Posterior Abdominal Wall

The posterior abdominal wall is a complex musculoskeletal structure that houses the abdominal aorta, the inferior vena cava, as well as important retroperitoneal organs, like the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys, renal glands, pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas, and duodenum. This vital anatomical structure consists of the posterior abdominal muscles, their respective fascia, lumbar vertebrae, and the pelvic girdle. The structure is supported by 12th thoracic rib, lumbar vertebrae, and pelvic rim.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Introduction

Posterior abdominal wall

  • Complex musculoskeletal structure representing the posterior boundary of the abdominal cavity
  • Supports retroperitoneal organs and contains important neurovascular structures
  • Boundaries:
    • Anteriorly by: 
      • Anterolateral abdominal muscles
      • Retroperitoneal organs
      • Parietal peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum and Retroperitoneum
    • Posteriorly by: 
      • Lumbar vertebrae
      • Muscles
      • Fascia 
    • Superiorly by the 12th rib and diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm 
    • Inferiorly by the pelvic brim
Skeletal boundaries of the posterior abdominal wall

Skeletal boundaries of the posterior abdominal wall:
On the left, boundaries (marked by green): superior boundary: 12th ribs, inferior boundary: pelvic brim. The lumbar vertebrae represent the posterior boundary.

Image by Lecturio.

Structures

  • Fascia
  • Muscles
    • Diaphragm
    • Psoas major and minor
    • Iliacus muscle
    • Quadratus lumborum
  • Extraperitoneal fat
  • Parietal peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum and Retroperitoneum
  • Vasculature 
    • Abdominal aorta
    • Inferior vena cava 
  • Somatic innervation: subcostal nerve and lumbar plexus

Fascia and Related Structures of the Posterior Abdominal Wall

Thoracolumbar fascia

Large area of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue that is made up of 3 layers:

  • Posterior:
    • Extends from the 12th rib to the iliac crest
    • Laterally goes to the internal oblique and transversus abdominis muscles
    • Overlies the latissimus dorsi muscle
  • Middle:
    • Together with the anterior layer, encloses the quadratus lumborum muscle
    • Together with the posterior layer, encloses the deep muscles of the back Muscles of the back The back is composed of several muscles of varying sizes and functions, which are grouped into intrinsic (or primary) back muscles and extrinsic (or secondary) back muscles. The extrinsic muscles comprise the superficial and intermediate muscle groups, while the intrinsic muscles comprise the deep muscles. Muscles of the Back
  • Anterior:
    • Attached to the iliac crest, anterior part of the transverse processes of lumbar vertebrae, and 12th rib
    • Thickens on the superior aspect to form the lateral arcuate ligament
    • Laterally, continues with the aponeurosis of the transversus abdominis muscle

Psoas fascia

  • Covers the psoas major muscle 
  • Thickened superiorly, forming medial arcuate ligament
  • Medially adheres to the lumbar vertebrae and pelvic brim
  • Continues with part of the iliac fascia inferiorly and the thoracolumbar fascia laterally
Abdominal wall muscles and the thoracolumbar fascia

Abdominal wall muscles and the thoracolumbar fascia (cross section at L3 level):
ES: erector spinae
LD: latissimus dorsi
PM: psoas major
QL: quadratus lumborum

Image by Lecturio.

Lumbar triangles

Similarly to the anterior abdominal wall Anterior abdominal wall The anterior abdominal wall is anatomically delineated as a hexagonal area defined superiorly by the xiphoid process, laterally by the midaxillary lines, and inferiorly by the pubic symphysis. Anterior Abdominal Wall, herniation can occur in weakened areas in the posterior abdominal wall. These herniations occur in the Grynfeltt-Lesshaft triangle (inferior lumbar triangle) or Petit triangle (superior lumbar triangle).

