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The vertebral column, also known as the backbone or spine, is the core part of the axial skeleton in vertebrate animals. The vertebral column is the defining characteristic of vertebrate endoskeleton in which the notochord (a flexible collagen-wrapped glycoprotein rod) found in all chordates has been replaced by a segmented series of mineralized irregular bones (or sometimes, cartilages) called vertebrae, separated by fibrocartilaginous intervertebral discs (the center of which is a notochord remnant).[1] The dorsal portion of the vertebral column houses the spinal canal, a cavity formed by alignment of the neural arches that encloses and protects the spinal cord.

The number of vertebrae in a region can vary but overall the number remains the same. In a human vertebral column, there are normally 33 vertebrae.[3] The upper 24 pre-sacral vertebrae are articulating and separated from each other by intervertebral discs, and the lower nine are fused in adults, five in the sacrum and four in the coccyx, or tailbone. The articulating vertebrae are named according to their region of the spine. There are 7 cervical vertebrae, 12 thoracic vertebrae and 5 lumbar vertebrae. The number of those in the cervical region, however, is only rarely changed,[4] while that in the coccygeal region varies most.[5] Excluding rare deviations, the total number of vertebrae ranges from 32 to 35.[6] In about 10% of people, both the total number of pre-sacral vertebrae and the number of vertebrae in individual parts of the spine can vary.[7][8][9] The most frequent deviations are: 11 (rarely 13) thoracic vertebrae, 4 or 6 lumbar vertebrae, 3 or 5 coccygeal vertebrae (rarely up to 7).[9]

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The vertebrae in the human vertebral column is divided into different regions, which correspond to the curves of the vertebral column. The articulating vertebrae are named according to their region of the spine. Vertebrae in these regions are essentially alike, with minor variation. These regions are called the cervical spine, thoracic spine, lumbar spine, sacrum, and coccyx. There are seven cervical vertebrae, twelve thoracic vertebrae, and five lumbar vertebrae.

The number of vertebrae in a region can vary but overall the number remains the same. The number of those in the cervical region, however, is only rarely changed.[4] The vertebrae of the cervical, thoracic, and lumbar spines are independent bones and generally quite similar. The vertebrae of the sacrum and coccyx are usually fused and unable to move independently. Two special vertebrae are the atlas and axis, on which the head rests.

A typical vertebra consists of two parts: the vertebral body and the vertebral arch. The vertebral arch is posterior, meaning it faces the back of a person. Together, these enclose the vertebral foramen, which contains the spinal cord. Because the spinal cord ends in the lumbar spine, and the sacrum and coccyx are fused, they do not contain a central foramen. The vertebral arch is formed by a pair of pedicles and a pair of laminae, and supports seven processes, four articular, two transverse, and one spinous, the latter also being known as the neural spine. Two transverse processes and one spinous process are posterior to (behind) the vertebral body. The spinous process comes out the back, one transverse process comes out the left, and one on the right. The spinous processes of the cervical and lumbar regions can be felt through the skin.

The vertebral column is curved in several places, a result of human bipedal evolution. These curves increase the vertebral column's strength, flexibility, and ability to absorb shock, stabilising the body in upright position. When the load on the spine is increased, the curvatures increase in depth (become more curved) to accommodate the extra weight. They then spring back when the weight is removed.[11]

The upper cervical spine has a curve, convex forward, that begins at the axis (second cervical vertebra) at the apex of the odontoid process or dens and ends at the middle of the second thoracic vertebra; it is the least marked of all the curves. This inward curve is known as a lordotic curve.

There are different ligaments involved in the holding together of the vertebrae in the column, and in the column's movement. The anterior and posterior longitudinal ligaments extend the length of the vertebral column along the front and back of the vertebral bodies.[13] The interspinous ligaments connect the adjoining spinous processes of the vertebrae.[14][better source needed] The supraspinous ligament extends the length of the spine running along the back of the spinous processes, from the sacrum to the seventh cervical vertebra.[15] From there it is continuous with the nuchal ligament.

