Functional Anatomy and Imaging of the Spine

  • John C. Keel
  • Gary J. Brenner


Painful disorders of the spine are among our most common medical complaints. Over a lifetime, 60–80 % of adults experience at least one significant episode of back pain. In a single year, 15–20 % will have back pain, and 2–5 % of the entire population will seek medical attention for back pain. Low back pain has been estimated as the fifth leading cause of all medical visits and the second leading cause of symptom-related medical visits. In the United States, the estimated annual cost of back pain is $20 billion to $50 billion. In particular, low back pain is one of the most important factors in medical costs and disability.


Vertebral Body Intervertebral Disc Nucleus Pulposus Facet Joint Transverse Process 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Borenstein D. Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol. 2001;13(2):128–34.PubMedCrossRefGoogle Scholar
  2. 2.
    Rubin D. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353–71.PubMedCrossRefGoogle Scholar
  3. 3.
    Hart L, Deyo R, Cherkin D. Physician office visits for low back pain: frequency, clinical evaluation, and treatment pattern from a US national survey. Spine. 1995;20(1):11–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Pai S, Sundaram L. Low back pain: an economic assessment in the United States. Orthop Clin North Am. 2004;35(1):1.PubMedCrossRefGoogle Scholar
  5. 5.
    Boden S, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg. 1990;72(3):403–8.PubMedGoogle Scholar
  6. 6.
    Martin B, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299(6):656–64.PubMedCrossRefGoogle Scholar
  7. 7.
    Davis P, et al. Expert panel on neurologic imaging. ACR appropriateness criteria low back pain. 2008.Google Scholar
  8. 8.
    Daffner R, et al. Expert panel on musculoskeletal imaging. ACR appropriateness criteria chronic neck pain. 2010.Google Scholar
  9. 9.
    Naderi S, Andalkar N, Benzel E. History of spine biomechanics: part I–the pre-Greco-Roman, Greco-Roman, and medieval roots of spine biomechanics. Neurosurgery. 2007;60(2):382–90.PubMedCrossRefGoogle Scholar
  10. 10.
    Marketos S, Skiadas P. Galen: a pioneer of spine research. Spine. 1999;24(22):2358.PubMedCrossRefGoogle Scholar
  11. 11.
    Sanan A, Rengachary S. The history of spinal biomechanics. Neurosurgery. 1996;39(4):657–69.PubMedCrossRefGoogle Scholar
  12. 12.
    Benini A, Bonar S. Andreas vesalius: 1514-1564. Spine. 1996;21(11): 1388–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Naderi S, et al. Functional anatomy of the spine by Avicenna in his eleventh century treatise Al-Qanun fi al-Tibb (the canons of medicine). Neurosurgery. 2003;52(6):1449–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Naderi S, Andalkar N, Benzel E. History of spine biomechanics: part II–from the renaissance to the 20th century. Neurosurgery. 2007;60(2):392–403.PubMedCrossRefGoogle Scholar
  15. 15.
    Spiegel P. The first clinical x ray made in America. AJR Am J Roentgenol. 1995;164:241–3.PubMedCrossRefGoogle Scholar
  16. 16.
    Hesselink J. Spine imaging: history, achievements. Remaining frontiers. AJR. 1988;150:1223–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Bogduk N. Clinical anatomy of the lumbar spine and sacrum. 4th ed. Philadelphia: Elsevier Churchill Livingstone; 2005.Google Scholar
  18. 18.
    Backonja M. Defining neuropathic pain. Anesth Analg. 2003; 97(3):785–90.PubMedCrossRefGoogle Scholar
  19. 19.
    Mekhail N, et al. Clinical applications of neurostimulation: forty years later. Pain Pract. 2010;10(2):103–12.PubMedCrossRefGoogle Scholar
  20. 20.
    Wyke B. The neurological basis of thoracic spinal pain. Rheumatol Phys Med. 1970;10:356–67.PubMedCrossRefGoogle Scholar
  21. 21.
    Merskey H, Bogduk N, editors. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994.Google Scholar
  22. 22.
