TMJ, Cervical, Thoracic Flashcards
Atlas
C1
Axis
C2
What are Superior/Sub-occipital Segments composed of?
Composed of two segments: Atlas and Axis
Connected to each other and occiput
They have an intimate relationship with the cranium
3 axes and 3 degrees of freedom
What number of axes and degrees of freedom in superior/sub-occipital segments?
C1-C2
3 axes and 3 degrees of freedom
DF at C0-C1
3DF at C0-C1
can flex, extend, sidebend, rotate a little bit
The facet joints that are on the occiput: Which are they?
the facets on the C1 vertebrae, and facets that comprise the AO joint: it is referred to as C0-C1 which is occiput to atlas and is also called AO
Superior facet of C1: concave or convex?
concave
–>Under the occiput can see the facet joints as they sit on the atlas –concave superior facet of C1
What part of upper cervical spine is capable of sidebending?
Sidebending only at C0-C1 and C2-C3: if sidebending at C1-C2 it means dens fracture—it cannot sidebend
Which upper cervical SP is large and bulbous?
C2
Order the cervical, thoracic and lumbar in order of most to least mobile:
Cervical (most mobile)–>
Lumbar–>
Thoracic (least mobile)
Why is it important to have stability at AA and AO?
To support the head and protect the SC and vertebral arteries
- -Tissues and muscles provide stability
- -Neck is different biomechanics than lumbar spine to be both stable and flexible
- -Some conditions ie downs and RA have instability in the upper cervical spine
- -Due to high mobility, do see arthritic changes in the cervical spine
Atlas
- what shape?
- what lateral masses?
- what is the small articular facet on?
- what do the TPs have for the vertebral arteries?
- Ring shaped, transverse diameter > AP diameter: Has a wide transverse diameter: wide transverse processes
- Two lateral masses: biconcave superior articular surface
- Small articular facet on anterior arch for odontoid
- TPs have foramen transversarium for vertebral arteries
Atlas: Ring shaped, transverse diameter > AP diameter
1, what kind of transverse diameter
- how to palpate it
- what kind of end is the TP
- Has a wide transverse diameter: wide transverse processes
- Find your earlobe, find the angle of mandible under earlobe and infront of mastoid process, drop into the divot and feel the TP of C1 (wont feel if in side-bending because goes under mastoid) it is sensitive area, and can feel it move when sidebending on the contralateral side to where youa re sidebending—it is anterior inferior and deep to the mastoid process
As finger is in the space as go back should abut the mastoid process, and as come anterior hit angle of mandible, and it is underneath the earlobe
- TP come to a slender tapered end
Atlas: 2 lateral masses-biconcave superior articular surface
from an anterior posterior medial lateral prospective
C1 holds C0:
C1 biconcave superior facets of C1 holding convex C0 occipital condyle
Atlas: Small articular facet on anterior arch for odontoid
The posterior part of the anterior ring has a facet joint, there is a concavity which articulates with the convexity of the anterior odontoid process
This is another AO joint:
ATLANTO-ODONTOID JOINT = (in AA complex) Concave facet on posterior of anterior ring that articulates with anterior odontoid
(atlanto-axial joint: C1-C2: between atlas and axis which is comprised of three joints = 2 facets + the atlanto-odontoid joint
What are the three joints at the AA JOINT AA complex ?
atlanto-axial joint: between atlas and axis which is comprised of three joints
2 facet Joints between C1 and C2 + the atlanto-odontoid joint
Name the two AO joints:
atlanto-odontoid joint : This is an AO joint in the AA complex
Atlanto occipital joint
Why are the TP of the cervical spine unique?
TP of cervical spine are unique and have the FORAMEN for the VERTEBRAL ARTERY which starts at C1 and it is a big foramen as it comes down through the cranium into the initial entrance to the neck—large space to allow for the artery to come through
Atlas: palpating the anterior tubercle?
Note: we cannot palpate the anterior tubercle as it is behind the trachea
Anterior tubercle we can palpate if all membranes are relaxed so cannot do in sit, need to do in relaxed in supine to feel the posterior arch (= posterior aspect of the ring) there is a tubercle (called a tubercle and not a spinous process because it does not protrude the way an SP does but it is palpable)
Which vertebrae does not have a vertebral body?
C1
The body of C1 is what has become the odontoid process of C2 is what is believed to have happened in evolution
There is a large foramen for the spinal cord as it exits through the foramen magnum
What is in the groove on the posterior arch of the atlas?
There is a groove on the posterior arch where vertebral artery comes down as it exits the brain and starts to come down through the transverse foramen in the transverse process
AXIS:
Odontoid
Spinous Process
Transverse Process
Odontoid central pivot for AA
–It is there specifically for rotation
Spinous process has 2 tubercles
- -There is a large SP and it is bifurcated (unique to cervical spine)
- -The bifurcation is usually palpable
TP has foramen for vertebral artery
Why is axis easy to palpate?
There is a long anterior-posterior dimension with this big SP that is easy to palpate, and is used as a landmark to count down from, it is a big vertebrae and is very unique
What is significance of the alar ligament?
Alar ligament important for alignment C1-C2, determining if odontoid fracture, open mouth xray looking at C1-C2 alignment and whether odontoid process is dead center
Vertebrae with spinous process that is bifurcated?
Spinous process has 2 tubercles
- -There is a large SP and it is bifurcated (unique to cervical spine)
- -The bifurcation is usually palpable
Does Axis TP have foramen for vertebral artery ?
TP has foramen for vertebral artery
Typical Cervical Vertebrae C3-C6
- is VB wider /high?
- Vertebral body is wider than high
Typical Cervical Vertebrae C3-C6:
why is superior lateral surface of the body raised?
Superior lateral surface of body raised for ucinate process
–Uncoverterbal joints, joints of luschka
–Uncinate process unique to cervical spine
Typical Cervical Vertebrae C3-C6:
What has the greatest degree of flexion/extension?
