V.C - B - Vertebral Column of Neck - Atlas, Axis, Occiput, Ligaments and Movements Of C.C.J, Arterial Supply, Pathology

Question 1

What are the functions of the vertebral column?

Answer 1

Weight transfer Protection (of spinal cord) Muscle attachment Haematopoeisis Mobility

Question 2

What classification of joint exists between the vertebral bodies?

Answer 2

Secondary cartilaginous - Iv disc Inner soft gelatinous, nucleus pulposus Outer tough fibrocartilaginous, annulus fibrosis

Question 3

What region of the vertebral column would you find the atlas and axis?

Answer 3

Cervical region

Question 4

Is the curvature in the cervical region primary or secondary?

Answer 4

The cervical curvature is a secondary curvature - around 2-3 months, the child is able to independently support its own head when upright and therefore a compensatory secondary curvature develops

Question 5

What shape is the atlas and what does it lie above? What does it lack?

Answer 5

The atlas is ring shaped and lies above the axis (C2 vertebrae) It lacks a spinous process and vertebral body and instead has an anterior and posterior vertebral arch

Question 6

That atlas has two lateral thick masses Where exactly do the lateral thick masses lie and what are they?

Answer 6

The lateral thick masses lie anteriorly and medially and they are the superior and inferior articular facets

Question 7

The lateral thick masses of the atlas are the superior and inferior articular facets which sit anteriorly and medially forming a bony bridge What do the superior articular facets of the atlas articulate with and what shape are they? What do the inferior articular facets of the atlas articulate with and what shape are they?

Answer 7

Superior articular facets of atlas - * articulate with the occipital condyles * concave in shape Inferior articular facets of atlas - * articulate with the superior articular facets of axis * round and flat in shape

Question 8

Describe the course of the vertebral artery up until C1 vertebral level?

Answer 8

Vertebral artery branches from the subclavian artery before passing through the transverse foramen of C6 transverse process

It travels superiorly and exits the C1 transverse foramen before passing in a groove around the superior articular facet of C1 at the base of the posterior arch

Question 9

After the vertebral arteries arch around the superior articular facets of C1, they move medially and join together to form what?

Answer 9

They move medially and join together to form the basilar artery

Question 10

What runs parallel to the vertebral artery at C1 level in the groove around the superior articular facet?

Answer 10

The first spinal nerve runs parallel to the vertebral artery within the groove

Question 11

What is the posterior transverse groove on the dens for?

Answer 11

The posterior transverse groove on the dens is the facet for the transverse ligament of atlas which holds the dens in place

Question 12

C2 articulates with C3 vertebrae via what joints? What connects the superior and inferior articular facets?

Answer 12

C2 articulates with C3 vertebrae via the intervertebral disc (secondary cartilaginous) and the facet joints (zygapophyseal, aka apopyhseal aka facet joint) Connecting the superior and inferior articular facets is the pars interarticularis

Question 13

What is fracture of the pars interartcularis known as?

Answer 13

Spondylolysis Spondylolysis is typically caused by a stress fracture of the bone, and is especially common in adolescents who over-train in activities. The pars interarticularis is vulnerable to fracture during spinal hyperextension, especially when combined with rotation, or when experiencing a force during a landing.

Question 14

What is the projecting feature from the centre of the superior nuchal line? What is the less noticeable and less consistent line below this known as?

Answer 14

The external occipital protuberance is the protuberance coming from the superior nuchal line The less noticeable and less consistent below this is known as the inferior nuchal line

Question 15

As stated, the inferior nuchal line is less noticeable and less consistent than the superior nuchal line What does the inferior nuchal line lie between?

Answer 15

The inferior nuchal line lie between the foramen magnum and the superior nuchal line

Question 16

Describe the occipital condyles? (ie shape and where they sit) What do the occipital condyles articulate with?

Answer 16

The occipital condyles are a pair of convex oval swellings flanking the foramen magnum They articulate with the superior articular facets of the atlas

Question 17

Describe the superior and inferior articular facets of the atlas? Describe the occipital condyles?

