Anatomy of the Cervical Spine

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Cervical spine

OAA complex Vertebrae C3-7

Principal characteristics Processus articularis superior g dorsal and cranial Processus articularis inferior g ventral and and caudal Foramina transversaria Processus transversus : -Tuberculum anterior (tuberculum caroticum) -Tuberculum posterior Processi spinosi from C3 to C6 are bifurcated

Principal characteristics

q Foramen vertebrale

Large and triangular

qProcessi uncinati

Processi uncinati OSTEOPHYTES Narrowing foramen intervertebrale

Compression n. spinalis a. vertebralis

Foramina transversaria

From C6 to C1 a. vertebralis v. vertebralis n. recurrens or n. sinuvertebralis

Foramen transversarium The twisting of the a. vertebralis at the height of foramen tranversarium is necessary to permit the rotation between C1 and C2

Processi transversi Attachment prevertebrale muscles Tuberculum anterior C6 = tuberculum caroticum

4. Tuberculum posterior 5. Sulcus n. spinalis 6. Tuberculum anterior

Processi transversi Ventral of the transverse processes lies the Truncus sympaticus In front of the prevertebral muscles And behind the carotid arteries

Nervi cervicales Ramus dorsalis and ramis ventralis of the cervical nerve divide as they leave the foramen intervertebrale

Nervi cervicales

Movements of the cervical spine Flexion

Extension

Lateroflexion

Rotation

Longus colli

Splenius capitis

Ilicostales cerv.

Rotatores

Scaleni

Semispinalis cap

Longissimus cap

Semispinalis cap

Sternocleidomast

Semispinalis cerv

Longissimus cerv

Semispinalis cerv

Splenius capitis

Multifidus

Splenius cervicis

Splenius cervicis

Sternocleidomast

Sternocleidomast

Atlas

1. Tuberculum posterior 2. Arcus posterior 3. Massa lateralis + fovea articularis superior 4. Processus transversus + foramen transversarium 5. Arcus anterior + tuberculum 6. Fovea dentis 7. Sulcus a.vertebralis 8. Massa lateralis + fovea articularis inferior

Fovea articularis

Superior: Oval or kidney shape Concave to superior Receives condylus occipitalis Axis oblique to medial and to ventral

Inferior: Flat Orientation to caudal and to medial Joint facet for axis

Atlas

• FOVEA DENTIS • SULCUS

ARTERIOSIS VERTEBRALIS

Suboccipital nerve or n. Spinalis C1

Ramus ventralis Rectus capitis lateralis Ramus dorsalis Rectus capitis posterior major Rectus capitis posterior minor Obliquus capitis superior Obliquus capitis inferior Semispinalis capitis

Atlas Tuberculum anterior

Tuberculum posterior

Processus transversus

Lig. longitudinale anterior

Lig. nucchae

Obliquus capitis superior

Longus colli

Rectus capitis post. minor

Obliquus capitis inferior

Membrana atlantooccipitalis anterior

Membrana atlantooccipitalis posterior

Levator scapulae

Rectus capitis lateralis Rectus capitis anterior

Foramen vertebrale

Is divided by lig. transversum atlantis 1. Ventral part articulating with the dens 2. Posterior part contains medulla spinalis

Axis

Froml above

Processus spinosus Lamina Processus transversus + foramen transversarium Pediculus Facies articularis superior Dens axis Corpus axis Foramen vertebrale Processus articularis inferior Impressio lig. alare Arcus anterior atlantis

Axis FACIES ARTICULARIS Superior For atlas Convex in ventrodorsal direction Orientation to cranial and lateral

Inferior For articulation with C3 Orientation to caudal and ventral

Dens axis Remainder of corpus atlas Anterior median crest: - longitudinal anterior ligament - longus colli

2 joint surfaces: • one anterior for articulation with posterior surface of the arcus anterior atlas • one posterior for ventral part lig. transversum Lig. alare from postero- lateral side dens

C2 Processus Transversus C2

Processus Spinosus C2

Second longest, Cf. C7

Levator scapulae Scalenus anterior

Obliquus capitis inferior Rectus capitis posterior major

Craniovertebal joints

OAA-complex 1. Atlanto-occipital joint 2. Atlanto-axial joint ü Only synovial joints ü There is no intervertebral disc

