C-Spine Anatomy

Question 1

What is the name of the supraspinous ligament as it continues to cranium?

Answer 1

Ligamentum Nuchae (or nuchal ligament)

Question 2

True / False 
Ligamentum Nuchae (or nuchal ligament) is fibroelastic

Answer 2

True

Question 3

What is the function of Ligamentum Nuchae?

Answer 3

It helps passively support the weight of the head in an upright position (fibro-elasticity helps with this).
Important midline attachment for muscles

Question 4

What is the course of the vertebral artery in the neck?

Answer 4

• Vertebral artery is a branch of the subclavian A
• ascends through transverse foramina to foramen magnum
• combines with contralateral vertebral A to form Basilar A
• it runs through the transverse foramen, right along the axis of flexion/extension (which is important so that it doesn’t get too stretched with these big cervical movements).

Question 5

What is the vertebral artery’s relationship to cervical nerve roots?

Answer 5

immediately anterior to cervical nerve roots

Goes through the transverse foramen

the location of the vertebral artery is at the axis of flexion/extension (mediolateral axis) to help protect it during flexion/extension

Question 6

What movements can disrupt the vertebral artery more than E and F

Answer 6

Rotation and LF

Question 7

What are the symptoms of vertebral artery compression?

Answer 7

symptoms of decreased blood flow with certain head positions (also known as vertebrobasilar - ischemia)

• dizziness
• vertigo
• fainting (syncope)
• visual disturbances with head turning

symptoms can be a result of an obstruction of blood flow due to compression of a vertebral artery

Remember the 5 D’s (dizziness, drop attacks [falling suddenly without losing consciousness], dysphagia, dysarthria, and diplopia)

Also from class: ataxia, nausea, numbness of unilateral face, nystagmus, fainting

Question 8

5. Describe the general size and shape of the central (vertebral) canal in the C-spine.

Answer 8

fairly triangular

large relative to the size of the segment

Question 9

What is the clinical significance of the size and shape of the central (vertebral) canal in the C-spine?

Answer 9

largest at the top C1

-because of the brainstem location and the cervical plexus forming in that area

Question 10

The diameter of the central (vertebral) canal is greatest in what position?

Answer 10

flexion

Question 11

The diameter of the central (vertebral) canal is least in what position?

Answer 11

extension

Question 12

Where is the uncinate process and what motion would it prevent?

Answer 12

A bony upward projection arising from each side of the upper surface of any of the cervical vertebrae numbered three to seven and forming a raised lateral margin

limits lateral translation

gives a little stability (in this highly mobile part of the spine) without hindering movement too much

Question 13

Describe the joints of Lushka.

Answer 13

Uncinate processes articulate with the vertebral body above to form the joints of Lushka.

They serve to limit lateral translation (they shouldn’t be very much weight bearing)

Question 14

What is the relationship of the joints of Lushka to spinal nerves?

Answer 14

Located just anterior to spinal nerves

Question 15

What would be the clinical significance of DJD at one of the joints of Lushka?

Answer 15

When loaded chronically, may form osteophytes, which may then impinge on spinal nerves (“crimp the nerve’s style”)

Question 16

What’s the name of the PLL as it continues cranially?

Answer 16

Tectorial Membrane.

Question 17

What is the function of the Tectorial Membrane?

Answer 17

helps hold the head onto the neck

helps hold dens, supports dens

can limit flexion and extreme extension (like in whiplash)

(PLL is wider than lumbar version in C-spine, while the ALL is narrower than the lumbar counterpart)

Question 18

What ligaments attach to the dens?

Answer 18

Alar ligaments (hold dens to skull)

Also known as “check” ligaments

Question 19

What motions would the alar ligaments check (restrict)?

Answer 19

Rotation

Lateral flexion

Question 20

Why is ligamentous instability around the dens important to recognize?

Answer 20

Whenever you encounter a patient that has neck pain as a result of trauma or cervical instability, you should always inspect the integrity of the transverse ligament before any other exam measures.

When the transverse ligament is damaged, the atlas can slide forward on the dens, decreasing the size of the vertebral canal for the spinal cord to go through.

This can result in neurological symptoms, such as pain, weakness, a lump in the throat, etc. In this compromised position, any movements can impinge upon the spinal cord and cause potentially irreversible damage.

Question 21

What is the position of the dens in relation to the brainstem? Why is it important?

Answer 21

brain stem is right behind the dens (brain stem is king of the hill), but safe because of heavy ligamentous stability (trauma can damage these, subsequently the dens can damage the BS)

Question 22

What is the role of the dens?

Answer 22

provides lots of mobility, so you want that spike but you need to at least hold it still (alar ligaments and transverse ligament of the atlas)

Question 23

Describe the role and the position of the transverse ligament.