  • Inferior lumbar (Petit) triangle:
    • Lies superficially 
    • Sometimes called the lumbar triangle
    • Bound by:
      • External oblique muscle anteriorly
      • Latissimus dorsi muscle posteriorly
      • Iliac crest inferiorly
  • Superior lumbar (Grynfeltt-Lesshaft) triangle: 
    • Deep; size varies per individual.
    • More commonly the site of herniation
    • Bound by:
      • Quadratus lumborum medially
      • Inferior oblique muscle laterally
      • 12th rib superiorly
      • Transversalis fascia as the floor of the triangle
      • External abdominal oblique as the roof of the triangle
Lumbar triangles

Lumbar triangles:
a: Superior lumbar triangle
b: Inferior lumbar triangle

Image: “Lumbar triangles” by Marc Rafols et al. License: CC BY 4.0

Muscles and Bones

Muscles

  • Diaphragm:
    • Forms superior border of the posterior abdominal region
    • Consists of 3 parts: 
      • Sternal 
      • Costal 
      • Lumbar
    • Contains 3 important apertures: 
      • Caval opening (T8)
      • Esophageal hiatus (T10)
      • Aortic hiatus (T12)
    • Origin: 
      • Xiphoid process
      • Ribs 7–12
      • Upper lumbar vertebrae
    • Insertion: the middle part of the central tendon
    • Functions: 
      • Major muscle of respiration, helping in inhalation (contraction) and expiration (relaxation)
      • Abdominal straining (increasing intraabdominal pressure)
      • Separates the abdominal cavity from the thoracic cavity 
    • Motor innervation: right and left phrenic nerves (originate from cervical spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: C3–C5)
    • Sensory innervation:
      • Phrenic nerve: for central part of diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
      • 6th–11th intercostal nerves for periphery of diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
  • Quadratus lumborum:
    • Posterior to the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys, lateral to psoas muscles
    • Origin: posterior border of the iliac crest
    • Insertion: L1–L4 vertebrae and inferior border of 12th rib
    • Functions: 
      • Laterally flexes the lumbar vertebrae
      • Stabilizes the 12th rib during respiration
    • Innervation: subcostal (T12) and lumbar (L1–L4) nerves
  • Psoas:
    • Major
      • Origin: T12–L4 vertebrae 
      • Insertion: lesser trochanter of femur
      • Function: hip flexion, lateral flexion of the trunk
      • Innervation: lumbar plexus (ventral rami of L1–L3)
    • Minor
      • Origin: T12 and L1 vertebrae
      • Insertion: attaches to the pectineal line on the superior pubic ramus
      • Function: weak flexor of the trunk
      • Innervation: ventral rami of L1–L3
  • Iliacus:
    • Origin: iliac fossa
    • Insertion: lesser trochanter of the femur 
    • Function: flexes thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh at the hip joint Hip joint The hip joint is a ball-and-socket joint formed by the head of the femur and the acetabulum of the pelvis. The hip joint is the most stable joint in the body and is supported by a very strong capsule and several ligaments, allowing the joint to sustain forces that can be multiple times the total body weight. Hip Joint 
    • Innervation: ventral rami of L2–L4 (femoral nerve)

Support of the posterior abdominal wall

  • 12th thoracic rib
  • Vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column:
    • 12th thoracic vertebrae
    • Lumbar vertebrae (L1–L5)
    • Sacrum
  • Ilium:
    • Largest of the 3 bones that merge to form the hip bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones
    • The iliac crest (the curved superior border of the ilium) forms the inferior boundary of the posterior abdominal wall.
Superior view of the pelvic girdle, 4 primary joints of the pelvis

Superior view of the pelvic girdle and the 4 primary joints of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis

Image by Lecturio.

Vasculature and Lymphatic Drainage

Abdominal aorta

  • Relation:
    • Continuation of the thoracic aorta
    • Enters the abdomen through the aortic hiatus in the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm at the level of the T12 vertebra
    • Travels down the posterior wall of the abdomen (anterior to the vertebral column)
    • Divides into the common iliac arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries at L4
  • Different arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries branch out from the anterior, lateral, and posterior parts of the abdominal aorta:
    • Unpaired branches:
      • Celiac trunk
      • Superior mesenteric artery
      • Inferior mesenteric artery
      • Median sacral artery
    • Paired branches:
      • Middle adrenal/suprarenal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
      • Renal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
      • Gonadal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
      • Inferior phrenic arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
      • Lumbar arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
      • Common iliac arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries (aorta bifurcates)
Table: Branches of the abdominal aorta
Location in the abdominal aorta Branches ( arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries) of the abdominal aorta Level Paired or unpaired
Anterior Celiac trunk T12 Unpaired
Superior mesenteric L1
Inferior mesenteric L3
Lateral Middle suprarenal/adrenal L1 Paired
Renal L1 to L2
Gonadal (testicular or ovarian) L2
Dorsal Inferior phrenic T12 Paired
Lumbar (4) L1, L2, L3, L4
Median sacral L4 (above the bifurcation) Unpaired
Terminal Common iliac L4 Paired
Vascular structures in the posterior abdominal wall

