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cervical > part 3 > Flashcards

part 3 Flashcards

1
Q

How are the nerve rami formed starting from the rootlets?

A
  1. Many rootlets converge to form the ventral and dorsal roots
  2. nerve root combine to form the spinal nerve
  3. spinal nerve immediately bifurcates to create the dorsal and ventral rami
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2
Q

Where are the cell bodies of the ventral and dorsal roots located?

A
  1. Dorsal root cell bodies are the in the dorsal root ganglion
  2. Ventral root cell bodies are in the the spinal cord
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3
Q

What is the spinal nerve?

A
  1. combine nerve of the dorsal and ventral roots

2. they combine once they pierce the dural sleeve

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4
Q

Where is the dorsal root ganglion located?

A
  1. vertebral canal or
  2. intervertebal formen or
  3. outside the formen (most likely in the lower cervical spine)
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5
Q

How are the rootlets and nerve roots oriented in the cervical spine?

A
  1. rootlets course laterally and downward with increasing obliquity as your travel down the spine
  2. C1 and C2 nerve roots are almost horizontal as they exit with limit obliquity as your progress down the cervical spine
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6
Q

How does the size of the nerve roots vary in the cervical spine?

A
  1. Upper four cervical nerve roots are smaller than the lower four
  2. below C1 and C2 the dorsal roots are 3x thicker than the ventral roots
  3. C1 dorsal root is absent in 8% of the population
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7
Q

What is a cervical disc hernation most likely to effect?

A
  1. spinal cord

2. ventral root

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8
Q

Why are cervical disc herniations less likely to occur?

A
  1. core formation that coincides with the UV formation
  2. UV joints
  3. wide PLL
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9
Q

What is the basic function of the autonomic nervous system?

A

regulate the internal environment of the body through innervation of smooth muscle cardiac muscle and glands

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10
Q

What are some of the functions of the sympathetic nervous system?

A
  1. constricting blood vessels
  2. increasing sweat output
  3. increasing blood pressure
  4. dilating bronchials
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11
Q

How are the neurotransmitters vary in the ANS?

A
  1. Sympathetic post ganglionic fibers use noradrenalin (ie norepinephrine)
  2. parasympathetic post gaonlion fibers use acetylcholine
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12
Q

What ANS branch has the longer lasting effect and why?

A
  1. sympathetic branch
  2. the preganglionic to postganlionic fiber ratio for the SNS is 1:10 compared to PNS 1:3 ratio
  3. The removal of the SNS neurotransmitter (norepinephrine,NE) is much slower because it is reabsorbed instead of broken down (acetylcholinesterase breaks down ACH)
  4. the slow removal of NE results in systemic circulation and widespread effect
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13
Q

What is the pathway of the SNS in the cervical spine?

A
  1. pregonlionic fibers travel up from the thoracic spine (T2-T6)
  2. the sympathetic trunk is formed with its three ganglions
  3. the ganglions and trunk lie in the carotid sheath
  4. from the gangion the nerves proceed to their target organs
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14
Q

Where is the superior ganglion located?

A

in the carotid sheath at the level of the second or third vertebrae

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15
Q

What structures does the superior ganglion serve?

A
  1. ninth and twelth cranial nerves
  2. cervical plexus
  3. plexus of internal carotid, phyrengeal and cardiac
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16
Q

where is the middle SNS ganglion located and what does it serve?

A
  1. located about C6
  2. C5 to carry fibers to carotid plexus and arteries of the head and neck
  3. C6 to carry fibers to subclavian artery and brachial plexus
  4. vertebral artery
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17
Q

Where is the inferior SNS ganglion located and what does it serve?

A
  1. located at the lateral border of longus colli at bout C7 and first rib
  2. Supplies C7-T1, cardiac plexus, subclavian and axillary artery and occationally the vagus nerve
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18
Q

Describe the clinic importance of the sympathetics of the vertebral artery?

A
  1. The fibers come off the middle sympathetic ganglion
  2. as the vertebral artery ascends it give off the SNS fibers to join the sinovertebral nerve to reenter the vertebral foramen
  3. it then innervates posterior dura, PLL and posterior disc
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19
Q

What are some clinic symptoms of cervical sympathetic involvement?

A
  1. vertigo
  2. vision changes
  3. tinnitus and deafness
  4. pharyngeal and larynegeal paresthesia
  5. paresthesia of arm and shoulder
  6. disturbances of heat and cold sensation
  7. tremor
  8. tachycardia
  9. increases in rate and depth of respiration
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20
Q

What are the steps in upper cervical flexion

A
  1. Occiput glides backward on the concave atlas
  2. the anterior aspect of lateral masses are compressed pushing atlas forward
  3. the atlas moves forward 2-3 mm until transverse ligament hits the dens
  4. atlas tilts forward around its axis about 17 degrees
  5. anterior arch drops down 2-4 mm and the posterior rises
  6. tilting increases the tension through the posterior structures
  7. tension pulls C2 up and over C3
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21
Q

What are the steps in upper cervical extension?

