hn1 anatomy of the spine

ANMT Head & NeckNotes 5/27/2016

HN1 Anatomy of the Spine

Anatomy of the Spine - Prentice, Chapter 25, pg. 754 - 763

Bones of the Vertebral Column (overview)

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The Cervical Spine & Intervertebral Articulations

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Intervertebral Disks

Disks (23)Cartilaginous end plate – hyaline cartilage that attaches to disc bodyAnnulus Fibrosus – laminated collagen fibers obliquely arranged to form the outer layerNucleus Pulposus – central, semi-elastic spongy hydrodynamic structure with mucoplysacharride, collagen and physaliphorous cells.

Dynamic, hydraulic suspension forming a mobile segment which distributes compressive forces.

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Ligamentous Structures

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Spinal Ligaments ( Trailguide workbook, p.115-117)Anterior Longitudinal Posterior LongitudinalLigamentum FlavumSupraspinousInterspinous

Anatomy Review (LP1 Handout)

Head/Cervical Ligaments (Trailguide workbook, p.113-114)Ligamentum Nuchae (head to C7, supraspinous ligament)Alar LigamentsTransverse ligament of the atlas

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Functional Anatomy (1st 2 paragraphs only)

Prevention of lnjuries (Cervical Spine only)

Student Handout — Anatomy Review

Vertebrae

Ligaments

Disks

NOTES:

C1 – Atlas - No body home (no body, contains brain stem), No SP but tubercles, large TVPAtlanto-Occipital joint – AO – 1 year old says “yes yes” - 10*flexion, 20* extension

C2 – Axis, Dens or ondontoid process (“body” of atlas), body, SP, TVPAtlanto-Axial joint – AA – 2 year old says “no no” - 8-10* rotation each direction

Cervical spinous processes pronged for ligamentum nuchae

Uncinated joints – Luschka's joints (also called uncovertebral joints, neurocentral joints)[1] are formed between uncinate processes above, and the uncus below. They are located in the cervical region of the vertebral column between C3 and C7. Two lips project upward from the superior surface of the vertebral body below, and one projects downward from the inferior surface of vertebral body above. They allow for flexion and extension and limit lateral flexion in the cervical spine.

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C1-C3: upper cervical, C4-C8,T1: brachial plexus

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https://en.wikipedia.org/wiki/Cutaneous_innervation

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HN2 Head / Neck Muscles

Temporalis (Travell, V 1, Ch 9, pg. 349)

Trigger Points

Attachments

Superiorly from the temporal fascia and the whole temporal fossa (zygomatic, frontal, parietal, sphenoid, temporal bones), superior to the zygomatic arch.

Inferiorly to the medial and lateral surfaces of the coronoid process of the mandible and along the anterior ramus of the mandible, almost to last molar.

Deep 90% slow twitch, superficial anterior/middle 74% and superficial posterior 52% slow twitch.

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Action

Elevation (all), lateral deviation (same side) and retraction (posterior) of the mandible

Symptoms

Head pain, toothache or tooth site pain, rarely aware of restricted jaw opening. Hypersensitive teeth and “teeth don't meet right” sensation.

Activation & Perpetuation

Bruxism, trauma, immobilization, dental procedure, neck traction, postural stress, activity stress, reflex contraction from infection/inflammation/other pain, excessive tension in supra/infra hyoids.

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Occipitofrontalis (Travell, V 1, Ch 14, pg. 427)

Trigger Points

“Wilson” TrP pattern

Attachments

Frontalis anteriorly, occipitalis posteriorly, connected superiorly by galea aponeurotica, which is firmly connected to the skin but glides over the periosteum.

Frontalis attaches below and in front to the skin over the eyebrow where it interdigitates with the orbicularis oculi muscle.

Occipitalis attaches below and behind to the superior nuchal line of the occipital bone.

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Action

Raises the eyebrow and wrinkles the forehead, expressing surprise and opening the eyes widely. Associated with overall increased muscle tension.

Symptoms

Deep aching pain, cannot bear weight of pillow due to pain,


TrPs satellite to clavicular SCM TrPs, work overload due to anxiety, facial expressions, etc.

Platysma (Travell, V 1, Ch 13, pg. 416)

Trigger Points

Attachments

Subcutaneous fascia of lower neck, above fibers interlace with orbicularis oris, corner of the mouth, other facial muscles and lower margin of the mandible.

