Week 8 Notes - 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 sidebends 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 Treatment of Cervicogenic Headache 1) Sub-Occipital Release (SOR) ◦ Treatment time 5-10 minutes ​ Patient supine, clinician takes fingers and craddles the occiput and places continuous pressure on the sub-occipital muscles. ○​ Dim lights in private room ○​ Not pushing fingers into the occiput but cradling it and allowing the weight of the head to rest on the clinician’s fingers ○​ It’s essentially a counter strain technique which allows relaxation of those muscles to occur ○​ DUring the technique the patient may demonstrate centralization of their headache symptoms where the pain moves back into the center of the spine and eventually disappears. ○​ After completing the release, allow the patient to stay in that position and rest their head on the table for a couple minutes, not sit straight up or headache many return. 2) Inion Traction ◦ 5-10 pounds of pressure ◦ Treatment time 5-15 minutes ​ Clinician places forearm at the base of the patient’s occiput, the clinician starts of with the forearm supinated so that the radius is resting right along the patient’s occiput, the other hand goes on the patient’s forehead. ​ The clinician simply pronates their forearm from a supinated position to a neutral position. This provides a traction on the cervical spine. ​ It is a very comfortable position for the clinician and can be held for an extended period of time and is very comfortable for the patient as well. ​ Treatment time is usually 5-15 minutes. 3)Muscle Energy Techniques ◦ Seated(preferred) or Supine -​ Purpose is to unlock the upper cervical spine facets ◦ Patient positioned in slight flexion, side-bending, and rotation away from involved side ◦ Patient completes 50% sub-maximal isometric contraction -​ Looking up and over their shoulder -​ ◦ Isometric contraction held for 5 seconds ◦ Clinician then passively moves patient into MORE flexion, side-bending, and rotation away from involved side ◦ Treatment is repeated for 3-5 repetitions -​ Basically looking at their armpit away from involved side and then looking up and over their shoulder -​ May get a cavatation/mobilization of the facet 4) Repeated Retractions (10 repetitions /per hour)* -​ Very effective for treating cervicogenic h/a -​ Even thought there is no disc at OA or AA, the patient will still respond as if there is when they perform repeated retractions Progression starts at top of the list, and if it doesn’t work, move down to the next one until you get resolution of the symptoms, only requires one of these techniques ◦ Retractions in Sitting -​ Start with this first because the patient can perform this on their own easily at any time ◦ Extension in Sitting ◦ Retraction/Extension in Sitting ◦ Retraction in Supine ◦ Extension in Supine ◦ Retraction/Extension in Supine ◦ Traction/Retraction/Extension in Supine off the end of the table -​ TIP: when patient is performing retraction, tell them to not let you hit there nose, and they go back further. This ensures that they go all the way to end range to receive the maximum benefit. 5) Upper Cervical Spine Stretching ◦ Seated(preferred) or Supine ◦ Patient Generated Stretch ◦ Clinician-Assisted Stretch ◦ 2-3 repetitions, held for 30-60 seconds to get maximum elongation of upper cervical spine muscles -​ Patient should retract first, then while maintaining retraction should nod (basically a very small flexion movement of the upper CS)(overpressure). There will be lots of pressure along the occiput. -​ You can also have patient place fist beneath their chin and then perform a nodding motion with some overpressure. 6) Mobilization of the Thoracic Spine ◦ Grade V rotational mobilization / manipulation of thoracic spine ◦ Evidence recommends thoracic spine thrust mobilization to decrease cervical spine pain (decreases upper and lower cervical spine pain) Thoracic Spine Manipulation CPR Clinical Prediction Rule to identify patients with cervical spine pain who are likely to benefit from thoracic spine manual therapy Findings for general cervical spine pain, not just upper cervical spine pain Signs & Symptoms Criteria ◦ Symptom duration < 30 days ◦ No symptoms distal to shoulder ◦ Cervical extension does not increase symptoms ◦ FABQPA score < 12 ◦ Diminished upper thoracic spine kyphosis ◦ Cervical extension ROM < 30 degrees 7) C7-T1 Mobilization / Manipulation ◦ Grade V traction mobilization / manipulation of C7-T1 -​ Several different ways but pictured is best. Clinician is gonna perform a traction/lifting technique with the patient in a seated position. Excellent for getting a cavatation at C7-T1. Effective for treating both upper and lower cervical spine pain. ◦ Study examined 20 college-aged students with c/o cervical and thoracic spine pain. One session of C7-T1 seated mobilization resulted in decreased pain, deceased pain pressure threshold, but no change in shoulder strength(hypothesized that RC cuff would increase by releasing the suprascapular nerve but did not see the change). 8) C1-C2 Self-Snag Technique ◦ Self-Sustained Natural Apophyseal Glide (SNAG) using a towel -​ Can be performed by clinician (headache SNAG) ◦ Designed to decrease pain in upper cervical spine and increase ROM in patients that have a locked upper cervical spine facet or an inflamed upper cervical spine facet ◦ Research shows that this technique results in decreased headache pain (by 54%) when compared to a placebo treatment 9) Mobilization of the Cervical Spine (not recommended, more of a last resort) ◦ Grade IV rotational mobilization of the cervical spine -​ Risks involved, can cause injury to vertebral artery ◦ Used to treat upper and lower cervical spine ◦ Beneficial for patient with cervicogenic headache ◦ Evidence recommends combining Grade IV mobilization with therapeutic exercise 10) Postural Education / Correction -​ Most have poor posture, forward head posture, -​ Common in students, people at a computer, answering phones ◦ Lumbar Roll / Cervical Roll  -​ Placing one at the belt line addresses posture at the lumbar spine which helps to correct cervical spine posture (helps get them out of the forward head posture) ◦ Headrest While Driving -​ Use headrest, adjust mirrors ◦ Slouch-Overcorrect (15 times / hour) ◦ Ergonomic Assessment of Workstation ◦ Visual Cues - green dot on computer to remind them