Cervical Spine

BY
DR SYEDA ABIDA HUSSAIN SHERAZI
Cervical Spine

C1 - C7
Clinical Anatomy

 Cervical Spine:
 Greatest range of
motion
↑ risk of injury
 Vertebral bodies:
 Smaller than other
vertebral sections
7 vertebrae:
 1st – Atlas
 2nd – Axis
Clinical Anatomy
 Cervical Spine:
 Atlas:
 No vertebral body
 Transverse processes
 No true spinous process
 Supports the weight of the
skull through 2 facet
surfaces (atlanto-occipital
joint or C0-C1
articulation)
 Flexion and extension (primary
movement)
 Lateral flexion (slight)
Clinical Anatomy
 Atlanto-occipital joint
dislocation:
 (15% of all fatal spinal
trauma)
 MOI: high speed motor
accident; Pt. unconscious
 Lateral cervical spine
radiograph:
 Prevertebral soft-tissue
swelling (white arrow)
 Malalignment between the
skull and the cervical spine
with widening of the
atlanto-occipital joints
(black arrow)
Clinical Anatomy
 Cervical Spine:
 Axis:
 2nd cervical vertebrae
 Small body with a
superior projection
(Dens)
 Atlanto-axial joint:
 Dens and atlas
articulation
 Rotation of the skull
Atlas and Axis
Ligamentous Anatomy

 Anterior longitudinal ligament

 Reinforces anterior discs, limits extension
 Posterior longitudinal ligament
 Reinforces posterior discs, limits flexion
 supraspinous ligament
 Thicker than in thoracic/lumbar regions
 Limits flexion
 Interspinous/intertransverse ligaments
 Limit flexion and rotation/limits lateral flexion
 Ligamentum flavum
 Attach lamina of one vertebrae to another, reinforces articular
facets
 Limits flexion and rotation
Ligamentous Anatomy

a = ligamentum flavum
b = interspinous
ligaments
c = supraspinous
ligament
 Palpable C7
 Anterior Curvature
 Shock absorption
 Ligaments
 Ligamentum Nuchae
 “Whiplash”
 Vertebral Arteries
 C3

 Spinal Nerves
 C1-T1
 Cervical Plexus
 C1-C4
 C4 -Phrenic Nerve - Breathing
 Brachial Plexus
 C5-T1
 Dermatomes

C1 – top of head
C2 – Temporal
C3 – Side of
jaw/neck
C4 – top of
shoulders

Myotomes C5 – Abduction
C1-2 – Neck Flexion C6 – Elbow Flexion/Wrist Extension
C3 – Lateral Neck Flexion C7 – Elbow Extension/Wrist Flexion
C4 – Shoulder Elevation C8 – Finger Flexion
T1 – Finger Abduction
Brachial Plexus
Brachial Plexus
ROOTS TRUNKS DIVISIONS CORDS BRANCHES
Dorsal Scapular Suprascapular
C5 Anterior
Upper Posterior Lateral Lateral Pectoral
C6
Anterior
C7 Middle Musculotaneous
Posterior
Posterior Axillary
C8 Radial
Lower Anterior

T1 Posterior
Medial Median
Ulnar
Medial Pectoral
Long Medial Antebrachial
Thoracic
Medial Brachial Cutaneous
Thoracodorsal
Subscapular
 Muscles

Trapezius
Sternocleidomastoid
Scalenes
Splenius
Semispinalis, Spinalis, Longissimus
Intervertebral Disc
 Intervertebral disk make up 20-30% of the height of the column and
thickness varies from 3mm in cervical region, 5mm in thoracic region
to 9 mm in the lumbar region.
 Ratio between the vertebral body height and the disk height will
dictate the mobility between the vertebra –
 Highest ratio in cervical region allows for motion
 Lowest ratio in thoracic region limits motion
 Disc Structure
 Nucleus Pulposus (NP) is located in the center except in lumbar lies slightly
posterior.
 Gelatinous mass rich in water binding PG (proteoglycan) AKA
(glycoaminoglycos) GAG-protein molecule.
 Chondrotin-4 sulfate in PG molecule gives the disc a fluid maintaining capacity
(hydrophyllic) - decreases with age.
 Hydration of the disc will also decrease with compressive loading - this loss of
hydration decreases its mechanical function.
Disc Structure

 80-90% is H2O – decreases with age.

 Disc volume will reduce 20% daily (reversible) which causes a loss of 15-25
mm of height in the spinal column.
 Acts as a hydrostatic unit allowing for uniform distribution of pressure
throughout the disc.
Disc Structure

 Compressive stresses on the disc translate into tensile stresses in the annulus
fibrosis
 This makes the disc stiffer which adds stability and support to the spine.
 Bears weight and guides motion.
 Avascular - nutrition diffusion
 Annulus Fibrosis
 Collagen arranged in sheets called lamellae (outer layers).
 These lamellae are arranged in concentric rings -10-12
layers that lessen in number with age and thicken (fibrose).
 Enclose the nucleus
 Controls the tensile loading from shear, accessory motions
in the anterior compartment.
Annulus Fibrosis

 Mostly avascular and lacking innervation but the outermost

layers are probably innervated (sinovertebral nerve).
 Thickest anteriorly.
Disc Pathology - Herniation
 Highest incidence at C5-6, C6-7, L4-5, and
L5-S1.
 Disc herniation
 Disc protrusion or bulge - contained
Annulus intact.
Localized – usually lateral
Diffuse – usually posterior
 Prolapsed – not contained
 Annular fibers disrupted – inner layers
 Extrusion - migration through all layers
Longitudinal Ligaments

