Normal Spinal Anatomy

By: Pamela E. Verkuilen, APNP

Fig 1: Sections of the spine Before discussing the confusing aspects of terminology used to describe back problems, it is important to first review the overall terminology used to describe the normal anatomy of the spine.

Vertebrae Define Sections of the Spine

Spine anatomy is divided into 4 major sections, typically defined by the number of vertebrae (the round bones that make up the structure of ones back bone) in each section. Vertebrae are also sometimes called vertebral bodies. (See Figure 1) 1. Cervical spine (neck)comprised of 7 cervical vertebrae (termed C1 to C7), starting with C1 at the top of the spine and ending with C7 at the bottom of the cervical portion of the spine. Neck problems can cause neck pain and/or pain that radiates down the arms to the hands and fingers. 2. Thoracic spine (upper back)made up of 12 thoracic vertebrae (known as T1 to T12), which are attached to the rib bones and sternum (breast bone). Because this part of the spine is firmly attached to the ribs and sternum, it is very stable and has fewer problems associated with motion. 3. Lumbar spine (lower back)typically including 5 vertebrae (known as L1 to L5), which have a great deal of motion and flexibility. Because this section of the spine bears most of the bodys weight and allows for the most motion (which stresses the anatomical structures), this is the area associated with most back problems. Problems in the low back can cause pain that radiates down the legs to the feet. Article continues below

4.

Sacral region (bottom of the spine)located below the lumbar spine,

the sacrum is a series of 5 bony segments fused together (known as S1 to S5) that create a triangular-shaped bone that serves as the base of the spine and makes up part of the pelvis.The segment where the lumbar spine meets the sacral region, L5S1, is an area that is prone to degenerate and create back problems. Four small bones that extend down from the sacrum make up the coccyx (the tailbone at the very bottom of the spine). Disorders are common in the lumbar spine and at the top of the sacral region, as this area supports most of the bodys weight which creates stress on the structures in this area. The combination of these two sections of the lower back is often referred to as the lumbosacral region. People with back problems that get better within a few weeks usually have a strained muscle (a pulled muscle) or other soft tissue damage. However, many back problems that dont get better within a few months are caused by some type of problem with a spinal disc or nerve.

Spinal Discs are in Between Each Vertebra

Spinal discs are located in between each of the vertebral bodies along the back bone and may also be referred to as an intervertebral disc, spinal disc, or disk. Each disc is named according to which two vertebral bodies it lies between. For instance:

The L4-L5 disc in the low back is between the L4 vertebrae and L5 vertebrae which make up the L4-L5 spinal segment. The L5-S1 disc at the bottom of the spine lies between the L5 vertebra and the first bony segment at the top of the sacrum, which is sacral segment 1 (or S1). The disc and vertebra above and below the disc comprise one segment of the spine usually called a spinal level or spinal segment. The L4 vertebra and L5 vertebra, along with the disc in between them, make up the L4-L5 segment Discs are always labeled for the vertebrae that they lie between, and this is consistent throughout the length of the spinefor the cervical, thoracic andlumbar spine. For example, the C1-C2 disc in the neck lies between the first and second vertebrae in the cervical spine, and the T1-T2 disc lies between the first and second vertebrae in the thoracic spine. However, the same is not true of how the spinal nerves are labeled, andback problems are often described by both the spinal segment and the nerve root that is affected. This is explained in more detail on the next page.

