__Manipulative_Therapy__Musculoskeletal_Medicine

Functional anatomy and radiology of the spinal column Chapter 3 arms folded in front of the chest (see Figure 3.1D). The final step, once the apparatus and the patient’s position have been set up, is to tape the wire to the cassette so that it cannot be displaced, and then instruct the patient to lean against the screen so as to remain steady during the long film exposure. 3.3.2 X-ray evaluation of lumbar spinal statics Figure 3.2 • Lateral view of the lumbar spine with perfect The purpose of the films taken in the standing posi- demonstration of the entire pelvis, including the iliac crests tion is mainly to study body statics. The only struc- and femoral heads. tures in the frontal plane that can be assessed by clinical examination are the occipital protuberance, over-exposure of the lumbar spine while spinous processes, iliac crests, intergluteal cleft, exposure of the lumbosacral junction is and the midpoint between the heels. In the sagittal good. Aligning the beam on the lumbosacral plane, clinical examination can show the posture of junction evens out the exposure, and has the head, position of the shoulders, the trochanters the additional advantage of providing good and the heels in relation to the plumb line, which imaging of the hip joints (see Figure 3.2). takes the line from a fixed point at the external auditory meatus. Clinical examination cannot pro- 2. If the beam is aligned to the center of the vide information about the position and inclination cassette (middle of the lumbar spine), the of the sacrum and the most caudal vertebrae (which effect is to project the iliac crests away mark the true base of the spinal column), informa- from each other, lying well apart as they do, tion which is essential for a full understanding and although they are very important for body evaluation of spinal statics. statics. The projection error produced at the much slimmer lumbar spine, on the other This may explain why clinicians interested in body hand, is only slight. statics have devoted their attention mainly to the question of body equilibrium as a whole, studying For both projections the focus-film distance should deviation of the head and deviation from the line of be as great as possible, depending on the power of gravity by means of statovectography. However, Rash the apparatus and the corpulence of the patient, & Burke (1971) pointed out that with static load each the ideal distance being at least 2 m (78 inches). For body segment should be vertically above the center technical reasons, the patient needs to stand with of the segment on which it rests. The principle is vio- lated if tension of the ligaments or excessive muscular contraction are required to maintain balance. X-ray examination under static conditions provides infor- mation on precisely this type of static disturbance. The mechanism of body statics differs consid- erably in the frontal and the sagittal planes. One way to appreciate this is to observe the effect of a heel insert, a pad or block placed under one foot. A healthy subject experiences a height difference of as little as 1 cm as uncomfortable, whereas if a heel insert of 1 cm is placed under both feet it is hardly noticed. This is because in the frontal plane the center of gravity lies over both feet, such that body equilibrium is (relatively) stable. As a result, any mechanical change (the insert under the foot) has an immediate effect. In the sagittal plane, in contrast, body equilibrium is labile, over the two 43

Manipulative Therapy Figure 3.3 • Normal body statics: (A) with the subject standing with his weight equally on both feet; (B) with support to raise the right foot; (C) with weight shifted onto the right leg. 44

