The accessory ossicle of the anterior arch of the atlas is a normal variant and is best appreciated on a lateral cervical/sagittal study. It is observed as a circular and corticated osseous density that articulates with the inferior aspect of the anterior arch of the atlas.
It is not associate...
Acute spinal cord ischaemia syndrome (ASCIS) is uncommon, but usually presents with profound neurological signs and symptoms, and prognosis is generally poor.
Acute spinal cord ischaemia syndrome represents only 5-8% of acute myelopathies 4,5 and <1% of all strokes 7. The demogra...
The alar ligaments join the lateral margins of the sloping upper margin of the dens to the margins of the foramen magnum (adjacent to the occipital condyles) and lie on either side of the apical ligament. They are paired ligaments that are very strong and limit rotation of the head.
This classification was proposed by Allen and Ferguson in 19823 and at the time of writing (July 2016) remains the most widely used system for describing subaxial cervical spine injury.
Allen and Ferguson classification is used for research purposes to classify subaxial spine injuries. It is ba...
The anatomy curriculum is one of our curriculum articles and aims to be a collection of articles that represent the core anatomy knowledge.
Head and neck anatomy
Abdominal and pelvic anatomy
Lower limb anatomy
Upper limb anato...
Ancient schwannomas are long-standing, slow growing schwannomas with advanced degeneration. These can have calcification, hyalinization, and cystic cavitation that can be identified on imaging. The term “ancient” has been traditionally used to describe schwannomas showing degenerative changes an...
Andersson lesions refer to an inflammatory involvement of the intervertebral discs by spondyloarthritis.
Rheumatic spondylodiscitis is a non-infectious condition that has been shown to occur in about 8% of patients with ankylosing spondylitis, as detected at radiography.
Angiolipomas (also sometimes known as haemangiolipomas, vascular lipomas, and fibromyolipomas) are rare soft tissue tumours composed of mature adipocytes and vessels. They can occur essentially anywhere, and can be subclassified into infiltrating and non-infiltrating varieties 1.
The most comm...
Ankylosing spondylitis (less commonly known as Bechterew disease and Marie Strümpell disease) is a seronegative spondyloarthropathy, which as the name suggests, results in fusion (ankylosis) of the spine and sacroiliac (SI) joints, although involvement is also seen in large and small joints.
Annular fissures are a degenerative deficiency of one or more layers that make up the annulus fibrosus of the intervertebral disc.
Many authors prefer the term annular fissure over annular tear, as the latter seems to imply acute injury 1,2. In the setting of severe trauma with di...
The annulus fibrosus surrounds the nucleus polposus and together they form the intervertebral disc.
The annulus comprises 15 to 20 collagenous (type I) laminae which run obliquely from the edge of one vertebra down to the edge of the vertebra below. The direction of the fibres al...
The spinothalamic tracts are ascending pathways primarily concerned with sensory function. They are responsible for transmitting pain, temperature, coarse (non-discriminative) touch and pressure sensations. The spinothalamic tracts can be separated into lateral and anterior tracts.
Anterior angulation of the coccyx may be a normal variant but poses a diagnostic challenge for those considering coccygeal trauma.
Four types of coccyx have been described
type I: the coccyx is curved slightly forward, with its apex pointing caudally (~70%)
type II: the coccyx...
The anterior atlanto-occipital membrane joins the upper border of the anterior arch of the atlas to the outer margin of the foramen magnum.
Anterior cord syndrome (also known as Beck's syndrome or anterior spinal artery syndrome) is a clinical subset of spinal cord injury syndromes, due to ischaemia/infarction of the anterior two-thirds of the spinal cord, typically sparing posterior third.
Patient present wi...
The anterior corticospinal tract is a descending neural pathway primarily concerned with motor function. There are separate lateral and anterior corticospinal tracts as fibres decussate at the cevicomedullary junction.
Corticospinal fibres arise from neurons ...
Anterior horn syndrome is a fairly generic term used to refer to flaccid paralysis and areflexia due to involvement of the anterior grey matter horns of the spinal cord. Sensation is typically preserved.
Causes of anterior horn syndrome include:
anterior spinal artery ischaemia
The anterior longitudinal ligament (ALL) arises from the anterior tubercle of the atlas, travels downwards, anterior to the vertebral bodies (firmly united to the periosteum) and intervertebral discs (attaching to the anterior annulus), attaching to the front of the upper part of the sacrum. It ...