Radiculopathy, Radiculitis and Radicular Pain

From top to bottom down the entire length of the spine, at each spinal level nerves exit through holes in the bone of the spine (foramen) on the right side and left side of the spinal column. These nerves are called nerve roots, orradicular nerves. They branch out at each level of the spine and innervate different parts of our body. For example, nerves that exit the cervical spine travel down through the arms, hands and fingers. This is why neck problems that affect a cervical nerve root can cause pain and other symptoms through the arms and hands (radiculopathy), and low back problems that affect a lumbar nerve root can radiate through the leg and into the foot (radiculopathy, or sciatica), thus prompting leg pain and/or foot pain. As mentioned earlier, there is no spinal cord in the lumbar spine. Because of this, and because the spinal canal is usually fairly spacious in the low back, problems in the lumbosacral region (the lumbar spine and sacral region of the spine) usually cause nerve root problems, not spinal cord injury. Even serious conditions such as a large disc herniation or fracture in the low back are less likely to cause permanent loss of motor function in the legs (paraplegia, or paralysis). The nerve roots are named for the level of the spine at which they exit. However, nerve roots are not labeled consistently throughout the length of the spine. Article continues below In the cervical spine, the nerve root is named according to theLOWER spinal segment that the nerve root runs between. For example, the nerve at the C5-C6 level is called the C6 nerve root. It is named this way because as it exits the spine the nerve root passes OVER the C6 pedicle (a piece of bone that is part of the spinal segment). In the lumbar spine, the nerve roots are named according to theUPPER segment that the nerve runs between. For example, the nerve root at the L4-L5 level is called the L4 nerve root. The nerve root is named this way because as it exits the spine it passes UNDER the L4 pedicle (a piece of bone that is part of the spinal segment). The area that the naming change occurs is at the C7-T1 level (Thoracic 1), meaning that there are 8 cervical nerve roots and only 7 cervical vertebrae. Here, the C8 nerve exits UNDER the C7 vertebra and OVER the T1 vertebra. From this point down through the upper back, lower back and sacral region, the nerve is named for the upper segment of the spine that the nerve root runs between (and the pedicle it passes UNDER as it exits the spine).

This is part of the picture. However, the doctor may still say that you have a problem with the L5 nerve root at the L4-L5 level. Since we just explained that the L4 nerve root exits at the L4-L5 level, this sounds like a contradiction. However, both statements are correct, and can be explained by the fact that there are two nerve roots at each level.

Two Nerve Roots at Each Level

It should be mentioned that two nerves cross each disc level and only one exits the spine (through the foramen) at that level.

Exiting nerve root. The nerve root that exits the spine at a particular level is referred to as the exiting nerve root. Example: The L4 nerve root exits the spine at the L4-L5 level. Traversing nerve root. Another nerve root goes across the disc and exits the spine at the next level below. It is called the traversing nerve root. Example: The L5 nerve root is the traversing nerve root at the L4-L5 level, and is the exiting nerve root at the L5-S1 level. A lot of confusion occurs because when a nerve root is compressed by disc herniation or other cause, it is common to refer both to the intervertebral level (where the disc is) and to the nerve root that is affected. Depending on where the disc herniation or protrusion occurs, it may impinge upon either the exiting nerve root or the traversing nerve root. For example: When the traversing nerve root is affected Lumbar radiculopathy. In the lumbar spine, there is a weak spot in the disc space that lies right in front of the traversing nerve root, so lumbar discs tend to herniate or leak out and impinge on the traversing nerve root. For example, a typical posterolateral (behind the disc and to the side) lumbar disc herniation at the L4-L5 level often affects the nerve that traverses the L4-L5 level and exits at the L5 level, called the L5 nerve root. See more about Lumbar Radiculopathy. When the exiting nerve root is affected Cervical radiculopathy The opposite is true in the neck. In the cervical spine, the disc tends to herniate to the side (laterally), rather than toward the back and the side (posterolaterally). If the disc material herniates to the side, it would likely compress the exiting nerve root. For example, the C6 nerve root would be affected at the C5-C6 level (because in the neck the exiting nerve root is named for the level below it). See more about Cervical Radiculopathy.

Radiculopathy and Sciatica

Another word for the nerve root is radicular nerve, and when a herniated disc or prolapsed disc presses on the radicular nerve, this is often referred to as a radiculopathy. Thus, a physician might say that there is herniated disc at the L4-L5 level, creating an L5 radiculopathy or an L4 radiculopathy, depending on where the disc herniation occurs (to the side or to the back of the disc) and which nerve root is affected. The lay term for a radiculopathy in the low back is sciatica.

Spinal Abnormalities Rarely Cause Back Problems

Spine surgeons and radiologists (who both may read and interpret MRI scans) sometimes differ in their method of labeling a particular spinal segment. This creates confusionamong both patients and insurance companiestriggering the question: Where is the problem?

