The Innervation of the Vertebral Column

The posterior elements of the vertebral col- NIKOLAI BOGDUK

umn are innervated by branches of the dorsal
Nikolai Bogduk, B.Sc.(Med.), B.S., Ph.D., Dip.Anal.,
rami of the spinal nerves, while the interver-
is a Senior Lecturer in the Department of Anatomy,
tebral discs and related ligaments are inner- University of Queensland, and a Visiting Medical
vated by various branches of the ventral rami Officer to the Pain Clinic, Princess Alexandra Hos-
and sympathetic nervous system. pital, Brisbane.
A knowledge of this nerve supply forms the
basis for a systematic classification of the
possible sources of primary spinal pain, and
the basis for several diagnostic techniques that
use needles to provoke and anaesthetize pu-
tative sources of pain. In particular, the dem-
onstration of a nerve supply to intervertebral This article is based on a paper presented at the 22nd Annual Conference
of the Anatomical Society of Austraha and New Zealand, Perth, May,
discs vindicates the concept fhat these struc- 1984, and the Inaugural Meeting of the Austrahan Spmal Research SocIety,
tures intrinsically may be sources of pain. AdelaIde, February, 1985

The Innervation of the vertebral
column forms the lInk between ver-
tebral disease and the spIne's most
common symptom - paIn. The nerve
supply of the vertebral column, there-
fore, has long been a matter of Interest
to clInicians dealIng with spinal paIn,
and consequently, has been a focus of
research actIvIty.
The results of recent research Into
the Innervation of the vertebral col-
umn have had, to date, three pnnclpal
ramificatIons. The broadest ramifica-
tion is that detailIng the InnervatIon
of the vertebral column has enabled
the pOSSIble sources of spinal paIn to
be claSSIfIed In terms of theIr nerve
supply. Although thIS may appear
redundant In the face of eXIsting top-
ographical and pathological claSSIfi-
cations of the causes of spinal pain,
a neurological claSSificatIon IS appro-
priate to the second ramification. ThiS
IS that knowledge of the course and
dlstnbutlon of the IntnnsiC nerves of
the vertebral column has permitted the
development of certaIn objective,
phySIologIcal, diagnostIc technIques.
USIng SUitable target pOInts, needles Anatomy
or electrodes can be Introduced onto
For the purpose of descnptlon, the
particular nerves, such as the branches
innervatIon of the vertebral column
of the cerVical and lumbar dorsal rami
can be conSIdered In two compart-
and used to dIagnose pain anslng from
ments - a ventral compartment con-
structures Innervated by these nerves.
sistIng of the Intervertebral diSCS, theIr
Electrodes can be used to stImulate
assOCIated ligaments, and the dura
the nerves In an effort to reproduce
mater ventral to the spinal cord and
pain In a controlled fashion, whereas
nerve roots; and a dorsal compart-
needles can be used to Inject local
ment, consIstIng of the JOints of the
anaesthetIC to anaesthetIze selected
vertebral arches and their lIgaments
nerves In an attempt to relIeve paIn.
and muscles. Throughout the vertebral
By uSing these techniques It IS pOSSIble,
column, the ventral compartment IS
In certain cases, to pin-pOInt the source
Innervated by the sinuvertebral nerves
of pain In terms of ItS nerve supply.
and other branches of the ventral ramI.
ThIS approach IS partIcularly worth-
The dorsal compartment is Innervated
whIle when alternatIve diagnostic tech-
by the branches of the dorsal ramI of
niques are Inappropnate or not avaIl-
the spinal nerves.
able.
The thud ramIfication IS essentially
IdeologIcal. By establIshIng the nerve Lumbar Dorsal Rami
supply to the cerVical and lumbar Although the lumbar dorsal rami
Intervertebral diSCS, anatomical re- are nomInally mentIoned In textbooks
search has VindIcated the concept that of anatomy (Hovelacque 1927, Ro-
Intervertebral diSCS Intnnslcally can be manes 1972, WarWIck and Williams
a source of paIn, as opposed to theu 1973), descnptlons of the skeletal diS-
role In spInal nerve compression. trIbution of these nerves are consplC-

The Australian Journal of PhYSiotherapy Vol 31, No 3, 1985 89

The Innervation of the Vertebral Column
uously absent. Demand for more an-
atomical data was prompted
principally by clInIcal interest In the
zygapophyseal JOInts. When It was
postulated that these JOInts mIght be
a source of back paIn, It became
relevant to determIne theIr pattern of
innervation. ThIS Issue, as well as the
comprehensive, detailed anatomy of
the lumbar dorsal ramI has been stud-
ied repeatedly sInce 1956, wIth each
study contributing new Information
(Pedersen et al1956, LeWIn et a11964,
Lazorthes and Jusklewenskl 1964,
Bradley 1974, Bogduk et al 1982,
Auteroche 1983, Pans 1983).
