The Axial Skeleton

.Figure 1 – Axial skeleton

1
 The longitudinal axis of the human body is a
straight line that runs through the body's
center of gravity.
 This imaginary line extends through the
head and down to the space between the feet.
 The axial skeleton includes the bones that
lie around the axis: skull bones, auditory
ossicles, hyoid bone, sternum, ribs, and
vertebral column (fig. 1).

2
Figure 2 – Cranial & Facial bones.

3
 The Skull
• The cranium is the skull without the mandible.
• The upper part of the cranium forms a box called
clavaira, which encloses and protects the brain.
• The skull bones that form the clavaira are termed
the cranial bones (fig. 2).
• The remainder lower part of the skull (including the
mandible) forms the facial skeleton (fig. 2).
• The skull bones, except for the mandible, are
immovably united together by sutures.
• The mandible is the only bone in the skull, which
articulates on each side by a mobile synovial joint
called the temporomandibular joint (T.M joint).
• The roof of the clavaira is called the clava or skull
cup (fig, 3). 4
.Figure 3 – The clava (skull cup)

5
.Figure 4 – The cranial cavities

6
• When the clava is removed, the base of the skull is
exposed.
• Internally the base of the skull is divided into three
cranial fossae, anterior, middle, and posterior (figure
4).
• The skull contains a number of cavities: The cranial
cavity, nasal cavity, two orbital cavities, oral cavity,
and sinuses (air filled spaces).
• The skull bones are made up of external and
internal tables of compact bone separated by a layer
of spongy bone called diploe.
• The bones are covered on the inner and outer
surfaces with periosteum.

7
 The Cranial Bones
• Form the cranial cavity, which encloses, supports,
and protects the brain.
• They are all singles except two of them are pairs.
• They include the following bones:
1. Frontal bone. – Single.
2. Ethmoid bone – Single .
3. Occipital bone – Single.
4. Sphenoid bone – Single.
5. Temporal bones – Paired.
6. Parietal bones – Paired.

A8
Temporal bone:
a.Squamous part.
b.Mastoid part.
c.Petrous part.
d.Tympanic plate.
e.Styloid process.

Sphenoid bone:
a.Body.
b.Greater wing.
c.Lesser wing.
d.Pterygoid process.
i. Medial pterygoid plate.
ii. Lateral pterygoid plate.
 Paranasal Sinuses 8C

1.Maxillary sinus: Inside maxillary bone.

2.Frontal sinus: Inside frontal bone between inner and outer tables,
behind ciliary arches.
3.Ethmoidal: Within the lateral mass of ethmoid bone. Consists of
three groups, each group of variable number:
a.Anterior.
b.Middle.
c.Posterior.
1.Sphenoidal: Inside the body of sphenoid.
Notice:
1.All paranasal sinuses open into the nasal cavity. Infection in the
nasal cavity may transmit into one of these sinuses (usually the
maxillary) causing sinusitis.
 The Facial Bones
• They form the skeleton of the face.
• It is obvious that their chief function is to surround
and protect the openings of the face (eyes, nose,
and mouth).
• They are all paired except two of which are single.
• They include the following bones:
1.Maxillary bones – Paired.
2.Zygomatic bones – Paired.
3.Nasal bones – Paired.
4.Lacrimal bones – Paired.
5.Palatine bones – Paired.
6.Inferior nasal conchae – Paired.
7.Vomer – Single.
8.Mandible – Single. 9
.Figure – 5 Superior view of skull

1
Superior View of Skull (fig. 5 and 6)
• Anteriorly, the frontal bone forms the forehead.
• Its upper border articulates with the anterior
borders of the two parietal bones forming the
coronal suture.
• The upper border of the two parietal bones
articulates with each other forming the sagittal
suture in the midline, which is perpendicular to the
coronal suture.
• The posterior borders of the two parietal bones
articulate with the upper border of the occipital bone
forming the lambdoid suture.
• The sagittal suture meets anteriorly the coronal
suture in the brigma; and posteriorly the lambdoid
suture in the lambda. 1
of newborn. Skull- Figure 6

1
• In newborn skull, the bones of the skull in the
regions of the brigma and lambda are separated by
unossified membranous intervals called the anterior
and posterior fontanelles, respectively.
• The anterior fontanelle is diamond shaped, which
is closed by 18 months of age.
• The posterior fontanelle is triangular in shape, and
is obliterated within 3 – 6 months after birth.
• The parietal foramen one on each side of the
sagittal suture, perforate the parietal bones, about
3.5 cm in front of the lambda.
• The region of maximum convexity of the parietal
bone is termed the parietal eminence (tuber) and can
be easily felt in living subject.
1
Figure 7 – Posterior view of skull.

1
 Posterior View of the Skull (fig. 7)
• The outline of this view of the skull is like a broad arch,
convex above and on each side, and flattened below.
• In the midline, there is a roughened elevation called the
external occipital protuberance.
• The inion is the most salient point on the external
occipital protuberance in the median plane.
• The superior nuchal lines, one on each side, are
transverse ridges that run laterally from the external
occipital protuberance.
• They form the boundary between scalp and neck.
• The highest nuchal lines (not always present) are
curved ridges situated about 1 cm above and parallel to
the superior nuchal lines.
• In this view the whole length of the lambdoid suture
can now be seen.
15
• On each side, its lower extremity meets the
parietomastoid and occipitomastoid sutures.
• The meeting point of the three sutures is called the
asterion.
• On each side, the inferolateral region of this view is
formed by mastoid processes of the temporal bone.