Functional anatomy and radiology of the spinal column Chapter 3 perfectly round surfaces of the hip joints. A slight mechanical change has little effect, because it is dynamic muscle function that is maintaining bal- ance in this plane. The muscular force required should, however, be minimal. Lumbar spinal statics in the frontal plane In the ‘ideal’ case the pelvis and spinal column lie Figure 3.4 • Normal reaction of the lumbar spine and pelvis symmetrically in a straight line in the AP view. The to standing on an unlevel plane. external occipital protuberance, spinous processes, pubic symphysis, and coccyx lie in the midline. These features reflect normal spinal statics and Such a spinal column is the exception in real life; are closely associated with the problem of differ- people simply do not place their weight symmetri- ence in leg length. From the point of view of body cally on both feet, but stand in a relaxed posture in statics, a difference in leg length becomes signifi- which the weight is taken mainly on one leg. Dur- cant only when accompanied by obliquity of the ing walking, the pelvis constantly swings from one base of the spinal column (see Figure 3.5). side to the other. The result is the constant creation of oblique planes. The main concern in assessing In the light of this fact, the age-old dispute over these is to discover how the spinal column reacts to how to measure a difference in leg length is beside obliquity in the frontal plane. the point. While it is possible clinically to establish the presence of pelvic tilt, we cannot determine the The physiological reaction to obliquity can be position of the sacrum relative to the sacral prom- seen by performing a test in healthy subjects: the ontory and the lumbar vertebrae that constitute the subject must first relax, stand with legs straight, base of the spinal column proper, as the pelvis may and rest the weight of the body on both feet; a be straight while the sacrum is tilted, or vice versa. block of wood is then placed under one foot. The The determining factor in spinal column and body subject’s pelvis then shifts to the higher side (see statics is the base of the spinal column. The only Figure 3.3). way to establish the position of these, and find how the spinal column reacts to an oblique base, is by The radiographic image shows not only the shift X-ray examination with the patient standing (see to the side, but also scoliosis and rotation to the Figure 3.6). lower side. The summit of the scoliotic curve is usually at the mid-lumbar region, with the thora- columbar junction vertically above the sacrum. The degree of rotation depends on the degree of lordo- sis of the lumbar spine. If there is no lordosis – as is often the case in acute lumbago – there is also no rotation. If there is kyphosis, there may even be rotation to the same side as the concavity. Reaction by the spinal column to an oblique plane is normal if: • scoliosis to the lower side results • there is rotation to the same side (when there is lordosis) • the thoracolumbar junction is vertically above the sacrum • the pelvis shifts to the higher side (see Figure 3.4). Slight thoracic scoliosis occurs in the opposite direction. 45

Manipulative Therapy Figure 3.5 • (A) Pelvic obliquity with level promontory and straight spinal column. (B) Following placement of a support to raise the foot, straightening of the pelvis but oblique promontory and deviation of the lumbar spine from the plumb line. Figure 3.6 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left. Left scoliosis with deviation of the head and neck to the left. (B) Straightening of the lumbar spine and head position following placement of a support to raise the right foot. 46

Functional anatomy and radiology of the spinal column Chapter 3 The most important findings where there is a • If the pelvis is shifted, usually toward the higher disturbance of body statics are: side, it should then return to the midline. • obliquity of the base of the spine without • If the scoliosis was statically balanced, it should scoliosis or with inadequate scoliosis, so that the decrease. thoracolumbar junction is not vertically above the lumbosacral These criteria should all be checked again by X-ray. The spinal column may react positively or • no lateral pelvic shift to the higher side negatively to the heel insert, either ‘accepting’ or ‘rejecting’ the correction. If the response is nega- • no rotation when there is scoliosis together tive it would be wrong to force correction upon the with lordotic posture of the lumbar spine patient, because this would only worsen the situa- or even rotation in the direction of the tion at the base (see Figure 3.7). concavity. The typical reaction to obliquity as seen radio- The practical decision to be made is whether to graphically has been studied by Illi (1954) and order a corrective heel insert. This is primarily a Edinger & Biedermann (1957), with the subject clinical decision, although the X-ray can provide walking on the spot. At each step, oblique planes useful clues. The following radiological criteria appeared together with corresponding scoliosis to show when a heel insert can be helpful in the case the side concerned; the summit of the scoliotic of obliquity of the base of the spine: curve appeared at L3. The thoracolumbar junc- tion remained vertically above the sacrum. Above • If scoliosis is not sufficient to bring the T12 there was a scoliosis of the thoracic spine to thoracolumbar junction into a position vertically the opposite side, but it was shallow. According to above the lumbosacral, or if scoliosis is absent. Edinger & Biedermann (1957), the thoracolumbar Use of a heel insert to raise one heel should junction forms a kind of point of interchange, and bring the thoracolumbar junction to the vertical, or at least nearly so. Figure 3.7 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left, and uncompensated left scoliosis. (B) Following placement of a support to raise the left foot, the pelvis and sacrum are more horizontal, but not L5. No change can be seen in the rest of the spinal column. The displacement of the pelvis and plumb line to the left indicates that the patient is placing more weight on the left leg. Positioning from L5 to S1 is exacerbated. 47