Below attaches to the subcutaneous fascia of the upper thorax.

Action

Pulls angles of the mouth downward and the thoracic skin upward.

Symptoms

Prickly pain,

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Secondary to SCM/scalene TrPs.

Orbicularis Oculi (Travell, V 1, Ch 13, pg. 416)

Trigger Points

Attachments

Palpebral portion in eyelids and orbital portion surrounding the lids. Fibers of the orbital portion form bony attachments alond the superior medial part of the orbit and attach medially to a short fibrous band (medial palpebral ligament). The fibers surround the palpebral fissure in concentric circles.

Palpebral – relating to the eyelids

Action

Palpebral portion gently closes eye. Activation of orbital portion strongly closes eye.

Symptoms

Pain, “jumpy print”, difficulty focussing.


Frowning, squinting, TrPs in sternal SCM.

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Zygomaticus Major (Travell, V 1, Ch 13, pg. 416)

Trigger Points

Attachments

Muscle of mouth control attaches above to the malar surface of the zygomatic bone and below to the angle of the mouth, blending with orbicularis oris.

Action

Draws angle of mouth upward as in smiling or saying “wheee”.

Symptoms

Pain


Myofascial dysfunction of masticatory muscles casusing trismus (spasm/lock jaw) may cause zygomaticus major TrPs.

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Buccinator (Travell, V 1, Ch 13, pg. 416)

Trigger Points

Attachments

Primary cheek muscle forming the lateral wall of the oral cavity. Anteromedially fibers converge toward the angle of the mouth where they become continuous with the orbicularis oris muscle. Laterally, it attaches to the pterygomandibular raphe, the tendinous inscription that anchors the superior pharyngeal constrictor. Posterolaterally, some fibers attach tot he outer surfaces of the alveolarprocesses of the maxilla above and the mandible below. The muscle is pierced by the parotid duct.

Action

Movement of food around the mouth, whistling, blowing, and swallowing, in addition to facial expression.

Symptoms

Subzygomatic jaw pain aggravated by chewing, perceived difficulty swallowing.


Ill fitting dental appliances, excessive blowing (i.e. snorkelling, SCUBA, etc.)

NOTE:

Platysma stretch – pin muscle on thorax/clavicle, extend, rotate opposite side, protract jaw

Buccinator internal massage reduce time, internal skin more sensitive

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HN3 Anterior Neck

Suprahyoids (Travell, V 1, Ch 12, pg. 397)Stylohyoid

Mylohyoid

Geniohyoid

Digastric (see below)

Trigger Points

Mylohyoid can refer to tongue. Head / neck pain stylohyoid & digastric.

Attachments

All have inferior attachment to hyoid bone.

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Stylohyoid attaches above to the styloid process of the temporal bone.

Mylohyoid attaches above to the entire length of the mylohyoid line of the mandible.

Geniohyoid attaches above, deep to mylohyoid, on the inner surface of the midportion of the mandible at the symphysis menti.

Action

Open the mouth, with the hyoid bone stabilized by the infrahyoids.

Infrahyoids (Travell, V 1, Ch 12, pg. 397)Sternohyoid

Thyrohyoid – Sternothyroid

Omohyoid

Trigger Points

Attachments

All, except sternothyroid, attach superiorly to the hyoid bone.

Sternohyoid attaches below to the sternum.

Thyrohyoid sttaches below to the thyroid cartilage and omohyoid, where Sternothyroid attaches above,then attaches below to the sternum.

Omohyoid has a superior and inferior belly seperated by a central tendon. The inferior belly attaches below to the cranial border of the scapula near the scapular notch. Above it attaches to the clavicle/firstrib by a fibrous expansion over the central tendon, passing over the anterior/middle scalenes, but deep to SCM.

The superior belly attaches to the hyoid.

Action

Stabilize the hyoid for normal subrahyoid operation of opening the mouth.

Symptoms

Omohyoid tension can contribute to first rib dysfunction and pain in superior shoulder blade.


Whiplash, mouth breathing, overuse chewing, etc.