Answer 17

Lateral masses lying anteromedially Superior articular facet of the atlas - these are concave in shape Inferior articular facet of the atlas - these are rounded and flat Occipital condyles - these are convex oval swellings that flank the foramen mangnum

Question 18

Many ligaments stabilise the cranio-cervical junction * Anterior longitduinal ligament * Interspinous ligament * Tectorial membrane * Small apical ligament * Alar ligaments * Nuchal ligaments * Transverse ligament Describe the anterior longitudinal ligament? (attachment, where it runs from, what it limits)

Answer 18

The anterior logntiduinal ligament is made up of 3 layers of dense collagen fibres running on the anterolateral surface of the vertebral bodies form skull to sacrum The superficial fibres span multiple vertebral segments and the deep fibres bind adjacent vertebrae The ligament limits extension of the vertebral column

Question 19

* Interspinous ligament * Tectorial membrane * Small apical ligament * Alar ligaments * Nuchal ligaments * Transverse ligament What does the interspinous ligament connect at the cranio-cervical junction?

Answer 19

The interspinous ligament connects the posterior margin of the foramen magnum to the posterior arch of the atlas

Question 20

* Tectorial membrane * Small apical ligament * Alar ligaments * Nuchal ligaments * Transverse ligament The posterior longitudinal ligament runs within the vertebral canal on the posterior aspect of the vertebral bodies from C2 to sacrum What is the superior extension of the posterior longitudinal ligament known as?

Answer 20

The superior extension of the posterior longitduinal ligament is the tectorial membrane of the atlanto-axial joint (occipitoaxial ligaments)

Question 21

* Small apical ligament * Alar ligaments * Nuchal ligaments * Transverse ligament Where does the small apical ligament run from? Where do the alar ligaments run from and what do they prevent?

Answer 21

The small apical ligament runs from the tip of the odontoid process to the foramen magnum

Alar ligament attach from opposite sides of the odontoid process to the medial side of occipital condyles & lateral margins of foramen magnum and limit axial rotation

Question 22

* Nuchal ligaments * Transverse ligament Where does the nuchal ligament extend from and what is it continous with? What does the transverse ligament and connect and what does it pass posteriorly to?

Answer 22

The nuchal ligament extends from the external occipital protuberance and the posterior border of the foramen magnum to the spinous process of C7 and is continous with the supraspinous ligament The transverse ligament connects BOTH lateral masses of the atlas and passes dorsal to the odontoid process

Question 23

* Anterior longitduinal ligament * Interspinous ligament * Tectorial membrane * Small apical ligament * Alar ligaments * Nuchal ligaments * Transverse ligament Describe each of the ligaments?

Answer 23

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Question 24

The vertebral and occipital arteries provide blood supply to the cranio-cervical region What branches to the vertebral arteries give off at the cranio cervical junction? Where do these branches travel and where do they anastamose?

Answer 24

The vertebral artery gives off anterior and posterior ascending arteries which pass ventral and dorsal to the body of the axis and odontoid process They anastamose in the apical arcade which is within the alar ligament

Question 25

What is the most mobile area of the spine and axial skeleton?

Answer 25

This would be the cranio-cervical junction

Question 26

Movements of Cranio-Cervical Junction The complex bony features, ligaments and joint orientations allows for rotation, flexion, extension and lateral bending of the neck What does this extensive range of motion mean the joint must compromise?

Answer 26

The extensive range of motion at the cranio-cervical joint means the joint must compromise on STABILITY

Question 27

What degree of rotation of the neck is the cervical spine capable of?

Answer 27

The cervical spine is capable of rotation up to 90 degrees in either direction

Question 28

Which joint is involved in axial rotation of the neck? * Atlanto-occipital joint or * Atlanto-axial joint What degree of axial rotation of the neck does this joint provide?

Answer 28

The atlanto-axial joint is where the largest degree of rotation occurs, approximately 15 degrees of the total 90 degree of axial rotation The atlanto-occipital joint is not involved in rotation of the neck

Question 29

What muscles bring about rotation of the neck?

Answer 29

Rotation of the neck is brought about by the suboccipital muscles, the sternocleidomastoid and trapezius muscles

Question 30

What factor of the atlanto-axial joint allows for the high degree of rotation in the neck? What occurs between the atlas and axis to provide movement?

Answer 30

The transverse ligament allows the atlas to pivot around the stationary dens The lateral masses of the atlas glide over the articular facets of the axis (one lateral mass moving anteriorly, the other moving posteriorly)

Question 31

What limits axial rotation of the neck?

Answer 31

The alar ligaments limit axial rotation of the neck

Question 32

* What degree of axial rotation is possible? * Where does the largest degree of rotation occur? * What muscles bring about rotation? * How does movement for rotation occur at the joint with the largest degree of rotation? * What limits rotation of the neck?