Atlanto-occipital joint Condyloid joint è 3 degrees of movement: 1. Rotation around vertical axis 2. Flexion-extension around transversal axis 3. Lateroflexion around sagittal axis Condyli occipitalis convex in ventrodorsal direction Fovea articularis superior concave with greatest diameter oblique to ventral and medial

Atlanto-axial joint 2 Lateral joints 1 Median joint Facies art. superior axis = egg-shaped Greatest diameter in ventrodorsal direction Convex from ventral to dorsal

Atlanto-axial joint

Atlanto-axial joint 2 CYLINDERS Dens

hollow cylinder:

With two joint surfaces

- acus anterior of the atlas vental - massa laterales bilateral - lig. Transversum atlantis dorsal

Craniovertebral ligaments

Membrana atlantooccipitales: • Anterior • Posterior • Laterale

Ligamentum transversum atlantis

Ligamentum cruciforme

Layers of OAA ligaments

Ligamenta alaria

STABILITY ATLAS « AXIS: lig. transversum atlantis + ligg. alaria

Membrana tectoria

Ligamentum apicis dentis

Ligamentum nuchae

Protuberantia occipitalis externa Æ processus spinosus C7 75 % elastic vessels Few collagen Very elastic No stabilizing function Insertion for neck muscles

Atlanto-occipital muscles Flexion

Extension

Lateroflexion

Rotation

Longus capitis

Rectus capitis posterior major

Sternocleidomast.

Obliquus capitis superior

Rectus capitis anterior

Rectus capitis posterior minor

Obliquus capitis superior

Rectus capitis posterior minor

Anterior fibers sternocleidomast.

Obliquus capitis superior

Obliquus capitis inferior

Splenius capitis

Semispinalis capitis

Rectus capitis lateral.

SCM

Splenius capitis

Longissimus capitis

Longissimus capitis

Splenius capitis

Trapezius

Atlanto-axial rotation Homolateral

Heterolateral

Obliquus capitis inferior

Sternocleidomastoïdeus

Rectus capitis posterior major

Semispinalis capitis

Rectus capitis posterior minor Longissimus capitis Splenius capitis

Movements cervical spine Flexion 130

(flex-ext)

OAA 20

Extension 130

(flex-ext)

to 30

> Flexion C4-C5-C6 > Extension C4-C5

Stopped by: • tension lig long posterior • Tension capsula • tension ligg flava, interspinale, supraspinale en nucchae

Stopped by: • tension lig. long. Anterior • Contact processi articulares • Contact arcus posterior

Lateroflexion 50 (25 side)

on each

Rotation 80 45

à 90 (40 elke zijde)

between occiput/atlas 8

Most OAA

Between atlas/axis there is no lateroflexion

Atlas and occiput rotate as a whole on the axis

à

Protuberantia occipitalis externa

INION PROTUBERANTIA OCCIPITALIS INTERNA FALX CEREBELLI CONFLUENS SINUUM HEROPHILE

Protuberantia occipitalis externa

Confluence sinuum Herophile

Trigonum vertebrale

Arteria vertebralis

1. Rectus capitis posterior major: linea nucchae inferior [processus spinosus C2 2. Obliquus capitis superior: occiput [processus transversus C1 3. Obliquus capitis inferior: processus transversus C1 [processus spinosus C2

Arteria vertebralis From a. subclavia - aa. spinalis posteriores - a. spinalis anterior - a. cerebelli inferior posterior - medulla spinalis - medulla oblongata - pons - cerebellum - fourth ventricle - dura mater – cranial part - inner ear

Hexagon of Willis

Hexagon of Willis

Hexagon of Willis

Circulus arteriosus cerebri

Kleyn and Nieuwhuyse’s test Head in extension and rotation left and right 45 sec

Nystagmus

Dizziness

Feeling of sickness, nausea

Tinnitus

Processus mastoideus 1. Protuberantia occipitalis externus 2. Linea nuchae superior 3. Processus mastoïdeus 4. Vertebra prominens

Sternocleidomastoïdeus Splenius capitis Longissimus capitis Venter posterior digastricus

Processus mastoideus

Nervus occipitalis major • Arnold’s nerve • R. dorsalis C2 • semispinalis capitis,

splenius capitis, trapezius • Sensitivity of the back of the head till the vertex • Cf. migraine

Processus transversus C1

Palpation processi spinosi Level processi spinosi C1 C2 C3 C4 Proc. spinosus C2

C5 C6 C7

in front of the SCM between angulus mandibulae and mastoid process ] eye first palpable spinal process ] base of the nose at the height of angulus mandibulae , level hyoid ] chin cranial border cartilago thyroidea ] horizontal caudal border cartilago thyroidea ] tip of the shoulder tuberculum caroticum, level cricoid ] middle part of the shoulder extension < C6 ] axilla

Palpation of the facet joints

2 ½ cm lateral to processi spinosi

Palpation processi transversi C3 - C4 - C5

C6

• Palpate in front of

trapezius • Cf. Sensitive • Truncus sympathicus !

