L3: The Back

&
Posterior Shoulder Region
Sirilug Magerd, PhD
Thirawass Phumyoo, PhD
Department of Basic Medical Science
1099203 Musculoskeletal system and connective system
Semester 1/2564 1
Overview of the Back & Vertebral Column

• Muscles of back; Nerve & • Vertebral column

Vascular supply • Curvatures of vertebral column
• Surface anatomy of Back Muscles • Movement of vertebral column
• Extrinsic Back Muscles • Vertebrae
• Intrinsic Back Muscles • Structure and function of vertebrae
• Splenius muscles
• Regional characteristics of
• Erector spinae muscles
vertebrae
• Transversospinalis muscle group
• Segmental muscles
• Suboccipital Muscles

2
Objectives

• Describe the vertebral column including its

joints and ligaments
• Describe the location, function, nerve and
blood supplies of the superficial,
intermediate and deep muscles of back
• Defines the boundaries of the triangle of
Auscultation and Lumbar triangle
• Explain the suboccipital region and
suboccipital triangle and their contents

3
 Surface Anatomy of Back
Key Bony Landmarks of the Back
• Vertebra prominens
• Scapula
• Iliac crests
• Posterior superior iliac spines

4
Left lateral view Posterior view
7 Vertebral Column: The Spine
Cervical
vertebrae
• Consists of vertebrae
that are separated by
12 intervertebral discs
Thoracic
vertebrae • Vertebrae: 33
• Vertebral canal: spinal
cord
5 • Flexible
Lumbar
vertebrae
• The movement b/w
two vertebrae is small

5 fused sacral vertebrae

4 coccygeal vertebrae (last 3 fused) 5

Primary & Secondary Curvatures
• Four curvatures of vertebral column
• Thoracic and sacral kyphoses (kyphosis) are concave anteriorly
• Cervical and lumbar lordoses (lordosis) are concave posteriorly

• Primary curvatures occur in fetus

• Secondary curvatures occur when;
• infant supports its head (cervical lordosis)
• assumes an upright posture & support its
weight (lumbar lordosis)

Lateral view
6
Surface anatomy of curvatures of vertebral column.
Abnormal
curvatures

7
 Typical vertebrae
• Has several consistent features:
• Body: the weight-bearing portion of a vertebra that tends to increase in size as one
descends the spine
• Vertebral arch: a projection formed by paired pedicles and laminae
• Transverse processes: the lateral extensions from the union of the pedicle and lamina
• Articular processes (facets): 2 superior & 2 inferior facets for articulation with adjacent
vertebrae
• Spinous process: a projection that extends posteriorly from the union of two laminae
• Vertebral notches: superior & inferior semicircular features that in articulated vertebrae
form an intervertebral foramen (two semicircular notches form a circle)
• Intervertebral foramina: the opening formed by the vertebral notches that is crossed by
spinal nerve roots & associated vessels
• Vertebral foramen (canal): a foramen formed from the vertebral arch and body that
contains the spinal cord & its meningeal coverings
• Transverse foramina: apertures that exist in transverse processes of cervical vertebrae only
& transmit the vertebral vessels 8
 Superior articular process
Vertebral body Pedicle Transverse
process
Pedicle Intervertebral
Vertebral disc
Transverse process foramen
Inferior
articular
process

Lamina Inferior
Spinous process vertebral
notch
Intervertebral
foramen

Typical vertebrae Superior

vertebral
notch

Lateral view
Superior view 9
Key Features of the Cervical Vertebrae
Atlas (C1)
Ringlike bone; superior facet articulates with occipital bone
Two lateral masses with facets
No body or spinous process
C1 rotates on articular facet of C2
Vertebral artery runs in groove on posterior arch
Axis (C2)
Dens projects superiorly
Strongest cervical vertebrae
Other Cervical Vertebrae (C3-C7)
Large triangular vertebral foramen
Transverse foramen, through which vertebral artery passes
C3 to C5: short bifid spinous process
C6 to C7: long spinous process
C7 called vertebra prominens
Narrow intervertebral foramina
Nerve roots at risk of compression 10
C1: Atlas C2: Axis

