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Cervical Spine Anatomy and Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C.

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Presentation on theme: "Cervical Spine Anatomy and Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C."— Presentation transcript:

1 Cervical Spine Anatomy and Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2 Clinical Anatomy Cervical Spine: Cervical Spine: Greatest range of motion Greatest range of motion ↑ ↑ risk of injury Vertebral bodies: Vertebral bodies: Smaller than other vertebral sections 7 vertebrae: 7 vertebrae: 1 st – Atlas 1 st – Atlas 2 nd – Axis 2 nd – Axis

3 Clinical Anatomy Cervical Spine: Cervical Spine: Atlas: Atlas: No vertebral body No vertebral body Transverse processes Transverse processes No true spinous process No true spinous process Supports the weight of the skull through 2 facet surfaces (atlanto-occipital joint or C0-C1 articulation) Supports the weight of the skull through 2 facet surfaces (atlanto-occipital joint or C0-C1 articulation) Flexion and extension (primary movement) Flexion and extension (primary movement) Lateral flexion (slight) Lateral flexion (slight)

4 Clinical Anatomy Atlanto-occipital joint dislocation: Atlanto-occipital joint dislocation: (15% of all fatal spinal trauma) (15% of all fatal spinal trauma) MOI: high speed motor accident; Pt. unconscious at the scene, respiratory arrest en route to hospital MOI: high speed motor accident; Pt. unconscious at the scene, respiratory arrest en route to hospital Lateral cervical spine radiograph: Lateral cervical spine radiograph: Prevertebral soft-tissue swelling (white arrow) Prevertebral soft-tissue swelling (white arrow) Malalignment between the skull and the cervical spine with widening of the atlanto-occipital joints (black arrow) Malalignment between the skull and the cervical spine with widening of the atlanto-occipital joints (black arrow)

5 Clinical Anatomy Cervical Spine: Cervical Spine: Axis: Axis: 2 nd cervical vertebrae 2 nd cervical vertebrae Small body with a superior projection (Dens) Small body with a superior projection (Dens) Atlanto-axial joint: Atlanto-axial joint: Dens and atlas articulation Dens and atlas articulation Rotation of the skull Rotation of the skull

6 Clinical Anatomy Cervical ligaments: Cervical ligaments: Anterior and posterior longitudinal ligaments: Anterior and posterior longitudinal ligaments: Limit extension and flexion Limit extension and flexion Ligamentum nuchae: Ligamentum nuchae: Limits flexion Limits flexion Interspinous ligaments: Interspinous ligaments: Between spinous processes Between spinous processes Limit flexion and rotation Limit flexion and rotation Ligamentum flavum: Ligamentum flavum: Connect laminae Connect laminae Limits flexion and rotation Limits flexion and rotation

7 Clinical Anatomy Brachial Plexus: C5 – T1 Brachial Plexus: C5 – T1 7 cervical vertebrae 7 cervical vertebrae 8 cervical nerves: 8 cervical nerves: 1 st 7: exit above the corresponding vertebrae 1 st 7: exit above the corresponding vertebrae C8: exits below the 7 th cervical vertebrae C8: exits below the 7 th cervical vertebrae

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9 Clinical Anatomy Muscular Anatomy: Muscular Anatomy: Cervical extension and flexion → bilateral contraction of cervical muscles Cervical extension and flexion → bilateral contraction of cervical muscles Side bending and rotation → unilateral contraction Side bending and rotation → unilateral contraction Superficial cervical musculature: Superficial cervical musculature: Splenius capitis Splenius capitis Splenius cervicis Splenius cervicis Upper trapezius Upper trapezius Sternocleidomastoid Sternocleidomastoid

10 Clinical Anatomy Splenius capitis: Splenius capitis: O: Lower half of ligamentum nuchae O: Lower half of ligamentum nuchae I: Mastoid process and adjacent occipital bone I: Mastoid process and adjacent occipital bone A: Lateral bending A: Lateral bending Splenius cervicis: Splenius cervicis: O: C7 spinous process through T6 O: C7 spinous process through T6 I: Transverse processes of C2 – C4 I: Transverse processes of C2 – C4 A: Rotation, extension A: Rotation, extension

11 Clinical Anatomy Upper trapezius: Upper trapezius: O: Occipital protuberance, nuchal line, upper portion of ligamentum nuchae O: Occipital protuberance, nuchal line, upper portion of ligamentum nuchae I: Lateral 1/3 of clavicle, acromion process I: Lateral 1/3 of clavicle, acromion process A: Cervical extension, cervical spine bending, scapular elevation, upward scapular rotation A: Cervical extension, cervical spine bending, scapular elevation, upward scapular rotation