The LI-4 dorsal ramI are, them-
selves, very short nerves that anse
from the lum bar spinal nerves and
pass backwards Into the Intertrans-
verse spaces where they dIvIde Into
their branches. The L5 dorsal ramus
differs, in that it is longer and travels
over the top of the ala of the sacrum
(Figure 1). The L 1-4 dorsal ramI/dIvide
into 2 or 3 branches. A medIal branch
and a lateral branch are represented
at all levels. An Intermediate branch
may arise independently from the dor-
sal ramus, or In common wIth the
lateral branch. The lateral branches
are distributed to the ihocostahs mus-
cles, and those from L 1-3 become
cutaneous over the buttock. The In-
termediate branches form an Interseg-
mental plexus that Innervates the lon-
gissimus muscle.
It is the medial branches that are
of paramount clinIcal interest. Each
of these nerves runs across the top of
a transverse process and then along
the junction of the root of the trans-
verse process WIth the root of the
superior articular process (FIgure 1).
Hooking medIally around the base of
the superior articular process, each
nerve is covered by the mamIllo-ac-
cessory ligament and then crosses the
vertebral lamina before ~upplYIng the
multifidus muscle and an interspInal
muscle and ligament. As it crosses the
vertebral lamina, each medIal branch
supplies two zygapophyseal JOInts: the
one above and the one below Its course
90 The Australian Journal of PhYSIotherapy Vol 31, No 3, 1985
Ibp ~----Io+~l~=tf
Ibp --I---{-I-~,
Figure 1: An Illustration of the left
lumbar dorsal rami (reproduced from
Bogduk et aI, 1982, With permission of
the publishers of the Journal of Anat-
omy). TP= transverse process, ZJ =
zygapophyseal Jomt; vr = ventral ra-
mus; 1b = lateral branch of dorsal
ramus; Ib = intermediate branch, Ibp
= intermediate branch plexus, mb =
medial branch; a = articular branch, IS
= interspinous branch.
(FIgure 1). Recent studies have re-
vealed that each zygapophyseal JOInt
receIves an addItional InnervatIon ven-
trally, from the related dorsal ramus
proper (Auteroche 1983, Pans 1983).
Each joint, therefore, receIves a mul-
tiple innervatIon: from a dorsal ramus,
and two medial branches.
The L5 dorsal ram us forms only a
medIal branch and a branch that re-
sembles the IntermedIate branches of
the other lumbar dorsal ramI. The
Intermediate branch Innervates the
lowest fibres of longIssImus. The me-
dIal branch has a dlstnbutlon and
course analogous to those of other
medIal branches, supplyIng the lowest
fibres of multIfIdus and the lumbo-
sacral zygapophyseal JOInt.
Cervical Dorsal Rami
The anatomy of the cerVIcal dorsal
ramI IS somewhat complex maInly WIth
respect to the nerves at the C 1 and
C2 level. The detaIls of thIS anatomy
and theIr clInIcal ImplIcatIons are re-
VIewed elsewhere (Bogduk 1982).
At the C3-8 levels, the dorsal ramI
have a unIform and SImple anatomy.
As at lumbar levels, the dorsal rami
themselves are very short and he In
the Intertransverse spaces. Each forms
a lateral and a medIal branch. Some-
tImes the medIal branch may be dou-
ble. The lateral branches Innervate the
more superfICIal postenor cerVical
muscles whereas each medial branch
crosses the subadjacent transverse
process and Winds around the waIst
of the adjacent articular pIllar (FIgure
2) and supplIes the multIfIdus and
semIspInalIs cerVIciS muscles. The re-
lationshIp of the medIal branches to
the articular pIllars IS constant, and
along thIS part of ItS course each
medial branch gIves off artIcular
branches to the zygapophyseal JOInts
above and below (FIgure 2).
