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86 Cards in this Set
- Front
- Back
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Anatomical and clinical anatomical components of the neck
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Anatomical components: 7 cervical vertebrae
Clinical anatomical components: occiput atlas and axis (C1 and 2) Remaining Cervical vertebrae Cervicothoracic junction Upper thoracic spine (1st 4 or so are like lower cervical) Temporomandibular joint |
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Symptoms/signs associated with neck disorders
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clinical symptoms/signs commonly seen
Neck -neck pain -Neck pain with UE symptoms/signs (radicular vs. referred) - headaches - intricate reflex mechanisms -neck pain w/ myelopathy s/s - sleep disturbances - common - elevated levels of stress (ask about lvl of stress 0-10 and observed relationship between stress and pain. Explain there's different kinds of stress and that it is related) |
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What are influences on perception of pain
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chemoreceptor
mechanoreceptor biopsychosocial Figure out what is the biggest influence If majority is biopsychosocial (stress, diet, etc.) and you're treating it just mechanically, it's not going to be that effective |
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General rule to figure out what to do w/ pts w/ upper quarter problems
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notes say
- motions of neck meant to optimize sense organs - so mobility is usually what you're working for - in low back, mobility is 2nd to stability on slide about perception of pain coming from chemoreceptors, mechanoreceptors, and biopsychosocial factors |
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Mechanical Neck Syndromes
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Spondylosis - age-related changes (spondylo)
Acceleration (WAD) injuries - soft tissue injuries related to speed and acceleration. Whiplash associated (WAD) is sub-category Overload of specialized connective tissues as a result of prolonged postures/loading conditions - postural issues |
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What is on the most important slide in the Clinical Anatomy of the Neck powerpoint?
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Shows the articular pillar - BAM!
-why mobilization/manipulation of c-spine can be precise 1. Articular pillar -top is superior facet, bottom is inferior facet - column of bone -put PIP in divot of pillar 2. Transverse foramen is other big difference (in c-spine) "Dense-ist" innervation of synovial jts. is in cervical spine. Vertebral artery test is not reliable for vertebral artery disease, but good for assessing response to motion. Talk to them while moving neck around. Won't be able to move to extreme range of motion. Dizziness - inner ear, vertebral artery, or facets |
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Orientation of facets in c-spine
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Transverse plane (kinda oblique)
Articular pillars in between facets Incline orientation is key |
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Age-related and degenerative changes of the central core
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Spondylosis
-neck pain (localized to neck) - Neck pain with referral (shoulder, etc.) - Radicular pain (worse than neck pain?) - myelopathy Ask questions several different ways to figure out referred and radicular pain Myelopathy - AZ has old active people with degenerative changes. Windsurfing - extreme ROM traumatizes S.C. |
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Cervical spondylosis
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Neck pain or neck pain with referral
-anatomical focus of these "wear and tear" degenerative changes Articulations - intervertebral disc, uncinate joints, apophyseal joints Uncinate - "hook-shaped process on the lateral borders (side edges) of the superior (top) surface of the vertebral bodies of the third to the seventh cervical vertebrae and first thoracic vertebra. This bony part prevents a vertebra from sliding backwards off the vertebra below it " |
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The cervical intervertebral disk
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nucleus 25% at birth
minimal by 3rd decade Not as hydrous as lumbar spine and motion is different disk structure allows for attenuation of motion Not as much surgical DISC stuff in c-spine (still see fusions, facetectomies, etc.) |
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Unciform Joints
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Vertebral bodies are more beveled than in T & L spine
Lateral processes = unciform Gliding occurs at unciform joints Creates body border that nuclear material can't escape past Also blocked by PLL, so doesn't usually escape into canal |
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Axis of motion in C-Spine
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Major functional difference
Axis is in transverse process area - not middle of disk! Vertebral artery runs through transverse processes - not too much distortion put on it from C2 down because the least distortion happens right at axis But, route is intense from C2 to basilar artery Most c-spine deaths happen from distortion of C1, C2, vertebral artery spasm - hypoxia to B. Stem |
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How do facets glide during c-spine motion?
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R rotation = up glide (flexion) on left
Down-glide (ext.) on right |
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Distribution of compressive load in C-spine
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Another major difference in C-spine
36% anterior 64% posterior Posterior neural arch -> responsible for majority of load transmission -> loss of arch (surgery) comprises stability of arch So, see fusions, not just laminectomies or facetectomies because posterior structures are weightbearing an loss of arch comprices stability Don't get facet degeneration earlier than in lumbar, but people with previous injury from trauma have more point degeneration (e.g. 26 year old who was in auto accident as 16 year old) |
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Mechanical and biochemical synovitis from facet degeneration
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Synovial joint!
