Anatomicalintroduction

3rd INTERVENTIONAL HANDS-ON PAIN RELIEF & NEUROMODULATION CADAVER WORKSHOP Anatomicalintroduction Gdansk-Poland

Programmeofthelecture Shortintroductionto theanatomyof: 1.Vertebralcolumn 2.Intervertebraldiscs 3.Intervertebralforamina 4.Vascularsupplyofthevertebralcolumnandspinalcord 5.Spinalnerve 6.Autonomicnervoussystem

Vertebral column generalcharacteristics Length: 60-70 cm 33-34 vertebrae 23-25 mobile presacralvartebrae 23 intervertebraldiscs Anterior aspect: retropharyngealspace thoracicinlet mediastinum diaphragm retroperitonealspace pelvicinlet subperitonealspace Lateral aspect: paravertebralspace Function: supportofthe trunk spinal cord protection attachment for themuscles hemopoiesis (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Motion segments ofthevertebralcolumn Motion segments pedicles connect and transfer loads vertebral bodies sustain compressive loads facet joints, lamina, processes motion control (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Motion segments andjointsofthevertebralcolumn zygapophyseal joint Motion segments cervical uncovertebral joint synovial joints zygapophyseal(facet) joints thoracic uncovertebraljoints (C3-C7), absent at birth posterior longitudinal ligament lumbar cartilaginous joint intervertebraldisc (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów. Elsevier Urban & Partner, Wrocław 2010 and Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission) anterior longitudinal ligament fibrous joints ligaments

Intervertebraldisc-anatomy anulus fibrosus nucleus pulposus vertebral end-plate anterior longitudinal ligament grey communicating ramus posterior longitudinal ligament sinuvertebral nerve/ventral ramus (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów.elsevier Urban & Partner, Wrocław 2010, with permission)

Intervertebraldisc-nutrition largestavascularstructure ofhuman body (!) by diffusion from vertebral bodies lymphatic drainage(?) (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Intervertebraldisc degenerativedisease biochemicalfactors proteoglycans content water-binding capacity keratin sulphate/chondroitin sulphate ratio mechanicalfactors in ageing lumbar discs do notchangetheheight nucleuspulposusindents end-plates by increasing pressure discogenicpain resultsfromcombinationof biochemical and mechanical components Vast majority of low-back pain mechanical in nature, usually related to spinal degeneration ( wear and tear ) (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów. Elsevier Urban & Partner, Wrocław 2010 and Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Intervertebralforamen bordersandcontents inferior vertebral notch fibrose capsule of the facet joint superior vertebral body intervertebral disc inferior vertebral body superior vertebral notch Sizeof the foramen is not directlyrelated with thesize of the spinal nerve S1 is the largest spinal nerve Contents spinal nerve spinalganglion sinuvertebralnerve spinal artery intervertebralvein (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów. Elsevier Urban & Partner, Wrocław 2010 and Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Intervertebralforamen cervicalregion closerelationship: vertebralvessels facet joints uncovertebraljoints (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Intervertebralforamen thoracicregion closerelationship: costovertebraljointsand pleura (Source: Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Intervertebralforamen-lumbarregion L5 is the largest of lumbar nerves but itsforamen is smaller then L1- L4 liable to compression (Source: Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Muscles of the back and thoracolumbarfascia Extrinsicmuscles (trapezius, latissimusdorsimm. etc.) relatedto upper limbandrespiratory function posterior abdominal wall mm. Intrinsic muscles long polysegmental (superficial) (erector spinaegroup) short polysegmental (deeper) (multifidus, semispinalis, iliocostalismm. etc.) short intersegmental(deepest) (interspinalis, intertransversalismm.) Muscles of the posterior abdominal wall (psoasmajor, quadratuslumborummm. etc.) intrinsic mm. extrinsic mm. (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów.elsevier Urban & Partner, Wrocław 2010, with permission)

Arterial supply of the vertebralcolumnandspinalcord Vertebralcolumn Spinalarteries (branchesofsegmental andintersegmental arteries) Spinalcord artery of Adamkiewicz Anteriorandposterior medullaryarteries Radicularbranchesof segmentalarteries Artery of Adamkiewicz (92% between Th8-L1; 70-80% on the left side) (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów. Elsevier Urban & Partner, Wrocław 2010 and Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Venous supply of the vertebral column and spinal cord Valveless, ofconsiderable volume,drainingatlow pressure segmentaldrainageintoazygosand cavalvenoussystem external and internal vertebral venous plexuses basivertebralvein intervertebralveins (Source: Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Spinalnerve roots Spinal roots Ventralroot - efferent fibers somatic visceral(preganglionic) Dorsalroot - afferent fibers somatic visceral length oftheroots -is the consequenceofspinalcord development (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów. Elsevier Urban & Partner, Wrocław 2010 and Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Spinalnerve rami -topography Ventralramus metameric (thoracicnn.) plexuses (cervical, brachial, lumbo-sacral) For the limbs andanterolateralaspects of thetrunk Dorsalramus metameric For the dorsalregion (Source: Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Ventralramusofspinalnerve-branches Ventralramus Branches: sinuvertebraln.(recurrent meningal r.) grey communicating rr. white communicating rr. (Th1-L2) pelvicsplanchnicnn. (S2-S4) (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów.elsevier Urban & Partner, Wrocław 2010 and FeltenD.L et al. Atlas neuroanatomii i neurofizjologii Nettera, Elsevier Urban & Partner, Wrocław 2007, with permission)