Greatest degree of flexion and extension at C5-C6
Where is the axis of movement in the cervical spine?
In the cervical spine fair degree of movement, axis of movement at C5-C6
Where does most movement occur in the cervical spine?
In the cervical spine fair degree of movement, axis of movement at C5-C6
Why most quadrapersis/tertra at C5-C6?
Greatest degree of flexion and extension at C5-C6
because most likely to be injured there
Whiplash etiology bc most movement of flexion and extension in that apex in the middle
Typical Cervical Vertebrae C3-C6
What is facet joint alignment?
Facet Joint alignment is unique in the cervical spine in that it is at 45 degrees
What angle is the facet joint in in frontal plane in the cervical spine?
45 degrees
name the angulation of facet joint in each part of the spine:
C, Th, L
Cervical facet joint at an angle of 45 degrees in the frontal plane
1. This allows for a lot of movement patterns
Thoracic is 60 degrees
Lumbar is 90 degrees
What is unique about C7 Vertebrae?
- Atypical Cervical Vertebrae:
It is a transitional vertebrae
***C7 has the longest SP in the cervical spine - “Prominens” because it is the largest one
- -> Otherwise it has regular cervical spine characteristics, has an uncinate process transverse foramen, but now has a costotrasnverse bar because it is transitional - Longest SP (in cervical spine)
How to palpate C7?
Find C7 from T1 by extending the head: C7 dips in and T1 does not because T1 is attached to rib 1: which prevents T1 from sliding forward when you extend the neck
C7 has the longest SP in the cervical spine
Which vertebrae is called the prominens?
C7:
It is called the Prominens because it is the largest one
Otherwise it has regular cervical spine characteristics, has an uncinate process transverse foramen, but now has a costotrasnverse bar because it is transitional
Which vertebrae has the longest SP in the cervical spine?
C7
costotransverse joint
The costotransverse joint is the joint formed between the facet of the tubercle of the rib and the adjacent transverse process of a thoracic vertebra. The costotransverse joint is a plane type synovial joint which, under physiological conditions, allows only gliding movement.
Typical Vertebrae
- what direction is the TP?
- what type of SP?
- Transverse Processes is lateral
- Spinous processes are bifid
Bifurcations
What is special about cervical transverse processes?
1) Transverse Processes is lateral
(gutter for NR-protect NR, issue if NR stuck in gutter or osteophyte)
2) Foramen for vertebral artery
What is good and bad about the gutter at the transverse process in the cervical spine?
Transverse Processes is lateral
GOOD
- –Have gutter like shape to protect the nerve root
- –It protects the NR which is exposed as it exits, so this serves as protection which is unique to the cervical spine
BAD
—Since the NR is in the gutter, if it gets stretched and gets stuck in the gutter then will get a problem with the nerve root
—Also issue if develop an osteophyte that develops in the gutter area that is sitting right on top of the nerve root
Cervical Facet Joints
–what type of articular facet?
- Posterior arch has superior and inferior articular facet
favor flexion/extension
- Aligned in sagittal plane at 45 degree angle
- Also called: Zygapophyseal joints / Apophyseal joints
- There is a space between these joints, there are uneven surfaces between the facet joints, the capsule has invaginations into the facet joints called meniscoids which are important because fatty and have a high degree of innervation. Therefore they get involved in entrapments in the cervical spin
What is the articular pillar?
dutton
dutton:
The articular pillars and zygapophysial (facet) joints of vertebrae C2–7 are located approximately 1 inch lateral to the spinous processes. The articular pillar is formed by the superior and inferior articular processes of the zygapophysial joint, which bulge laterally at the pedicle–lamina junction. The articular facets on the superior articular process are concave and face superolaterally to articulate with the reciprocally curved and orientated facet on the inferior articular process of the vertebra above. The articular pillars bear a significant proportion of axial loading.
articular pillar
Posterior arch has superior and inferior articular facet, favor flexion/extension
- —-There are articular facets on the posterior arch
- —-Since on 45 degree angle flexion and extension are easy to do (note that the other movements are also easy to do)
- —-All of the facets are aligned one on top of the other and in the cervical spine there is a line up that layer on top of each other called the articular pillar
- This is the only part of the spine that when we do our mobilization treatments on the facet itself
- We will access on the articular pillar (whereas on lumbar spine did SP, TP and not facet because facet joint was too deep)
- Layering effect—it is designed to move
Alignment of facet joint in the saggital plane: 45 Degree Angle
CONCAVE ON CONVEX
Superior faces up, back, and medial
Inferior faces down, forward and lateral
Note: angulation progressively increases as you go down the cervical spine
What direction does superior of the cervical facet face?
up, back, and medial
What direction does inferior of the cervical facet face?
down, forward and lateral
What is the : Zygapophyseal joints?
facet joint
What is the Apophyseal joints?
facet joint
What are meniscoids?
There is a space between facet joints, there are uneven surfaces between the facet joints, the capsule has invaginations into the facet joints called meniscoids which are important because fatty and have a high degree of innervation. Therefore they get involved in entrapments in the cervical spine.
What happens when meniscoids degenerate?
-In degenerative diseases the meniscoids between facet joints start to atrophy and the meniscoids start to disappear as you get older
–This causes decreased integrity in the joint and decreased stability of the facet joint
–This increased mobility and decreased stability leads to osteophyte formation in the cervical spine
More movement occurring in the facets and the constraint/ligaments and musculature
How many joints in the A/A Joint?
of mechanically linked joints and what are they
3 mechanically Linked Joints
Atlanto Odontoid Joint and AA Joints
Subcranial Biomechanics
Flexion/Extension:
- Atlanto-odontoid and A/A (C0-C1 and C1-C2) joints, No opening on Xray
- C1-C2 held together by transverse ligament
- Kept together by transverse ligament
Does flexion/extension take place at C0-C1 / C1-C2?
