Yiannis Sotiralis PT , Cert. M.D.

T, OMT Clinical Instructor

 SIGNIFICANCE OF CERVICAL SPINE DISORDERS
Some epidemiological data

Neck pain is reported to be the second o As much as 50% to 75% of individuals

most common musculoskeletal disorder have neck or shoulder pain at least
that leads to disability and injury claims once in their life.

The economic burden of neck pain is second o The 12-month prevalence of neck pain
only to low back pain in workers ranges from 12.1% to 71.5% in the
compensation claims in the United States. general population and from 27.1% to
47.8% in workers.
 SIGNIFICANCE OF CERVICAL SPINE
DISORDERS
Most people with neck pain do not experience a complete resolution of symptoms,
with between 50% and 85% of those who experience neck pain reporting neck pain
again 1 to 5 years later.
Cervical spinerelated musculoskeletal disorders account for approximately 25% of
the patients seen in outpatient physical therapy in the United States.

The cervical spine consists of several pairs of joints. It is an area in which stability has
been sacrificed for mobility, making the cervical spine particularly vulnerable to
injury because it sits between a heavy head and a stable thoracic spine and ribs.
Cervical Spine Kinematics: Functional Anatomy
and Mechanics
(C0 to C2) upper

The cervical spine supports and orients the head in

space relative to the thorax to serve the sensory
systems.
It must therefore have sophisticated mobility and
stability mechanisms to meet the demands placed
on this region of the musculoskeletal system.

The cervical spine is divided into two areasthe

cervicoencephalic for the upper cervical spine and
the cervicobrachial for the lower cervical spine
(C3 to C7) lower
Or mid C3-C4
 ATLANTO-OCCIPITAL JOINTS C0 to C1

The occipital condyles articulate with the superior occipital condyle

articular facets of the atlas (C1)

The principal motion of these two joints is

flexion-extension (15 to 20), or nodding of the head.
Almost 50% of total ROM
Side flexion is approximately 10, whereas rotation is
negligible.

The atlas (C1) has no vertebral body as such. During development, the vertebral body of
C1 evolves into the odontoid process, which is part of C2.
 Ligaments that stabilize the atlantooccipital
joints.
Anteriorly and posteriorly are the
atlanto-occipital membranes.
The anterior membrane is strengthened
by the anterior longitudinal ligament.

The posterior membrane replaces the

ligamentum flavum between the atlas
and occiput.

The tectorial membrane, which is a broad

band covering the dens and its ligaments,
is found within the vertebral canal and is
a continuation of the posterior
longitudinal ligament.
 The atlanto-axial joints (C1 to C2)
The most mobile articulations of the spine
Flexion-extension is approximately 10
Side flexion is approximately 5
Rotation approximately 50, the primary
movement of these joints. Almost 50% of
total ROM
With rotation, there is a decrease in height of
the cervical spine at this level as the vertebrae
approximate because of the shape of the facet
joints.
The odontoid process of C2 acts as a pivot
point for the rotation.
Generally, if a person can talk and chew, there is probably Can you think a clinical
some motion occurring at C1 to C2. implication from this info?
 Ligaments that stabilize the atlanto-axial
joints.

Main supporting ligament is the transverse

ligament of the atlas, which holds the dens
of the axis against the anterior arch of the
atlas. (weakens or ruptures in rheumatoid arthritis)

As the ligament crosses the dens, there are

two projections off the ligament, one going
superiorly to the occiput and one inferiorly
to the axis. The ligament and the projections
To the occiput form a cross, and the three parts
transverse ligament projections taken together are called the
To the axis
cruciform ligament of the atlas
 Before we continue some basic elements about coupling

Coupling occurs normally in spinal segments when two movements with different
shafts combined. (rotation with lateral flexion) (normally in the same side)

May defers in different spine locations and it depends on:

Spine position and curvature

Facet joints orientation

Viscosity, elasticity, and thickness of the vertebral discs

Extensibility of muscles, ligaments and capsular tissues

 Elements about coupling

Coupling behavior in vertebral column has been an issue of many controversies.

Different data from the research.
Somewhat of a general agreement that:

We have different, probably opposite side coupling for upper cervical spine

For the C3-C7 segments and the upper thoracic spine same side coupling.

For mid thoracic spine mixed patterns. Neutral, the same, or opposite coupling.

Lower thoracic spine. Almost impossible coupling.

Lumbar spine. Same side coupling or non predictable coupling.

Example of data
 Facet joint orientation

Cervical Region = 45 degrees frontal plane all

movements are possible such as flexion,
extension, lateral flexion, and rotation.

Thoracic Region = 60 degrees

frontal plane
lateral flexion and rotation
no flexion/extension

Lumbar Region = 90 degrees

sagittal plane
only flexion and extension.
 Joints from C3-C7

Below C2 every segmental movement involves in a

degree some movement from all the other levels.