1
.Figure 8A – Lateral view of skull

1
 Lateral View of the Skull (fig. 2, and 8)
 The superior and inferior temporal lines begin as a
single line from the posterior margin of the
zygomatic process of frontal bone and diverge as
they arch backward.
 Posteriorly, the upper line fades away, but the
lower line curves downward and forward to become
continuous with the supramastoid crest.
 The latter is continuous with the posterior root of
the zygomatic process of the temporal bone.
 This process articulates with the temporal process
of the zygomatic bone to form the zygomatic arch.
 The temporal fossa is bounded by the temporal
line, the zygomatic arch, and the frontal process of
the zygomatic bone. 1
 The anterior part of this fossa presents an irregularly H
– shaped arrangement of sutures between the frontal
bone, the parietal bone, the squamous part of the
temporal bone, and the greater wing of sphenoid bone.
 A small circular area can be outlined so as to include
portion of all four bones.
 This area is called the pterion.
 The anterior branch of the middle meningeal artery is
marked by the pterion.
 The pterion is about 3.5 cm behind the frontozygomatic
suture, and 4 cm above the zygomatic arch.
 The mastoid part of temporal bone lies behind and
below the squamous part.
 Its upper border articulates with the parietal bone
forming the parietomastoid suture.
2
 Its posterior border articulates with the occipital
bone forming the occipitomastoid suture.
 The mastoid process is nipple in shape projects
downward from the mastoid bone.
 The mastoid foramen pierces the mastoid bone
immediately above the base of the mastoid process
and near, or on, the occipitomastoid suture..
 Above and in front of this process is the external
auditory (acoustic) meatus.
 Above and behind this meatus there is triangular
depression with a bony spicule called the
suprameatal triangle and spine, respectively.
 The zygomatic process of the temporal bone is
attached to the squamous part by two roots, anterior
and posterior.
2
 The anterior root passes medially in front of the
mandibular fossa and becomes continuous with the
articular tubercle.
 The posterior root runs backwards, forming the
lateral boundary of the fossa.
 At its commencement, the anterior root presents
the tubercle of the root of the zygoma.
 The temporal fossa communicates with
infratemporal fossa through the gap between side of
skull and zygomatic arch.
 The infratemporal fossa is better to be studied at
base of skull.
 The anterior wall of the temporal fossa is formed
by zygomatic bone, adjoining part of greater wing of
sphenoid, and a small portion of frontal bone.
2
Here the temporal surface of the zygomatic bone
presents the zygomaticotemporal foramen, which
transmits the zygomaticotemporal nerve and a
minute artery.

2
.Figure 9A – Anterior view of skull

2
.Figure 9B – Anterior view of skull

2
 Anterior View of the Skull (fig. 9)
 It is marked by three bony apertures, the two orbital
apertures and the anterior bony aperture of the nasal
cavities.
 On each side of median plane, about 3 cm above the
upper margin of orbital aperture, the frontal bone
presents a rounded elevation, called the frontal
tuberosity.
 Below the tuberosity there is a curved ridge, termed
the superciliary arch.
 The medial ends of the two arches are joined by a
median elevation called the glabella.
 The frontal bone lies above the orbital apertures, and
forms the forehead.
 The frontal air sinuses are placed within the frontal
bone between its outer and inner tables, behind the
 Anteriorly, the two nasal bones articulate with each other
forming the internasal suture; posteriorly articulate with
the frontal process of the maxillary bone; their inferior
borders together with the nasal notch of the maxillary
bones form the boundary of the anterior bony nasal
aperture.
 On each side, below the orbital aperture, the body of the
maxillary bone predominates in the skeleton of the face.
 The infraorbital foramen pierces the maxilla, about 1 cm
below the infraorbital margin.
 The maxillae or maxillary bone presents three processes:
(1) the frontal process (ascends up behind the nasal bone);
(2) the zygomatic process articulates with the zygomatic
bone; (3) the alveolar process, which fused with the
contralateral side forming the lower boundary of the nasal
aperture and the upper dental arch.
2
 The upper dental arch presents 16 sockets for the
upper or maxillary teeth.
 The anterior nasal spine is a median sharp
projection from the alveolar process at the lower
border of the nasal aperture.
 Within each body of the maxillary bone (maxillae)
there is a pyramidal-shaped cavity lined with
mucous membrane termed the maxillary air sinus.
 The base of the maxillary sinus lies against the
lateral wall of the nasal cavity; whereas the apex
extends toward the zygomatic bone.
 The growth of the maxillary bones is responsible
for the elongation of the face between the ages of 6
– 12 years
2
Figure 10A – Orbital opening & cavity.

29
.Figure 10B – Orbital opening & cavity

3
 The Orbital Opening (fig. 10)
 It is a quadrangular-shaped aperture that forms the
base of the orbital cavity.
 Its upper margin is formed entirely by the frontal
bone, and is interrupted at the junction of the medial
third with the lateral two-thirds by the supra-orbital
notch or foramen.
 The medial margin is formed above by the frontal
bone and below by the frontal process of the
maxilla.
 The lower margin is formed medially by the maxilla
and laterally by the zygomatic bone.
 The zygomatic process of the frontal bone, above,
and the frontal process of the zygomatic bone,
below share in the formation of the lateral margin. 3
 The Orbital Cavity (fig. 10)
 It is pyramidal in shape.
 Its axis is directed backwards and medially.
1. The roof of the cavity:
 Is formed almost entirely by the frontal bone.
 Anteromedially, it splits to tables by the frontal sinus.
 Anterolaterally, there is a deep depression called the
lacrimal fossa, occupied by the lacrimal gland.
2. The medial wall:
 Presents anteriorly the lacrimal groove, for the lacrimal
sac.
 The groove is limited anteriorly by the lacrimal crest of
frontal process of maxilla, and posteriorly by lacrimal
crest of lacrimal bone.
 Inferiorly, the groove communicates with the nasal
cavity through the nasolacrimal canal.
32
 Behind that groove, the wall is formed from before
backwards by the lacrimal bone, the ethmoid bone,
and the body of the sphenoid bone.
 The ethmoid bone makes the largest part of this wall.
 The junction of the upper border of this bone with
the roof is interrupted by the anterior and posterior
ethmoidal foramea, through which the vessels and
nerves of the same names pass into the anterior
cranial fossa.
 The anterior opening of the optic canal lies at the
posterior end of the junction of the roof with the
medial wall.
 It transmits the optic nerve and the ophthalmic
artery.
 The canal establishes communication between the
orbit and the middle cranial fossa. 3
3. The floor: Is mostly formed by the maxillary bone,
but anterolaterally by the zygomatic bone.
4. The lateral wall:
 Is formed by the frontal process of zygomatic bone,
anteriorly, and by greater wing of sphenoid bone,
posteriorly.
 It is continuous anteriorly with the roof and floor of
the cavity, but posteriorly separated from them by
superior and inferior orbital fissures, respectively.
The superior orbital fissure communicates with the
middle cranial fossa and transmits the oculomotor,
trochlear and abducent nerves and the terminal
branches of opthalmic nerve, and the ophthalmic
veins.
 The inferior orbital fissure communicates the orbital
cavity anteriorly with the infratemporal fossa and
 The medial margin of the fissure is interrupted at
its mid-point by the infra-orbital groove, which
passes forwards and becomes continuous with the
infra-orbital canal.
 The canal ends anteriorly at the infra-orbital
foramen.
 Through the anterior part of the inferior orbital
fissure a communicating vein pass, which connects
the inferior ophthalmic vein with the pterygoid
venous plexus.