Answer 32

* Up to 90 degrees of axial rotation of the neck is possible in either direction * The largest degree of rotation occurs at the atlanto-axial joint, approximately 15 degrees * Muscles bringing about rotation are sub-occipital, sternocleidomastoid and trapezius muscles * The transverse ligament allows the atlas to pivot around the stationary dens allowing the lateral masses of the atlas to glide over the superior articular facets of the axis * The alar ligaments limit axial rotation of the neck

Question 33

What are other movements of the atlanto-axial joint limited by?

Answer 33

Other movements of the atlanto- axial joint are limited by the odontoid process abutting against the margins of the atlas and the transverse ligament

Question 34

Flexion/Extension of the Cranio-Cervical Junction What percentage of flexion/extension movements of the neck occur at the cranio-cervical junction?

Answer 34

25% of flexion/extension of the neck occurs at the cranio-cervical junction

Question 35

What joints facilitate the flexion/extension movements of the neck at the cranio-cervical junction?

Answer 35

The atlanto-occipital joint facilitates most of the flexion/extension movements of the neck at the CCJ The atlanto-axial joint contributes a few degrees to flexion/extension at the CCJ

Question 36

What degree of flexion/extension is the atlanto-occipital joint capabale of and what way do the bones move to bring this about?

Answer 36

The atlanto-occipital joint is capable of 20 degrees of flexion/extensions and this is brought about by the sliding of the occipital condyles on the lateral masses of the atlas

Question 37

What joint does flexion of the head occur at? What happens to the occiput during flexion of the head?

Answer 37

Flexion of the head occurs at the atlanto-occipital joint During flexion of the head, the occipital condyles slide posteriorly and the occiput moves superiorly away from the posterior arch of the atlas

Question 38

What limits flexion of the head?

Answer 38

It is the nuchal ligament and posterior suboccipital muscles that limit flexion of the head

Question 39

From an upright position, what is the driving force of flexion of the head? What prevents the neck from flexing in a relaxed state due to the action of gravity?

Answer 39

In an upright position, the driving force of flexion of the head is the weight of the head The nuchal ligament and the muscle tone of the post-vertebral muscles of the neck prevent the head from flexing in a relaxed state when in an upright position

Question 40

From a supine position, what brings about flexion of the head?

Answer 40

From a supine position flexion of the head is brought about by the anterior neck muscles

Question 41

* What joint does flexion of the head occur at? * What happens to the occiput during flexion of the head? * What limits flexion of the head? * From an upright position, what is the driving force of flexion of the head? * What prevents the neck from flexing in a relaxed state due to the action of gravity? * From a supine position, what brings about flexion of the head?

Answer 41

* Flexion of head occurs at the atlanto-occipital joint * During flexion of the head, the occipital condyles slide posteriorly and the occiput moves superiorly away from the posterior arch of the atlas * Flexion of the head is limited by the nuchal ligament and posterior suboccipital muscles * Driving force of flexion of the head in an upright position is the weigh of the head * The nuchal ligament and tone of the post-vertebral neck muscles prevent flexion in a relaxed state * From supine, anterior neck muscles cause flexion

Question 42

What joint does extension of the head occur at? What happens to the occiput during extension of the head?

Answer 42

Extension of the head occurs at the atlanto-occipital joint During extension of the head, the occipital condyles move anteriorly and the occiput moves closer to the posterior arch of the atlas

Question 43

What is extension of the head limited by and what may excessive force lead to?

Answer 43

Extension of the head is limited by the collision of the occiput and posterior arch of the atlas Excessive force may lead to fracture due to collision of the occiput and posterior arch of atlas

Question 44

What is extension of the neck from an upright position controlled by? (ie what resists extension due to the weight of the head) From a prone position, what is extension of the neck initiate by?

Answer 44

Extension of the neck from an upright positon is controlled by the anterior neck muscles acting against the weight of the head - like flexion From a prone position, extension of the neck is initiated by the post-vertebral muscles of the neck (splenius, erector spinae, trnsversospinalis muscle groups)

Question 45

* What joint does extension of the head occur at? * What happens to the occiput during extension of the head? * What is extension of the head limited by and what may excessive force lead to? * What is extension of the neck from an upright position controlled by? (ie what resists extension due to the weight of the head) * From a prone position, what is extension of the neck initiate by?

