Chapter 6 - The Vertebral Column and Meninges Surrounding The Spinal Cord

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Clinical Neuroanatomy, 29e
Chapter 6: The Vertebral Column and Meninges Surrounding the Spinal Cord
INTRODUCTION
The spinal cord is vulnerable to injury arising in the structures that surrounds it. More than in any other part of the nervous system, pathologic lesions
impinging on the spinal cord often originate in the membranes or vertebral column that surrounds it. The neurologic clinician must, therefore, be very
familiar with these structures and their relationship to the spinal cord.
INVESTING MEMBRANES (MENINGES)

Three membranes surround the spinal cord: The outermost is the dura mater (dura), the next is the arachnoid, and the innermost is the pia mater (pia)
(Figs 6–1 and 6–2). The dura is also called the pachymeninx, and the arachnoid and pia are called the leptomeninges.
FIGURE 6–1
Schematic illustration of the relationships between the spinal cord, spinal nerves, and vertebral column (lateral view), showing the termination of the
dura (dura mater spinalis) and its continuation as the filum terminale externum. (Compare with Fig 5–4.)
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FIGURE 6–2
Drawing of a horizontal section through a vertebra and the spinal cord, meninges, and roots. Veins (not labeled) are shown in cross section. The
vertebra and its contents are positioned as they customarily would be with CT and MR imaging procedures.
Dura Mater
The dura mater is a tough, fibrous sheath that extends from the foramen magnum to the level of the second sacral vertebra, where it ends as a blind
sac (see Fig 6–1). The dura of the spinal cord is continuous with the cranial dura. The epidural, or extradural, space separates the dura from the
bony vertebral column; it contains loose areolar tissue and a venous plexus. The subdural space is a narrow space between the dura and the
underlying arachnoid.
Arachnoid Mater
The arachnoid is a thin, transparent sheath separated from the underlying pia by the subarachnoid space, which contains cerebrospinal fluid (CSF).
Pia Mater
The pia mater closely surrounds the spinal cord and sends septa into its substance. The pia also contributes to the formation of the filum terminale
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The filum terminale stabilizes the cord and dura lengthwise.
Arachnoid Mater
The arachnoid is a thin, transparent sheath separated from the underlying pia by the subarachnoid space, which contains cerebrospinal fluid (CSF).
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Pia Mater
The pia mater closely surrounds the spinal cord and sends septa into its substance. The pia also contributes to the formation of the filum terminale
internum, a whitish fibrous filament that extends from the conus medullaris to the tip of the dural sac. The filum is surrounded by the cauda equina,
and both are bathed in CSF. Its extradural continuation, the filum terminale externum, attaches at the tip of the dural sac and extends to the coccyx.
The filum terminale stabilizes the cord and dura lengthwise.
Dentate Ligament
The dentate ligament is a long flange of whitish, mostly pial tissue that runs along both lateral margins of the spinal cord between the dorsal and
ventral rootlets (see Fig 6–2). Its medial edge is continuous with the pia at the side of the spinal cord, and its lateral edge pierces the arachnoid at
intervals (21 on each side) to attach to the inside of the dura. The dentate ligament helps to stabilize the cord from side to side.
Spinal Nerves
There are eight pairs of cervical nerves. The first seven emerge above each respective cervical vertebra; the eighth (C8) lies below vertebra C7 and
above the first thoracic vertebra (see Fig 6–1). Each of the other spinal nerves (T1–12, L1–5, S1–5, and normally two coccygeal nerves, Co1 and
C o 2) emerges from the intervertebral foramen below the respective vertebra. The cauda equina is made up of dorsal and ventral roots that arise from
lumbar and sacral segments of the cord. These roots sweep downward within the dural sac, below the termination of the cord, and give the
appearance of a horse’s tail.
Investment of Spinal Nerves
As the ventral and dorsal roots (on each side) at each segmental level converge to become a spinal nerve, they are enclosed in sleeves of arachnoidal
and dural tissue (see Fig 6–2). The dorsal root sleeve contains the dorsal root ganglion near the point at which both sleeves merge to become the
connective tissue sheath (perineurium) of a spinal nerve. The dorsal root (with its ganglion) and the ventral root of the nerve (surrounded by fat and
blood vessels) course through the intervertebral foramen, except in the sacral segments where the dorsal root ganglia lie within the sacrum itself.
SPINAL CORD CIRCULATION

