Lectures cervical and thoracic spine Flashcards
occiput-atlas articulation
- occiput is a convex surface
- atlas is a concave surface
- primary motion is “nodding” 15-20 deg
- side flexion about 10 deg
- no real rotation
Atlas C1
- no body or spinous process
- it develops into ondontoid process of C2
- transverse processes are large
atlas -axis articulation ROM
- C1-C2
- primary motion is rotation 50 deg
- flex / ext 10 deg
- side flex 5 deg
transverse cruciate ligament
-holds dens of the axis against the ant. arch of C1
alar ligament
-arise from either side of odontoid and attach to medial aspect of occiput
C3-c6 typical vertebrae
- standard body
- posterior arch
- transver process
- foramen
- spinous process
- width of body incr as it bears more weight
C7 transitional vertebra variation
- largest spinous process in C/S
- not bifid SP like the other above
- Prime attachment fro ligamanetum nuchae, traps, rhombus minor etc.
zygoapophyseal joint
- superior facets face upward, backward, and medially
- inferior facets face downward, forward and laterally
- angle in cervical 45 deg
Cloward’s areas
C3-4 above scap by level of clavicle
C4-5 medial border top of scapular triangle
C5-6 medial border bottom of scap triangle
C6-7 inf border of scap
intervertebral foramen
- transmits nerve roots to and from the spinal canal to extremities
- nerve roots usually pinched by disc of same level
- also contains dural root sleeve, lymphatic channels, small arteries and veins and recurrent meningeal nerve
cervical nerve roots
- more nerve roots than vertebral levels
- C1 nerve roots passes above C1 vertebrae
- thus each nerve root below this is named for the vertebrae above it
- C8 exits b/w C7- T1
nerve root vulnerability
- epineurium is poorly developed with less collagen and more fragile collagen
- perineurium, which acts as diffusion barrier is absent at nerve root level
- fasciculi do not branch , thus more fragil and less flexible
open pack of cervical spine
slight extension
close pack cervical spin
-full extension
capsular pattern of C/S
side flexion and rotation equally limited, extension
Cervical SPine ROM
flexion 440 deg
extension 75
sidebending 35-45
rotation 80-90
uncinated joints
- saddle shape
- limits side flexion if C/S
- uncis is on the superior part f cervical vertebrae
- joint seems to form as the annulus degenerates
- not really fully developed until about 18 yo
- effectively converts a planar joint to more of a concave and beveled surface
vertebral artery
- first branch of subclavian artery
- enters the foramen at C6
- torturous oath, transversing up to the occiput at C2
3 common sites of distortion
- skeletal muscles and fascial bands at or near C6 where artery first enters
- osteophytes around C4-5 and C5-6
- sliding motion of AA articulation
vertebral artery compromise
- rotation of head >50 deg may lead to contra kinking of vertebral artery
- VBI test to be done before quadrant
intervertebral disc
- no disc b/w O-C1 or C-2
- annulus fibrosus has proprioceptors and free nerve endings that are pain sensitive
- there is virtually no nucleus left after 45 years of age
- as disc decr in size, uncinated process grows
what biomechanics rule does
O-C1 follow
C2-T1
O-C1 - convex on concave rule
C2- T1 follows concave on convex rule
Canadian C Spine dangerous mechanisms
- fall from elevation >/= 3 feet/ 5 stairs
- axial load to head
- MVC high speed >100 km/hr, rollover, ejection
- motorized recreational vehicles
- bicycle struck or collision
- ** simple reared MVC excludes
cSpine rule not applicable if
- non-trauma case
- GCS <15
- unstable vital signs
- age <16
- acute paralysis
- known vertebral disease
- previous c-spine surgery
acute radiculopathies are associated with…
disc herniation
chronic radiculopathies are associated with …
spondylosis
contraindications to manual therapy
- cervical instability esp cranioverterbral region
- presence of cancer in C/S
- fracture
- sublaxation
- advanced neurologic signs
- surgical fusion
Thoracic vertebrae facet facing…
inferior facet face down , forward and slightly medially
-oriented about 60 deg from horizontal
Rule of 3’s
T1-3 same level as TP
T4-6 SP at a level 1/2 way in b/w its own TP and the TP of the vertebrae below
T7-9 is at the level of the TP of the vertebrae below it
T10 same as T9
T11 same as T6
T12 same as T3
intercostalbrachial nerve
- lateral cutaneous branch of the secondintercostal nerve
- supplies floor of axilla
- joins with medial branch brachial cutaneous n (medial side of arms to dital elbow)
critical zone
- T4-T9
- spinal canal is narrower here
- blood supply is reduced
- large herniated disc can cause central cord compression
- segmental stiffness may affect neurodynamics in spine and periphery
thoracic capsular pattern
-side flexion and rotation equally limited, then extension
in thoracic flexion which way does facet moves
- Facets glide up and forward
- this pushes the superior demifacet of the rib head
- concave tubercle of the rib glides superiorly on convex TP at costotransverse joint
in thoracic extension which way does facet move
- Facet glide down and back
- post rotation of the rib head at costovertebral joint
- inf glide of the rib at costotransverse joint
in thoracic right side bending which way does facet move
-right sidebending, right inferior facet of the superior vertebrae glides inferolaterally and the left glides superomedially
ROM of thoracic spine
flexion 20-45 deg extension 25-45 deg side flexion 20-40 deg rotation 35-50 deg costovertebral expansion 3-7.5 cm ***ankylosing spondylitis: <2.5cm of expansion at T4
T5 nerve root referral
pain around nipple
t7-t8 nerve root referral
pain in epigastric area
t10-t11 nerve root referral
pain in umbilical region
t12 nerve root referral
pain in groin
Causes of flat thorax
- impaired superior gliding of the facet joints
- reduced ant translation of the superior vertebral body on infer vertebral body
- restricted internal torsion of the rib joints
- segmental or multisegmental soft tissue restrictions
causes of side flexion restrictions
- inability of the facet in the ipsi side to glide forward and toward the contra side.