    Simons D, Travell J, Simons L. Travell & Simons’ myofascial pain and dysfunction: the trigger point manual, vol. 2. Baltimore: Lippincott Williams & Wilkins; 1999.Google Scholar
  23. 23.
    Slipman C, et al. Symptom provocation of fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to dermatomal maps? Spine. 1998;23(20):2235–42.PubMedCrossRefGoogle Scholar
  24. 24.
    Slipman C, et al. Clinical evidence of chemical radiculopathy. Pain Physician. 2002;5(3):260–5.PubMedGoogle Scholar
  25. 25.
    Huston C, Slipman C. Diagnostic selective nerve root blocks: indications and usefulness. Phys Med Rehabil Clin N Am. 2002;13:545–65.PubMedCrossRefGoogle Scholar
  26. 26.
    Mathis J, editor. Image-guided spine interventions. New York, Berlin, Heidelberg: Springer; 2004.Google Scholar
  27. 27.
    Magee D. Orthopedic physical assessment. 4th ed. Philadelphia: Saunders; 2002.Google Scholar
  28. 28.
    White A, Panjabi M. Clinical biomechanics of the spine. Philadelphia: Lippincott; 1978.Google Scholar
  29. 29.
    Maigne R, Liberson W. Orthopedic medicine: a new approach to vertebral manipulations. Springfield: Charles C. Thomas; 1972.Google Scholar
  30. 30.
    Junghanns H. Der lumbosacralwinkel. Dtsch Z Chir. 1929;213:332.CrossRefGoogle Scholar
  31. 31.
    Oliver J, Middleditch A. Functional anatomy of the spine. Oxford: Butterworth-Heinmann Ltd; 1991.Google Scholar
  32. 32.
    Schneck C. Functional and clinical anatomy of the spine. SPINE. 1995;9(3):525–58.Google Scholar
  33. 33.
    Mathis J, Deramond H, Belkoff S, editors. Percutaneous vertebroplasty and kyphoplasty. 2nd ed. New York: Springer; 2006.Google Scholar
  34. 34.
    Gilad I, Nisan M. Sagittal evaluation of elemental geometrical dimensions of human vertebrae. J Anat. 1985;143:115.PubMedCentralPubMedGoogle Scholar
  35. 35.
    Schmorl G, Junghanns H. The human spine in health and disease. New York: Grune & Stratton; 1959.Google Scholar
  36. 36.
    Twomey L, Taylor J. Physical therapy of the low back. 2nd ed. Edinburgh: Churchill Livingstone; 1994.Google Scholar
  37. 37.
    Davis P. Human lower lumbar vertebrae: some mechanical and osteological considerations. J Anat. 1961;95:337–44.PubMedCentralPubMedGoogle Scholar
  38. 38.
    Hellems H, Keates T. Measurement of the normal lumbosacral angle. Am J Roentgenol. 1971;113:642.CrossRefGoogle Scholar
  39. 39.
    Bogduk N. The menisci of the lumbar zygapophyseal joints: a review of their anatomy and clinical significance. Spine. 1984;9(5):454–60.PubMedCrossRefGoogle Scholar
  40. 40.
    Goldwaithe J. The lumbo-sacral articulation: an explanation of any cases of lumbago, sciatica and paraplegia. Boston Med Surg J. 1911;164:365–72.CrossRefGoogle Scholar
  41. 41.
    Mooney V, Robertson J. The facet syndrome. Clin Orthop. 1976;115:149–56.PubMedGoogle Scholar
  42. 42.
    Yang K, King A. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine. 1984;9(6):557–65.PubMedCrossRefGoogle Scholar
  43. 43.
    Foley B, Buschbacher R. Sacroiliac joint pain: anatomy, biomechanics, diagnosis and treatment. Am J Phys Med Rehabil. 2006; 85:997–1006.PubMedCrossRefGoogle Scholar
  44. 44.
    Mixter W, Barr J. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med. 1934;211:210.CrossRefGoogle Scholar
  45. 45.
    Grignon B, Roland J. Can the human intervertebral disc be compared to a diarthrodial joint? Surg Radiol Anat. 2000;22(2):101–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Mow V, Huiskes R. Basic orthpaedic biomechanics and mechano-biology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2005.Google Scholar
  47. 47.
    Fardon D, Milette P. Nomenclature and classification of lumbar disc pathology. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine. 2001;26(5):E93–113.PubMedCrossRefGoogle Scholar
  48. 48.
    Benneker L, et al. 2004 Young investigator award winner: vertebral endplate marrow contact channel occlusions and intervertebral disc degeneration. Spine. 2005;30(2):167–73.PubMedCrossRefGoogle Scholar