12 Clinical Anatomy Levator scapulae: Levator scapulae: O: Spinous process of C7, transverse processes of C1 through C4 O: Spinous process of C7, transverse processes of C1 through C4 I: Superior medial border of scapula I: Superior medial border of scapula A: Extension of cervical spine, scapular elevation and downward rotation A: Extension of cervical spine, scapular elevation and downward rotation

13 Clinical Anatomy Scalenes: Scalenes: Anterior scalene: Anterior scalene: O: Anterior portion of transverse processes C3-C6 O: Anterior portion of transverse processes C3-C6 I: Sternal attachment of 1 st rib I: Sternal attachment of 1 st rib Middle scalene: Middle scalene: O: Anterior portion of transverse processes C2-C7 O: Anterior portion of transverse processes C2-C7 I: Lateral to insertion of anterior scalene on 1 st rib I: Lateral to insertion of anterior scalene on 1 st rib Posterior scalene: Posterior scalene: O: Anterior portion of transverse processes C5-C6 O: Anterior portion of transverse processes C5-C6 I: Medial portion of 2 nd rib I: Medial portion of 2 nd rib Action: Lateral bending of cervical spine Action: Lateral bending of cervical spine

14 Clinical Anatomy

15 Sternocleidomastoid: Sternocleidomastoid: O: Medial clavicular head, superior sternum O: Medial clavicular head, superior sternum I: Mastoid process I: Mastoid process A: Flexion of cervical spine, rotation to opposite side, lateral bending A: Flexion of cervical spine, rotation to opposite side, lateral bending

16 Clinical Evaluation History: History: Location of pain: Location of pain: Localized pain: Localized pain: Muscle strain, ligament sprain, vertebral fracture, facet syndrome Muscle strain, ligament sprain, vertebral fracture, facet syndrome Radiating pain: Radiating pain: Trauma to cervical nerve root or spinal cord Trauma to cervical nerve root or spinal cord Onset of pain: Onset of pain: Acute, chronic, insidious Acute, chronic, insidious

17 Clinical Evaluation History: History: Mechanism of Injury: Mechanism of Injury: Insidious onset: Insidious onset: Overuse and postural conditions Overuse and postural conditions Acute onset: Acute onset: Axial load (compression fracture) Axial load (compression fracture) Flexion (compression of anterior vertebral body and intervertebral disc; facet joint sprain; posterior muscle strain) Flexion (compression of anterior vertebral body and intervertebral disc; facet joint sprain; posterior muscle strain) Extension (compression of posterior vertebral body and intervertebral disc; anterior longitudinal ligament sprain) Extension (compression of posterior vertebral body and intervertebral disc; anterior longitudinal ligament sprain) Lateral bending (nerve root compression, facet joint compression) Lateral bending (nerve root compression, facet joint compression)

18 Clinical Evaluation History: History: Mechanism of Injury: Mechanism of Injury: Acute onset: Acute onset: Rotation (disc trauma, ligament sprain, vertebral dislocation) Rotation (disc trauma, ligament sprain, vertebral dislocation) Consistency of pain: Consistency of pain: Inflammatory induced pain: consistent pain Inflammatory induced pain: consistent pain Mechanical pain (i.e. nerve compression): varies in intensity, moving spine may ↑ or ↓ pain Mechanical pain (i.e. nerve compression): varies in intensity, moving spine may ↑ or ↓ pain History: History: Previous injury Previous injury Scar tissue formation Scar tissue formation Injured disc Injured disc Osteophyte within intervertebral foramina Osteophyte within intervertebral foramina

19 Clinical Evaluation Inspection: Inspection: Cervical curvature: Cervical curvature: Lordotic curvature – normal Lordotic curvature – normal Lateral bending posture - ↓ pressure on nerve roots away from the bend Lateral bending posture - ↓ pressure on nerve roots away from the bend

20 Clinical Evaluation Inspection: Inspection: Position of head on the shoulders: Position of head on the shoulders: Unilateral spasm – lateral flexion of head towards involved side Unilateral spasm – lateral flexion of head towards involved side Torticollis: Wry neck Torticollis: Wry neck Rotation of chin opposite the side of the tilt Rotation of chin opposite the side of the tilt Congenital or acquired spasm of the SCM Congenital or acquired spasm of the SCM

