Upper Cervical Spine Anatomy PDF

Upper Cervical Spine Anatomy Upper Cervical Spine consists of Occiput, Atlas (C1) & Axis (C2) Joints include OA & AA Alar & Transverse Ligaments support upper cervical spine - holds the dens in place should there be an injury to the Upper cervical spine Biomechanically, OA allows flexion, extension,...

Upper Cervical Spine Anatomy Upper Cervical Spine consists of Occiput, Atlas (C1) & Axis (C2) Joints include OA & AA Alar & Transverse Ligaments support upper cervical spine - holds the dens in place should there be an injury to the Upper cervical spine Biomechanically, OA allows flexion, extension, lateral flexion - NO ROTATION Biomechanically, AA allows rotation only (70% of total cervical rotation) In Lower Cervical Spine, coupling of lateral flexion & rotation is ipsilateral ​ When a patient rotates to the right at the facet joint this is the same as side bending to the right ​ To maximally close the facets we want to extend, side bend, and rotate to the same side ○​ Example: to maximally close C5 facet on the right - extend, side bend, and rotate to the right ​ To maximally open C5 facet on the right - flex, side bend, and rotate to the left In Upper Cervical Spine, coupling of lateral flexion & rotation is contralateral ​ To maximally close the right OA - extend the upper cervical spine, side bend to right, and rotate to the left ​ To maximally open the right OA - flex the upper cervical spine (nodding), side bend left, and rotate right Upper Cervical Spine Musculature Sub-Occipital Muscles ◦ Rectus Capitus Posterior Major ◦ Rectus Capitus Posterior Minor ◦ Oblique Capitus Inferior ◦ Oblique Capitus Superior ​ These muscles form a triangle at the base of the skull ​ The triangle is found on the left and right sides ​ The greater occipital nerve runs through the triangle Origin: Axis & Atlas Insertion: Occipital Bone Action: Extension, Side-bending, and Rotation of Upper Cervical Spine ​ Main function is to hold up the head while doing activity Greater Occipital Nerve Entrapment ​ Very small muscles that tend to fatigue fairly quickly ​ When fatigued they will spasm which pinches the greater occipital nerve, causing tension headache (AKA cervicogenic headache) In patients with forward head posture the head increases its weight because of the lever that's placed on the cervical spine ​ Lower cervical spine is placed in position of flexion ​ Have to extend upper cervical spine using suboccipital muscles to work on computer, watch TV, drive Signs and Symptoms of Upper Cervical Spine Dysfunction ​ Cervical spine pain (upper or lower; many suffer from both simultaneously) ​ Headache (cervicogenic headache) ​ Decreased cervical spine ROM (particularly OA and AA ​ Neurologic / cranial nerve symptoms in upper cervical spine ○​ In lower cervical spine neurological symptoms will be seen as cervical radiculopathy or or radiating pain into the upper extremity TABLE ​ ​ Tension - extended forward head posture and spasm of suboccipital muscles ○​ Starts as occipital pain then refers to parietal region, front region, then temporal region behind the patient's eyes ​ Some patients start with cervicogenic that results in tension ○​ Often see both together because patient starts with C5 locked facet that results in spasm of paraspinal muscles, alteration of posture which results in spasm of suboccipital muscles  ​ Some patients start with tension that results in cervicogenic ○​ Start with suboccipital symptoms that results in spasm of paraspinal muscles of the lower cervical spine Cervicogenic Headache (Tension Headache / Mechanical Headache Syndrome) Cervicogenic Headache occurs in the presence of: ◦ Upper or Lower cervical spine disc dysfunction - no disc at OA or AA but both will respond to both types of treatment ◦ Upper or Lower cervical spine facet dysfunction - most common cause ◦ Upper or Lower cervical spine postural dysfunction - poor posture for an extended period of time but no tissue change ◦ Upper cervical spine instability (0.1-0.6%) ◦ Down Syndrome (10-20% occurrence, 1-2% symptomatic) ◦ Rheumatoid Arthritis ◦ Cervical spine trauma / Whiplash ​ Occipital region -> top of head -> frontal bone -> temporal region -> behind the eyes ​ No disc in OA or AA but repeated retraction exercises will cause pain to centralize from behind the eyes -> temporal