6. Atlantoaxial Joint
C1
C2
Dens
Zygapophyseal
joints
JOINT between the atlas (C1) and the
axis (C2); has a range of motion in the
transverse plane for rotation.
The DENS of C2 acts as a pivot
point for the rotation of C1.
The articulating surfaces of the two
vertebrae form ZYGAPOPHYSEAL (FACET)
JOINTS that allow flexion-extension,
side bending, and rotational
movements.
7. Lower Cervical Vertebrae
• C3 to C7
– May be referred to as
the subaxial region
– Disc at every level
– Vertebral structures
are similar
8. Lower Cervical Vertebrae
C3 - C7
Transverse
Process
Body
Sulcus for
Spinal Nerve
Lateral
Mass
Lamina
Pedicle
Superior
Articular Facet
Vertebral
Foramen
Bifid Spinous Process
Transverse
Foramen
Axial View
9. Sulcus for Spinal
Nerve
Uncinate
Process
Uncovertebral Joint
(Joint of Luschka)
Lower Cervical Vertebrae
C3 - C7
Anterior View
The vertebral bodies of the subaxial cervical spine have upward projections on
the lateral margins called UNCINATE PROCESSES.
These processes articulate with the level above to form the UNCOVERTEBRAL
JOINT. These are also called JOINTS OF LUSCHKA.
10. Spinal syndromes
• Subtle autonomic and visceral changes
associated with spinal dysfunction and
treatment, and the visceral disorders that
mimic and are mimicked by spinal dysfunction
are important in manual therapy.
11. Cervical syndromes
• Upper and mid-cervical spine disorders (occiput to C4)
symptoms
1. Headache
2. Migraine
3. Dizziness
4. Dysphasia
5. Globus sensations(Lump in throat)
6. Hoarseness
7. General irritability, autonomic reactions
8. Disturbances in hearing,sight,cognition
concentration, and memory.
12. Cervical syndromes
• Numerous clinical reports have shown
symptomatic improvement after mobilization
treatment.
• The close proximity of the vertebral artery and
nerves, medulla oblongata, cerebellum, pons,
the vagus and hypoglossal nerves, and the
sympathetic ganglions of the neck may explain
why mobilization of the upper cervical spine
alleviates such symptoms.
13. Cervical syndromes
• Lower cervical spine dysfunctions (C4 to T3) present
primarily with local pain and symptoms radiating into the
upper thoracic area, shoulder girdle, and arm.
• However, clinicians often report that mobilization in this
region influences symptoms that seem to originate in the
upper cervical spine.
• It is possible that decreased mobility in one part of the
spine (e.g., lower cervical or thoracic) disturbs function and
provokes symptoms in another region (e.g., upper cervical).
• Manual therapists sometimes augment mobilization
treatment for upper cervical symptoms with mobilization to
the lower cervical and upper thoracic regions, at least on a
trial basis .
14. Thoracic syndromes
• In thoracic spine spatial relationships in the spinal
canal and the intervertebral foramen are larger
than in other regions.
• This is probably why thoracic nerve root irritation
is rare.
• On the other hand, the numerous small joints in
this region, including the costovertebral and
costotransverse joints, make the thoracic region
more susceptible to painful joint restrictions,
including the facet syndrome.
15. Thoracic Vertebrae
• Body - progressive increase in mass
from T1 to T12
• Pedicles - small diameter
• Laminae - vertical, with “roof tile”
arrangement
• Spinous processes - long,
overlapping, projected downward
• Intervertebral foramen - larger, less
incidence of nerve compression
16. Thoracic Vertebrae, T1-T12
• Body - heart shaped when viewed
superiorly.
• Vertebral foramen - round
• Pedicles - small in diameter
• Spinous processes - long and
projected downwards
18. Thoracic syndromes
• With a segmental hypo-mobility in the thoracic region,
careful manual evaluation, particularly end-feel testing,
reveals a characteristic mobility restriction between
two vertebrae.
• Local symptoms center on the affected vertebral joint,
usually with tight and painful paravertebral
musculature on the involved side.
• Associated symptoms can also include pain in the
corresponding intercostal area, hyperesthesia in the
area of the associated dermatome, dominant pain in
the anterior aspect of the thorax, and antalgic
postures.
20. Thoracic syndromes
• Injuries to the thoracic spine can produce a painful
segmental hypo-mobility in both children and adults.
• However, patients over the age of fifty become more
susceptible to thoracic segmental hypo-mobility as a result
of the degenerative changes common in this age group.
• Thoracic symptoms can be aggravated when older patients
become bedridden, associated severe pain and dyspnea
can raise suspicions of heart or pulmonary involvement.
• The OMT evaluation revealing a painful segmental
restriction can be critical to the differential diagnosis in
these cases.
• A successful trial treatment of specific mobilization
techniques can confirm the therapist's tentative diagnosis.
21. Thoracic syndromes
• Painful thoracic joint syndromes can be mistakenly attributed to
intercostal neuralgia or myogenic syndromes, even if local pain
persists in the involved area of the spine.
• The characteristic radiating pain associated with thoracic segmental
dysfunctions, if dominant, can also mimic internal organ diseases,
making differential diagnosis in the thoracic region difficult.