The C3 dorsal ramus forms two
medIal branches. One follows a course
analogous to that of the medIal
branches at lower levels whIle the
other, destined to become the thIrd
OCCIpItal nerve, crosses the lower half
of the C2-3 zygapophyseal JOInt. Ar-
tIcular branches to thIS JOInt are de-
rIved from the thud OCCIpItal nerve as
It crosses the JOInt, or from a com-
munIcating loop between the C2 and
C3 dorsal ramI that also crosses the
dorsal aspect of the JOInt (FIgure 2).
Thoracic Dorsal Rami
The most detaIled descnptlon of the
thoraCIC dorsal ramI, currently avall-

Figure 2: An Illustration of a .deep
dissection of the cervical dorsal rami
(reproduced from Bogduk, 1982, with
permission of the publishers of Spine)
The superficial posterior neck muscles
have been resected The lateral
branches (1 b) of the dorsal rami and
the nerves to the mtertransversarll (nl)
have been transected, leavmg only the
medial branches (m) mtact. The C1
dorsal ramus supplies the obllquus
superior (os), obllquus mferlor (01) and
the rectus capitis (rc) muscles The
medial branches of the C2 and C3
dorsal rami respectively form the
greater occipital (gon) and third OCCip-
Ital (ton) nerves. Communlcatmg loops
(c) connect the C1, 2 and 3 dorsal rami
Branches (nnS) of the C2,3) medial
branches mnervate the semlspmalls
capitis, while the C3-8 medial branches
send articular branches (a) to the zyg-
apophyseal Jomts before mnervatmg
multifidus (M) and semlspmalls cervl-
CIS (SSCe), and those at C4 and C5
form superficial cutaneous branches
(s) TP = transverse process of atlas,
SP = spmous process of T1
able, IS that In Hovelacque's (1927)
textbook, but as wIth prevIous text-
book descnptlons of the cervIcal and
lumbar dorsal ramI, thIS descnptlon
The Innervation of the Vertebral Column
does not address theIr skeletal dIStfl-
butlon. It can only be presumed that
It must be analogous to that of the
cervIcal and lumbar dorsal ramI.
Sinuvertebral Nerves
The sInuvertebral nerves are recur-
rent branches of the ventral ramI that
re-enter the Intervertebral foramIna to
be dIstrIbuted WIthIn the vertebral
canal. They are mIxed nerves, each
formed by a somatIc root from a
ventral ramus and an automatic root
from a grey ramus communIcantes.
The earlIest descnptlons of these
nerves (L uschka 1850, SoulIe 1905,
Hovelacque 1927) were focussed at
thoracIc levels and each slnuvertebral
nerve was descrIbed as sendIng
branches to the neck of the nb, to the
vessels of the vertebral canal, the
vertebral bodIes, the dura mater and
the postenor longItudInal lIgament.
There was no mentIon of a dIstnbutIon
to the Intervertebral dISCS, and the
gr
InnervatIon of the thoraCIC dISCS stIll
remaIns unstudIed. It was the putatIve
InnervatIon of the lumbar Interverte-
bral dISCS, however, that prompted
further study of the sInuvertebral
nerves.
Although earlIer, contrary descnp-
tlons of the lumbar sInuvertebral
nerves eXIst (SpurlIng and Bradford
Figure 3: An Illustration of the anatomy
1939, SpurlIng and Grantham 1940), of typical lumbar smuvertebral nerves
and are sometImes stIll propagated (reproduced from Bogduk, 1983, With
(Lamb 1979, Anderson 1980, Wyke permission of the publishers of Spine)
The view IS of the left half of the floor
1980), (see Bogduk 1985 for reVIew),
of the vertical canal. A ventral ramus
formal studIes of these nerves are In
(VA) and dorsal root ganglion (drg)
agreement (Lazorthes et a11947, Ped- have been retracted to reveal the orlgm
ersen et a1 1956, Bogduk et al 1981). of a smuvertebral nerve (svn) from a
Each lumbar sInuvertebral nerve enters somatic root (s) from the ventral ramus
and an autonomic root (a) from a grey
the vertebral canal Just below a pedI-
ramus communicans (gr). Ascendmg
cle, lyIng close to the bac k of the (a) and descendmg (D) branches are
vertebral body. Each forms an as- distributed to the postenor longltudmal
cendIng branch that passes rostrally, ligament (PLL) and the mtervertebral
diSCS (IVD) at the level of entry of the
parallel to the postenor longItudInal
nerve and at the next level above.
