anaesthesia anatomy

ANAESTHESIA ANATOMYANAESTHESIA ANATOMY

Li XuetaoLi Xuetao

DEPARTMENTOF HUMAN ANATOMY DEPARTMENTOF HUMAN ANATOMY

KUNMING MEDICAL UNIVERSITYKUNMING MEDICAL UNIVERSITY

BACKBACK

(VERTEBRAL REGION)(VERTEBRAL REGION)

VertebraeVertebrae 椎骨、脊柱椎骨、脊柱

Case: Tension HeadacheCase: Tension Headache

Mr. PortMr. Port

a 53-year-old lorry drivera 53-year-old lorry driver

headaches in the headaches in the

occipital regionoccipital region （枕区）（枕区）Pain start with drivingPain start with driving

lying down brought relieflying down brought relief

pain for six monthspain for six months

Slight wear and tear between Slight wear and tear between the cervical vertebrae bodythe cervical vertebrae body

Sitting posture correctionSitting posture correction

Answer the questions regarding Answer the questions regarding the case at the end of this the case at the end of this

chapter chapter

1. What classes of joints are there 1. What classes of joints are there between typical cervical vertebrae? between typical cervical vertebrae?

2. What are the normal curvatures of the 2. What are the normal curvatures of the vertebral column? vertebral column?

3. What movements occur between typical 3. What movements occur between typical cervical vertebrae? What movements cervical vertebrae? What movements occur at the atlanto-occipital (occur at the atlanto-occipital ( 寰枕关寰枕关节）节） and the atlanto-axialand the atlanto-axial （寰枢关节）（寰枢关节） joints? joints?

4. Where does the vertebral artery lie in 4. Where does the vertebral artery lie in relation to the cervical vertebrae? relation to the cervical vertebrae?

5. How might the function of the vertebral 5. How might the function of the vertebral artery be assessed? artery be assessed?

6. Why was the headache felt in the 6. Why was the headache felt in the occipital region? occipital region?

Surface Surface Anatomy Anatomy

11.. 棘突 ：第棘突 ：第 77 颈椎棘突较长，常作为 颈椎棘突较长，常作为 辨认椎体序数的标志； 辨认椎体序数的标志；

两侧肩胛冈内侧端的连线平第两侧肩胛冈内侧端的连线平第 33 胸椎胸椎棘突； 棘突；

两侧髂嵴最高点的连线平第两侧髂嵴最高点的连线平第 44 腰椎棘腰椎棘突。突。

2.2. 枕外隆凸：颅后部明显的骨性突起。枕外隆凸：颅后部明显的骨性突起。 3.3. 乳突：在耳廓的后方。乳突：在耳廓的后方。 4.4. 肩胛冈：外侧端为肩峰。肩胛冈：外侧端为肩峰。

5.5. 肩胛骨下角：两肩胛骨下角的连线肩胛骨下角：两肩胛骨下角的连线平对第平对第 77 胸椎棘突。胸椎棘突。

6.6. 骶管裂孔和骶角：骶管裂孔是椎管骶管裂孔和骶角：骶管裂孔是椎管的下口，裂孔两侧向下的突起为骶角，的下口，裂孔两侧向下的突起为骶角，是骶管麻醉的进针定位标志。是骶管麻醉的进针定位标志。

7.7. 髂嵴和髂后上棘：两侧髂嵴最高点髂嵴和髂后上棘：两侧髂嵴最高点的连线平第的连线平第 44 腰椎棘突。两侧髂后上腰椎棘突。两侧髂后上棘的连线平第棘的连线平第 22 骶椎棘突。骶椎棘突。

LAYERSLAYERS

Superficial Superficial layerslayers

Deep fasciaDeep fascia MusclesMuscles

Superficial layersSuperficial layers

SkinSkin Superficial fasciaSuperficial fascia

SkinSkin

Thick Thick Full of hairFull of hair folliclesfollicles, , sweat glands & sebaceous glands sweat glands & sebaceous glands

