Cervical Spine I Flashcards
Describe the vertebral artery anatomy
Arises from subclavian artery and passes upward on longus colli to enter C6 foramen up to C1 to 1st cervical nerve and veins piercing post OA membrane and then foramen magnum to join basilar artery
Percentages of vertebral vs carotid cerebral blood flow
Vertebral is 11% and carotid is 89%
Name the AO ligaments
Anterior and posterior Atlanto occipital membranes
Name the C2 with occiput ligaments
Tectorial membrane
Alar ligament
Apical ligament
Name the AA joint ligaments
Anterior and posterior atlantoaxial membrane
Transverse/cruciate ligament
Anterior Atlanto Occipital Membrane
Connects
Provides
Anterior foramen magnum to anterior arch C1
AP stability
What ligament is a continuation of the ALL ligament?
Anterior Atlanto Occipital membrane
Posterior Atlanto Occipital Membrane
Connects
Provides
Occiput to post ring of C1
Prevents anterior and vertical translation of C1/C2
Which ligament is analogous to posterior Atlanto occipital membrane in cervical spine?
Yellow ligament
Tectorial Membrane
Connects
Provides
C2 body to foramen magnum
Limits flx, ext, vertical translation
Alar Ligament
Connects
Provides
Dens obliquely to occipital condyles
Rotation
(L LIMITS C1 ROTATION OF HEAD TO R)
Which C2 with oxxiput ligament has no major significance?
Apical
Which cervical ligament is continuation of PLL
Tectorial membrane
Anterior Atlanto Axial Membrane
Connects
C1 to C2 anteriorly
Posterior Atlanto Axial Membrane
Connects
Post ring of atlas and axis
Which AA ligament is continuation/analogous to yellow lig?
Posterior Atlanto Axial membrane
When is true yellow ligament (lig flavum) present and why?
Not present until C2/C3 to allow UCS rotation. Compromises stability for mobility
Transverse ligament
Connects
Dens in tact with anterior arch C1
MOST IMPORTANT LIG IN UCS
Nuchal ligament
Connects
Function
Posterior occipit to C7
No major sig
ALL
Connects
Function
Entire length of spine
Little known
Name the suboccipital muscles
Recurs capitus post major/minor
Oblique capitus superior/inferior
The sub occipital muscles all produce what functions?
B/L extension and unilateral SB and rot of UCS
Rectus capitis posterior major connects?
C2 SP to inf nuchal line on occiput
Rectus capitis posterior minor connects?
C1 post tubercle to inferior nuchal line on occiput
Oblique capitis superior connects
C1 TP to lateral inferior nuchal line
Obliques capitus inferior connects
C2 SP to C1 TP
Name the lower cervical flexors
SCM
Longus Colli
Hyoids
Scalenes
Name the upper cervical flexors
Longus capitus
Rectus capitis anterior and lateralis
Longus colli
Connects
Function
Anterior arch atlas to T3 vertebral body
Deepest anterior cervical muscle, provides cervical flexion and important stabilization
Hyoids
Connect
Function
Hyoid bone to mandible and thorax
Neck flexion and stability, open mouth
Scalenes
Connects
Function
Anterior: C3-C6 TPs to 1st rib
Middle: C2-C7 TPs to 1st rib
Posterior: C4-C6 TPs to 2nd rib
Unilateral: IPS SB and Rotation
B/L: inspiration
Name the cervical extensors
Splenius capitis
Semispinalis capitis
Splenius capitis
Connects
Function
T1-T3 SPs and nuchal lig C5-C7 to superior nuchal line and mastoid
Ipsilateral rotation
Semispinalis capitis
Connects
Function
C4-C6 TPs and C7-T1 SPs to lat EOP
B/L extension
U/L contralateral SB
Levator
Connects
Function
C1-C4 TP to superior angle scap
Elevates and downwardly rotates scap
Platysma
Connects
Function
Most superficial anterior cervical muscle
Wide mouth opening
Cricoid
Connects
Function
Vertebral artery entered transverse foramen of C6 here
Total C spine flexion/extension
Flx: 45-50
Ext: 75-80
Total C spine SB/Rot
SB: 35-40
Rot: 65-75
C0-C1 flx/ext
Flx: 5
Ext: 10
C0/C1SB and rot
SB: 5