  49. 49.
    Roofe P. Innervation of anulus fibrosus and posterior longitudinal ligament. Arch Neurol Psychiatry. 1940;44:100–3.CrossRefGoogle Scholar
  50. 50.
    Malinský J. The ontogenetic development of nerve terminations in the intervertebral discs of man. (Histology of intervertebral discs, 11th communication). Acta Anat. 1959;38:96–113.PubMedCrossRefGoogle Scholar
  51. 51.
    Rabischong P, et al. The intervertebral disc. Anat Clin. 1978;1:55–64.CrossRefGoogle Scholar
  52. 52.
    Yoshizawa H, et al. The neuropathology of intervertebral discs removed for low back pain. J Pathol. 1980;132:95–104.PubMedCrossRefGoogle Scholar
  53. 53.
    Bogduk N. The lumbar mamillo-accessory ligament: its anatomical and neurosurgical significance. Spine. 1981;6(2):162–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Palmgren T, et al. An immunohistochemical study of nerve structures in the annulus fibrosus of human normal lumbar intervertebral discs. Spine. 1999;24:2075–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Ashton I, Roberts S, Jaffray D. Neuropeptides in the human intervertebral disc. J Orthop Res. 1994;12:186–92.PubMedCrossRefGoogle Scholar
  56. 56.
    Slipman C, et al. Interventional spine: an algorithmic approach. Philadelphia: Saunders Elsevier; 2008.Google Scholar
  57. 57.
    Bogduk N, Tynan W, Wilson A. The nerve supply to the human lumbar intervertebral discs. J Anat. 1981;132:39–56.PubMedCentralPubMedGoogle Scholar
  58. 58.
    Ledsome J, et al. Diurnal changes in lumbar intervertebral distance, measured using ultrasound. Spine. 1996;21(14):1671–5.PubMedCrossRefGoogle Scholar
  59. 59.
    Nachemson A, Moriss J. In vivo measurements of intradiscal pressure: discometry, a method for the determination of pressure in the lower lumbar discs. J Bone Joint Surg. 1964;46:1077–92.PubMedGoogle Scholar
  60. 60.
    Lirk P, et al. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology. 2003;99(6):1387–90.PubMedCrossRefGoogle Scholar
  61. 61.
    Adams M, Hutton W, Stott J. The resistance to flexion of the lumbar intervertebral joint. Spine. 1980;5(3):245.PubMedCrossRefGoogle Scholar
  62. 62.
    Leong J, et al. The biomechanical functions of the iliolumbar ligament in maintaining stability of the lumbosacral junction. Spine. 1987;12:669–74.PubMedCrossRefGoogle Scholar
  63. 63.
    Windsor R, Falco F. Clinical orientation to spinal anatomy. Atlanta: O2 Communications; 2003.Google Scholar
  64. 64.
    Cailliett R. Low back pain syndrome. Philadelphia: F.A. Davis Company; 1981.Google Scholar
  65. 65.
    Bogduk N, MacIntosh J. The applied anatomy of the thoracolumbar fascia. Spine. 1984;9(2):164–70.PubMedCrossRefGoogle Scholar
  66. 66.
    Lee C, Rauschning W, Glenn W. Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine. 1988;13(3):313–20.PubMedCrossRefGoogle Scholar
  67. 67.
    Bogduk N, editor. Practice guidelines: spinal diagnostic and treatment procedures. San Francisco: International Spine Intervention Society; 2004.Google Scholar
  68. 68.
    Baker R, et al. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003;103(1–2):211–5.PubMedCrossRefGoogle Scholar
  69. 69.
    Scanlon G, et al. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine. 2007;32(11):1249–56.PubMedCrossRefGoogle Scholar
  70. 70.
    Huntoon M. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005;117(1–2):104–11.PubMedCrossRefGoogle Scholar
  71. 71.
    Rathmell J. Atlas of image-guided intervention in regional anesthesia and pain medicine. Philadelphia: Lipincott; 2006.Google Scholar
  72. 72.
    Murthy N, Maus T, Behrns C. Intraforaminal location of the great anterior radiculomedullary artery (artery of adamkiewicz): a retrospective review. Pain Med. 2010;11:1756–64.PubMedCrossRefGoogle Scholar
  73. 73.
    Houten J, Errico T. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J. 2002;2(1):70–5.PubMedCrossRefGoogle Scholar
  74. 74.