A
  1. occiput glides forward on the concave atlas
  2. pressure on the posterior aspect of the lateral masses pushes the atlas backward 2-3 mm
  3. the progress of the atlas is stopped by the dens
  4. the atlas the rotations 12 degress around its axis
  5. anterior arch then elevats 2-4 mm and increase tension of anterior structures
  6. tension of anterior structures pulls C2 down and back over C3
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22
Q

What are the steps in upper cervical RIGHT lateral flexion?

A
  1. Occiput glides to the left on the atlas compressing right lateral mass
  2. pressure on right lateral mass pushes axis to the right 2-3 mm into the dens
  3. Because the atlas and the axis do not side bend the right axis is pushed down and back on C3 for 5 degrees
  4. to keep the face forward the occiput and atlas rotation left
  5. while the atlas is pushed right the left lateral mass cause the left occiput to rise
  6. elevation of the left occiput causes increased tension in the left alar ligament
  7. tensioning of the alar compresses the AA joint causing further right rotation of the axis
  8. right rotation of axis requires left rotation of atlas and occiput to keep the face forward
  9. total side bend is about 9 degrees
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23
Q

What are the steps in upper cervical RIGHT rotation

A

1.Right rotation of occiput about 1 degree pulls the atlas into right rotation
2.left lateral mass of atlas is pulled into the dens
right rotation of occiput increases alar tension and compress of AA joint
3.compression of AA joint forces axis into left rotation of 2-3 degrees
4.occiput and axis rotate about 40 degrees before the left alar pull the axis into right rotation
5.axis rotates10 degrees and side bends on C3
atlas and occiput then rotate an addition 3 degrees
6.tension of the alar during rotations also causes a left side bend of the occiput
7.left side bend of the occiput pushes the atlas to the left
8.left glide of atlas causes right lateral mass to further left side bend occiput

24
Q

When evaluating the cervical spine neurology what structures must you differentiate?

A
  1. nerve roots
  2. root pouches
  3. cutaneous nerves
  4. myotomes
  5. dermatomes
  6. DTR
  7. brachial plexus stretch
  8. scalenes anticus
  9. clavicular depression or first rib elevation
  10. pectoralis minor or scapular retraction
  11. forminal compression
  12. vertebral artery
25
Q

Why are nerve roots subject to injury?

A
  1. lack of perineural tissue
  2. lack of epineural tissue
  3. poor mobility
26
Q

How does a lack of perineural and epineural tissue increase nerve root risk of injury?

A
  1. Perineural protects against stretch

2. Epineural protects against compression

27
Q

Why does the nerve root have poor mobility?

A

it securely bound by 1- nerve sheath, 2- reflection of the prevertebral fascia 3- slips of the musculotendinous attachments to the transverse process

28
Q

How does the root pouch effect nerve root mobility?

A

a. the funnel shaped extension of the the root pouch allow the roots to stretch with flexion
b. the root can become fibrotic in presence of degenerative changes leading to decreased mobility
c. often they run a sharp angles to increase mobility

29
Q

What happens to a nerve root when it is compressed?

A
  1. increased connective tissue around the schwann cell
  2. axonal and myelin degeneration
  3. proliferation of schwann cells
  4. pressure blockade from the build up of inflammatory byproducts
  5. large extracellular space make it subject to edema build up
30
Q

What is the upper extremity equivalent of the the straight leg raise and what does it mean?

A
  1. Upper limb tension testing

2. it means the a component of the brachial plexus is irritable to stretch

31
Q

What is Adson’s test?

A
  1. a test for scalenus anticus
  2. decrease the triangular space by contracting the muscle and repositioning the head
  3. before repositioning and contracting monitor the radial pulse
  4. reposition into rotation towards
  5. contract by having them take a deep breath and hold it
32
Q

What is the pathway of the subclavian artery?

A
  1. ascends from the thorax off of the the brachiocephalic artery on the right and aortic arch on the left
  2. travels up and over the 1st rib
  3. passes under the coracoid process and pec minor
  4. anterior to the GH joint
  5. continues down the arm as the brachial artery
33
Q

How can you differentiate between a nerve and a vascular response to testing?

A
  1. The distribution of signs and symptoms is the key
  2. a nerve will have segmental distribution with hypo or hyper sensitivity in specific cutaneous regions
  3. vascular will have nonspecific areas such as the entire hand
34
Q

What are some possible contribution to an elevated first rib?

A
  1. high costal breather
  2. scoleosis
  3. stuck first rib after a forceful inspiration
35
Q

What are some possible causes of a depressed clavicle?

