Spinal Anatomy (eBook)

Foreword 5
Preface 6
Contents 7
Part I: Phylogenesis and Ontogenesis 9
Comparative Anatomy of the Axial Skeleton of Vertebrates 10
Introduction 10
The Organization Plan for the Vertebrates 10
Adaptive Constraints of the Living Environment 11
Constraints of the Aquatic Environment 11
Constraints of the Terrestrial Air Environment 11
Fish 11
Terrestrial Vertebrates 12
Amphibians (About 7000 Species) 13
Reptiles (Approximately 8950 Species) 14
The Cervical Spine 15
Birds (Approximately 10,000 Species) 16
Mammals (About 5500 Species) 16
The Cervical Spine 17
Structure 17
Movements 18
The Craniovertebral Musculature 19
Postures 20
Thoracic Spine and Lumbosacral 21
Structures 21
Musculature 22
Postures 22
References 25
Embryology of the Vertebral Column 26
Genetic and Biochemical Considerations 26
Embryology of the Vertebromedullary Axis 27
Early Development 27
Trilaminar Embryo 28
The Notochord 29
Primary Neurulation 29
Secondary Neurulation 29
Formation and Differentiation of Somites 29
References 30
The Growing Spine 32
A Mosaic of Growth Cartilage 32
Vertebral Growth Is Growth by Endochondral Ossification 32
Embryology Holds First Truths 32
The Fetal Period: The Strongest of All Growth Is the Intra-Uterine Period 33
Vertebral Curves Are Not Primitive But Acquired 34
At Birth, 30% of the Spine Is Ossified 34
The First Five Years of Life Are Decisive: Living Growth 34
Growth Between 5 Years and the Beginning of the Puberty 37
Puberty, a Decisive Turn: New Acceleration 37
Each Level of the Spine: A Different Growth 37
The Cervical Spine 37
Central Spinal Canal at the End of Growth 37
Cervical Spine Height 38
The Superior Cervical Spine 38
The Growth of the Atlas (Figs. 27, 28, and 29) 38
The Growth of the Axis Is Even More Complex 40
The Lower Cervical Spine 40
The T1-S1 Segment (Figs. 31a, b, 32, and 33) 41
The Thoracic Spine T1-T12 (Figs. 34 and 35) 41
The Lumbar Spine L1-L5 (Figs. 36 and 37) 42
The Sacrum 42
The Intervertebral Disc 44
The Growth of the Thorax: 4th Dimension of the Spine 44
Bodyweight 47
Parasol Effect 50
What Size Deficit for Which Arthrodesis? 51
First Scenario: Arthrodesis of the Thoracic Spine 51
Second Scenario: Arthrodesis of the Lumbar Spine 53
All Scoliosis Will in Time Become Identified as a Growth Cartilage Disease 54
The Growth of the Spine: From Normal to Pathological 54
Managing Infantile Scoliosis Is Controlling the Vilebrequin Effect 55
Suggested Readings 58
The Growth Cartilages of the Spine and Pelvic Vertebra 60
Neurocentral Cartilage (NCC) 60
The Ring Apophysis 68
Ossification of the Pelvic Vertebra 73
Bone Age During Puberty 75
References 81
Morphologic and Functional Evolution of the Aging Spine 82
Age-Related Structural Alterations 82
The Intervertebral Disc 82
Structural Modifications 82
A Fragile Avascular Tissue 83
A Genetic Predisposition? 83
Genesis and Contributions to Aging on Histomorphological Features 83
Aggravating Factors 85
Mechanical Factors 85
Inflammatory Factors 86
Vascular Factors 86
Specific Features in the Cervical Spine 88
Lumbar and Cervical Tandem Lesions 88
The Posterior Arch 89
Facet Joints or Zygapophyseal Joints 89
Spinous Processes 91
Ligaments 91
Muscles 92
Bone 94
Aging and Neurological Control of Posture 96
Proprioception 96
Vision and Visual Motor Control 97
The Vestibule 97
Central Integration 98
Functional Alterations Associated with Aging 98
Postures and Dynamic Balances in Normal Adults 98
Bipedal Folding Chains 99
Sagittal BFC 99
The Spine 99
The Pelvic Girdle 102
The Two Lower Limbs 103
Coronal BFC 103
Transversal BFC 104
Postural Control 106
Functional Alterations Related to Aging (Table 1) 107
Body Balance After Surgical Correction 111
References 114