Arteries
A. Anterior Spinal Artery
This artery is formed by the midline union of paired branches of the vertebral arteries (Figs 6–4 and 6–5). It descends along the ventral surface of the
cervical spinal cord, narrowing somewhat near T4.
FIGURE 6–4
Cross section of the cervical spinal cord. The diagram shows the anterior and posterior spinal arteries with their branches and territories. There are
numerous variations in the vascular supply.

FIGURE 6–4
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Cross section of the cervical spinal cord. The diagram shows the anterior and posterior spinal arteries with their branches and territories. There are
numerous variations in the vascular supply.
FIGURE 6–5
Vascularization of the spinal cord (ventral view).

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CLINICAL CORRELATIONS
Abnormal masses (tumors, infections, hematomas) may occur in any location in or around the spinal cord. Tumors (eg, meningiomas,
neurofibromas) are often located in the intradural extramedullary compartment. Epidural masses, including bone tumors or metastases, can
displace the dura locally and compress the spinal cord (Fig 6–3). Spinal cord compression may progress rapidly and can result in paraplegia or
quadriplegia. If diagnosed early, however, it may be readily treated. Thus, suspected spinal cord compression requires urgent workup. Intradural
extramedullary masses, most often in the subarachnoid space, may push the spinal cord away from the lesion and may even compress the cord
against the dura, epidural space, and vertebra. Intramedullary, and therefore intradural, masses expand the spinal cord itself (see Fig 5–24). An
epidural mass is usually the least difficult to remove neurosurgically. Clinical Illustration 6–1 describes a patient with an epidural abscess.
FIGURE 6–3
Epidural tumor in Hodgkin’s disease, showing compression of the thoracic spinal cord (Weil stain). The illustration is positioned to conform with
customary CT and MR imaging procedures.

FIGURE 6–3
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Epidural tumor in Hodgkin’s disease, showing compression of the thoracic spinal cord (Weil stain). The illustration is positioned to conform with
customary CT and MR imaging procedures.
B. Anterior Medial Spinal Artery
This artery is the prolongation of the anterior spinal artery below T4.
C. Posterolateral Spinal Arteries
These arteries arise from the vertebral arteries and course downward to the lower cervical and upper thoracic segments.
D. Radicular Arteries
Some (but not all) intercostal arteries from the aorta supply segmental (radicular) branches to the spinal cord from T1 to L1. The largest of these
branches, the great ventral radicular artery, also known as the artery of Adamkiewicz, enters the spinal cord between segments T8 and L4 (see
Fig 6–5). This artery usually arises on the left and, in most individuals, supplies most of the arterial blood supply for the lower half of the spinal cord.
Although occlusion in this artery is rare, it results in major neurologic deficits (eg, paraplegia, loss of sensation in the legs, urinary incontinence).
E. Posterior Spinal Arteries
These paired arteries are much smaller than the single large anterior spinal artery; they branch at various levels to form the posterolateral arterial
plexus. The posterior spinal arteries supply the dorsal white columns and the posterior portion of the dorsal gray columns.
F. Sulcal Arteries
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branches unite directly with the posterior and anterior spinal arteries to form an irregular ring of arteries (an arterial corona) with vertical
connections. Sulcal arteries branch from the coronal arteries at most levels. Anterior sulcal arteries arise at various levels along the cervical and
E. Posterior Spinal Arteries
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These paired arteries are much smaller than the single large anterior spinal artery; they branch at various levels to form the posterolateral arterial
plexus. The posterior spinal arteries supply the dorsal white columns and the posterior portion of the dorsal gray columns.
F. Sulcal Arteries
In each segment, the branches of the radicular arteries that enter the intervertebral foramens accompany the dorsal and ventral nerve roots. These
branches unite directly with the posterior and anterior spinal arteries to form an irregular ring of arteries (an arterial corona) with vertical
connections. Sulcal arteries branch from the coronal arteries at most levels. Anterior sulcal arteries arise at various levels along the cervical and
thoracic cord within the ventral sulcus (see Fig 6–4); they supply the ventral and lateral columns on either side of the spinal cord.
Veins
An irregular external venous plexus lies in the epidural space; it communicates with segmental veins, basivertebral veins from the vertebral column,
the basilar plexus in the head, and, by way of the pedicular veins, a smaller internal venous plexus that lies in the subarachnoid space. All venous
drainage is ultimately into the venae cavae.
THE VERTEBRAL COLUMN

