PRINCIPLES OF MANUAL MEDICINE THIRD EDITION BY PHILIP E. GREENMAN

1 98 Principles of Manual Medicine there may be minor forward-bending, backward­ bending, and side-bending components to the rota­ Cervical spine dysfunction can result in altered afferent tional restriction, adequate treatment to the rota­ stimulation by these mechanoreceptors and nocicep­ tional restriction restores the minor movement tors and influence the integrated function of the mus­ motion simultaneously. At the occipitoatlantal (CO­ culoskeletal system, as well as contribute to local and re­ C 1 ) junction, there are two dysfunctions possible. gional symptoms. The suboccipital cervical muscles There will be either forward-bending or backward­ have a large number of spindles per unit mass. The pro­ bending restriction with coupled side-bending and ro­ prioceptive function of these muscles must have a high tation restrictions to opposite sides. level of significance. Recent magnetic resonance imag­ ing (MRI) research in this region has demonstrated The structural diagnostic process begins by identi­ fatty replacement of the rectus capitis posterior major fying levels of palpable deep-muscle hypertonicity. and minor muscles in some patients with posttraumatic This identifies segments that need motion testing. cervicocranial syndromes (see Chapter 2 1). The diagnostic and therapeutic processes seem to be most satisfactory by beginning from below and mov­ Autonomic Nervous System Relationships ing cephalad. Sympathetic autonomic nervous system control of The bony landmark of most value in the typical cerebral blood flow emanates from the superior cervi­ cervical segments is the articular pillar. They are pal­ cal ganglion. This structure is intimately related to the pated in the deep fascial groove between the semi­ longus colli muscle and the anterior surface of C2 to spinalis medially and the cervical longissimus laterally. which it is intimately bound by deep connective fascia. The paired examiner fingers can localize to the right Somatic dysfunction of C2 is frequently found in pa­ and left articular pillars of any given cervical segment tients with cervicocephalic syndromes and in those and introduce motion testing. The typical cervical seg­ with internal visceral disease. A small branch of the ment articular pillar is the size of the examiner's fin­ second cervical nerve connects with the vagus as it de­ ger pad. The identification of the articular pillars be­ scends through the trunk. Hypothetically, this neural gins by first identifying the spinous process of C2 and connection may account for the clinical observation C7. The C2 spinous process is the first bony promi­ of somatic dysfunction of C2 in the presence of vis­ nence in the midline caudad to the external occipital ceral disease. protuberance (inion). The spinous process of C7 (ver­ tebra prominens) is the spinous process that remains STRUCTURAL DIAGNOSIS palpable during cervical backward bending. The ar­ ticular pillars of C2 and C7 are at the same level of the The anatomy and biomechanics of the cervical spine spinous processes. Placing the examiner's fingers be­ result in five somatic dysfunctions. The typical cervical tween the pillars of C2 and C7 puts the finger pads in segments have nonneutral dysfunction with either contact with C3, C4, C5, and C6. This provides the forward-bending or backward-bending restriction to­ ability to localize to any specific cervical segment. The gether with coupled side-bending and rotation restric­ structural diagnostic process can be performed m tion to the same side. At the atlantoaxial (C 1-C2)junc­ both the patient sitting and supine positions. tion, the primary somatic dysfunction is that of restriction of rotation to one side or the other. While Figure 13.6. Figure 13.7.