Anterior longitudinal
Supraspinous

Posterior longitudinal

Ligamentum flavum (elastic)

PLL diverts herniation posteriolaterally

Posterior Structures (Elements) of Motion
Segment
 Pedicles and lamina form the neural arch.
 Facet joints between the superior and inferior articulating
surfaces.
 Transverse and spinous processes.
 Interspinous and supraspinous ligaments.
 Ligamentum flavum.
 Intervertebral foramina.
Facet Joint

 Articulation between
the superior (concave)
and inferior (convex)
facets.
 Guide intervertebral
motion through their
orientation in the
transverse and frontal
planes.
Facet Joint Capsule
 Limit motions.
 Strongest in thoracolumbar and cervicothoracic regions where the
curvatures change.
 Resist flexion and undertake tensile loading in the superior portion with
axial loading or extension.
 Resists rotation in lumbar region.
Intervebral Foramina
 Exit for nerve root.
 The size is dictated by the
disc heights and the pedicle
shape.
 Will lose space with
osteophytic formation,
hypertrophy of ligaments
and loss of disc height with
aging – lateral stenosis.
 Decreases by 20% with
extension and increases
24% with flexion
Cervical Injuries

 Fairly uncommon in athletics(6-7%) - but greater

than 90% of all mortalities are cervical related.
 Cervical injuries are primarily technique related:
 Spearing
 Tackling or falling head first.
 Must have an emergency plan:
 All personnel know roles and equipment use.
 All unconscious athletes - suspect head/neck
 Always suspect the worse until proven otherwise
Cervical Injuries

 Common MOIs
 Axial Loading
 Flexion Force
 Hyperextension Force
 Flexion-Rotation Force
 Hyperextension-Rotation
 Lateral Flexion
C-Spine Injuries

 Cervical Fracture or Dislocation

 Weakness or Paralysis
 Cervical Nerve Root Injury
 Herniated Disc
 Laceration

 Cord Shock (Central Cord Syndrome)

 Hemorrhage

 Contusion

 Cervical Stenosis
C-Spine/Neck Injuries

 Cervical Strain
 Active motion most painful
 Cervical Sprain (Whiplash)
 Passive and active motion painful
 Torticollis (Wry Neck)
 Muscle spasm and facet irritation
 Brachial Plexus Stretch or Compression
Evaluation Techniques

 HOPS
 History, Observation, Palpation, Special Tests
 Your first priority!
 Establish the integrity of the spinal cord and nerve roots
 History and several specific tests provide information
History
History

 Location of pain

 Onset of pain

 Mechanism of injury (etiology)

 Consistency of pain

 Prior history of cervical spine injury

Location of Pain

 Localized pain
 Typically indicative of muscular strain, ligamentous sprain,
facet joint injury, fracture and/or subluxation or dislocation

 Radiating pain
 Heightened risk of likely spinal cord, cervical nerve root
and/or brachial plexus injury
Onset of Pain/Mechanism of
Injury
 Acute onset
 Generally associated with one specific mechanism of
injury/event

 Chronic or insiduous (unknown) onset

 Generally related to overuse injuries (accumulative
microtrauma) and/or postural abnormalities and deficiencies
Consistency of Pain

 Pain from inflammation (strain, sprain, contusion) generally

persists despite changes in cervical spine position

 Pain of mechanical nature (nerve root compression) varies

depending upon cervical spine positioning and can be
minimized or eliminated
Prior History of Cervical
Spine Injury

 Must evaluate for residual symptoms associated with

previous injury

 Must appreciate structural changes (scar tissue, etc.) which

may predispose individual to current injury and symptoms
Inspection
Inspection

 Cervical spine curvature

 Position of head relative to shoulders

 Soft tissue symmetry

 Level of shoulders
Cervical Spine Curvature

 Normal cervical spine has lordotic curve

 Increased lordotic curve (forward head) indicative of poor

posture and muscular weakness or imbalance

 Lessened lordotic curve indicative of muscular

spasm/guarding and/or nerve root impingement
Lordotic Curve
Position of Head Relative
to Shoulders
 Head should be seated symmetrically on cervical spine

 Lateral flexion from unilateral spasm of muscles – strain

and/or spasm (guarding)

 Rotation from unilateral spasm of sternomastoid muscle –

strain and/or spasm (guarding) or torticollis
Torticollis
Soft Tissue Symmetry

 Observe for bilaterally comparable muscle mass, tone and

contour
 Dominant extremity may be hypertrophied vs. non-dominant
extremity
 Excessive tone indicative of possible strain/spasm
 Atrophy indicative of neurological injury
Level of Shoulders

 Inspect height of:

 Acromioclavicular (AC) joints
 Deltoids
 Clavicles

 Dominant extremity often appears depressed relative to non-

dominant extremity
Palpation
Anterior Palpation

 Hyoid bone
 Atlevel of C3 vertebrae, note movement with
swallowing
 Thyroid cartilage
 Atlevel of C4/C5 vertebrae, also moves with
swallowing, protects larynx
 Aka – “Adam’s apple”
 Cricoid cartilage
 At level of C6/C7 vertebrae, point where esophagus
and trachea deviate, rings of cartilage
Anterior Palpation

 Sternomastoid
 Sternum (near SC joint) to mastoid process
 Carotid artery
 Primary pulse point
 Lymph nodes
Posterior and Lateral Palpation