Cervical vertebrae
C1-C7

11
Key Features of Vertebrae
T1-T12 Heart-shaped body, with facets for rib articulation
Small circular vertebral foramen
Long transverse processes, which have facets for rib articulation in T1-T10
Long spinous processes, which slope posteriorly & overlap next vertebrae
L1-L5 Kidney-shaped body, massive for support
Mid-sized triangular vertebral foramen
Facets face medial or lateral direction, which permits good flexion &
extension
Spinous process is shot
L5: largest vertebra

12
Key Features of Vertebrae
Sacrum Large, wedge-shape bone, which transmits body weight to pelvis
Five fused vertebrae, with fusion complete by puberty
Four pairs of sacral foramina on dorsal & ventral (pelvic) side
Sacral hiatus, the opening of sacral vertebral foramen
Coccyx Co1 often not fused
Co2-Co4 are fused
No pedicles, laminae, spines
Remnant of our embryonic tail

13
 Laminectomy

• Surgical excision to remove the laminae

• To relieve pressure on the spinal cord or nerve roots,
caused by a tumor, herniated IV disc, or bony hypertrophy
14
 Joints and Ligaments of the Craniovertebral Spine
• The craniovertebral joints include
• Atlanto-occipital joint (atlas and occipital bone of the skull)
• Atlantoaxial joint (atlas and axis)
• Both are synovial joints that provide a relatively wide range of motion compared with
other joints of the vertebral column.
Features of the Atlanto-occipital and Atlantoaxial Joints

15
 Joints and Ligament of Spine: Craniovertebral joint

Craniovertebral joints and ligaments. (Radiograph reprint with permission from

16
Major N: A Practical Approach to Radiology. Philadelphia, Saunders, 2006.)
 Atlanto-Occipital joint

• Articulate between atlas & occipital bone

• Synovial joint (condyloid type)
• No IV disc
• “Yes” movement (head up & down / flexion & extension)
• Excessive movement is prevented by ant. & post. atlanto-occipital membrane

Posterior view 17
 Atlantoaxial joint

• 2 lateral joints between lateral masses of C1 & C2

• 1 median joint between dens of C2, ant. arch and transverse ligament of C1
• “No” movement (rotation)

• Excessive rotation is prevented by alar ligament

18
 Tectorial membrane
(cut edge)
Craniovertebral joint

Alar ligament

Cruciate ligament
Tectorial membrane
(cut edge)
• Cruciate ligament:
• Transverse ligament of C1 (lateral mass)
• Longitudinal bands (superior, inferior)
• Alar ligaments (dens to lateral margin of foramen magnum)
• Tectorial membrane (body of C2 to occipital bone) 19
 Joints and Ligament of Spine: Vertebral arches & Bodies

• The joints of the vertebral arches

• Zygapophyseal joints occur between the sup. and inf. articular processes (facets) of
adjacent vertebrae and allow for some gliding or sliding movement.
• The corresponding ligaments connect the spinous processes, laminae, and bodies of
adjacent vertebrae.
• The joints of the vertebral bodies
• Intervertebral joints occur between the adjacent vertebral bodies.
• These stable, weight bearing joints also serve as shock absorbers owing to the
presence of the intervertebral disc between the bodies.
• Intervertebral discs

20
Features of the Zygapophyseal and Intervertebral Joints

21
Joints of the Vertebral Arches and Bodies

22
Joints of the vertebral column

Zygapophysial Joint
(Facet joint)
*
*
• Joints of the vertebral arches
• Plane synovial joint between superior and
inferior articular processes surrounded by
a loose articular capsule

• Innervated by articular branches arise from medial branches of the posterior

rami of spinal nerves

23
Joints of the vertebral column

Joint of the vertebral bodies

• Cartilaginous joint

• Designed for weight-bearing & strength

• The articulating surfaces are connected

by intervertebral disc & ligaments

24
Joints of the vertebral column

Intervertebral discs

• Intervertebral discs consist of the following:

• Outer fibrocartilaginous anulus fibrosus
• Inner gelatinous nucleus pulposus (a remnant of the embryonic notochord)
• The lumbar intervertebral discs are the thickest.
• The upper thoracic intervertebral discs are the thinnest.
• The anterior and posterior longitudinal ligaments help to stabilize these joints. 25
Ligaments of the Vertebral Column

• Anterior Longitudinal Ligament

• Posterior Longitudinal Ligament
• Ligamentum Flavum 26
Ligaments of Intervertebral joints

Anterior longitudinal ligament Posterior longitudinal ligament

• Runs on the anterior surface of the • Runs within the vertebral canal along the
vertebral bodies & discs from the posterior aspect of the vertebral body
occipital bone to the sacrum from C2 to the sacrum
• Maintain stability of the IV disc anteriorly • Prevent hyperflexion of vertebral column
• Prevent hyperextension of the vertebral and posterior protrusion of IV disc
column 27
 Ligaments of the Vertebral Column

Intertransverse Ligamentum nuchae /

Nuchal ligament
ligament

Interspinous
ligament
Supraspinous
ligament

• Interspinous Ligaments / Intertransverse Ligaments

• Supraspinous Ligament
• Ligamentum nuchae 28
Craniovertebral joint and ligaments

29
 Movements of the Spine

• Flexion, extension, lateral bending, and rotation

• Range of movement is limited by:
• Thickness, elasticity and compressibility of IV disc
• Shape and orientation of zygapophysial joints
• Tension of articular capsule
• Resistance of back muscles and ligaments
• Cervical ≥ Lumbar > Thoracic regions 30
 Vasculature of Vertebral Column

• Spinal branches from

• Vertebral and ascending cervical arteries: in the neck
• Posterior intercostal arteries: in the thoracic region
• Subcostal and lumbar arteries: in the abdomen
• Iliolumbar and lateral & medial sacral arteries : in pelvis 31
 Nerves of Vertebral Column
• (Recurrent) meningeal branches of the spinal nerves

32
 Muscles of the Back

Extrinsic Back Muscles Intrinsic Back Muscles

• Superficial and intermediate muscles that • Deep muscles that specifically act on the
produce, control limb & respiratory vertebral column, producing its movements
movements & maintaining posture
33
The Superficial Extrinsic Back Muscles

The Intrinsic Back Muscles

34
 Superficial Muscles of the Back: Extrinsic Back Muscles
The Superficial Extrinsic Back Muscles
• Trapezius
• Latissimus dorsi
• Levator scapulae
• Rhomboids
• Connect to the vertebral column with the
superior appendicular skeleton
(pectoral girdle & humerus)
• Produce and control limb movement
• Receive their nerve supply from the anterior rami
of cervical nerves
• Trapezius receives its motor fibers from CNXI
(the accessory nerve)
The Intermediate Extrinsic Back Muscles
• Serratus posterior
• Serratus posterior superior
• Serratus posterior inferior
• Superficial respiratory muscles
(more proprioceptive rather than motor in function)
• Muscles of thoracic wall
• Innervated by intercostal nerves
• Superior by the 1st four intercostal
• Inferior by the last four
35
Trapezius
O : External occipital protuberance,
superior nuchal line, ligamentum
nuchae, spines of C7 - T12
I : Spine of scapula, acromion and
lateral one-third of clavicle

N : Spinal accessory n. (motor), cervical spinal n.

C3 - C4 (pain & proprioception)
A : Superficial transverse cervical artery
Act : Upper fiber; elevates shoulder,
Middle fiber; adducts scapula,
Lower fiber; depresses scapula
36
Latissimus dorsi
O : Spinous process of T7 – L5,
thoracolumbar fascia, ribs 9 - 12,
iliac crest
I : Floor of intertubercular groove
of humerus

N : Thoracodorsal n. (C6-C8)
A : Thoracodorsal a.
Act : Adducts, extends,
medially rotates arm

37
 Thoracolumbar fascia

• Invests the deep muscles of the back

• The posterior aponeuroses of transversus abdominis and
internal abdominal oblique muscles 38
 Boundary
Triangle of Auscultation Medial : Trapezius
Lateral : Scapula
Lower : Latissimus dorsi
Floor : 6th – 7th rib

Copyright 2011, John Wiley & Sons, Inc.