A Sixth Lumbar Vertebra

One of the reasons for the confusion is that some people, approximately 10% of adults, have a congenital anomaly in their lower back. One of the most common anomalies is the presence of a sixth lumbar vertebra. Having one extra lumbar vertebra provides no advantage or disadvantage to the individual and is rarely a cause of back problems, but it can create some confusion. For example: Radiologists commonly count down from the last rib when numbering the lumbar vertebral bodies. Surgeons on the other hand, count up from the sacrum when numbering the lumbar vertebrae. Neither method of labeling lumbar vertebrae is incorrect, but obviously it can create confusion. For an individual with 5 vertebral bodies, they would be in agreement when labeling the L4-L5 level. If the individual has 6 lumbar vertebrae, however, the radiologist would typically refer to the lowest level as L6-S1 and the level above that L5-L6, which in the surgeons mind, would be correctly labeled L4-L5. Article continues below It is obviously very important to clearly identify the location of lumbosacral anomalies in order to avoid injection or surgical exposure of the incorrect level. This becomes particularly important for minimally invasive procedures. A physical exam and complementary imaging studies, such as an MRI scan and x-ray, can help improve the accuracy and the communication of the diagnosis.

When Spinal Anomalies Cause Back Problems

Patients are sometimes told that a spinal anomalysuch as a sixth lumbar vertebrae or an extra sacral bonehas been found on an x-ray and is causing their back problems. However, anomalies such as these in the lumbar spine and sacral spine are simply variants of normal bony architecture and are typically of no consequence. In other words, it would be very rare for an abnormality such as a sixth lumbar vertebra or extra bone in the sacrum to cause back problems. The one exception to this general guideline is in cases where the last transverse process (a bony protrusion near the vertebra) is partially attached to the sacrum, or sacralized. If this bony protrusion is attached to the sacrum, it can create a rudimentary joint (pseudoarticulation) where there shouldnt be one. The resulting motion in this section of the spine can sometimes be a cause of localized low back pain. This condition can usually be successfully treated without surgery. For instance, an injection of steroid medication at the pseudoarticulation of the transverse process and the sacrum can often be both diagnostic and therapeutic.

Cervical Spine Anatomy and Neck Pain

By: Peter F. Ullrich, Jr., MD Neck anatomy is a well-engineered structure of bones, nerves, muscles, ligaments and tendons. The cervical spine (neck) is delicate housing the spinal cord that sends messages from the brain to control all aspects of the body while also remarkably flexible, allowing movement in all directions, and strong. The neck begins at the base of the skull and through a series of seven vertebral segments connects to the thoracic spine (the upper back). With its complex and intricate construct, and the many stresses and force that can be placed on it through a trauma or even just daily activities, the cervical spine is at risk for developing a number of painful conditions, such as:

Cervical degenerative disc disease Cervical herniated disc Cervical stenosis Osteoarthritis Simple muscle strain resulting in a painful or stiff neck.

This article explores how the neck functions in greater detail, as well as common causes of cervical neck pain, a stiff neck, arm pain and other symptoms of cervical spine disorders. Article continues below

The Cervical Spine: Roles and Functionalities

The cervical spine maintains several crucial roles, including:

Housing and protecting the spinal cord. A bundle of nerves that extends from the brain and runs through the cervical spine andthoracic spine (upper and middle back) prior to ending just before the lumbar spine (lower back), the spinal cord relays messages from the brain to the rest of the body. Supporting the head and its movement. The cervical spine literally shoulders a big load, as the head weighs on average between 10 and 13 pounds. In addition to supporting the head, the cervical spine allows for the head's flexibility, including rotational, flexion/extension and lateral bending motions. Facilitating flow of blood to the brain. Vertebral openings (vertebral foramen) in the cervical spine provide a passageway for vertebral arteries to pass and ensure proper blood flow to the brain. These openings are present only in the vertebrae of the cervical spine. The cervical vertebrae play a key role in maintaining these functions in the neck.

What is Degenerative Disc Disease?

Fig. 1: Degenerative disc disease Degenerative disc disease is one of the most common causes of low back pain, and also one of the most misunderstood. Many patients diagnosed with low back pain caused by degenerative disc disease are left wondering exactly what this diagnosis means for them. Common questions that are often on patients minds include: If I have low back pain from degenerative disc disease in my thirties, how much worse will it become with age? Will the degenerative disc disease become a crippling condition? Will I end up in a wheelchair? Should I restrict my activities? Can I still play sports? Will the degenerative disc disease spread to other parts of the spine? Will the low back pain from degenerative disc disease cause any permanent damage?