 Occiput
 Posterior aspect of skull, many ms. attachments
 Transverse processes
 Can only palpate C1 transverse processes approx.
one finger below mastoid processes
 Spinous processes
 Flexcervical spine, C7 and T1 are prominent
 Can palpate C5 and C6, maybe C3 and C4
 Trapezius
 Upper fibers from occiput and cervical spinous
processes to distal clavicle
Special Tests
Special Tests

 Range of motion testing

 Active
 Passive
 Resisted
 Ligamentous/capsular tests
 Neurological tests
 Brachial plexus evaluation
 Reflex tests
 Upper motor neuron lesions
Active Range of Motion

 Best done in sitting or standing

 Flexion – touch chin to chest

 Extension – look straight above head
 Lateral flexion – approximately 45 degrees
 Rotation – nose over tip of shoulder
Passive Range of Motion

 Best done laying supine

 Flexion – firm end feel

 Extension – hard end feel (occiput on cervical spinous
processes)
 Lateral flexion – firm end feel (stabilize opposite shoulder)
 Rotation – firm end feel
Resisted Range of Motion

 Easiest to perform all in seated position –

stabilize proximally to avoid substitution

 Flexion – resistance to forehead

 Extension – resistance to occiput
 Lateral flexion – resistance to temporal and
parietal regions
 Rotation – resistance to temporal region or side
of face
Ligamentous/Capsular Testing

 No specific named tests for cervical spine

 End feels associated with passive ranges of motion

essentially become end points for joint capsule and
ligamentous stress tests
Neurological/Vascular Tests

 Brachial plexus evaluation

 Dermatomes = sensory map
 Myotomes = motor function
 Reflex tests
 Cervical distraction/compression tests
 Spurling test
 Upper motor neuron lesions
 Babinski test
 Oppenheim test
 Loss of bowel and/or bladder control
 Vertebral artery test
Neurological Testing

 Dermatomes
 Reflexes
 Babinski
 Oppenheim
 Biceps
 Brachioradialis
 Triceps
 Myotomes
Brachial Plexus – Reflex Tests

 C5 – biceps brachii reflex (anterior arm near antecubital

fossa)

 C6 – brachioradialis reflex (thumb side of forearm)

 C7 – triceps brachii reflex (at insertion on olecranon

process)
Brachial Plexus Traction Test

 Mimics mechanism of injury

 Cervical spine laterally flexed and opposite shoulder is
depressed
 Positive if radiating/”burning” pain in upper extremity
 If traction injury, symptoms noted on side of depressed
shoulder
 If compression injury, symptoms noted in direction of lateral
flexion
Cervical
Distraction/Compression Tests
 Distraction
 Patient supine, clinician stabilizes head
 Passive traction force applied to cervical spine
 Positive test if neuro symptoms and/or pain reduced
with traction force
 Compression
 Patient sitting, clinician pushes down on top of
patient’s head
 Positivetest if pain and/or neuro symptoms
reproduced in cervical spine and/or upper extremity
Spurling Test

 Same positioning as cervical compression test

 Instead of linear axial load through top of head, clinician
extends and laterally rotates neck with compression to
impinge on nerve root/s
 Positive if pain and/or neuro symptoms reproduced in
cervical spine and/or upper extremity
Spurling Test
Upper Motor Neuron Lesions

 Symptoms of catastrophic head and/or spinal

cord injury associated with trauma
 Babinski test
 Blunt device stroked along plantar aspect of foot
from calcaneus to 1st metatarsal head
 Positive test if great toe extends and other toes splay
 Oppenheim test
 Fingernail ran along medial tibial border/crest
 Positive test if great toe extends and other toes splay
Babinski Test
Vertebral Artery Test

 Assesses patency of vertebral artery

 Patient placed supine on table
 Clinician supports head at occiput
 Patients neck passively extended, laterally flexed and then
rotate toward laterally flexed side for ~30 seconds
 Positive test if dizziness, confusion, nystagmus, unilateral
pupil changes and/or nausea present
Cervical Spine Pathologies
Cervical Spine Injuries

 Acute injuries typically trauma induced and involve

excessive movement/s of the spine and injury to related
structures

 Chronic conditions result from poor posture, muscle

imbalances, decreased flexibility and/or repetitive
movement related to activity
Cervical Spine Injuries

 Brachial plexus injuries (stinger/burner)

 Compression or distraction
 Cervical nerve root impingement
 Degenerative disc changes
 Acute disc injury
 Sprain/strain syndrome
 Difficult to differentiate
 Vertebral artery impingement
Cervical Injuries
 Brachial Plexus (C5-TI) “burners or stingers”
 MOI: stretch or compression
 S/S:burning or stinging neck/arm/hand, muscle
weakness, supraclavicular tenderness (Erb’s Point),
neck pain
 chronic: numbness ,tingling, and weakness lasts longer
Brachial Plexus Pathology
TESTS:
• Brachial Plexus
 Neurological findings!! Traction Test
• Tinel’s Sign
• Spurling’s Test
• Cervical Distraction

• Burning, achy pain

• Muscle weakness
• Point tenderness
• Mechanism of Injury
Brachial Plexus Injury

 Compression force – nerve roots pinched

between adjacent vertebrae
 Increased risk if spinal stenosis (narrowing of
intervertebral foramen) exists
 Distractionforce – tension or “stretch” force
on nerve roots
 Most common at C5/C6 levels but may involve
any cervical nerve root
 Erb’s point – 2-3 cm above clavicle anterior to C6
transverse process, most superficial passage of
brachial plexus
Erb’s Point
Brachial Plexus Injury