Innervation of facet jt. capsule is greater than any other in body. Sense organ reflexes are tied in (watch bird across the sky, turn toward voice) People experience not just pain, but balance issues Neck feeds proprioceptive /kinesthetic info to CNS |
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Referred pain from cervical apophyseal joints
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From studies with injected irritants
Overlap of dermatomal regions, but generally moves inferiorly. C2-3 at back of head/upper neck C3-4: Lateral aspect of neck and upper shoulder C4-5: back of neck C5-6: Upper edge of shoulder C6-7: back of scapula Neck pain much worse than referred, but referred found in these areas Facet degeneration produces unilateral pain (at least on side is worse than the other) |
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Nerve root involvement of C-spine
levels involved related to areas of |
increased motion
increased shear stresses Degenerative changes (spondylosis) C5-6 C4-5, C6-7 See most problems in these areas, most motion |
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Anatomical "hazards" to nerve root complex
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Osteophytes:
-uncovertebral joints - apophyseal joints Chemical insult of nucleus pulposus Degenerative changes of annulus fibrosus |
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Facet has intimate relationship with what structure, which can lead to what issue?
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nerve root
-inflammation Bone spurs on UP or facet joint can compromise nerve root |
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Pathomechanics of nerve root injury
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Mechanical compression + inflammation around nerve root
Induces more nerve root injury than each factor alone |
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Features of nerve root irritation
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Symptoms:
Extremity pain > spine pain Quality of pain differs from referred pain (more intense) Clear demarcation of pain pattern in extremity Proximal pain and distal paresthesias Neural tension testing reproduces extremity pain gentle spinal motions result in excessive irradiation |
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Features of nerve root compression
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Signs:
Muscle wasting muscle weakness sensory impairment quality of reflexes altered AP can't travel down axon More likely to see post-surgery |
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What is the hallmark of nerve root irritation
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Proximal pain and distal paresthesias
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Presentation of C5 nerve root issues (irritation)
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upper arm and shoulder pain
elbow paresthesias weakness -deltoid -supraspinatus -shoulder external rotators - elbow flexors Altered biceps reflex |
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Presentation of C6 nerve root issues (irritation or compression?)
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pain pattern toward anterior elbow
paresthesia of radial forearm, thumb Weakness -shoulder external rotators - elbow flexors - radial wrist extensors Altered brachioradialis reflex |
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Presentation of C7 nerve root issues (irritation/compression)
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Most frequently involved
pain pattern posterior forearm paresthesias in ring, long, and index fingers Weakness - triceps -wrist extensors - wrist flexors Altered triceps reflex |
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Presentation of C8 nerve root issues (irritation/compression)
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interscapular pain
medial arm pain paresthesias ulnar forearm weakness - ulnar wrist flexion - flexor digitorum profundus - hand intrinsics - thumb |
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Spinal cord involvement as result of cervical spondylosis leads to
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myelopathy
Remember the vasculature - affects CNS function Cervical extension narrows canal and "clogs" up vasculature |
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Contents of spinal canal
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vasculature
connective tissues -specialized -non-specialized Neural tissue Cerebrospinal fluid Adipose tissue |
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How much of the spinal canal is taken up by the cord in the neck?
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Cord occupies 1/2 of canal in upper C-spine
- lots of margin for error - bone spurs might not compromise cord Cord occupies 3/4 of canal lower down (around C6) Brainstem can also slosh around in there and get hurt |
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Descending tracts of SC
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Anterior/medial corticospinal tract
Lateral corticospinal tract Rubrospinal m/l Reticulospinal tracts m/l Vestibulospinal tracts |
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Ascending tracts of SC
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D &V Spinocerebellar
Dorsal columns - proprio Ant Spinothalamic - Spinotectal Lateral spinothalamic - pain |
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Myelopathy
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Myelopathy - term for compromise of spinal cord (not just anterior horn according to Dr D)
Gait complaints - #1 complaint - not bizarre like ataxia -looking at the ground to avoid tripping -compromise to dorsal columns proprioception LMN reflex and motor changes at level of lesion Loss of hand dexterity UMN signs below level of lesion Hoffman sign Deep burning sensation in spine |
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Fascial arrangement in the neck:
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Compartmentalization
Highly compartmentalized Easy region to do an operation on move components to get to central core, so surgical risk is actually lower |
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What structures are stressed w/ whiplash injury?