Anterior sacral meningocele is a congenital defect seen in the anterior aspect of the spine. It is defined as a meningeal cyst that occurs in the presacral space secondary to agenesis of a portion of the anterior sacrum.
In approximately 50% of cases, associated malfor...
The anterior spinal artery supplies the anterior portion of the spinal cord and arises from the vertebral artery in the region of the medulla oblongata. The two arteries (one of which is usually bigger than the other) anastamose in the midline to form a single anterior spinal artery at the level...
Anterior subluxation of cervical spine (also known as hyperflexion sprain) is a ligamentous injury to the cervical spine.
Patient presents with neck pain. There may be symptoms due to spinal cord oedema.
It results from ligamentous injury, however, there may b...
Anterior vertebral body beaking occurs in a number of conditions and may eminate from the central portion or the lower third of the vertebral body.
Morquio syndrome 1 (middle for Morquio)
Hurler syndrome 2
The term anterolisthesis refers to anterior displacement (forward slip) of vertebral body relative to one below.
The apical ligament joins the apex of the dens to the anterior margin of the foramen magnum. It is the weak, fibrous remnant of the notochord.
Arachnoid cysts are relatively common benign and asymptomatic lesions occurring in association with the central nervous system, both within the intracranial compartment (most common) as well as within the spinal canal. They are usually located within the subarachnoid space and contain CSF.
Arachnoiditis is a broad term encompassing inflammation of the meninges and subarachnoid space.
Arachnoiditis affecting the cauda equina may be referred to as spinal/lumbar adhesive arachnoiditis.
Lumbar spine arachnoiditis can result in leg pain, sensory c...
The arcuate foramen (foramen arcuale atlantis, ponticulus posticus or posterior ponticle, or Kimerle anomaly) is a frequently encountered normal variant of the atlas and is easily appreciated on a lateral plain film of the cranio-cervical junction.
It develops by calcification of the oblique at...
The artery of Adamkiewicz, also known as the great anterior radiculomedullary artery or arteria radicularis anterior magna, is the name given to the dominant thoracolumbar segmental artery that supplies the spinal cord.
The artery of Adamkiewicz has a variable origin but ...
The ascending lumbar vein is a paired structure which forms a part of the venous drainage of the lumbar vertebral column.
location: near midline on the side of the vertebral column in the lumbar region
origin and termination: continuation of the lateral sacral veins; joins the subcost...
The atlanto-axial articulation is a complex of three synovial joints, which join the atlas (C1) to the axis (C2).
paired lateral atlanto-axial joints: classified as planar-type joint between the lateral masses of C1 and C2, though somewhat more complex in shape wit...
The atlanto-occipital articulation is comprised of a pair of condyloid synovial joints that connect the occiput (C0) to the first cervical vertebra (atlas/C1).
Each joint is comprised of two concave articular surfaces on the superior aspect of the lateral mass of a...
Atlanto-occipital assimilation is the fusion of the atlas (C1) to the occiput and is one of the transitional vertebrae.
Atlanto-occipital assimilation occurs in ~0.5% (range 0.25-1%) of the population 2-4.
Atlanto-occipital is typically asymptomatic but s...
Atlanto-occipital dissociation (AOD) injuries are severe and include both atlanto-occipital dislocations and atlanto-occipital subluxations.
The tectorial membrane and alar ligaments provide the most the stability to the atlanto-occipital joint, and injury to these ligaments results ...
The atlantodental interval (ADI), as the name suggests, is the horizontal distance between the anterior arch of the atlas and the dens of the axis, used in the diagnosis of atlanto-occipital dissociation injuries and injuries of the atlas and axis.
It is the distance (in mm) between the posteri...
The atlas is the first cervical vertebra, commonly called C1. It is an atypical cervical vertebra with unique features. It articulates with the dens of the axis and the occiput, respectively allowing rotation of the head, and flexion, extension and lateral flexion of the head. Unlike the rest o...
Of the cervical vertebrae, the atlas (C1), axis (C2) and vertebra prominens (C7) are considered atypical cervical vertibrae.
The atlas (C1) lacks a body or spinous process. It has an anterior and posterior arches with lateral masses. Its superior articular surfaces articulate with the occiput a...
Of the five lumbar vertebrae, L5 is considered atypical due to its shape. The remaining lumbar vertebrae are largely typical.
T1 and T9 to T12 are considered atypical vertebrae. T1 bears some resemblance to low cervical vertebrae. T9 has no inferior demifacet. T10 often, but not always, shares features with T11 and T12.