Manipulative Therapy should not swing more than 4 cm from one side to the other. The relation of the scoliosis to rotation and its dependence on the presence of curvature in the sagittal plane was studied by Lovett (1907), who found that rotation of the lumbar spine (in the sense of scoliosis) occurs if lordosis is present, but not in kyphosis. The explanation for this lies in the fact that, whereas the vertebral bodies have good mobility during side-bending, the joints of the ver- tebral arches are forced together in lordosis and so resist movement. In contrast, in kyphosis there is less close contact between the joints of the vertebral arches; but the vertebral bodies are pressed more firmly against each other, so that these are less free to side-bend. As a result, either there is no rotation at all or rotation occurs in the opposite direction. This is sometimes the case in patients with acute lumbago or in radicular compression syndrome (see Figure 3.8). The situation can also be found clini- cally in healthy subjects. On passive side-bending of a subject in lordosis, the spinous processes remain in the midline, and the vertebrae rotate in the sense of scoliosis. If the same is done in kyphosis, the spinous processes form a scoliotic curve: in other words, they move in parallel with the vertebral bodies. Lumbar spinal statics in the sagittal plane In the sagittal plane, we often speak of ‘normal’ Figure 3.8 • Typical relief position in lumbago or radicular curvatures; these are generally held to be the con- compression syndrome (‘paradoxical scoliosis’). Level vex cervical curve (lordosis), concave thoracic pelvis, uncompensated right scoliosis with left rotation and curve (kyphosis), convex lumbar curve (lordosis), deviation of the thorax and head to the left; lumbar lordosis and concave sacral curve (kyphosis). Sollmann & absent. Breitenbach (1961) demonstrated on the basis of 1000 X-ray films in the sagittal plane that there is no such thing as a general norm; at best we can speak of an ‘individual norm.’ They do not, how- ever, lay down any criteria for this kind of norm. Cramer (1958) showed, on the basis of 150 measurements of the lumbar spine with the subject standing, that there is a constant correlation between the tilt of L5 and that of T12, and more important still, that the T12 vertebra lies an average of 4 cm dorsally to L5. The results of our own study (Lewit 1973) gave complete confirmation of Cramer’s find- ings and also showed that the plumb line for the head follows a line down from the external acous- tic meatus exactly to the navicular bone. We found that the sacral promontory lay an average of 4 mm 48

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.9 • Lateral view of the lumbar spine with forward- Figure 3.10 • Lateral view of the lumbar spine with thrust position of the thoracolumbar junction. anteposition due to ‘flabby’ posture. anterior to this plumb line, and the transverse axis of The curvatures of the spine are an expression the hip joints 12 mm anterior to the plumb line. of static function, and should therefore be interpreted in terms of whether they fulfill this Deviations from this norm indicate a distur- function. In the frontal plane, balance is bance of body statics as a result of lack of muscle relatively stable; in the sagittal plane, muscle coordination. This is most evident in muscle spasm activity is the determining factor. Curvature of the due to acute lumbago or radicular pain, when there lumbar spine in the sagittal plane is normal if the is forward-thrust posture (see Figure 3.9), in which thoracolumbar junction is dorsal to the the thoracolumbar junction lies exactly over or lumbosacral, if there is no forward shifting of the ventral to the lumbosacral junction. The reverse is sacral promontory (no more than 8 cm in front of found in ‘flabby’ posture, in which the sacral prom- the center of the cassette, which is double the ontory lies well forward of the plumb line for the average). The position of the thoracolumbar head, and T12 lies dorsal to L5 by some distance junction vertically above the lumbosacral is also the (see Figure 3.10). most important criterion in the frontal plane. If there is obliquity at the base, the normal reaction is ‘Flabby’ posture is the expression of imbalance scoliosis and rotation of the spinal column (if of the muscles of the pelvic girdle; it may be the lordosis is present) and a shift of the pelvis to the result of weakened abdominal and gluteal muscles, higher side. but equally well of hyperactive hip flexors. 3.3.3 The pelvis The curvature of the lumbar spine is of course also dependent on pelvic tilt which, in turn, varies The pelvis and the spinal column together consti- according to the ‘type’ of pelvis, as is shown in the tute a functional unity, in which the pelvis serves following section. One further point to note is that a slight cur- vature (a ‘flat’ spine) goes hand in hand with hypermobility and lack of stability, while greater curvature (in both the sagittal and the coronal plane) corresponds to stability and less mobility. 49