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Because of axis, lots of stress on anterior structures w/ whiplash injury
Sympathetic chain runs up carotid sheath - may report excess sweating/vasoconstriction on one side Let people know they're not crazy for having weird symptoms - lots of structures anterior to axis Trachea Muscles |
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Attachments of trapezius muscles and what will you see if you dissect them away?
Relationship with anterior neck flexors |
Attaches occiput and cervical spine.
They must be fixed for scapular movement. Synergistic relationship between trapezius (action over scapula) and anterior neck flexors People with whiplash injuries can't move their shoulders because neck flexors were stretched and they can't stabilize (longus coli, longus capitus) |
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Deep anterior neck flexors
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longus capiti
Longus colli Primary role in stabilizing neck and head also flex |
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Position for treatment of acute whiplash injury
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may have lying on bench at 45 degrees, support head and neck with pillow
Do arm exercises with band (flexion) Requires good scapular motion Prevent extension (of what?) |
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Sternocleidomastoid
"muscle collar" |
muscle collar of SCM and Trapezius with SCM anterior and Traps posterior (see picture)
Traps and SCM are one in some animals - innervated by same nerve (spinal accessory) Form collar of muscle. Can act at C1 and C2 Trauma to side of neck can cause palsy to CN XI |
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Why is there an art to stretching the SCM?
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part is anterior to axis and part is posterior
So, mm. has lots of different actions Relevant to torticollis Actions - extension?(occipit tips into ext so eyes look up), contralateral rotation, axial flexion, (forward glide...??) |
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Motions of SCM
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Brings head/neck forward -axial flexion
Furthest from axis- more damage in tension Occipital extension Cervical flexion Lateral bend Contralateral rotation Ppl with extension injuries move head forward. OK to wear collar backward as long as they're doing movement. |
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How to stretch right scalene muscles
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Attach: Ant aspect of transverse processes down to rib
To stretch: Axial ext R rotation (is that true?) Side glide left Must stabilize rib |
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Track of the neurovascular bundle (in the neck)
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Between scalenes (ant and mid)
Costoclavicular space under pectoralis minor Some surgeons don't start with conservative treatment b/c ant. scalene tendon can't be stretched Elevated rib or depressed clavicle compromises costoclavicular space Diagnosis made through combo of cervical position, postural, and movement of rib and/or clavicle |
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Brachial plexus and neurovascular bundle of upper quarter - involved in what condition?
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Thoracic Outlet
More controversy about TOS than you realize Compromise of neuroVASCULAR buncle Provocational stresses to jts. Postural positioning of shoulder 60-70% of physicians don't buy into TOS - don't know so call it TOS Need vascular as well |
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Importance of abdominal wall in upper quarter syndromes
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Abdominal wall - relationship of thorax and pelvis
Weak - collapse over abdominal cavity Forward head/neck Scapula roll around ribcage IR of Humerus Impingement (it's a chain of motions/events!) To assess pec minor tightness - supine w/ med scapula off table, push down and back through long axis of humerus Ab weakness diff to test in ppl w/ back pain Forward head position -> increased compression on cervical facets |
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Abdominal wall functions
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Controls the relationship between abdominal wall and thorax
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Splenius muscle group
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Latin for bandage
Deep to trapezius From spinous processes attach to cervical transverse processes and mastoid process Actions: Extend rotate (ipsi) on same plane as levator scapulae muscles |
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Levator Scapula Muscle
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Almost exactly like Deep ES - goes up and forward to cervical transverse processes, twists on itself
Creates compression and posterior shear Degeneration of muscle fibers happens with rotator cuff issues Degenerative changes - obligatory anterior shear People think they're finding levator trigger points when it's really supraspinatus From superior angle and medial border of scap to T processes of C1-4 Head/neck forward - elongation of levator |
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Is lat pull-down a good exercise?