Part II: Postural Anatomy 117
The Standing Position: Its Principles and Spinopelvic Relations 118
Introduction 118
Form and Position of the Pelvis 118
Limits for Pelvic Parameters 119
Influence of the Pelvic Incidence on the Shape of the Pelvis [4] 120
The Lumbar Lordosis 121
Remarks 123
Pelvic Incidence Relationship Lumbar Lordosis 124
Global Balance of the Thoracic and Lumbar Spine. Position of C7 (Fig. 11) 124
Values of Overall Balance 125
Mechanisms for the Compensation of the Spinopelvic Balance 125
Spinopelvic Origin Balance 126
Spinal Imbalance 126
Primary Compensation Mechanisms 126
Influence of the Shape of the Pelvis on Pelvic Version 126
Algorithm of Spinopelvic Balance (Table 1) 127
Analysis of Spinal and Discal Constraints: Influence of Spinopelvic Balance 127
Conclusion 127
References 130
The Reserve of Hip Extension and Its Relationship with the Spine 131
Applications 134
Stretching 134
Surgery 135
Conclusions and Perspectives 135
References 135
The EOS System: Overall Assessment of Balance of the Vertebral Column and Its Movements 136
Information Provided for 2D Alignment of the Body (Fig. 2) 136
Information Provided by 3D Volumic Surface Reconstructions Obtained Through Computer Software 138
References 143
Part III: Descriptive Anatomy 144
The Cranial Vertebra 145
Phylogenesis 145
Centre of Gravity of the Head 147
How to Recognize the Exact Position of the Head on Lateral Radiographs? 147
What Radiological References May We Use? (Fig. 13) 150
How Is the Sagittal Cervical Balance Below the Cranial Vertebra? 151
References 153
Surgical Anatomy of the Vertebral Pedicle 154
Anatomical Studies, Dimensions and Orientation of Vertebral Pedicles in a Normal Spine 154
Overview 154
Comparative Anatomy by Location 155
Orientation [6] (Figs. 2 and 3) 155
Interpedicular Dimensions [3, 6] 156
Radiological Assessment of Pedicle Dimensions 156
Applications to the Target Pedicle and Contribution of Navigation 157
Point of Entry to the Pedicle [7] (Fig. 5) 157
Special Cases 158
The Pedicle in Scoliosis (Figs. 6 and 7) 158
Dysplastic Pedicles of Neurofibromatosis [8] 158
The Pedicle in Vertebral Malformations 159
Conclusion 160
References 161
Sacrum Anatomy: New Concepts 162
Study of Radiological Correlation of Pelvic Parameters and Lumbar Lordosis in Standing, Sitting and Lying (Supine) Positions (Fig. 1) 162
Introduction 162
Patients and Methods 162
Radiography 163
Radiological and Statistical Analyses 163
Results 163
Discussion 163
Neurovascular Risks During the Insertion of the S1 Screw: An Anatomical Study 164
Introduction 164
In Vivo CT Measurements 165
Results 165
Discussion 165
Pelvic Fixation: Surgical Techniques 166
The Biomechanical Zones at the Level of the Sacrum (Fig. 3) 166
Screw Insertion at S1 and S2 (Fig. 4) 166
Jackson’s Intrasacral Rod (Fig. 5) 167
The Galveston Stem (Fig. 6) 167
Iliac Screw Insertion (Fig. 7) 167
Iliosacral Screw Insertion (Fig. 8) 168
S2 Iliac Screw Insertion (Fig. 9) 168
“T-Construct” by Vialle (Fig. 10) 170
References 170
The Pelvic Vertebra, the Cephalic Vertebra and the Concept of the Chain of Balance 172
Introduction: Foundation for the Concept 172
Anatomical Basis for the Pelvic Vertebra 173
Morphologically 173
Intrapelvic Degrees of Freedom 174
On the Other Hand, the Degrees of Freedom Around the Pelvic Vertebra Are Quite Considerable 175
Plasticity of the Pelvic Vertebra 175
The Texture and the Bone Architecture of the Pelvis 175
Physiological, Pathophysiological and Mechanical Implications of the Pelvic Vertebrae 176
The Pelvic Vertebra as an “Intercalary Bone” 176
Practical Consequences of These Findings 179
Therapeutic Consequences 180
The Paralytic Pelvic Obliquity Correction Strategy 180
