Chapter 22 Craniovertebral Junction. Overview The craniovertebral (CV) junction is a collective term...

Chapter 22Chapter 22

Craniovertebral Junction

OverviewOverview

The craniovertebral (CV) junction The craniovertebral (CV) junction is a collective term that refers to is a collective term that refers to the occiput, atlas, axis, and the occiput, atlas, axis, and supporting ligamentssupporting ligaments

Accounts for approximately 25% Accounts for approximately 25% of the vertical height of the entire of the vertical height of the entire cervical spinecervical spine

AnatomyAnatomy

Foramen magnumForamen magnum– The smaller anterior region of the foramen The smaller anterior region of the foramen

magnum is characterized by a pair of magnum is characterized by a pair of tubercles to which the alar ligaments attach. tubercles to which the alar ligaments attach.

– The posterior portion of the foramen The posterior portion of the foramen magnum houses the brainstem-spinal cord magnum houses the brainstem-spinal cord junction. junction.

– The demarcation of these two regions is The demarcation of these two regions is marked by a pair of tubercles to which the marked by a pair of tubercles to which the transverse ligament of the atlas attaches. transverse ligament of the atlas attaches.

AnatomyAnatomy

The occipito-atlantal (O-A) joint is The occipito-atlantal (O-A) joint is formed between the occipital formed between the occipital condyles, and the superior condyles, and the superior articular facets of the atlas (C 1)articular facets of the atlas (C 1)

AnatomyAnatomy

The AtlasThe Atlas– The atlas (C 1) is a ring-like The atlas (C 1) is a ring-like

structure that is formed by two structure that is formed by two lateral masses, which are lateral masses, which are interconnected by anterior and interconnected by anterior and posterior archesposterior arches

– Since this vertebra does not have a Since this vertebra does not have a spinous process, there is no bone spinous process, there is no bone posteriorly between the occipital posteriorly between the occipital bone and the spinous process of C 2bone and the spinous process of C 2

AnatomyAnatomy

The superior-lateral aspect of The superior-lateral aspect of each of the posterior arches has a each of the posterior arches has a transverse foramen to transverse foramen to accommodate the vertebral accommodate the vertebral arteryartery

AnatomyAnatomy

Axis (C 2)Axis (C 2)– The axis serves as a transitional The axis serves as a transitional

vertebra between the cervical spine vertebra between the cervical spine proper and the craniovertebral regionproper and the craniovertebral region

– A unique feature of the axis, the A unique feature of the axis, the odontoid process, or dens is located odontoid process, or dens is located on its superior aspecton its superior aspect

The dens extends superiorly from the The dens extends superiorly from the body to just above the C 1 vertebra, body to just above the C 1 vertebra, before tapering to a blunt point before tapering to a blunt point

AnatomyAnatomy

The dens functions as a pivot for the The dens functions as a pivot for the upper cervical joints, and as the center upper cervical joints, and as the center of rotation for the A-A joint.of rotation for the A-A joint. – The anterior aspect of the dens has a The anterior aspect of the dens has a

hyaline cartilage covered mid-line facet for hyaline cartilage covered mid-line facet for articulation with the anterior tubercle of articulation with the anterior tubercle of the atlas (the median A-A joint). the atlas (the median A-A joint).

– The posterior aspect of the dens is usually The posterior aspect of the dens is usually marked with a groove where the marked with a groove where the transverse ligament passes. transverse ligament passes.

AnatomyAnatomy

The aThe atlanto-axial (A-A) jointtlanto-axial (A-A) joint is a is a relatively complex articulation:relatively complex articulation:– Two lateral zygapophysial joints between Two lateral zygapophysial joints between

the articular surfaces of the inferior the articular surfaces of the inferior articular processes of the atlas, and the articular processes of the atlas, and the superior processes of the axissuperior processes of the axis

– Two medial joints: one between the anterior Two medial joints: one between the anterior surface of the dens of the axis, and the surface of the dens of the axis, and the anterior surface of the atlas, and the other anterior surface of the atlas, and the other between the posterior surface of the dens between the posterior surface of the dens and the anterior hyalinated surface of the and the anterior hyalinated surface of the transverse ligamenttransverse ligament