 Signs and symptoms

 Immediate and significant pain
 “Burning” or radiating pain in upper extremity
 Dropped shoulder on affected side
 Myotome and dermatome deficiencies at affected
nerve root levels
 Generally, symptoms minimize or resolve quickly
 Ifrecurrent, takes less trauma to induce symptoms
and longer for symptoms to diminish
Cervical Nerve Root
Impingement
 Disc related conditions
 Degenerative disc changes
 Disc herniations – most at C5/C6 or C6/C7 levels
 Oftenpresents with head in position of least
compression on affected nerve root/s
 Similarneuro symptoms to brachial plexus injuries at
involved level/s
 Narrowing of intervertebral foramen
 Exostosis (bone spur)
 Facet degeneration
Cervical Nerve Root
Impingement
 Causes:
 Spinal stenosis
 Disc
herniations (C5-6 or C6-7) are most
common
 Chronic Muscular Tension/Facet Joint Syndrome
 Pain characteristics:
 Radiating pain into upper extremity
 Upper quarter screening reveals:
 Sensory deficits and/or muscle weakness
Sprain/Strain Syndrome

 Since unable to directly palpate facet joints,

difficult to differentiate pain/spasm associated
with sprain of joint capsule from strain of
musculature
 Inflammation from sprain/strain may irritate
nerve roots in close anatomical orientation to
affected area and produce neuro symptoms
 Severe sprains (dislocations) will present with
postural change due to joint disassociation
Cervical Strains and Sprains

 S/S:
 limited AROM/RROM/PROM,
 diffuse tenderness,
 no peripheral pain or paresthesia,
 normal neurological
Vertebral Artery Impingment

 Due to anatomic location, may be compromised with same

mechanism of injury as brachial plexus/cervical nerve root
impingement injuries
 Signs and symptoms
 Dizziness
 Confusion
 Nystagmus
Cervical Disk, Nerve Impingement,
or Fracture/Dislocation

S/S:
 Abnormal neurological
 Peripheral pain or paresthesia,
 specific tenderness
Cervical Facet Joint Syndrome

S/S:
 limited AROM/RROM/PROM,
 Achy and intermittent pain – relieved by position changes,
 peripheral pain or paresthesia is unlikely,
 normal neurological
 unless chronic and symptoms have developed
Neck Injuries

 Contusions to Neck
 MOI: Clothes lining
 Voice box injury, Tracheal injury
 Loss of voice, Raspy voice
 Inability to swallow
CERVICAL SPINE DISORDERS
Whiplash
 Acceleration- deceleration injury
  
 Motor Vehicle accident
 Football
 High velocity sports ( Skiing)
 Rear end collision are responsible for about 85% of all whiplash
 AT THE TIME OF IMPACT: the trunk of the body, which is supported by
a car seat , moves rapidly forward. The moment of inertia of the head
creates a relative backward acceleration of the head and neck.
Structures involvements
REAR END COLLISION (Hyper-extension of neck)
 Anterior longitudinal ligament
 Disc
 Articular Facet capsule
 Muscluar strain
 Retropharyngeal Haematoma
 Intraesophageal haemorrhage
 Sympathetic chain reaction
 REAR END COLLISION (Hyper- Flexion of neck)
 Tears of the posterior cervical musculature
 Sprains of the ligament nuchea and posterior longitudinal ligament
 Articular facet joint disruption
 Posterior intervertebral disk injury with nerve root hemorrhage
 Flexion at the atlanto-axial joint will stress the alar ligament complex as
the atlas and head attempt to rotate anterior over the axis.
 LATERAL IMPACT: LATERAL
FLEXION OF NECK
Articular facet capsules on both sides
and intervertebral disks will be most at
risk ( if there is little coupling, lateral
flexion will compress the ipsilateral
articular facet joint and distract the
contra lateral joint.
 Signs/Symptoms
 Pain
 Muscles spasm
 Swelling
 Stiffness
 Warm
 Tender
 Dizziness
 Headache
 Neurological symptoms
 Limited neck mobility
 Acute Phase ( may last as long as 2-3 weeks)
 Treatments: Encourage Active range of motion : Cx, Tx and upper limbs
(within limits of pain)/Active assisted range of motion
 Cyrotherapy/Heat
 Soft tissue work
Subacute Phase ( may last as long as 2-10 weeks)
 Treatments: Soft tissue , Stretching and joint mobilisation and stability
exercises
Chronic Phase
 Treatments: Stretching and joint mobilisation and stability exercises
 Facet Joints (zygapophyseal)
dysfunctions
 
 Cervical Facet joints can be responsible for a significant portion of chronic
neck pain, particularly in the upper cervical spine, where they can cause
local neck pain and pain referred to the head.
 Joints between C3-C7 can refer pain to the supraspinous process and into
the arm.
 If the patient has atlanto-occipital, atlanto-axial, C2-C6 zygapophyseal
involvement.
 
