Welcome to Anatomy!!!

Block 1 Review: Back and Thorax

Vertebral Column
33 vertebrae

7 cervical

12 thoracic

5 lumbar

5 fused sacral

4 fused coccygeal

Curvatures

Primary- thoracic and sacral

Secondary- cervical and lumbar

When/why do we develop these curvatures?

Abnormal Spinal Curvatures

Scoliosis- lateral deviation of the

spinal column
Unequal growth of VC,
erosion, or weakness/paralysis
of vertebral muscles

Kyphosis- increased primary

curvature of the thoracic region
Hunchback, can be a result of
osteoporosis

Lordosis- increased secondary

curvature of the lumbar region
Pregnant women and obese
people!

Spina Bifida
Results from abnormal closure of the vertebral arch
during development

Folic acid deficiency

What drugs can cause this?

Types include

Spina Bifida Occulta- failure of vertebral arch to close, small

tuft of hair on lower back

Meningocele- protrusion of meninges through the unclosed

vertebral arch

Meningomyelocele- protrusion of meninges and spinal cord

through the unclosed vertebral arch

Spina Bifida Examples

Whiplash Injury
Force drives trunk forward
and causes the head to lag
behind which results in
hyperextension of the
upper part of the neck and
hyperflexion of the lower
part of the neck

Axis and Atlas

Remember

C1- Atlas, articulates with

the skull

C2- Axis, dens, articulates

with the atlas

NO VERTEBRAL DISCS
between Skull-C1 and C1-C2

What is (arguably) the most

important ligament in the
body?

Transverse ligament of
atlas!!

Fractures of C1 and C2
Jeffersons

Anterior and posterior fracture of the arches of C1

Think of someone diving head first into a pool

Medical emergency if the transverse ligament of atlas is

compromisedwhy?

Hangmans

Fracture of the pedicles of C2

Forcible hyperextension of the neck

Fractures of C1 and C2 (cont)

C1- Jeffersons

C2- Hangmans

Case Study 1
45 year old male patient comes into your office with CC of
back pain
Recently moved into a new home with his family
Pain radiates to left leg
Decreased Ankle and Knee reflexes on the left side
What are the DDx? What other tests would you order?
What nerves are involved with the Ankle and Knee
reflexes? What is the Dx? What would the treatment
options be?

Vertebral discs
A little disc anatomy

Central portion is soft/jelly like and called the nucleus

pulposus

Nucleus pulposus is surrounded by a fibrous protective

structure called the anulus fibrosis

Protected by the anterior longitudinal ligament (ALL) and

posterior longitudinal ligament (PLL) from 3-9 oclock and
6 oclock respectively
Herniation can occur at 5 and 7 oclock

Disc Herniation
Most commonly occurs in the lumbar region (L4-5 or L5S1) and cervical regions (C5-6 or C6-7)
Remember our case!

Lower back pain

Decreased reflexes on affected side

Heavy lifting

Nerve root one number below the disc will be

compressed, except for cervicaladd 2!

Ex: herniation of disc in between L3/4 will compress L4

nerve root

Disc Herniation Examples

Vertebral Venous Plexus

Just keep in mind that the venous
plexus of the vertebral system
DOES NOT HAVE VALVES!!!
As a result they can be a site of
early metastasis to vertebrae and
the CNS
What cancers/sites can contribute
to this metastasis?

Carcinomas of lung, breast, prostate

Think: this INTERNAL venous plexus

will anastamose with the cranial
dural sinuses, pelvic vein, azygous
vein, and caval system

FUN FACT: Plexus that connects the

thoracic and pelvic veins to internal
vertebral venous plexus is called Baston
venous plexus!

Case Study 2
Scott just recently started college and has not been
feeling well for the past few days. His roommate has
taken him to your ER for help. He noted a fever and
complains of headaches, stiff neck, vomited 2x this
morning before coming into the office, and that the
lights are too bright in the hospital. DDx? What
tests would you order to rule in/out diagnoses? What
are your treatment options for your patient?

Lumbar Puncture

Thoracic Outlet Syndrome

Causes

Cervical rib- elongation of the transverse processes of C7

Hypertrophic muscles

Thoracic tumors and infections

Presentation

Pain, numbness, or tingling in the upper limb due to

compression of the lower portion of the brachial plexus

More extreme cases could result in compression of the

subclavian artery which could cause ischemic damage to
the muscles!!

Rib Fractures
Flail chest

Section of ribs fracture and is able to move freely

This becomes an issue during inspiration as this segment

moves inward while the rest of the chest moves outward

Rib fractures

It takes a lot of force to break the 1st rib but if broken this could
compromise nearby structureswhat are those structures?