- soft tissue restriction on the ipsi side
- restricted ipsi lateral translation of the superior vertebrae in the horizontal plane
- unilateral rib dysfunction
- unilateral adverse neural tissue
extension restrictions of thoracic spine
- inability if the thoracic motion segment to rotate backward in the saggital plane
- more common in upper thoracic spine and cervicothoracic junction C7-T2
Fixed extension restriction caused by
Aging due to risk height degeneration
-alteration in shape of the vertebral body
Unilateral extension restriction
- Loss of extension, ipsi rotation and sidebending
- may be caused by facet joint restriction in inferior or lateral glide
- posterolateral disk protrusion on ipsi side
- space occupying lesion like disk or osteophyte
Round back
-decr pelvic inclination, generalized kyphosis
hump back
-localized, sharp kyphosis, usually normal pelvic inclination
flat back
-decr pelvic inclination, but no major kyphosis
Dowager’s Hump
-often in post-menopausal women, wedge fracturing of upper thoracic vertebrae
scoliosis
- one or more lateral curvatures of the lumbar or thoracic spine
- non-structural is correctable
- structural is typically fixed
- designated by the level of the apex of the curve
- direction of the scoliosis is designated by the side of convexity
- vertebrae tend to rotate toward the convexity of spine creating rib hump
non -structural causes of scoliosis
- poor posture
- nerve root irritation
- inflammation in the spine
- leg length
- hip contractures
TOS thoracic outlet syndrome
- usually changes in sensory before motor
- poorly localized pain in supraclavicular fossa
- ant shoulder frequently spreads to head/arm
- paresthesias in post arm/forearm/hand
- symptoms aggs by extreme shoulder girdle and head positions
- sleep is disturbed
- coldness and whiteness
T/S and Cancer
- most malignant spinal tumprs are secondary tumors
- T/S most common site of metastases
- key to ask about:
- history of cancer
- resting or night pain
- unexplained wt. loss
- failure of conservative therapy
- Note age of patient (over 50)
Pain of myocardial Origin
- frequently radiates:
- Over the left pectoral region
- left shoulder
- medial arm
- Jaw
Abdominal Pain Referral
- Transmitted through T6-12 disks
- watch out for Cholecystitis and peptic ulcer disease
- cholecystitis pain onset 1-2 hrs after a heavy meal
- -peptic ulcers may be time related to meals as well
T4 Syndrome
- symptom complex especially upper T-spine
- unknown cause
- Hand or hands always affected
- T4 actually means T2-7
- Glove like distribution of paresthesias
- Dull aching or pressure in or around head
- No changes in reflex or myotomes
T-Spine landmarks
- 2nd costocartilage articulates at sternal angle level with T4-5
- 7th costocartilage articulates at xiphoid level T9-10
- Nipple Line T4
Spine of scap T3
inferior angle T7-9
What should I clear with pain in thoracic spine
- Above T4- need to clear upper quarter including C/S
- Below T8- probably do a L/S eval with “seated thoracic rotation”
- T4-T8 celar C/S and go through mid-thoracic clearing as well as shoulder girdle
Cervical extension movement fault tests
- shoulder flexion : C/S anterior shear with extension
- supine head lift: translation
- Weak DNF’s
- prone head lift: translation lower C/S
- Quad rock back: C/S extension
treatments for a cervical extension movement fault
-unloading UE's capital flexion -DNF strengthening - QUad rock back with C/S control -shoulder flexion with C/S control - improve upper T/S extension flexibility
cervical flexion movement fault tests
- C/S flexion
- quadruped position
- B/L shoulder flexion
- Prone head lift: through post sheer
treatment for cervical flexion movement fault
- normalize scapular position
- normalize lordotic curve
- improve thoracic mobility
- encourage mild thoracic slumping
- stretch SCM/scalenes
- Prone and quad C/S rolling into flex/extensopn PICR
cervical rotation movement fault test
- cervical rotation : SB’s or extends
- U/L shoulder flexion: C/S rotation
- Supine head lift: translation , asymmetrical
- Prone head lift: translation with SB
- quad rock back: C/S extension/ rotation
treatment for cervical rotation movement fault
- normalize scapular position/muscle pulls
- C/S rotation in neutral flex-ext PICR training
- quadruped rockbacks with neutral C/S control
- B/L wall shoulder flexion with C/S control
- improve rotation control in different UE positions
thoracic flexion movement fault tests
- shoulder flexion
- quadruped rock back
- Prone head lift
- Pec and Lat length
treatment for thoracic flexion movement fault
- Prevention of T/S flexion is key in preventing other painful syndromes
- improve T/S extension
- improve pec and lat length