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If done within physiological limits of glenohumeral joint and levator scapula loading
But, common injuries with theses exercises Not enough shoulder ROM -> clear bar by bringing head forward - tension on levator then loading w/ weight Vulnerable position of GH capsule |
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Stretching Ant and Mid scalene
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extension
IPSIlateral rotation (Tprocesses move away from front) Side glide away depress/stabilize rib |
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Stretching levator scapula
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axial flexion
contralateral rotation side glide away Depress scapula toward armpit |
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Stretching upper trapezius
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Flexion
IPSI-lateral rotation (spinous processes away) Side glide away (laterally flex also?) Depress scapula |
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Stretching pec minor`
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With scapula hanging off table (in supine), push humerus down and back
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Semispinalis muscle group
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Column of muscle you palpate
Starts transverse processes - runs medial to spinous processes and base of occiput (like multifidus) Articular pillar just lateral Head always has flexion moment Semispinalis creates powerful extension force Traction on semispinalis -maintains neutral position Head jerk when falling asleep in class (semispinalis turns off) using the lateral border of semispinalis to palpate cervical articular pillar Traps and splenius are flat Lateral to convexity of semispinalis |
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Upper cervical spine
lower C-spine |
Upper - Occiput, C1, C2
Lower - All below C2 Separate them because they have different anatomy and biomechanics |
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Articulations of upper c-spine
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Occiput on Atlas (O-A)
- R&L occipital condyles (large prominences sit in "cups" of C1. Rocks in flexion/ext. Head impact explodes the axis. Sometimes brainstem is not compromised because of strong ligamentous support. Called Jefferson's fracture) Atlas on Axis (A-A) -R &L apophyseal joints -Odontoid process and arch of atlass -transverse ligament and odontoid process (prevent compromise of BS and SC. T-lig runs between condylar articulations - majority of cervical rotation (50%? 90*) - can assess by side bending to R (causes R rotation) then turning head to L. use position for treatment too |
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How much motion is there at the articulation between the occiput and atlas?
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40-45* (or 30-40*) occipital motion in flex/ext
Not much motion in rotation or side bend Can have forward head but still look up (axial flexion and occipital ext) No vertebral body - like a washer Developmentally - C1 body joins C2 to make Dens |
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Ligaments of atlas/axis
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Alar ligaments - attach tip of odontoid to occiput - direct connection of c2 to occiput
Test - sidebend occiput and feel immediate movement of C2 spinous process (test for weakened connective tissue usually. Ruptured alar lig not compatible with life) PLL-Transverse ligament complex - behind the dens- stretches across and keeps it from moving posterior within atlas Inferior oblique? is this something separate or part of alar ligs? |
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Transverse ligament
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Keeps dens/odontoid in place
There is some give/play in the ligament to allow for flexion of the occiput Potential to fracture odontoid with high velocity flexion/extension (example of strength of the ligament) |
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Muscles of suboccipital triangle
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Attachments are general
Rectus Capitus Posterior Major - across 2 segments, C2 to occiput, extension force Rectus Capitus Posterior Minor - across 1 segment, C1 to occiput, ext force Superior Oblique - C1 to occiput, helps create extension of O on A Inferior Oblique - C2 (spinous) to C1 (transverse), biggest cross-section, powerful rotary force, can palpate Create triangle with Rectus medial and obliques on side lengths |
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Where is the greater occipital nerve?
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Under the inferior oblique muscle
-runs up back of occiput to top of head - ram's horn headache - nerve pierces superficial muscles (Look at pictures!) Layers: skin Trapezius Splenius Semispinalis Suboccipital mms Greater occipital nerve = posterior ramus of C2 |
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What is the path of the vertebral artery in the upper c spine?
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tortuous route - makes 5 90 degree turns from bottom of C2 to basilar artery
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What is the posterior ramus of C2 called/
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greater occipital nerve
-sensory nerve that pierces semispinalis, trapezius, and splenius (and suboccipitals, or are those already accounted for?) |
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3 potential pathologies in C1/C2 region
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1st - continual prolonged contraction of muscles -> altered sensation in greater occipital nerve
2nd - potential pathology - arthritis of facet of C1/C2, neck pain, headache 3rd - whip into extension - loss of space and nerve compression between c1 & C2 (lamina. no disk) |
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What to look at with ram's horn headache
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muscle, health of joint, discomfort with loading quadrants
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Anatomical features of C2 Dorsal root ganglion
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Occupies 76% of foramen height
Lies on posterior surface of C1-C2 apophyseal joint Compressed between arch of C1 and lamina of C2 with combined rotation and extension In subpedicular recess of IVF |
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Clinical syndromes: C2 nerve root ganglion
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Cervicogenic headache
-unilateral, no neck sideshift -constant, dull, aching, non-pulsatile -provoked by head and neck movements Potential etiologies - ganglion compression from hyperextension -- rotation whiplash injury -C1-C2 facet arthritis |
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Applying clinical anatomy of the c-spine to syndromes of the neck and thorax - acceleration injuries
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Acceleration injuries
-neck pain -" " w/ referral - radicular pain - visceral disturbances * - Autonomic disturbances * - Thoracic pain - Rib pain -CNS signs/symptoms * * tend to go unrecognized. Pts. feel crazy |
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What are the impacts (what hits what) during a whiplash injury
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head tossed into extension or ext/sidebend - back of occiput hits thorax
Then thrown forward Chin and sternum stop motion |
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What are some things that are injured in whiplash injuries?