 Unilateral or Bilateral
 Arthritis
 Inflammation
 Overuse
 Signs/Symptoms
Dull achy Pain
Limited range of motion Cx
Soft tissue changes
Headache
 Cervical Disc Dysfunctions
Disc Herniation
 Occurs: Suddenly or insidiously
 Involves 30-55 years
 C5-C6, C6-C7 and C4-C5

 Repetitive microtruama/Loading - Annular Fissure or Herniated pulposes

 Can cause radiculopathy ( either by local compression or chemical irritation to the nerve
roots)
 Can cause symptoms of nerve damage (depending on the size of lesions or inflammation or
compression)
 Can cause myelopathy (if spinal cord compression)
 May develop axial pain, referred pain, radicular pain
 
 Usually unilateral
 Pain Cx (scupular area)
 Upper limbs
 Degenerative Joints Disease/ cervical spondylosis/ cervical stenosis
DJD
 Chonic condition - commonly progressive degeneration of the cervical facets
joints or intervertebral disc.
 Cause unknown but may be accelerated by trauma, overuse, genetic
predisposition, heavy lifting , long driving
 DJD must be considered a normal aging process.
 It preferential affects the C5-C7 vertebrae and affects the intervertebral disc and
facet joints.
 Lateral canal stenosis is the most common cause of
cervical radiculopathy - may cause symptoms of neck
pain, shoulders pain , radiating pain in the arm, numbness
or muscles weakness. These symptoms occur as a result of
the degenerative process, which in part involves the
development of hypertrophy spurs along the margins of
the disc or facets joints and this spur formation often
associated with hypertrophy of the ligmentum flavum. If
the spurring continue, it may compress the contents of the
spinal canal, it is called central (spinal) stenosis AS
opposed to narrowing of the intervertebral formations as
in lateral stenosis. Central stenosis can lead to cervical
myelopathy.
 Stiffness
 Signs/Symptoms
 neck pain
 shoulders pain ,
 radiating pain in the arm,
 Numbness
 muscles weakness
 Muscles tightness
 CERVICAL HEADACHE (Cervicogenic)
 Cervical headache refers to headache arising from dysfunction or inflammation of
the musculoskeletal structures of the upper cervical spine.
 
 Atlanto-occiptal joints, atlanto-axial joints , C3-C3 zygapophyseal joints and disk,
and the capsules, ligaments and muscles crossing these joints.  
 It is thought that the most important that the most common causes of Cervicogenic
headache are generate joints disease or trauma (whiplash injury) that is either
sudden or gradual ( repetitive occupational or postural strain).
 
 Headache is the second most frequently reported symptom in the acute
acceleration/deceleration injury.
 Greater occipital nerve: Entrapment of the Greater occipital nerve can occur when
the muscles that cross joints compress it sufficiently or alter joint mechanics.
 
 Extrasegmental headache results from compression of the dura at any cervical
level.
Assessment
 Observation
 AROM
 PROM
 PROM with over pressure
 PPIVMs
 PAIVMS
 Muscles assessment
 Dermatomes
 Myotomes
 Reflexes
 Clinical test
THORACIC
SPINE
THORACIC SPINE

 Thethoracic spinal segments possess the

potential for a unique array of movements
 THORACIC SPINE

• THORACIC VERTEBRAE CHARACTERISTICS

1. Presence of articular facets on vertebral bodies
for Ribs’ attachment
2. Long/thin SPs directed backward/downward in
relation to motion segment & overlap each other
3. Tip of SP lies posterior & inferior to the body of
the vertebra
 Act as lever to rotate the vertebral body
 Results in gliding of facets joints during flex / ext
THORACIC SPINE

 The SPs of T1, T2, T3

Project directly backward & the tip is on the
same line as the Transverse Process

 The SPs of T4 to T6
Located half a vertebra below the one to
which they are attached
Thoracic Spine

 The SPs of T7 to T9
Located a full vertebra
lower than the vertebra to
which they are attached
 The SPs of T10 to T12
Palpable at the same level as
the vertebral body to which
they are attached
Thoracic Spine

 THORACIC VERTEBRAL BODIES

Roughly equal in transverse / AP diameter
 FACET JOINTS
 Vertical & at 60˚ angle from horizontal plane
 Superior faces upward / backward
 Inferior facet faces downward / forward
 ATYPICAL THORACIC VERTEBRAE
T1 and T12
Atypical Thoracic Vertebrae
(T1)
The midway b/w cervical & thoracic
spine
Inferior facet surface orientation is
typically thoracic and superior facet
surface is cervical
T1-Dysfunction greatly affects the
functional capacity of thoracic outlet &
related structures
 Atypical Thoracic Vertebrae
(T12)
 Superior facet surface is usually typically thoracic and
inferior facet is lumber
 Location of change b/w thoracic Kyphosis & lumber
Lordosis
 A location of change in mobility of 2 areas of spine
 A point of frequent dysfunction
 T3
 The axis of rotation for the shoulder girdle
 T6
 The axis of rotation for entire thoracic spine
Thoracic Spine

 Spinal Canal
 Narrower with only a small epidural space b/w spinal cord &
bony arch
 Narrowest between T4 & T5
 IV Foramina … Quite larger
 Clinical Thoracic Spine
 Begins at T3
 T1 & T2 with their nerve root should be considered with
cervical spine
THORACIC SPINE
EVALUATION
 Pain in upper back and scapular region
 Cervical disk or trigger points (long thoracic nerve or suprascapular nerve
involvement)

