Upper C-spine Flashcards
What are important anatomical structures of the C1?
Anterior and posterior arches connected by lateral mass
Posterior aspect of anterior arch contains articular cartilage fro odontoid process
Lateral mass: superior concave and inferior convex articular facets
What are anatomical structures of C2?
Articulation of dens with C1
Articulation of C2 with C1 via superior and inferior facets
Where does rotation in upper C spine come from?
50% of rotation comes from AA joint because of: slopeness of facets, absence of discs, and biconvexity of AA joint
What are the ligaments of atlas to occiput?
ALL turns into AAO membrane
Lig flavum turns into PAO membrane
What are ligaments of axis to occiput?
PLL turns into tectorial membrane
What are ligaments of atlas to axis (AA joint)?
transverse ligament: passes behind dens, stabilizing dens against atlas, controls ant-post movement of AA joint
What happens if transverse ligament is injured?
dens will go back into the cord, and will have reproduction of cord symptoms
3mm motion is okay, 8-10 mm before you feel cord compression
What are ligaments of axis to occiput?
Alar ligament: resists flexion, contralateral SB, and contralateral rotation; tested in neutral, CV flex, and CV ext
What are the posterior muscles of the neck?
Rectus capitis posterior major
Rectus capitis posterior minor
Superior oblique
Inferior oblique
What is O,I, A of rectus capitis posterior major?
C2 SP to lateral aspect of nuchal line; bilaterally extends head, unilateral ipsilateral SB and rot
What is O, I, A of rectus capitis posterior minor?
C1 to medial aspect of nuchal line; extends head
What is O, I, A of superior oblique?
C1 TP to lateral aspect of nuchal line; bilaterally extends head, unilateral ipsilateral SB and contralateral rot
What is O, I, A of inferior oblique?
C2 SP to C1 TP; ipsilateral rotation
What are anterior neck muscles?
rectus capitis anterior
rectus capitis lateralis
longus capitis
longus colli
What is O, I, A of rectus capitis anterior?
lateral mass of C1 to base of the occiput; head flexion
What is O, I, A of rectus capitis lateralis?
C1 TP to jugular process; ipsilateral SB of head
What is O, I, A of longus capitis and longus colli?
Segmental attachment, helps with anterior sagittal rotation that goes with flexion Important for postural control Eccentric control when extending head Injured during MVA longus colli: T3-C1
What nerves innervate the upper cervical muscles?
Dorsal and ventral rami of C1-C3 supplies all structures: muscles, OA AA and C2-3 Z joint, all ligaments, and vertebral arteries
What are biomechanics of upper C spine flexion?
OA: convex occipital condyles glide post on concave atlas
AA: C1 moves inferiorly on C2; C2 glides forward on C3
What are biomechanics of upper C spine extension>?
OA: convex occipital condyles glide anteriorly on concave atlas
AA: atlas moves superiorly; C2 moves backwards on C3
What are biomechanics of upper C spine rotation?
OA: ipsilateral condyle glides posteriorly
AA: ipsilateral moves posteriorly; contralateral facet moves anteriorly; atlas translates to opposite side
What are biomechanics of upper C spine side bend?
OA: ipsilateral condyle glides anteriorly
What are osteokinematics of OA and AA joint?
OA: primary flex/ext motion
AA: primary rotation motion
What are the coupled movements of the upper C spine?
SB and rot occurs in opposite direction
What happens with coupled motions during upper cervical R rot?
R rot and L SB of OA joint; R rot and R SB of joints of lower cervical spine
What happens with coupled motions during upper cervical R SB?
R SB and L rot of OA joint; R SB and R rot of joints of lower cervical spine
What are causes of vertebral artery injury?
MVA (extension injury)
Trauma (compression from osteophytic or disc, stretching, kinking)
Cervical instability and fractures
Manipulation or sudden neck movements
What are signs and symptoms of vertebral artery problems?
5 Ds
can also have paresthesia/tingling on lip area or anywhere on their face
What are effects of neck movement on VA?
rotation, rotation + ext, rot + ext + traction
These movements may occlude the contralateral VA; some evidence suggests ipsilateral VA occlusion if rotation continues beyond 30 degrees
How do you assess VA for the safety of treatment?
listen carefully for signs and symptoms
screen for high risk people/history of vascular and arterial conditions
have patients perform active neck rotation while monitoring signs/symptoms
avoid treatments with combined extension and rotation
Takes 6 weeks to heal damaged VA
What is pain patter for cervical pathologies?
UCS: base of neck, head and face
C4-5: base of neck and top of shoulder
C5-6, C6-7: scapula, across shoulder and post/lat aspect of upper arm
What are parts of the UCS examination?
Observation, AROM (OP), scanning of joints, resisted testing, muscle imbalance, PPIVM, palpation, neuro exam (CN, CNS, segmental testing), special tests (compression/distraction, ligament testing)
What are aspects of the CNS testing?
muscle tone: increased spasticity Clonus DTR: hyper reflexive Babinski: ext of great toe and abd of 2-5 toes Hoffman: snapping tip of middle finger
What are the general treatment guidelines for UCS?