Vascular structures in the posterior abdominal wall (in relation to the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys and skeletal frame)

Image by Lecturio.

Inferior vena cava

  • Relations:
    • Formed at the L5 level by the 2 common iliac veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Ascends to the right of the aorta
    • Goes through the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm at the T8 level
  • Tributaries:
    • Hepatic veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Inferior phrenic veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Right suprarenal vein
    • Right gonadal vein
    • Renal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: The left gonadal, inferior phrenic and suprarenal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins enter the left renal vein, which then drains into the inferior vena cava.
    • Lumbar veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins

Lymphatic drainage

  • Most lymph nodes are located beside the vascular channels running along the posterior abdominal wall.
  • Lymphatic drainage:
    • GI tract: superior and inferior mesenteric lymph nodes
    • Adrenal glands Adrenal Glands The adrenal glands are a pair of retroperitoneal endocrine glands located above the kidneys. The outer parenchyma is called the adrenal cortex and has 3 distinct zones, each with its own secretory products. Beneath the cortex lies the adrenal medulla, which secretes catecholamines involved in the fight-or-flight response. Adrenal Glands and retroperitoneum: lumbar or para-aortic lymph nodes
    • Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: iliac and lumbar lymph nodes
    • Gonads/reproductive tract: lumbar, iliac inguinal lymph nodes
  • All drain the abdominal viscera into the cisterna chyli through the right and left lumbar and intestinal trunks.

Innervation

Somatic innervation comes from the ventral rami of the subcostal and lumbar spinal nerves. 

  • Subcostal nerve:
    • From the ventral ramus of T12
    • Motor supply to the abdominal wall muscles (external oblique, internal oblique, transverse abdominis, and rectus abdominis)
    • Sensory innervation to the T12 dermatome (anterolateral region)
  • Lumbar plexus:
    • Iliohypogastric nerve:
      • Origin: ventral rami of L1 spinal nerves
      • Motor innervation: supplies the internal oblique and transversus abdominis muscles
      • Sensory innervation: hypogastric region
    • Ilioinguinal nerve:
      • Origin: ventral rami of L1
      • Motor innervation: internal oblique and transversus abdominis muscles along with the iliohypogastric nerve
      • Sensory innervation: superomedial aspect of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh and anterior surface of the external genitalia
    • Genitofemoral nerve:
      • Origin: ventral rami of L1–L2 spinal nerves 
      • Genital branch: the cremaster muscle (male), skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of mons pubis and labia majora (female)
      • Femoral branch: sensory innervation of the femoral triangle
      •  Both sensory and motor parts of the cremasteric reflex
    • Femoral nerve:
      • Origin: L2–L4 spinal nerves
      • Motor innervation: pectineus, sartorius, rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius
      • Sensory innervation: gives rise to the medial and intermediate cutaneous nerves of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh, supplying the anterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh and medial leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg
      • Joints: innervates hip and knee joints
    • Lateral femoral cutaneous nerve:
      • Lateral cutaneous nerve of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
      • Origin: L2–L3 spinal nerves
      • Sensory innervation: cutaneous sensation from the lateral part of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
      • No motor function
    • Obturator nerve:
      • Origin: L2–L4 spinal nerves
      • Motor innervation: medial thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh compartment (hip adductors)
      • Sensory innervation: medial aspect of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
    • Accessory obturator nerve: present in about 30% of cases (comes from L3–L4 spinal nerves)
Lumbosacral plexus

Lumbosacral plexus:
Innervation to the posterior abdominal wall comes from the ventral rami of the subcostal and lumbar spinal nerves.