35
 The Cranial Cavity
 It is the inner aspect of the clavaria.
 It presents numerous ridges which correspond to
the sulci of the cerebral hemispheres.
 It is lined by the outer layer of the dura mater
(endocardium) , which is a fibrous membrane.
 The cranial cavity consists of two parts, the
internal surface of the cranial vault (clava) and the
internal surface of the base of the skull.

3
.Figure 3 – The clava (skull cup)
Internal Surface of Clava (fig. 3)
 It is marked in the midline by a median groove, the
sagittal sulcus, which accommodates the superior
sagittal venous sinus.
 The sulcus extends from the upper end of frontal
crest to the internal occipital protuberance, where it
becomes continuous with one of the transverse
groove (usually the right) in which lie the transverse
venous sinus.
 On each side of the sagittal sulcus, there are small
depressions, the granular foveolae, which
accommodate the arachnoid granulations.

37
.Figure 4 – The cranial cavities
Figure 11A – Internal surface of base of skull.

38
Figure 11B – Internal surface of base of skull.

39
Internal Surface of Base of Skull (fig. 4, and11)
Presents three cranial fossae, anterior, middle, and
posterior:
1. Anterior Cranial Fossa:
 Contains the frontal lobes of the cerebral hemispheres
of brain.
 Its floor consists, a central (median) portion, and on
each side a lateral portion.
a. The median portion:
 Forms the roof of nasal cavity.
 It is formed anteriorly by horizontal (cribriform) plate of
the ethmoid bone, and posteriorly by the anterior part of
the body of the sphenoid bone, the jugum sphenoidal.
 A sharp triangular plate called the crista galli projects
upward from the midline of the anterior part of the
cribribriform plate of the ethmoid bone. 40
 The foramen cecum is a small pit situated in front of
the crista galli, and opens sometimes into the roof of
nasal cavity.
 It transmits a small vein from nasal mucosa to
superior sagittal sinus.
 On each side of crista galli is a narrow slit for the
passage of the anterior ethmoidal nerve.
 The cribriform plate presents several small openings
through which the olfactory nerves pass to end in
olfactory bulbs.
b. The lateral portions:
 Each is mainly formed by the orbital plate of frontal
bone; whereas the small posterior part is formed by
the lesser wing of sphenoid bone.
 The medial end of the posterior border of the lesser
wing is expanded backward and medially to form the
.Figure 4 – The cranial cavities
Figure 11A – Internal surface of base of skull.
:Middle Cranial Fossa .2
 It is deeper than the anterior cranial fossa.
 It houses the temporal lobes of the cerebral
hemispheres of brain.
 It consists of a central (median) portion, and on
each side a lateral portion.
a. The median portion:
 Is formed by the body of the sphenoid bone.
 Anteriorly there is a shallow sulcus termed the
sulcus chiasmaticus.
 The sulcus leads on each side to the optic canal.
 Behind this sulcus the body of the sphenoid
exhibits the shape of a Turkish saddle called the
sella turcica.
42
 The anterior slope of the sella turcica presents a
raised area called the tuberculum sellae.
 Behind this tubercle is a deep depression called
the hypophysial fossa that contains the hypophysis
cerebri.
 Behind this fossa, a plate of bone projects upward
to form the dorsum sellae.
 The supralateral angles of the dorsum sellae
expanded to form the posterior clinoid processes.
 A shallow groove passes forwards from the
foramen lacerum on each side of the body of
sphenoid.
 The groove is occupied by the internal carotid
artery.

43
b. The lateral portions:
 Each is formed anteriorly by the greater wing of
sphenoid bone; posteriorly by the anterior surface of
the petrous part of temporal bone; and laterally by
the squamous part of the temporal bone, which is
wedged between the greater wing and the anterior
surface of the petrous.
 The superior orbital fissure lies between the
greater and lesser wing of sphenoid, and transmits
the lacrimal, frontal, trochlear, oculomotor,
nasociliary, and abducent nerves together with the
superior ophthalmic vein.
 The greater wing of the sphenoid is pierced by:

44
(1) foramen rotundum: Lies just behind the medial
end of the superior orbital fissure, and transmits the
maxillary nerve.
(2) foramen ovale: Lies posterolateral to the foramen
rotundum, and transmits the mandibular nerve and
the accessory meningeal artery.
(3) foramen spinosum: Lies posterolateral to the
ovale, and transmits the middle meningeal artery.
 The foramen lacerum is an irregular space between
the apex of petrous part of temporal bone and the
body of sphenoid.
 It is closed in the living persons by cartilage and
transmits only a small vein.

45
 The posterior wall of the foramen lacerum contains
the upper opening of the carotid canal which
transmits the internal carotid artery.
 This artery runs forward in a groove along the side
of the body of sphenoid bone to reach the anterior
clinoid process.
 The anterior surface of the petrous part of temporal
bone presents a shallow depression near the apex of
the bone called the trigeminal impression, which is
occupied by the trigeminal ganglion.
 Around elevation, the arcuate eminence produced
by the underlying anterior semicircular canal can be
seen posterolateral to the trigeminal impression.

46
 Lateral to arcuate eminence, the anterior surface of
petrous is formed by tegmen tympani, which forms
the roof of the mastoid antrum and extends forwards
to roof the tympanic cavity (middle ear), and
auditory tube.
 Lateral to trigeminal impression, the anterior
surface of petrous presents two grooves running
anteriorly, the medial groove is occupied by the
greater petrosal nerve (branch of the facial nerve),
and the lateral groove is occupied by the lesser
petrosal nerve (branch from the tympanic plexus).

47
.Figure 4 – The cranial cavities
Figure 11A – Internal surface of base of skull.
3. Posterior Cranial Fossa:
 It is deeper than the middle fossa, occupied by
hind brain (cerebellum, pons, and medulla
oblongata).
 It is formed mainly by the occipital bone, but the
small anterolateral part is formed by the posterior
surface of the petrous and the lateral part by the
mastoid bone, behind the base of the petrous bone.
 Anteriorly in the median plane the occipital bone
presents the largest foramen in the skull, the
foramen magnum, through which the spinal cord
with its meninges, the vertebral arteries, and the
ascending spinal part of the accessory nerve pass.