There is no flexion/extension available at C1-C2 so the flexion and extension that takes place is C0-C1
NOTE
C1-C2: 2 A/A joints and the AO joint in that complex have no openings on Xrays with flexion and extension: move together as a unit during flexion/extension
-if there was it would indicate an instability between C1 and C2 because they are designed to rotate.
In C1-C2, how many joints are are designed for rotation?
In C1-C2 there are three joints which are designed for rotation..
The two A/A joints and the AO joint in that complex have no openings on Xrays with flexion and extension-if there was it would indicate an instability between C1 and C2 because they are designed to rotate.
Is there an opening on xray at C1-C2 on flexion/extension?
They move together as a unit during flexion/extension. The occiput slides on C1 and there is an opening at C2-C3 and further down but no opening at C1-C2 and if there is it is a ligament or bony issue.
What holds C1-C2 together?
Transverse ligament
Why is the transverse ligament critical?
It is to keep the odontoid in constant contact with the anterior arch of C1
**If you see movement in flexion on an xray between C1 and C2 it is either because a fx and displacement of the odontoid or a torn transverse ligament
if odontoid displaced it can travel cranially or into cord.
If instability between these two and get a gliding between C1-C2 and compress the cord: die
What keeps congruency C1-C2?
- What type of joint are they
2) What gives them convexity?
3) so what keeps them congruent?
1) C1-C2 are planar flat joints from bony perspective
2) cartilage of both atlanto and axial part have convexity to them, there is a lot of literature that calls it a BICONVEX joint because of the cartilage on both surfaces and not because of the bone.
3) These two convexities not congruent so they are filled with meniscoids from the surrounding capsule to take up the space.
Occiput motion:
- Glide of occiput on C1 when go into flexion and extension. If you put your fingers on your occiputs and tuck your chin you will feel occiput slide posteriorly, if jut chin feel occiput roll anteriorly –feel glide of occiput on C1 when jut and nod
- We look for this in the mobility in the C0-C1 joint
- So the bone is flat but the cartilage makes it have the biconvex curvature
- The transverse ligament goes across to keep the relationship of the anterior part of the odontoid with the posterior part of the arch close together –when flex they should not open up
Subcranial Biomechanics
Rotation
1) Trochoid Joint between the odontoid , anterior arch of C1 and lateral masses
——In the subcranial area the rotation is a trochoid joint between the odontoid and the anterior arch (then it extends out to the lateral masses because all three of those joints are linked)
2) Odontoid stays in place and the osteo-ligamentous ring turns around the odontoid
[For rotation, if the axis stays still and rotate around it—the movement occurs around the axis, If you initiate rotation it is your occiput moving first and then the ring of C1 moves around C2]
Where is the trochoid joint for subcranial?
Trochoid Joint between the odontoid , anterior arch of C1 and lateral masses
**subcranial area the rotation is a trochoid joint between the odontoid and the anterior arch
**Then it extends out to the lateral masses because all three of those joints are linked
Does the odontoid move during rotation?
Odontoid stays in place and the osteoligamentous ring turns around the odontoid
If you initiate rotation what moves first?
If you initiate rotation it is your occiput moving first and then the ring of C1 moves around C2
A/O Joint: C1-C2
- # of joints
- degrees of freedom
- why is there an exception here for biomechanics?
1) 2 symmetrical joints, mechanically linked superior articular facets of lateral masses and occipital condyles
2) 3 degrees of freedom: Axial rotation, Flexion/Extension, Lateral Flexion
3) The cervical spine rule exception because in this joint sidebending and rotation are not coupled and they occur contralaterally:
degrees of freedom at C1-C2 (A/O)
3 degrees of freedom: Axial rotation, Flexion/Extension, Lateral Flexion
Biomechanics
A/O C1-C2
are sidebending and rotation occurring to same or opposite side?
The cervical spine rule exception because in this joint sidebending and rotation are NOT coupled and they occur contralaterally:
Different form lumbar spine: this occurs all the time regardless of whether in flexion or extension: they always occur in the opposite direction
A/O
C0-C1
What is difference from the movement of the rest of the cervical spine?
Suboccipital mechanics: sidebending and rotation occur to opposite sides
Different from rest of the cervical spine: sidebending and rotation coupled to the same direction
Cervical Spine: where is sidebending and rotation coupled?
C0-C1, C1-C2: the subcranial section: sidebending and rotation always occur in the OPPOSITE direction (this is neutral mechanics)—it does not matter if the neck is in neutral or non-neutral position—they are always in the opposite direction only in the upper cervical spine
In the rest of the cervical spine sidebending and rotation are always coupled to the same side –it doesn’t matter if it is neutral, flexion or extension
When are facet joints in the cervical spine considered to be engaged?
facet joints in the cervical spine are always considered to be engaged no matter what position they are in because of the angle of the facet joint
(**Subcranial section is difference)
Idling, always in the same direction, always does the same thing, different from the rest of the spine
All cervical joints: C3-C7: couple in the same direction all the time: sidebend and rotation
C0-C1-C2: the sub-occipital unitl: couple in opposite direction all the time: sidebend and rotation
Coupling
C0-C1-C2
vs
C3-C7
All cervical joints: C3-C7: couple in the same direction all the time: sidebend and rotation
C0-C1-C2: the sub-occipital unitl: couple in opposite direction all the time: sidebend and rotation
Tectorial Membrane
Extension of the PLL
*within vertebral column: posterior body of axis over dense, covers cruciate ligament, inserts in foramen magnum
Posterior neck near dura mater
Big/thick/dense/ broad / strong
Ligament that is the continuation of the PLL
Tectorial Membrane
Ligament that is the continuation of the ALL
Anterior AO and AA Membranes
Ligament that is the continuation of the Ligamentum Flavum
Posterior AO and AA Membranes
Ligament that is the continuation of the Supraspinous ligament
Ligamentum Nuchae
Anterior AO and AA Membranes
The continuation of the ALL.