The Three-Dimensional Equilibrium of High Grade Spondylolisthesis 182
Compensation Phenomena Occurring at the Level of the Pelvic Vertebra 183
The Possibilities of Anatomical Changes in the Pelvic Vertebra with Bilateral Pelvic Osteotomies of Sagittal Reorientation of the Trunk 183
The Therapeutic Consequences of the Notion of the Cephalic Vertebra Are Just as Important 185
Conclusion 187
References 187
The Cranial and Pelvic “Vertebrae” Are They Real Vertebrae? 189
Introduction 189
Formation and Growth of the Skull 189
Somites 189
Basicranial Chondrogenesis (Figs. 2, 3, 4, and 5) 190
Craniofacial Ossification (Figs. 6 and 7) 191
Craniofacial Growth 192
Conclusion 193
Formation, Growth, and Aging of the Pelvic Ring 193
Phylogenesis 193
Formation and Growth of the Sacrum 195
Formation and Growth of the Coxal Bone [24–26] 197
Formation and Growth of the Sacroiliac Joint (SIJ) 200
How Is the Acetabulum Oriented According to the Pelvic Position? 201
References 206
The Intervertebral Disc 207
General Characters 207
Biomechanical Specifications 207
Anatomical Structure [1–3] 207
IVD Ultrastructure (Fig. 4) 208
Glycosaminoglycans (GAG) [7–13] 208
Collagen [14–16] 209
Water and Chemical Composition of Human Discs [8] 209
Proteolytic Enzymes [17] 209
Vascularization and Innervation of the Disc 210
Role of the Disc 210
Movements and Constraints 211
Variations According to Spinal Levels 212
Disc Fissuring and Herniation (Figs. 9 and 10) 213
References 215
Anatomy of the Thoraco-Lumbar Facet Joint 217
Formation of the Posterior Thoraco -Lumbar Joints [1] 217
Morphology of Posterior Thoraco-Lumbar Joints (TLJ) 217
Morphology of the Posterior Thoracic Joints 217
Morphology of the Posterior Lumbar Joints 218
Participation of the Posterior Articulations in the Overall Stability of the Spine [1] 219
Vertical Stability 219
Horizontal Stability 221
Participation of Posterior Articulations in Vertebral Dynamics [1] 223
Flexion-Extension and Tilt-Rotation (Fig. 8) 223
Facet Asymmetry 224
Innervation of the Posterior Articulations 224
Most Common Pathologies of Posterior Lumbar Joints 224
References 226
The Spinal Ligaments 228
Ligaments in the Suboccipital Area 228
Ligaments of the Lower Cervical Area 232
The Ligaments of the Thoracic Area 232
Ligaments of the Lumbar Area 233
The Ligaments of the Sacral Area 238
Ligaments in Spinal Pathology 238
Traumatology 238
Degenerative Pathology 239
Cervical Level 239
Thoracic Level 240
Lumbar Level 240
Tumor Pathology 241
Spinal Deformities 241
References 241
Sacroiliac Joints 242
Descriptive and Functional Anatomy of the Pelvic Girdle 242
The Pubic Symphysis 242
Sacroiliac Joints 242
The Sacrococcygeal Joint 243
Biomechanical 243
Static: The Pelvic Girdle Is Hyperstable 243
Kinematics of the Sacroiliac Joint 244
Conclusion 248
References 249
The Normal and Pathological Spinal Muscle 250
Introduction 250
Normal Descriptive Anatomy 250
The Cervical Muscles 250
Deep Muscles 250
The Peripheral Muscles 251
The Sternocleidomastoid (SCM) 251
The Trapezius 253
The Intermediate Muscles Extending Upwards 254
The Intermediate Muscles Extending Downwards 255
Scaleni 255
Thoraco-Lumbar Muscles 256
Posterior Muscle Group 257
The Deep Plane 257
The Intermediate Plane 257
The Superficial Plane 258
Lateral Muscle Group 258
Anterior Muscle Group (Fig. 20) 259
The Aponeurosis 262
The Thoraco-Lumbar Aponeuroses 262
Action 263
Stabilizing Action 263
Dynamic Action 264
Histophysiology 265
Distribution of Muscle Fibers According to the Spinal Level 265
Morphological and Functional Variations of Muscle Fibers 266
Paravertebral Muscles in Spinal Pathology 266
Elemental Lesions, Lesional Groups 267
Lumbar Instability Resulting in Chronic Low Back Pain 268
Arthrogenic Kyphosis 268