21 Clinical Evaluation Inspection: Inspection: Position of the head on the shoulders: Torticollis Position of the head on the shoulders: Torticollis 18 years age male with congenital torticollis with the left SCMM tight as a band unabeling him to turn his head to the right Infant with torticollis: The attitude of the head and neck results from a combination of head tilt and rotation. A tight SCM muscle causes head tilt towards the tight side with rotation of the chin to the opposite side

22 Clinical Evaluation Inspection: Inspection: Bilateral soft tissue comparison: Bilateral soft tissue comparison: Trapezius and other musculature: Trapezius and other musculature: Hypertrophy, atrophy Hypertrophy, atrophy Level of the shoulders: Level of the shoulders: Height of acromioclavicular joints Height of acromioclavicular joints Deltoids Deltoids Clavicles Clavicles

23 Clinical Evaluation Palpation: Palpation: Anterior Structures: Anterior Structures: Hyoid bone: Hyoid bone: Have patient swallow noting superior and inferior movement Have patient swallow noting superior and inferior movement Level of 3 rd cervical vertebrae Level of 3 rd cervical vertebrae Thyroid cartilage: Thyroid cartilage: Adam’s apple Adam’s apple Level of 4 th and 5 th cervical vertebrae Level of 4 th and 5 th cervical vertebrae Cricoid cartilage: Cricoid cartilage: Level of 6 th cervical vertebrae Level of 6 th cervical vertebrae

24 Clinical Evaluation Palpation: Palpation: Anterior structures: Anterior structures: Sternocleidomastoid: Sternocleidomastoid: Have patient rotate head Have patient rotate head Scalenes: Scalenes: Posterior to SCM (C3- C6 level) Posterior to SCM (C3- C6 level) Carotid artery Carotid artery Lymph nodes Lymph nodes

25 Clinical Evaluation Palpation: Palpation: Posterior and Lateral Structures: Posterior and Lateral Structures: Occiput and superior nuchal line Occiput and superior nuchal line Transverse processes Transverse processes Spinous processes: Spinous processes: Have patient flex c- spine Have patient flex c- spine C7 and T1 C7 and T1 Trapezius Trapezius

26 Clinical Evaluation Range of Motion: Range of Motion: Active neck flexion and extension: Active neck flexion and extension: Test position: patient can be standing or seated Test position: patient can be standing or seated Motion: Atlanto-occipital joint Motion: Atlanto-occipital joint Flexion: patient touches chin to chest (45 0 ) Flexion: patient touches chin to chest (45 0 ) Extension: patient looks up towards ceiling (45 0 ) Extension: patient looks up towards ceiling (45 0 ) Active neck lateral flexion: Active neck lateral flexion: Test position: patient seated or standing Test position: patient seated or standing Patient takes ear to shoulders (45 0 ) Patient takes ear to shoulders (45 0 )

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28 Clinical Evaluation Range of Motion: Range of Motion: Active rotation: Active rotation: Test position: patient seated, head held upward and facing forward Test position: patient seated, head held upward and facing forward Patient attempts to look over each shoulder Patient attempts to look over each shoulder Motion: Atlanto-axial joint (45 0 ) Motion: Atlanto-axial joint (45 0 )

29 Clinical Evaluation Range of Motion: Range of Motion: Passive flexion: Passive flexion: Patient position: supine Patient position: supine ATC: grab patient’s head (under occiput) and attempt to bring chin to chest ATC: grab patient’s head (under occiput) and attempt to bring chin to chest Passive extension: Passive extension: Patient position: supine, head off end of table Patient position: supine, head off end of table ATC: grasp patient’s head and move into extension ATC: grasp patient’s head and move into extension

30 Clinical Evaluation Range of Motion: Range of Motion: Passive lateral flexion: Passive lateral flexion: Patient position: supine, head in neutral position Patient position: supine, head in neutral position ATC: one hand under occiput, tilt head/neck to bring ear to shoulder ATC: one hand under occiput, tilt head/neck to bring ear to shoulder Passive rotation: Passive rotation: Patient position: supine Patient position: supine ATC: grasp patient’s forehead and occiput, rotate head and neck ATC: grasp patient’s forehead and occiput, rotate head and neck

31 Clinical Evaluation

32 Range of Motion: Range of Motion: Resisted range of motion: Flexion Resisted range of motion: Flexion Patient: supine with cervical spine and head in neutral position Patient: supine with cervical spine and head in neutral position Stabilization: superior aspect of sternum Stabilization: superior aspect of sternum Resistance: to the forehead Resistance: to the forehead Muscles tested: SCM and anterior scalenes Muscles tested: SCM and anterior scalenes

