Craniovertebral Joint

• CV instability can result from:

  • trauma
  • RA
  • AS
  • corticosteroid use
  • recurrent upper respiratory tract infections
  • Grisel's syndrome
  • spontaneous AA dislocation
  • down syndrome
  • osteoporosis
• typical cervical spine are C2-7; atypical are OA + AA
• typical cervical spine:

  • upper cervicals tend to have more rotation + less side-bending
  • lower cervicals tend to have more side-bending + less rotation
• C2-C7:

  • can be neutral, flexed, or extended
  • somatic dysfunctions have side-bending + rotation to the same side
  • make up ~50% of flexion + extension of cervical spine
  • make up ~50% of rotation of cervical spine
• OA:

  • ~50% of flexion/extension of cervical spine
  • primarly gliding motion on cervical condyles
  • somatic dysfunctions found with flexion or extension + with side-bending + rotation to opposite sides
• C1 tranverse process palpation:

  • posterior to SCM
  • anterior to angle of mandible
  • superior by cartilage of auricle

  
• ligaments that resist distraction also resist flexion of the CV joint
• tectorial membrane has been shown to be major restrain to distraction of the head from the atlas + axis
• anterior shear test for transverse ligament:

  • pt in supine
  • anterior arches of C2 are stabilized downwards towards table
  • occiput + C1 are lifted using lumbrical motion
  • pt instructed to count backwards outloud for 15 sec or until end-feel percieved
  • positive: reproduction of pt symptoms or excessive, mushy end-feel

  
• anterior stability test of OA joint:

  • pt in supine
  • pads of fingers 2-5 cradle occiput
  • pads of thumbs turned medially to fix the transverse mass of atlas + axis
  • anterior translation force applied
  • positive: reproduction of pt symptoms or empty end-feel
• brainstem S + S:

  • dizziness
  • drop attacks
  • diplopia
  • dysphagia
  • dysarthria
  • ataxia
  • nausea
  • numbness
  • nystagmus
• clinical CV instability frequently has normal radiographic findings
• the transverse foramen contains:

  • vertebral artery
  • sympathetic plexus
• high risk factors for cervical instability"

  • > 65 years
  • dangerous mechanism
  • paresthesia in extremities
• dangerous mechanisms include:

  • fall from elevation > 3 feet or 5 stairs
  • axial load to head (i.e. diving)
  • MVC high speed, rollover, or ejection
  • motorized recreational vehicle
  • bicycle struck or collision
• posterior stability test of OA joint:

  • tests transverse lig
  • sides of cranium gentle compressed with palms of both hands
  • pads of index fingers over arch of C2 - using lumbrical action - translate C2 anterior under fixed occiput
  • + = excessive anterior translation of C1/2 (relative posterior translation of occiput)
• general (longitudinal) distraction:

  • tests tectorial membrane
  • distraction performed with head + neck in neutral
  • + = reproduction of pt s + s
  • if negative, stress ligaments further by biasing CV flexion

  
• specific (longitudinal) distraction:

  • tests AA membrane
  • C2 neural arch fixed + CV flexed to eliminate stabilizing effect of ligamentum nuchae
  • + = reproduction of pt s + s
• if the transverse ligament is torn, C1 will translate forward (sublux) on C2 during flexion
• modified sharp-purser (safety test):

  • tests transverse ligament + subluxation of C1 on C2
  • pt in sitting
  • CV flexion
  • + = reproduction of s + s or hearing/feeling a clunk
  • if negative, PT stabilizes C2 posteriorly + applies posterior force to forehead of pt
• if the sharp-purser test is positive, the examination is terminated. the pt should be placed in a cervical collar and emergency services contacted
• aspinall's test:

  • tests transverse lig
  • stabilize occiput on atlas in flexion
  • hold occiput in flexed position
  • apply anterior force to posterior aspect of atlas
  • + = pt feels lump in throat

  
• positive transverse ligament stress testing may result in:

  • muscle spasm
  • abnormally stretchy capsular end feel
  • production of neurological symptoms
  • consistent swallowing during the test
• transverse shear test:

  • tests alar lig
  • stabilize mastoid
  • C1 moved in transverse direction
  • test repeated stabilizing C1 + translating mastoid
  • + = reproduction of s + s; empty end feel
  • can also be performed on C1 + C2

  
• alar ligament:

  • resists contralateral side bending
  • stressed by passive contralateral side bending + rotation of occiput on atlas
  • tension of alar lig during side bending results in ipsilateral rotation
• side bending stress test

  • alar lig
  • pt in supine
  • C2 neural arch fixated with mild compression
  • push pt right ear towards left side of neck (SB right)
  • minimal side bending occurs with strong capsular end feel + solid stop
  • + = empty end feel or excessive translation
  • performed in neutral, CV flexion, + CV extension

  
• kinetic test for alar lig:

  • pt in sitting
  • C2 spinous process palpated for motion
  • pt asked to rotate head
  • + = C2 spinous process does not immediately move when head is rotated (ligament laxity)

  
• hypertonic or fibrotic rectus capitis posterior major may give false negative for alar lig kinetic test
• rectus capitis posterior major function:

  • extend + rotate head ipsilaterally
• rotational stress test:

  • alar lig
  • pt in sitting
  • spinous process + lamina of C2 stabilized
  • head is side bent
  • C2 should immediately begin rotating contralateral to side bend
  • + = C2 does not immediately move
• supine nodding test:

  • flexion:
  • chin deviation indicates occiput is unable to glide on the side of deviation
  • extension:
  • chin deviation indicates occiput is unable to glide on the opposite side of deviation
• craniovertebral function:

  • make head movements independent from rest of vertebral column
  • orients the head in 3 planes
• OA joint has 2 main functions:

  • transmit forces from head to cervical spine
  • provide significant degree of mobility in sagittal plane
• AA rotation test:

  • pt in supine
  • neck maximally flexed to chest - locks out C2-7
  • pt rotates head
  • observe available ROM
• AA rotation ROM: 30-35 deg
• ROM assessment of AA:

  • CV side bending
  • head rotated in opposite direction