    Kaplan M, Cooke J, Collins J. Intravascular uptake during fluoroscopically guided cervical interlaminar steroid injection at C6-7: a case report. Arch Phys Med Rehabil. 2008;89(6):1206.CrossRefGoogle Scholar
  75. 75.
    Melzack R, Wall P. Pain mechanisms: a new theory. Science. 1965;150:971–9.PubMedCrossRefGoogle Scholar
  76. 76.
    Meyerson B, Linderoth B. Mechanisms of spinal cord stimulation in neuropathic pain. Neurol Res. 2000;22(3):285–92.PubMedGoogle Scholar
  77. 77.
    Prager J. What does the mechanism of spinal cord stimulation tell Us about complex regional pain syndrome? Pain Med. 2010; 8(11):1278–83.CrossRefGoogle Scholar
  78. 78.
    Yang S, et al. Identifying pathogens of spondylodiscitis: percutaneous endoscopy or CT-guided biopsy. Clin Orthop Relat Res. 2008;466:3086–92.PubMedCentralPubMedCrossRefGoogle Scholar
  79. 79.
    Jarvik J, Deyo R. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586–97.PubMedCrossRefGoogle Scholar
  80. 80.
    A.C.o.D.a.C. Media, editor. ACR manual on contrast media, Version 7 edn. American College of Radiology; 2010, p. 81.Google Scholar
  81. 81.
    Zukotynski K, et al. The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain. J Orthop Surg Res. 2010;5:13.PubMedCentralPubMedCrossRefGoogle Scholar
  82. 82.
    Carragee E, et al. 2009 ISSLS prize winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine. 2009;34(21):2338–45.PubMedCrossRefGoogle Scholar
  83. 83.
    National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Washington D.C.: National Osteoporosis Foundation; 2010. Available at:
  84. 84.
    Smith J, Finnoff J. Diagnostic and interventional musculoskeletal ultrasound: part 1. Fundamentals. PMR. 2009;1(1):64–75.CrossRefGoogle Scholar
  85. 85.
    Smith J, Finnoff J. Diagnostic and interventional musculoskeletal ultrasound: part 2. Clinical applications. PMR. 2009;1(2):162–77.CrossRefGoogle Scholar
  86. 86.
    Ultrasound: not effective in diagnosing spinal injuries. ACR Bull, 1996.Google Scholar
  87. 87.
    Nazarian L, et al. Paraspinal ultrasonography: lack of accuracy in evaluating patients with cervical or lumbar back pain. J Ultrasound Med. 1998;17:117–22.PubMedGoogle Scholar
  88. 88.
    Greher M, et al. Ultrasound-guided lumbar facet nerve block. A sonoanatomic study of a new methodologic approach. Anesthesiology. 2004;100:1242–8.PubMedCrossRefGoogle Scholar
  89. 89.
    Greher M, et al. Ultrasound-guided lumbar facet nerve block. Accuracy of a new technique confirmed by computed tomography. Anesthesiology. 2004;101:1195–200.PubMedCrossRefGoogle Scholar
  90. 90.
    Shim J, et al. Ultrasound-guided lumbar medial branch block: a clinical study with fluoroscopy control. Reg Anesth Pain Med. 2006;31(5):451–4.PubMedGoogle Scholar
  91. 91.
    Eichenberger U, et al. Sonographic visualization and ultrasound-guided block of the third occipital nerve. Prospective for a new method to diagnose C2–C3 zygapophysial joint pain. Anesthesiology. 2006;104:303–8.PubMedCrossRefGoogle Scholar
  92. 92.
    Kim S, et al. Sonographic estimation of needle depth for cervical epidural blocks. Anesth Analg. 2008;106(5):1542–7.PubMedCrossRefGoogle Scholar
  93. 93.
    Vesalius A. On the fabric of the human body. A translation of De Humani Corporis Fabrica Libri Septem. San Francisco: Norman Publishing; 1998.Google Scholar
  94. 94.
    Rothstein J, Serge H, et al. The rehabilitation specialist’s handbook. Philadelphia: F.A. Davis Company; 1998.Google Scholar
  95. 95.
    White A, Panjabi M. The basic kinematics of the human spine. A review of past and current knowledge. Spine. 1978;3(1):12–20.PubMedCrossRefGoogle Scholar

Copyright information

© American Academy of Pain Medicine 2015

Authors and Affiliations

  1. 1.Spine Center, Beth Israel Deaconess Medical CenterBostonUSA
  2. 2.Department of OrthopedicsHarvard Medical SchoolBostonUSA
  3. 3.Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonUSA
  4. 4.Harvard Medical SchoolBostonUSA

Personalised recommendations