48
 The foramen magnum is bounded anteriorly by the
basilar part, laterally by the lateral (condylar) parts, and
posteriorly by the squamous part of the occipital bone.
 The squamous part is the largest part of the occipital
bone.
 It is divided by the internal occipital crest into two
fossae.
 The crest runs from the foramen magnum to the
internal occipital protuberance.
 The latter is situated on the inner surface of the
occipital bone opposite the external occipital
protuberance.
 In front of the foramen magnum, the dorsum sellae, the
posterior part of the body of sphenoid, and the basilar
part of the occipital bone form a continuous slope called
the clivus, upon which the brain stem lies.
49
 The posterior surface of the petrous presents near
its center the internal acoustic meatus, which
transmits the facial nerve, nervous intermedius,
vestibulocochlear nerve, and Labyrinthine artery.
 The jugular foramen lies between the petrous and
the occipital bone, just below the internal acoustic
meatus.
 It transmits the glossopharyngeal, vagus, and
accessory nerves and the internal jugular vein.
 The superior border of the petrous is grooved by
the superior petrosal sinus.
 The inferior petrosal sinus grooves the articulation
between the petrous and occipital bone.
 The groove runs laterally from the apex of the
petrous to jugular foramen.
50
 Medial to the jugular foramen, there is around
elevation termed the jugular tubercle.
 This tubercle lies in front of the internal opening of
the anterior condylar (hypoglossal) canal, through
which the hypoglossal nerve passes.
 The grooves for the right and left transverse
sinuses, one on each side passes laterally from the
internal occipital protuberance to reaches the base
of the petrous, where each becomes continuous
with an S-shaped groove for the sigmoid sinus
grooving the mastoid bone and terminates at the
jugular foramen.
 The proximal part of the sulcus is pierced by the
mastoid foramen, which transmits an emissary vein
from the sinus.
51
Figure 12 A – The mandible(Anterior view).

52
.Figure 12 B – The mandible (Lateral view)

53
Figure 12 C – The mandible (Medial view).

54
.Figure 12 D – The mandible (Medial and lateral view)

55
The Mandible (fig. 12 A, B, C, and D)
 Consists of an anterior transverse part called the body
and a posterior vertical part termed the ramus (fig. 5.14).
The body is horseshoe shaped.
Body:
Anteriorly the external surface of the body is marked in
the midline by a faint ridge called the symphysis menti,
which indicates the line of fusion of the two halves of
the fetal bones.
 Inferiorly the ridge splits to enclose a triangular area
called the mental protuberance.
 The base of the protuberance is raised on each side to
form the mental tubercle.
 The oblique line is a faint ridge that runs backward and
upward from the mental tubercle to become continuous
with the anterior border of the ramus. 56
 The mental foramen lies below the 2nd premolar
teeth, usually midpoint between the upper and lower
borders of the body.
 It transmits the mental nerve and vessels.
 The lower border of the body of the mandible (base
of the mandible), is marked near the symphysis
menti by a rough small depression called the
digastric fossa.
 Posteriorly the lower border of the body continues
with the lower border of the ramus.
 The upper border of the body is called the alveolar
process, which exhibits 16 sockets for the lower
(mandibular) teeth.
 The incisive fossa is a shallow depression, which
lies below the incisor teeth.
57
 The internal surface of the body is marked by an
oblique ridge called the mylohyoid line, which
begins behind the third molar tooth and runs
forward and downward to end at the symphysis
menti.
 The fossa below the mylohyoid line is called the
submandibular fossa for submandibular salivary
gland.
 The fossa above the mylohyoid line is termed the
sublingual fossa for the sublingual salivary gland.
 The posterior surface of the symphysis menti, is
marked immediately above the terminal ends of the
mylohyoid lines by the upper and lower mental
spines (genial tubercles).

58
Ramus:
 The ramus of the mandible is quadrilateral.
 Its lower border is continuous anteriorly with the base
of the mandible, and posteriorly meets the posterior
border at the angle of the mandible.
 Its upper border presents two processes separated by
a wide notch called the mandibular incisure or notch.
 The anterior process is called the coronoid process.
 The posterior process is called the condylar process.
 It is expanded above to form the head of the mandible,
which is covered with fibrocartilage.
 The head articulates with the mandibular fossa to form
Temporomandibular (T.M.) joint
 The neck of the mandible is the constricted portion
below the head.

59
 The medial surface of the ramus exhibits a little above its
center an irregular foramen called the mandibular foramen.
 The foramen leads into a bony canal termed the
mandibular canal.
 The canal runs downward and forward in the ramus and
then horizontally forwards in the body of the mandible
below the sockets of the teeth, with which it communicates
by small canals.
 Anteriorly the mandibular canal divides into mental and
incisive canals.
 The mental canal opens laterally on the mental foramen.
 The incisive canal continues forwards below the incisor
teeth.
 The mandibular foramen transmits the inferior alveolar
nerve and vessels.
 The mandibular foramen is obscured by a thin triangular
process termed the lingula.
 The mylohyoid groove begins behind the lingual.
 It runs downward and forward on the medial
surface of the ramus and the inner surface of the
body, where it terminates below the posterior end of
the mylohyoid line.

61
62
63
64
6
 Lateral Radiograph of the cranium
The labeled features include the paranasal sinuses:
Ethmoid (E), Sphenoid (S), and Maxillary (M), and
Hypophyseal fossa (H) for the pituitary gland, the
Petrous part of the temporal bone (T), Mastoid cells
(Mc), Groove for the branches of the middle
meningeal vessels (Mn), Arch of atlas (A), Internal
occipital protuberance (P), and the Nasopharynx (N).
The right and left orbital plates of the frontal bone
are not superimposed; thus, the floor of the anterior
cranial fossa appears as two lines (L).
65
66
1. Frontal sinus; 2. Nasal bone; 3. Hard
palate; 4. Hyoid bone; 5. Anterior glenoid
process; 6. Posterior glenoid
process; 7. Lambdoid suture; 8.
Sphenoidal air sinus; 9. Mastoid air
cells; 10. Posterior tubercle of atlas
vertebra; and 11. Spinous process of
axis vertebra.
66
 Fracture of the skull
Skull fractures are common in adults, but not in children.
The site of the fracture depends on the area of the skull
that receives the truma. The type of the fracture depends
on the severity of blow and the age of the patient.