lIgament, as far as the next hIgher
Intervertebral diSC. It supplIes thIS dISC
and the postenor longItudInal lIga-
ment, en route. A shorter, descendIng skeletal dIstrIbution, each lumbar
branch ramifies In the dISC and lIga- sInuvertebral nerve IS dlstnbuted to
ment at the level of entry of the parent the vessels of the vertebral canal and
nerve (Figure 3). In addItIon to thIS to the ventral aspect of the dura mater.
The Australian Journal of Physiotherapy Vol 31, No 3, 1985 91
The Innervation of the Vertebral Column
Enigmatically, despite textbook de-
scriptions of the thoraCIC sInuvertebral
nerves and numerous studies of the
lumbar sInuvertebral nerves, the cerv-
ical sinuvertebral nerves have re-
mained undescnbed untl1 recently.
Hovelacque (1927) had noted the or-
igin of the cervical slnu vertebral nerves
from the cervical ventral rami and the
sympathetic nerves accompanyIng the
vertebral artery, but did not explore
theu dIstnbution wIthIn the vertebral
canal. Others have studIed the men-
ingeal distnbutlon of these nerves us-
Ing histologIcal techniques, but dId
not focus on theIr macroscopic anat-
omy or skeletal dIstrIbutIon, other
than a mentIon (Kimmel 1960) that
the C 1-3 slnuvertebral nerves, en route
to the posterIor cranial fossa, Inner-
vate the ligaments of the median at-
lanto-axlal JOInt.
A recent study (WIndsor et a11985)
has revealed the anatomy of the cerv-
ical slnuvertebral nerves. Not surprIS-
Ingly, It IS lIke that of the lumbar
nerves. Each cervical slnuvertebral
nerve cucumvents a pedIcle and as-
cends to the dISC at the next hIgher
level, supplying that disc, the one at
its level of entry, and the Intervening
posterior longitudInal lIgament (Figure
4).
The distribution of sinuvertebral
nerves to the dura mater, at all levels
of the vertebral column has been well
studied (Kimmel 1960, Edgar and
Nundy 1964). The salIent features are
that each sinuvertebral nerve forms
ascending and descending meningeal
branches. At lower thoraCIC and lum-
bar regions the descendIng branches
are the longer, extending up to two
segments caudally, while the ascendIng
branch ascends up to one segment. A
reciprocal pattern IS seen at upper
thoracic and cervIcal levels where the
ascending branches extend two to three
segments rostrally but the descending
branch only up to one segment cau-
dally. There IS conSiderable overlap
between nerves from different seg-
ments, but most conspicuously,
branches of the slnuvertebral nerves
92 The Australian Journal of PhYSiotherapy Vol 31, No 3, 1985
Figure 4: A sketch of the cervical
slnuvertebral nerves as seen In a spec-
Imen In which the spinal cord and the
left halves of the neural arches have
been removed Each slnuvertebral
nerve IS formed by a somatic root from
the ventral ramus of a spinal nerve (sn)
and an autonomic root (ar) from the
sympathetiC nerves that accompany
the vertebral artery Within the verte-
bral canal each slnuvertebral nerve
diVides Into ascending (a) and de-
scending (d) branches that Innervate
the Intervertebral discs (Ivd) and pos-
tenor longitudinal ligament (pll) En
route to the postenor cranial fossa,
the C1-3 slnuvertebral nerves cross
and Innervate the ligaments of the
atlanta-axial JOints
are distrIbuted only to the ventral
surface of the dura mater. The pos-
tenor dura IS deVOid of nerve endIngs
Ventral Rami
It had been generally unrecognized,
untIl recently, that In addItion to
branches from the sInuvertebral
nerves, Intervertebral diSCS receive an
InnervatIon from outSide the vertebral
canal. A pIlot study (Taylor and
Twomey 1979) Indicated that branches
to the lumbar Intervertebral diSCS arose
from the lumbar ventral rami as they
emerged from the Intervertebral for-
amIna. ThIS was subsequently con-
fumed (Bogd uk et a1 1981). Branches
from the ventral rami Innervate the
posterolateral corner of the lumbar
Intervertebral diSCS. The lateral and
antenor aspects, along With the ante-
nor longitudInal hgament, are Inner-
vated by branches from the grey ram I
communIcantes (FIgure 5).