Answer 23

The transverse ligament is responsible for keeping the anterior facet of the atlas against the dens of the axis. It attaches on the medial side of each large, lateral process of the atlas with the anterior side of the middle part touching the odontoid process. This creates a wide space in the vertebral canal for the spinal cord to pass through, posteriorly.

Question 24

What are the predominant motion(s) that occur at OA and how much of this motion occurs here?

Answer 24

Sagittal plane: 15* total
Flexion: 5*
Extension: 10*
“little nodding” motion

Frontal plane (lateral flexion): 5*

Question 25

What are the predominant motion(s) that occur at AA (and how much of this motion occurs here?)

Answer 25

``` 50% of transverse plane motion (rotation) occurs at C1-C2 Horizontal plane (rotation): 35*-40* ``` Sagittal plane: 15* total Flexion: 5* Extension: 10*

Question 26

What is the facet orientation in the mid C- spine?

Answer 26

between frontal and horizontal planes (inclined anteriorly) | 45 degree oblique

Question 27

What is Fryette's law for cervical?

Answer 27

rotation ann lateral flexion in the same direction R rotation: R lat flex + R rotation…. R Lat flex: R Lat flex + R rotation.

Question 28

How are facets sliding with movement?

Answer 28

With Flexion: superior and anterior | With Extension: inferior and posterior

Question 29

The facet orientation allows what motions?

Answer 29

Allows all motions, although combined lateral flexion and rotation are most natural

Question 30

Describe what happens to the contact area of the facet joint during the motion of flexion

Answer 30

decreases in surface area

Question 31

Describe what happens to the diameter of the IVF during the motion of flexion

Answer 31

increases

Question 32

Describe what happens to the contact area of the facet joint during the motion of extension:

Answer 32

is maximized for maximized load bearing

Question 33

Describe what happens to the diameter of the IVF during the motion of extension

Answer 33

decreases | the superior segment slides inferiorly causing a slack capsule

Question 34

What is excessive extension limited by?

Answer 34

Largely limited by impaction of the spinous processes, so we don’t need as much soft tissue to limit excessive extension

Question 35

Describe forward head position (FHP)

Answer 35

the upper cervical spine is in an extended position, while the lower cervical spine is in a flexed position.

Question 36

What muscles get adaptively shortened in FHP? (general rule)

Answer 36

Anything posterior to axis of upper c-spine can get adaptively shortened (occipitals) Anything anterior to the axis of the lower c-spine can get adaptively shortened (SCM)

Question 37

What happens with the facets during lateral flexion?

Answer 37

the ipsilateral facets approximate (slightly) and the contralateral facets distract (slightly). ipsilateral facet slides down contralateral facet slides up

Question 38

Describe the ALL in the C- spine:

Answer 38

ALL is narrower compared to lumbar in C-spine hyperextension is mostly limited by impaction of the spinous processes, so we don’t need as much soft tissue to limit excessive extension. Not a “down-hill” force in the cervical spine, like in lumbar (ie. weight of body that would cause shifting of the vertebrae)

Question 39

Describe the PLL in the C- spine:

Answer 39

PLL is wide compared to lumbar we need more protection for the brainstem so wider makes sense There is not a lot of bony mass to limit flexion

Question 40

Contraction of bilateral sternocleidomastoid muscles causes what motion(s)?

Answer 40

flexion and protrusion | they are long/superficial flexors

Question 41

Contraction of unilateral sternocleidomastoid muscles causes what motion(s)?

Answer 41

ipsilateral lateral flexion | contralateral rotation

Question 42

Contraction of bilateral suboccipital muscles causes what motion(s)?

Answer 42

extension | (they are short/deep extensors?

Question 43

(true or false) C1 is palpable. If so, what part?

Answer 43

True. Can palpate transverse processes gentle handling just inferior to mastoid process Can contralaterally lateral flex head or ipsilaterally rotate head to get the transverse process to “pop out” while palpating

Question 44

(true or false) C2 is palpable. If so, what part?

Answer 44

True. Can palpate the spinous process. The first spinous process you feel as you drop off the skull toward the spine. Some of the other spinous processes are too close together to feel so you may document that you mobilized mid C-spine instead of on a certain segment.

Question 45

What is the “articular pillar”?

Answer 45

In the cervical vertebral column, the articular processes collectively form the articular pillars

Question 46

A patient with an inflamed cervical nerve root on the right is likely to have pain with what motions?

Answer 46

extension right lateral flexion right rotation

Question 47

A patient with a large central disc protrusion in the cervical spine is likely to have what symptoms?

Answer 47

Central would be UMN symptoms (pressing on cord - Myelopathy) bilateral hyperreflexia in UEs and/or LEs

Question 48

A patient with a large lateral disc protrusion in the cervical spine is likely to have what symptoms?

Answer 48

Lateral would be more s/s of nerve root irritation or compression paresthesia hard neuro signs radiculopathy