Manipulative Therapy both as the base of the column and at the same hyperlordosis is found will therefore be different in time as the connection with the lower limbs. The the case of a high promontory (assimilation) type pelvis transmits motion from the lower limbs, at and in that of a low promontory (overload) type. the same time acting as a shock-absorber. The spi- Similarly, a low L5/S1 intervertebral disk will be nal column rests on the pelvis much as the mast of differently assessed. a boat rests securely on the firm base of the mast step (Benninghoff, 1944). The sacroiliac joints and Identification of pelvic type (see Figure 3.11 and the pubic symphysis allow for a degree of mobility Table 3.1) is extremely important for the with enough spring to act as a buffer while also assessment of dysfunctions, especially in the providing adequate stability. lumbar and pelvic region. Pelvic types The function of the pelvis and its influence on The sacroiliac joints body statics depend largely on its type; we owe the recognition of this relationship to Erdmann & There is some mobility of the otherwise firm pelvic Gutmann (1965). The variability observed here girdle, due to the role of the sacroiliac joints and is evidence of the phylogenetic instability of this the pubic symphysis. The major role is that of the region; evidence of this variability can be seen in sacroiliac joints. our description of the last lumbar vertebra as a ‘transitional’ vertebra; it is difficult here to speak The sacrum is wedge shaped in two directions; of any such thing as a ‘norm.’ If the variations are first the whole structure tapers in the caudal direc- asymmetrical as between the two sides, this results tion. A double contour is usually seen in the AP in obliquity at the base of the spinal column, and view, since there is another wedge in the ventro- the effects on spinal statics are considerable. If the dorsal direction; the sacrum is somewhat broader variations are symmetrical, this affects the length ventrally, at least in its craniad part, although in of the sacrum, which is closely associated with its this respect too there are considerable variations. position and inclination. It is helpful to note that the greater the distance between the two contours of the joint, the nar- Erdmann & Gutmann (1965) distinguish the rower the joint space appears. If on the other hand following pelvic types with respect to the associ- we see only one contour, the joint space appears to ated mechanism of pathology (see Figure 3.11 and be wide and clearly defined. This is often the case Table 3.1). The authors call these Hohes Assimili- with the high promontory type, and is a further sign ationsbecken (high promontory assimilation pelvis), of hypermobility. Normalbecken (normal pelvis) and Überlastungs- becken (overload pelvis): It is important to point out that, despite its unusual shape and limited mobility and the fact • High promontory: the ‘assimilation’ type that there are no muscles to move the sacrum presents a long sacrum and high sacral against the ilium, the sacroiliac joint is a true promontory, with a tendency to hypermobility synovial joint (Colachis et al 1963; Duckworth (see Figure 3.17) 1970; Mennell 1952; Weisl 1954). According to Duckworth, the sacrum rotates relative to the ilia • Normal type: this is of average length, with a around an axis corresponding to the shortest sacro- tendency to restrictions. iliac ligaments, at the level of S2. This movement is one of nutation; with each step taken during • Low promontory: the ‘overload’ type has a walking, the weight of the spinal column produces low promontory and marked inclination of the a forward nodding motion of the sacrum, together sacrum. with the sacral promontory, acting as a shock- absorber. This mobility of the sacrum within the All the points summarized in Table 3.1 should be pelvic girdle is easily palpated and is familiar to borne in mind when evaluating X-ray films; it will gynecologists in the management of labor. Perpen- be seen that the type of pelvis affects the spi- dicular to this ‘functional’ motion, the joint play nal curvatures, the height of the last interverte- consists in a springing, wing-like motion about a bral disk, and the shape of the vertebral bodies, and therefore also the mobility of the most caudal motion segments. The assessment to be made when 50

