DSA3: Cervical Region

Faculty: Sajid Surve, D.O.

Reading Assignment: Cervical Region: Foundations of Osteopathic Medicine, 3rd Edition, Chap. 38
Will be discussed in: MLM3 Tuesday, February 19th, 10a-11p

Learning Objectives AOA NBOME

Comp Comp
On a written exam, student should be able to:
Define normal anatomy of the cervical spine and related structures. 1,2 1,3

Recall the major motions available to the cervical spine. 1,2 1,3

Recognize unique biomechanics and proper nomenclature of somatic dysfunctions of the cervical spine. 1,2,3 1,2,3

Define normal anatomy of the cervical spine and related structures.

The cervical spine is comprised of 7 vertebrae. The first cervical vertebra (commonly referred to as the “atlas”) connects with the oc-
cipital condyles of the occiput to create joint called the occipito-atlantal (OA) joint. The vertebral body of C1 creates a thin anterior
band of bone and a tubercle, with the remainder of the bone fused instead with the vertebral body of the second cervical vertebra
(sometimes referred to as the “axis”), creating a post around which C1 can swivel. This relationship between C1 and C2 is called the
atlanto-axial (AA) joint. The relationship between C2 and C3, and all remaining cervical segments, are based on their facet joints. They

are collectively referred to as the “typical cervicals.” See above for a lateral view of the cervical spine in both illustration and x-ray. The
cervical spine normally demonstrates a small lordotic curve. The obliquely oriented facets have their superior facet processes facing
backwards, upwards, and medial (BUM) like the lumbar spine. Unlike the thoracic or lumbar spines, however, the typical cervical spine
has bifid spinous processes to allow for muscular and ligamentous attachments. The transverse processes are also very short, and have a
foramen to allow the vertebral arteries to pass through them, as shown on the right above. The typical cervical spine is also unique be-
cause the front edge of the vertebral body has a lateral lip called the uncinate process, which articulates with the segments above and
below to form a secondary joint called the uncovertebral joint, or “Lushka’s joint.” These joints serve to accentuate flexion and exten-
sion while limiting sidebending. As a result, the cervical spine is incapable of exhibiting group mechanics. Instead, each vertebra oper-
ates independently. Where the facet joints come together, the bony articular processes align with one another to create a bilateral col-
umn that can be felt posteriorly on either side of the spinous process. These bony columns are referred to as the “articular pillars,” and
serve a similar function to the transverse processes of the thoracic and lumbar spine in terms of helping to determine cervical segment
rotation.
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DSA3: Cervical Region
Faculty: Sajid Surve, D.O.
On the left we can see a closer view of the OA and AA joints. Take notice
of the shape of the superior articular facets on C1, and their anteriorly bi-
convergent configuration. They create a rocking horse-like mechanic for
the occiput, with the primary motion being flexion and extension. Indeed,
50% of total cervical flexion is accounted for by the OA joint. Next, look
at the post of the dens (sometimes called the odontoid process), and how
the ligamentous attachments create a sling around it. The net sum of these
anatomical features is that the AA joint is built almost exclusively for rota-
tion. As with the OA, about 50% of total cervical spine rotation is account-
ed for by the AA joint.

To the right is an illustration of the ligamentous anatomy

of the cervical spine. Notice that the anterior and poste-
rior longitudinal ligaments, ligamentum flavum, and su-
praspinous ligaments all originate from the upper cervical
spine and occiput, as they make their way down the en-
tire spine. Also notice the depth and thickness of the
nuchal ligament which lies in the midline of the cervical
spine.
Below is a T2-weighted MRI image of the cervical spine,
which shows many of the structures already mentioned.
Also take notice of the spinal cord, which is especially
thick in the cervical spine due to the fibers that will even-
tually branch off and become the brachial plexus. When comes to nerves, also take notice of cranial nerve X, the vagus nerve (bottom
right), which exits the jugular foramen and passes right past the transverse processes of C1 and C2 on its way to the rest of the body.
For this reason, upper cervical somatic dysfunction has profound impact on the autonomic nervous system, which will be discussed at
length in year 2.

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DSA3: Cervical Region
Faculty: Sajid Surve, D.O.
In terms of musculature for the cervical spine, they can be divided into three rough categories: deep muscles, superficial muscles, and
suboccipital muscles. The deep muscles are pictured just below. They include the longus colli muscles which are deep flexors, and the
scalenes which are primarily for sidebending the cervical spine, with sone secondary rotation. The scalenes are also accessory muscles or
respiration, given their insertions on the 1st and 2nd ribs. The suboccipital region serves to strengthen the relation between the head
and cervical spine, and is rich with muscles, nerves, and vasculature as pictured to the right. Treating this region can have profound
effects on headaches of both tension and migraine type due to the myriad structures that inhabit this space.

Superficial muscles in the cervical spine

are represented in the line drawings to the
left. They include the sternocleidomas-
toid, which is interesting because it moves
the cervical spine without actually attach-
ing to it, as well as the splenius and sem-
ispinalis groups. As stated earlier, several
other muscles also traverse the cervical
spine on their way down to other regions,
such as the trapezius and erector spinae
muscles. Another muscle not pictured
that attaches to the cervical spine is the
levator scapulae from the superior medial
border of the scapula.
Take time to learn which muscles are en-
gaged when the cervical spine flexes, ex-
tends, sidebends, and rotates respectively.
Also consider the far-reaching implica-
tions of cervical spine somatic dysfunc-
tion. If any of these muscles were to be-
come hypertonic, what would a patient
look like when they came to your office?

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DSA3: Cervical Region
Faculty: Sajid Surve, D.O.
Recall the major motions available to the cervical spine.

The major motions are flexion/extension, rotation, and sidebending. The average norms for these ranges are listed above, although there
is a fair amount of variability from person to person depending on age, flexibility, resting muscle tone, and other factors.

Recognize unique biomechanics and proper nomenclature of somatic dysfunctions of the cervical spine.

Occipito-atlantal Joint
As stated previously, the OA has a primary motion of flexion and extension. A small amount of sidebending and rotation also occurs
at the OA joint, which is coupled to opposite sides. As such, the OA is completely non-Fryette’s in both its biomechanics and nomen-
clature. The convention is to list flexion/extension first, followed by sidebending, then rotation:

OA F/E SxRy
Atlanto-axial Joint
Because of its anatomical arrangement, the AA joint has an inconsequential amount of sidebending, flexion, and extension. Instead,
when looking at somatic dysfunction of the AA joint, the only plane that is assessed and commented upon is rotation:

AA Rx
Typical Cervicals
From C2 through C7, the vertebrae behave in a more familiar fashion. Because of the uncovertebral joints groups cannot form, so es-
sentially every level acts as a Type II dysfunction, and is named accordingly:

Cn FRSx or ERSx (or FRxSx and ERxSx)

The cervical spine is less likely than the thoracic or lumbar spine to actually conform to Type II mechanics. It is not uncommon to
find segments that are neutral as well, but with sidebending and rotation to the same side (NRxSx). For this reason, no assumptions
can be made and segments must always be assessed in all planes.
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