CHAPTER 43 Spinal cord and spinal nerves: gross anatomy
This chapter deals with the gross anatomy of the structures which lie within the vertebral canal and its extensions through the intervertebral foramina, the spinal nerve or radicular (‘root’) canals. The spinal cord, its blood vessels and nerve roots lie within a meningeal sheath, the theca, which occupies the central zone of the vertebral canal and extends from the foramen magnum, where it is in continuity with the meningeal coverings of the brain, to the level of the second sacral vertebra in the adult. Distal to this level the dura extends as a fine cord, the filum terminale externum, which fuses with the posterior periosteum of the first coccygeal segment. Tubular prolongations of the dural sheath extend around the spinal roots and nerves into the lateral zones of the vertebral canal and out into the root canals, eventually fusing with the epineurium of the spinal nerves. Between the theca and the walls of the vertebral canal is the epidural (spinal extradural) space, which is loosely filled with fat, connective tissue containing small arteries and lymphatics, and an important venous plexus. Three-dimensional appreciation of the anatomy of the spinal theca and its surroundings is essential for the efficient management of spinal pain and of spinal injuries, tumours and infections. Equally significant clinically is the anatomy of the often precarious blood supply of the spinal cord and its associated structures. The increasing application and refinement of diagnostic imaging and endoscopic procedures lend a new importance to topographical detail here.
SPINAL CORD (MEDULLA)
The spinal cord occupies the superior two-thirds of the vertebral canal (Fig. 18.1, Fig. 43.1). It is continuous cranially with the medulla oblongata, and narrows caudally to the conus medullaris, from whose apex a connective tissue filament, the filum terminale, descends to the dorsum of the first coccygeal vertebral segment. The cord extends from the upper border of the atlas to the junction between the first and second lumbar vertebrae: its average length in European males is 45 cm, its weight approximately 30 g. (For dimensional data consult Barson & Sands 1977.)
Fig. 43.1 A, Brain and spinal cord with attached spinal nerve roots and dorsal root ganglia, photographed from the dorsal aspect. Note the fusiform cervical and lumbar enlargements of the cord, and the changing obliquity of the spinal nerve roots as the cord is descended. The cauda equina is undisturbed on the right but has been spread out on the left to show its individual components. B–D, Formation of typical spinal nerve, ventral aspect. B, Cervical level; C, Thoracic level; D, Lumbar level. E, Lower end of spinal cord, filum terminale and cauda equina exposed from behind. The dura mater and the arachnoid have been opened and spread out. F, Spinal cord segment showing mode of formation of a typical spinal nerve and the gross relationships of the grey and white matter. (B–D, From Sobotta 2006.)
(Dissection by MCE Hutchinson, GKT School of Medicine; photograph by Kevin Fitzpatrick on behalf of GKT School of Medicine, London.)
During development, the vertebral column elongates more rapidly than the spinal cord, so that there is an increasing discrepancy between the anatomical level of spinal cord segments and their corresponding vertebrae. At stage 23, the vertebral column and spinal cord are the same length, and the cord ends at the last coccygeal vertebra: this arrangement continues until the third fetal month. At birth, the spinal cord terminates at the lower border of the second lumbar vertebra, and may sometimes reach the third lumbar vertebra. In the adult, the spinal cord is said to terminate at the level of the disc between the first and second lumbar vertebral bodies, which lies a little above the level of the elbow joint when the arm is by the side, and also lies approximately in the transpyloric plane (p. 1054). However, there is considerable variation in the level at which the spinal cord ends. It may end below this level in as many as 40% of subjects, or opposite the body of either the first or second lumbar vertebra: very occasionally it ends as high as the caudal third of twelfth thoracic or as low as the disc between the second and third lumbar vertebrae. Its position rises slightly in vertebral flexion, and there is some correlation with the length of the trunk, especially in females. The spinal cord varies in transverse width, gradually tapering craniocaudally, except at the levels of the enlargements. It is not cylindrical, being wider transversely at all levels, especially in the cervical segments.
A posterolateral sulcus exists from 1.5 to 2.5 mm lateral to each side of the posterior median sulcus. Dorsal roots (strictly rootlets) of spinal nerves enter the cord along the sulcus. The white substance between the posterior median and posterolateral sulcus on each side is the posterior funiculus. In cervical and upper thoracic segments a longitudinal posterointermediate sulcus marks a septum dividing each posterior funiculus into two large tracts: the fasciculus gracilis (medial) and fasciculus cuneatus (lateral). Between the posterolateral sulcus and anterior median fissure is the anterolateral funiculus. This is subdivided into anterior and lateral funiculi by ventral spinal rootlets which pass through its substance to issue from the surface of the cord. The anterior funiculus is medial to, and includes, the emerging ventral rootlets, whilst the lateral funiculus lies between the roots and the posterolateral sulcus. In upper cervical segments, nerve rootlets emerge through each lateral funiculus to form the spinal accessory nerve which ascends in the vertebral canal lateral to the spinal cord and enters the posterior cranial fossa via the foramen magnum (Fig. 28.11).