Idiopathic Scoliosis 269
Muscle Integrity After Posterior Arthrodesis 270
References 270
Configuration of the Posterior Lumbar Muscles: Study of Lumbosacral Malformations and the Extraforaminal Approach (ELIF) 272
Purpose 272
Background 272
Anatomy [6] 272
Patients and Method 272
Results 273
Discussion 274
Conclusion 276
References 276
Vertebral Column: Muscles, Aponeurosis, and Fascia 277
History 277
Organogenesis 278
General and Semantic Organization of the Muscle 279
Curvatures: Anatomical and Biomechanical Fundamentals 279
Musculo-Aponeurotic Static and Dynamic Mechanical Imperatives 282
Comparative Anatomy: Curves and Muscles 283
Numbers 283
Old Nomenclature 284
Modern Nomenclature 284
Muscle Insertions 284
Intrinsic and Semantic Morphology 285
Sarcomere and Myofibrils 285
Titin: The Primary Elastic Protection of the Sarcomere 288
Muscles and Aponeurosis 289
Muscle Fasciculi and Aponeurosis 289
Muscle Fasciculi and Pennation: Topographical Economics 289
Aponeurosis: Fundamental Structure 290
A Historical Conceptual Error 290
Intrinsic Structure of the Aponeurosis: Endomysium and Perimysium Aponeurosis 291
Mechanism of the Aponeurosis 293
Muscle with Parallel Fascicles: Pseudo-Penniform 296
Unipennate Muscle (Fig. 30) 296
Bipennate Muscle 296
Angles of Pennation Articulation and Muscular Power 297
Muscular Action and Topography 298
Topography and Global Functionality 298
Muscle Direction 301
Muscle Torsion 303
Monoarticular Muscles and Mechanical Rotary Results 304
Polyarticular Muscles and Resultant Mechanical Rotators 305
Mechanical Properties 306
Muscular Work 306
Muscle Yield 306
Fascicle Mechanic Performance and Physiological Cross-Sectional Area (PCSA) 306
Global Mechanical Properties of the Muscle–Aponeurosis–Tendon Complex 309
Muscle Functions and Composite Beam (Fig. 49) 309
Purpose, Symmetry, Variability 310
Volume and Strength of Muscles 311
Law of Third Dimensional Articular Dynamic Rotational Centering 311
Muscular Ambivalence: Articular Chains and Stato-Dynamic Effects of Muscles 312
Muscle Force and Levers 312
Compliance 312
New Compliance Concepts: Muscular Fascicles and Fascia (aponeurosis) 313
Fasciae 313
Terminology: Fascia of Contention 313
Structure of the Fascia 314
Properties of Fascia 314
Clinical Implications 315
Muscle and Infiltration Fat: Aging 315
Conclusion 316
References 317
Functional Anatomy of the Erector Spinae: Review 319
Introduction 319
Descriptive Anatomy of the Paravertebral Gutter 319
Plane of the Transverse—Spinous Process Muscles (Deepest) 319
Plane of the Spinalis and Semispinalis Muscles 320
Plane of Longissimus and Iliocostal Muscles 320
Plane of the Splenius Muscles 320
Anatomical Models (Figs. 1 and 2) 320
Control and Genesis of Trunk Movements During Walking 322
Erector Spinae Muscle Activity During Locomotion 323
Theory of Chronic Lumbago of Muscular Origin 323
Conclusion 324
References 324
Connective Tissues of the Posterior Aspect of the Trunk 326
Introduction 326
Fascia Superficialis (FS) 327
Introduction and definition 327
Composition and Location of the FS 328
Function 328
Fascia Profundis (FP) 329
Lumbosacral Region 329
Posterior Layer of the Fascia Profundis, Lumbosacral Region 329
Middle Layer of the Fascia Profundis, Lumbosacral Region 329
Anterior Layer of the Fascia Profundis, Lumbosacral Region 329
Thoracic Region 330
Posterior Layer of the Fascia Profundis, Thoracic Region 330
Intermediate Layer of the Fascia Profundis, Thoracic Region 332
Anterior Layer of the Fascia Profundis, Thoracic Region 332
Cervico-Cranial Region 332
Posterior Layer of the Fascia Profundis, Cervico-Cranial Region 332
Intermediate Layer of the Fascia Profundis, Cranio-Cervical Region 332