Fractures of the Anterior Cranial Fossa

Fracture of the orbital plate of the frontal bone may
results in hemorrhage into the orbital cavity, resulting in a
condition known as exophthalmos. The conjunctiva
becomes engorged (chemosis).
The cribriform (horizontal) plate of ethmoid bone may be
involved in this fracture. The latter fracture causes tearing
in the covering meninges. As a result the patient will have
epistaxis (nasal bleeding). 67A
with leakage of CSF (cerebrospinal fluid) into the nose
(cerebrospinal rhinorrhea).

Fracture of the Middle Cranial Fossa

Fractures in this area of the base of skull are common,
since it is a weak area, due to the presence of many
foramina, canals, and cavities (middle ear and sphenoidal
air sinus).
 The seventh and eighth cranial nerves are commonly
injured as they pass through the petrous part of temporal
bone.
If the lateral wall of the cavernous sinus is tourn, the III,
the IV, ophthalmic and maxillary branches of the V, and
VI cranial nerves may injured. Cerebrospinal fluid (CSF)
may leak into the sphenoidal air sinus, from which pass
The internal carotid artery may be torn, producing
an arteriovenous fistula within the cavernous sinus.
As a result arterial blood rushes into cavernous
sinus, enlarging it and forcing retrograde blood
into venous tributaries, especially the ophthalmic
vein. Subsequently, the eyeball protrudes
(exophthalmos) and the conjunctiva becomes
engorged (chemosis)

68
 Fractures of the Posterior Cranial Fossa
a. Fractures of the occipital bone: Blood may
escape into the nape of the neck deep to
postvertebral muscles. The mucous membrane of
the roof of the nasopharynx may be torn, and blood
escape there.
b. Fractures involving the jugular foramen: May
results in injuries to the69ninth, tenth, and eleventh
cranial nerves. The strong bony walls of the
anterior condylar (hypoglossal) canal usually
protect the hypoglossal nerve from injury.
the hypoglossal nerve is not included in such
injuries.
69
 Fracture of the Nasal Bones
The nasal bones are the most common facial fracture,
resulting in laceration of the covering skin. Sever fractures
may be associated with injuries to nasal septum.

Fracture of the Maxilla

Massive truma to the face may results in fracture to the
maxillary bone. As a result, there will be extensive swelling
in the face. Blood enters the maxillary sinus, and
subsequently leak from the nose (epistaxis). The facial
truma may involved the cribriform plate of ethmoid,
resulting of leakage of CSF into nasal cavities
(cerebrospinal rhinorrhea). The infraorbital nerve may be
injured, resulting in anesthesia of the skin cheek and
upper gum.
70
 Fractures of the Zygomatic Bone or Zygomatic
Arch
This fracture may occur after car accidents. Although it
can occur as an isolated fracture, but usually it is
associated with multiple other fractures.

Fracture of the Mandible

Severe mandibular truma may results in a single fracture
or multiple fractures of the mandible.
71
.Figure 13 – The hyoid bone

72
 Hyoid Bone (fig. 13)
 It is U-shaped and consists of a body and two
greater and two lesser horns.
 It lies in the neck below the mandible and just
above the larynx.
 It forms a base for the tongue.
 It is connected to the styloid process of the
temporal bone by the stylohyoid ligament.

7
.Figure 14 – The sternum

74
 The Sternum (fig. 14)
 Consists of three parts: manubrium sterni, body, and
xiphoid process.
 The manubrium is the upper part of the sternum.
 Its upper border presents the supra sternal (jugular) notch.
 The manubrium sterni articulates on each side with the
corresponding clavicle, and the 1st and upper part of the 2nd
costal cartilages.
 The body of the sternum articulates above with the
manubrium to form the manubriosternal joint or sternal angle
or angle of louis, below with the xiphoid process to form the
xiphisternal joint, and on each side with the corresponding
lower part of the 2nd costal cartilage and the 3rd to the 7th
costal cartilages.
 The xiphoid process is the lowest and smallest part of the
sternum.
 It is a thin plate of hyaline cartilage.
75
.Figure 15 – The thoracic cage

76
 The Ribs (fig. 15)
 There are twelve pairs of ribs, all of which are
attached posteriorly to the thoracic vertebrae.
 The upper seven pairs are attached anteriorly
directly by their costal cartilages to the sternum, and
are called true ribs.
 The 8th , 9th, and 10th pairs of ribs are attached
anteriorly to each other and to the seventh rib by
means of their costal cartilages and are referred to
as false ribs.
 The 11th and 12th pairs have no anterior attachment
and are known as floating ribs.
 The 3rd – 9th ribs are typical ribs.
 The remaining ribs (1st , 2nd , 10th , 11th , and 12th )
are atypical ribs. 77
.Figure 16A – Typical rib (anterior view)

78
Figure 16B – Typical rib (posterior view).

A 79
B 79
 Typical ribs (fig. 16)
 Each has a head, neck, tubercle, shaft, and angle.
 The head has two facets for articulation: The lower with the
numerically corresponding vertebral body and the upper with
the vertebra immediately above.
 The neck is a constricted portion situated between the head
and the tubercle.
 The tubercle lies on the outer surface of the rib at the
junction of the neck with the shaft.
 It has an articular part bear a small facet for articulation
with the transverse process of the numerically corresponding
vertebra; and a rough non articular part serves for
ligamentum attachments.
 The shaft or body is thin and twisted on its long axis.
 Its internal surface exhibits the costal groove, which runs
close and parallel to the inferior border of the shaft.
 The costal angle is where the shaft of the rib bends sharply
forward. It is about 5 – 6 cm from the tubercle. 80
.Figure 17A – The first and Second rib (superior view)

81
.Figure 17B – The first and second ribs (superior view)

82
 The anterior end of each rib is attached to the
corresponding costal cartilage.

Atypical Ribs
a. The first rib (fig. 17):
 It is the shortest and most sharply curved rib.
 It is important clinically because of its close
relationship to the nerves of the brachial plexus.
 The head has a single facet.
 The tubercle and angle coincide.
 The inner border presents the scalene tubercle.
 The superior surface has two shallow grooves, the
anterior groove for the subclavian vein, whereas the
posterior, for the subclavian artery and inferior trunk
of the brachial plexus. 83
.Figure 18 – The second rib

84
b. The second rib (fig. 17B, and 18):
It is less curved, and considerably longer than the
first. The angle is closed to the tubercle.

c. The tenth to twelfth ribs:

 The 10th rib has a single articular facet on its head.
 The 11th and 12th ribs are short and little curved.
 They have single articular facets on their heads.
 They have no neck or tubercle.
 The 11th rib has a slight angle and a shallow costal
groove.
 The 12th has no angle and it is much shorter than
the 11th .