Middle rib fractures can cause pneumothorax or lung/spleen

(left side) puncture

Lower rib fractures can cause tearing of the diaphragm which

could further result in diaphragmatic hernias

Lungs!!!
Right main bronchus

Shorter, wider, and

more vertical than the
left main bronchus

Why is this significant?

Remember: right lung

has 3 lobes!!

Left main bronchus

Smaller in diameter but

longer than the right
main broncus, passes
under the aortic arch

Pneumothorax
Accumulation of air in the thorax that ultimately causes the
lung to collapse
Traumatic pneumothorax- occurs due to puncture through the
thoracic wall

Open pneumothorax- air can freely flow through the puncture

wound

Tension pneumothorax- air enters wound upon inspiration and

cannot get out of throacic cavity during expiration, pressure builds

Symptoms

Dyspnea and chest pain, treat by relieving the pressure in the

chest cavity

Spontaneous vs. Tension Pneumos

Spontaneous Pneumo

Tension Pneumo: notice the shift

in the mediastinal structures
AWAY from the collapsed lung!

Pleural Effusion
Accumulation of fluid within the pleural
space

Remember the pleura is the visceral

covering of the lungs!

Patient will suffer from dyspnea due to

fluid compressing the lungs
What will you find on physical exam?

Auscultation: decreased breath sounds

over area of the effusion

Percussion: dull to flat sounds

Treat by thoracentesis

8th intercostal space, midaxillary line

Insert needle above the superior margin

of the lower rib to avoid the intercostal
nerve!

More Lung Pathologies

Pneumonia

Inflammation of the lungs

Caused by bacteria, viruses, fungi

Types
Lobar- affects entire lobe
95% caused by Strep pneumoniae

Legionella and Klebsiella also causes

Bronchopneumonia- inflammation of the walls of the bronchioles, look for

multiple foci, isolated acute consolidation, affecting many lobes
Strep pneumoniae, S. aureus, H. influenzae, Klebsiella

Interstitial (atypical)- non-productive cough, diffuse patchy inflammation

localized to interstitial area
Viruses (Influenza, CMV, RSV, adenovirus), Mycoplasma, Legionella,
Chlamydia

Legionella pneumonia:
consolidation in lower
lobes

Diffuse interstitial
infiltrates: atypical
pneumonia
Pneumococcal
pneumonia: left
lower lobe
consolidation
with pleural
effusion

 Tuberculosis

Infectious lung disease, Mycobacterium tuberculosis

Cough, fever, sweats, tiredness, weight loss

Primary TB: look for infiltrative process in middle or lower lung

regions

Secondary TB: reactivation of dormant infection, look for lesions

in right upper lobe

Pulmonary edema

Fluid accumulation within the lungs

Can be caused by left ventricular failure

Back up of blood on the left side of the heart would cause
increased hydrostatic pressure within the pulmonary veins
which would result in fluid being pushed into the alveoli

Lymphatic drainage of the Lung

Heart Embryology
Embryonic Structure

Gives rise to

Truncus arteriosus

Ascending aorta and pulmonary

trunk

Bulbus cordis

Smooth parts of L & R ventricles

Primitive atrium

Trabeculated part of L & R atria

Primitive ventricle

Trabeculated part of L & R

ventricles

Primitive pulmonary vein

Smooth part of left atrium

Left horn of sinus venosus

Coronary sinus

Right horn of sinus venosus

Smooth part of right atrium

(sinus venarum)

Right common cardinal vein and

right anterior cardinal vein

SVC

Human Heart Development

Congenital Heart Defects

Right to left shunts: deoxygenated blood from
the right side of the heart is shunted over to
the left side due to differences in pressure

Early cyanosis (blue babies)

Persistent truncus arteriosus: lack of formation

of the aorticopulmonary septum, most patients
have a VSD

Transposition of the great vessels: aorta and

pulmonary arteries are switched, fatal unless a
shunt is present
What structure can physicians keep patent
with prostaglandin E analogues?

Tetralogy of Fallot
Pulmonary stenosis

Overriding aorta

VSD

Right ventricular hypertrophy

CHDs cont
Left to right shunts: not as big of a problem initially
because oxygenated blood is being shunted to the right
side of the heart, can progress to a right to left shunt
however (Eisenmenger syndrome)

Ventricular septal defect: most common CHD, due to

incomplete formation of the ventricular septum, can be
asymptomatic

Patent ductus arteriosus: DA fails to close after birth,

machine like continuous murmur
What can we administer to close the DA?

Indomethacin! This decreases PGE synthesis leading

to closure of the DA

Coarctation of the aorta: aortic narrowing near

insertion of DA, can be seen in Turners syndrome
(think 15 year old girl with no history of menstruation!)

Hypertension in upper extremities and weak/delayed pulse

in lower extremities

Also might see rib notching due to increased pressure

through internal thoracic artery!

Heart <3

Heart Valves