The axis is the second cervical vertebra, commonly called C2. It is an atypical cervical vertebra with unique features and important relations that make it easily recognisable. Its most prominent feature is the odontoid process, which is embryologically the body of the atlas (C1)1,2. It plays an...
Baastrup syndrome (also referred to as kissing spines) results from adjacent spinous processes in the lumbar spine rubbing against each other and resulting in hypertrophy and sclerosis with focal midline pain and tenderness relieved by flexion and aggravated by extension.
Bamboo spine is a radiographic feature seen in ankylosing spondylitis that occurs as a result of vertebral body fusion by marginal syndesmophytes. It is often accompanied by fusion of the posterior vertebral elements as well.
A bamboo spine typically involves the thoracolumbar and or lumbosacr...
Basilar invagination, also called basilar impression, is a congenital or acquired craniocervical junction abnormality where the tip of the odontoid process projects above the foramen magnum.
The terms basilar invagination and basilar impression are often used interchangeably becau...
A mnemonic to help recall the cases of basilar invagination is:
P: Paget disease of bone
F: fibrous dysplasia
R: rheumatoid arthritis, rickets
O: osteogenesis imperfecta, osteomalacia
C: Chiari I and Chiari II, cleidocranial dysostosis
The basion-axial interval (BAI), as the name suggests, is the horizontal distance between the basion and the posterior cortex of the axis, used in the diagnosis of atlanto-occipital dissociation injuries.
It is the distance (in mm) between the basion and the superior extension of the posterior ...
The basion-dens interval (BDI), as the name suggests, is the distance between the basion and the tip of the dens, used in the diagnosis of atlanto-occipital dissociation injuries.
It is the distance from the most inferior portion of the basion to the closest point of the superior aspect of the ...
Batson venous plexus (Batson veins) is a network of veins with no valves that connect deep pelvic veins draining the bladder, prostate and rectum to the internal vertebral venous plexus 1. These veins are important because they are believed to provide a route for spread of pelvic cancer metastas...
Bertolotti syndrome refers to the association between lumbosacral transitional vertebrae (LSTV) and low back pain, and can be an important cause in young patients.
It is considered controversial and has been both supported and disputed since Mario Bertolotti first described it in 1917. Some st...
Bilateral facet dislocation is a flexion distraction type of dislocation.
It has been thought to result from hyperflexion, however, recent studies suggest a buckling force to be the cause 1.
loss of apposition at facet joint: bilateral facet joints ...
Block vertebra is a type of vertebral anomaly where there is a failure of separation of two or more adjacent vertebral bodies.
In a block vertebra, there is partial or complete fusion of adjacent vertebral bodies.
there is a frequent association with hemivertebrae/abse...
Blunt cerebrovascular injury (BCVI) is an uncommon but serious consequence of blunt trauma to the head and neck.
It is often part of multi-trauma with a significant series of blunt trauma CTA reporting an incidence of approximately 1% 3. A large systematic review and meta-analysis...
The Borden classification of dural arteriovenous fistulas (DAVF) groups these lesions into three types based upon the site of venous drainage and the presence or absence of cortical venous drainage. It was first proposed in 1995 1 and remains popular although, at the time of writing (July 2016) ...
The brachial plexus is a complex neural network formed by lower cervical and upper thoracic ventral nerve roots which supplies motor and sensory innervation to the upper limb and pectoral girdle. It is located in the neck extending into the axilla posterior to the clavicle.
Brown-Séquard syndrome is the result of a hemicord lesion (i.e. damage or impairment to the left or right side of the spinal cord).
Due to some fibres crossing within the cord whilst others cross in the brainstem, the neurology is bilateral, namely 1:
Bullet shaped vertebra refers to the anterior beaking of the vertebral body.
It is seen in the following conditions:
mucopolysaccharidosis (Morquio disease, Hurler disease)
weapons and munitions inspired signs
Burst fractures are a type of compression fracture related to high-energy axial loading spinal trauma that results in disruption of the posterior vertebral body cortex with retropulsion into the spinal canal.
They usually present as back pain and or lower limbs neurologi...
Butterfly vertebra is a type of vertebral anomaly that results from the failure of fusion of the lateral halves of the vertebral body because of persistent notochordal tissue between them.
an anterior spina bifida, with or without an anterior meningocele
can be part of...
Calcific tendinitis of the longus colli muscle is an inflammatory/granulomatous response to deposition of calcium hydroxyapatite crystals in the tendons of the longus colli muscle.