Superficial fasciaSuperficial fascia

Dense, especially the Nuchal regionDense, especially the Nuchal regionFull of FatFull of FatCutaneous nerve & Superficial Cutaneous nerve & Superficial

blood vesselsblood vessels

Cutaneous nerveCutaneous nerve

Greater occipital nerveGreater occipital nerve

3rd occipital nerve3rd occipital nerve

Spinal nerve (cutaneous Spinal nerve (cutaneous branches of dorsal rami)branches of dorsal rami)Superior cluneal nerve Superior cluneal nerve (cutaneous branches of (cutaneous branches of dorsal rami)dorsal rami)

Middle cluneal nerve Middle cluneal nerve (cutaneous branches of (cutaneous branches of dorsal rami)dorsal rami)

Inferior cluneal nerve Inferior cluneal nerve (posterior femoral (posterior femoral cutaneous nerve cutaneous nerve

Herpes Zoster

Infections (Shingles)

Superficial Blood VesselsSuperficial Blood Vessels

NuchalNuchalOccipital arteryOccipital artery

Superficial cervical arterySuperficial cervical artery

dorsal scapular arterydorsal scapular artery

Thoracic Thoracic dorsal dorsal

Posterior intercostals arteryPosterior intercostals artery

dorsal scapular arterydorsal scapular artery

thoracodorsal arterythoracodorsal artery

Lumber Lumber Lumbar arteryLumbar artery

SacrococcygeaSacrococcygeall

Superior Cluneal arterySuperior Cluneal artery

Inferior cluneal arteryInferior cluneal artery

Deep FasciaDeep Fascia

Nuchal fasciaNuchal fascia: a deep investing : a deep investing

membrane which covers the deep membrane which covers the deep

muscles of the back of the neck.muscles of the back of the neck.

Thoracolumbar fasciaThoracolumbar fascia: a deep investing : a deep investing

membrane which covers the deep membrane which covers the deep

muscles of the back of the trunk.muscles of the back of the trunk.

Nuchal FasciaNuchal Fascia

ThoracolumbaThoracolumbar Fasciar Fascia

a deep investing a deep investing membrane which membrane which covers the deep covers the deep muscles of the muscles of the back of the trunkback of the trunk

3 layers in 3 layers in lumbar regionlumbar region

Q.L

Erector spinae

MUSCLESMUSCLES

intrinsic back intrinsic back musclesmuscles

movement and movement and stabilization of stabilization of the vertebral the vertebral

