CCE4 MT*

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1.

2.

3.

5 Ds and 3 Ns
(Vertebrobasilar
Ischemia)

*Dizziness
Diplopia (double vision)
Dysarthria (difficulty speaking)
Dysphagia
Drop Attack (sudden fainting spell)
Ataxia (difficulty walking)
Nystagmus (have only some fields
of vision)
Nausea/Vomiting
Numbness on of face or of
trunk*

94% of the VBA strokes

that occurred ______

during SMT were during

rotational & extreme extension
positions

ADI (Atlantodental
interval)

Lateral cervical x-ray in neutral and

flexionmore sensitive (stress)

Basilar
occlusionLocked
In Syndrome (less
common, more
severe, really
rare!)

All sensory portions remain intact

(therefore CNVIII is preserved
auditory in)

11.

Big Uns/ Large

Muscles

levator scap
traps
erector spine
semispinalis
Splenius Cervicis & Capitis

12.

Boundaries of
the IVF

Pedicles
Body, disc, Luschka joint
Pillars, Zyopophyseals

13.

Brudzinski's:

tests for Meningitis, + finding= patient

buckles the knees upon neck flexion
meningitis confirmed w/spinal
tap=look for WBC's bc bacterial
infection

14.

C7 nerve root:

Extends elbow, flexes wrist, extends

fingers

15.

Capsular
Ligament has the
___ ____ of
innervation and
is ___ _____

Highest concentration of innervation

and is pain sensitive

16.

Cervical
Compression:

significant force to increase pressure on

foramen to increase pain
Neutral
Jacksons: rotate and compress
Maximal Compression (Cervical Kemps:
Lateral flexion, contra. Rotation,
extension)
Quadrant: lateral flexion + rotation
Spurling: compress w/impulse in neutral
then compress w/impulse in lateral
flexion (aka. IMPULSE Test)

17.

Cervical
Distraction:

should decrease pressure on foramen to

relieve pain (+ findingforaminal
encroachment), but can increase pain
during test due to adhesions/muscle
spasmsmeaningful Negative

18.

Cervical Flexion/
Dural Stretch
Tests

L'Hermither's (Ler-Meets):
Brudzinski's:
Soto Hall:

10.

Normal 3mm in adults, 5mm in

children
4.

Adson's:

tests anterior scalenesIpsilateral

rotation, neck extension, and
forced/deep inspiration.
+=reproduce symptoms or
decrease pulse pressure
(compression of artery)however
there are tons of false + (could be
cervical rib)
Halstead's/Revers Adson's: tests
middle scalenescontralateral
rotation, neck extension, forced
inspiration. Could False + (cervical
rib)

5.

Algometry/Dolarimetry

accurate measure of tenderness

(most of time reduces tenderness):
good to determine malingerers
(typically following MVAs)

6.

ALL

(Gray ramus communicans)

7.

Annulus Fibrosis has

_____ pain.

*Discogenic Pain

what is this?
8.

9.

Anterior muscles
include:

Atlas (C1) ROM has most

____

deep vague, referred pain when

the source: annulus fibers*
deep neck flexors (Longus
Coli/Capitis)
scalenes
SCM
strap muscles
platysma
most rotation

*CN IV remains intact

Superior oblique muscle: moves down
and in*

19.

Cervical Trauma
Davis Series

Lateral Csp x-ray: doesn't require

movement, most things will show up
here, if negative
AP Csp X-ray and APOM X-ray: if
either are positiverefer out, if
negative

32.

Hemorrhagic
stroke:

there is bleeding in the brain (aneurysm)

creating pressure on adjacent arteries and
cutting off blood supply to other areas

33.

History

*Onset: mode of arrival (when/how?)