 Lower thoracic region pain

 Facet joint involvement

 W/ deep inspiration and chin tucked to chest
THORACIC KYPHOSIS

 Smooth posterior convexity

 Flatspots without the thoracic kyphosis shows vertebral
dysfunction
 Fractureof Anterior part is common because of
considerable load on anterior spine
 Intra-diskal
pressure is high resulting in disk
degeneration earlier in middle & lower thoracic spine
Note: Symptoms from thoracic spine are less than from
cervical & lumber spines
Scheuermann’s Disease
(Dorsolumbar
 ETIOLOGY
Kyphosis)
 Result of wedge fractures of 5 degrees or greater in 3 or more consecutive
vertebrae w/ disk space abnormalities and irregular epiphyseal endplates
 Can develop into more serious conditions
 SIGNS AND SYMPTOMS
 Kyphosis of the thoracic spine and lumbar lordosis w/out back pain
 Progresses to point tenderness of the spinous processes; young athlete may
complain of backache at the end of a very physically active day
 Hamstring muscles are characteristically tight
 MANAGEMENT
 Prevent progressive kyphosis - work on extension exercises and postural education
 Bracing, rest, and NSAID’s may be helpful
 Stay active but avoid aggravating movements
Lumber
spine
Anatomy

 The lumbar spine consists of 5 lumbar vertebrae

 Between each of the lumbar vertebrae is the
intervertebral disc (IVD)
 The articulations between two consecutive
lumbar vertebrae form three joints
 One joint is formed between the two vertebral bodies
and the intervertebral disc (IVD)
 The other two joints are formed by the articulation of
the superior articular process of one vertebra and the
inferior articular processes of the vertebra above.
Anatomy

 Vertebra
 In general, the lumbar vertebrae increase in size from L 1 to L
5 in order to accommodate progressively increasing loads
Anatomy

 The Zygapophyseal Joint

 In the intact lumbar vertebral column, the primary function of
the zygapophyseal joint is to protect the motion segment from
anterior shear forces, excessive rotation, and flexion
Anatomy

 Ligaments
 Anterior longitudinal ligament (ALL)
 Extends from the sacrum along the anterior aspect of the entire
spinal column, becoming thinner as it ascends
 Posterior longitudinal ligament (PLL)
 Found throughout the spinal column, where it covers the posterior
aspect of the centrum and IVD
Anatomy

 Ligaments
 Ligamentum flavum (LF)
 Connects two consecutive laminae
 Interspinous ligament
 Connects two consecutive spinal processes
 Supraspinous Ligament
 Connects the tips of two adjacent spinous processes
Anatomy

 Ligaments
 Iliolumbar Ligament
 Functions to restrain flexion, extension, axial
rotation, and side bending of L‑5 on S‑1
 Pseudo ligaments
 These ligaments, the intertransverse, transforaminal,
and mamillo-accessory, resemble the membranous
part of the fascial system separating paravertebral
compartments, and do not have any mechanical
function
Anatomy

 Muscles
 Quadratus Lumborum
 The importance of this muscle from a rehabilitation viewpoint is
its contribution as a lumbar spine stabilizer
 Lumbar multifidus (LM)
 The lumbar multifidus is an important muscle for lumbar
segmental stability through its ability to provide segmental
stiffness and control motion
Anatomy

 Muscles
 Erector spinae
 The erector spinae is a composite muscle consisting of the
iliocostalis lumborum and the thoracic longissimus. Both of these
muscles are subdivided into the lumbar and thoracic longissimii
and iliocostallii
Anatomy

 Muscles
 Thoracolumbar fascia (TLF)
 Assists the in transmission of extension forces during lifting
activities
 Stabilizes the spine against anterior shear and flexion moments
Anatomy

 Nerve Supply
 The nerve supply to the lumbar spine follows a
general pattern
 The outer half of the IVD is innervated by the
sinuvertebral nerve and the grey rami
communicants, with the posterior-lateral aspect
being innervated by both the sinuvertebral nerve and
the grey rami communicants. The lateral aspect
receives only sympathetic innervation
 Thezygapophyseal joints are innervated by the
medial branches of the dorsal rami
Examination

 The physical examination of the lumbar spine must include

a thorough assessment of the neuromuscular, vascular and
orthopedic systems of the hip, lower extremities, low back
and pelvic regions
Examination

 History
 The clinician should establish the chief complaint of the
patient, in addition to the location, behavior, irritability, and
severity of the symptoms
 Although dysfunctions of the lumbar spine are very difficult to
diagnose, the history can provide some very important clues
Examination

 Systems Review
 It must always be remembered that pain can be referred to the
lumbar spine area from pathological conditions in other
regions
Examination

 Observation
 Observation involves an analysis of the entire patient as to
how they move, and respond in addition to the positions they
adopt
 Although spinal alignment provides some valuable
information, a positive correlation has not been made between
abnormal alignment and pain
Examination

 Palpation
 Whenever it is performed, palpation of the lumbar spine area
should be performed in a systematic manner, and should be
performed in conjunction with palpation of the hip and pelvic
area
Examination

 Active range of motion

 Normal active motion, which demonstrates considerable
variability between individuals, involves fully functional
contractile and inert tissues, and optimal neurological function
 It is the quality of motion and the symptoms provoked, rather
than the quantity of motion that is more important
Examination

 Combined motion testing

 Using a biomechanical model
 A restriction of cervical extension, side bending and
rotation to the same side as the pain is termed a
closing restriction. This restriction is the most
common pattern producing distal symptoms.
However, a limitation in cervical flexion accompanied
by the production of distal symptoms can also occur
 A restriction of cervical flexion, side bending and
rotation to the opposite side of the pain is termed an
opening restriction
Examination