columncolumn

respiration and respiration and movements of movements of

the upper the upper extremityextremity

extrinsic back extrinsic back musclesmuscles

IntermediaIntermediate groupte group

Deep Deep groupgroup

Superficial Superficial groupgroup

TrapeziusTrapezius

levator scapulaelevator scapulae

Rhomboid minorRhomboid minor

Rhomboid majorRhomboid major

Latissimus dorsiLatissimus dorsi

Superficial GroupSuperficial Group

Triangle Of AuscultationTriangle Of AuscultationS

UP

ER

IOR

SU

PE

RIO

R

INF

ER

IOR

INF

ER

IOR

Latissimus dorsi

Latissimus dorsi

TrapeziusTrapezius

medial border o

f scapula

medial border o

f scapula

Serratus posterior Serratus posterior superiorsuperior

Serratus posterior inferiorSerratus posterior inferior

Intermediate GroupIntermediate Group

DEEP GROUPDEEP GROUP

Spinotransversales MusclesSpinotransversales Muscles

Splenius CapitisSplenius Capitis

Splenius CervicisSplenius Cervicis

ErectorErector Spine Muscles Spine Muscles

IliocostalisIliocostalis

Longissimus Longissimus

SpinalisSpinalis

DEEP GROUPDEEP GROUP

Transversospinales musclesTransversospinales muscles

SemispinalisSemispinalis

RotatoresRotatores

MultifidusMultifidus

Segmental back musclesSegmental back muscles

Levatores costarumLevatores costarum

InterspinalesInterspinales

IntertransversariiIntertransversarii

P59P59

DEEP GROUPDEEP GROUP

Suboccipital MusclesSuboccipital Muscles

Rectus Capitis Posterior Rectus Capitis Posterior MinorMinor

Rectus Capitis Posterior Rectus Capitis Posterior MajorMajor

Superior Oblique Superior Oblique

Inferior ObliqueInferior Oblique

Rectus Capitis Rectus Capitis Posterior MajorPosterior Major

Superior Rectus Superior Rectus ObliqueOblique

Inferior Rectus Inferior Rectus ObliqueOblique

Vertebral Artery Suboccipital N

(Dorsal Ramus Of CⅠ)

Suboccipital Suboccipital TriangleTriangle

Superior Lumbar TriangleSuperior Lumbar Triangle(Triangle Of Grynfeltt-Lesshaft )(Triangle Of Grynfeltt-Lesshaft )

twelfth ribtwelfth ribSerratus Serratus

posterior posterior inferior inferior

Erector spinae Erector spinae internal obliqueinternal oblique

External External Abdominal Abdominal ObliqueOblique

Latissimus DorsiLatissimus Dorsi Iliac CrestIliac Crest

Inferior Lumbar TriangleInferior Lumbar Triangle(Petit's Lumbar Triangle)(Petit's Lumbar Triangle)

Deep ArteriesDeep Arteries

Nuchal RegionNuchal Region

Occipital ArteryOccipital Artery

Superficial Cervical ArterySuperficial Cervical Artery

Dorsal Scapular ArteryDorsal Scapular Artery

Vertebral ArteryVertebral Artery

Thoracic RegionThoracic Region

Posterior Intercostals ArteryPosterior Intercostals Artery

Dorsal Scapular ArteryDorsal Scapular Artery

Thoracodorsal ArteryThoracodorsal Artery

Lumber RegionLumber RegionLumbar ArteryLumbar Artery

Subcostal ArterySubcostal Artery

Sacrococcygeal Sacrococcygeal RegionRegion

Superior Cluneal ArterySuperior Cluneal Artery

Inferior Cluneal ArteryInferior Cluneal Artery

NuchalNuchalVertebral veinVertebral vein

Internal jugular veinInternal jugular vein

Subclavian veinSubclavian vein

ThoraciThoracicc

Posterior Intercostals vein – azygos Posterior Intercostals vein – azygos veinvein

Subclavian veinSubclavian vein

Axillary veinAxillary vein

LumberLumber Lumbar vein – inferior vena cavaLumbar vein – inferior vena cava

SacrocoSacrococcygeal ccygeal Internal iliac veinInternal iliac vein

DEEP VEINSDEEP VEINS

Vertebral Vertebral ArteryArtery

AtlasAtlas

Vertebral VeinsVertebral Veins

Deep NerversDeep Nervers

Dorsal rami of spinal nerveDorsal rami of spinal nerve

Accessory nerveAccessory nerve

Thoracodorsal nerveThoracodorsal nerve

Dorsal scapular nerveDorsal scapular nerve

Dorsal Rami of Spinal NerveDorsal Rami of Spinal Nerve

Accessory NerveAccessory Nerve

Transient Transient postoperativpostoperative paralysis of e paralysis of

spinal spinal accessory accessory

nervenerve

Thoracodorsal Nerve

Dorsal Scapular Dorsal Scapular NerveNerve

Vertebral ColumnVertebral Column

Osteology and ArthrologyOsteology and Arthrology

OsteologyOsteology

7 C, 12 T, 5 L, 5 S (Fused as Sacrum), 4 7 C, 12 T, 5 L, 5 S (Fused as Sacrum), 4 coccygealcoccygeal

Primary CurvesPrimary CurvesSecondary CurvesSecondary CurvesAnterior/Posterior alignmentAnterior/Posterior alignment

