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Vertebral Column > Vasculature of the Vertebral Column > Flashcards

Vasculature of the Vertebral Column Flashcards

1
Q

Where does arterial supply to the cervical vertebral column arise from?

A
  • Vertebral arteries
  • Ascending cervical arteries
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2
Q

Where do the vertebral arteries arise from?

A
  • From the subclavian arteries as the V1 (osteal) segment
  • Upon entering the C6 transverse foramen, it is the V2 segment
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3
Q

Describe the V2 segment of the vertebral artery

A
  • Arises from the C6 transverse foramen
  • Runs anterior to cervical nerve roots
  • Artery is covered by intertransverse muscles
  • Accompanied by a sympathetic plexus from the inferior cervical sympathetic ganglion
  • Surrounded by a venous plexus, which becomes the vertebral vein
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4
Q

Describe the anterior branches of the vertebral artery and what they supply

A
  • Supply the ventral surface of the cervical vertebral bodies
  • May also supply the uncovertebral joints of Luschka
  • Most commonly present at C3, C4
  • At C2, an anterior arterial ascending branch supplies the ventral aspect of the body of C2 and an arch around the odontoid process.
  • Anterior branches directly penetrate the cortical bone.
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5
Q

Describe the posterior branches of the vertebral artery and what they supply

A
  • Supply the dorsal surfaces of the cervical laminae and the spinous processes.
  • Most commonly present at C4, C5
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6
Q

Describe the lateral branches of the vertebral artery and what they supply

A
  • Mostly responsible for supply of deep neck musculature
  • Osteoarticular branches supply the facet joints
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7
Q

Describe the medial branches of the vertebral artery and what they supply

A
  • One branch passes deep to the posterior longitudinal ligament and anastomoses with the artery of the other side, forming an arterial plexus.
    • Main blood supply to the vertebral body
    • Enters via the dorsal surface of the vertebral body
    • Single nutrient vessel enters at midline and penetrates to about 1/2 of vertebral body depth
  • Another branch forms an arcuate pattern on the posterior spinal canal, supplying:
    • Lamina
    • Spinous processes
    • Pedicle
    • Facet joints
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8
Q

Describe the ascending cervical arteries

A
  • Main origins:
    • Inferior thyroid artery (72.3%)
    • Thyrocervical trunk (10.7%)
  • Sends off spinal branches through the intervertebral foraminae into the spinal canal
    • Main function is to supply the spinal cord and meninges
    • Can give some supply to the edges of the dorsal vertebral body and ventral laminae
    • Spinal branches further branch into anterior and posterior segmental medullary arteries
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9
Q

Describe the anterior meningeal branch of the vertebral artery

A
  • Arises from the medial surface of the vertebral artery above C3 transverse foramen.
  • Osseous branches supply:
    • Body of the odontoid process of C2
    • Articular plate of the atlanto-occipital and atlanto-axial joints
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10
Q

Where do the posterior intercostal arteries which supply the thoracic vertebrae run?

A
  • They cross the anterolateral aspects of the vertebral bodies.
  • As they do this they give off:
    • Periosteal branches
    • Equatorial branches
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11
Q

Where does the blod supply to the thoracic vertebrae arise from?

A

Posterior intercostal arteries

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12
Q

What are the major banches given off by the posterior intercostal artery to supply the thoracic vertebral column?

A
  • Spinal branch enters the spinal canal at the level of the costotransverse joint via the intervertebral foramen.
  • This artery gives off:
    • An anterior branch that will supply the dorsal aspect of the ventral vertebral body
    • A posterior branch that will supply the ventral aspect of the laminae
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13
Q

Where does the blood supply to the lumbar vertebral column come from?

A
  • The lumbar arteries
  • Origin of the lumbar arteries: 4 pairs of arteries arising from the posterolateral aspect of the abdominal aorta
  • A 5th pair arises from the middle sacral artery
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14
Q

Describe branches of the lumbar arteries supplying the lumbar vertebral column

A
  • Gives spinal branches which enter the spinal canal via the intervertebral foraminae.
    • A posterior spinal canal branch gives off well-defined branches to supply the epidural fat, dural sac, laminae and the base of each spinous process.
    • The branch from each lamina bifurcates to supply superior and inferior articular processes.
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15
Q

Which arteries supply the sacrum?