• The site where breathing sound can be heard most clearly

39
 Boundary
Lumbar triangle Medial : Latissimus dorsi
Lateral : External abdominal oblique
Lower : Iliac crest
Floor : Internal abdominal oblique

• A site for hernia and infections are occasionally present

40
Levator scapulae
O : Transverse processes of C1-C4
I : Upper part of medial border of
scapula

N : C3 - C4 , dorsal scapular n. (C5)

A : Deep transverse cervical a.
Act : Elevates, medial rotate scapula
41
Rhomboids
Rhomboid major
O : Spinous process of T2 – T5
I : Medial border of scapula
N : Dorsal scapular n. (C4-C5)
A : Deep transverse cervical a.
Act : Retract (adduct) scapula

Rhomboid minor
O : Spinous process of C7 – T1
I : Root of spine of scapula
42
Intermediate muscles of the Back

Serratus posterior
• Serratus posterior superior lies deep
to rhomboid muscles
• Serratus posterior inferior lies deep
to latissimus dorsi

43
 Serratus posterior Serratus posterior superior
O : Ligamentum nuchae,
spines of C7-T3
Semispinalis capitis I : 2nd - 4th ribs
Splenius capitis

Levator scapulae
Ligamentum nuchae N : 2nd – 5th intercostal n.
Supraspinatus
Acromion of scapula
Serratus posterior superior
Act : Elevate ribs
Teres minor
Infraspinatus Splenius cervicis
Teres major

Serratus anterior
Posterior layer of thoracolumbar fascia Serratus posterior inferior
Serratus posterior inferior O : Spines of T11 – L2
External oblique I : 9th - 12th ribs
Iliac crest
N : 9th – 12th intercostal n.
Act : Depress ribs
44
 Deep Muscles of the Back: Intrinsic Back Muscles

Divided into 3 groups

• Superficial layer
• Intermediate layer
• Erector spinae
• Deep layer
• Transversospinalis
• Segmental

• Extend from the pelvis to the cranium

• Maintain posture and control movements of the vertebral column and head
45
 Superficial and Intermediate layers of Intrinsic Back Muscles

superficial layer of
intrinsic back muscles:
Splenius
• Splenius capitis intermediate layer of
• Splenius cervicis intrinsic back muscles:
Erector spinae
• Iliocostallis
• Longissimus
• Spinallis

46
Deep Muscles of the Back
Superficial layer
Splenius capitis
O : Lower half of nuchal ligament,
spinous process of C7-T3
I : Mastoid process, lateral third of
superior nuchal line
N : Middle cervical nerve
Act : *Extend head and neck, lateral flex
neck and rotate head to same side
Splenius cervicis
O : spinous process of T3-T6
I : transverse process of C1-C3
N : Lower cervical nerve
Act : *Extend neck, lateral flex and rotate
cervical of vertebral column to same47side
Deep Muscles of the Back
Intermediate Layer of Intrinsic Back Muscles: Erector spinae muscles

• Lie in a groove on each side

of the vertebral column
between spinous process
and the angle of ribs

• Iliocostalis (lumborum, thoracis , & cervicis)

• Longissimus (thoracis, cervicis, & capitis)
• Spinalis (thoracis, cervicis , & capitis) 48
 Deep Muscles of the Back
Intermediate layer
• Longitudinal gr.
• Straighten & rotate back
• Lie Between spinous process and angle of rib

Iliocostalis lumborum
O : sacrum, spinous process of T11-L5,
iliac crest
I : inferior border of angle of 6th -12th rib
N : dorsal rami of spinal nerve Erector spinae
Act :extension, rotation & lateral flexion of (Sacrospinalis)
vertebral column