85
 The spaces between ribs are called the intercostals
spaces, and are occupied by intercostal muscles,
blood vessels, and nerves.
 The wall of the thoracic cavity is formed posteriorly
by the thoracic part of vertebral column; anteriorly
by sternum and costal cartilages; laterally by ribs,
and intercostal muscles.
 The superior thoracic aperture is bounded
posteriorly by the first thoracic vertebra; laterally by
the first pair of ribs; and anteriorly by the upper
border of the manubrium sterni (supra sternal
notch).
 Through it the thoracic cavity communicates with
the root of the neck.

86
 The inferior thoracic aperture is bounded posteriorly by the 12 th
thoracic vertebra; laterally by the 12th pair of ribs; and anteriorly by
costal cartilages of ribs 7 – 10 and xiphoid process.
 This aperture is closed by the diaphragm, which separates the
thoracic cavity from abdominal.
 Anteriorly, the angle below the sternum is called the infrasternal
angle (fig. 15).

Cervical Rib (A Rib Arising From the Anterior Tubercle

Of the transverse Process of the 7th Cervical vertebra)
 Usually have free end, however sometime it articulate with the first
rib or connected to that rib by a ligament.
 Cervical rib, in some of the patients, may applied a pressure on the
lower trunk of the brachial plexus, results in a referred pain over the
medial side of the forearm and hand, associated with wasting of the
muscles of the hand.
 Sometime it also produce pressure on subclavian artery, which
may interfere with the circulation. 87
.Figure 19 – The vertebral column (5 regions and 4 curves)

88
 The Vertebral Column
 The vertebral column is a chain of ossified
elements called vertebrae, flexibly connected by
intervening discs of deformable substance.
 It provides support to the skull, pectoral girdle,
upper limbs, and thoracic cage.
 It transmits the body weight via the pelvic girdle to
the lower limbs.
 Typically in human body, there are 33 vertebrae
divided into five regions (fig. 19), from above
downwards: 7 cervical, 12 thoracic, 5 lumbar, 5
sacral (fused to form the sacrum), and 4 coccygeal
(fused to form the coccyx).

89
 Normally in the adult in the standing position the
vertebral column presents in the sagittal plane four
curvatures: cervical, thoracic, lumbar, and sacral
(fig. 19).
a. The cervical curve: Is convex forwards, begin at
the C1 vertebra (atlas), and ends at the T2 vertebra.
b. The thoracic curve: Is concave forwards, extends
from the T2 – T12 vertebra.
c. The lumbar curve:
 Is convex forwards and is more pronounced in the
male.
 It extends from the T12 vertebra to the lumbosacral
angle.
d. The sacral curve: Its concavity faces downwards
and forwards, and extends from the lumbosacral
joint to the apex of coccyx. 90
 The thoracic and sacral curves are called primary
curves because they form first during fetal
development.
 The cervical curve appears at about 6 weeks – 3
months after birth when the child holds its head up.
 The lumbar curve appears at 6 months when the
child begins to sit up, and becomes more
accentuated when the child begins to walk at about
one year.
 Therefore, the cervical and lumbar curves are
known as secondary curves.
 In the upper part of the thoracic region of the
vertebral column, there is often a slight lateral
curvature, with its convexity directed towards the
right side in right-handed persons, and to the
opposite side in the left-handed persons. 91
Kyphosis: Is an exaggeration in the sagittal thoracic
curvature, which may be caused by structural
changes in the vertebral bodies and/or intervertebral
disc or by muscular weakness.
Lordosis: Is an exaggeration in the sagittal lumbar
curvature results from an increase in the weight of
the abdominal contents.
Scoliosis: Is a lateral deviation of the vertebral
column, which occurs most commonly in the
thoracic region and is attributed to muscular or
vertebral defects.

92
.Figure 20A – the intervertebral disc

93
.Figure 20B – the intervertebral disc

94
Intervertebral discs (fig. 20 A and B)
 They lie between the bodies of adjacent vertebrae
from the second cervical to the sacrum.
 They form strong joints, permit various movements
of the vertebral column, and absorb vertical shock.
 Each disc consists of a peripheral part of
fibrocartilage called the anulus fibrosus and an inner
soft, pulpy, highly elastic part called the nucleus
pulposus.
 The upper and lower surfaces of the bodies of
adjacent vertebrae that abut onto the disc are covered
with thin plate of hyaline cartilage.
 In old age the disc becomes thin and less elastic,
and the vertebrae are compressed, results in a
decrease in the length of vertebral column.
95
Figure 21 – Parts of typical vertebra: A. Superior and B.
Lateral view.

A B

96
 Parts of Typical Vertebra (fig. 21)
 Each vertebra has an anterior mass called body, and a
posterior arch called, vertebral arch.
 These two elements surround a foramen called the vertebral
foramen.
 The vertebral arch is formed on each side anteriorly by a
short, thick, and rounded bone called pedicle, and posteriorly
by a long flat bone called lamina.
 The pedicle (on each side) projects backward from the body
to joins the lamina.
 The right and left lamina joins posteriorly in the midline.
 On each side, from the junction of the pedicle and the
lamina, three processes arise:
a. An upper process: The superior articular process.

97
b. A lower process: The inferior articular processes.
c. A lateral process: The transverse process.
 A single spinous process (spine) projects backwards
from the junction of the two laminae.
 The two superior articular processes of a vertebra,
each bears a facet, directed posteriorly and often
laterally, which articulates with the corresponding
facet on the inferior articular processes of the vertebra
immediately above them.
 In turn, the two inferior articular processes of that
vertebra, each bears a facet, directed forwards and
often somewhat medially, and articulate with the
corresponding facet of the superior articular
processes of the vertebra immediately below them.
 The two transverse processes and the single
spinous process serve as points of attachment for
.Figure 22 – Typical cervical vertebra

99
 Cervical Vertebrae
 The 3rd – 6th cervical vertebrae are typical vertebrae.
 The remaining vertebrae (1st, 2nd , and 7th) are atypical.
 The typical vertebrae (fig. 22 and 25) have the following
characteristics:
1. The body is small and broad from side to side.
2. The vertebral foramen is large and triangular.
3. The transverse processes presents close to its origin the
foramen transversarium for the passage of the vertebral
artery and vein.
4. The spine is short and bifid.
5. The depth of the superior and inferior vertebral notches
are almost, equal.
6. The facets of the superior articular processes are faced
backwards and upwards, those of the inferior articular
processes are directed forwards and downwards.
100
 Each transverse process exhibits anterior and
posterior roots, which end laterally as anterior and
posterior tubercles.
 The anterior tubercle of the sixth vertebra is large,
(called carotid tubercle) because the common
carotid artery, ascends in front of the tubercle.
 Here, the artery can be effectively compressed.