AnatomyAnatomy

Supporting structuresSupporting structures– In the absence of an intervertebral In the absence of an intervertebral

disk (IVD) in this region, the disk (IVD) in this region, the supporting soft tissues of the joints supporting soft tissues of the joints of the upper cervical spine must be of the upper cervical spine must be lax to permit motion, while lax to permit motion, while simultaneously being able to simultaneously being able to withstand great mechanical stresseswithstand great mechanical stresses

AnatomyAnatomy

LigamentsLigaments– Nuchal Nuchal – TransverseTransverse– Alar and accessory alar Alar and accessory alar – ApicalApical– Vertical and transverse bands of the Vertical and transverse bands of the

cruciformcruciform– Capsule and accessory capsular Capsule and accessory capsular

ligamentsligaments

AnatomyAnatomy

Nuchal ligamentNuchal ligament– A bilaminar fibroelastic and intermuscular A bilaminar fibroelastic and intermuscular

septum that spans the entire cervical spineseptum that spans the entire cervical spine– Extends from the external occipital Extends from the external occipital

protuberance, to the spinous process of the protuberance, to the spinous process of the seventh cervical vertebraseventh cervical vertebra

– When the O-A joint is flexed, the superficial When the O-A joint is flexed, the superficial fibers tighten and pull on the deep laminae, fibers tighten and pull on the deep laminae, which in turn, pull the vertebrae which in turn, pull the vertebrae posteriorly, limiting the anterior translation posteriorly, limiting the anterior translation of flexion and, therefore, flexion itselfof flexion and, therefore, flexion itself

AnatomyAnatomy

Transverse ligamentTransverse ligament– The major responsibility of the transverse The major responsibility of the transverse

portion of the cruciform ligament is to portion of the cruciform ligament is to counteract anterior translation of the atlas counteract anterior translation of the atlas relative to the axis, thereby maintaining relative to the axis, thereby maintaining the position of the dens relative to the the position of the dens relative to the anterior arch of the atlasanterior arch of the atlas

– The transverse ligament also limits the The transverse ligament also limits the amount of flexion between the atlas and amount of flexion between the atlas and axisaxis

AnatomyAnatomy

Alar ligamentsAlar ligaments– The alar ligaments connect the The alar ligaments connect the

superior part of the dens to fossae on superior part of the dens to fossae on the medial aspect of the occipital the medial aspect of the occipital condyles, although they can also condyles, although they can also attach to the lateral masses of the attach to the lateral masses of the atlasatlas

– Function to resist flexion, contralateral Function to resist flexion, contralateral side bending and rotation of the neck side bending and rotation of the neck

AnatomyAnatomy

Vertebral arteryVertebral artery– Supplies the most superior Supplies the most superior

segments of the cervical spinal cordsegments of the cervical spinal cord

AnatomyAnatomy

MusclesMuscles– DeepDeep

Posterior suboccipitalsPosterior suboccipitals

BiomechanicsBiomechanics

O-A JointO-A Joint– The primary motion that occurs at The primary motion that occurs at

this joint is flexion and extension, this joint is flexion and extension, although side bending and rotation although side bending and rotation also occuralso occur


A-A JointA-A Joint– The major motion that occurs at all The major motion that occurs at all

three of the A-A articulations is axial three of the A-A articulations is axial rotation, totaling approximately 40° rotation, totaling approximately 40° to 47° to each sideto 47° to each side

– Flexion and extension movements Flexion and extension movements also occur: amount to a combined also occur: amount to a combined range of 10-15º (10º of flexion, and range of 10-15º (10º of flexion, and 5º of extension) 5º of extension)


The direction of the conjunct The direction of the conjunct motion appears to be dependent motion appears to be dependent on the initiating movementon the initiating movement– If the initiating movement is side If the initiating movement is side

bending (latexion), the conjunct bending (latexion), the conjunct rotation of the joint is to the rotation of the joint is to the opposite sideopposite side

– If the initiating movement is rotation If the initiating movement is rotation (rotexion), the conjunct motion (side (rotexion), the conjunct motion (side bending) is to the same side. bending) is to the same side.