Patients can present with debilitating symptoms that are unrelated to the degree of calcif...
Camptocormia (bent spine syndrome) is a rare syndrome characterised by involuntary flexion of the thoracolumbar spine with weight-bearing which reduces when laying down, and is due to isolated atrophy of the paraspinal muscles.
This condition may be associated
Parkinson disease: ...
The Castellvi classification is used for lumbosacral transitional vertebra (LSTV):
type I: enlarged and dysplastic transverse (at least 19 mm)
type II: pseudoarticulation of the transverse process and sacrum with incomplete lumbarisation/sacralisation; enlargemen...
The cauda equina is the collective term given to nerve roots distal to the conus medullaris, which occupy the lumbar cistern.
It is said to look like a horses tail.
Cauda equina syndrome refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots. It is considered a diagnostic and surgical emergency.
Cauda equina syndrome is rare with prevalence estimated at approximately 1...
Caudal epidural injections, or sacral hiatus epidural injections, are one of several possible spinal epidural injections.
Typically, epidural injections are performed in patients who are currently not surgical candidates. The caudal injection can be performed when patients are on ...
Caudal regression syndrome (CRS) represents a spectrum of structural defects of the caudal region. Malformations vary from isolated partial agenesis of the coccyx to lumbosacral agenesis.
Caudal regression syndrome is rare, with an estimated incidence of 1:7500-100,000 7,10.
Central cord syndrome is the most common type of incomplete spinal cord injury, accounting for ~10% of all spinal cord injuries. As the name implies, this syndrome is the result of a contusion of the central portion of the cervical spinal cord.
Most often central cord syndrome occ...
The central sacral vertical line (CSVL) is used in the assessment of spinal scoliosis.
It is a line constructed on frontal films of the spine and pelvis as follows:
a line connecting the top of the iliac crests is drawn
a second line is drawn perpendicular to the first, which bisects the sac...
Cervical degenerative changes can be graded using a very old but reliable classification given by Kellgren et al. It is based on findings on a lateral cervical spine radiograph although it can also be applied on MRI evaluation of spine.
The key parameters are osteophyte formation, intervertebr...
Cervical interlaminar epidural injections are one of some possible spinal epidural injections. For an alternative approach for the same region, please refer to the article on cervical transforaminal epidural injections.
Typically epidural injections are performed in patients with ...
The cervical plexus is formed by the ventral (anterior) rami of the C1 to C5 nerve roots and innervates the diaphragm, provides motor supply to some neck muscles and cutaneous sensation to the skin of the head, neck and chest.
anterior rami of C1 to C5 nerves
Cervical rib is a supernumerary or accessory rib arising from the seventh cervical vertebra. They occur in ~0.5% of the population, and are more common in females.
Although cervical ribs are usually asymptomatic, they are the most important anatomic rib variant clinically, because they can caus...
The cervical spine is the upper part of the spine extending from the skull base to the thorax at the level of the first vertebra with a rib attached to it. It normally consists of seven vertebrae. Its main function is to support the skull and maintain the relative positions of the brain and spin...
A floating pillar, also referred as pedicolaminar fracture-separation injury, is characterised by fractures through the pedicle and lamina of a cervical spine vertebrae creating a free-floating articular pillar fragment. It is an unstable cervical spine fracture that results from hyperflexion–la...
There are several cervical spine fracture classification systems:
Anderson and D'Alonzo classification (odontoid fracture)
Levine and Edwards classification (for traumatic injuries to axis)
Allen and Ferguson classification (subaxial spine injuries)
Cervical spine fractures can occur secondary to exaggerated flexion or extension, or because of direct trauma or axial loading.
The cervical spine is susceptible to injury because it is highly mobile with relatively small vertebral bodies and supports the head which is both heavy and...
Cervical spine injuries can involve the cervical vertebral column, intervertebral discs and cervical spine ligaments, and/or cervical spinal cord. The cervical spine accounts for ~50% of all spinal injuries.
5-10% of patients with blunt trauma have a cervical spine injury 1.
Cervical spine ligaments ordered from anterior to posterior include:
anterior longitudinal ligament (ALL)
anterior atlanto-occipital membrane
alar ligaments (paired)
cruciate ligament of the atlas
longitudinal band: joins the body of the axis to the foramen magnum
Chalk stick or carrot stick fractures are fractures of a fused spine, classically seen in ankylosing spondylitis.