Atypical Cervical Vertebrae

C1 vertebra or Atlas (fig. 23 and 24):
 Consists two lateral mass, one on each side,
connected by a short anterior and a longer, and
much curved posterior arch.
 Each lateral masse has two articular surfaces,
placed on the upper and lower surfaces,
respectively.
.Figure 23 – Atlas vertebra (superior view)

102
.Figure 24 – Atlas and Axis vertebrae

103
 The upper facets are kidney-shaped, and articulate
with the corresponding occipital condyles of the
occipital bone forming the atlanto-occipital joints.
 The lower facets are circular and articulate with the
corresponding superior articular facets of the axis.
 The anterior arch presents anteriorly in the midline,
the anterior tubercle; and posteriorly articular facet
for the dens of axis vertebra.
 The posterior arch exhibits posteriorly in the
midline posteriorly, the posterior tubercle.
 The vertebral artery runs in a wide groove situated
on the upper surface of the posterior arch, behind
the lateral mass.

104
C2 Vertebra or Axis (fig. 24):
 The axis vertebra has a tooth-like process called
the odontoid process or dens that projects
superiorly from the superior surface of the body
through the anterior portion of the vertebral foramen
of the atlas.
 On the anterior aspect of the dens, there is an oval
articular facet, which articulates with similar facet on
the back of the anterior arch of the atlas.
 Posteriorly, the dense is grooved by the transverse
ligament of the atlas.
 The superior articular facets differ from those of
other cervical vertebrae that they do not form an
articular pillar with inferior facets; being
considerably anterior to the latter.
105
Figure 25 – A. Typical cervical vertebra, and B. C7 vertebra.

106
C7 vertebra (fig. 25):
 Has long, horizontal and unbifid spinous process,
to which the lower end of the ligamentum nuchae is
tied.
 The foramen transversarium is small and transmits
the vertebral vein only.

107
.Figure 26 – Typical thoracic vertebra

108
 Thoracic Vertebrae
 The 2nd - 8th thoracic vertebrae are typical.
 The remaining vertebrae (1st, 9th, 10th, 11th, and 12th) are
atypical.
 The typical thoracic vertebra has the following
characteristics: (fig. 26):
1. The body is medium size and heart shaped.
2. On each side the body presents a superior and
inferior demi-facets near the upper and lower borders,
respectively for articulation with the heads of the ribs.
3. The vertebral foramen is small and circular.
4. Each transverse process presents a costal facet near
its apex for articulation with the tubercle of the
numerically corresponding rib.
5. The spine is long and directed backward and
downward.
109
 6. The facets of the superior articular process are
directed backward, and a little laterally and upwards;
those of the inferior articular process are faced
forwards and a little medially and upwards.

Atypical Thoracic Vertebrae

T1 Vertebra (fig. 27): It has on each side of the
vertebral body a complete superior facet for
articulation with the 1st rib, and an inferior demi-facet
for articulation with the 2nd rib.
T10 – T12 Vertebra (fig. 28 and 29):
 Each one of these vertebrae has only one facet on
each side near the upper border of the vertebral
body by which they articulate with the heads of the
numerically corresponding ribs. 110
Figure 27 – T9 vertebra.

111
.Figure 28 – T10 vertebra

112
.Figure 29 – T11 vertebra

113
Figure 12 – The 1st, 9th,
10th, 11th, and 12th
thoracic vertebrae (right
lateral aspect).

114
115
116
 Although T9 typical, often fail to form joints with the
tenth ribs, and the inferior demifacets on the body are
then are then absent.
 The facets on the bodies of T10 vertebrae are
semilunar in shape, but when they are oval when the
tenth ribs fail to articulate with T9 vertebra.
 The facets on the bodies of T11 and T12 vertebrae are
circular.
 Those facets of T12 vertebra lie somewhat below the
upper border of the body and extend on to the pedicle.
 The body of T12 vertebra is large and approximates to
the lumbar type.
 The transverse processes of T11 and T12 vertebrae
lack articular process.
 In addition, the transverse processes of T12 vertebra
present lumbar features.
117
.Figure 30 – The lumbar vertebra

118
 Lumbar Vertebrae
Lumbar vertebrae have the following characteristics:
1. The bodies are kidney shaped, and are larger than
those of the cervical and thoracic vertebrae.
2. The vertebral foramena are triangular and larger
than in the thoracic, but smaller than in cervical
region.
3. The transverse processes are long and slender
and have neither foramena nor articular facets.
4. The spinous processes are short, flat, and
quadrangular and projects backward.
5. The superior articular facets are directed
backwards and medially, the inferior facets face
forwards and laterally.
L5 vertebra differ from others by the following
features:
a.Its transverse processes are short and stumpy.
b.The inferior articular processes are far apart.

120
.Figure 31 – The sacrum

121
.Figure 32 – The sacrum (posterior view)

122
 Sacrum (fig. 31 and 32)
 Consists of five vertebrae fused to form a
triangular-shaped bone, which has an apex, a base,
and two surfaces, anterior and posterior.
 The base of the bone lies superiorly.
 The oval-shaped upper surface of the S1 vertebra
forms the great part of the base.
 It is connected with the L5 vertebra by an
intervertebral disc.
 The anterior margin of this surface bulges
forwards to form the sacral promontory.
 Behind the upper surface of S1 vertebra, there is a
triangular opening, which represents the upper end
of the sacral canal.
123
 Posterolateral to this opening, on each side, the
superior articular processes project upwards for
articulation with the inferior articular facets of the L5
vertebra.
 The lateral part of the base is called ala of the
sacrum.
 The inferior surface of the S5 vertebra forms the
apex of the sacrum, which exhibits an oval facet for
articulation with the coccyx.
 The anterior (pelvic) surface of the sacrum is concave.
 It presents four transverse ridges, which indicate the line
of fusion of the bodies of the five sacral vertebrae.
 On each side, lateral to these transverse ridges, there are
four anterior sacral foramina, through which communicate
with the sacral canal.
124
 They transmit the anterior rami of the upper four
sacral spinal nerves.
 The portion of the sacrum lateral to these foramina
is called the lateral mass.
 Superiorly, the lateral side of the lateral mass
presents an L-shaped articular facet, known as the
auricular facet for articulation with the
corresponding iliac bone.
 The posterior surface of the sacrum (gluteal
surface) is convex.
 In the median plane the median sacral crest
represents the fused spines of sacral vertebrae.
 On each side, the posterior surface represents four
posterior sacral foramina, which communicate with
the sacral canal and transmit the posterior rami of
the sacral spinal nerves. 125
 The intermediate (medial) sacral crest lies medial to
the sacral foramina.
 It is formed by the fused articular processes of the
sacral vertebrae.
 Lateral to the posterior sacral foramina, the lateral
sacral crest represents the fused transverse processes.
 Lateral to the median sacral crest the fused laminae of
the sacrum form the upper part of the posterior wall.
 The lamina of the S4 and S5 vertebrae and sometime
S3 are missing, results in an n–shaped gap in the
posterior wall of the sacral canal, which is called the
sacral hiatus.
 The inferior articular processes (sacral cornua) of S5
vertebra project downwards on each side of the sacral
hiatus.