Posterior AO and AA Membranes
the continuation of the ligamentum flavum. Goes between the two lamina.
Ligamentum Nuchae
external occipital protuberance/inion –> C7 (SP)
thick posterior fascial band: suspends neck and critical for postural alignment
instead of the supraspinous ligaments and intraspinous ligaments
what is inion?
external occipital protuberance
Cruciform Ligament
cross
- Vertical:
occiput –> posterior axis/C2 (anchors the transverse portion) - Transverse : portion keeps the dens in place on C1
- ->layer of articular cartilage on anterior surface-smooth articulation with dens
What is the most important ligament in the cervical spine?
Transverse portion of the cruciform ligament
KEEPS DENS IN PLACE on C1
STRONG
trauma in hyperextension the dens will break before the ligament will tear
layer of articular cartilage on anterior surface: smooth articulation between dens and ligament
Posterior dens articulates with anterior of this ligament
For whom is transverse of cruciform ligament impaired?
What is the result?
RA or Downs
- ->instability at C1-C2
- **need to be very careful handling upper cervical spine in that population because can create a lot of damage if not careful
Dentate Ligaments
2
- Apical Ligament
2. Alar Ligament
Apical Ligament
Dentate Ligament
Odontoid –> Basiput
(Dens–>foramen magnum)
small, maintains alignment, attach to peak of dens
Alar Ligament
2 Dentate Ligaments
posterior-lateral odontoid –> occipital condyles
(Dens–> occipital condyles)
critical for cervical spine
two posterlateral to the odontoid that goes to the occipital condyle to the
need to be stable and symmetrical for the odontoid to stay center
Cervical Extension
- What does the overlying vertebral body do?
- what happens to posterior IV space?
- what fibers widen?
- what structures limit it?
- are joint surfaces congruent?
- Overlying vertebral body TILTS and SLIDES POSTERIORLY
IV SPACE: compress posteriorly
Anterior Fibers of Annulus: widens
Limited by ALL and posterior arches
Joint surfaces maximally congruent, maximal stability
CERVICAL EXTENSION
what does vertebral body above do?
overlying vertebral body tilts and slides posteriorly
–>Vertebrae above slides down on the vertebrae below because they are stacked-backward glide of one facet joint over the other :
–>The overlying vertebral body tilts and glides posteriorly
CERVICAL EXTENSION
what happens with the IV space?
IV space compresses posteriorly because extension moment
CERVICAL EXTENSION
what happens with anterior fibers of annulus?
They are widened
CERVICAL EXTENSION
what limits it?
Limited by ALL and posterior arches
**Limited by anterior structures: anterior AO and anterior longitudinal ligament will prevent the separation on the anterior portions
**Posterior arches also will limit extension
Cervical SPINAL MOTION
In what position are Joint surfaces maximally congruent, maximal stability
CERVICAL EXTENSION
Below C2, facets are always considered to be non-neutral and therefore they are considered to be controlling vertebral movement
–>if they are non neutral this means they are engaged which means that there is contact
Sidebending and rotation always occur to the SAME side
==>Since non-neutral they control the movement
Cervical spine below C2: What is and isnt coupled?
Sidebending and rotation coupled , flexion and extension are uncoupled movements ALWAYS
Cervical Extension
Degrees
Closed Packed Position:
Flexion/Extension are uncoupled movements
70 DEGREES (magee)
C0-C1 => 15 degrees are at the A/O (C0-C1)
NONE AT C1-C2
The rest happens in the remainder of the cervical spine
CERVICAL FLEXION
- what does vertebral body do?
- where does nucleus go
- what is stretched
- what structure limits (3)
- are the facets engaged?
- upper vertebral body tilts and slides ANTERIORLY
- Nucleous posterior
- Stretch posterior annulus
- limited by PLL, ligamentum nuchae, and ligamentum flavum
- facets barely engaged
CERVICAL FLEXION
where does the VB go?
upper vertebral body tilts and slides ANTERIORLY
Facet joint above slides and tilts anteriorly
CERVICAL FLEXION
where does nuclesu go?
Nucleus posterior
Nucleus goes in the opposite direction from the movement
CERVICAL FLEXION
what is stretched
Stretch posterior annulus
CERVICAL FLEXION
what 3 structures limit?
imited by PLL, ligamentum nuchae, and ligamentum flavum
CERVICAL FLEXION
are the facets engaged?
facets barely engaged
It is the least stable position (more anterior-posterior shearing)
They are engaged, but the least
What is a more stable position in cervical: flexion vs extension?
extension stable
flexion least stable
CERVICAL FLEXION
decrees
80-90 degrees
CERVICAL SIDEBENDING
right sidebending: what close/open?
Right Facets Close
Left Facets Open
***coupled with rotation below C2
CERVICAL SIDEBENDING
degrees
20-45 degrees to each side
Explain cervical sidebending
As sidebend facet slides up to allow for opening to sidebending—as slides because of the angle it also rotates
As sidebend to the right which means rotating to the right, close on the right and open on the left: back and down on the right and up and forward on the left
What creates the sidebend with rotation couple in the cervical spine?
If sidebend right facet slides up it also slides down as it closes on the opposite side: when right opens, facet on right slides up and forward and as it opens, other side closes and slides back and down—this creates the rotation with sidebending (the going forward)-because of the 45 degree angle it cannot go any other way
Cervical sidebend
in right opens, where does right facet go? left?
Facet on right slides up and anterior and as it opens the left side closes and slides posterior and inferior—the forward gliding creates rotation simultaneously with sidebending
What area of the curve most motion?