Palliative: decrease symptoms (meds)
Provocative: increase symptoms*

Oblique X-ray: involves little

movement, if negative

Referred Radiation: most common type of

radiating pain, nothing wrong w/nerve
root, but rather a spinal cord problem=
Spinal Cord Fasciculation (higher # of action
potential w/in a certain nerve pool)

Stress x-rays (Flexion/extension):

most sensitive view for stress on ADI
Cervical TVP points
_____

anteriorly (why we contact articular

processes)

21.

Compression:

Stenosis

22.

Compression
fractures: when do
you get consult?

A/P < 2/3= Invoke rule of Xavier

Onasisget consult

23.

Concentric:

slightly less safe, (shortening muscle

while contracts} more sensitive/more
risk

24.

Concussion

bump

25.

Contusion

Bruise

26.

Csp has the lowest

_____ ____ b/c only
supporting the
weight of the head)

Compressive strength

27.

Eccentric:

least safe b/c it is lengthening the

muscle, but most sensitive/most
risk

20.

28.

29.

Eden's: tests

Facet Angles

Costoclavicularelevation, retraction,
depression of shoulder, cervical
flexion, and full inspiration.
+=reproduction of symptoms
Superior facet: Posterior and superior

Site & Severity: VAS is most reliable

method of measuring pain, Does it
influence ADL?
34.

Horner's
Syndrome

*Loss of sympathetic function

(hyposympathetictionia)
Ipsilateral ptosis (drooping eye lid)
Ipsilateral pupil constriction: Anisicordia
one pupil constricted, one dilated
Anhydrosislack of sweat
Flushing on side of face b/c it is overheating:
tissue gets hot b/c not sweating*

35.

How are
Vertebrobasilar
attacks related
to Spinal
Manipulative
Therapy?

During the adjustment, a piece of the clot

breaks off and clogs/occludes the artery
(most commonly from Thrombotic
embolism)

36.

Instability Tests

Rust's Sign:
Sharp-Purser Test: Atlanto-Dental
Instability

37.

Isometric

: least likely to aggravate a muscle (safest),

but also least sensitive/least risk

38.

Laceration

Cut

39.

Ligamentum
Flavum Basics

Elastic Tissuecauses yellow color

Assists in maintaining upright posture
Aneural (no nerve supply)
Hypertrophic degenerative changes

40.

Ligamentum
Flavum No IVF
encroachment
b/c

No IVF encroachment b/c of huge

articular pillarscan only cause
canal/central stenosis only b/c of big
articular Pillars protecting IVFs: acts like
a barrier

41.

Ligamentum
Flavum Trauma
and age

Hypertrophic degenerative changessince

no nerves (avoid certain ROM instead of
surgery)

Inferior facet: anterior and inferior

30.

31.

Films (neck is only

exception where
take films before do
examination)

Special caution to events of cervical

traumaassume Cervical fracture
until proven otherwise
1st thing: Clear the Cervical Spine!
Cervical Trauma Davis Series

Foraminal
Encroachment
Syndrome/
Radiculopathy

Cervical Compression:
Cervical Distraction
Shoulder Depressor test
Shoulder Abduction/Bakody's Test
Upper Limb Tension Test:
Radicular Cluster/ Foraminal
Encroachment Syndrome:

42.

Little Uns/Small
muscles include:

rotatores
multifidus
Intertransversalis
Interspinous
Suboccipital

43.

Luschka Joint/ Lateral

Interbody joint/
Uncovertebral joint
Degeneration

hypertrophies outward and

extends into IVF and irritates
meningescauses foraminal
encroachment syndrome

this is not a true ____

____ in ____

51.

Most reported
case of VBA
accident occurs
before
practitioner
removes hands

* PICA occlusionWallenberg Syndrome

(less severe)
Basilar occlusionLocked In Syndrome
(less common, more severe, really rare!)*

52.

Nafzigger's/Jugular
Compression

*push on jugular veins B/L to ^venous

pressure->^Intrathecal pressure w/I
meninges
Any pain increas*
Apply simultaneous compression the
internal and external jugular veins for
2mins/moreif increase in pain in
back, hip, thigh, leg, and down to
ankle and if toe feels numb and
tingling than test is +

53.