Vertebral SegmentsVertebral Segments

Primary CurvePrimary Curve

Secondary Curves LateralSecondary Curves Lateral

Vertebral ColumnVertebral Column

OsteologyOsteology Typical VertebraeTypical Vertebrae BodyBody 椎体椎体

Superior and inferior surfaces of body (plateaus)Superior and inferior surfaces of body (plateaus) Thickened around the rim, location of epiphyseal platesThickened around the rim, location of epiphyseal plates Cartilaginous end-platesCartilaginous end-plates

Vertebral ArchVertebral Arch 椎弓椎弓 Pedicles, LaminaePedicles, Laminae Transverse ProcessesTransverse Processes Spinous ProcessSpinous Process Facets – superior articular and inferior articular Facets – superior articular and inferior articular

Spinal ForamenSpinal Foramen 椎孔椎孔 Intervertebral ForamenIntervertebral Foramen 椎间孔椎间孔

Typical VertebraeTypical Vertebrae

Typical VertebraeTypical Vertebrae

Typical CTypical C

Luschka JoinLuschka Join 钩椎关节钩椎关节

钩椎关节及其毗邻钩椎关节及其毗邻

Typical CTypical C

C6C6

C1/C2C1/C2

Typical ThoracicTypical Thoracic

Facet Joints (C and T)Facet Joints (C and T)

Facets LFacets L

Typical LumbarTypical Lumbar

Sacrum and CoccyxSacrum and Coccyx

Vertebral ColumnVertebral Column

ArthrologyArthrology

Intervertebral DiscsIntervertebral Discs 椎间盘椎间盘Fibrocartilaginous jointsFibrocartilaginous joints 纤维软骨连接纤维软骨连接 Increase in size from C to L (3mm to 9 Increase in size from C to L (3mm to 9

mm)mm)Ratio remains the sameRatio remains the sameMake up 20-30% of length of columnMake up 20-30% of length of column

Intervertebal DiscsIntervertebal Discs

Discs Discs

DiscsDiscs

ArthrologyArthrology

Facet Joints (Typical)Facet Joints (Typical) Superior articular facets of one vertebrae with Superior articular facets of one vertebrae with

inferior facets of vertebrae aboveinferior facets of vertebrae above Synovial gliding joints Synovial gliding joints Surrounded by joint capsule and small capsular Surrounded by joint capsule and small capsular

ligamentsligaments The type and amount of motion in any given part The type and amount of motion in any given part

of the spine is dictated by the orientation of the of the spine is dictated by the orientation of the articular facets as well as the fluidity, elasticity and articular facets as well as the fluidity, elasticity and thickness of the intervertebral discsthickness of the intervertebral discs

ArthrologyArthrology

Typical movements in sections of the Typical movements in sections of the spinespine

LumbarLumbarThoracicThoracicCervicalCervical

Major Ligaments of the SpineMajor Ligaments of the Spine

Anterior Longitudinal Ligament - ALLAnterior Longitudinal Ligament - ALL Dense band along anterior and lateral surface of Dense band along anterior and lateral surface of

the vertebral bodies from C2 to sacrumthe vertebral bodies from C2 to sacrum Superficial - bridge several vertebraeSuperficial - bridge several vertebrae Deep – short, run from V to V, blends with fibers of anulus Deep – short, run from V to V, blends with fibers of anulus

fibrosusfibrosus Limits extension of V columnLimits extension of V column

From C1 to skull, called From C1 to skull, called Atlanto-Occipital Atlanto-Occipital MembraneMembrane

ALLALL

Atlanto-Occipital MembraneAtlanto-Occipital Membrane

A and P Longitudinal LigamentA and P Longitudinal Ligament

Major LigamentsMajor Ligaments

Posterior Longitudinal LigamentPosterior Longitudinal LigamentRuns along posterior surface of vertebral Runs along posterior surface of vertebral

bodies (anterior to spinal canal) bodies (anterior to spinal canal) C2 to SacrumC2 to SacrumShort fibers attach ligament to posterior disc, Short fibers attach ligament to posterior disc,

reinforce disc posteriorlyreinforce disc posteriorlySuperiorly, continues to occiput, called Superiorly, continues to occiput, called