Middle Layer of the Fascia Profundis, Cranio-Cervical Region 332
Anterior Layer of the Fascia Profundis, Cranio-Cervical Region 333
Innervation 333
Fibres and Receptors 333
General Conclusion 336
References 339
The Spinal Canal 341
The Central Spinal Canal (Vertebral Foramen) 341
Limits (Fig. 1) Superior and Inferior 341
Peripherals (in the Horizontal Plane) 341
Diameter—Internal Surface 341
The Reserve Volume (RV) 343
The Cervical Spinal Canal 343
Thoracic Spinal Canal 344
Lumbar Spinal Canal 344
The Lateral Recess 346
The Intervertebral Foramen 347
Form and Orientation 347
The Cervical Intervertebral Foramen 348
The Lumbar Intervertebral Foramen 349
The Transverse Canal 350
The Spinal Canals and the Movements of the Column 350
Degenerative Pathology and the Effects on the Spinal Canals 352
Spinal Canal and Lateral Recess 353
The Intervertebral Foramen 353
References 358
The Spinal Cord 359
Description 360
Anatomofunctional Organization of the Neural Centers of the Gray Matter 362
The Central Formation Area 362
Dorsal Horns 368
The Ventral Horns 371
Anatomofunctional Organization of the White Matter 376
Somatosensory Ascending Pathways (Fig. 20) 376
Descending Pathways 381
The Pyramidal Tract or Corticospinal Tract (Fig. 22) 381
Extra Non-pyramidal Tracts 382
In Total 383
References 384
Spinal Nerves (Innervation of the Spine) 386
General and Nomenclature 386
Descriptive Anatomy of Spinal Nerves 386
Relations of the Nerve Roots 386
At the Lumbar Level [1–6] 386
1.1.1 Anomalies of the Lumbar Roots [16–18] (Fig. 7) 389
Innervation of the Spine 389
Innervation of the Ventral Territory [22–24] 390
Innervation of the Dorsal Territory [1, 21, 25, 26] 393
Applications 394
References 396
Anatomy of the Spinal Meninges 397
Introduction 397
Phyllogenesis 397
Ontogenesis 397
Descriptive and Topographical Anatomy of the Spinal Meninges in Adults 398
The Dura Mater 399
Morphology 399
The Fixation-Points of the Spinal Dura Mater 399
Vascularization 401
Arteries 401
Veins 401
Lymphatics 401
Innervation 401
The Relationships of the Dura Mater with the Leptomeninges and the Spinal Nerves 402
The Arachnoid Mater 402
The Pia Mater 405
Meningeal and Perineurial Cysts 407
The Epidural Space 408
The Subdural Space 409
Functional Anatomy 409
Mechanical Functions 409
The Spinal Meninges in the CSF Dynamic System 410
The CSF System in the Immune Defense of the CNS 411
The Meninges in the CNS Development and Injury 411
References 411
Intrinsic Innervation of the Spine 414
Intervertebral Disc and Vertebral Body (Figs. 1, 2, and 3) 414
Which Receptors? 414
Which Pathways to the Spinal Root? 414
Evolution 417
Clinical Anatomy 417
Neural Arch (Fig. 4) 417
Which Receptors? 417
Which Pathways to the Spinal Root? 417
Clinical Anatomy 418
Conclusion 418
References 418
Spinal Vascularization 420
Embryology [3, 4] 420
Spine 420
Spinal Cord 420
Blood Supply of the Spinal Structures 421
Prespinal Vessels 421
Thoracic Aorta (Figs. 2 and 3) 421
Abdominal Aorta (Fig. 4) 422
Blood Supply of the Vertebral Structures (Figs. 5 and 6) 424
The Vertebral Body [10, 11] 424
The Ventral Group 424
The Dorsal Group 425
The Costovertebral Joint 425
The Dorsal Arch 425
Intracanalicular System 425
Dorsal System 426
The Intervertebral Foramen [6] 426
Blood Supply of the Spinal Cord (Figs. 5, 7 and 8) 426
The Radiculomedullary Arteries 426
At the Cervical Level 427
At the Thoracolumbar Level 428
The Great Ventral Radiculomedullary Artery (The Artery of Adamkiewicz) 428
Other Variations 428
The Longitudinal Arterial Axis 428
Ventral Spinal Artery 428
Dorsal Spinal Arteries 429
Lateral Spinal Artery [13] 430
Intrinsic Spinal Cord Vascularization 430
Central Arteries 430
Peripheral Arteries 430
Anastomotic Arterial Pathways [14] 431