NCV

Nerve Conduction Velocity: speed of

ction potential propagation b/w 2
points of peripheral n

54.

Neurologic
Evaluation
Sensory:

2 point discrimination (most

sensitive examination procedure)
Vibration (Tuning Fork) PCML
Light touchASTT
Pain & TemperatureLSTT
Dermatomes

55.

Nucleus Pulposus,
what happens
with the
inflammatory
process?

The inflammatory process releases

chemicals that cause pain

Spurs can cause this (from Zjoints and Lushka joint)

Not a true synovial joint in humans

44.

45.

Luschka Jt DJD and

cervical Z joint DJD
can cause _____

Cervical Neurologic symptms

Lymphatic Chains and

inflammation/scarring

Normally impalpable but in some

casesPalpable:
Lymphadenopathy
Inflamed Nodes: soft & tender,
NEVER mobile, regular borders
Scarred Nodes: hard, non-tender,
& mobile, can scleros, have regular
borders (no clinical indication)

46.

Magnetic resonance
Arteriography: VBA

If suspect patient has a dissecting

aneurysm we can do an MRA to
be sure

47.

Meninges contain ____

and _____. They are also
_____ _____.

CSF and spinal cord

56.

Occlusive

something is clogging the artery

(atherosclerosis, thrombus, embolism)

Meninges are very pain sensitive

57.

examples of meninges
include:

Dura materarachnoid materpia

mater

Passive ROM is
better for what?

Meningitis s/sx

*Severe headaches (mc)

More sensitive to determine asymmetry

than AROM
*Use Goniometer or gravity inclinometer
to quantify results
Any restriction or pain?*

58.

Pathognomonic
test:

test that names the pathologyspinal

tap to measure WBCs

59.

Pathognomonic
test (L'Hermither's
(Ler-Meets)

want to administer tests when the

patient is the most symptomatic: upon a
spinal tap, oligodendroproteins will
be present (abnormal)=MS

60.

Pharynx function:

transfers both air and food to

appropriate vital organ

48.

Stiffness/ Neck pain (mc)*

49.

Meningitis Tests

(any kind of neck flexion)any

flu like symptoms and pain refer
for spinal tap
If can touch chin-chestprobably
don't have meningitis
If cant touch chin-chestother tests
should be performed to rule it out:

50.

Most common age of

SCIWORA:

more in children than adults

61.

PICA
occlusionWallenberg
Syndrome (less
severe) sx

*Ataxia

70.

Ipsilateral loss of CN V
-Loss of pain and temperature on
one side of face
-Loss of corneal reflex
Contralateral loss of STT
-Loss of pain and temperature on the
trunk
Loss of CN IX and CN X
-Dysphagia, Intractable Hiccups
(never ending), Hoarseness
Nystagmus: Eye flutters with certain
views
-Nausea, vertigo, vomiting
Horner's Syndrome

what kind of test it

is?

PLL

71.

Rust Sign:

Patient will hold head w/ both

hands to diminish movement and
decrease pain

72.

Rust's Sign:

patient holds head/neck to help

minimize any movement and
decrease pain

73.

SCIWORA:

SCIWORA: spinal cord injury with out

radiographic abnormality (rare but
happens)

74.

Shoulder
Abduction/Bakody's
Test:

+ findings= relief of pain symptoms

relaxes brachial plexus and tension in
IVF

(recurrent meningeal/Sinuvertebral
nerve)

63.

Position of the
Trachea and what it
can indicate

evaluate for Tracheal deviation:

could indicate Lung disease
(collapsed lung), Tumor (cancer),
atelectasisrings should align
w/sternal notch

64.

posterior muscles

Big Uns/ Large Muscles

what does it realx?

75.