The vertebral column consists of 33 vertebrae joined by ligaments and cartilage. The upper 24 vertebrae are separate and movable, but the lower 9 are
fixed: 5 are fused to form the sacrum, and the last 4 are usually fused to form the coccyx. The vertebral column consists of 7 cervical (C1–7), 12 thoracic
(T1–12), 5 lumbar (L1–5), 5 sacral (S1–5), and 4 coccygeal (Co1–4) vertebrae. In some individuals, vertebra L5 is partly or completely fused with the
sacrum.
Figure 6–1 illustrates the relation of the spinal cord itself to the surrounding vertebrae. Recall that the spinal cord tapers and ends at the L1 or L2 level
of the vertebral column. Below that level, the dural sac within the vertebral column contains the cauda equina.
CLINICAL ILLUSTRATION 6–1
A 61yearold former house painter with a history of alcoholism was admitted to the medical service after being found in a hotel room in a confused
state that was attributed to alcohol withdrawal syndrome. The patient did not complain of pain but said he was weak and could not get out of bed.
He had a fever. The intern’s initial neurologic examination did not reveal any focal neurologic signs. The lumbar puncture yielded CSF containing a
moderate number of white blood cells and protein of about 100 mg/dL (elevated) with normal CSF glucose. Despite treatment with antibiotics, the
patient did not improve, and neurologic consultation was obtained.
On examination, the patient was confused and uncooperative. He stated he was weak and could not walk. Motor examination revealed flaccid
paraparesis. Deep tendon reflexes were absent in the legs, and the plantar responses were extensor. The patient was not cooperative for vibratory
or position sense testing. He denied feeling a pin as painful over any part of the body; however, when the examiner watched for a facial wince on
pinprick, a sensory level T5–6 could be demonstrated. On gentle percussion of the spinal column, there was tenderness at T9–10.
Imaging of the spinal column revealed an epidural mass. The patient was taken to surgery, and an epidural abscess, extending over five vertebral
segments, was found. The spinal cord under the abscess was compressed and pale, probably as a result of ischemia (vasospasm leading to
inadequate perfusion with blood).
The motor status of this patient suggested a spinal cord lesion, which was confirmed on sensory examination. Percussion tenderness over the
spine, which is often seen with epidural abscesses or tumors, provided additional evidence for disease of the spinal column. Epidural spinal cord
compression is especially common in the context of neoplasms (eg, breast, prostate) that metastasize to the spine. The possibility of spinal cord
compression should be considered, and the vertebral column gently percussed, in any patient with a known malignancy and recentonset or
worsening back pain. As noted earlier, epidural spinal cord compression can be effectively treated in many patients if recognized early in its course.
However, if it is not diagnosed and rapidly treated, it can progress to cause irreversible paraplegia or quadriplegia. Any patient with suspected spinal
cord compression must be evaluated on an urgent basis.
The vertebral column is slightly Sshaped when seen from the side (Fig 6–6). The cervical spine is ventrally convex, the thoracic spine ventrally concave,
and the lumbar spine ventrally convex, with its curve ending at the lumbosacral angle. Ventral convexity is sometimes referred to as normal lordosis
and dorsal convexity as normal kyphosis. The pelvic curve (sacrum plus coccyx) is concave downward and ventrally from the lumbosacral angle to
the tip of the coccyx. The spinal column in an adult is often slightly twisted along its long axis; this is called normal scoliosis.
FIGURE 6–6
cord compression must be evaluated on an urgent basis.
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The vertebral column is slightly Sshaped when seen from the side (Fig 6–6). The cervical spine is ventrally convex, the thoracic spine ventrally concave,
and the lumbar spine ventrally convex, with its curve ending at the lumbosacral angle. Ventral convexity is sometimes referred to as normal lordosis
and dorsal convexity as normal kyphosis. The pelvic curve (sacrum plus coccyx) is concave downward and ventrally from the lumbosacral angle to
the tip of the coccyx. The spinal column in an adult is often slightly twisted along its long axis; this is called normal scoliosis.
FIGURE 6–6
The vertebral column.