That lumbar dISCS do, In fact, re-
ceive an InnervatIon has now been
estabhshed beyond doubt, for contrary
to opposing opinIon (Wyke 1980),
several studIes have now demonstrated
nerve fibres and nerve endings as
deeply as the penpheral third of the
annulus flbrosus In specimens of an-
tenor, postenor, and lateral segments
of lumbar diSCS (Mahnsky 1959, Shl-
nohara 1970, Bogduk et a11982; Yosh-
Izawa et a1 1980).
The Innervation of thoraCIC dISCS
has not been studied, but the cervical
dISCS appear to have an Innervation
SImIlar to that of lumbar dISCS. Hov-
elacque (1927) had descnbed branches
to the lateral aspects of the cervical
diSCS from the vertebral nerve, and
thiS has been confIrmed (WIndsor et
a1 1985). Moreover, whIle reveahng
only a few examples of dlssectable
nerves to the front of the cervical
diSCS, a recent study (W Indsor et a1
1985), uSing histological methods,
showed nerve fibres and nerve endings
In specimens of diSC matenal obtained
at operation for antenor cervical fu-
Sion, confirming Ferhc's (1963) earher
report of the same phenomenon.
Clinical Applications
Any component of the vertebral
column that receIVes an InnervatIon IS
theoretically capable of beIng a pri-
mary source of pain. In thiS context,
the term 'pnmary' IS used to denote
pain that occurs when nerve endings

Figure 5: The distribution of nerves to
the external aspects of the lumbar
mtervertebral discs (reproduced from
Bogduk, 1983, with permission of the
publishers of Spme) TP = transverse
process; ALL = antenor longltudmal
ligament, VR = ventral ramus, ST =
sympathetic trunks, gr = grey ram I
communicantes, 1 = branches to an-
terior longitudinal ligament, 2 =
branches to the lateral aspects of m-
tervertebral diSCS, 3 = branches from
grey rami, 4 = branches from ventral
ramI.
are stImulated by IntnnsiC leSIons of
the vertebral column or dura. ThIS
contrasts WIth leSIons that produce
paIn by Irntating spInal nerve trunks.
The mechanIsm of thIS latter form of
paIn and ItS clInIcal dIstInctIon are
revIewed elsewhere (Bogduk 1984b).
The Innervation of the Vertebral Column
The sources of pnmary splndl paIn
can be classIfied accordIng to theIr
nerve supply. Thus, sources Innervated
by the dorsal ramI Include the zyga'"
pophyseal JOInts, the InterspInous lIg-
aments and the postenor spInal mus-
cles. Sources Innervated by the
sInuvertebral nerves Include the In-
tervertebral dISCS, the posterIor lon-
gItudInal lIgament, the vessels of the
vertebral canal, and the dura mater.
Added to thIS lIst may be the vertebral
bodIes, for although nerve endIngs
have not been demonstrated In verte-
bral bodIes, It IS conceIvable that
IntrInSIC dIsease of the bodIes could
Irntate nerves runnIng WIth the vessels
WIthIn them. WhIle the Intervertebral
dISCS have been lIsted In the dlstnbu-
tion of sInuvertebral nerves, It must
be noted that these structures receIve
an addItional InnervatIon from the
ventral ramI, and the latter may pro-
VIde an addItIonal or alternatIve path-
way for the medIatIon of paIn from
these litructures. Further elaboratIon
of thIS claSSIfIcatIon, In terms of pa-
thology, IS avaIlable In other publI-
catIons (Bogduk 1980a, 1980b, 1982,
1983, 1984a, 1984b).
The constancy of the course of the
medIal branches of the dorsal ramI,
across the transverse process at the
lum bar levels and around the artIcular
pIllars at cerVIcal levels permIts the
locatIon of these nerves to be plotted
on radIographs. Consequently, needles
or electrodes can be accurately Intro-
duced onto these nerves for dIagnostIC
and therapeutIc procedures, the detaIls
of WhICh are explained elsewhere (Bog-
duk and Long 1980, SIUljter and
Mehta 1981, Bogduk 1982).