Iliocostalis thoracis Iliocostalis cervicis

O : upper border of 6th -12th rib O : 1st - 6th rib
I : upper border of angle of 1st - 6th rib I : posterior tubercle of C4-C6
49
Intermediate layer Deep Muscles of the Back

Longissimus thoracis
O : combine with iliocostalis lumborum,
transverse process of lumbar vertebrae
I : transverse process of T1-T12; between
tubercles and angles of lower 9 to 10 ribs
N : dorsal rami of spinal nerve
Act :extension, rotation & lateral flexion of Erector spinae
vertebral column (Sacrospinalis)
Longissimus cervicis Longissimus capitis
O : transverse process of T1-T6 O : transverse process of upper thoracic vertebrae,
I : posterior tubercle of articular process of C4-C7
transverse process of C2-C6 I : mastoid process
Act : extend, lateral flex head and rotate head to same side
50
Intermediate layer Deep Muscles of the Back

Erector spinae
(Sacrospinalis)

Spinalis thoracis
O : spinous process of T10/T11-L2
I : spinous process of T1-T8
N : dorsal rami of spinal nerve
Act :extension of vertebral column

Spinalis cervicis
Spinalis capitis
51
Deep Muscles of the Back
Deep Layer

Transversospinalis group
• Semispinalis (4-6 segments)
• Multifidus (2-4 segments)
• Rotatores (1-2 segments)

The segmental muscles

• Interspinalis
• Intertransversarii
• Levators costarums
52
Deep Muscles of the Back

Deep Layer of Intrinsic Back Muscles: Transversospinalis group

O : transverse processes
I : spinous process
N : dorsal rami of spinal nerves
Act : extends head, stabilizes vertebrae
• Deep to the erector spinae 53
Deep Layer of Intrinsic Muscles

54
Deep Muscles of the Back Deep Layer
The Segmental Muscles

• Deep to the erector spinae

55
Deep Layer of Intrinsic Muscles

56
 Intrinsic Muscles

Superficial layer Intermediate layer Deep layer 57

 Suboccipital Region

Bony Landmark
• Superior : inferior nuchal line
• Inferior : Axis (C2)
• Lateral : mastoid process, transverse
process of C1 & C2
• Medial : spine of axis, posterior
tubercle of Atlas (C1)

58
Contents of the Suboccipital Region
4 muscles, 2 nerves, 2 arteries

59
 Suboccipital Muscles
Muscle Origin Insertion Innervation Main Action

Rectus capitis Lateral inferior Extends head &

Spine of axis Suboccipital n. (C1)
posterior major nuchal line rotates to same side

Rectus capitis Tubercle of Median inferior Suboccipital n. (C1)

Extends head
posterior minor posterior arch of C1 nuchal line

Obliquus capitis Atlas transverse Suboccipital n. (C1) Extends head &

Occipital bone
superior process bends it laterally

Obliquus capitis Atlas transverse Suboccipital n. (C1) Rotates atlas to turn

Spine of axis
inferior Process face to same side
60
Suboccipital Triangle

Boundary
• Superomedial : rectus capitis post. major
• Superolateral : Obliquus capitis superior
• Inferolateral : Obliquus capitis inferior
• Roof : semispinalis capitis
• Floor : posterior altanto-occipital membrane & posterior arch of atlas
• Contents : vertebral artery & suboccipital nerve & venous plexus 61
 Arteries of the Back
• Supplied by branches of the post. intercostal a., which
arise from the thoracic aorta or subclavian a.
• The 1st and 2nd post. intercostal a.
arise from the costo-cervical trunk,
a branch of the subclavian a.

• Post. intercostal a. give rise to cutaneous

and muscular branches, as well as spinal • Vascular supply the sacrum
branches that supply spinal cord 62
 Veins of the Back
• Drain into the azygos vein via the post. intercostal v., hemiazygos vein,
and ascending lumbar veins
• The inferior of spinal column is drained by the vertebral venous plexus

• The external vertebral venous plexus is divided

into anterior and posterior portion that run
along the exterior of the spinal column 63
 Cutaneous Nerves of the Back

• Receives its innervation from branches of the spinal nerves.