Facet joints 450 approx.

Total ROM for flexion (C2-C7) between 330 480

Total ROM for extension (C2-C7) between 360 590

Spinal processes limits extension

 Mechanism of paradoxical movements of the atlas

At full flexion of the neck the atlas can extend, and usually does so.
At full extension the atlas can move towards flexion.

If, during flexion, the chin is tucked

backwards, paradoxical extension
of the atlas is virtually assured
 Cervical ligaments at a glance
Anterior and posterior
longitudinal ligaments:
Limit extension and
flexion
Ligamentum nuchae:
Limits flexion
Interspinous ligaments:
Between spinous
processes
Limit flexion and rotation
Ligamentum flavum:
Connect laminae
Limits flexion and rotation
 Suboccipital muscles

Rectus capitis posterior major goes from the

spinous process of the axis (C2) to the occipital
bone

Rectus capitis posterior minor goes from the

middle of the posterior arch of the atlas to the
occipit

Obliquus capitis superior goes from the

transverse process of the atlas to the occiput

Obliquus capitis inferior

ACTION bilaterally extend the head / laterally flex-rotate to the contracted side

Longus colli
Origin: lower anterior
vertebral bodies and
transverse processes
Insertion: anterior vertebral
bodies and transverse
processes several segments
above
Action: flexes the head and
neck
Nerve: ventral rami C2-C6
Prevertebral Musculature
Longus capitis
Origin: upper anterior
vertebral bodies and
transverse processes
Insertion: anterior vertebral
bodies and transverse
processes several segments
above
Action: flexes the head and
neck
Nerve: ventral rami C1-C3
Rectus capitis anterior
Origin: anterior base of the
transverse process of the
atlas
Insertion: occipital bone
anterior to foramen
magnum
Action: flexes the head
Nerve: ventral rami C2,3
Rectus capitis lateralis
Origin: transverse process
of the atlas
Insertion: jugular process of
the occipital bone
Action: bends the head
laterally
Nerve: ventral rami C2,3
Anterolateral Neck Musculature (Scalene muscles)

anterior Middle Posterior

Nerve: ventral rami C3-C6 Nerve: ventral rami C3-C8 Nerve: ventral rami C5-C7

Action:
if transverse process fixed: elevates the ribs for respiration

if ribs fixed: rotates to side opposite of contraction

laterally flexes to the contracted side
bilaterally flexes the neck
 Superficial Neck Musculature

Sternocleidomastoid Platysma
Action: Action:
rotates to side opposite of contraction depress mandible and lower lip
laterally flexes to the contracted side tenses the skin over the lower neck
bilaterally flexes the neck Nerve: cervical branch of facial nerve (VII
Nerve: cranial)
motor: spinal accessory (XI cranial)
sensory: ventral rami of C2,(C3)
 Always Remember

There is a number of muscles that can

contribute in an indirect way in cervical
spine pathology
Shoulder girdle muscles

And thoracic thoracic-lumbar region

may be a part of our assessment
 The intervertebral discs

Make up approximately 25% of the height of the cervical

spine.
No disc is found between the atlas and the occiput (C0 to
C1) or between the atlas and the axis (C1 to C2).
It is the discs rather than the vertebrae that give the
cervical spine its lordotic shape.
The nucleus pulposus functions as a buffer to axial
compression in distributing compressive forces, whereas
the annulus fibrosus acts to withstand tension within the
disc.
The intervertebral disc has some innervation on the
periphery of the annulus fibrosus.
 The intervertebral discs
The cervical intervertebral discs are not like
lumbar discs.
They lack a concentric anulus fibrosis around
their entire perimeter.
The cervical anulus is well developed and thick
anteriorly; but it tapers laterally and posteriorly
towards the anterior edge of the uncinated
process on each side.
 The intervertebral discs
Moreover, a criss-cross arrangement of collagen
fibres as seen in lumbar discs, is absent.
Instead, fibres of the anterior anulus consistently
converge upwards towards the anterior end of the
upper vertebra .

This arrangement is consistent with that vertebra

pivoting about its anterior end.
In effect, the anterior anulus is an interosseous
ligament, disposed like an inverted ``V'' whose apex
points to the axis of rotation.

An anulus is lacking posteriorly . It is represented only by a few fibres near the median
plane 1 mm thick. Lateral to these fibres, the anulus is absent. The back of the disc is
covered only by the posterior longitudinal ligament.
 The vertebral arteries

They arise from the subclavian arteries, one on each S

FORM
side of the body, then enter deep to the
transverse process at the level of the 6th cervical
vertebrae (C6), or occasionally at the level of C7.

They proceed superiorly, in the transverse foramen of

each cervical vertebra.

