Vertebral artery Flashcards
What percentage of blood does the vertebral artery supply to the brain?
20%
Where does the vertebral artery arise?
subclavian artery
Portions of the vertebral artery?
- Proximal
- Transverse
- Suboccipital: most vulnerable
- Intracranial
Suboccipital portion of the Vertebral Artery
Extends from its exit at the axis (C2) to its point of penetration into the spinal canal
Where is the vertebral artery most vulnerable to compression and stretching?
C1–2 with Cervical rotation
The artery vulnerable to impingement from the following?
Cervical extension at the CV joints
Excursion of the transverse mass of C1 during rotation
Ossification of the atlantoaxial membrane
5 D’s And 3 N’s
Dysarthria (difficulty with speech) Dysphagia (difficulty swallowing) Drop attacks (blacking out/passing out) Dizziness Double vision Ataxia Nausea/vomiting Numbness Nystagmus
Other symptoms for vertebrobasilar artery insufficiency:
Lightheadedness Disorientation and anxiety Tinnitus or other hearing disturbances Pallor, tremors and sweating Other neurological symptoms Neck pain and HA’s
Differentiation of Vestibular symptoms (BPPV) from VBI
The type, degree, frequency and duration of the dizziness or other symptoms
• The production or aggravation of the symptoms by neck movements
or sustained positions, particularly
those involving rotation or extension
• The temporal history of the symptoms relative to the history of the
patient’s complaint
• The status of the symptoms
• Any previous treatment and its effect on the symptoms.
CONTRAINDICATIONS AND PRECAUTIONS FOR GRADES I–IV JOINT MOBILIZATION
hypermobility/instability inflammation or effusion hard end feel medically unstable acute pain that worsens acute radiculopathy bone disease or frature spinal arthropathy blood clotting disorder
Relative precautionss of joint mobilizations:
malginancy total joint replacement bone disease connective tissue disorder pregnancy recent trauma early healing stages inability to communicate steroid usage rashes/open wounds elevated pain levels
Signs and Symptoms of Cervical Instability
Severe muscle spasm • Patient does not want to move head (especially into flexion) • Lump in throat • Lip or facial paresthesia • Severe headache • Dizziness • Nausea • Vomiting • Soft-end feel • Nystagmus • Pupil changes
Trauma patient eval:
Subjective with detailed VBI and trauma history
Canadian spine rules include a brief AROM screen before you ever to anything else to the patient
If the passes VBI and Canadian Spine Rules progress to evaluation
Cervical Instability testing is done first before any further evaluation occurs
AROM, PROM, MRS,
Functional Movement Screening
Special Test
No history of trauma:
Subjective includes brief VBI screen AROM, PROM, MRS Hypermobile vs Hypomobile determination Functional Movement Screening Special Test Treatment
Canadian C-Spine Rule’s For Acute Trauma patients
- Are they cognitively intact?
- Are they under 65 y/o?
- They can move more than 45d Rot (even if it causes pain)?
- No crazy injury circumstance (distraction/high speeds, etc.)
- No pain at rest in midline?
- No Paresthesia in arms following trauma.
Check the ligament integrity in the upper cervical spine
Modified Sharp-Purser Test
Alar Ligament Stress Test
Transverse Ligament of Atlas Test
VBI signs
5 D’s and 3 N’s Vomiting Visual disturbances Severe HA’s Weakness in Extremities Sensory changes in face or body Facial Paralysis (motor changes) Lightheadedness Hearing difficulties
Non-VBI Conditions
BPPV Migraines Anemia Meniere’s Facial Palsy
Modified Sharp Purser
Head flexed to 30d. Then assess symptoms
Pressure on forehead with palm while blocking C2 spinous with pincher grip-assess symptoms
While continuing posterior translation force gently flexed the head further than 30d
Positive modified sharp purser:
reproduction of myelopathic symptoms during forward flexion or
Decrease/reduction in neuro symptoms during an anterior to posterior movement or
Head slides back (excess displacement during the AP movement).
Who should always have sharp pursers performed?
Patient with RA, Ankylosing Spondylitis, and Down’s Syndrome
Alar ligament stress test
Neck Slightly flexed
Hold C2
SB or Rotate patients head
C2 should move opposite direction instantly or within first 20-30d
Longitudinal Ligament/Tectorial Membrane
Posterior Atlanto-Occipital Membrane Test
Patient Supine or Sitting in neutral spine or slight flexion
Fixate axis with lumbrical grip
Distract occipit until end-feel
Positive: Instability Symptom
Transverse Ligament test/Upper Cervical Flexion test/Reverse Sharp Purser/Anterior translation Stress Test
patient supine position.
contact the posterior aspect of the bilateral C1 transverse processes with their fingers.
The palms of the clinician are placed under the occiput of the patient.
Lift the head and C1. (The clinician applies an anterior force to the C1 transverse processes with his or her fingers lifting the head as the force is applied
This position is held for 15–20 seconds, and if no symptoms occur the clinician can apply a downward force on the patient’s forehead using the anterior aspect of the shoulder.
Priority tests for cervical instability:
Sharp Purser, Membrane Test, Alar Ligament Test
Neck flexion
C1,C2
Neck side bending
C3
Shoulder elevation
C4
Shoulder abduction
C5
Elbow Flexion
C6
Wrist extension
C6
Elbow extension
C7
Wrist flexion
C7
Thumb extension
C8
Finger abduction
T1
Biceps reflex
C5, C6
Triceps reflex
C7 C8
Upper Limb Tension test 1
median nerve, anterior interosseous nerve
C5-C7
Upper Limb Tension Test 2
median, axillary and musculocutaneous nerve
Upper Limb Tension Test 3
radial nerve
Upper Limb Tension Test 4
Ulnar nerve C8,T1
Provocation Tests
Upper cervical flexion rotation test
Upper limb tension tests
Foraminal compression tests
Vertebral artery tests
Symptom relief tests
Distraction test
Shoulder abduction test
Three Muscles Most Commonly Implicated with Headaches
SCM
Upper Trap
SOC (Superior Obliquus Capitis)
Shoulder Abduction (Relief) Test screens what nerve levels?
C4-C5 or C5-C6
Injury of occipital-atlanto region can lead to
cognitive dysfunction
cranial nerve dysfunction
sympathetic system dysfunction
Symptoms of injury to cervicobrachial region (C3-C7)
neck and/or arm pain headaches restricted ROM paresthesia altered myotomes and dermatomes radicular signs
Sub-divisions of sub occipital portion of vertebral artery
w/in the transverse foramen of C2
b/w C2 and C1
In the transverse foramen of C1
b/w the posterior arch of the atlas and its entry into the foramen magnum