The striking segmented pattern of the spine is established during embryogenesis when somites are rhythmically added to the posterior of the embryo. Somite formation begins around the third week when the embryo begins gastrulation and continues until all somites are formed. Their number varies between species: there are 42 to 44 somites in the human embryo and around 52 in the chick embryo. The somites are spheres, formed from the paraxial mesoderm that lies at the sides of the neural tube and they contain the precursors of spinal bone, the vertebrae ribs and some of the skull, as well as muscle, ligaments and skin. Somitogenesis and the subsequent distribution of somites is controlled by a clock and wavefront model acting in cells of the paraxial mesoderm. Soon after their formation, sclerotomes, which give rise to some of the bone of the skull, the vertebrae and ribs, migrate, leaving the remainder of the somite now termed a dermamyotome behind. This then splits to give the myotomes which will form the muscles and dermatomes which will form the skin of the back. Sclerotomes become subdivided into an anterior and a posterior compartment. This subdivision plays a key role in the definitive patterning of vertebrae that form when the posterior part of one somite fuses to the anterior part of the consecutive somite during a process termed resegmentation. Disruption of the somitogenesis process in humans results in diseases such as congenital scoliosis. So far, the human homologues of three genes associated to the mouse segmentation clock, (MESP2, DLL3 and LFNG), have been shown to be mutated in cases of congenital scoliosis, suggesting that the mechanisms involved in vertebral segmentation are conserved across vertebrates. In humans the first four somites are incorporated in the base of the occipital bone of the skull and the next 33 somites will form the vertebrae, ribs, muscles, ligaments and skin.[16] The remaining posterior somites degenerate. During the fourth week of embryogenesis, the sclerotomes shift their position to surround the spinal cord and the notochord. This column of tissue has a segmented appearance, with alternating areas of dense and less dense areas.

Spinal stenosis is a narrowing of the spinal canal which can occur in any region of the spine though less commonly in the thoracic region. The stenosis can constrict the spinal canal giving rise to a neurological deficit.

The general structure of human vertebrae is fairly typical of that found in mammals, reptiles, and birds. The shape of the vertebral body does, however, vary somewhat between different groups. In mammals, such as humans, it typically has flat upper and lower surfaces, while in reptiles the anterior surface commonly has a concave socket into which the expanded convex face of the next vertebral body fits. Even these patterns are only generalisations, however, and there may be variation in form of the vertebrae along the length of the spine even within a single species. Some unusual variations include the saddle-shaped sockets between the cervical vertebrae of birds and the presence of a narrow hollow canal running down the centre of the vertebral bodies of geckos and tuataras, containing a remnant of the notochord.[26]

Reptiles often retain the primitive intercentra, which are present as small crescent-shaped bony elements lying between the bodies of adjacent vertebrae; similar structures are often found in the caudal vertebrae of mammals. In the tail, these are attached to chevron-shaped bones called haemal arches, which attach below the base of the spine, and help to support the musculature. These latter bones are probably homologous with the ventral ribs of fish. The number of vertebrae in the spines of reptiles is highly variable, and may be several hundred in some species of snake.[26]

In birds, there is a variable number of cervical vertebrae, which often form the only truly flexible part of the spine. The thoracic vertebrae are partially fused, providing a solid brace for the wings during flight. The sacral vertebrae are fused with the lumbar vertebrae, and some thoracic and caudal vertebrae, to form a single structure, the synsacrum, which is thus of greater relative length than the sacrum of mammals. In living birds, the remaining caudal vertebrae are fused into a further bone, the pygostyle, for attachment of the tail feathers.[26]

Explore this special issue which focuses on proceedings from the First Annual Lumbar Total Disc Replacement Summit that was held on October 25, 2016 in Boston, MA. This five-article supplement focuses on the Summit, which brought together seventeen thought-leaders in the spine surgery community. These experts employed a modified-Delphi method to determine where consensus existed pertaining to the utilization of lumbar total disc replacement as a standard of care for a subpopulation of patients suffering from degenerative disc disease. The funding for this supplement was provided by Aesculap Implant Systems, LLC.

Published December 15, 2017

The AOSpine Knowledge Forum Tumor (AOSKFT) has built upon the inaugural focus issue in spine oncology by the Spine Oncology Study Group (SOSG) by using the same evidence-based medicine format to introduce new complementary topics, report on practice changing advances and breakthroughs, and reinforce fundamental management principles unique to these complex patients.