The advent of these technIques has
brought WIth It a greater awareness of
the InCIdence of spInal paIn due to
dIsorders of the postenor elements of
the vertebral column, as opposed to
dISC dIsease. These technIques now
permIt screenIng for these dIsorders
and the ObjectIve confIrmatIon or ex-
clUSIon of theIr presence. Further-
more, they are enabhng studIes of the
senSItIVity of other dIagnOStic proce-
The Australian Journal of PhySiotherapy Vol 31, No 3, 1985
dures, In partIcular, manual dIagnOSIS.
One study, thus far, has compared
the dIagnOSIS made by a manIpulatIve
therapIst WIth that based on dIagnostIC
blocks, and attests to a remarkably
hIgh senSItIVIty of manual dIagnOSIS
In patients WIth zygapophyseal dIsor-
ders (lull 1984).
The concept of prImary disc pain
was based on the observatIon that
paIn could be produced dUrIng dIS-
cography (HIrsch 1949, LIndholm
1950, SImmons and Segl1 1975, Park
1980). In thIS procedure cerVIcal or
lum bar dISCS are dIstended WIth InjeC-
tIons of contrast medIum or salIne.
The InjectIon IS locahsed to the dISC
and does not affect the nerve roots.
The observatIon that paIn could be
evoked by thIS procedure IndIcated
that the dISCS must have an IntrInSIC
nerve supply, but prevaIlIng anatom-
Ical eVIdence and opInIon denIed thIS.
The paIn was, therefore, enIgmatiC
and consequently the valIdity of diS-
cography as a diagnostIc procedure
was dIsputed. The resolutIon of the
nerve supply to the lumbar and cerv-
Ical dISCS now prOVIdes the hItherto
mISSIng anatomIcal substrate for pn-
mary dISC paIn, and VIndIcates the
onglnal concept.
Comparable to the concept of dISC
paIn IS that of prImary dural pain.
The dura, by haVing an IntnnsiC In-
nervation, IS a pOSSIble source of
prImary paIn, caused by mechanIcal
or chemical IrrItatIon of nerve root
sleeves. That such IrrItatIon can pro-
duce pain has been demonstrated ex-
perImentally (El Mahdi et a1 1981).
The ImphcatIon IS that, In condItIons
lIke dISC hernIation, paIn can be due
to irrItatIon of the dura rather than
to nerve compreSSIon. What remaIns
IS for thIS concept to attract a greater
conSIderatIon In the dIfferential dIag-
nosIs of spInal paIn than It has hItherto
attracted.
Concluding Remarks
Research Into the InnervatIon of the
vertebral column has In recent years
93
The Innervation of the Vertebral Column
expanded the conceptual and practIcal
armamentanum for the dIagnOSIS of
spinal paIn, at least wlth respect to
the cerVIcal and lumbar vertebral col-
umn. Companson of modern lItera-
ture wIth that of the past reveals an
expanded awareness of the pOSSIble
causes of paIn, but moreover, better
means of obJecttvely valIdatIng dIffer-
ential dIagnoses. A major frontIer,
however, remaIns and that IS the tho-
racic vertebral column. The thoraCIC
region has been the 'CInderella' of
spInal paIn research, ostenSIbly be-
cause of the apparent Infrequency of
thoracic spinal paIn, but thoraCIC pain
syndromes are becomIng recognIsed
with Increased frequency. Therefore,
there is now a need for studIes of the
neurology of the thoraCIC regIon to be
undertaken, so that dIagnostIC tech-
niques, comparable to those avaIlable
for the neck and low back, can be
deVIsed.
References
Auteroche P (1983), Innervat10n of the zygapo-
physeal Jomts of the lumbar spme, Anatomla
Cbmca, 5, 17 28
Anderson J (1980), PathogeneSIs of back pam,
m R Grahame and JAD Anderson (Eds) Low
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Bogduk N (1979), The lumbar zygapophysIaI
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Proceedmgs of a SymposIUm on Low Back
Pam, Mampuiative Therapists' ASSOCiatIOn of
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Bogduk N (1980a), Lumbar dorsal ramus syn
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541
Bogduk N (1980b), The anatomy and pathology
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Bogduk N (1982), The elImeal anatomy of the
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