DORSAL AND VENTRAL ROOTS
The paired dorsal and ventral roots of the spinal nerves are continuous with the spinal cord (Fig. 43.1F; see also p. 754). They cross the subarachnoid space and traverse the dura mater separately, uniting in or close to their intervertebral foramina to form the (mixed) spinal nerves. Since the spinal cord is shorter than the vertebral column, the more caudal spinal roots descend for varying distances around and beyond the cord to reach their corresponding foramina. In so doing they form a divergent sheaf of spinal nerve roots, the cauda equina, which is gathered round the filum terminale in the spinal theca, mostly distal to the apex of the cord.
Ventral spinal roots contain efferent somatic and, at some levels, preganglionic sympathetic, axons which extend from neuronal cell bodies in the ventral horns and intermediolateral columns respectively. There are also afferent nerve fibres in these roots. The rootlets comprising each ventral root emerge from the anterolateral sulcus in groups over an elongated vertical elliptical area (Fig. 43.1F). Dorsal spinal roots bear ovoid swellings, the spinal ganglia, one on each root proximal to its junction with a corresponding ventral root in an intervertebral foramen. Each root fans out into six to eight rootlets before entering the cord in a vertical row in the posterolateral sulcus. Dorsal roots are usually said to contain only afferent axons (both somatic and visceral) which are the central processes of unipolar neurones in the spinal root ganglia, but they may also contain a small number (3%) of efferent fibres and autonomic vasodilator fibres.
MENINGES
DURA MATER
Epidural space
The epidural space lies between the spinal dura mater and the tissues which line the vertebral canal (Fig. 43.2). It is closed above by fusion of the spinal dura with the edge of the foramen magnum, and below by the posterior sacrococcygeal ligament which closes the sacral hiatus. It contains loosely packed connective tissue, fat, a venous plexus, small arterial branches, lymphatics and fine fibrous bands which connect the theca with the lining tissue of the vertebral canal. These bands, the meningovertebral ligaments, are best developed anteriorly and laterally. Similar bands tether the nerve root sheaths or ‘sleeves’ within their canals. There is also a midline attachment from the posterior spinal dura to the ligamentum nuchae at atlanto-occipital and atlanto-axial levels (Dean & Mitchell 2002). The venous plexus consists of longitudinally arranged chains of vessels, connected by circumdural venous ‘rings’. The anteriorly placed vessels receive the basivertebral veins.
Epidural injections
Contrast media and other fluids injected into the epidural space at the sacral level can spread up to the cranial base (p. 760). Local anaesthetics injected near the spinal nerves, just outside the intervertebral foramina, may spread up or down the epidural space to affect the adjacent spinal nerves or may pass to the opposite side. The paravertebral spaces of each side communicate via the epidural space, particularly at lumbar levels.
For a review of the morphology of the epidural space and a discussion of the nature of the lining layer of the vertebral canal, see Newell (1999).
Subdural space
The subdural space is a potential space in the normal spine because the arachnoid and dura are closely apposed (Haines et al 1993). It does not connect with the subarachnoid space, but continues for a short distance along the cranial and spinal nerves. Accidental subdural catheterization may occur during epidural injections. Injection of fluid into the subdural space may either damage the cord by direct toxic effects or by compression of the vasculature.
ARACHNOID MATER
The spinal arachnoid mater, which surrounds the spinal cord, is continuous with the cranial arachnoid mater (Fig. 43.3). It is closely applied to the deep aspect of the dura mater. At sites where vessels and nerves enter or leave the subarachnoid space, the arachnoid mater is reflected on to the surface of these structures and forms a thin coating of leptomeningeal cells over the surface of both vessels and nerves. Thus a subarachnoid angle is formed as nerves pass through the dura into the intervertebral foramina. At this point, the layers of leptomeninges (arachnoid and pia) fuse and become continuous with the perineurium. The epineurium is in continuity with the dura. Such an arrangement seals the subarachnoid space so that particulate matter does not pass directly from the subarachnoid space into nerves. The existence of a pathway of lymphatic drainage from the CSF is controversial.
PIA MATER
The spinal pia mater (Fig. 43.3) closely invests the surface of the spinal cord and passes into the anterior median fissure. As in the cranial region, there is a subpial ‘space’, however over the surface of the spinal cord the subpial collagenous layer is thicker than in the cerebral region, and it is continuous with the collagenous core of the ligamentum denticulatum.