If I open on one side the other side closes
*the reason most motion at C5-C6 is that it is the apex of the curve—the center of the lordosis is C5
(at areas of transition: also in
C7-T1 when go from lordosis to kyphosis,
T7-T9 center of apex of kyphosis,
T12 transition,
and L3)
CERVICAL SIDEBENDING
degrees
20-45 degrees
CERVICAL ROTATION
how does the facet slide?
inferior glide of facet on the side to which it is rotating
CERVICAL ROTATION
- How does the facet slide?
- Where does most rotation occur in the cervical spine?
- How many degrees of rotation?
- Where is most rotation with sidebending? Where least?
- inferior glide of facet on the side to which it is rotating
- Largest range is C1-C2: 32-45
- Degrees: 70-90 degrees to each side
- Amount of rotation that occurs with sidebending decreases from C2 to C7
CERVICAL ROTATION
Left rotation of the head and neck what occurs at:
1) A/O
2) A/A
3) Lower Cervical Spine
**what limits rotation
Left rotation of the head and neck
1) A/O sidebending right and slightly flexed
2) A/A in full left rotation
3) Lower cervical spine in combined movement of lateral flexion and slight extension
**limited by ligament, annulus, and facets
CERVICAL ROTATION
what do the facets do?
Inferior glide of the facet on the side to which is is rotating
Because it is the side sidebending towards which is side of extension, on other side get the opening of flexion ???
- Closing in the side you are rotating towards
- Sidebend to right rotating to the right, close on the right and open on the left: slide posterior and inferior on the right, sueprior anterior on the left
CERVICAL ROTATION
How does the facet slide?
inferior glide of facet on the side to which it is rotating
Closing on the side you are rotating towards
Sidebend to right rotating to the right, close on the right and open on the left: slide posterior and inferior on the right, superior anterior on the left
CERVICAL ROTATION
Where does most rotation occur in the cervical spine?
Largest range is C1-C2: 32-45
A/A
50% of rotation in the cervical spine is at C1-C2
CERVICAL ROTATION
How many degrees of rotation?
Degrees: 70-90 degrees to each side
CERVICAL ROTATION
Where is most rotation with sidebending? Where least?
Amount of rotation that occurs with sidebending decreases from C2 to C7
Angle of facet joint changes causing less rotation as go down (and not so much rotation in thoracic spine, don’t rotate lumbar)
Motions of lower cervical spine:
Flexion
Extension
Sidebending
Rotation
Flexion: 80-90 degrees
Extension: 70 degrees (15 at A/O)
Sidebending: 20-45 degrees
Rotation: 70-90 degrees
upper and lower cervical spine do different things
full rotation to the left
LOWER: C-spine in combined movement of left lateral flexion and slight extension
—>Combined movement: left lateral flexion with slight extension because of the lordosis
A/A in full left rotation and slightly flexed
—>Left rotation, but C0-C1 (AO) is going to be side-bent right and slightly flexed: in order to keep the eyes level: opposite direction of what happens in the lower cervical spine (the side bending and flexion)
Limited by ligament, annulus and facets (these will all limit this)
When lower neck is going one way, upper is going the other way to level your eyes
Uncovertebral Joints
ucinate process have cartilage lined vertebral surfaces facing MEDIAL and SUPERIOR
Capsule is continuous with annulus fibrosis of disc
LIMITS LATERAL FLEXION
Which way do ucinate process face?
MEDIAL and SUPERIOR
do ucinate processes have anything lining the vertebral surfaces?
ucinate process have cartilage lined vertebral surfaces facing
in uncovertebral joint, with what is the capsule continuous with?
Capsule is continuous with annulus fibrosis of disc
what does uncovertebral joint limit?
LIMITS LATERAL FLEXION
Are we born with ucinate process?
Not born with uccinate processes, they develop during childhood and mature by second decade of life.
Become fully articular by second or third decade in life and develop pseudo-synovial joint because not a true synovial joint.
By the time they start functioning this way they are considered to be true articulations.
what is the relationship of capsule of uncovertebral joint and the disc?
Capsule is continuous with the annulus fibrosis of the disc
Important relationship with the disc which supports the neck
What motion does uncovertebral joint limit?
Limits lateral flexion
As you try to sidebend the neck they get in the way and limit the range of sidebending
Uncovertebral joint function:
5
- Limits Side-bending of the neck
- Becomes weight bearing with degeneration
- Protects nerve root from being compressed by disc
- Anterior wall of vertebral foramen
- Supports dorsal and lateral annulus fibrosis
Uncovertebral joint function:
Limits Side-bending of the neck
Limits lateral flexion
As you try to sidebend the neck they get in the way and limit the range of sidebending
Uncovertebral joint function:
Becomes weight bearing with degeneration
As lose water in the disc and the vertical height or dimension of the neck diminishes, the uncovertebral joint becomes a weight bearing joint
Uncovertebral joint function:
Protects nerve root from being compressed by disc
protects the NR from being compressed by the disc,
the uncovertebral joints prevent disc from going posterior-lateral due to the uccinate process being in the way, this protects the NR
Uncovertebral joint function:
Anterior wall of vertebral foramen
It creates the anterior wall of the vertebral foramen—lateral recess foramen
Uncovertebral joint function:
Supports dorsal and lateral annulus fibrosis
Supports dorsal and lateral annulus fibrosis
ROM in Cervical Spine
Flexion
Extension
Lateral Flexion
Rotation
EXTENSION: 70 Degrees
FLEXION: 80-90 degrees (2 fingers from sternum)
LATERAL FLEXION: 45 degrees to each side
ROTATION: 80-90 degrees to each side
ROM in CERVICAL SPINE
EXTENSION
FLEXION
A/O Extension
Suboccipital Motion
Lower Cervical Spine
EXTENSION: 70 degrees
FLEXION: 80-90 degrees
A/O Extension: C0-C1: 15 Degrees
Suboccipital Motion: 20-30 degrees
Lower Cervical Spine: 100-110 degrees
ROM in Cervical SPINE
LATERAL FLEXION
suboccipital:
A/O
C1-C2
C2-C3
LATERAL FLEXION: 45 degrees each side
SUBOCCIPITAL: 8 degrees
A/O: C0-C1: 3 degrees
C1-C2: nothing
C2-C3: 5 degrees
ROM in CERVICAL SPINE
ROTATION
A/O
AA
ROTATION: 80-90
A/O: C0-C1: 7 degrees
AA: C1-C2: 50% of total ROM
No lateral flexion, no sidebending, but a lot of rotation at C1-C2
How many degrees of freedom at C0-C1?
