and suboccipital triangles. (A) rectus
capitis posterior minor attaching to the posterior tubercle of C1, (B) horizontal segment of
the third part of the vertebral artery (V3)
within the suboccipital triangle, (C) posterior
arch of C1, (D) inferior oblique (obliquus
capitis inferior), (E) spinous process of C2,
(F) splenius cervicis.

The superior oblique (obliquus capitis superior) is

attached at the posterior aspect of the lateral mass and
tranverse process of the atlas and superiorly to the
lateral part of the occipital bone between the superior
and inferior nuchal lines, overlapping the rectus capitis
posterior major.
Suboccipital Triangle (Fig. 39–9)
The suboccipital triangle is an area bounded superomedially by the rectus capitis posterior major, superolaterally by the superior
oblique, and inferolaterally by the
inferior oblique. It is covered by the semispinalis capitis
medially and by the splenius capitis laterally. The floor of
the triangle is formed by the posterior atlanto-occipital
membrane and the posterior arch of the atlas. Across
the floor runs the terminal extradural part of the vertebral artery (V3), and the dorsal ramus of the first cervical nerve
(suboccipital nerve) emerges from the floor.
Across the roof of the suboccipital triangle passes the
greater occipital (C2) nerve and the occipital artery.
The vertebral arteries pass behind the superior facet of
C1 and across the posterior arch of the atlas and penetrate the posterior atlanto-occipital membrane and enter
the dura.
The occipital artery passes behind the superior
oblique and semispinalis. The vertebral artery and
the C1 nerve root, which are surrounded by the vertebral venous plexus, course along the upper surface
of the posterior arch of the atlas. The vertebral artery
gives off muscular branches, passes medially behind the
atlanto-occipital joint and above the posterior arch of
C1, and turns upward and anterior to penetrate the
dura.
Posterior Cervical
Neurovascular Anatomy
Vertebral Artery
The vertebral artery takes origin from the subclavian
artery and passes anterior to the transverse process of
the seventh cervical vertebra (V1). The vessel then
passes to enter the foramen transversarium of the sixth
cervical vertebra and ascends through the respective
foramina transversarii to the second cervical vertebra
(V2). It is anterior to the spinal nerves and provides
a spinal branch to each intervertebral foramen. Its
course from C6 to the C2 vertebra is vertical with a
medial inclination. The third part of the vessel is considered as the suboccipital segment (V3), which passes
from the foramen tranversarium of the second cervical
vertebra to C1 and then to the dural entry. It is composed of two segments. The first segment consists of
the vertical segment, which ascends from the transverse foramen of C2 to the transverse foramen of C1,
with a lateral inclination because the foramen of C1 is
more lateral than that of C2. It also has a slight posterior convexity in this segment. The second segment is
horizontal, passing medially from the foramen transversarium of C1, behind the atlanto-occipital joint, and
across the posterior arch of C1 to enter the dura. Here it
lies in the floor of the suboccipital triangle before piercing the lateral angle of the posterior atlanto-occipital
membrane.6
Occipital Artery
The occipital artery is a large branch of the external
carotid artery that passes posteriorly on the occipitomastoid suture of the skull deep to the digastric and
longissimus capitis muscles. It traverses the upper part
of the roof of the suboccipital triangle and passes to the
scalp at the lateral margin of the semispinalis capitis. It
gives off descending branches that lie both superficial
and deep to the semispinalis capitis, where there is an
anastomosis with ascending branches of the transverse
cervical and costocervical arteries. The companion
veins form a venous plexus around the semispinalis
muscle.
Posterior Vertebral Venous System
The venous compartment of the posterior cervical
spine consists of the suboccipital plexus and the
vertebral venous plexus of the spine. Vertebral veins
form within the suboccipital triangle and from the
plexus of veins that descend alongside the vertebral
artery. The condylar emissary vein also drains into the
suboccipital venous plexus. The suboccipital venous
plexus is located superficial to the muscles of the suboccipital triangle. These veins form a confluence and
pass down as superficial veins to the brachiocephalic
veins. The vertebral venous plexus within the spine
gives origin to two vertebral veins that exit through the
sixth foramen tranversarium with the vertebral artery,
and one passes through the foramen tranversarium of
the C7 vertebra.
The vertebral plexus of veins of the spine receives the
segmental drainage of the cervical part of the spinal
cord along the nerve roots, in addition to the tributaries
from the internal vertebral plexus. The two vertebral
veins join the brachiocephalic vein in the root of the
neck.
Internal Jugular Vein
The internal jugular veins lie immediately anterior to
the transverse processes of the cervical vertebrae.

Cervical Nerve Roots

Each dorsal and ventral root is composed of a series of
eight rootlets that extend from the posterolateral and
anterolateral surfaces of the spinal cord, respectively.
The Cl, C2, and C3 nerves, distal to the ganglion, divide
into dorsal and ventral rami. The ventral rami of the C1
and C2 nerve roots pass behind the vertebral artery, posterior to the facet joints, unlike those of the inferior cervical nerves,
which pass anterior to the facet joints.
The dorsal rami divide into medial and lateral
branches that supply the skin and muscles of the posterior region of the neck. The Cl cervical nerve, termed
the suboccipital nerve, leaves the vertebral canal between the occipital bone and atlas and has a dorsal
ramus that is larger than the ventral ramus.
A radicular artery is located anteriorly, between the
nerve root dura and the root sleeve, and an extradural
venous plexus is located circumferentially within the
connective tissue of the nerve root sleeve. The nerve
root is deep to the lateral half of the lamina and
the medial half of the superior facet, which overlies the
nerve root axilla. The nerve then passes superior to
the superior and lateral margin of the inferior pedicle.
The motor and sensory roots exit the spinal canal within
a common dural sleeve, but in the neural foramen, the
dural sleeve divides into an anteroinferior sleeve carrying the motor root, and a posterosuperior sleeve containing the sensory
root division. At the dorsal root
ganglion, which is within the neural foramen, a single
dural sleeve once again covers both sensory and motor
divisions.
Suboccipital Nerve
The suboccipital (Cl) nerve lies in the groove between
the vertebral artery and bone on the posterior arch
of the atlas. Its posterior ramus passes posteriorly to supply the two recti, the two obliques, and the upper fibers
of the semispinalis capitis. The anterior ramus passes
around the lateral aspect of the atlanto-occipital joint
and passes anteriorly to join the cervical plexus. Neither
branch innervates the skin.
Greater Occipital Nerve
The greater occipital nerve is the dorsal ramus of C2
and emerges below the posterior arch of the atlas. It
passes around the lower border of the inferior oblique
muscle and then superiorly across the roof of the suboccipital triangle. It pierces the semispinalis capitis muscle
and innervates the skin of the posterior scalp to the vertex. The C2 ganglion is located between the posterior
arch of C1 and the lamina of C2.
The foregoing overview of the key anatomical structures of the posterior cervical spine introduces the basic
anatomical considerations that shall be referenced in the
following chapters describing the specific steps in various
techniques for posterior cervical instrumentation.
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