Ventralramusofspinalnerve-branches Sinuvertebraln. (recurrentmeningealn.) sensory and autonomic fibers Branches: meningeal to ventral surface of the duralsac and nerve root sleeves sinuvertebralnerve skeletal posterior longitudinal ligament, posterior aspect of the intervertebraldisc, periosteum vascular vesselsofthevertebralcanal (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów.elsevier Urban & Partner, Wrocław 2010, with permission)

Dorsalramusofspinalnerve-branches Dorsalrami (L1-L5) pass through the intertransverselig. (L1-L4) lateralbranch motor (longissimus and iliocostalis mm.) sensory (skin -nn. cluniumsuperiores; L1-L3) medial branch sensory (facet joints, skin) motor (multifidus and interspinalis mm.) (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006 and Felten D.L et al. Atlas neuroanatomii i neurofizjologii Nettera, Elsevier Urban & Partner, Wrocław 2007, with permission)

Epidural andsubduralspace (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów.elsevier Urban & Partner, Wrocław 2010, with permission)

Autonomicnervoussystem Division sympathetic parasympathetic enteric Projections efferent (preganglionic, postganglionicneurons) afferent (neuronalbodiesinspinalganglia) Autonomic ganglia paravertebral prevertebral intramural Autonomic plexuses characteristic topography regional functional significance sympathetic and parasympathetic components (Source: Drake R. L. et al. Gray. Anatomia. Podręcznik dla studentów.elsevier Urban & Partner, Wrocław 2010, with permission)

Autonomicnervoussystem Sympathetic nervous system Preganglionic neurons intermediolateral grey matterof thespinal cord (Th1-L2, L3) Postganglionic neurons sympathetic trunk (21-25 paravertebral ganglia) prevertebralganglia Parasympathetic nervous system Preganglionic neurons Parasympatheticnucleiof CN III, CN VII, CN IX, CN X Sacralparasympatheticnucleus(S2-S4) Postganglionic neurons intramuralganglia

Sympathetictrunk cervicalpart On prevertebrallayer of deep cervical fascia Superior cervical ganglion Topography: C2, C3 transverse processes Middle cervical ganglion Topography: C6 transverse process Cervicothoracic(stellate) ganglion Topography: Th1 transverse process posteriorlyto subclaviana. at origin of vertebral a. behindthepleura (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006 and Felten D.L et al. Atlas neuroanatomii i neurofizjologii Nettera, Elsevier Urban & Partner, Wrocław 2007, withpermission)

Sympathetictrunk thoracicpart Topography: Th2 ganglion -in the 2nd intercostalspace superior thoracicganglia -against thecostal heads Th11, Th12 ganglia-lateral to vertebral bodies Th2 ganglion keyganglion for theupperlimb Branches: to thoracic aortic plexus (Th1-Th5) to pulmonary andcardiac plexus (Th1-Th5) thoracic splanchnic nerves (Th5-Th12) nerve of Kuntze -ascending ramifrom Th1-Th5 ganglia to brachial plexus (in ca. 54% of cases) (Source: Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Sympathetictrunk thoracicpart Thoracicsplanchnicnerves Greatersplanchnicnerve(Th5-Th9) Topography: piercesthecrusofdiaphragm projection to the coeliacand renal plexus Lesser splanchnicnerve (Th10-Th11) Topography: piercesthecrusbetween sympathetic trunk and greater splanchnic nerve projection to the renal andcoeliac plexus Least splanchnic nerve (Th12) Topography: passesundermedialarcuateligament projectionto renal plexus

Sympathetictrunk abdominalpart Topography: along medial margin of psoasmajor m., posterior to common iliac aa. right posterior to vena cava inf. left posterior to lateral aortic lymph nodes Fourlumbarganglia L2 ganglion key ganglion for the inferior limb Lumbarsplanchnicnn. projecting to abdominal plexuses (Source: Felten D.L et al. Atlas neuroanatomii i neurofizjologii Nettera, Elsevier Urban & Partner, Wrocław 2007, with permission)

Autonomicplexusesofabdomen Coeliacplexus Topography at Th12-L1 vertebrallevel, anterior to the cruraof the diaphragm,attheoriginofcoeliactrunk Components sympathetic: greaterandlessersplanchnicn. 1st,2ndlumbar splanchnicnn. parasympathetic: n. vagus Superior hypogastricplexus Topography attheanterior wallofaorta,l5 and promontory, between common iliac aa., more commonly on the left side Components: sympathetic: branches of intermesentericplexus, 3 rd,and 4 th lumbar splanchnicnn., parasympathetic: pelvic splanchnicnn. (S2-S4) via hypogastricnerves (Source: Putz R., Pabst R. Sobotta.Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006 and Felten D.L et al. Atlas neuroanatomii i neurofizjologii Nettera, Elsevier Urban & Partner, Wrocław 2007, with permission)

Sympathetictrunk sacralpart Topography: anterior to the anteriorsacral foramina 4-5 sacral ganglia (often merge) twosacral splanchnicnerves projectionto inferior hypogastricplexus Ganglion impar(ganglion of Walther) anterior to sacrococcygealjunction sympatheticinnervationof perinealregion (Source: Putz R., Pabst R. Sobotta. Atlas Anatomii Człowieka, Elsevier Urban & Partner, Wrocław 2006, with permission)

Autonomicplexusofpelvis Inferior hypogastricplexus Topography related to internal iliac vessels, Components: sympathetic sacral splanchnicnn. sympathetic fibers from lumbar ganglia (via hypogastricnerves) parasympathetic pelvic splanchnicnn. (S2-S4) Hypogastricnerves mainly ascending sympathetic fibers (few parasympathetic) (Source: Felten D.L et al. Atlas neuroanatomii i neurofizjologii Nettera, Elsevier Urban & Partner, Wrocław 2007, with permission)