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Cervical spine pain is one of the more common complaints seen in outpatient orthopaedic physical therapy. With the relation to the rest of the upper quarter, the shoulder and thoracic spine, it is essential we be as proficient as possible when assessing and treating the region. While this may seem obvious, it is interesting to note how hesitant some clinicians are in treating the upper cervical spine. Why? Because it is different and there is risk for fatal injury. The upper cervical spine is made up of the Atlantooccipital Joint and the Atlantoaxis Joint. These joints have different anatomical and kinesiological considerations compared to the rest of the cervical spine. With the frequency with which the cervical spine is involved in upper quarter dysfunction, as well as temporomandibular dysfunction, it is imperative we have a solid understanding of the joints.  Atlantooccipital Joint The Atlantooccipital Joint (AO) is made up of the atlas and occiput. The atlas has no body, pedicles, laminae, or spinous process, unlike typical vertebrae. There is an anterior arch with an anterior tubercle for attachment of the anterior atlanto-occipital membrane (Neumann, 2010). The posterior arch is larger and has a posterior tubercle. Additionally, there are two large transverse processes that are palpable between the mastoid process and mandibular ramus. There are two large concave facets that face medially and superiorly in order to accept the occipital convex condyles that face inferiorly and laterally (Abernethy, 2014). The atlanto-occipital membrane connects the anterior portion of the foramen magnum to the anterior arch of C1 for anterior-posterior stability. The posterior atlanto-occipital ligament connects the posterior ring of C1 to the occiput at the foramen magnum as well. This ligament is important for anterior translation of C1 and vertical translation of the occiput. Additionally, there are joint capsules surrounding the AO joints that limit movement in each direction. There are 2 degrees of freedom in the AO joint: flexion/extension and frontal sidebend (Abernethy, 2014). The OA joint is responsible for 10 degrees of flexion, 25 degrees of extension, 5 degrees of sidebend, and 4 degrees of conjugate rotation. To fully comprehend the arthrokinematics of the AO joint, we must know the plane of the joint. During flexion, there is a bilateral lateral, posterior, and superior (LPS) motion, while there is a bilateral medial, inferior, and anterior motion for extension (MIA). In order to determine which part and which side of the joint is restricted, we assess sidebend. Upper cervical sidebend to the left, results in left AO MIA and right AO LPS. In other words, if you sidebend the upper cervical spine to the left, you are essentially flexing on the right and extending on the left. To determine which side is at fault for the motion restrictions, sidebending should be reassessed in flexion and extension. For example, if sidebending to the left feels restricted in neutral, it is possible that either flexion on the right or extension on the left (or both) are limited. In a normal joint, sidbending should be smooth and through an axis that runs through the tip of the nose. When placed in flexion (of the same restricted motion), sidebend to the left now biases the right joint. By initially placing the AO joints in flexion, the condyles are moved lateral, posterior and superiorly (LPS). Thus, if there is a restriction on that right side, the condyle will meet its barrier sooner compared to neutral. By placing the AO joints in extension, the condyles are then moved medially, inferiorly, anteriorly (LIPS). This forces the condyle on the left to meet its barrier sooner compared to neutral if there is a restriction. Typically, a flexion limitation is found due to the frequency with which we see forward head posture. If you find an extension limitation, I recommend re-checking the joints.
The axis of rotation is through the dens. When rotating to the left, the ipsilateral side of the atlas glides posteriorly, while the contralateral side glides anteriorly (Abernethy, 2014). The AA joint is responsible for 35 degrees of rotation bilaterally, 8 degrees of flexion, and 10 degrees of extension. There are two methods that are commonly used for assessing motion at the AA joint. One is the Flexion-Rotation Test, where the cervical spine is maximally flexed (and maintained there), while rotation is performed bilaterally. The issue with this test is that it tends to also include motion at the C2-3 joint, resulting in at least 45 degrees of rotation in a normal joint bilaterally. To truly assess AA rotation, maximally sidebend the cervical spine ipsilaterally and rotate contralaterally, while maintaining chin tuck (if chin tuck is lost, isolation to C1-2 is lost). This is also a position for manipulation. It should be noted that in those with moderate degeneration of the cervical spine (and presents of significant osteophytes), cervical sidebend may be limited, resulting in decreased ability to isolate the AA joint. Ligament and Artery Testing People are often wary of treating upper cervical dysfunction manually due to some of the potential risks for fatal injury. The cervical vertebrae house the spinal cord and vertebral arteries - structures that are necessary for ordinary brain and motor function. Therefore, we must assess two areas: stability and blood flow. It is recommended that stability is assessed first due to the end range positions required for vertebral artery testing. The two ligament tests required are the Transverse Ligament Test and the Alar Ligament Test. The transverse ligament runs from one side of the arch of C1 wrapping around the dens to the other side of the arch of C1 (Abernethy, 2014). This ligament is 7-8 mm thick and keeps the dens in contact with the atlas, preventing anterior dislocation. The alar ligaments run superiorly and laterally from the dens to the occiput, resisting posteiror translation of the dens and occipital rotation contralaterally. If any of the tests are positive, a provocation of neural symptoms may occur. Structural stability of the atlas may also be assessed by compressing the transverse processes of C1 medially at the same time. If movement is detected, there lies the possibility of a Jefferson fracture. This often occurs with an axial blow to the head. Once instability has been cleared, we must check the patency of the vertebral arteries, as the vetebrobasilar system is responsible for 11% of blood flow. The vertebral artery branches off the subclavian and passes superiorly with the longis colli, enters the transverse foramen usually at C6 (but anywhere between C4-7), wraps back around the articular pillar and enters the posterior AO membrane, before entering through the foramen magnum. Here it joins the opposite vertebral artery to form the basilar artery. Vertebrobasilar Insufficiency is assessed with the Vertebral Artery Test. If you look at the diagnostic accuracy of the test, it would appear there isn't really a reason to even perform the test. With a sensitivity of 0% and a specificity of .67-.9%, a negative test means absolutely nothing and a positive test means the patient may have vertebrobasilar insufficiency. Positive symptoms include: dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea and vomiting, sensory changes, nystagmus, etc. While the diagnostic accuracy is poor for this test, there is still a common perception in the medical community that it is a "good" test for VBI. If you perform some manual therapy technique and the patient has a reaction and you did not perform the test, you will likely be found guilty of negligence. So perform the test. As with our normal exams, remember to screen for other potential non-musculoskeletal causes for dysfunction by assessing things like dermatomes, myotomes, reflexes, BP, pulse, respiratory rate, etc. 
As you can see, the upper cervical spine is not as difficult to assess as we make it out to be. Using the anatomy of the joints and our understanding of the kineseology, we can determine where/if any mobility restrictions exist. We can then proceed to couple that with our typical cervical spine assessment to find any strength/motor control limitations that contribute to dysfunction. The upper cervical spine is an important region to regularly assess due to its potential to contribute to TMJ and upper quarter dysfunctions. Any hypo/hyper-mobility can result in altered muscle tone or nerve firing patterns. These can result in altered kinematics in neighboring joints or altered joint alignments, such as an elevated 1st rib. Do not let the fear of VBI or instability prevent you from performing a complete evaluation and assessment. References:
Abernethy, Jeff. "Upper Cervical." Upper Cervical Spine Orthopaedic Residency Lecture. Scottsdale Healthcare Osborn Campus, Scottsdale, AZ. 9 January 2014. Lecture. Neumann, Donald. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd edition. St. Louis, MO: Mosby Elsevier, 2010. 315-322. Print.
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