The skin of the back is divided into six regions. The central vertebral region is the area of the skin overlying the vertebral column. The deltoid area lies over the shoulder joints. The scapular region encloses the scapula on both sides. The area of the skin beneath the scapula is called infra-scapular region. The area beneath the ribs and above the hip bone forms the lumbar region on both sides. The sacral region is the area of skin between the two hip bones.

Image: “Deep Muscles of the back (posterior view)” by Phil Schatz. License: CC BY 4.0

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Muscles of the Back

The major muscles of the back are divided into three groups:

  1. Extrinsic muscles:
  • Trapezius: elevates and depresses the scapula.
  • Latissimus dorsi: responsible for adduction, internal rotation and extension of the shoulder joint.
  • Rhomboid major and Rhomboid minor: keep the scapula pressed to the thoracic wall.
  • Levator Scapulae: elevates the scapula.
  1. Intermediate muscles:
  • Serratus posterior superior: elevates the rib cage.
  • Serratus posterior inferior: depresses the rib cage.
  1. Intrinsic muscles:
  • Spinotransversale muscles, which include splenius capitus and splenius cervicus. Both of these are responsible for extension of the neck.
  • Errector spinae muscles are arranged in three groups. Illiocostalis lies laterally, longissimus is in the middle and spinalis is the most medial one.
  • Transversospinales are arranged in a group of three. Semispinalis lie superficially, multifidus in between the two sets of muscles and rotares are located the deepest.


    Image: “Deep Muscles of the back (posterior view)” by Phil Schatz. License: CC BY 4.0


Image: “Deep Muscles of the back (posterior view)” by Phil Schatz. License: CC BY 4.0

Bony Prominences of the Back

Surface anatomy of the back

Image: “Surface anatomy of the back.” by Henry Vandyke Carter, Henry Gray (1918) in “Anatomy of the Human Body”, Gray’s Anatomy. License: Public Domain

The following bony prominences constitute the surface anatomy of the back:

  • The spinous process of the vertebra in thin lean individuals. The spinous process of cervical vertebra 7, is the most prominent.
  • The acromion and the spine of scapula.
  • Iliac crest and posterior superior iliac spine of the hip bones.
  • Rib cage in thin lean patients or in patients having a barrel chest.

Triangles of the Back

Triangle of auscultation

Triangle of auscultation

Image: “Posterior dissection of the Visible Human Male showing the triangle of auscultation. The borders and superficial contents of the triangle are highlighted and labeled. Triangle of auscultation in pink.” by Daniel G. Bates – Visible Human Male, dissection created using the VH Dissector and further edited. License: CC BY-SA 3.0

The triangle of auscultation is an area on the back, where the breathing sounds are best audible, due to relative thinning of musculature. The borders of the triangle are defined by the trapezius muscle superiorly and medially, the latissimus dorsi inferiorly and the medial border of scapula laterally.

Inferior lumbar triangle

The inferior lumbar triangle, also known as petit triangle, lies superficially. The latissimus dorsi forms the medial boundary, the external oblique forms the lateral boundary while the iliac crest forms the inferior boundary. The inferior lumbar triangle is site of herniation of the abdominal viscera.

Superior lumbar triangle

This is also known as Grynfeltt-Lesshaft triangle and lies deep to the inferior lumbar triangle. The superior lumbar triangle is found in cadavers in a consistent fashion. It is also a common site of herniation of abdominal viscera. Quadratus lumborum muscle lies medial to it, the internal oblique forms lateral margin and 12th rib lies superiorly.

Lumbar Puncture

Lumbar puncture (LP), is an invasive procedure during which cerebrospinal fluid (CSF) is aspirated from the spinal canal. The CSF can further be analyzed for diagnostic purposes. The CSF pressure can also be measured. LP is usually performed after a neurological examination  is completed. This procedure is most likely in the setting of concern for infection (such as meningitis) or idiopathic intracranial hypertension (pseudotumor cerebri). 

During the LP, the patient is asked to lie in left lateral position with knees and hips in flexed position. The intercristal line, which is the line joining the superior parts of the iliac crest, is located and marked. This marks the region between L4 and L5 lumbar vertebrae. The needle is advanced between the spinous processes of these two vertebrae and CSF is collected and submitted for analysis. If the opening pressure is measured, this is done prior to CSF collection, but requires some repositioning of the limbs for accurate measurement. LP can also be performed in the seated position. One of the common complications of LP is post-LP headache. Using a small, non-cutting needle will reduce this risk. While there is less data to suggest that positioning helps minimize post-LP headache, it is still common to ask the patient to remain in the supine position for a half an hour after completing the procedure.

Projection of Viscera onto the Back

It is important to know the surface anatomy of various organs and viscera and their projection onto the back. This is useful in various procedures as well as the clinical examination of various body systems.

  • Lungs and visceral pleura roughly lie at T10 while the parietal pleura at T12. This is helpful in thoracocentesis or pleural tap, during which excess fluid is drained from the pleural cavity for therapeutic and diagnostic purposes.

  • Kidneys are retro-peritoneal structures and therefore can be easily approached during surgical procedures.

  • The pain of aortic aneurysm and acute pancreatitis radiates to the back. Similarly, the pain of pancreatic cancer may be referred to the back.

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