Restore mobility
Posture
Movement impairment
Stability and coordination
What must we keep in mind when treating headaches?
We must differentiate cervicogenic headache from other types
What are the classifications of HA?
Vascular: pounding, associated with dizziness, visual disturbances, etc
Neurological: intense nerve type pain
Musculoskeletal: posture, position or activity related
Others
What are the types of HA?
Migraine
Tension
Cervicogenic
What are signs and symptoms of migraines and who gets them?
Prevalent in females
Episodic, lasts 4-72 hrs
Pulsating or throbbing, can be associated with neurological symptoms (aura, visual disturbance, altered concentration)
Can be aggravated by physical activity
What is pain pattern for cervicogenic HA?
history of neck pain
unilateral HA; associated pain in neck, shoulder, arm
Variable pain, moderate intensity, non throbbing
What are aggravating and easing factors for cervicogenic HA?
Agg: reproducible with neck mvmt, posture, position; changes with your treatment
Easing: use of modalities, medications change in position/posture, lying down
what are signs and symptoms of cervicogenic HA?
Decreased neck movements
Patterns of HA (50% are occipital/suboccipital in MVA)
What are causes of cervicogenic HA?
pressure on OA, AA, C2-3; hypo or hyper mobility; muscle shortening; DJF; trauma; tension in joint capusule
What is PT intervention for HA?
postural correction: forward head posture can stress upper cervical structures and lead to HA
Restore glides and mobility; soft tissue work, traction
Ther ex/movement impairment
What are causes, signs and symptoms of tension HA?
Causes: stress or lack of sleep Description: tightness anywhere on cranium or suboccipital region Bilateral, trigeminal distribution Women>Men Agg/Ease: usually psychological
What is treatment for tension HA?
light stretching, joint mobilization, suboccipital release, patient education, posture
What injuries happen in MVA?
Whiplash: acceleration-deceleration injury to neck; injury to soft tissue
CC: neck pain/neck stiffness; neck pain and HA
How is whiplash diagnosed?
patient history, examination, X-ray/imaging
What are factors predicting impact and recovery for whiplash?
Direction of force: head on more detrimental
Velocity of impact
Curvature of CS
Symptoms present immediately or later post injury
# of accidents
Head position:
After MVA what structures should be examined?
Muscles: deep neck flexors Discs Joint/joint capsule Ligaments Nerves/NR
What are location of symptoms for MVA?
sub-occipital, neck, shoulders, scapula, back, unilateral/bilateral frontal HA, retro-orbital pain, facial/throat pain, numbness/paresthesia in either UE, laryngeal disturbances
In addition to the normal special questions what other questions must be asked for UCS?
Hearing or vision disturbances, dizziness, feeling of unsteadiness, depression or fatigue, irritability, insomnia, light-headed
Should related to VA, ligament integrity, CN, disc, and any other questions that might help rule out damage to intracranial structures
What are special diagnostic tests used for UCS injuries?
CT, myelography, EMG in presence of neuro signs
X rays to rule out fracture (open mouth for dens)
What are SE findings during acute stage of whiplash?
Pain is dominant complaint
Cautious/apprehensive with active movements of neck; shoulder or arm movement may be tolerated
May c/o dizziness with active movements
What are OE findings during acute stage of whiplash?
AROM to tolerance
Neuro exam: cranial nerves, central, segmental
Ligament tests if tolerated
palpation deferred
What are OE and findings for sub acute whiplash?
Active movement to end range (limited by stiffness and spasm)
OE: complete neuro, cervical spine stability testing, hypermobility/hypomobility with PPIVMs and PAIVMs as necessary
Address other areas as necessary
What are OE findings for chronic whiplash?
Symptoms may become intermittent Limited active movements Weak muscles Postural changes OE: palpation findings, neurodynamic tests, muscle activation, detailed biomechanical assessment
What is intervention during acute stage of whiplash?
Goal: protect structures and mobility within tolerance
Cervical collars
Modalities: ice, etc
Patient education
ROM exercises (NWB): gentle ROM, isometrics
Walking program
What is intervention for subacute/chronic whiplash?
Goal: gain mobility and stability Exercise (ROM/stabilization/isometrics) Prevention Postural re-education Joint mobilization, as necessary Soft tissue techniques Muscle imbalance
What are other traumatic injuries of the UCS?
A-O dislocation: 100% fatal, shear force of occiput on atlas
Fracture of posterior arch of atlas: result of vertical compression; results in massive sub occipital HA
A-A dislocation: rupture of transverse ligament, watch for cord compression signs
What is a Jefferson fracture?
Fracture of anterior and posterior arches of C1
Break in 4 places
Usually from blow to back of head
Dens fracture?
common in MVA
picked up on open mouth x-ray
What is hangman’s fracture?
Fracture of pedicles of C2 with dislocation of the body of C2 on C3
Results in dens into brainstem
Not always fatal