Side bending of the head to the Side bending of the head to the right produces:right produces: – Left rotation of the O-A joint, Left rotation of the O-A joint,

accompanied by a translation of the accompanied by a translation of the occiput to the leftocciput to the left

– Left rotation of the A-A jointLeft rotation of the A-A joint – Right rotation of C 2-3Right rotation of C 2-3

During rotation of the head to the During rotation of the head to the right (rotexion): right (rotexion): Right side bending and right rotation Right side bending and right rotation

occur at the A-A joint and at C 2-3 occur at the A-A joint and at C 2-3 Left side bending and right rotation Left side bending and right rotation

occur at the O-A joint, accompanied occur at the O-A joint, accompanied by a translation to the rightby a translation to the right


The biomechanics of this region The biomechanics of this region are exploited using the are exploited using the differentiation test to help differentiation test to help determine the segment involveddetermine the segment involved

ExaminationExamination

HistoryHistory– HeadachesHeadaches– Jaw, facial or eye pain (see Systems Jaw, facial or eye pain (see Systems

review)review)– Ear pain or middle ear symptoms (tinnitus)Ear pain or middle ear symptoms (tinnitus)– DizzinessDizziness– Paresthesia of the tongue, face or headParesthesia of the tongue, face or head– Tongue sensitivity changes (e.g., acidic, Tongue sensitivity changes (e.g., acidic,

metallic tastes)metallic tastes)


Systems reviewSystems review – The craniovertebral region houses The craniovertebral region houses

many vital structures:many vital structures: The spinal cordThe spinal cord The vertebral arteryThe vertebral artery The brain stemThe brain stem


Systems review Systems review – Periodic loss of consciousnessPeriodic loss of consciousness– DysphasiaDysphasia– DiplopiaDiplopia– HemianopiaHemianopia– AtaxiaAtaxia– HyperreflexiaHyperreflexia– Babinski responseBabinski response


Systems Review Systems Review – Positive Hoffman or Oppenheim testPositive Hoffman or Oppenheim test– Flexor withdrawalFlexor withdrawal– NystagmusNystagmus– Quadrilateral paresthesiaQuadrilateral paresthesia– Bilateral upper limb paresthesiaBilateral upper limb paresthesia– Peri-oral anesthesiaPeri-oral anesthesia– Drop attacksDrop attacks– Wallenberg syndromeWallenberg syndrome


Tests and measuresTests and measures– AROMAROM– Passive overpressurePassive overpressure– Isometric resistanceIsometric resistance

If the patient is able to flex their If the patient is able to flex their neck, a C-V fracture or a neck, a C-V fracture or a transverse ligament compromise transverse ligament compromise can be provisionally ruled outcan be provisionally ruled out

Much more a function of the lower Much more a function of the lower cervical spine, side bending is cervical spine, side bending is nonetheless significantly nonetheless significantly decreased in cases of decreased in cases of craniovertebral instability or craniovertebral instability or articular fixationarticular fixation

RotationRotation

Neck rotation is considered as Neck rotation is considered as thethe functional motion of the functional motion of the craniovertebral jointscraniovertebral joints

If symptoms are not reproduced If symptoms are not reproduced with neck rotation, it is doubtful with neck rotation, it is doubtful whether a craniovertebral whether a craniovertebral dysfunction is presentdysfunction is present

Loss of RotationLoss of Rotation

Serious causes:Serious causes:– Fracture (Dens, Hangman’s)Fracture (Dens, Hangman’s)– Muscle splintingMuscle splinting– Rotation is the most likely (single) Rotation is the most likely (single)

motion to bring on VA signs or motion to bring on VA signs or symptomssymptoms

Loss of rotationLoss of rotation

Biomechanical causesBiomechanical causes– A loss of rotation associated A loss of rotation associated withwith

pain and a history of recent trauma pain and a history of recent trauma could indicate an acute/sub-acute, could indicate an acute/sub-acute, post-traumatic arthritispost-traumatic arthritis

– A loss of rotation associated A loss of rotation associated withoutwithout pain and a history of chronic trauma pain and a history of chronic trauma could indicate a chronic, post-could indicate a chronic, post-traumatic arthritistraumatic arthritis