Rot: 0
C1-C2 flex/ext
Flx: 5
Ext: 10
C1-C2 SB and rot AROM
SB: 0
Rotation: 35-40
C2-C7 flx/ext
Flx: 35-40
Ext: 55-60
C2-C7 rot/SB AROM
Rotation: 30-35
SB: 30-35
Upper vs lower cervical spine arthros
Upper: SB and rot opp
Lower: SB and rot same
OA arthros flx/ext/SB
Flx: Convex occipital condyles glide posterior
Ext: convex occipital condyles glide anterior
SB to R: R C0 MIA, L C0 LPS with conjunct L rot
AA arthros flx, ext, rotation
Flx: vex C1 facets roll ant and glide post
Ext: vex C1 facets roll post and glide ant
R rot: C1 R facet glides post and C1 L facet glides anterior
Mid cervical spine arthros
Flx: glide up and forward
Ext: glide down and back
R SB: R down and back, L up and forward
R ROT: R down and back, L up and forward
L UCS rotation and alar ligament
L UCS rotation will tighten the R alar ligament, moving R occipital condyle left, producing R SB
Canadian C Spine Rules
Automatic radiograph
Automatic radiograph:
Age>65
Fall over 1 meter or 5 stairs
Axial load to head
MVA > 100km/hr
Bike collision
Paresthesias in extremities
Canadian C spine Rules 2nd tier
If no to automatic radiographs section:
Injury was rear end collision
Delayed onset neck pain
Absence of midline tenderness of c spine
Ambulatory at any time
Able to sit in ER
Canadian C spine rules last tier
Able to AROM rotate 45 each way
If no: radiograph
Cervical Spine Stenosis
- define
- associated with
Narrowing of spinal canal, central or lateral
Spondylosis
What is most common cause of cervical spinal disorders in those > 55 yrs old
Stenosis
Names the 3 kinds of cervical spine stenosis
Traumatic
Congenital
Degenerative
Degenerative cervical spine stenosis can be due to?
Osteophytes, lig flavum hypertrophy, DDD
Cervical spine flx opens canal by how much and ext closes canal by how much
Flx opens 31%
Ext closes 26%
Best PT rec for short term relief for cervical spine stenosis
Acupuncture and cervical collar
Best PT rec for cervical spine stenosis
Traction
Thoracic manipulation
Flx based protocol
Traction guidelines for cervical spine stenosis
15-20m at 16-24# in 24 degrees cervical flexion
Cervical myelopathy
- definition
- classified by
Cervical cord compression
Gait dysfunction
Cervical myelopathy sx
Unsteady gait
+ Hoffman’s / + babinksi
B/L or Q/L parasthesias
Hyper reflexia
B/B issues
Intrinsic muscle wasting of hands
Cervical myelopathy cluster
Gait deviations
+ Hoffman’s
+ inverted Supinator
+ babinski
Age > 45
3/5 = +30.9 LR
1/5 = -.18 LR
Whiplash
Do not test what
Tx
Can be either flexion or ext based, ext worse
Vertebral artery for first 4-6 weeks
Cervical collar 3 weeks or until capsular pattern reduces
Median recovery time for whiplash
31 days
Whiplash prognostic factors for full recovery
<35 yrs old
NDI < 32%
Whiplash prognostic factors for ongoing pain
Age > 35
NDI > 40%
Hyperalgesia sx and cold intolerance
Percentage of patients who do well in PT for whiplash
40% do well
40% mod well
20% no improvement
Cervical radiculopathy
Common nerve and age
C6/C7
40-50
Cluster to identify cervical radic
+ULTT
< 60 degrees towards painful side
+ spurlings
+ distraction
2/4 21%
3/4 65%
4/4 90%
PT tx for cervical radic
Mixed but usually involves
Cervical side glides
Cervical traction
Thoracic manipulation
Deep neck flx strengthening
Disc lesions in C spine
Sx
Limited flx, scapular/arm pain
Traction helps, posterolateral prolapse rare in C spine
Acute Torticollis causes
Disc derangement
Facet it dislocation
SCM spasms
Facet impingement c2/c3
Tx for acute toeticollis from disc derangement and facet impingement
Disc derangement: traction with ext
Impingement: mobs
4 categories for differential diagnoses
- Movement
- Neuro
- Compression/distraction
- Segmental tests/stress
When is it good to use sustained postures for testing?