33 Clinical Evaluation Range of Motion: Range of Motion: Resisted range of motion: Extension Resisted range of motion: Extension Patient: prone with cervical spine and head in neutral position Patient: prone with cervical spine and head in neutral position Stabilization: superior aspect of thoracic spine Stabilization: superior aspect of thoracic spine Resistance: to the skull over the occiput Resistance: to the skull over the occiput Muscles tested: trapezius (upper 1/3, levator scapulae, cervical paraspinal muscles) Muscles tested: trapezius (upper 1/3, levator scapulae, cervical paraspinal muscles)

34 Clinical Evaluation Range of Motion: Range of Motion: Resisted range of motion: Lateral flexion Resisted range of motion: Lateral flexion Patient: seated with cervical spine and head in neutral position Patient: seated with cervical spine and head in neutral position Stabilization: over the AC joint on the side toward the motion Stabilization: over the AC joint on the side toward the motion Resistance: over the temporal and parietal bones on the side toward the motion Resistance: over the temporal and parietal bones on the side toward the motion Muscles tested: SCM, scalenes, paraspinal muscles on the side being tested Muscles tested: SCM, scalenes, paraspinal muscles on the side being tested

35 Clinical Evaluation Range of Motion: Range of Motion: Resisted range of motion: Rotation Resisted range of motion: Rotation Patient: seated with cervical spine and head in neutral position Patient: seated with cervical spine and head in neutral position Stabilization: over the anterior shoulder on the side toward the rotation Stabilization: over the anterior shoulder on the side toward the rotation Resistance: over the temporal bone on the side toward the motion Resistance: over the temporal bone on the side toward the motion Muscles tested: SCM, multifidus, rotators Muscles tested: SCM, multifidus, rotators

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37 Clinical Evaluation C1-C2 Neck flexion C3 Neck lateral flexion C4 Shoulder shrug C5 Shoulder abduction, ER C6 Elbow flexion, wrist extension C7 Elbow extension, wrist flexion C8 Thumb extension T1 Finger abduction and adduction

38 Clinical Evaluation Neurological Screening: Neurological Screening: Nerve root: C5 (Biceps brachii) Nerve root: C5 (Biceps brachii) Patient: seated and relaxed Patient: seated and relaxed ATC: thumb placed over biceps tendon, strike the thumb nail with reflex hammer ATC: thumb placed over biceps tendon, strike the thumb nail with reflex hammer

39 Clinical Evaluation Neurological Screening: Neurological Screening: Nerve root: C6 (Brachioradialis) Nerve root: C6 (Brachioradialis) Patient: seated and relaxed Patient: seated and relaxed ATC: taps the brachioradialis with reflex hammer ATC: taps the brachioradialis with reflex hammer

40 Clinical Evaluation Neurological Screening: Neurological Screening: Nerve root: C7 (Triceps) Nerve root: C7 (Triceps) Patient: seated and relaxed Patient: seated and relaxed ATC: support arm in position of extension and abduction, tap the triceps tendon with reflex hammer ATC: support arm in position of extension and abduction, tap the triceps tendon with reflex hammer

41 Clinical Evaluation Babinkski Test: Babinkski Test: Athlete: Supine with shoes and socks removed Athlete: Supine with shoes and socks removed ATC: At the foot of the athlete holding a blunt tool ATC: At the foot of the athlete holding a blunt tool Procedure: ATC runs the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe Procedure: ATC runs the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe Positive test: Great toe extends while other toes splay Positive test: Great toe extends while other toes splay Implications: Lesion of upper motor neurons, may be caused by trauma to the brain Implications: Lesion of upper motor neurons, may be caused by trauma to the brain Comments: This reflex occurs naturally in newborns. However, this reflex should cease quickly after birth Comments: This reflex occurs naturally in newborns. However, this reflex should cease quickly after birth

42 Clinical Evaluation Oppenheim Test: Oppenheim Test: Test: Upper motor neuron lesions Test: Upper motor neuron lesions Patient position: supine Patient position: supine ATC: at patient’s side ATC: at patient’s side Procedure: examiner’s fingernail is run along the crest of the anteromedial tibia Procedure: examiner’s fingernail is run along the crest of the anteromedial tibia Positive test: great to extends and the other toes splay Positive test: great to extends and the other toes splay


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