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Vertebrae
Most vertebrae share a common architectural plan. A typical vertebra (not C1, however) has a body and a vertebral (neural) arch that together
surround the vertebral
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transverse processes and superior and inferior articular processes with facets. The ventral portion of the neural arch is formed by the ventral
body.
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Vertebrae
Most vertebrae share a common architectural plan. A typical vertebra (not C1, however) has a body and a vertebral (neural) arch that together
surround the vertebral (spinal) canal (Fig 6–7). The neural arch is composed of a pedicle on each side supporting a lamina that extends posteriorly to
the spinous process (spine). The pedicle has both superior and inferior notches that form the intervertebral foramen. Each vertebra has lateral
transverse processes and superior and inferior articular processes with facets. The ventral portion of the neural arch is formed by the ventral
body.
FIGURE 6–7
Computed tomography image of a horizontal section at midlevel of vertebra L4.
Articulation of a pair of vertebrae is body to body, with an intervening intervertebral disk and at the superior and inferior articular facets on both
sides. The intervertebral disks help absorb stress and strain within the vertebral column.
A 74yearold male, with a history of prostate cancer, complained of 3 weeks of lower back pain. He noted that he felt tingling in his feet and legs,
extending all the way up to the waist. He did not complain of weakness, but admitted that he had fallen several times while walking stairs.
Physical examination revealed a sensory level (loss of pinprick and light touch sensation) in both legs, extending to just below the umbilicus.
Vibration and position sense were present but impaired in the legs. There was mild (4+/5) weakness of the legs. Deep tendon reflexes (knee jerks,
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that had infiltrated the vertebral body at T1, which was now
compressing the spinal cord. The patient was immediately referred for treatment.
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Articulation of a pair of vertebrae is body to body, with an intervening intervertebral disk and at the superior and inferior articular facets on both
sides. The intervertebral disks help absorb stress and strain within the vertebral column.
A 74yearold male, with a history of prostate cancer, complained of 3 weeks of lower back pain. He noted that he felt tingling in his feet and legs,
extending all the way up to the waist. He did not complain of weakness, but admitted that he had fallen several times while walking stairs.
Physical examination revealed a sensory level (loss of pinprick and light touch sensation) in both legs, extending to just below the umbilicus.
Vibration and position sense were present but impaired in the legs. There was mild (4+/5) weakness of the legs. Deep tendon reflexes (knee jerks,
Achilles reflexes) were hyperactive in the legs, and the plantar response was extensor bilaterally.
Imaging revealed a tumor, most likely metastatic from the patient’s prostate cancer, that had infiltrated the vertebral body at T1, which was now
compressing the spinal cord. The patient was immediately referred for treatment.
This case illustrates several important points: First, back pain and neurological complaints in the legs must always trigger consideration of spinal
cord compression. Second, while sensory symptoms (such as numbness or tingling or pain) often occur early, patients may not complain of motor
loss early in the course of disease—this patient did not explicitly complain of weakness, although he admitted to falling and was found on
examination to have mild weakness of the legs. Third, because the spinal cord is shorter than the vertebral column, there is not perfect alignment
between the segment of the bony vertebral column that is involved, and the affected segment of the spinal cord. In this case, a lesion of the T1
vertebra compressed the T4 spinal cord. The anatomic relationship between the segments of the bony vertebral column and the spinal cord within it
are shown in Figure 5–3 and Table 5–1.
Each disk (Fig 6–8) contains a core of primitive gelatinous largecelled tissue, the nucleus pulposus, surrounded by a thick annulus fibrosus. The
disks are attached to the hyaline cartilage, which covers the superior and inferior surfaces of the vertebral bodies. The water content of the disks
decreases with age, resulting in a loss of height in older individuals.
FIGURE 6–8
Computed tomography image of a horizontal section through L4 at the level of the L3–4 intervertebral disk. (Reproduced with permission from
deGroot J: Correlative Neuroanatomy of Computed Tomography and Magnetic Resonance Imagery, 21st ed. New York, NY: Appleton & Lange; 1991.)