When AROM, PROM, resistance not producing sx
Shoulder abduction test
Patient sitting or standing, have patient put arm on top of their head
+ test is reduction in sx for C5/C6 compression
Dizziness test
Seated, PROM to head rotation, then head stable and rotate trunk. If sx with both then possible vertebral A
If sx only with head rotation, possible inner ear
Cervical reflexes
C5: biceps
C6: brachioradialis
C7: triceps
Cervical cutaneous innervation
C1: vertex of head
C2: post auricular
C3: lateral neck
C4: upper trap
C5: lateral arm/deltoid
C6: post thumb
C7: post mid finger
C8: post pinky finger
T1: medial forearm
T2: axilla
Cervical myotomes
C1: head flx - Rectus capitis ant and lat
C2: head ext - Rectus capitis post
C3: neck SB: scaleni
C4: shld elevate: UT and levator
C5: shld abd: deltoid, Supra
C6: elbow flx, wrist ext: biceps, ECRL/B
C7: elbow ext, wrist flx: triceps, FCR
C8: thumb ext: EPL/EPB
T1: finger add/abd: interrosseous
C5/C6/C7/C8/T1 root syndrome pain referrals
C5 - scap, arm down to radial wrist/hand no fingers
C6 - to index finger and thumb
C7 - index/mid/ring finger, back of arm
C8 - 4th/5th fingers
T- - no scap or finger pain, medial arm and forearm
C8 diff diagnosis
TOS
PANCOST TUMOR
Craniovertebral scan
What order to screen
Test UCS first and then vertebral artery
Cervical cord compression/myelopathy cardinal sx
B/L or Q/L parasthesias
Hyper reflexia below lesion level (@ or above lesion level will be hypo)
+ clonus, babinski, Hoffman’s, inverted supinator
Arm/leg weak
B/L lack coordination
Shimizu reflex or scapulohumeral reflex
Apply caudal direction force to tip of spine of scap and acromion
+ is elevation of scap or abd humerus
+ UMN above C3
Most common C spine adverse event
Craniovertebral artery dissection (57%)
SAEs under 50 age usually due to
Trauma
Risk factors for arterial dysfunction
Diabetes
Hypertension
High cholesterol
Corticosteroid use
Migraines
Trauma
Cardiac disease
Vascular disease
Blood clotting disorders
Anticoagulants
Smoker
Recent infection
Immediately post partum
Absence of mechanical source for sx
Early presentation sx for vascular adverse event
Mid upper cervical pain
Pain around ear/jaw
Frontotemporoparietal head pain
Occipital headache
Pain “unlike any other” (main finding)
Besides HVLA, what else do you want to stay away from for vascular compromise?
Any end range techniques
Cranial nerve scan
1: olfactory: smell
2/3: optic/occulomotor: pen light on pupil to constrict
3/4/6: occulomotor, torchlear, abducens: follow H pattern
5: trigrminal: clench teeth for massater palpation
7: facial: smile, puff cheeks, raise eyebrows
8: acoustic: can follow commands
9/10: glossooharyngeal/vagus: stick out tongue and say ah tongue midline
11: spinal acc, resist shld shrug and rot head
12: hypoglossal: tongue stick out and side to side