Palpation processi transversi

Tuberculum caroticum

• A. carotis communis in front • A. vertebralis in foramen

transversarium • Junction a. vertebralis, a. carotis communis, a. thyroïdea inferior • Infiltrations ganglion stellatum

Palpation C7-Th1

Cervical rib Cervical rib Insertion scalenus muscles

Ligamentous connection with the 1st rib

Cervical rib

Real cervical rib

Processus megatransversus False cervical rib – ligamentous

Ganglion stellatum • At the height of the CT-

junction • Sympathetic ganglia C7 - C8 - D1 • Situated between: q proc. transversus C7 q head of 1st rib q dorsal to a. vertebralis q on apex of the lung

Ganglion stellatum Sibelleau’s space vertebropleurale

• Lig.vertebropleurale

pleurakoepel

• Lig. costopleurale costopleurale

• Membrana supra-

pleuralis

Ganglion stellatum • From this ganglion, fibers derive for … • a. carotis communis • a. subclavia • a. vertebralis • cupula pleura • trachea • heart (plexus cardiacus posterior)

Summary cervical muscles POSTERIOR

ANTERIOR

LATERAAL

DEEP

SUBOCCIPITALES • Rectus capitis posterior major and minor • Obliquus capitis superior and inferior • Multifidus • Interspinalis • Intertransversarii

Longus colli Longus capitis Rectus capitis anterior

Scaleni

MIDDLE

Semispinalis capitis Longissimus capitis en cervicis Iliocostales Splenius capitis en cervicis Levator scapulae

SUPERF. Trapezius

Sternocleidomastoïdeus

4 Local muscle systems Longitudinal system • Interspinal • Intertransversal Diagonal system • Spinotransversal • Transversospinal

Interspinal system

Intertransversal system

4 Local muscle systems

Scaleni Longissimus capitis/cervicis Intertransversarii Obliquus capitis superior Rectus capitis lateralis

Dorsal: Spinalis cervicis Rectus capitis posterior major Rectus capitis posterior minor Interspinalis cervicis Ventral Longus colli (longit.vezels)

Transversospinal system • Splenius capitis • Splenius cervicis • Obliquus capitis inferior • Longus colli (oblique

vessels)

Spinotransversal system • Multifidis • Semispinalis cervicis

/capitis • Longus capitis • Longus colli (oblique vessels) • Rectus capitis anterior

4 systems

Splenius capitis

1. Trapezius 2. Levator scapulae 3. sternocleidomastoïdeus

Spinotransversal muscle = homolateral rotation

Dissection 13. Sternocleidomastoïdeus 17. Levator scapulae 19. Trapezius 20. Splenius capitis 27. Semispinalis capitis

Splenius capitis Patient prone, Head rotated to heterolateral to create space between SCM and trapezius Therapist at the cranial end of the table and heterolateral Palpating fingers placed at the height of C2-C3 We ask an extension of the head against resistance

Semispinalis capitis • Transversospinal muscle =

heterolateral rotation • Deep to trapezius and splenius capitis • Suboccipital between trapezius and SCM

Levator scapulae

Proc. transversi C1-C4 [ angulus superior scapulae Palpation lateral of C7 Lifting scapulae Homolateral lateroflexion cervical

Test shortening levator scapulae

Sternocleidomastoid

Sternocleidomastoid

• Sidebending

homolateral • Rotation heterolateral • Bending head foreward

Sternocleidomastoid

• N. ACCESSORIUS

• RAMI VENTRALIS

NN SPINALIS C2 C3 - (C4)

Relation temporal bone - cervical spine • Pars petrosa ossis temporale, tentorium • • • •

cerebelli Foramen jugulare Canalis caroticus in pars petrosa Art. temporomandibulare SC and AC joint « OAA-complex, occiput, temporale