Answer 45

* Extension of head occurs at atlanto-occipital joint * During extension, the occipital condyles move anteriorly and the occiput moves closer to the posterior arch of the atlas * Extension of the head is limited by collision of the occiput with the posterior arch of the atlas (excessive force may lead to fracture) * Extension of the neck from an upright position is controlled by the anterior neck muscles acting against the weight of the head - like flexion * From a prone position, extension is initiated by the post-vertebral muscles of the neck

Question 46

LATERAL FLEXION OF THE NECK Cranio-cervical junction is capable of a very small degree of lateral flexion What degree of lateral flexion is it capable of? How do the occipital condyles move?

Answer 46

Cranio cervical junction is capable of a very small degree of lateral flexion - approximately 5 degrees The occipital condyles move lateral over the lateral masses of the atlas * The ipsilateral condyle moves towards the midline * The contralateral condyle moves away from the midline

Question 47

What is lateral flexion of the neck (CCJ and from C3-C7) limited by?

Answer 47

Lateral flexion of the CCJ is limited by the contralateral alar ligament (remember these ligaments attach from occipital condyle to the dens) Lateral flexion of the neck is also limited by the ucinate process present on C3-C7

Question 48

PATHOLOGY * Dislocation of atlanto-occipital joint * Dislocation of atlanto-axial joint * Rheumatoid arthritis When does atlanto-occipital dislocation occur? What is the main cause?

Answer 48

Atlanto-occipital dislocation occurs when the ligaments and bony structures become damaged The main cause of dislocation here is due to trauma - often there is some sort of neurological impairment

Question 49

PATHOLOGY * Dislocation of atlanto-occipital joint * Dislocation of atlanto-axial joint * Rheumatoid arthritis Atlanto-occipital dislocation most commonly occurs in children and adolescents Why is this? (4 reasons)

Answer 49

* This is because there is a more horizontal plane of articular surfaces * The ligaments are more lax * There is a relatively large head * There is a higher effective fulcrum in the cervical spine

Question 50

State again the reasons why atlanto-occipital dislocations are more common in children and adolescents? How are atlanto-occipital dislocations diagnosed?

Answer 50

There is a more horizontal plane of articular surfaces The ligaments are more lax There is a relatively large head There is a higher effective fulcrum in the cervical spine Antlanto-occipital dislocations are diagnosed using CT or MRI scans

Question 51

There are 3 different types of atlanto-occipital dislocation Describe each and state which is most common and which is most unstable?

Answer 51

Type 1 is the most common dislocation where the occipital dislocates anteriorly Type 2 is the most unstable where there is longitudinal distraction of the occiput Type 3 results in dorsal dislocations of the occiput

Question 52

What is the management for atlanto-occipital dislocations?

Answer 52

Conservative management using neck collars or Fusion

Question 53

PATHOLOGY * Dislocation of atlanto-occipital joint * Dislocation of atlanto-axial joint * Rheumatoid arthritis What does the atlanto-axial joint rely on heavily rather than bony features to prevent dislocation? What are the main causes of atlanto-axial dislocation? (list 3)

Answer 53

The atlanto-axial joint relies on the transverse ligament heavily rather than bony features to prevent dislocation The main cause of atlanto-axial dislocation are * Trauma * Congenital abnormalities (eg Down’s syndrome) * Inflammation (eg Rheumatoid arthritis)

Question 54

Which type of odontoid fracture is the most common and the only type linked with atlanto-axial dislocations? Where does the fracture occur between?

Answer 54

Type II odntoid fractures are the most common and the only type linked with atlanto-axial disocations They occur at the base of the dens between transverse ligament and body of C2

Question 55

How does atlanto-axial dislocations present? How are they diagnosed?

Answer 55

They present with * Severe neck pain * Numbness * Weakness * Movement restrictions * Respiratory distress * Lower cranial nerve dysfunctions Diagnosed using CT and MRI

Question 56

There is no uniform agreed method of treatment for atlanto-axial dislocations Which age group are they most often seen in? What is the treatment?

Answer 56

Alanto-axial dislocations most often seen in adolescents The can be treated by fusion of the atlanto-axial joint or by using a cervical halter traction

Question 57

Rheumatoid arthritis is an inflammatory process affecting the joints and ligaments in the cervical spine What joint is commonly affect in the cervical spineand how long have these people usually had RA?

Answer 57

The occipitoatlantoaxial junction is where destructive changes due to RA are most often pronounced and these people have usually had RA for at least 10 years