• Many internal organs share a common innervation with the
thoracic spine, so symptoms can be similar with heart, gallbladder,
nephrolithiasis(kidney stone), appendicitis, and thoracic spinal
disorders.
• The terms pseudoangina pectoris, pseudodyskinesia, and
pseudoappendicitis are used to describe these diagnostic problems.
22. • In a 1963 study, Bechgaard compared hospital
admission diagnoses with discharge diagnoses in
seventy-five patients with thoracic segmental
pain syndromes.
• The admission diagnoses all related to visceral
disorders. However, in 85 percent of these cases,
symptoms were permanently relieved with
mobilization, local anaesthetic injection, or
traction tests, and the discharge diagnosis was
changed to segmental pain syndrome.
23. “facilitated segment”
• The word "facilitated“ means made easier or
more efficient.
• In the case of the facilitated segment, it means
that the stimulus threshold in a particular spinal
cord segment has been reduced. This means that
the facilitated segment of the spinal cord is highly
excitable, and that a smaller stimulus will trigger
excessive impulse firing in the segment.
• For example, if the segment that innervates the
stomach becomes facilitated, the stomach
becomes hypersensitive.
24. • The "facilitated segment" phenomenon further confuses
attempts to distinguish between visceral and somatic
problems, especially in the thoracic spine.
• Any irritation within structures that share nervous
innervations may decrease the pain threshold in the related
vertebral segment.
• For example, not only can irritation of a thoracic nerve root
mimic symptoms of angina pectoris, but actual angina
pectoris with symptoms in the thorax, shoulder, and arm
can irritate the thoracic spine (via a facilitated segment)
and cause or aggravate problems there.
• Angina pectoris symptoms may even be temporarily
relieved with thoracic mobilization.
25. • Movement restrictions in the costo-vertebral and costo-
transverse joints are difficult to differentiate from other
segmental syndromes.
• If the symptoms are of articular origin, pressure applied to
the rib or movement of the rib in a cranial or caudal
direction increases symptoms.
• Older people who have been bedridden for a period of time
and athletes often exhibit these costal syndromes.
• In extreme cases, the severity of the pain may require the
patient to be hospitalized.
• Tumors in the thoracic spine may irritate a thoracic nerve
root and produce symptoms similar to segmental
dysfunction .
26. • Body - L1 to L5 progressive increase
in mass
• Pedicles - longer and wider than
thoracic; oval shaped
• Spinous processes - horizontal,
square shaped
• Transverse processes - smaller than
in thoracic region
• Intervertebral foramen - large, but
with increased incidence of nerve
root compression
Lumbar Vertebrae, L1-L5
27. Lumbar syndromes
• Lumbar spine syndromes simultaneously
affecting a disc and facet joints are frequently
seen by manual therapists.
• In addition to the more common disc ,
synovial joint, and nerve root pathologies, the
lumbar spine is also susceptible to facet joint
blocking by the meniscoids and to disc joint
irritation by microrupture of the annulus.
28. Lumbar syndromes
• The movement restrictions and antalgic
postures associated with these conditions
stem both from irritation of free nerve
endings within the injured lumbar structures
themselves and from pressures and irritation
secondary to swelling and inflammatory
exudate from neighboring injured tissues.
29. Lumbar syndromes
• Acute low back pain, or lumbago, originating
from a lumbar segment, is often misdiagnosed as
a muscle sprain or spasm, because pain is
localized in the paravertebral musculature.
• However, any spasm or increased tension of the
back extensor musculature would create or
emphasize a lumbar lordosis, and most cases of
acute low back pain are associated instead with a
flattened or kyphotic lumbar curvature with an
antalgic lateral shift.
30. Lumbar syndromes
• Acute low back pain often recurs and can progress to a
chronic lumbar dysfunction associated with
degenerative discs and nerve root involvement.
• With nerve root involvement, patients describe
varying forms of lower extremity pain and
paraesthesia.
• These symptoms must be differentiated from
pseudoradicular pain of visceral origin.
• Visceral pain that mimics a nerve root problem and
refers pain into the lower extremities is unlikely to
benefit from mobilization treatment.
31. Neurologic evaluation of nerve root
syndromes
• The differential diagnosis of nerve root syndromes
requires a working knowledge of the innervations
patterns of the spinal nerve roots (including
dermatomes, mytomes, and sclerotomes)
and the peripheral nerves.
• Normal anatomical variations and overlapping patterns
of segmental innervations require testing not only the
key muscles and dermatomes in the suspected spinal
region, but also the key muscles and dermatomes in
the spinal segments above and below the suspected
lesion
32. Sensory innervation of the skin
• When a patient reports diffuse sensory
disturbance there can be a significant amount
of dermatomal overlap.
• Patterns of peripheral innervation are more
clearly delineated.
33. Motor innervation
• In the presence of motor loss, the manual
therapist first determines whether the weakness
is of peripheral or central origin
Monoradicular lesions are distal to the ventral
horn and therefore can only be flaccid (not
spastic). These paresis can be differentiated with
the use of manual muscle testing, evaluation of
muscle atrophy, and electromyography or
chronaximetry.