Image by Lecturio.

Clinical Relevance

  • Hiccups: involuntary, spasmodic contractions of the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm, leading to quick inhalations that are interrupted by the involuntary closure of the glottis. Hiccups can result from irritation of nerve endings or of medullary centers in the brain stem Brain Stem The brain stem is a stalk-like structure that connects the cerebrum with the spinal cord and consists of the midbrain, pons, and medulla oblongata. It also plays a critical role in the control of cardiovascular and respiratory function, consciousness, and the sleep-wake cycle. Brain Stem (which control respiration). Among the causes are indigestion, diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm irritation, alcoholism, cerebral lesions, and thoracic and abdominal lesions, all of which disturb the phrenic nerves.
  • Congenital diaphragmatic hernias Congenital diaphragmatic hernias Congenital diaphragmatic hernias are embryologically derived defects in the diaphragm through which abdominal structures can pass into the chest cavity. The presence of intestines and intra-abdominal organs in the chest interferes with embryonic development of the lungs, which is the major cause of pathology postnatally. Congenital Diaphragmatic Hernias: embryologically derived defects in the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm through which abdominal structures can pass into the chest cavity. Prenatal diagnosis is commonly made by ultrasonography during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care followed by confirmation on chest x-ray after birth. Immediate respiratory resuscitation at birth with endotracheal intubation and mechanical ventilation are required. Surgical repair is the only curative option. Prognosis varies, but children with diaphragmatic hernias usually suffer from lifelong pulmonary complications. 
  • Psoas sign: abdominal exam finding in acute appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis. Finding is RLQ pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with passive right hip extension (characteristic of retrocecal appendix, where the inflamed appendix lies against the right psoas muscle).
  • Psoas abscess: purulent collection in the iliopsoas muscle compartment. The condition can be secondary to spread from adjacent structures or by hematogenous spread from a distant site. Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus is the most common bacterium causing this infection. Tuberculosis Tuberculosis Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis-related abscesses  are seen in regions where Mycobacterium Mycobacterium Mycobacterium is a genus of the family Mycobacteriaceae in the phylum Actinobacteria. Mycobacteria comprise more than 150 species of facultative intracellular bacilli that are mostly obligate aerobes. Mycobacteria are responsible for multiple human infections including serious diseases, such as tuberculosis (M. tuberculosis), leprosy (M. leprae), and M. avium complex infections. Mycobacterium tuberculosis is endemic. Common signs and symptoms include back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, and abdominal and flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. Diagnosis is via CT scan, along with cultures of blood and abscess material. Management includes drainage and use of appropriate antibiotics.
  • Pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess: infection affecting the renal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis and the renal parenchyma. This condition arises mostly from a bladder infection ascending to the upper urinary tract. Typical symptoms are flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, and nausea with vomiting. The kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys can be examined through the costovertebral angle (formed by the 12th rib and vertebral column) of the posterior abdominal wall. The diagnosis is established via clinical presentation and laboratory findings (in blood and urine). Imaging studies are performed if severe illness is noted or if there is no response to initial treatment (antibiotics).

References

  1. Drake, R., Vogl, A.W.,  Mitchell, A. (2020) Regional anatomy, posterior abdominal region. Chapter 4 of Gray’s Anatomy for Students, 4th ed. Churchill Livingstone/Elsevier, pp. 365–373.
  2. Moore, K. L., Dalley, A. F., Agur, A. M. R. (2014). Abdomen. Chapter 2 of Clinically Oriented Anatomy, 7th ed. Lippincott Williams & Wilkins, pp. 309–321.
  3. Morton D.A., Foreman K., Albertine, K.H. (Eds.) (2019). Posterior abdominal wall. In: The Big Picture: Gross Anatomy, 2nd ed. McGraw-Hill. Retrieved from https://accessmedicine.mhmedical.com/content.aspx?bookid=2478&sectionid=202020626
  4. Nunn, J.F., Khan, Y.S. (2020). Anatomy, abdomen and pelvis, posterior abdominal wall nerves. StatPearls. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK557605/

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