Once they have passed through the transverse

foramen of C1, the vertebral arteries travel across the
posterior arch of C1 and through the suboccipital
triangle before entering the foramen magnum.
 The carotid arteries

The carotid arteries are major blood vessels in

the neck that supply blood to the brain, neck,
and face. There are two carotid arteries, one on
the right and one on the left. Each carotid
artery branches into two divisions:

1. The internal carotid artery supplies blood to

the brain. ICA
2. The external carotid artery supplies blood
to the face and neck. EKA
 Vertebral Artery Test
Definition/Description
The vertebral artery test is used in Physiotherapy to test the vertebral artery blood flow,
searching for symptoms of vertebral artery disease.
Vertebral artery disease is also known as vertebrobasilar ischaemia (VBI).

Technique
To test the blood flow in the vertebral
artery (VA), one should put the patient on
his back and perform an passive extension,
followed by a passive rotation of the neck.
The rotation should be performed in both
directions.
 Vertebral Artery Test

The manoeuvre causes a reduction of the lumen at the third division of the vertebral
artery, resulting in decreased blood flow of the intracranial VA of the contralateral side.
It causes an ischemia due to blood loss in the pons and the medulla oblongata of the
brain. This results in dizziness, nausea, syncope, dysarthria, dysphagia, and disturbances
of the hearing or vision, paresis or paralysis of patients with VBI.
 Vertebral Artery Test
Evidence
Because of the inconsistency in the literature, there will be false positive/negative blood
flow results in cervical spine rotation.
Thus, the controversial findings in todays literature cannot be used to guide evidence-
based practice except to support the need for educated caution and authority in the pre-
treatment screening and treatment of the patients.

Ct et al. says that the positive predictive value of this test (the proportion of
subjects with a positive test who are correctly diagnosed) is 0%, and the negative
predictive value of this test ranged from 63%-97%. The test was found not valid
enough to detect a reduced blood flow in the VA.

Therefore, the value of this test is

questionable.
 Brachial plexus

Is a network of nerves formed by the

anterior rami of the lower four cervical
nerves and first thoracic nerve (C5, C6, C7,
C8, and T1).
This plexus extends from the spinal cord,
through the cervicoaxillary canal in the neck,
over the first rib, and into the armpit.
It supplies afferent and efferent nerve fibers
to the chest, shoulder, arm and hand.
 Trunks
These roots merge to form three
Brachial plexus trunks:
1. "superior" or "upper" (C5-C6)
Divisions 3 6 3 5 2. "middle" (C7)
Each trunk then splits in two, 3. "inferior" or "lower" (C8, T1)
to form six divisions:
3 anterior divisions of the
upper, middle, and lower
trunks
3 posterior divisions of the 5 roots
upper, middle, and lower
trunks
Cords
These six divisions regroup to
become the three cords or large
fiber bundles. 3 6 3 5
1. Posterior cord the three
posterior divisions of the trunks
(C5-C8,T1)
2. Lateral cord the anterior
divisions of the upper and
middle trunks (C5-C7) 5 roots
3. Medial cord is a continuation of
the anterior division of the
lower trunk (C8,T1)
 Representation of the brachial plexus using color to illustrate the
contributions of each nerve root to the branches

C5,C6,C7,C8,T1.

C5,C6,C7,C8,T1.

C8,T1 /C7

Median, Radial and Ulnar nerve are mainly involved in our neurodynamic testing.
 Neurodynamic testing. Biomechanic properties of the neural tissue

During movement the following mechanical adaptations can

CLINICAL SIGNIFICANCE

occur. (related to the nerves)

Sliding
Intraneural blood flow (vasa nervorum)
Compression Axonal flow
Nerve impulse transmission
Stretching - lengthening
 Neurodynamic testing. Biomechanic properties of the neural tissue

Sliding of a nerve depends on :

CLINICAL SIGNIFICANCE

1. The movement ability of a joint

2. Nerve integrity

3. Nerve mechanical interactions with the tissues

surrounding it

David S. Butler Mobilisation of the Nervous System 1991

 Neurodynamic testing. Biomechanic properties of the neural tissue

The loose connection of peripheral nerves in combination with the mobility

CLINICAL SIGNIFICANCE

(sliding) of nerve roots create a protective mechanism against the nervous

irritation

The loss of neural tissue mobility is a biomechanical dysfunction "problem

which leads to possible pathology without necessarily associated with loss
of motion.

David S. Butler The Sensitive Nervous System 2000

 Neurodynamic testing. Biomechanic properties of the neural tissue

Peripheral nerves dont need to

be inflamed or injured to cause
CLINICAL SIGNIFICANCE

symptoms

The muscle tension may cause

symptoms

Piriformis Syndrome

Michael Shacklock Clinical Neurodynamics 2005

Rise in intraneural tension in PNS

Neural Tension
and or Compression

Rise in intradural tension in CNS

Upper limb neurodynamic testing
Upper limb neurodynamic testing
Upper limb neurodynamic testing
Median Nerve
Ulnar Nerve
Radial Nerve