A
  • Iliolumbar arteries
  • Lateral sacral arteries
  • Median sacral arteries
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16
Q

Describe the iliolumbar arteries

A
  • Usually branch from the posterior trunk of the internal iliac artery
  • Run superolaterally in front of the sacroiliac joint
  • A lumbar branch may anastomose with the 4th lumbar artery
  • A small spinal branch enters the spinal canal via the interventricular foramen between the 5th lumbar and the 1st sacral vertebrae
  • May also arise directly from the posterior aspect of the internal iliac artery
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17
Q

Describe the lateral sacral arteries

A
  • On each side, there is a superior and inferior branch, originating from the posterior branch of the internal iliac artery.
  • Pass medially and descend anterior to sacral anterior rami.
  • Give off spinal branches which pass through the anterior sacral foraminae to supply the vertebrae.
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18
Q

Describe the median sacral artery

A
  • Small unpaired artery arising from the posterior aspect of the abdominal aorta, superior to its bifurcation.
  • Runs anterior to the bodies of the last one or two lumbar vertebrae, the sacrum and the coccyx.
  • Can give rise to the 5th pair of lumbar arteries
  • As it descends over the sacrum, it gives off branches to anastomose with those of the lateral sacral arteries.
    • These support the branches which enter the spinal canal via the anterior sacral foraminae
  • Small periosteal branches and equatorial branches supply the anterior aspect of the sacrum, similar to the superior regions of the vertebral column.
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19
Q

What happens to blood vessels which surround the intervertebral disc during early development?

A

They gradually dissipate resulting in an avascular structure

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20
Q

How (generally) does the vertebrae receive its blood supply?

A
  • Segmentally, from branches of vessels that lie adjacent to it.
  • These branches anastomose with the anterior and posterior spinal arteries to supply the spinal cord.
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21
Q

Which parts of the vertebrae are vascularised?

A
  • The part of the body immediately adjacent to the disc is avascular.
  • The more central region is vascular.
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22
Q

Why is the central vascular region of the vertebrae zoned?

A

It is likely that diffusion of O2 and nutrients for disc metabolism is zoned because of the arrangement of the lamellae of the annulus fibrosus.

(Probably)

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23
Q

Describe the arterial supply to the central region of the vertebral column

A
  • Central region can be divided into 3 zones:
    • Innermost zone supplied by the tortuous nutrient artery
    • Middle zone supplied by the metaphyseal arteries
    • The most peripheral zone is supplied by the peripheral arteries
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24
Q

What happens to the nucleus pulposis with age?

A
  • Dehydrates and loses its elastic property
  • Loses proteoglycans
  • Gains collagen
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25
Q

What does loss of proteoglycans in the nucleus pulposus result in?

A
  • Loss of glycosaminoglycans
    • This is responsible for reduced osmotic pressure of the disc matrix and so a loss of hydration
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26
Q

What happens when the disc matrix is dehydrated?

A
  • The IV disc stiffens and loses its important ability to deform and reform under changing pressure.
  • When load is applied, the disc will lose height.
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27
Q

What results from degeneration of the IV discs

A
  • Necrotic appearance due to cell death
  • Can put excess pressure on supporting structures:
    • Apophyseal joints adjacent to the damaged disc
    • Ligamentum flavum
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28
Q

What would result from reduced tensional force on the ligamentum flavum?

A

May result in thickening and remodelling and due to its inherent loss of elasticity, the ligament may bulge into the vertebral canal, resulting in spinal stenosis

29
Q

When do IV discs degenerate?

A
  • Far earlier than other musculoskeletal tissues
  • About 20% of people in their teens have discs with mild signs of degeneration
  • Degeneration increases steeply with age, particularly in males
  • Around 10% of 50-year-old discs are severely degenerated
  • Around 60% of 70-year-old discs are severely degenerated
30
Q

What are Schmorl’s nodes?