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Digastrics (Travell, V 1, Ch 12, pg. 397) “Pseudo-SCM P”

Trigger Points

Attachments

Posterior belly arises from the mastoid notch of the mastoid process of the temporal bone, deep to longissimus capitus, spenius capitus and SCM. The anterior belly arises from the infereior border of the mandible, close to the its symphysis. The anterior belly passes posteriorly/inferiorly and the posterior belly passes anteriorly/inferiorly to join at a common tendon that usually attaches indirectly tothe hyoid bone through a fibrous loop or sling called the suprahyoid aponeurosis. This common tendonperforates the stylohyoid muscle, near the front half of the posterior belly.

Action

Mandibular depression, nearly always bilaterally. Coughing, swallowing and retrusion of the mandible activate.

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Symptoms

Difficulty swallowing, lump in the throat, , something stuck in throat, CL likely to point to SCM superior attachment but with no reduction in ROM (Posterior Digastric). Anterior digastric primarily pain referal into teeth.


TrPs typically secondary to masseter /SCM TrPs. Bruxing, retruding mandible, mouth breathing, Eagle syndrome (long styloid process), visual blurring, trauma, whiplash, etc.

Longus Colli (Travell, V 1, Ch 12, pg. 397)

Trigger Points

Jaw, ear, back of neck

Attachments

Three portions, superior oblique, inferior oblique and vertical, attach to the anterior vertebral bodies from T3 to the tubercle on the anterior arch of the atlas.

Action

Weak neck flexor w/ lateral flexion to same side w/ rotation to the same side.

Longus Capitus (Travell, V 1, Ch 12, pg. 397)

Trigger Points

Jaw, ear

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Attachments

Extends upwards from the anterior tubercles of C3-6 to the basilar part of the occipital bone.

Action

Flexes the head with rotation to the same side.

Other Anterior Neck MusclesRectus Capitas Anterior lies deep to longus capitis and passes upward and slightly medially from the lateral mass of the atlas to the basilar part of the occipital bone in front of the foramen magnum.

Rectus Capitas Lateralis arised form the superior surface of the transverse process of the atlas, attaching superiorly at the lateral part of the occipital bone.

Symptoms

Unresolved posterior neck pain, difficulty swallowing, dry mouth, sore throat w/o infection, hoarse voice, peristent throat tickle/lump,


Forward head posture, whiplash, trauma, etc.

Notes:

Paul St. John diagrams for deep anterior cervical muscles

omo – shoulder

glossus – tongue

genio – chin

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HN4 Scalenes

Scalenes (Travell, V 1, Ch 20, pg. 504)

Trigger Points

Attachments

Anterior scalene attaches above to the anterior tubercles of the transverse processes of C3-6. Below it attaches by a tendon to the scalene tubercle on the inner border of the first rib and upper surface of the rib anterior to the groove for the subclavian artery.

Middle scalene attaches above to the posterior tubercles on the transverse processes of C2-7 (sometimes only 4/5). Below it attaches to the cranial portion of the first rib, posterior and deep to the groove for the subclavian artery.

Posterior scalene attaches above to the posterior tubercles on the TVP of C5/6-7 and below to the lateral surface of the second and sometimes third rib.

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Scalene minimus, if present, extends above to the anterior tubercle on the transverse process of C6/7 and below to the fascia surrounding the plural dome and the inner border of the first rib.

Action

Functions: Stabilize Cervical Spine Laterally, Assist Inhalation by Elevating Ribs, Assist Contralateral, Control of Unilateral Actions Below

Actions:

Fixed Below

Unilaterally

Laterally flex cervical spine

Move head obliquely forward and sideways

Bilaterally

Anterior flex cervical spine

Fixed Above

Elevate Ribs

Auxiliary Respiration Muscle

Symptoms

Referred pain to shoulder/upper arm, scalene anticus syndrome (pain ant/post arm, medial border scapula and anterior scalene tenderness), venous obstruction, vasomotor changes, arterial insufficiency, elevated first rib, neurovaso entrapment, TOS, numbness, tingling, edema of arm/hand, entrapment of subclavian vein,


Trauma, pulling, lifting, carrying awkward objects, playing musical instruments, over respiration, paradoxical breathing, coughing, sleep w/ head/neck low, small hemipelvis/upper arm, loss of limb/breast, awkward leaning position, whiplash.

Often secondarily to SCM/LS TrPs.