FIGURE 6–8
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Computed tomography image of a horizontal section through L4 at the level of the L3–4 intervertebral disk. (Reproduced with permission from
deGroot J: Correlative Neuroanatomy of Computed Tomography and Magnetic Resonance Imagery, 21st ed. New York, NY: Appleton & Lange; 1991.)
LUMBAR PUNCTURE
Site
The spinal cord in adults ends at the level of L1–2. Thus, a spinal (lumbar) puncture can be performed below that level—and above the sacrum—
without injuring the cord. Indications and contraindications for lumbar puncture are discussed in Chapter 24. Lumbar puncture and careful CSF
analysis should be carried out as quickly as possible (although increased intracranial pressure or intracranial mass should first be ruled out; see
Chapter 24) in any patient in whom meningitis is a possibility, since a delay in treatment can reduce the likelihood of good outcome.
Technique
Lumbar puncture is usually performed with the patient in the lateral decubitus position with legs drawn up (Fig 6–9); in this position, the manometric
pressure of CSF is normally 70 to 200 mm of water (average, 125 mm). If the puncture is done with the patient sitting upright, the fluid in the
manometer normally rises to about the level of the midcervical spine (Fig 6–10). Coughing, sneezing, or straining usually causes a prompt rise in
pressure from the congestion of the spinal veins and the resultant increased pressure on the contents of the subarachnoid and epidural spaces. The
pressure subsequently falls to its previous level.
FIGURE 6–9
Decubitus position
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Reserved.(Reproduced with• permission
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Lange; 1985.)
pressure of CSF is normally 70 to 200 mm of water (average, 125 mm). If the puncture is done with the patient sitting upright, the fluid in the
manometer normally rises to about the level of the midcervical spine (Fig 6–10). Coughing, sneezing, or straining usually causes Universidad
a prompt rise delinRosario
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pressure from the congestion of the spinal veins and the resultant increased pressure on the contents of the subarachnoid and epidural spaces. The
pressure subsequently falls to its previous level.
FIGURE 6–9
Decubitus position for lumbar puncture. (Reproduced with permission from Krupp MA: Physician’s Handbook, 21st ed. New York, NY: Appleton &
Lange; 1985.)
FIGURE 6–10
Lumbar puncture site with the patient in sitting position. The approach to the sacral hiatus for saddleback anesthesia is also indicated.