Shoulder Depressor
test:

(push down on shoulder and head):

analogous to SLR in lower extremity
+ finding requires radiation down the
arm, but can have a meaningful
Negative due to muscle stretching

76.

SOL tests, what are

the done for and
how?

increase Intrathecal/meningeal/Dural
pressure (Intrathoracic/intrabdominal
pressure by <3mm of pressure will
collapse the veins and reduce venous
draining w/in cord):

Little Uns/Small muscles

65.

Presence of a mass:

"lumps/bumps" could be various

possibilities: TP, lymph nodes. Do not
give name/Dx, but rather explain
what feeling (size, tender,
consistency, border, mobile/fixed,
location)

Valsava's
Nafzigger's/Jugular Compression
77.

Soto Hall:

not designed to diagnose a specific

conditionbut rather to localize
possible cervical/thoracic lesion
passive neck flexion while stabilizing
sternum. +=pain

78.

Spurs on both Csp

joints can cause...

foraminal encroachment

Stellate Ganglia is a
concern for what?:

Concern for whiplash injuries

unusual injuries

66.

Radial Nerve:

elbow extension, wrist extension,

finger extension

67.

Radicular Cluster/
Foraminal
Encroachment
Syndrome:

+ findings for all 4 tests 90% chance

Reason for x-ray

Suspect an unstable Csp (risk to cord

or nerve roots)
Could be a severe stable Csp (no risk
to cord/nerve roots)

79.

early signs of osteoarthritis after few

months

80.

68.

69.

Research creating
immobilization and
restriction in mice
showed____

Can cause foramina encroachment

shoulder abduction to 90, external

rotation, and open and close hand for
up to 3 minutesrecord + finding and
how long it took. Modified Roo's Test: if
immediate, eliminate external rotation
and time
(most reliable & quantifiable, not
specific)

improve over time:*

62.

Roo's test:

Horner's Syndrome
Suboccipital
muscles include:

Rectus Capitis Posterior Minor

Rectus Capitis Posterior Major
Superior Oblique
Inferior Oblique
Triangle contents

81.

Teardrop fracture
(unstable)

Flexion/ axial compression Fx

Ligamentous

82.

Thoracic Outlet
Tests:

Roo's test (most reliable &

quantifiable, not specific)
Adson's: forced/deep inspiration
Halstead's/Revers Adson's
Eden's
Wright's/Hyperabduction

83.

Thyroid gland history

Baby boomers: used to get X-ray Tx

for acne and now they are getting
thyroid cancer

84.

Tissue Compliance

measure how hard/soft tissues are;

cervical adjustments have been
shown to increase tissue compliance
(softnessmuscles in spasm have less
compliance (harder)=bone--+
finding

what has less

compliance?

85.

Torgue Index:

*Lateral cervical x-ray

Ratio of width of canal to the
vertebral body width
If <0.8Dx=Stenosis*

86.

Transverse Odontoid
(Dentate Ligament)
contacts where?

Connects bone to itself (from

lateral mass of atlas to other side
of lateral mass of atlas)

Transverse Odontoid
(Dentate Ligament)
Ligamentous Damage
(unlikely unless
following has
happened)

*Ligamentous Damage (unlikely

unless following has happened)

87.

RA (major causes for ligamentous

laxity)
Down's Syndrome (some people
born w/o ligament)

91.

Valsava's

^Intrathecal Pressure->^pressure w/in

meninges (Paraspinal contractcould
cause false +)

92.

Vertebrobasilar
attacks location

Most common b/w C1/C2rotation &

extension (94.6%)--1 risk
Superior facet of C3especially if
person has arthritis--2 risk
Luschka joint of C4/5 or C5/6
especially if someone has Osteoarthritis
or spur formation--3 risk
C6 and Longus Coli Muscle--4 risk
Atlas and foramen Magnum--5 risk

93.