Differential Diagnosis

Carpal Tunnel — pg. 515-518

Thoracic Outlet Syndrome — pg. 518—521

Scalenus Anticus Syndrome & First Rib Involvement —- 521- 522

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Myofascial Pseudothoracic Outlet Syndrome - pg. 522

Scalene cramp test – place chin in hollow behind clavicle, positive is pain.

Scalene relief test – abduct arm, medially rotate – symptom relief?

Scalene finger flexion test – hold MCP straight and flex fingers. Positive scalene is no fingers can reach MCP/palm, positive ED 1-2 fingers cannot reach.

Corrective Actions

Stretching — pg. 530 – Side bending in supine w/ ipsilateral hand under buttocks, combine contralateral flexion with ipsi/contralateral rotation.

Coordinated Respiration — pg. 531-532 supine and prone belly breathing, breathing into hands, etc.

Notes:

Seated breathing with flexion on exhale, extension on inhale

Prone breathing w/ MT hands on abdomen/side to monitor and guide breathing into abdomen/sides

Shoulder issues: suboccipitals, scalenes, shoulder

Brachial plexus – no trapezius innervation or axilla sensory

Sibson's fascia – supraplural membrane

GTO sense tension, spindle sense stretch/length

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HN5 Sternocleidomastoid

Sternocleidomastoid (Travell, V 1, Ch 7, pg. 310)

Trigger Points

Attachments

Action

Symptoms



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HN6 Splenius, Semis, Longissimus, Multifidi, Rotatores

Splenius Capitis (Travell, V 1, Ch 15, pg. 432)

Trigger Points

Attachments

Action

Splenius Cervicis (Travell, V 1, Ch 15, pg. 432)

Trigger Points

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Attachments

Action

Symptoms


Semispinalis Capitis (Travell, V 1, Ch 16, pg. 445)

Trigger Points

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Attachments

Action

Longissimus Capitus (Travell, V 1, Ch 16, pg. 445)

Trigger Points

Attachments

Action

Multifidi (Travell, V 1, Ch 16, pg. 445)

Trigger Points

Attachments

Action

Rotatores (Travell, V 1, Ch 16, pg. 445)

Trigger Points

Attachments

Action

Symptoms



Fibromyalgia, Osteoarthritis and Cervicogenic Headache - Pg 456—457

Neuropathy — Pg 459

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HN7 Suboccipitals

Suboccipitals (Travell, V 1, Ch 7, pg. 310)

Trigger Points

Attachments

Action

Symptoms


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HN8 Cervical Posture

Military Neck, Packet

Etiology

Symptoms and Signs

Management

Forward Head Posture, Packet

Etiology

Symptoms and Signs

Management

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HN9 Neck Strains & Sprains

Neck/Back Strains, Prentice, Ch 25, pg 779

Etiology

Symptoms and Signs

Management

Cervical Sprain (whiplash), Prentice, Ch 25, pg 780

Etiology

Symptoms and Signs

Management

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HN11 Cervical Vertebrae Issues

Cervical Disk Injuries — Prentice, Chapter 25, pg 784

Etiology

Symptoms and Signs

Management

Cervical Fractures - Prentice, Chapter 25, pg 776 — 777

Etiology

Symptoms and Signs

Management

Cervical Dislocations - Prentice, Chapter 25, pg 777 — 779

Etiology

Symptoms and Signs

Management

Cervical Spine Stenosis — Prentice, Chapter 25, pg 781 — 783

Etiology

Symptoms and Signs

Management

Special Tests - Prentice, Chapter 25, pg 769 & 771

Cervical Compression and Spurling’s Test

Slump Test

Vertebral Artery Test

Shoulder Abduction Test

Distraction Test (Packet)

Valsalva Test (Packet)

Swallowing Test (Packet)

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HN12 Cervical Nerve Issues

Brachial Plexus Neuropraxia (Burner) — Prentice, Chapter 25, pg783 — 784

Etiology

Symptoms and Signs

Management

Pinched Nerve Syndrome — Student Packet

Etiology

Symptoms and Signs

Management

Cervical Cord and Nerve Root Injuries -— Prentice, Chapter 25, pg 780 - 781

Etiology

Symptoms and Signs

Management

Acute Torticollis (Wryneck) —— Prentice, Chapter 25, p. 780, Packet

Etiology

Symptoms and Signs

Management

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HN13 Headaches

Diagnostic Categories for Head, Neck and Facial PainTravell, Chapter 5, pg. 241 —245