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Mandible is pulled down by anterior musculature - jaw problems
Soft tissue heals quickly - 8-12 weeks Facet jt. injuries (subchondral bone, cartilage)) and autonomic/CNS issues take ~1 yr to resolve Carotid sheath has CNS structures and vasculature Visceral tube - trachea and esophagus Lots of small strap muscles in front of throat - sternum to hyoid - regulate trachea for speech, open mandible |
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What is in the carotid sheath?
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Common carotid artery and internal carotid
Internal jugular vein Vagus nerve Upper part of sheath CN IX, XI, XII Not in sheath but in wall: sympathetic chain Structures damaged in extension - trouble swallowing pills - 1 side of face warmer, sweats more - voice sounds different (trachea) |
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Autonomic nervous system symptoms from whiplash
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SNS
Preganglionic cell in T and upper L spinal cord (thoracolumbar outflow) T1-L2 Preganglionic axon travels to sympathetic chain -synapses at that level with postganglionic nerve -travels up or down chain to synapse with postgangionic nerve Passes through chain to synapse on ganglia located in abdomen (celiac, superior mesenteric, inferior mesenteric) -Passes thru chain to synapse directly with adrenal gland Post ganglionic axon leaves ganglion & travels to target organ (smooth muscle, cardiac muscle, or gland. no other targets) |
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Thoracic considerations - multiple rib fractures
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picture of healing of multiple rib fractures from MVA
bony callouses potential for involvement of sympathetic chain |
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Classification of musculoskeletal and/or CNS symptoms from acceleration injuries in Cspine
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Cervico-encephalic - neck and evidence of concussion
Cervico-brachial - neck pain and UE complaint |
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Complaints from Cervico-encephalic syndrome
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headache
vertigo fatigue poor concentration noise/light irritabilitiy - trigger headaches cognitive dysfunction Ppl need to know there's a reason why they're feeling this. Can't speed up process, but knowledge is therapeutic |
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Cervicobrachial syndrome
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neck pain
neckpain with referral radicular pain |
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Mandible only articulates on
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temporal bone
Different occlusal relationship between teeth with occipital extension motions of occiput affect loading of TMJ |
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What does it mean if the jaw deviates to the left while opening?
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1. hypomobility on R
2. hypermobility on L |
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What are some attempts to fix TMJ disfunction
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file teeth
splints mouthguard |
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TMJ disc
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disc creates 2 different joint cavities
First movement in opening: Occurs between disc and mandible -hinges Further opening: anterior translation of both disc and condyle Retrodiscal Pad - the pain sensitive tissue - part of jt. complex - protrusion of jaw unloads that |
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Muscles of mastication
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masseter
Temporalis Medial pterygoid - attaches on inside of mandible (deep to masseter), north/south orientation Lateral pterygoid - east/west orientation Digastric and hyoids assist opening of mouth All supplied by trigeminal nerve |
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Medial and Lateral pterygoid muscles
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Lat - protrudes jaw, pulls dic anteriorly (east/west orientation)
Med - side to side jaw movement (north/south orientation) |
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Main message about muscles of mastication
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lateral pterygoid creates anterior translation
proprioceptive training to teach limits |
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Forward head posture
Causes and effects |
Facet syndrome (facet jt. compression - irritation of facet can cause referred pain to shoulder),
suboccipital tightness, headaches, anterior neck musculature (shortening of anterior structures - changes had at TMJ - Lots of mouth breathers (open mouth unless you actively contract muscles) - ear aches, jaw pain (from constant contraction) |
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Hollistic approach to neck pain
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pain source influenced by lots of inputs
Inflammation Altered mechanics Personality (magazines out of place...) Stress Diet/medications Smoking Temperature/humidity (barometric pressure affects equilibrium) Senses - hyper Quality of sleep (fibromyalgia - inability to get last REM sleep) Pathology |
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Intricate "balance of head, neck, and TMJ and response to pain threshold
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semispinalis creates extension
Superior oblique - ext Longus capitus - flex Hyoids - flex Temporalis and masseter going up |