A
  • Vertical protrusion / herniation of the nucleus pulposus through the cartilaginous and bony end plate into the vertebral body.
  • Causes a defect in the vertebrae superior and inferior to the herniated disc.
  • Most common endplate defect.
31
Q

List the types of Schmorl’s nodes

A
  • Traumatic
  • Idiopathic
  • Developmental
  • Genetic
  • Decreased bone mineral density
32
Q

Explain the immune response to a Schmorl’s node

A

When a disc herniates into the vertebral endplate it could be considered by the body as ‘non-self tissue’ and when it comes into contact with blood, will trigger an auto-immune reaction.

33
Q

What are the symptoms associated with Schmorl’s nodes?

A
  • Severe back pain
  • Inflammation
  • When the auto-immune response is not present, Schmorl’s nodes are often asymptomatic
34
Q

Why is there a greater arterial supply to the cervical and lumbar vertebral regions?

A

Because there are cervical and lumbar enlargements

35
Q

At what spinal level is the cervical enlargement?

A

C4-T1

36
Q

At what spinal level is the lumbar enlargement?

A

T11-S1

37
Q

What is the purpose of the cervical and lumbar enlargements?

A

They facilitate increased neural input from and output to the limbs

38
Q

Which arteries supply the cervical and lumbar enlargements?

A
  • Large caliber anterior segmental radiculmedullary arteries:
    • The artery of Lazorthes (cervical enlargement)
    • The artery of Adamkiewicz (lumbar enlargement)
39
Q

Describe spinal cord infarction

A
  • Rare - accounts for 1% of all strokes
  • Emboli arises from anywhere in the circulatory system and moves into the:
    • anterior spinal artery (most common)
    • posterior spinal artery (rare)
  • causing ischaemia and subsequent infarction.
  • Early presentation:
    • Numbness
    • Aching
    • Tingling
    • Lower extremity weakness
    • Cramping
    • Bowel and bladder paralysis
    • Pain
40
Q

What results from involvement of the posterior horn in posterior spinal artery infarction?

A

May cause loss of sensory function

41
Q

Why is posterior spinal infarction so rare?

A

Due to the extensive lateral vascular network

42
Q

Describe Beck’s system

(Anterior spinal artery syndrome)

A
  • One of the causes of spinal cord infarction
  • Caused by hypo-perfusion of the anterior spinal artery due to an occlusion of the vessel, leading to ischemia in the anterior 2/3 of the spinal cord.
    • The anterior spinal artery supplies the anterior 2/3 of the spinal cord via the sulcal (central) artery.
43
Q

What are the common causes of Beck’s syndrome?

A
  • Aortic aneurysms
  • Direct trauma to the aorta
  • Surgery on the aorta
  • Acute disc herniation
  • Cervical spondylosis
  • Kyphoscoliosis
  • Trauma to the spinal column
  • Emboli
44
Q

What is cervical spondylosis?

A

Neck pain caused by age-related damage to bones and tissues

45
Q

What are the symptoms of Beck’s syndrome?

A
  • Patient normally presents with:
    • An acute and painful myelopathy with additional symptoms such as impaired bladder and bowel control.
    • Pain and temperature sensation and bilateral motor function below the lesion are lost.
    • Sense of vibration and position are intact because of the preservation of the dorsal columns.
    • Autonomic dysfunction: orthostatic hypotension
46
Q

What does the intrinsic venous system drain?

A

Involves only the spinal cord, not the spinal column itself

47
Q

Where do the sulcal veins drain blood from?

Where do they drain to?

A

Collect blood from:

  • Both halves of the medial aspects of the anterior horns
  • Anterior grey commissure
  • White matter of the anterior funniculus

Drain into the anterior median vein

48
Q

How are the radial veins formed?

Where do they drain to?

A
  • In the peripheral grey matter and adjacent white matter, capillaries travel towards the periphery of the spinal cord forming radial veins.
  • Drain into a venous ring on the spinal surface which drains into components of the extrinsic venous system.
49
Q

How is reflux regulated in the radiculomedullary veins?