3 DF
Intervertebral Disc
1) How much of the height of the cervical spine?
2) what shape does the disc give to the cervical spine?
3) what innervates the outer 1/3 of the IV disc?
4) are there nociceptors in the disc?
- 35% of the height of the cervical spine
- gives the lordotic shape
- outer 1/3 innervated by the vertebral nerves and sunnovertebral nerves
- wide distribution of nocioceptors
IV DISC
what % of height of the cervical spine?
35%
IV DISC
is it level?
Gives the lordotic shape
**not completely level, more height anteriorly
IV Disc
is it innervated?
Outer 1/3 innervated by the vertebral and sinoverterbral nerves
Innervation to the capsule, nerve, and disc
Painful with bulge because the sinnovertebral nerve which innervated multiple levels above and below gives pain when herniated disc
why pain when disc bulge?
Painful with bulge because the sinnovertebral nerve which innervated multiple levels above and below gives pain when herniated disc
IV Disc
nociceptors:
cervical spine has a wide distribution of nocireceptors which is why cervical discs are so painful for patients.
What makes cervical discs so painful for patients?
The cervical spine has a wide distribution of nocireceptors which is why cervical discs are so painful for patients.
- Does the cervical spine have a good posterior annulus?
- What do we have instead to protect the posterior?
- What gives posterior integrity? (3)
- Cervical spine does not have a good posterior annulus
have fiber directions that are not criss crossed and instead they are CONCENTRIC and these converge on the posterior aspect, annulus comes around from the back but DOES NOT COMPLETE THE TOTAL BACK, since not total presence in back can have issues posteriorly due to the structure
- Bagdook says the uccinate serve to protect the posterior instead
- Integrity of posterior from
- PLL
- tectoral membrane,
- ligamentum nuchae,
thick posterior structures for posterior integrity of spine in cervical area
Borders of the Nerve Root Foramen
Superior
Inferior
Anterior
Posterior
SUPERIOR : inferior pedicle above
INFERIOR: superior pedicle below
ANTERIOR: joints of von lushka/uncovertebral joints/uccinate process
POSTERIOR: facet joint
BORDERS OF NERVE ROOT FORAMEN
Superior
Superior: inferior pedicle above
BORDERS OF NERVE ROOT FORAMEN
Inferior
Inferior: superior pedicle below
BORDERS OF NERVE ROOT FORAMEN
Anterior
Anterior: uncovertebral joints
BORDERS OF NERVE ROOT FORAMEN
Posterior
Posterior: facet joint
How does the anterior border of the nerve root foramen differ for the cervical spine compared to thoracic and lumbar?
thoracic and lumbar spine the disc creates this border,
so anterior border of the foramen differs for the cervical spine
=Anterior: uncovertebral joints
How much of the nerve root foramen occupied by nerve?
1/5-1/4 of the foramen
*nerve surrounded by dural sleeve
—>There is wiggle room around the nerve
—>The issue is if the nerve root becomes inflamed and irritated, it becomes edemanus and starts taking up the whole space.
Prolapse posterior-lateral
Are they common in cervical spine? Why or why not?
Rare to find prolapse posterior-laterally since the ucinate process protects the nerve root
lateral recess stenosis
lateral aspect if where the nerve root comes out, the foramen, lateral recess foramen, if there is an impingement and have the NR compressed it is a lateral recess stenosis
central stenosis
central stenosis would be abutting or impinging the cord in central canal
Why is it rare to find cervical spine prolapse posterior-laterally?
Rare to find prolapse posterior-laterally since ucinate process protects NR
Rare to have a posterior lateral herniation in the neck because the ucinate process blocks disc there, so it protects the nerve
The nerve still gets compressed in the cervical spine because start losing space in the lateral foramen because develop osteophytes
4 types of compression of nerve roots:
- osteophytes at uncovertebral joints
- swelling of facet capsule
- venous congestion of dural sleeve
- Nerve root ischemia
Compression of NRs
*Osteophytes at uncovertebral joints
- Because the uncovertebral joint becomes WB as lose height in the disc, as develop DDD/ DJD in the neck the height decreases and have forces on joint and develop osteophytes at the uncovertebral joint-and the ucinate process and the joint itself forms the anterior border of the nerve root foramen—nerve will get stuck on the jagged pieces that develop off of the ucinate process
- The nerve will get stuck on these pieces on the uccinate process
Compression of NRs
*Swelling of facet capsule
- The facet creates the posterior border of the nerve root foramen
- Facet capsule can also become swollen and take up space-narrowing of the canal
Compression of NRs
*Venous congestion of dural sleeve
*Inflammation and endemenous changes of the nerve root itself so the dura becomes more swollen, takes up more space and ultimate outcome is NR ischemia
Compression of NRs
*NR ischemia
*Inflammation and endemenous changes of the nerve root itself so the dura becomes more swollen, takes up more space and ultimate outcome is NR ischemia
CERVICAL SPINE POSITIONS
Neutral/Resting
Closed Packed
Capsular Pattern
Neutral/Resting: slightly extended
Closed Packed: completely extended
Capsular Pattern: ie right facet: Left Lateral Bending Left rotation Forward Bending Deviates Right
CERVICAL SPINE POSITIONS
Neutral/Resting
slightly extended
The neutral resting position of the neck is lordosis
CERVICAL SPINE POSITIONS
Closed Packed
Closed Packed: completely extended
[Maximal closure of the facet joints is being in total extension (looking up at the ceiling)]
CERVICAL SPINE POSITIONS
Capsular Pattern
ie right facet
Capsular Pattern:
ie right facet:
- Left Lateral Bending (b/c cannot open right facet)
- Left rotation (b/c cannot open right facet)
- Forward Bending Deviates Right (right because the left facet opens and the right doesn’t and will get a deviation to the right when go into forward bending)
(when extending will be normal because it is already closed on the right and it is able to close normally on the left)
Cervical Assessment
3 things on observation
- Head/neck posture
- Relation to midline
- Willingness to move head and neck
Cervical Assessment
Subjective
what are Grieves three mandatory questions?
