part 4

Question 1

What are the different parts of the subclavian artery

Answer 1

Part 1- different left compared to right
a.right comes off the brachiocephalic trunk behind the SC joint > ascends superior and lateral to anterior scalene
b.left comes aortic arch behind the common carotid > passes superior border of the anterior scalene
Part 2- passes posterio to the anterior scalene
Part 3- passes up and over 1st rib into the supraclavicular triangle > turns into axillary artery

Question 2

What structure separates the subclavian artery and vein?

Answer 2

anterior scalene

Question 3

What are the four anatomical spaces relevant to the thoracic outlet?

Answer 3

1. sternocostovertebral
2. scalene triangle
3. costocalvicular space
4. pectoralis minor space

Question 4

What are the borders of the sternocostovertebral space?

Answer 4

1. Sternum anteriorly
2. spine posteriorly
3. first rib laterally

Question 5

What is found in the sternocostovertebral space?

Answer 5

1. subclavian vein
2. subclavian artery
3. brachial plexus
4. apex of the lung
5. pleura
6. sympathethetic trunk
7. jugular vein
8. lymphatics of the neck

Question 6

What are the borders of the scalene triangle?

Answer 6

Anterior scalene
middle scalene
first rib

Question 7

What are the borders of the costoclavicular space?

Answer 7

1. one third of the clavicle and subclavius anteriorly
2. first rib and sclene insertion medially
3. superior border of the scapula posteriorly

Question 8

What is found in the costoclavicular space?

Answer 8

1. costoclavicular ligament
2. subclavian vien
3. subclavian artery
4. brachial plexus

Question 9

What are the borders of the pectoralis minor space and what is found in the space?

Answer 9

1. ribs
2. pectoralis minor
3. brachial plexus and axillary vessels

Question 10

Are cervical rib a pathological condition?

Answer 10

No, only 1.2% of patient with upper extremity symptomology are found to have cervical ribs

Question 11

How many types of congenital fibromuscular band are been identified in the thoracic outlet?

Answer 11

1- anterior tip of incomplete cervical rib to posterior scalene tubercle
2- tip of enlarger C8 TP to posterior scalane tubercle
3- muscular band from body of T1 TP across the space to the first rib
4- connection between anterior and middle scalene
5- scalenes minimus from TP of lower cervical spine to attachbtween Middle and anterior scalene
6- scalene minimus that attaches to the pleura
7- passess beneth the subclavian vein

Question 12

What are some examples of congenital anomolies that influence the thoracic outlet?

Answer 12

1. fibrous bands
2. hypoplastic first rib
3. exostosis of the first rib or clavicle

Question 13

Describe the myofacial layer that cover the region of the thoracic outlet

Answer 13

1. Deep cervical fascial wraps arond the posterior belly of the omohyoid
2. it travels down and splits to envelope the subclavius
3. it then joints the clavicopecotoral fascia with a thickening of the costocoracoid membrane
4. splits again to enclose pectoralis minor
5. it terminates at suspensory ligament of the axilla

Question 14

What is the true tissue in lesion the anterior scalene TOS

Answer 14

1.C3 innervates anterior scalene
increases tone in anterior scalene and effect TOS
2.C3 innervates diaphragm
3.dysfunction of the diaphragm leads to upper respiratory breathing

Question 15

What is costocalvicular syndrome?

Answer 15

the vascular structures are compressed by clavicle on the first rib with retracted and depressed scapula

Question 16

Why is there some controversy over costoclavicular syndrome?

Answer 16

some studies have demonstrated that as the clavicle is depressed it actually moves forward and increases the space between the first rib and clavicle

Question 17

How can you test for costoclavicular syndrome?

Answer 17

1. exagerated military posture
2. deep inspiration
3. monitor pulse

Question 18

What is hyper abduction syndrome?

Answer 18

1. At 180 degree of elevation the neurvscular bundle is bent at a 90 degree angle around the coracoid process
2. contraction of the pec minor or subscapularis will compress the neurovascular bundle

Question 19

What are some possible causes of the pec minor space compression?

Answer 19

1. postural kyphosis
2. overuse of accessory respiratory muscles
3. direct trauma to muscle or rib
4. upper thoracic spine dysfunction
5. costal or intercostal leasion
6. facilitated segment of the CT juntion

Question 20

How might the GH joint contribute to TOS issues?

Answer 20

compression follow anterior subluxation due to failure of the GH ligaments or coraco-clavicular ligaments

Question 21

How would differentiate TOS from other pathology?

Answer 21

1. Signs of peripheral neuritis due to intermittent interruption of blood flow
2. There is the potential for an effect on the pulse
3. there is a non segmental pain referral pattern

Question 22

What role do the C5, 6, 7 segments have on sympathetic distribution?

Answer 22

1. C5 and 6 transmit sympathetic fibers to the brachial plexus
2. C7 transmits fibers to the brachial plexus, subcalvian vessel and phrenic nerve

Question 23

How would you test for anterior scalene involvement of TOS?