A
  1. fracture
  2. bra straps
  3. poor posture- kyphosis causing the clavicle to fall down on the first rib
  4. SC positional fault or meniscus entrapment
36
Q

How would you test for a depressed clavicle?

A
  1. let the patients arm hand down towards the floor
  2. make a long neck
  3. take a deep breath in
  4. monitor the pulse before and after
37
Q

How would you mobilize the first rib?

A
  1. lock the cervical spine by rotating towards
  2. slack in the scalene by side bending towards
  3. web space mobilization through the rib
38
Q

How would you test for pec minor compression of the subclavian artery or brachial plexus?

A
  1. Passively stretch the shoulder girdle back

2. have the patient maximally exhale and hold

39
Q

How and why would you assess respiratory function in cervical patients?

A
  1. Phrenic nerve has branches from C3-C5

2. Supine assessment with one hand on the chest and one on the abdomen

40
Q

Since articular cartilage is aneural what are the possible sources of pain?

A
  1. bone on bone
  2. irritated ligament
  3. irritated vascular structure
  4. irritated scar tissue
41
Q

What tissues can causes radicular symptoms?

A

Any tissue that is provoked has the potential to cause radicular symptoms since the brains reference is only segmental

42
Q

How can you differentiate between a provoked segmental structure and a true nerve compression?

A

The nerve will present with a “shock like” sensation when it is hit or compressed in the foramen

43
Q

What are some reasons a distraction of a spinal segment cause pain?

A
  1. stretching of ALL
  2. anterior capsule
  3. scar tissue
  4. dry disc fragment
44
Q

What other test must you perform to confirm forminal stenosis when you find that nerve root compression increases symptoms

A

increases or decreases in:

  1. cutaneous innervations
  2. DTR
  3. myotomes
  4. dermatomes
45
Q

How does upper cervical rotation effect the vertebral artery

A

Right rotation crimps the left and stretches the right

46
Q

Why is there controversy over performing the vertebral artery test?

A
  1. Some say you shouldn’t perform it because the test is dangerous itself
  2. Some say of done gently it may find a condition
47
Q

What is thoracic outlet syndrome?

A

collection of symptoms and physical signs related to the obstruction of the brachial plexus and/or subclavian artery/vein

48
Q

How has the TOS diagnosis changed over the years?

A

1.it is found in records as far back as 1740
the cervical rib was describe as a cause of the 2.symptoms as far back as 1860
3.1905 the anterior scalenes was indicated
4.1920 ligaments from the cervical rib were indicated
5.1929 the rest of the scalenes were indicated due a fibrous infusion
6.early 40s the region of the first rib and clavicle was indicated
7.mid 40s the pectoralsis minor was indicated

49
Q

What are the three major categories of TOS causes

A
  1. compression of the structures of the TOS
  2. intermittent interruption of blood flow
  3. sympathetic involvement
50
Q

What is the posterior triangle of the neck?

A
  1. apex- SCM and trap
  2. anterior- SCM
  3. Post- trap
  4. base clavicle
51
Q

According to Liveson p 238 what nerve has a superficial path through the posterior cervical triangle and why is this significant?

A
  1. spinal accessary
  2. it is also intimately associated with aerolar tissue and lymph nodes and is at high risk for injury with cervical lymph biopsy
52
Q

Describe the path of the brachial plexus out the the axilla

A
  1. passes between the anterior and middle scalenes
  2. passes beneath supraclavicular nerve, nerve to subclavius and inferior belly of omohyoid
  3. travels above the subclavian artery
  4. passes below the clavicle
  5. passess between the first digitation of serratus anterior and subscapularis
  6. as it enters the axilla the lateral and posterior cords are lateral the axillary artery (the continuation of the the subclavian artery) while the medial cord is behind the artery
  7. Ultimately the nerves surround the artery
53
Q

What are the sympathetic contributions to the brachial plexus?

A

C5 and C6- receive contributions from the cervical sympathetic chain
C7 and C8- cervicothoracic ganglion
T1- cervicothoracic ganglion

54
Q

What rami make up the phrenic nerve?

A

ventral C3-5

55
Q

Describe the pathway of the phrenic nerve?

A
  1. C3-C5 branch off the cervical plexus
  2. emerges lateral border of anterior scalenes
  3. descends down the middle scalene under the prevertebral fascia
  4. travels behind SCM, inerior omohyoid, internal jugular, transverse cervical artery, suprascapular artery
  5. anterior the the subclavian vein
  6. entering the thoracic cavity it passes in front of the internal thoracic artery
  7. descends on the anterior pulmonary hilum
56
Q

Where does the phrenic nerve get its sympathetic fibers?

A

cervical sympathetic ganglion

cervical (6 decks)

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