Some authors define the chalk stick fracture as a fracture through a Pagetoid long bone (see Paget disease).
They usually occur through the disco-vertebral ...
Chamberlain line is a line joining the back of hard palate with the opisthion on a lateral view of the craniocervical junction.
It helps to recognise basilar invagination which is said to be present if the tip of the dens is >3 mm above this line.
McGregor developed a modificatio...
Chance fractures, also referred as seatbelt fractures, are flexion-distraction type injuries of the spine that extend to involve all three spinal columns. These are unstable injuries and have a high association with intra-abdominal injuries.
They tend to occur from a flexi...
Charcot-Marie-Tooth (CMT) disease, also known as hereditary motor and sensory neuropathy (HMSN), is the most commonly inherited neuropathy of lower motor (to a lesser degree sensory) neurons.
Signs and symptoms usually become first evident in childhood. Typically this sta...
Chordomas are uncommon malignant tumours that account for 1% of intracranial tumours and 4% of all primary bone tumours.
They originate from embryonic remnants of the primitive notochord (earliest fetal axial skeleton, extending from the Rathke's pouch to the coccyx). Since chordomas arise in ...
Clasp-knife deformity is relatively common anomaly found at the lumbosacral junction and characterized by a large midline defect of the posterior arch of the sacrum (usually S1/S2 and occasionally S3) along with hypertrophy (or overgrowth) of the spinous process of the vertebra above (usually L5...
Clasp-knife syndrome, also called spina bifida engagement syndrome or spina magna or long spinous process syndrome, is one of the causes of low back pain.
When a clasp-knife deformity is accompanied by pain on extension secondary to protrusion of the enlarged spinous process (knife blade) into ...
Spinal meningeal cysts can be classified according to a system published by Nabor et. al 2:
type I: extradural meningeal cyst without neural tissue
type Ia: extradural spinal arachnoid cyst
type Ib: sacral meningocele
type II: extradural meningeal cyst containing neural tissue, e.g. Tarlov c...
Clay-shoveler fractures are fractures of the spinous process of a lower cervical vertebra.
Often these injuries are unrecognised at the time and only found incidentally years later when the cervical spine is imaged for other reasons.
Acutely they tend to be associated wi...
The Cobb angle is the most widely adopted technique to quantify the magnitude of spinal deformities, especially in the case of scoliosis, on plain radiographs. A scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more 4.
To measure the Cobb angle, one mu...
The coccyx is the small triangular bone at the termination of the vertebral column which sits inferior to the apex of the sacrum. The coccyx is one leg of the tripod formed in conjunction with the ischial tuberosities for support in a seated position. Additionally, it serves as the insertion sit...
Congenital absence of a spine pedicle is a rare congenital condition, but awareness of its characteristic imaging appearance is important to avoid misdiagnosis.
Failure to recognise this entity can lead to misdiagnosis of unilateral facet subluxation/dislocation, leading to unnecessary treatmen...
Congenital anomalies of the posterior arch of the atlas (C1) are relatively common anomalies. They may range from partial defects presenting as clefts to complete absence of the posterior arch (aplasia).
These anomalies are classified according to Currarino (see below). It should not be confuse...
Congenital lumbar spinal stenosis (CLSS) is a type of vertebral central canal stenosis and has a different epidemiology with less severe degenerative change compared to acquired/degenerative lumbar spinal stenosis.
CLSS tends to affect patients at a younger age (30-50 years old) ...
The conus medullaris is the terminal end of the spinal cord.
After the cord terminates, the nerve roots descend within the spinal canal as individual rootlets, collectively termed the cauda equina. The conus medullaris most commonly terminates at the L1/2 intervertebral disc leve...
Conus medullaris syndrome is caused by an injury or insult to the conus medullaris and lumbar nerve roots. It is a clinical subset of spinal cord injury syndromes. Injuries at the level of T12 to L2 vertebrae are most likely to result in conus medullaris syndrome.
The conus medullari...
The corduroy sign refers to a vertically oriented, thickened trabeculations seen in intraosseous haemangiomas of the spine.
It is caused by replacement of the normal cancellous bone by thickened vertical trabeculae surrounded by fat marrow or vascular lacunae in intraosseous haemangiomas 2.
Coronal balance is one of the features that needs to be assessed on long spine radiographs obtained for spinal deformity, particularly scoliosis. It measures whether or not the upper spine is located over the midline (normal) or off to one side.
To assess coronal balance, a vertical (plumb) li...