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.11 • The pelvic types. Angle a = angle of inclination of sacral promontory; angle d = angle of inclination of sacrum. 1, Head and base plumb line; 2, plumb line of promontory. (A) High promontory. (B) Normal type. (C) Low promontory. craniocaudal axis, the effect of which is a distrac- It is appropriate at this point to deal with a condition tion of the joint. described as pelvic distortion, which requires expla- nation from the functional anatomical point of view. The degree of mobility in the sacroiliac joint should The finding on palpation is that the posterior superior be as little as possible, yet never to the point of iliac spine (PSIS) is lower on one side than the other. restriction, just as a shock-absorber is firm but The finding is the same if the finding is made at the never immobile. posterior border of the iliac crests at the point where they can be palpated in the vertebral region. Ventrally the opposite is found: on the side where the PSIS is lower, the anterior superior iliac spine (ASIS) is 51

Manipulative Therapy Table 3.1 Pelvic types High promontory Normal Low promontory (assimilation) (overload) Inclination of sacrum 35˚–50˚ Inclination of end-plate of S1 50˚–70˚ 30˚–50˚ 15˚–30˚ Position of L4 disk 15˚–30˚ At the height of the iliac 50˚–70˚ Above the line of the iliac crests Below the line of the iliac Position of the promontory in crests At the center crests the pelvic girdle Eccentric (dorsal) At the center or ventral Shape of L5 vertebra Trapeze shaped Shape of L5 disk Rectangular Wedge shaped and thinner Trapeze shaped Rectangular and higher than L4 Wedge shaped and thinner Segment with maximum than L4 L4/L5 than L4 mobility L5/S1 L4/L5 Effect of iliolumbar ligament Good fixation of L5 Weight-bearing structure Slight fixation of L5 End-plate of S1 Good fixation of L4 and L5 End-plate of S1 L5/S1 joints and sacroiliac joint Spinal curvature Flat Average Considerable X-ray statics Promontory and hip joints lie Promontory and hip joints lie Promontory and hip joints behind plumb line for head Clinical signs in front of plumb line for head almost on line of plumb line for head Arthroses of L5/S1, sacroiliac Hypermobility, pathological joint and hip changes of L5 disk; Restrictions, pathological ligament pain changes of L4 disk found to be higher than on the contralateral side, and Figure 3.12 • The mechanism of pelvic distortion (after vice versa. The ventral parts of the iliac crests behave Cramer 1965). in the same way as the anterior iliac spines. The mid- dle portion of the iliac crests may be symmetrical, although this need not be so. On first impression it seems as if one ilium is twisted relative to the other about a frontal transverse axis, although this is in fact impossible if the pubic symphysis is intact. The functional anatomy involved can best be illustrated anatomically by Cramer’s diagram (1965) (Figure 3.12). This shows a one-sided nuta- tion of the sacrum brought about by its rotation between the ilia around its longitudinal axis. This in turn results in rotation of one ilium about a hori- zontal axis and of the other about a vertical one. All attempts to visualize these changes radio- graphically have remained without success as far as we know. However, we have been successful in 52

Functional anatomy and radiology of the spinal column Chapter 3 showing X-ray evidence of a disturbance of body of the angle between the sacrum and the lumbar statics in the presence of pelvic distortion (see spine. This disappeared following treatment of the Figure 3.13). The pelvis was found to be shifted atlanto-occipital and atlantoaxial joints. Lewit & toward the higher side, and there was deviation Rosina (1999) were able to induce pelvic distortion Figure 3.13 • Disturbed statics in pelvic distortion. (A) With deviation between the lumbar spine and the sacrum. (B) No improvement after insertion of support to raise the left foot. (C) Normal findings following treatment of atlanto-occipital and atlantoaxial joints. 53