Posterior rami of the spinal nerves supply nerve fibers to synovial joints of the vertebral
column, deep muscles of the back, and the overlying skin.
• Upper T6 from medial branches of dorsal rami
• Lower T6 from lateral branches of dorsal rami
Anterior rami of the spinal nerves supply the extrinsic muscles of the back 64
References
Posterior shoulder region
Objectives

•Posterior shoulder region.

• Describe the structures and functions of the muscles.
• Describe the structures and functions of blood vessels
and nerve supply.
• Describe the clinical correlation.
Should know

Movement of glenohumeral joint

• Flexion
• Extension
• Medial rotation
• Lateral rotation
• Abduction
• Adduction
Must know

Scapulohumeral (intrinsic shoulder) muscles

• Six muscles are relatively short muscles that pass from the scapula to the humerus and
act on the glenohumeral joint.
• Deltoid m.
• Teres major m.
• Rotator cuff m. (4 muscles)
• Supraspinatus m.
• Infraspinatus m.
• Subscapularis m.
• Teres minor m.
Must know

Deltoid muscle
Must know

Teres major muscle

Must know

Rotator cuff muscles

Must know

Rotator cuff muscles

Must know

Rotator cuff muscles

Must know

Rotator cuff muscles

Must know

Superior transverse scapular ligament

Must know

Arterial supply
• Suprascapular artery
(from thyrocervical
trunk of subclavian
artery)
• Posterior circumflex
humeral artery (from
third part of axillary
artery)
• Circumflex scapular
artery (from
subscapular artery)
• Dorsal scapular artery
(from transverse
cervical artery of
thyrocervical trunk)
Must know

Venous drainage
• Axillary vein
• Posterior circumflex
humeral vein
• Subscapular vein
• Circumflex scapular vein
• Subclavian vein
• External jugular vein
• Suprascapular vein
• Dorsal scapular vein
Must know

Nerve innervation
• Suprascapular nerve (from superior trunk of brachial plexus)
• Innervate: Supraspinatus & Infraspinatus muscles
• Axillary nerve (from posterior cord of brachial plexus)
• Innervate: Teres minor & Deltoid muscles
Must know
Must know

Nerve innervation
• Upper subscapular nerve (from posterior cord of brachial plexus)
• Innervate: Subscapularis muscle
• Lower subscapular nerve (from posterior cord of brachial plexus)
• Innervate: Subscapularis & Teres major muscles
Should know

Cutaneous nerve
• Supraclavicular nerve
• Superior lateral cutaneous of
arm
• Intercostobrachial nerve
Must know

Spaces
• Quadrangular space
• Superior: Subscapularis & Teres minor m.
• Inferior: Teres major m.
• Medial: Long head of triceps brachii m.
• Lateral: Surgical neck of humerus
• Contents: Axillary nerve &
Posterior circumflex humeral artery
• Triangular space
• Superior: Subscapularis & Teres minor m.
• Inferior: Teres major m.
• Lateral: Long head of triceps brachii m.
• Contents: Circumflex scapular vessels
Should know

Surface anatomy
Should know

Surface anatomy
Should know

Surface anatomy
 Clinical Correlation
Nice to know

• Muscle function test

• Middle deltoid
• Shoulder abduction
• Posterior deltoid & Teres major
• Shoulder extension
• Supraspinatus
• Initial shoulder abduction
• Infraspinatus & Teres minor
• Lateral rotation of shoulder
• Subscapularis
• Medial rotation of shoulder
 Clinical Correlation
Nice to know

• Suprascapular notch syndrome

 Clinical Correlation
Should know

• Entrapment of axillary nerve and posterior circumflex humeral artery

• Space-occupying lesions or disruption in the anatomy due to trauma.
• Symptoms include axillary nerve related weakness of the deltoid muscle in the case of any
significant mass lesions in the quadrangular space.
 Clinical Correlation
Should know
 Clinical Correlation
Nice to know
 Clinical Correlation
Should know
References