- Dizziness, vertigo, drop attacks
- Headache, RA, other inflammatory arthritis or treatment by steroids
- Neurological involvement of the lower extremities
Cervical Assessment
history (7)
- work and leisure activities
- bifocals/progressives
- swallowing
- mouth breather
- sleeping position
- pillows
- headaches
Cervical Assessment
Questionnaires
- Neck Disability Index (NDI)
2. Neck Pain and Disability Scale (NPAD)
Cervical Assessment
Structural Examination (6)
- Temperature
- Moisture
- Edema
- Nodules
- Spasm
Alignment
Observation: head and neck posture
Some patients will come in with something to support neck if in a lot of pain-head feels too heavy for neck-hold with hand, pillow, collar—and will describe head too heavy for neck and cannot support it
Observation: relation to midline
Relationship of head to midline, head should be in the midline, observe what is going on with that patient in midline
Observation: Willingness to move head and neck
This is easy to see if they are turning their head
Look at at the lordosis of the cervical spine. The earlobe should be in line with the acromion
How to assess cervical lordosis?
- Look at at the lordosis of the cervical spine. The earlobe should be in line with the acromion
- the patient stand against the wall so that the apex of their thoracic is against the wall, and measure distance from apex of cervical lordosis to wall should be no more than 4-6 centimeters. This can give a sense of patient kyphosis as well
- Tool to measure FHP called the craniovertebral angle: tragus (bump on ear) of ear to posterior aspect of C7: a diagonal line from tragus of ear to C7 and measure acute angle: the smaller the angle the more the FHP
what happens to cervical lordosis with age?
As patient deteriorates and their thoracic kyphosis becomes more extensive and also don’t maintain lumbar posture so get a swayback and get a problem and cannot correct by saying stand up straight and pick up head because have to work from the base—interconnection between cervical thoracic and lumbar spine is important and will be doing abdominal stabilization for the patient to stabilize from the base and then elevate the thorax and straighten out the cervical spine.
As patient position changes and habits change –cellphone posture, tablet, computer and slumped—in a “C” position taking away cervical lordosis due to this issue. The mouse –when people sit with computer on desktop with a bad chair and mouse way up so sitting with bad posture and killing their arm –really bad news. Spend time on education on using phone and texting and laptop ergonomics
craniovertebral angle
Measure FHP
Line 1: tragus (bump on ear) of ear to posterior aspect of C7:
a diagonal line from tragus of ear to C7
Line 2: horizontal
and measure acute angle:
More acute angle = more FHP
Gregory Grieves 3 mandatory questions
Dizziness, vertigo, drop attacks
*causes
***Dizziness and vertigo can also occur to middle ear issues-vestibular dysfunction
- **Drop attack: patient just passes out and they don’t know why
- –>Related to vertebral basular insufficiency: can occur due to inflammatory problem, due to predisposition to an issue in the upper cervical spine, can have a problem with RA (hypermobility at C1-C2 ie downs)
Gregory Grieves 3 mandatory questions
History of RA, other inflammatory arthritis or treatment by steroids
If someone takes steroids for a long period of time then they have a predisposition to have a loss of integrity of the ligament
Prolonged steroid use can create issues in the upper cervical spine which can create issues in dizziness, vertigo, balance
what is the issue with prolonged steroid use?
If someone takes steroids for a long period of time then they have a predisposition to have a loss of integrity of the ligament
Prolonged steroid use can create issues in the upper cervical spine which can create issues in dizziness, vertigo, balance
Gregory Grieves 3 mandatory questions
Neurological involvement of the lower extremities
Looking at myelopathies: compression of upper cervical spine, look at if issues with coordination, weakness in the LEs and if it is bilateral it is cord involvement, all related to a cervical myelopathy
Myelopathy
Looking at myelopathies: compression of upper cervical spine, look at if issues with coordination, weakness in the LEs and if it is bilateral it is cord involvement, all related to a cervical myelopathy
- severe ->spasticity and paresis
- gait issue if corticospinal tract or spinocerebellar tract abnormalities
- if get worse–> UE involvement: bc lamina of the cord and get compression of the external portion of the cord
If someone has issues with gait and has not been to the neurologist, send them there
If excess dizziness: send to ENT
If someone has issues with gait and has not been to the neurologist, send them there
If excess dizziness: send to ENT
HISTORY: Work, leisure activities
- Plumbers, electricians, aerialists etc who have positions in their jobs that have neck in hyperextension/other repetitive positions that are stressful for the neck.