Vertebrobasilar
Attack sx

symptoms in 50% of population (50%

Asymptomatic):
Sudden severe onset of atypical
headache or neck pain of unknown
cause Red flag*
Other signs: 5 Ds and 3 Ns
(Vertebrobasilar Ischemia)

94.

What and where is

the cervical
intumescentia?

C5-T1

What are 2 joints

of the cervical
spine?

Luschka Joint/ Lateral Interbody joint/

Uncovertebral joint

95.

Zygopophyseal Joint:
96.

AS

what are
Pathologic Nodes:

ADI (Atlantodental interval)

Lateral cervical x-ray in neutral and
flexionmore sensitive (stress)
88.

89.

types of Disc Lesions

(in order)

Uncinate process
Articulate w/ ________.
what does it do?

90.

Upper Limb Tension

Test:

Bulge
Herniation
Protrusion
Prolapse
Sequestration
Extrusion

varied, increased size, granular,

irregular borders/consistency, & fixed to
deeper tissues2 ways to get in lymph
Supraclavicular and Infraclavicular
nodes

97.

What are the 2

types of strokes
that occur?

Mechanism: (2 types) 4: 1 ratio b/w

Occlusive
Hemorrhagic Strokes

98.

What are the

Ligaments of the
Spinal Column?

ALL
PLL
ligamentum flavum
Interspinous Ligament
Supraspinous ligament
Intertransverse ligament

99.

What are the

ligaments of the
Upper Cervical
spine?

Alar and Apical ligaments

vertebral body above

Decreases disc bulges (cups discs)
Protects nerve roots
+ finding=radicular pain/Paresthesias
upon stretching and relief of
symptoms upon relaxation

Safest place for a fracture in the

cervical spine b/c of it being the thickest
and having greatest ROM

Transverse Odontoid (Dentate

Ligament)

What are the

structures of
the anterior
neck?

pharynx
larynx
trachea
esophagus
thyroid gland
lymphatic channels
stellate ganglia

101.

What is a
myopathy?

A condition that irritates the muscle

(muscle pathology)

102.

What is a
Vertebrobasilar
Attack?

Vertebral artery is having a dissecting

aneurysmsudden onset

100.

103.

What is special
about the ROM
of the Cervical
Spine?

Only place w/in the spine that the

spinal cord can be damaged w/o any
fracture or dislocation

104.

What is the
Vertebrobasilar
Accident Risk
Test?

Cerebrovasular Accident=Stroke
-Stroke involving Ischemic Necrosis of the
brain cells

105.

what is unique
about
L'Hermither's
(Ler-Meets):

originally developed to diagnose MS

(autoimmune demyelination of CNS,
can also be used to test for spinal cord
pathologies such as syringomyelocele
(syrinx), UMN (hyperreflexia and
clonus), + finding= "electrical shock
sensation" down to middle of spine
indicates spinal cord lesion
Active test: let head fall forward In flexion

107.

108.

What is used to view Disc

Lesions?

MRI

110.

Wright's/Hyperabduction:

tests Pectoralis minor

hyperabduction of
shoulder/horizontal
hyperabduction
+=reproduction of symptoms

111.

Zygopophyseal Joint is a
____ _____ joint, has a ____
____ and a _____ _____

Synovial Gliding Joint

Capsular Ligament
Synovial Hygiene

There is a tear in the intima of the

vertebral artery
*Blood can separate the intima form the
media layer
Blood collects and stops moving inside wall
(colts)*

106.

109.

what is unique
about Longus
Coli/Capitis

*whiplash

what is unique
about Rectus
Capitis
Posterior
Minor

tissue bridge connection to meninges to

help control position of spinal cord w/
canal (theory)

what is unique
about Splenius
Cervicis &
Capitis

(important: responsible for posterior

translation)can strengthen to prevent
upper crossed syndrome

swelling or hematoma that puts pressure

against pharynx/esophaguscan cause
dysphagia*

chronic spasm can create headaches!

(m/c cause of headaches)