Answer 23

1. Allen (contralteral rotation) and Adson’s (ipsalateral rotation) test
2. Rotate the head
3. slightly extend the neck
4. monitor pulse
5. take a big breath in

Question 24

Why is monitoring the pulse during TOS testing subject to debate?

Answer 24

1. Roo himself pointed out the compression of the vasculature has “little to do with cause of symptoms in about 99% of the cases”
2. studies confirm that testing proceedures cause vascular changes in healthy populations also

Question 25

What is Chamberlain’s Line?

Answer 25

line between the posterior margin of the hard palate and the posterior margin of the foramen magnum

Question 26

What is Fielding’s sign?

Answer 26

Lateral view, distance between anterior arch of C1 and odontoid process, normally less than 3 mm, 3-5 mm rupture of transverse lig, 10-12 rupture of all ligaments

Question 27

What is Fishgold Line?

Answer 27

line between mastoid processes

Question 28

What is McGregor's line?

Answer 28

Hard plate to most caudal point of the occiput

Question 29

What is McRae's line

Answer 29

line across the foramen magnum

Question 30

What is steel's rule of thirds?

Answer 30

Inner space of C1 is about 3 cm and is equally occupied by dens, spinal cord, and free space

Question 31

How does the projection angle effect an x-ray?

Answer 31

As the beam fans out it creates some distortion; therefore, in the lower segments of the spine you will have what appear to be narrowing of the disc space.

Question 32

What are radiopaque objects?

Answer 32

objects that block x-rays

Question 33

What is a Jefferson fracture?

Answer 33

1. burst fracture of C1 typically into four parts 2. may result from compression second vertebrae or hyperextension 3. pain in the upper neck with limited neuro signs, but may effect vascularture causing symptoms of harmner’s syndrome, temp sensation, medullary syndrome, ataxia

Question 34

How are odontoid fractures classified?

Answer 34

type I: fracture through the tip requiring fusion type II: fracture through the base requiring fusion type III: fracture through the body of C2 usually stable and require immobilization

Question 35

What is the key characteristic of an x-ray of a dens fracture?

Answer 35

the Dens should be centered between that lateral masses

Question 36

What is Ponticulus Ponticus?

Answer 36

1. small boney bridge from the posterior arch of C1 that encircles the vertebral artery 2. it may or may not form an accessory foramina 3. incidence is anywhere from 5-37%

Question 37

What makes dosing and treating the cervical spine more complicated?

Answer 37

your have a unique interaction of the sympathetic nervous system, vestibular system, ocular reflexes, closed head injuries and the effects of upper cervical instability

Question 38

How do you avoid exacerbation of neurologic overlaying when dosing exercises for the cervical spine?

Answer 38

Go back to the basic set of 10 no matter what functional quality you are dosing for

Question 39

What is the standard order of movement direction with selective tissue training?

Answer 39

1. all pain free motions 2. movement in painful plane away from pain 3. movement in painful plane towards but not into pain

Question 40

The trigeminal nucleus receives nociceptive input from what nerves?

Answer 40

1. trigeminal 2. facial 3. glossopharyngeal 4. vagus 5. C1-C3

Question 41

How do you test upper cervical motion?

Answer 41

1. mechanically lock the lower cervical spine using flexion and extension and the principles of protraction (OA ext with lower cervical flexion) and retraction (OA flex with lower cervical extension) 2. OA side bending flexion and extension quadrant using protraction and retraction 3. OA side bend neutral with lower cervical full rotation 4. AA rotation with ligamentous locking by flexing the spine 5. AA rotation with couple motion locking by lateral flexion and AA rotation away

Question 42

Give some examples of lower cervical locking for upper cervical isolation exercises?

Answer 42

1. side bending of the lower cervical spine will lock the cervical spine using couple motions so that you can isolate upper cervical rotation in the opposite direction 2. flexion of the lower cervical spine can ligamentously lock the lower cervical spine for isolated upper cervical extension or rotation 3. Rotation of the cervical spine can lock the lower cervical spine for isolated upper cervical flexion and extension training 4. extension of the lower cervical spine can ligamentously lock for isolated upper cervical flexion

Question 43

What muscles are primarily tonic and phasic in the cervical spine?

Answer 43

1. tonics: multifidi, suboccipitals, deep neck flexors (longus colli primary), rotatory muscles 2. phasics: splenius capitis, semispinalis capities and cervicis

Question 44

How does the theory of co-contractions change in the cervical spine?

Answer 44

1. typically as the load increases both that primary mover and secondary musculature have to increased in activation 2. in the cervical spine just the prime move will increase in activation

Question 45

Why is it inappropriate to focus on a single muscle as the cause of pain or weakness?

Answer 45

1. the brain recruits muscles in synergies 2. instead exercises should focus on normalizing tissue tolerances to resolve noxious input to correct recruitment patterns