Migraine Headache —- Pg. 241

Tension—type Headache —- Pg. 241-242

Cluster Headaches and Chronic Paroxysmal Hemicrania —- Pg. 244-245

Miscellaneous Headaches, Unassociated with Structural Lesion & Head and Neck Pain Associated with Head Trauma — Pg. 245-246

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HN14 TMJ

TMJ Packet, Travell, Vol. 2, Chapter 5, pg 248-260

Temporomandibular Joints & Anatomy -— pg 248

Biomechanics —- pg 248

Biomechanics in Internal Derangement —- pg 249-250

First paragraph (end at “Clicking occurs when...”)

Second paragraph (“Clicking occurs when...”) to the end of this section.

Role of Occlusmn in TM Disorders

Impact of TMJ Disorders on Myofascial TrPs (do not include case study)

Screening Examination for Temporomandibular Joint Disorders

Joint Capsule Tenderness — pg 256

Exam Procedures

Clinical Significance

Joint Sounds - pg 257

Exam Procedures


Mandibular Range of Motion — pg 259

Exam Procedures


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Masseter —— Travell, Chapter 8, pg. 331

Trigger Points

Attachments

Action

Symptoms


Psychological Stresses

Other Stresses

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HN15 Pterygoids

Lateral Pterygoid —— Travell, Chapter 11, pg. 379

Trigger Points

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Attachments

Action

Symptoms


Medial Pterygoid —— Travell, Chapter 10, pg. 365

Trigger Points

Attachments

Action

Symptoms


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HN17 HOPRS

HOPRSHistory

Observation

Palpation

ROM (active, passive, manual resistive)

Special Orthopedic Tests

OHSHITOccupation

Hobbies

Surgeries - scars

Hospitalization

Illness

Trauma - scars

BLESS ME (Biopsychosocial)Body

Lifestyle

Emotions

Society

Spirit

Mind

Environment

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OPQRHN

Onset – acute or gradual

Provocation or Palliative – what changes pain

Quality of pain – sharp, dull ache

Radiate

Site – where is it

Time of day – behavior over course of day

OPQRHN Nerve Joint Muscle

Onset Acute Acute Acute or gradual

Provocation Likes cold, not heatDoesn't like stretch or compression

Likes cold, not heatPosition can change P

Likes heat, not coldPosition can change P

Quality Numb, tingle, burn, sharp

Ache, deep, stiff, sharp Dull ache

Radiates Along nerve, dermatone Local Referral, fascial, embryological development

Site Nerve or path Specific, non moving Vague, changing

Time of Day AM OK, PM ^P AM Stiff, PM OK, but overuse can ^P

AM stiff, warm up w/ use, overuse can ^P

Posture - ask to exaggerate, how do you like to stand, how do you feel, etc. - drive to more natural

Palpation – temperature, texture, tenderness, tone

Myotome – myfascial pain referral pattern

Please read to prepare for class:

Pat Archer: Therapeutic Massage in Athletics

Ch. 12 pg. 225-240 Evaluation: identifying Problems and Assessing

needs

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Additional resources to have in this class:

Pat Archer: Therapeutic Massage in Athletics

Ch. 6 pg 100 — 106 The Physiology of Healing

Ch. 7 pg 111 — 127 Lymphatic Facilitation Techniques

Table 6-1 Summary of Healing Process, pg 106

Table 13-2 Treatment Massage According to Stage of Healing, pg 245

Prentice: Neuromuscular Therapy lniugy Assessment

Ch. 22, The Shoulder Complex

pg 659 — 660 Table 22-1: Muscles of the Shoulder Complex

pg 663 — 670 Assessment of the Shoulder Complex

Ch. 25, The Spine

pg 759 Table 25-1: Muscles That Move the Vertebral Column

pg 764 — 776 Assessment of the Spine

Travell: Myofascial Pain and Dysfunction, Vol 1

Part 2: Head and Neck Pain-and-Muscle Guide

Part 3: Upper Back, Shoulder, and Arm Pain-and-Muscle Guide

NOTES:

VALUES

Values

Actions

Lifestyle / Habits

Universe / Understanding

Environment

Society

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hn1 anatomy of the spine

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