 Key muscle tests

 The key muscle tests examine the integrity of
the neuromuscular junction and the contractile
and inert components of the various muscles
 With the isometric tests, the contraction should
be held for at least five seconds to demonstrate
any weakness
 If the clinician suspects weakness, the test is
repeated 2-3 times to assess for fatiguability,
which could indicate spinal nerve root
compression.
Examination

 Sensory testing
 The clinician checks the dermatome patterns of the nerve
roots, as well as the peripheral sensory distribution of the
peripheral nerves
 Dermatomes vary considerably between individuals
Examination

 Position Testing
 Position testing in the lumbar spine is an osteopathic technique
used to determine the level and type of zygapophyseal joint
dysfunction
Examination

 PassivePhysiological Intervertebral
Mobility testing (PPIVM)
 These are most effectively carried out if the
combined motion tests locate a hypomobility,
or if the position tests are negative, rather than
as the entry tests for the lumbar spine
 Judgments of stiffness made by experienced
physical therapists examining patients in their
own clinics have been found to have poor
reliability.
Examination

 Passive AccessoryIntervertebral
Movement test (PAIVM)
 Passive accessory intervertebral movement
tests investigate the degree of linear or
accessory glide that a joint possesses, and are
used on segmental levels where there is a
possible hypomobility, to help determine if the
motion restriction is articular, peri-articular or
myofascial in origin
 LUMBAR SPINE
EVALUATIONS
 STANDING EVALUATION
 FLEXFORWARD -
PALPATING SPINOUS
PROCESSES &
TRANVERSE PROCESSES
 SITTING ALIGNMENT

 PATELLULAR REFLEX -
LUMBAR 4
INVOLVEMENT
 ACHILLES REFLEX -
SACRAL 1
INVOLVEMENT
LYING ON BACK
 TEST ABDOMINALS - RECTUS ABDOMINUS ,
ILIOPSOAS (HIP FLEXORS)
 (STATIC W/ STABILIZED THIGHS - HIP FLEX AT 45
DEGREES
 STRAIGHT LEG RAISE
 PAIN WHEN TESTING UNAFFECTED SIDE - POSSIBLE
HERNIATED DISK
 PAIN WHEN TESTING AFFECTED SIDE - POSSIBLE
SCIATIC NERVE STRETCHED
LYING ON BACK
(CONTINUED)
Bowstring sign
To test for sciatic nerve - use
pressure to popliteal (back of
knee)
Gain slens sign
To test sacro-iliac lessions
(switch blade legs while on side)
OTHER PROBLEMS
OCCURING WITH THE SPINE
 SOFT TISSUE TRAUMA - CONTUSIONS
 NERVE INFLAMATION OR COMPRESSIONS - FROM DISK
PROTRUSIONS
 FRACTURES TO THE SPINOUS OR TRANSVERSE PROCESSES
 SPONDYLOLYSIS (FRACTURE TO INTERARTICULAR PROCESS
 SPONDYLOLISTHESIS (FORWARD SLIPPAGE OF THE VERTEBRA
OTHER PROBLEMS
OCCURING WITH THE SPINE
(CONTINUED)
GROIN STRAINS
HIP DISLOCATIONS
Intervention Strategies

 The optimal intervention for patients with acute back pain

remains largely enigmatic
 A number of clinical studies have failed to find consistent
evidence for improved intervention outcomes with many
intervention approaches
Intervention Strategies

 Acute phase
 Goals
 Decrease pain, inflammation, and muscle spasm
 Promote healing of tissues
 Increase pain-free range of segmental motion
 Regain soft tissue extensibility
 Regain neuromuscular control
 Allow progression to the functional stage
Intervention Strategies

 Functional phase
 Goals:
 Correction of imbalances of strength and flexibility
 Incorporate neuromuscular re-education
 Strengthening of entire kinetic chain
 Postural correction and retraining
 To initiate and execute functional activities without pain and
while dynamically stabilizing the spine in an automatic manner
 REHABILITATION OF BACK
 AND HIP INJURY
ICE MESSAGE
 MOVEMENT TO REGAIN FLEXIBILITY &
RANGE
 STRENGTHENING EXERCISES
 SIT UPS & CRUNCHES (WORK OBLIQUES AS WELL)
 PELVIC TILTS - (FLATTENING OF BACK AGAINST
FLOOR)
 HIP LIFTS - (FROM LYING ON BACK POSITION)
 BACK EXTENTIONS - TO 90 DEGREES
 PSOAS& HAMSTRING STRETCH - (KNEES TO
CHEST)
 COMMON ABNORMLITIES OF LUMBER SPINE
 