Tectorial MembraneTectorial MembraneLimits flexionLimits flexion

PLLPLL

Tectorial MembraneTectorial Membrane

LigamentsLigaments

SupraspinousSupraspinous 棘上韧带棘上韧带Spinous process to spinous process – tip to Spinous process to spinous process – tip to

tiptipC7 to sacrumC7 to sacrum

Limits flexionLimits flexion In cervical region, becomes much thicker In cervical region, becomes much thicker

with a greater elastic contentwith a greater elastic contentCalled Called Ligamentum NuchaeLigamentum Nuchae

SupraspinousSupraspinous

Ligamentum NuchaeLigamentum Nuchae

LigamentsLigaments

InterspinousInterspinous 棘间韧带棘间韧带Found between spinous processesFound between spinous processesMost well developed in lumbar regionMost well developed in lumbar regionsupportsupport

InterspinousInterspinous

InterspinousInterspinous

LigamentsLigaments

Ligamentum FlavumLigamentum Flavum 黄韧带黄韧带Connects laminaConnects lamina 椎板椎板 of one to lamina of of one to lamina of

the otherthe otherFound from axisFound from axis 枢椎枢椎 to sacrumto sacrum 骶骨骶骨Limit flexionLimit flexionContinuation to the skullContinuation to the skull 颅骨颅骨 is called is called

Posterior Atlanto-Occipital membranePosterior Atlanto-Occipital membrane

后寰枕关节膜后寰枕关节膜

Ligamentum FlavumLigamentum Flavum 黄韧带黄韧带

Atlanto-Occipital Membrane-Atlanto-Occipital Membrane-PosteriorPosterior

LigamentsLigaments

IntertransverseIntertransverse 横突间韧带横突间韧带Only well-developed in Lumbar RegionOnly well-developed in Lumbar RegionBetween transverse processesBetween transverse processesLimit lateral flexionLimit lateral flexion 侧曲侧曲

Atlanto-Axial JointAtlanto-Axial Joint寰枢关节寰枢关节

Atlas and AxisAtlas and Axis PivotPivot 旋转运动旋转运动 Two convex superior facets of axis with two Two convex superior facets of axis with two

concave inferior facets of the atlasconcave inferior facets of the atlas Atlas also posses a facet on the internal surface of Atlas also posses a facet on the internal surface of

the anterior arch which articulates with the dens of the anterior arch which articulates with the dens of the axisthe axis

Major ligaments from spine support – Major ligaments from spine support – Ant. Ant. Atlanto-Occipital, Tectorial Membrane, Post. A-Atlanto-Occipital, Tectorial Membrane, Post. A-OO

C1/C2C1/C2

C1/C2C1/C2

C1/C2C1/C2

A-A JointA-A Joint

Alar – from dens to occiputAlar – from dens to occiputTransverse - around dens Transverse - around dens CruciateCruciate

Sup. Longitudinal BandSup. Longitudinal Band Inferior Longitudinal BandInferior Longitudinal BandTransverseTransverse

Atlanto-Occipital JointAtlanto-Occipital Joint寰枕环节寰枕环节

Two concave superior facets of atlas Two concave superior facets of atlas articulate with two convex surfaces of articulate with two convex surfaces of occipital condyles of the skulloccipital condyles of the skull

Supported by major ligamentsSupported by major ligamentsSmall saddle jointSmall saddle jointVery limited motion Very limited motion – nodding type – nodding type

motions in all directions.motions in all directions.

Atlanto-OccipitalAtlanto-Occipital

Atlanto-OccipitalAtlanto-Occipital

Movement of the Vertebral ColumnMovement of the Vertebral Column

Flex Flex 屈屈Extend Extend 伸伸Rotation Rotation 旋转旋转Lateral flex Lateral flex 侧曲侧曲

Thank youThank you

That’s all for today! That’s all for today!