After the initial pressure has been determined, three or four samples of 2 to 3 mL each are withdrawn into sterile tubes for laboratory examination.
FIGURE 6–10
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Lumbar puncture site with the patient in sitting position. The approach to the sacral hiatus for saddleback anesthesia is also indicated.
Routine examination usually includes cell counts and measurement of total protein. Cultures and special tests, such as those for sugar and chlorides,
are done when indicated. The pressure is also routinely measured after the fluid is removed.
Herniated nucleus pulposus (also termed a ruptured or herniated disk) may be asymptomatic or can compress a neighboring spinal root (or, less
commonly, may compress the spinal cord). These effects tend to occur most commonly at lower cervical and lumbar or upper sacral levels. When
root compression occurs at lumbosacral levels, it can cause sciatica. Note that, as a result of the anatomic relation between the spinal roots and the
vertebral column (see Fig 6–1), a herniation of the L4–5 disk will tend to compress the L5 root. The symptoms of nerve root compression may
include pain, sensory loss (in an appropriate dermatomal pattern), weakness (of a lowermotorneuron type in muscles innervated by the root in
question), and diminution or loss of deep tendon reflexes mediated by the compressed root. Nerve root compression resulting from herniated disks
often responds to conservative therapy. In certain cases, surgery may be needed.
Spina bifida results from the failure of the vertebral canal to close normally because of a defect in vertebral development. Associated
abnormalities may be caused by defective development of the spinal cord, brain stem, cerebrum, or cerebellum. Other developmental defects, such
as meningoceles, meningomyeloceles, congenital tumors, or hydrocephalus, may also occur.
There are two main types of spina bifida: spina bifida occulta, involving a simple defect in the closure of the vertebra, and spina bifida with
meningocele or meningomyelocele, involving saclike protrusions of the overlying meninges and skin that may contain portions of the spinal cord
or nerve roots.
Meningocele is herniation of the meningeal membranes through the vertebral defect. It usually causes a soft, cystic, translucent tumor to appear
low in the
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Vertebral Column and Meninges Surrounding the Spinal Cord, Page 16 / 27
In meningomyelocele, nerve roots and the spinal cord protrude through the vertebral defect and usually adhere to the inner wall of the meningeal
sac. If the meningomyelocele is high in the vertebral column, the clinical picture may resemble that of complete or incomplete transection of the
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Routine examination usually includes cell counts and measurement of total protein. Cultures and special tests, such as those for sugar and chlorides,
are done when indicated. The pressure is also routinely measured after the fluid is removed.
Herniated nucleus pulposus (also termed a ruptured or herniated disk) may be asymptomatic or can compress a neighboring spinal root (or, less
commonly, may compress the spinal cord). These effects tend to occur most commonly at lower cervical and lumbar or upper sacral levels. When
root compression occurs at lumbosacral levels, it can cause sciatica. Note that, as a result of the anatomic relation between the spinal roots and the
vertebral column (see Fig 6–1), a herniation of the L4–5 disk will tend to compress the L5 root. The symptoms of nerve root compression may
include pain, sensory loss (in an appropriate dermatomal pattern), weakness (of a lowermotorneuron type in muscles innervated by the root in
question), and diminution or loss of deep tendon reflexes mediated by the compressed root. Nerve root compression resulting from herniated disks
often responds to conservative therapy. In certain cases, surgery may be needed.
Spina bifida results from the failure of the vertebral canal to close normally because of a defect in vertebral development. Associated
abnormalities may be caused by defective development of the spinal cord, brain stem, cerebrum, or cerebellum. Other developmental defects, such
as meningoceles, meningomyeloceles, congenital tumors, or hydrocephalus, may also occur.
There are two main types of spina bifida: spina bifida occulta, involving a simple defect in the closure of the vertebra, and spina bifida with
meningocele or meningomyelocele, involving saclike protrusions of the overlying meninges and skin that may contain portions of the spinal cord
or nerve roots.
Meningocele is herniation of the meningeal membranes through the vertebral defect. It usually causes a soft, cystic, translucent tumor to appear
low in the midline of the back.
In meningomyelocele, nerve roots and the spinal cord protrude through the vertebral defect and usually adhere to the inner wall of the meningeal
sac. If the meningomyelocele is high in the vertebral column, the clinical picture may resemble that of complete or incomplete transection of the
cord.
Complications
Some patients may have a mild or severe headache after the procedure. The headache may be caused by the loss of fluid or leakage of fluid through
the puncture site; it is characteristically relieved by lying down and exacerbated by raising the head. Injection of the patient’s own blood in the epidural
space at the puncture site (blood patch) may give partial or complete relief. Serious complications, such as infection, epidural hematoma, uncal
herniation, or cerebellar tonsil prolapse, are rare.
CSF Analysis
CSF examination is discussed in Chapter 24.
IMAGING OF THE SPINE AND SPINAL CORD