The ligamentum denticulatum is a flat, fibrous sheet which lies on each side of the spinal cord between the ventral and dorsal spinal roots. Its medial border is continuous with the subpial connective tissue of the cord and its lateral border forms a series of triangular processes, the apices of which are fixed at intervals to the dura mater. There are usually 21 processes on each side. The first crosses behind the vertebral artery where it is attached to the dura mater, and is separated by the artery from the first cervical ventral root. Its site of attachment to the dura mater is above the rim of the foramen magnum, just behind the hypoglossal nerve: the spinal accessory nerve ascends on its posterior aspect (Fig. 28.11). The last of the dentate ligaments lies between the exiting twelfth thoracic and first lumbar spinal nerves and is a narrow, oblique band which descends laterally from the conus medullaris. Changes in the form and position of the dentate ligaments during spinal movements have been demonstrated by cine-radiography.
Beyond the conus medullaris, the pia mater continues as a coating of the filum terminale.
COVERINGS AND RELATIONS OF THE SPINAL ROOTS AND NERVES IN THE RADICULAR CANAL
Tubular prolongations of the spinal dura mater, closely lined by the arachnoid, extend around the spinal roots and nerves as they pass through the lateral zone of the vertebral canal and through the intervertebral foramina (Fig. 43.3, Fig. 43.4A). These prolongations, the spinal nerve sheaths or root sheaths, gradually lengthen as the spinal roots become increasingly oblique. Each individual dorsal and ventral root runs in the subarachnoid space with its own covering of pia mater. Each root pierces the dura separately, taking a sleeve of arachnoid with it, before joining within the dural prolongation just distal to the spinal ganglion. The dural sheaths of the spinal nerves fuse with the epineurium, within or slightly beyond the intervertebral foramina. The arachnoid prolongations within the sheaths do not extend as far distally as their dural coverings, but the subarachnoid space and its contained CSF extend sufficiently distally to form a radiologically demonstrable root sleeve for each nerve. Shortening or obstruction of this sleeve seen on MRI indicates compression of the spinal nerve. At the cervical level, where the nerves are short and the vertebral movement is greatest, the dural sheaths are tethered to the periosteum of the adjacent transverse processes. In the lumbosacral region there is less tethering of the dura to the periosteum, though there may be an attachment posteriorly to the facet joint capsule.
CEREBROSPINAL FLUID (CSF)
The cerebrospinal fluid is described in detail on page 242. Although there is free communication between the spinal and cerebral subarachnoid spaces, the mode of circulation of the spinal CSF and the contribution that it makes to the overall circulation of CSF remains uncertain in man: CSF may be absorbed from the spinal subarachnoid space, and spinal arachnoid granulations and villi have been described (Kiddo et al 1976).
SPINAL NERVES
In those body segments which largely retain a metameric (segmental) structure, e.g. the thoracic region, spinal nerves show a common plan (Fig. 43.5). The dorsal, epaxial, ramus passes back lateral to the articular processes of the vertebrae and divides into medial and lateral branches which penetrate the deeper muscles of the back: both branches innervate the adjacent muscles and supply a band of skin from the posterior median line to the lateral border of the scapula (Fig. 43.6). The ventral, hypaxial, ramus is connected to a corresponding sympathetic ganglion by white and grey rami communicantes. It innervates the prevertebral muscles and curves round in the body wall to supply the lateral muscles of the trunk. Near the midaxillary line it gives off a lateral branch which pierces the muscles and divides into anterior and posterior cutaneous branches. The main nerve advances in the body wall, where it supplies the ventral muscles and terminates in branches to the skin.
Fig. 43.6 Cutaneous distribution of the dorsal rami of the spinal nerves. The nerves are shown lying on the superficial muscles. The nerves are numbered on the right side; the spines of the seventh cervical, sixth and twelfth thoracic, and first and fifth lumbar vertebrae are labelled in on the left side.
Spinal nerves are united ventral and dorsal spinal roots, attached in series to the sides of the spinal cord. The term spinal nerve strictly applies only to the short segment after union of the roots and before branching occurs. This segment, the spinal nerve proper, lies in the intervertebral foramen: it is sometimes mistakenly called the ‘nerve root’. There are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal. The abbreviations C, T, L, S and Co, with appropriate numerals, are commonly applied to individual nerves. The peripheral nerves emerge through the intervertebral foramina. At thoracic, lumbar, sacral and coccygeal levels the numbered nerve exits the vertebral canal by passing below the pedicle of the corresponding vertebra, e.g. L4 nerve exits the intervertebral foramen between L4 and L5. However, in the cervical region, nerves C1–7 pass above their corresponding vertebrae. C1 leaves the vertebral canal between the occipital bone and atlas and hence is often termed the suboccipital nerve. The last pair of cervical nerves does not have a correspondingly numbered vertebra and C8 passes between the seventh cervical and first thoracic vertebrae. Each nerve is continuous with the spinal cord by ventral and dorsal roots; the latter each bears a spinal ganglion (‘dorsal root ganglion’).