126
 They articulate with the corresponding cornua of
the coccyx.
 The sacral canal is formed by the vertebral
foramina of the sacral vertebrae.
 It contains the cauda equina including the filum
terminale.
 The female sacrum is relatively shorter and wider
than in the male.
 In the male the anterior surface shows a much
more curvature from above downwards than in the
female.
 However individual variation is so great that this
cannot be relied on to determine the sex.

127
 Fig. 31))Coccyx
 The coccyx consists of four vertebrae fused
together to form a single small triangular bone.
 The base of the coccyx lies superiorly, and is
formed by the upper surface of the body of the first
coccygeal vertebra.
 It has an oval facet for articulation with the apex of
the sacrum.
 Posterolateral to this facet, the coccygeal cornua
projects upwards to articulate with the sacral
cornua.
 Sometime, Co1 vertebra is separate.
 On each side of the body of Co1 vertebra, a
rudimentary transverse process projects laterally
and slightly upwards.
128
129
130
131
132
 Fractures of the Vertebral Column
Direct truma may cause fracture to the transverse
processes, spinous processes, or laminae. Sometime,
however severe muscular contraction may cause fractures
to these vertebral structures.

Anterior Compression Fractures

 May result from sudden forceful flexion as in automobile
accident.
 Typically, the injury is anterior crush or compression
fractures of the body of one or more vertebrae.
 In such cases the vertebral arches remains unbroken,
and the posterior longitudinal ligament and the
intervertebral ligament remain intact. In such fracture the
123 spinal cord is not injured.
  If violent anterior movement of the vertebra occurs in
addition to compression, a vertebra may be displaced
anteriorly on the vertebra inferior to it, such as dislocate of
C6 or C7 vertebra.
 Usually, these will be dislocates and fractures the articular
facets between the two vertebrae and ruptures in the
interspinous ligament.

Lateral Compression Fractures

Excessive lateral flexion may results in fracture of the lateral
part of the body of the vertebra.
134
Injuries of the Posterior Parts of the Vertebrae
 This type of injuries may occurs after as severe hyper
extension.
 Sever hyperextension of the neck may pinch the
posterior arch of C1 vertebra between the occipital
bone and C2 vertebra.
 In these cases, the C1 vertebra usually breaks at
one or both grooves for the vertebral arteries.
 The anterior longitudinal ligament and adjacent
annulus fibrosis of C2 and C3 IV disc may also
rupture.
 If this occurs, the spinal cord is usually severed.
Individuals with this injury seldom survive.
135
 Vertical Compression Fractures
Usually occur in the cervical and lumbar regions, where
there is possible to fully straighten the vertebral column.
In the cervical region, with the neck straight, an excessive
vertical force applied from above will cause the ring of the
atlas to be disrupted and the lateral masses to be displaced
laterally (Jefferson's fracture).
If the neck is slightly flexed, the truma is transmitted to the
lower cervical vertebrae, causing disruption of the
intervertebral disc and breakup of the vertebral body, with
protrusion of fragments posteriorly into the spinal cord.
In the straightened lumbar region, an extensive force from
below can cause the vertebral body to break up, with
protrusion of fragments posteriorly into the spinal cord.
136
Fractures Dislocation
 A combination of a flexion and rotation type of injuries,
may results in fracture and dislocations.
 The upper vertebra is excessively flexed and twisted on
the lower vertebra.
 In such condition, the articular processes are fractured
and the ligaments are torn.
 The spinal cord is usually severely damaged.
Fractures of the Odontoid Process of the Axis
These fractures are relatively common, results from falls
or blows on the head. Excessive mobility of odontoid
fragment or tear of the transverse ligament can result in
compression injury to the spinal cord.
137
 Cervical Vertebrae Dislocation
Cervical vertebrae can be dislocated in neck injuries with
less force with less force than is required to fracture them.
Slight dislocation can occur without injury to the spinal cord.
Severe dislocation, however, damaged the spinal cord.

Thoracolumbar Dislocation
Dislocation of vertebrae in the thoracic and lumbar regions
is uncommon, because the inter locking of their articular
processes.
138
 Fracture of the Interarticular part of the
Vertebral Lamina of L5 (Spondylolysis of L5)
 Such fracture may result in forward displacement of L5
vertebral body relative to sacrum (S1) vertebra.
 It may results in pressure on the spinal nerves of the cauda
equine as they pass into the superior part of the sacrum,
causing back and lower limb pain.

139
 Spina Bifid
Spina bifid occulta is a common congenital anomaly of the
vertebral column, in which the laminae of L5 and or S1 fail
to develop normally and fuse. Its location is often indicated
by a tuft of hair. Most people have no back problem.
Spina bifid cystic anomaly is associated with herniation of
the meninges (meningomyelocele). Usually neurological
symptoms are present in severe cases are present (e.g.
paralysis of limbs and disturbance in bladder and bowel
control).
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 Lumbar Spinal Puncture
To obtain a sample of CSF from the lumbar cistern, a lumbar
puncture needle, fitted with a stylet, is inserted into the
subarachnoid space.
Lumbar spinal puncture is performed with the patient
leaning forward or lying on the side with the back flexed.
Flexion of the vertebral column facilitates insertion of the
needle by stretching the ligament flava and spreading the
laminae and spinous processes of the L3 and L4 (or L4 and
L5) vertebra. At these levels in adults, there is little danger
of damaging the spinal cord.
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