Manipulative Therapy by rotating the head to one side and then the other, The shape of the joints determines the func- but radiographic examination showed this effect to tion of the lumbar spine; it mainly allows for ante- have been a palpatory illusion. and retroflexion and tends to inhibit side-bending, which occurs in combination with rotation. The 3.3.4 The lumbar spine joints inhibit rotation about a sagittal axis. Just as side-bending happens in combination with rotation, Although only a little shorter than the thoracic so rotation of the trunk produces the effect of lat- spine, the lumbar spine consists of only five ver- eral flexion. tebrae. However, in ante- and retroflexion as well as in side-bending, the corresponding motion seg- If the joints of the vertebral arches determine ments play a significant part in ensuring the mobil- the quality of the movements of the lumbar spine, ity of the trunk. Meanwhile the inferior part of the its great mobility depends on the thickness of the lumbar spine also carries the weight of the trunk, so lumbar intervertebral disks. Their thickness usu- the vertebral bodies and articular processes of the ally increases from L1 down to L4; consequently lumbar spine are the most robust. maximum mobility is usually found at the L4/5 seg- ment. Only in the ‘high promontory’ pelvic type is The joints of the vertebral arches form massive maximum thickness and mobility found at L5/S1. gliding surfaces that can enable considerable excur- Retroflexion, however, is usually most extensive in sion and also provide stability. The greater part of the the L5/S1 segment. articular facets runs vertically, almost in the sagittal plane. Ventrally, the smaller part is turned almost at X-ray anatomy of the lumbar spine a right angle to point medially, in the frontal plane. Frequently, however, the articular facets simply form The oval shadow of the pedicles of the vertebral an arc, whose concave aspect faces dorsally. If the arches are the most striking feature in the AP views two parts do stand at right angles to each other, the of the lumbar spine (see Figures 3.14 and 3.15). joint spaces can be easily visualized by X-ray; if they The last pedicles (only) are projected onto the form an arc, this cannot be done. Given that the lateral edge of the fifth lumbar vertebra; they are joints of the vertebral arches only develop their final also less distinct. This is partly owing to the trian- shape after birth, during the first years of life there is gular shape of the spinal canal in the inferior lum- considerable variation in this respect. bar spine. Taking the pedicle as a starting point, it is Figure 3.14 • Anatomical structures of the lumbar spine. (A) Dorsal aspect of the lumbar spine and sacrum. (B) X-ray: AP projection. (C) Ventral aspect of the lumbar spine and sacrum. 1, Spinous process; 2, superior articular process; 3, lamina of the vertebral arch; 4, pars interarticularis; 5, joint space; 6, inferior articular process; 7, glimpse into the spinal canal; 8, posterior superior iliac spine; 9, dorsal part of the sacroiliac joint; 10, intervertebral disk; 11, transverse process; 12, vertebral body; 13, pedicle; 14, ventral part of the sacroiliac joint. 54

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.15 • Schematic drawing of the AP X-ray view of a possible to identify the lamina of the vertebral arch lumbar vertebra (after de Sèze et al 1969). and trace it along to the spinous process. Lateral to and above the pedicle we find the superior articu- lar processes; from the vertebral arch downwards and below the pedicle, the inferior articular proc- esses can be traced in a caudal and lateral direction toward the superior articular processes of the next vertebra below. The two inferior articular proc- esses form an arch; this, together with the spinous process of the caudal neighboring vertebra, forms a frame around a lucency which offers a glimpse into the spinal canal. At this point the canal is not cov- ered by bone, and this is the location where lumbar puncture can be performed. Where both articular processes meet is the joint space. It is possible to see into the joint space if part of it is aligned in the sagittal plane. The lateral view (see Figure 3.16) also shows the thick pedicles, situated immediately behind Figure 3.16 • Anatomical structures of the lumbar spine. (A) Lateral view. (B) Lateral view (X-ray). 1, Pedicle; 2, pars interarticularis; 3, inferior articular process; 4, superior articular process; 5, joint space; 6, intervertebral foramen; 7, transverse process. 55