Loss of rotationLoss of rotation

To differentiate the potential To differentiate the potential biomechanical causes for the loss biomechanical causes for the loss of rotation, the following tests are of rotation, the following tests are used:used:– Combined motion testing (No H and I Combined motion testing (No H and I

or Figure of 8 in this region)or Figure of 8 in this region)– Relevant passive glide delivered at Relevant passive glide delivered at

the end of range for end-feel or pain the end of range for end-feel or pain reproductionreproduction

– Linear/planar segmental stress testsLinear/planar segmental stress tests

Combined motionsCombined motions

Flexion and extension at the O-A Flexion and extension at the O-A joints involves anterior-posterior joints involves anterior-posterior gliding of the occipital condylesgliding of the occipital condyles

The same gliding (although The same gliding (although reciprocal in opposing facets) is reciprocal in opposing facets) is utilized in rotationutilized in rotation

Therefore, if a symptom or range Therefore, if a symptom or range of motion of motion isis drastically altered by drastically altered by adding craniovertebral flexion or adding craniovertebral flexion or extension an assumption could be extension an assumption could be made that the dysfunction is at made that the dysfunction is at the O-A jointthe O-A joint not the A-A joint not the A-A joint

Similarly,Similarly, if a symptom or range if a symptom or range of motion of motion is notis not drastically altered drastically altered by adding craniovertebral flexion by adding craniovertebral flexion or extension an assumption could or extension an assumption could be made that the dysfunction is be made that the dysfunction is at the A-A jointat the A-A joint not the O-A joint not the O-A joint

ExampleExample

The RIGHT O-A joint cannot flex (i.e., The RIGHT O-A joint cannot flex (i.e., the the rightright occipital condyle cannot glide occipital condyle cannot glide posteriorly):posteriorly):– The predominant functional loss will be The predominant functional loss will be

decreased RIGHT rotationdecreased RIGHT rotation– The The restrictionrestriction of RIGHT rotation will of RIGHT rotation will

increaseincrease with C-V flexion with C-V flexion – However, The However, The restrictionrestriction of RIGHT rotation of RIGHT rotation

will will decreasedecrease (be less obvious) with C-V (be less obvious) with C-V extensionextension

ExampleExample

The RIGHT O-A joint cannot extend The RIGHT O-A joint cannot extend (i.e., the (i.e., the rightright occipital condyle cannot occipital condyle cannot glide anteriorly):glide anteriorly):– The predominant functional loss will be The predominant functional loss will be

decreased LEFT rotationdecreased LEFT rotation– The The restrictionrestriction of LEFT rotation will of LEFT rotation will

increaseincrease with C-V extension with C-V extension – However, The However, The restrictionrestriction of LEFT rotation of LEFT rotation

will will decreasedecrease (be less obvious) with C-V (be less obvious) with C-V flexionflexion

Relevant passive joint Relevant passive joint glideglide Example:Example:

– If it was determined in the combined If it was determined in the combined motion testing that the RIGHT O-A motion testing that the RIGHT O-A joint is more restricted or painful with joint is more restricted or painful with flexionflexion

– The joint is taken to the limit of its The joint is taken to the limit of its range of motion i.e., range of motion i.e., right rotation in right rotation in flexionflexion (the two motions associated (the two motions associated with a posterior glide of the right O-A with a posterior glide of the right O-A joint) and the end feel is assessedjoint) and the end feel is assessed

Relevant passive joint Relevant passive joint glideglide Example:Example:

– If it was determined in the combined If it was determined in the combined motion testing that the RIGHT O-A joint motion testing that the RIGHT O-A joint is more restricted or painful with is more restricted or painful with extensionextension

– The joint is taken to the limit of its The joint is taken to the limit of its range of motion i.e., range of motion i.e., left rotation in left rotation in extension extension (the two motions associated (the two motions associated with an anterior glide of the right O-A with an anterior glide of the right O-A joint) and the end feel is assessedjoint) and the end feel is assessed

End feelEnd feel

End feel assessment:End feel assessment:– Firm end feel, with or without pain Firm end feel, with or without pain

may require mobilization/muscle may require mobilization/muscle energy depending on findings at energy depending on findings at contralateral jointcontralateral joint