Degenerative Disc Disease is a Misnomer

A large part of many patients confusion is that the term degenerative disc disease sounds like a progressive, very threatening condition. However, this condition is not strictly degenerative and is not really a disease: Article continues below Part of the confusion probably comes from the term "degenerative", which implies to most people that the symptoms will get worse with age. The term applies to the disc degenerating, but does not apply to the symptoms. While it is true that the disc degeneration is likely to progress over time, the low back pain from degenerative disc disease usually does not get worse and in fact usually gets better over time. Another source of confusion is probably created by the term "disease", which is actually a misnomer. Degenerative disc disease is not really a disease at all, but rather a degenerative condition that at times can produce pain from a damaged disc. For more information view Degenerative Disc Disease Interactive Video. Disc degeneration is a natural part of aging and over time all people will exhibit changes in their discs consistent with a greater or lesser degree of degeneration. However, not all people will develop symptoms. In fact, degenerative disc disease is quite variable in its nature and severity.

Medical Practitioners Disagree on Degenerative Disc Disease

Finally, many patients are confused about degenerative disc disease because many medical professionals dont agree on what the phrase describes. In practical terms, this means that few practitioners agree on what does and does not constitute a diagnosis of degenerative disc disease. Even medical textbooks dont usually attempt to give an accurate description. Therefore, while many practitioners believe that degenerative disc disease is a common cause of low back pain in young adults, very few agree on the implications. While there is still a lot of debate in the medical community about degenerative disc disease, a few aspects of the condition are known. This article will discuss aspects of degenerative disc disease that are more commonly accepted, such as the theory of the degenerative cascade, as well as some areas of theory that are still a source of debate in the medical community.

What's a Herniated Disc, Pinched Nerve, Bulging Disc...?

There are many different terms used to describe spinal disc pathology and associated pain, such as "herniated disc", "pinched nerve", and "bulging disc", and all are used differently by doctors. Unfortunately, healthcare professionals to not agree on a precise definition of any of these terms, and patients may be frustrated when they hear their diagnosis referred to in different terms. A variety of interchangeable terms (ruptured disc, torn disc, slipped disc, collapsed disc, disc protrusion, disc disease, black disc) can add to the confusion. Rather than caring about which term is used, it is more useful for patients to gain a clear understanding of the precise medical diagnosis. The medical diagnosis identifies the actual causeof the patients symptoms - low back pain, leg pain, neck pain, pain, and more. The medical professional determines the cause of the patients pain through a combination of a review of the patients medical history through a combination of: Review of the patient's medical history A complete physical exam One or more diagnostic tests (if needed) Article continues below

Two Causes of Pain: Pinched Nerve vs. Disc Pain

In identifying the cause of the patients pain, there are two general types of spinal disc problems used by physicians: Pinched nerve When a patient has a symptomatic herniated disc, the disc itself is not painful, but rather the leaking disc is pinching a nerve. This produces pain called radicular pain (e.g., nerve root pain) leading to pain that may be referred to other parts of the body, such as from the low back down the leg or from the neck down the arm. Leg pain from a pinched nerve is usually described as sciatica. o On Spine-health.com, this nerve root pain is called a herniated disc. (Other common causes of a pinched nerve may includespinal stenosis and bone spurs from spinal arthritis. Disc pain When a patient has a symptomatic degenerated disc (one that causes low back pain and/or leg pain), it is the disc space itself that is painful and the source of pain. This type of pain is typically called axial pain. o On Spine-health.com, disc space pain called degenerative disc disease.

Either of the above two conditions can occur in the neck, upper back or lower back. They tend to be most common in the lower back because the lower back bears the most torque and force on a day to day basis. It should be kept in mind that all the terms herniated disc, pinched nerve, bulging disc, slipped disc, ruptured disc, etc. refer to radiographic findings seen on a CT scan or MRI scan. While these test results are important, they are not as meaningful in determining the cause of the pain as the patient's specific symptoms and the doctor's physical exam results.