Anastomoses of the Afferent Arterial Supply 431
Superior or Cervicothoracic Area 431
Midthoracic Area 431
Thoracolumbar Area 431
Peri-Axial Anastomoses 431
Intra-Axial Anastomoses 431
Venous Drainage of the Spinal Structures (Figs. 12 and 13) 431
Intra-Vertebral Venous Network 431
Medullary Venous Network 431
Intradural Drainage 432
Extradural Plexuses [15, 16] 433
Extra-Vertebral Venous Network 434
Vertebral Veins 434
Perivertebral Venous Plexuses 434
Ventral External Plexuses (Longitudinal Prevertebral Vein) 434
Dorsal External Plexuses (Deep Cervical and Dorsal Intercostal Veins) 434
Basivertebral Veins 435
Communications Between the Vertebral Venous System and Systemic Veins 435
Longitudinal Prevertebral Vein and Azygos System 435
Inferior Vena Cava 435
Focus on the Filum Terminale [12] 435
References 436
Part IV: Functional Anatomy 437
Systemic Approach to the Functioning of the Spine 438
Introduction 438
Organization of a System 439
Qualitative Analysis of the Vertebral System (Fig. 1) 439
The Entries 439
Transducers (Receivers or Sensors) 440
Controls 440
Tissue-Based Control 440
Cellular Control 441
Neurological Checks 441
Outputs 441
Feedback 442
Quantitative Analysis of the Vertebral System 442
Partial Analysis 442
Analysis of Overall Functional Capacity 442
Performances 443
Fault Factors of the Vertebral System 444
Failures Related to the Vertebral Structure 444
Transducer Failures 445
Failures Related to Controls 445
Conclusion 445
References 445
Kinematics of the Spine 447
Methods for Measuring Spinal Mobility 449
In Vitro Measurements 449
In Vivo Measurements 449
Amplitude of Spinal Movements 449
Segmental Amplitudes and Motion Analysis 454
The Upper Cervical Spine (OC1C2) 454
The Lower (Sub-Axial) Cervical Spine 456
The Thoracic Spine 462
The Lumbar Spine 462
Evolution of Amplitudes with Age 462
The Movements of the Vertebral Column in Daily Life 464
References 474
Spinal Balance 475
The Choice of Words 475
Balance 475
Alignment 475
Equilibrium 475
Posture 475
Stability 475
From Alignment to Equilibrium 476
Importance of Spine Anatomy 476
The Pelvis 476
Thoraco-Lumbar Spine 476
The Cervical Spine 477
Spine and Central Nervous System: (CNS) and (PNS) 477
A Word from Neurosciences 477
Search for Harmony 478
A Look at the Future 479
References 479
Biomechanics and Spinal Modelling 480
Introduction 480
Geometric Modelling of the Spine 480
Geometric Modelling of the Skeleton from Biplane Imagery 480
Biomechanical Modelling of Spine 483
Biomechanical Modelling and Conceptual Analysis 484
Subject-Specific Modelling and Treatment Planning 486
Personalized Simulation to Estimate the Resistance of an Osteoporotic Vertebra 486
Personalized Simulation to Estimate the Effect of a Scoliosis Brace 487
Postural Alignment, Barycentremetry and Muscle Modelling 488
Conclusion 490
References 490
Anatomy Is a Living Language 493
Anatomy: Open Thought on Modernity 493
Embryology: The Essence (of Things) of Life 493
Growth: A Volumetric Revolution, a Morphological Emancipation 493
Growth Is Not Linear 493
The Interdependence of Growths Explains the Domino Effect 494
The Vilebrequin Effect Is Omnipresent 494
Puberty Idiopathic Scoliosis: Indomitable 494
COBB Angle: A Virtual Value 494
Balance: A Priority, an Ardent Obligation 494
After Growth the Spine Continues Its Destiny 494
The Time Has Come to Review the Hierarchies 494
The Muscles and Their Fascia Play an Essential Role 494
The Curvatures of the Column Promote Mobility, Elasticity, Resistance, and Balance 494
Scoliotic Disease Is a Life-Long Illness 495
The Surgeon Has a Physical Relationship with the Anatomy 495
Anatomy: A Regalian Discipline 495
Research: Positive Insubordination 495
Tomorrow: Another Day 495
Index 496