– Loose end feel, with pain is more Loose end feel, with pain is more suggestive of a suggestive of a hypermobility/instability – need to hypermobility/instability – need to perform stability testsperform stability tests


The craniovertebral region The craniovertebral region demonstrates a high degree of demonstrates a high degree of mobility, but little stabilitymobility, but little stability

Some stability is provided by the Some stability is provided by the ligaments, although they afford ligaments, although they afford little protection during a high little protection during a high velocity injuryvelocity injury


Segmental stability tests. The C-V Segmental stability tests. The C-V junction is stressed in the junction is stressed in the following directions:following directions:– Longitudinal (traction)Longitudinal (traction)– Anterior (transverse ligament)Anterior (transverse ligament)– Coronal (alar)Coronal (alar)– Transverse (articular)Transverse (articular)


Neurological testsNeurological tests– Cervical myelopathy, involving an Cervical myelopathy, involving an

injury to the spinal cord itself is injury to the spinal cord itself is associated with multi-segmental associated with multi-segmental paresthesias, upper motor neuron paresthesias, upper motor neuron (UMN) signs and symptoms such as (UMN) signs and symptoms such as spasticity, hyperreflexia, visual and spasticity, hyperreflexia, visual and balance disturbances, ataxia, and balance disturbances, ataxia, and sudden changes in bowel and bladder sudden changes in bowel and bladder functionfunction


Special testsSpecial tests– Vertebral artery testsVertebral artery tests– Vestibular testsVestibular tests– Sharp-Purser testSharp-Purser test


Other tests that can be used:Other tests that can be used:– PalpationPalpation– Positional testsPositional tests– Uni-planar passive physiological Uni-planar passive physiological

mobility testsmobility tests


PalpationPalpation– Asymmetrical joint geometry is common in Asymmetrical joint geometry is common in

this regionthis region– Examination of the skin overlying the spine Examination of the skin overlying the spine

has been found to be very helpful as certain has been found to be very helpful as certain skin changes in a particular location may skin changes in a particular location may point in the direction of a dysfunctional point in the direction of a dysfunctional spinal areaspinal area

– Palpation can be performed at any time Palpation can be performed at any time during the examination or as a separate during the examination or as a separate entityentity

InterventionIntervention

The structure at fault should determine The structure at fault should determine the intervention:the intervention:– If ligamentous tissue damage or an intra-If ligamentous tissue damage or an intra-

articular lesion is suspected the safest articular lesion is suspected the safest initial approach would be to help in initial approach would be to help in unloading the joint and controlling the unloading the joint and controlling the extremes of motion with a soft collarextremes of motion with a soft collar

– Articular. Depending on the stage of Articular. Depending on the stage of healing, an initial (10-14 day) healing, an initial (10-14 day) resting/immobilization period, followed by a resting/immobilization period, followed by a progressively increasing mobilization / progressively increasing mobilization / activation programactivation program


– Contractile tissue. Within the Contractile tissue. Within the patient’s pain tolerance, contractile patient’s pain tolerance, contractile lesions should be treated lesions should be treated aggressively with the emphasis on aggressively with the emphasis on regaining maximal muscle lengthregaining maximal muscle length


Acute phaseAcute phase– The goals of this phase include:The goals of this phase include:

Reduce pain, inflammation and muscle Reduce pain, inflammation and muscle spasmspasm

Reestablish a non-painful range of Reestablish a non-painful range of motionmotion

Improve neuromuscular postural controlImprove neuromuscular postural control Retard muscle atrophyRetard muscle atrophy Promote healingPromote healing


Functional phaseFunctional phase– The goals of this phase are:The goals of this phase are:

To significantly reduce or to resolve the To significantly reduce or to resolve the patient’s painpatient’s pain

Restore full and pain-free range of Restore full and pain-free range of motionmotion

Fully integrate the entire upper kinetic Fully integrate the entire upper kinetic chainchain

Restore full cervical and upper quadrant Restore full cervical and upper quadrant strength and neuromuscular controlstrength and neuromuscular control

Chapter 22 Craniovertebral Junction. Overview The craniovertebral (CV) junction is a collective term...

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