region -> to frontal bone -> top of head -> the occiput before disappearing Upper Cervical Spine Interventions Manual Therapy has been found effective in treating pain, headache, & limited mobility Greater short-term pain relief with manual therapy than exercise alone Before implementing manual therapy*, patients should be screened for upper cervical spine instability and vertebral artery dysfunction ◦ *Including mobilization, manipulation, traction, or extension off the end of the table - these techniques increase risk of significant injury to the OA and AA region (UCS instability) or loss of consciousness or death (vertebral artery) ​ Therapeutic exercise is the only treatment option for UCS instability or vertebral artery dysfunction Evaluation of the Upper Cervical Spine Prone Vertebral Artery Test Supine Vertebral Artery Test Sharp-Purser Test Alar Ligament Test Transverse Ligament Test ​ Gold Standard Reference Test is plain radiograph (or MRI) assessing atlas dens interval (ADI). ADI of greater than 3-4 mm is considered abnormal ​ ADI is the space between the dens and the front of the atlas ​ ADI greater than 3-4 mm is indicative of injury to alar ligament or transverse ligament, or both ​ The ligaments hold the dens in place so there is no movement of the dens which could result in injury to the spinal cord ​ If ligaments are stable - patients can do normal activities and movement ​ If ligaments are unstable - the dens is able to move posteriorly towards the spinal cord and can result in impingement or other spinal cord injury such as quadriplegia or tetraplegia (cause them to be on respirator and use of power wheelchair ​ Important to clear UCS in collision athletes (more likely to suffer spinal injury due to axial load) Prone Vertebral Artery Test Patient Position: Prone with patient’s hands under chin Force Application: Patient uses hands to move upper cervical spine to end-range extension for 10+ seconds while clinician performs cranial nerve screening (screen CN II, III, IV, V, VI, VII, VIII, IX, X, and XII) Positive Test: Dizziness, nausea, or abnormal cranial nerve function Diagnostic Accuracy: 10 Sens Spec + LR - LR N/A N/A N/A N/A Supine Vertebral Artery Test Step One Hold each position for a minimum of 10 seconds while assessing CN function Positive test is dizziness, nausea or abnormal CN function Step Two Also known as the Progressive Minimized DeKleyn’s Test Progress from steps 1-4 only if test is negative Step Three:Hold each position for a minimum of 10+ seconds while assessing CN function Positive test is dizziness, nausea or abnormal CN function Step Four: Also known as the Full DeKleyn’s Test Diagnostic Accuracy: Sens Spec + LR - LR N/A N/A N/A N/A Sharp-Purser Test Patient Position: Seated with slight upper cervical spine flexion Hand Placement: One hand on forehead, one hand on C2 (to find the C2 find the external occipital protuberance, move inferior to it, then 1 finger below that space) Force Application: Force is applied posteriorly through the patient’s forehead and anteriorly at C2 Positive Test: Feeling of instability (“clunk”) or neurologic symptoms ​ Great for ruling in UCS instability and tests both ligaments at once ​ Should perform this on someone that suffers an axial load injury, whiplash, cervicogenic or tension headaches Diagnostic Accuracy: Author ​ Sens Spec + LR - LR Matthews ​ 0.19 0.71 0.67 1.13 Stevens ​ 0.44 0.98 28.44 0.56 Uitvlugt ​ 0.69 0.96 15.64 0.33 Alar Ligament Stress Test Patient Position: Supine Hand Placement: One hand on SP of C2, other hand on the occiput, apply gentle compression with clinician’s shoulder on crown of head Force Application: Clinician passively side bends occiput while stabilizing C2 Positive Test: Failure to feel ligamentous end-feel, indicating alar ligament injury Diagnostic Accuracy: Author ​ Sens Spec + LR - LR Kaale (Right)​ 0.69 1.00 94.09 0.33 Kaale (Left)​ 0.72 0.96 16.37 0.29 Transverse Ligament Stress Test Patient Position: Supine with eyes open Hand Placement: Fingers of both hands placed over “posterior arch” of C1 Force Application: Clinician attempts to move occiput and C1 anteriorly on C2 (hold position for 10+ seconds) Positive Test: Cranial Nerve Symptoms indicating instability of the transverse ligament Diagnostic Accuracy: Author ​ Sens Spec + LR - LR Kaale​ 0.65 0.99 51.44 0.35