Imaging methods have great value in determining the precise site and extent of the involvement of pathologic processes in the spine and neighboring
structures. (The methods themselves are discussed in detail in Chapter 22.)
Plain Xrays
Because Xrays (plain films) demonstrate the presence of calcium, various projections (anteroposterior, lateral, and oblique) of the affected area show
the skeletal components of the spine and foramens (Figs 6–11 and 6–12). Fractures or erosions of the vertebral column’s bony elements are often
easily seen, but the films provide little or no information about the spinal cord or other soft tissues.
FIGURE 6–11
Roentgenograms through the neck (lateral view).

easily seen, but the films provide little or no information about the spinal cord or other soft tissues.
FIGURE 6–11
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Roentgenograms through the neck (lateral view).
FIGURE 6–12
Roentgenogram of lumbar vertebrae (left lateral view). (Compare with Fig 6–6, right side.)

FIGURE 6–12
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Roentgenogram of lumbar vertebrae (left lateral view). (Compare with Fig 6–6, right side.)
Computed Tomography (CT)
Information about the position, shape, and size of all the elements of the spine, cord, roots, ligaments, and surrounding soft tissue can be obtained by
a series of transverse (axial) CT images (or scans) (see Fig 6–7). CT myelography is done after contrast medium is injected into the subarachnoid space
(Figs 6–13 and 614).
FIGURE 6–13
Computed tomography image of a horizontal section at the level of vertebra T12 in a 3yearold child. The subarachnoid space was injected with
contrast medium.

FIGURE 6–13
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Computed tomography image of a horizontal section at the level of vertebra T12 in a 3yearold child. The subarachnoid space was injected with
contrast medium.
FIGURE 6–14
Reformatted CT image of midsagittal section of the lumbar spine of a patient who fell from a thirdfloor window. There is a compression fracture in the
body of L1, and the lower cord is compressed between bony elements of L1 (arrows). The subarachnoid space was injected with contrast medium.
(Reproduced with permission from Federle MP, BrantZawadski M: Computed tomography in the evaluation of trauma, 21st ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 1986.)

Reformatted CT image of midsagittal section of the lumbar spine of a patient who fell from a thirdfloor window. There is a compression fracture in the
body of L1, and the lower cord is compressed between bony elements of L1 (arrows). The subarachnoid space was injected with contrast medium.
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(Reproduced with permission from Federle MP, BrantZawadski M: Computed tomography in the evaluation of trauma, 21st ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 1986.)
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging can be used in any plane. It has been used, especially with sagittal images, to demonstrate the anatomy or pathology of
the spinal cord and surrounding spaces and structures (Figs 6–15 to 6–18). Because the calcium of bone does not yield a magnetic resonance signal,
MRI is especially useful in showing suspected lesions of the soft tissues in and around the vertebral column (Figs 6–16 and 6–19).
FIGURE 6–15
Magnetic resonance image of a coronal section through the body and (curved) lumbar spine. (Reproduced with permission from deGroot J: Correlative
Neuroanatomy of Computed Tomography and Magnetic Resonance Imagery, 21st ed. New York, NY: Appleton & Lange; 1991.)

FIGURE 6–15
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Magnetic resonance image of a coronal section through the body and (curved) lumbar spine. (Reproduced with permission from deGroot J: Correlative
Neuroanatomy of Computed Tomography and Magnetic Resonance Imagery, 21st ed. New York, NY: Appleton & Lange; 1991.)
FIGURE 6–16
Magnetic resonance image of a coronal section through the neck at the level of the cervical vertebrae. Because of the curvature of the neck, only five
vertebral bodies are seen in this plane. (Reproduced with permission from Mills CM, deGroot J, Posin J: Magnetic Resonance Imaging Atlas of the Head,
Neck, and Spine. Philadelphia, PA: Lea & Febiger; 1988.)

FIGURE 6–16

Magnetic resonance image of a coronal section through the neck at the level of the cervical vertebrae. Because of the curvature of the neck, only five
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vertebral bodies are seen in this plane. (Reproduced with permission from Mills CM, deGroot J, Posin J: Magnetic Resonance Imaging Atlas of the Head,
Neck, and Spine. Philadelphia, PA: Lea & Febiger; 1988.)
FIGURE 6–17
Magnetic resonance image of a midsagittal section through the lower neck and upper thorax of a patient with AIDS. Multiple masses are seen in the
vertebral bodies at several levels (arrows): Pathologic examination showed these to be malignant lymphomas.