Sternocleidomastoid spasm • OS TEMPORALE Æ INTERNAL

ROTATIE • MASTOID to caudal and frontal • POSTERIOR ROTATION of the

SKULL • FORWARD HEADPOSITION

Sternocleidomastoideus • Processus mastoïdeus è

SC angle 45°à 60° • 90° forward headposition

Hyperactivity SCM – trigger points • Spatial disorientation • Vertigo • Nausea • Paroxysmal dry cough • Rough throat • Watery eyes • Red eyes

Sternocleidomastoideus

Sternocleidomastoideus

STERNOCLEIDOMASTOID PLAYS A LEADING PART IN CERVICAL PROPRIOCEPTION

Referred pain • JAW • MAXILLA • SUPRAORBITAL • AUDITORY CANAL • PHARYNX • ATM • FRONTAL BONE

Trigeminocervical complex • Cranial nerves 5 - 7 - 9 -10 -11 en 12

Spinal nerves C1 till C4

ACC SSC PH SN PPT NV SSN SCG ICA TNC

= Anterior cingulate cortex = Somatosensory cortex = Posterior hypothalamus = Suprachiasmatic nucleus = Pterygopalatinum = Trigeminal nerve = Salivatory nucleus = Superior cervical ganglion = Internal carotid artery = Trigeminal nucleus caudalis

Salivary glands

Parotid gland N. Auriculotemporalis Parasympatisch: n. glossopharyngeus Sympatisch: cervicale ganglia via a. carotis externa

Submandibular glands

Ductus submandibularis or ductus of Wharton Palpation intrabuccal Looking for possible lithiasis

Sternohyoid muscles

Sternothyroid muscles

Incisura jugularis • D3 ♀ • D2 ♂ • Tracheotomy • 3 cm cranial of caudal

border larynx

Omohyoideus • lowering hyoïd • Mainly at the end of

swallowing • Tightens neck fascia

and keeps vena jugularis interna open

Internal jugular vein

95 %

Internal jugular vein

Internal jugular vein • VENA SUBCLAVIA • VENA BRACHIO-

CEPHALICA • VENA CAVA

SUPERIOR • RIGHT ATRIUM

Jugular venous pressure • 45 ° • 30 sec • Proximal clavicula • Disorder right atrium

Common carotid artery • A. carotis communis

sinistra from arcus aortae • A. carotis communis

dextra from a. subclavia

Carotid sheath

• Vena jugularis interna • Arteria carotis communis • Nervus vagus • Parts of the ansa cervicalis

Common carotid artery

Compare pulsations a. carotis communis/a. femoralis in inguinal region

Common carotid artery

Tuberculum caroticum Splitting up at C3-C4 in - a. carotis externa - a. carotis interna At the height of upper border lamina cartilago thyroïdea

Sinus caroticus At this splitting Centre bloodpressionregulation Innervated by: - n. glossopharyngeus (IX) - n. vagus (X) - Truncus sympathicus

Carotid body Chemoreceptor situated at the sinus caroticus Increase CO2 Decrease O2 Innervated by: - n. glossopharyngeus (IX) - n. vagus (X) - truncus sympathicus

Trigonum caroticum

• Sternocleidomastoid • Digastricus pars

posterior

• Omohyoid venter

superior

Trigonum caroticum • A. carotis externa and its branches (a. thyroïdea and a. • • • • •

lingualis) A. carotis interna N. hypoglossus N. vagus N. accesorius Truncus sympathicus and its ganglia

External carotid artery

arterial supply neck, face, skull and crown of the skull

Internal carotid artery 2/3 intern of the skull • lobus frontalis • lobus temporalis • lobus pariëtalis • lobus occipitalis • laterale ventricles • 3rd ventricle • Eyes • Cortex • capsula interna and deep brainstructures

Differentiation of structures 1. a. Subclavia 2. plexus brachialis 3. a. carotis communis

Thyroid cartilage Adam’s apple at C4

Lower border cartilago at C5

Cricoid cartilage

C6

Cricothyrotomy

Cricothyroid ligament

Trachea • 16 till 20 • • rings of cartilage • In contact with thyroid

gland and with the carotic sheath

Thyroid gland 19. Lobus dexter 20. Lobus sinister 24. Isthmus

C5 – D1

Thyroid gland THYROÏDEA GLANDULA Palpation Tests Percussion retrosternal Auscultation