- Recreational soccer where bop ball on head a lot: compressive effect on their neck
HISTORY
Bifocals, progressives
- For patients that are 40 and older and wear glasses that are bifocals: cervical radiculopathy because there is a small reading component on the bottom of the glasses and if they are not placed adequately the patient moves head to get focus in reading part and hyperextend to get over the bifocal part to read in the distance part: related to computer, book, newspaper: need to hold the paper and hyperextend neck to read the newspaper—create an issue
- Walking downstairs with bifocals—need to look over the reading part to see the distance part to see the steps because the reading part distorts the distance
- Suggest patient get separate glasses for reading so that you don’t have to change head posture, workspace glasses are only two zones-computer and reading without the distance
- May want a distance lens for skiing -but then cannot read trail map…
history
swallowing
anterior herniation in cervical spine
*anterior herniation the impingement will be on the esophagus and the patient will say they feel like there is something in their throat and not swallowing well
history
Mouth breather
In a position of extension when mouthbreath—snorers—this is a question also use for TMJ because mouth breathing also creates TMJ problems and sleep apnea problems and are snorers and have neck problems and it is all correlated.
history
Sleeping position
- Worst position to sleep in for neck is prone—if neck issue get them out of sleeping in prone
- Can impinge nerve root the entire night and give cervical radiculopathy
history
pillows
for normal alignment
Don’t want to sleep on acromion because don’t want to cause impingement in the shoulder so want a bit rotated,
but also don’t want too much rotation in trunk because will have problems: can protract the shoulder you are resting on and then accommodate for the space between the ear and the bed so fill the space
history
headaches
Common that neck patients get headaches:
C1 position if rotated or sidebent and stuck will give a bad headache
(hair washing sinks at the hairdresser sit at occiput at C1-hyperextend you into the sink and if have an occluded neck this is very bad and there are documented CVAs)
Cervical spine and TMJ patients get a lot of headaches
Neck Disability Index (NDI)
what it measures
who scores it
how many categories
- Related to pain and disability
- Self scored, give to patient in waiting room to do
- 20 categories, 5 things to assess problems related to neck injuries
- Used more than the NPAD
Neck Pain and disability Scale (NPAD)
Measurements with neck movements, neck pain intensity, pain emotion and cognition and how it interferes with life function
PALPATION
Hyoid
C3
First piece you find in neck under chin as come down, in a horseshoe shape sitting in front of C3, if flex neck a little bit place a pincer grasp around hyoid and glide it medially and laterally-it does not feel so nice-should have a certain amount of mobility that is normal from medial to lateral
PALPATION
Thyroid
C4-C5 (adams apple)
- Under a gland which is a softer material and feel for osseous formation underneath, when swallow can feel it move
- Should have some mobility
- Feel for the size of it-some have goiter that is there.
***Sometimes will find enlarged so refer to doctor especially if lethargic, hair loss, weight gain are sx of thyroid disease.
PALPATION
Cricoid
C6
- –Indentation under the thyroid
- –Uncomfortable to be palpated
***This is where you put a tracheostomy because it is cartilage, easy to get in there, and under the glands
PALPATION
Occiput
Inion/external occipital protuberance
Back of the neck, protrudes in back middle of head
PALPATION
mastoid process
Place your fingers directly under the patient’s earlobes and you will feel a rounded prominence on each side under your fingers. These are the mastoid processes (Figure 4.8).
PALPATION
SP C2
Place your finger on the inion and move inferiorly into an indentation (posterior arch of C1). As you continue
to move inferiorly, the rounded prominence that you feel is the spinous process of C2
PALPATION
SP C7
C7 is the prominens and is long and slender and almost feels like T1 does
longest cervical SP
Extend the head slightly. The C6 vertebra will drop off slightly at the beginning of the movement, followed by C7 with a slight increase in extension, and T1 will not drop off at all.
PALPATION
Articular Pillars
Come off the side of the SP and feel a bamobo like structure that goes down on both sides, must do in prone and supine when muscles are relaxed
PALPATION
Posterior Triangle
BRACHIAL PLEXUS IN POSTERIOR TRIANGLE
Borders:
Anterior: SCM
Posterior: Upper Trapezius
Inferior /base: Clavicle
***plexus is sitting underneath clavicle in the posterior part of it in the posterior triangle
PALPATION
Anterior Triangle
Anterior: Midline of neck
Posterior: SCM is the back
Top: Angle of jaw is top of the triangle
TP C1
between mastoid and inferior angle at the mandible:
Between the angle of the angle of jaw and mastoid underneath the earlobe
If push too hard it will be tender, if maligned will be tender, if maligned will not be symmetrical
If very side bent one of the transverse processes will be disappear under the mastoid and will not be able to find it on that side and will be very prominent on the contralateral side
What is palpated at this cervical level?
C3
Hyoid
What is palpated at this cervical level?
C4
Thyroid = Adam’s Apple
What is palpated at this cervical level?
C5
Thyroid = Adam’s Apple
What is palpated at this cervical level?
C6
Cricoid
–be careful not to gag the patient
What is an inion?
external occipital protuberance
Where is C1 TP palpated?
Between mastoid and inferior angle of the mandible
borders of the posterior triangle
anterior: SCM
posterior: upper traps
base: clavicle
Functional Testing:
1) Swallowing
2) Look up at Ceiling
3) Look down at shoes
4) Check Shoulder
5) Tuck Chin In
6) Poke Chin Out
1) Swallowing
2) Look up at Ceiling
3) Look down at shoes
4) Check Shoulder
5) Tuck Chin In
6) Poke Chin Out
Functional Testing
Swallowing
6 things this will test
Tests:
- lips
- jaw
- pharynx
- larynx
- suprahyoid
- infrahyoid
- *Submandibular and suprahyoid muscles are funcitoning
- *make sure lips, jaw, pharynx, larynx, suprahyoid, infrahyoid are functioning
**check the soft tissue anterior cervical spine / movement anteriorly
when injure, especially deceleration / acceleration : head whipped back and forth, anterior muscles get strained and get anterior swelling and that becomes dysfunctional for the patient as well. Make sure things are moving ok.
Functional Testing
Look up at Ceiling
Look down at shoes
Check Shoulder
quick sense of what is going on