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FIGURE 6–18
Magnetic resonance image of a sagittal section of the lumbosacral spine. The arrow heads point to an intervertebral disc herniation at the L3–L4 level.
(Reproduced with permission from Aminoff MJ, Greenberg DA, Simon RP: Clinical Neurology, 6th ed. New York, NY: McGrawHill Education; 2005.)

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FIGURE 6–19
Magnetic resonance image of a midsagittal section through the lumbosacral spine. The mass visible in the body of L4 represents a metastasis of a
colon carcinoma (arrow).

FIGURE 6–19

Magnetic resonance image of a midsagittal section through the lumbosacral spine. The mass visible in the body of L4 represents a metastasis
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colon carcinoma (arrow).

Chapter
BOX 6–16: The Vertebral Column and Meninges Surrounding the Spinal Cord, Page 26 / 27
©2023 McGraw Hill.Clinical
Essentials for the All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
Neuroanatomist
After reading and digesting this chapter, you should know and understand:
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BOX 6–1
Essentials for the Clinical Neuroanatomist
After reading and digesting this chapter, you should know and understand:
The structure of the meninges (pia, arachnoid, dura)
Principles of spinal cord circulation
Anatomy of the spine, including overall structure of the vertebral column (Fig 6–6) and the structure of the vertebrae (Figs 6–7 and 6–8)
The principles underlying lumbar puncture
Principles of imaging of the spine and spinal cord
REFERENCES
Atlas SA: Magnetic Resonance Imaging at the Brain and Spine . 5th ed. Wolters Kluwer, 2017.
Byrne T, Benzel E, Waxman SG: Diseases of the Spine and Spinal Cord . Oxford University Press, 2000.
Cervical Spine Research Society: The Cervical Spine . 2nd ed. JB Lippincott, 1989.
Crock HV, Yoshizawa H: The Blood Supply of the Vertebral Column and Spinal Cord in Man . SpringerVerlag, 1977.
Naidich TP: Imaging of the Spine . Saunders, 2011.
Rothman RH, Simeone FA: The Spine . WB Saunders, 1975.
Uhlenbrock D: MR Imaging of the Spine and Spinal Cord . Thieme, 2011.
White AA, Paujabi MM: Clinical Biomechanics of the Spine . JB Lippincott, 1978.


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Clinical Neuroanatomy, 29e

INVESTING MEMBRANES (MENINGES)

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Investment of Spinal Nerves

SPINAL CORD CIRCULATION

A. Anterior Spinal Artery

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Vascularization of the spinal cord (ventral view).

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B. Anterior Medial Spinal Artery

C. Posterolateral Spinal Arteries

E. Posterior Spinal Arteries

THE VERTEBRAL COLUMN

CLINICAL ILLUSTRATION 6–1

The vertebral column.

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Computed tomography image of a horizontal section at midlevel of vertebra L4.

CLINICAL ILLUSTRATION 6–2

CLINICAL ILLUSTRATION 6–2

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CSF examination is discussed in Chapter 24.

IMAGING OF THE SPINE AND SPINAL CORD

Roentgenograms through the neck (lateral view).

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Roentgenograms through the neck (lateral view).

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Computed Tomography (CT)

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Magnetic Resonance Imaging (MRI)

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Universidad del Rosario

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Universidad del Rosario

colon carcinoma (arrow).

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The structure of the meninges (pia, arachnoid, dura)

Principles of spinal cord circulation

The principles underlying lumbar puncture

Principles of imaging of the spine and spinal cord

Naidich TP: Imaging of the Spine . Saunders, 2011.

Rothman RH, Simeone FA: The Spine . WB Saunders, 1975.

Uhlenbrock D: MR Imaging of the Spine and Spinal Cord . Thieme, 2011.

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