Do not pass the Adam’s apple cranially Caudally till 3rd or 4th

Thyroid gland THYROÏDEA GLANDULA

Goitre

Superior mediastinum Sternohyoïdeus, sternothyroïdeus, longus colli Relic of thymus a. en v. thoracica interna Vena brachiocephalica Arteria brachiocephalica Upper ½ vena cava superior Arcus aortae Arteria carotis communis Arteria subclavia Nervus vagus

Between manubrium sterni and D1 tot D4

Trachea, oesophagus Upper part plexus cardiacus Upper part ductus thoracicus

Hyperthyroidism Loss of weight Increase of appetite Sensitive, nervous Warm, sweaty hands Slight peripheric tremor Beating periferal pulsations Tachycaria Retraction of the eyelid Goiter with or without noise Hyperreflexia

Hypothyroidism Constipation Loss of hair Angina pectoris Hoarse, scratching voice Scaly skin Loss of the eyebrows Bradycardia Xantheloma’s Goiter Relaxation tendonreflexes is delayed Carpal tunnel syndrome Those patients cannot sweat Intolerance for cold Fatigue Gaining weight

Hyoid bone • Corpus • Cornu majus • Cornu minus

Hyoid bone Connection with: • mandibula • processus styloïdeus • processus mastoïdeus • scapula • sternum • cartilago thyroïdea

Supports the tongue

Palpation of the hyoid bone

C3 Level epiglottis

Corpus

Cornua minores ½ lower border mandibula and Adam’s appel

Cornua majores

Hyoid bone Testing mobility laterolateral and craniocaudal Stretching suprahyoïdal muscles Stretching infrahyoïdal muscles

Mylohyoid muscle

Lateral cervical region Borders Contents: • Lymphnodes • n. accessorius • plexus cervicalis • plexus brachialis

Fossa supraclavicularis major

Pancoasttumor Virchow’s node trapezius SCM

Fossa supraclaviculairs major

Palpation of the lymph nodes

Palpation of the lymph nodes

Submandibular

Submandibular

Occipital

Deep cervical

Cervical

Scalenus Muscles Anterior

Medius

Posterior

Tub.ant. C3C6

Tub. Tub. Posterior C2- Posterior C5C7 C7

Tuberculum Lisfranc 1e rib

Upper border Outer side 2e 1e rib rib posterior to sulcus art. subclavia

Homolateral lateroflexion – heterolateral rotation

Homolateral lateroflexion

Homolateral lateroflexion

Lifts 1e rib

Lifts 1e rib

Lifts 2e rib

Flexion CWK Flexion CWK Flexion CWK

Scalenus anterior In case of a spasm Vascularisation problems Æa. subclavia Æa. carotis interna Æ n. phrenicus Æ ganglion stellatum at C7 Æ cupula pleura Æ lig. vertebropleurale

Stretching • Scaleni

âcaudal • Levator scapulae

â caudal and dorsal • Sternocleidomastoïdeus

â caudal and ventral

Landmarks C1

Dens, niveau nasopharynx

C2

Angulus mandibulae, level soft palate

C3

Level hyoïd

C3-C4

Upper border cartilago thyroïdea Splitting a. carotis communis

C4

Lower side chin

C4-C5

Lower border cartilago thyroïdea

C6

Cartilago cricoïdea

D1

Angulus superior scapulae

D2-D3

Incisura jugularis sterni

D3

Spina scapulae

Margo medialis scapulae 5 à 6 cm off the spinal line D4-D5

2e chondrale ribjunction (angle of Louis)

D7

Angulus inferior scapulae

D9

Processus xyphoïdeus

Scalenus muscles

n. phrenicus

Test Oshner-Gage

Subclavian artery

1. Arteria subclavia 2. Plexus brachialis 3. Arteria carotis interna

Subclavian artery

PALPATION Left a. subclavia Right a. subclavia

arcus aortae truncus brachiocephalica

Brachial plexus

Brachial plexus

Brachial plexus

Scalenii triangles

Brainwork … anatomy / pathology Group 1: • Relations to the m. omohyoideus Group 2: ` • Relations of the brachial plexus Group 3: • Relations to the thyroid gland Group 4: • Supra-orbital headache Group 5: • Relations to the ATM Group 6: • Relations to the masseter muscle Group 7: • Relations to the ganglion stellatum