 Spinal stenosis
 Facet syndrome
 Degenerative disc disease
 Sciatica
 PIVD
 Spondylolisthesis
 Cauda equine syndrome
 Fractures
 Carcinomas
 There are a lot of abnormalities of lumber region but we are describing some of them that
are common cause of lumbago.
 1. Degenerative disc disease:
 Degenerative disc disease is not really a disease but a term used to
describe the normal changes in your spinal discs as you age. Spinal
discs are soft, compressible discs that separate the interlocking bones (
vertebrae) that make up the spine. The discs act as shock absorbers for
the spine, allowing it to flex, bend, and twist. Degenerative disc disease
can take place throughout the spine, but it most often occurs in the
discs in the lower back (lumbar region) and the neck (cervical region).
 Psychological Tools
 This degenerative disc disease treatment involves use of behavioral
methods to help patient self-manage their low back pain. For example,
cognitive therapy involves teaching the patient to alleviate low back
pain by means of relaxation techniques, coping techniques (such as
visualization), and other method.
 Epidural Steroid Injections
 Stretching to Reduce Low back pain
 It may take several weeks or months of regular stretching to see
improvement, patients with chronic low back pain often find that better
range of motion in their low back leads to relief of their low back pain.
 Psoas Major Muscle stretching exercise.
 Water exercises (also called pool therapy or aquatic therapy)
 Stationary exercise biking
 Heat and Ice therapy
 Hamstring stretches
 Sciatica:
 The term sciatica describes the symptoms of leg pain—and possibly
tingling, numbness or weakness—that originate in the lower back and travel
through the buttock and down the large sciatic nerve in the back of the leg.
Exercise walking
 Sciatica Nerve Pain
 Sciatica is often characterized by one or a combination of the following
symptoms:
 Constant pain in only one side of the buttock or leg (rarely can occur in
both legs)
 Pain that is worse when sitting
 Leg pain that is often described as burning, tingling or searing (vs. a dull
ache)
 Weakness, numbness or difficulty moving the leg or foot
 A sharp pain that may make it difficult to stand up or to walk
 Treatment:
 Sciatica Exercises for a Herniated Disc
 Specific exercises for leg pain and other symptoms from a lumbar herniated disc
are prescribed according to which positions will cause the patient's symptoms to
move from the leg (or foot) and into the low back.
 For many patients, getting the pain to move up from the leg to the low back is
accomplished by getting into a backwards bending position, called extension
exercises or press-ups.
 The low back is gently placed into extension by lying on the stomach (prone
position) and propping the upper body up on the elbows, keeping hips on the
floor. This should be start slowly and carefully, since some patients cannot tolerate
this position at first.
 Hold the press-up position initially for five seconds, and gradually work up to 30
seconds per repetition. Aim to complete 10 repetitions.
 From the prone position (lying flat on the stomach), press up on the hands while
the pelvis remains in contact with the floor. Keep the lower back and buttocks
relaxed for a gentle stretch.
 Exercises Piriformis Muscle Stretches
 Stretching the piriformis muscle is almost always necessary to relieve the pain along
the sciatic nerve and can be done in several different positions.
 A number of stretching exercises for the piriformis muscle, hamstring muscles, and
hip extensor muscles may be used to help decrease the painful symptoms along the
sciatic nerve and return the patient's range of motion.
 For
 Buttocks stretch for the piriformis muscle:
 Begin on all fours. Place the affected foot across and underneath the trunk of the
body so that the affected knee is outside the trunk. Extend the non-affected leg
straight back behind the trunk and keep the pelvis straight. Keeping the affected leg
in place, scoot the hips backwards towards the floor and lean forward on the
forearms) until deep stretch is felt. Do not force body to floor. Hold stretch for 30
seconds, then slowly return to starting position. Aim to complete a set of three
stretches.
 sciatica from piriforms syndrome:
 PIVD
 The term pivd or prolapse intervertebral disc means the protrusion or extrusion of the
nucleus pulposus through a rent in the annulus fibrosus.
 It has a four stages-
 Bulging- At this early stage, the disc is stretched and doesn't completely return to its
normal shape when pressure is relieved. It retains a slight bulge at one side of the disc.
Some of the inner disc fibres could be torn and the soft jelly (nucleus pulposus ) is
spilling outwards into the disc fibres but not out of the disc.
 Protrusion- At this stage, the bulge is very prominent and the soft jelly center has
spilled out to the inner edge of the outer fibres, barely held in by the remaining disc
fibres.
 Extrusion- In the case of a herniated spinal disc, the soft jelly has completely spilled
out of the disc and now protruding out of the disc fibres.
 Sequestration- Here some of the jelly material is breaking off away from the disc into
the surrounding area.
 Causes:
 Heavy manual labour
 Repetitive lifting and twisting
 Postural stress
 obesity
 Poor and inadequate strength of the trunk
 Sitting for long hours
 increasing age (a disc is more likely to develop a weakness with
increasing age)
 What are the symptoms of PIVD ?
 Lower Back /Lumbar Herniated Disc Symptoms
 Severe low-back pain
 Pain radiating to the buttocks, legs, and feet
 Pain made worse with coughing, straining or laughing
 Muscle spasm
 Tingling or numbness in legs or feet
 Muscle weakness or atrophy in later stages
 Loss of bladder or bowel control in case of cauda equina
syndrome
 Physical Therapy Management in Acute Phase of PIVD:
 a) CONTROLLED REST- is recommended i.e rest in the form of-
 1. Posture and activity modification- Avoid flexed postures, sitting for long
duraton, bending or lifting activities, asymmetric postures ( flexion and
rotation). All these increase the disc pressure.
2. Local support in the form of corset (lumbosacral belt), abdominal binder, tape
etc. These measures will enhance healing and prevent reinjury to the healing
disc. Within 10 days fibrin is laid down. If spine is maintained in lordosis, the
annulus will heal in shortened position and nucleus will be b) MODALITIES
TO REDUCE PAIN AND SPASM-
*TENS:
 Relieves pain in both acute and chronic phases.
*US: as phonophoresis increases extensibility of connective tissues
*Moist heat: used as an adjunct before applying specialised techniques to
decrease muscle spasm.
*SWD- pulsed SWD in acute condition and continuous SWD in chronic cases.
*Soft tissue manipulation- to reduce local muscle spasm and induce relaxation.
*Traction- may be beneficial to relieve nerve root compression and
radiculopathy or paraesthesias in the acute phase of PIVD. retained centrally