A
  • Initially thought that bicuspid valves prevented the reflux of blood from the radiculomedullary veins back into the longitudinal veins.
    • Human cadaver study showed no bicuspid valves.
  • Now understood that:
    • ​Dural folds extend into the lumen of the vein
    • Periradicular veins are tortuous, reducing venous reflux
    • A bottleneck is created by a narrowed dural part and widened intra- and extra- dural parts
    • Significant smooth muscle fibres in the walls of the intradural and extradural parts of the radiculomedullary veins
50
Q

Describe Batson’s plexus

(Extradural vertebral venous plexus)

A

Has 3 major divisions:

  • Internal vertebral plexuses
  • External vertebral plexuses
  • Basivertebral plexuses
51
Q

What is Batson’s plexus responsible for?

A
  • Draining blood from the radiculomedullary veins
  • Draining the vertebral column itself
52
Q

Describe the internal vertebral venous plexuses

A
  • Anterior and posterior internal vertebral plexues communicate superiorly with the suboccipital venous systems.
  • Has 4 longitudinal veins - 2 anteriorly ad 2 posteriorly
53
Q

Describe the anterior internal vertebral plexus

A

Lies on either side of the posterior longitudinal ligament and connects to the basivertebral plexus via transverse branches.

54
Q

Describe the posterior internal vertebral plexus

A

Anterior to the ligamentum flavum and connects to the posterior external vertebral plexus via perforating branches.

55
Q

Describe the external vertebral plexuses

A

Has anterior and posterior parts.

  • Anterior external vertebral plexus:
    • ​Formed from tributaries from the vertebral body
  • Posterior external vertebral plexus:
    • Veins passing through the ligamentum flavum form the posterior external vertebral venous plexus, which surrounds the posterior elements of the vertebrae.
56
Q

How do the internal and external venous plexuses communicate?

A

Via intervertebral veins, which accompany the spinal nerves through the intervertebral foramina

57
Q

Describe the basivertebral plexus

A
  • Form within the vertebral bodies and run horizontally within them
  • Emerge from foraminae on the surfaces of the vertebral bodies , particularly on the posterior surface
  • Some drain to and contribute to the anterior external vertebral plexus
  • The majority of blood in these plexuses, however, drain to the anterior internal vertebral plexus
58
Q

Describe the extradural venous drainage in the cervical region

A

Occurs via 3 major pairs of vessels:

  • Vertebral veins
  • Deep cervical veins
  • Jugular veins
59
Q

Describe the extradural venous drainage from the thoracic and lumbar regions

A

Occurs via the azygos system and ascending lumbar veins:

  • The ascending lumbar vein joins the azygos vein on the right and the hemiazygos on the left
  • The hemiazygos crosses to join the azygos around T9 level
  • The accessory hemiazygos drains the upper left thoracic vertebral levels (T3-T8)
60
Q

Describe the extradural venous drainage in the lumbosacral region

A
  • Ascending lumbar veins communicate with the IVC via 4 horizontal lumbar segmental veins.
  • Great variation in lumbar venous drainage; spinal venous blood has been shown to drain to:
    • Left renal vein
    • Vein of the crus of the diaphragm
  • Sacral veins empty to:
    • Lateral sacral veins
    • Internal iliac veins
61
Q

What are the four routes of metastasis via blood?

A
  • Contiguous spread
    • local invasion
  • Compartmental spread
    • direct seeding to body cavities
  • Haematogenous spread
    • via the vasculature of the body
  • Lymphangitic spread
    • through lymphatic vessels and ‘preferentially to regional lymph nodes and later to distant sites
62
Q

What is step 1 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(1) Invade locally through surrounding extracellular matrix and stromal layer cells

63
Q

What is step 2 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(2) Intravasate into the lumen of blood vessels

64
Q

What is step 3 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(3) Survive the rigors of transport through the vasculature

65
Q

What is step 4 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(4) Arrest at different organ sites

66
Q

What is step 5 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(5) Extravasate into the parenchyma of distant tissues

67
Q

What is step 6 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(6) Initially survive in these foreign microenvironments in order to form micrometastases

68
Q

What is step 7 of the invasion-metastasis cascade?

A

Epithelial cells in primary tumours:

(7) Reinitiate their proliferative programs at metastatic sites, thereby generating macroscopic, clinically detectable neoplastic growths

69
Q

List some primary cancers which often metastasise to bone

A
  • Breast cancer
  • Lung cancer
  • Especially prostate cancer

Vertebral Column (13 decks)

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