Manipulative Therapy the bodies of the vertebrae. The superior and infe- Figure 3.17 • High promontory pelvic type with obliquity at rior articular processes arise from the pedicles. It L4, left scoliosis, and rotation. Here the line between the two is often also possible to see the joint space if the iliac crests runs level with the L5/S1 disk. medial part of the joint lies in the frontal plane. Between the superior and inferior articular proc- identification becomes well-nigh impossible, unless esses is the pars interarticularis (pars isthmica), an X-ray of the thoracic spine is also available. which tends to be the site of spondylolysis in true Sometimes, instead of the massive transverse proc- spondylolisthesis. Between the pedicles of adjacent ess of L5, a transitional lumbosacral vertebra may vertebrae can be seen the intervertebral foramen, have a pars lateralis which forms a pseudarthrosis dorsal to the vertebral bodies and intervertebral with the pars lateralis of S1, and may even cause disk and bordered dorsally by the articular proc- clinical symptoms. esses. It lies almost exactly in the frontal plane, and its width is almost that of the spinal canal. The The most serious anomaly, clinically, is probably lamina is covered by the articular processes, and spinal canal stenosis. In the lateral view the usual dorsal to these can be seen the massive spinous finding shows massive vertebral bodies with short, processes. The transverse processes are projected stubby pedicles and markedly narrow intervertebral onto the articular processes, appearing as a thick foramina. The line of the inferior articular proc- shadow. esses is noticeably steep. In the AP view the mas- sive appearance of the articular processes is striking, The fifth (last) lumbar vertebra occupies a spe- it is possible to see clearly into the joint space, and cial position in that it serves a transitional function the lucency between the inferior articular processes between the mobile lumbar spine and the rigid pel- below the spinous process is particularly narrow. vis. In terms of its shape, it is therefore adapted The effect is to give the spinal canal a trefoil shape. to the base (craniad end) of the sacrum. In the CT offers the best insight into the anatomical rela- lateral view, the vertebral body of L5 is trapezoid. tions in the spinal canal; it can also visualize the An important point to note is that the powerfully narrow lateral recesses and the narrowed, trefoil- developed transverse processes of L5 – often resem- shaped spinal canal. A narrow spinal canal adversely bling the pars lateralis of the sacrum – provide affects root compression and is often accompanied attachment to the iliolumbar ligaments, which stabi- by radicular claudication. lize the last lumbar vertebra in the pelvis. L5 there- fore plays a part in the shock-absorbing function of It is of course important to be able to assess the pelvis. The intervertebral foramen of L5 is usu- the thickness of the intervertebral disks correctly. ally narrower than the others of the lumbar spine, Straightforward disk hypoplasia is a quite common despite the generally powerfully developed pedicle anomaly, and should not be confused with disk of L5. This vertebra is usually considerably inclined, so the L5/S1 joints usually lie in the frontal plane, to prevent forward gliding. The most important anomalies of the lumbosac- ral junction have already been dealt with under ‘pelvic types’ (see Section 3.3.3). When there is a transitional vertebra, it can be difficult to decide whether this is a sacralized L5 or a lumbarized S1. It is especially difficult if the image shows six vertebrae with lumbar characteristics and the task is to decide whether the last is indeed a lum- bar vertebra or a lumbarized sacral vertebra. In cases where a neurosurgical intervention is to be carried out, this decision can be very important. The most reliable criterion to use is an imaginary line drawn between the two iliac crests: this line usually corresponds to the fourth interverte- bral disk (see Figure 3.17). If, however, this line projects across the middle of a vertebral body, the 56

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.18 • The anterior inferior border of the vertebral in the lateral projection. A focus-film distance of body of L5 is lower (arrow) in relation to the sacrum on at least 1.5 meters is needed to keep distortion to the left side than on the right. The L5/S1 disk is therefore a minimum. narrower on the left. There is compensatory lumbar scoliosis with marked rotation. Careful assessment of rotation can be impor- tant, because rotation is to some extent related to degeneration. This is especially true in the case of scoliosis and the degree of lordosis; if the relation- an L5 transitional disk. If this vertebra shows no ship is disproportionate, this can be a sign of dys- signs of degenerative changes and no shift that function. Rotation of a vertebra is recognized by a might indicate laxity, the practitioner should not deviation of the spinous process and the pedicles in be too hasty in diagnosing a narrow disk as degen- the direction opposite to that of rotation. On the eration. A useful sign of disk hypoplasia is a find- side of rotation the pedicle appears wider and it ing that shows abbreviated end-plates either side is easier to see into the joint space; the transverse of a narrow disk. Although we usually rely on process is slightly shorter (because it is nearer the lateral views for the assessment of disks, marked cassette). Deviation of the spinous process alone asymmetry in the AP view can be a useful sign, should never be taken to be a sign of rotation; particularly for the L5/S1 disk, where anomalies absence of the other criteria, especially the corre- are frequently found (asymmetrical L5/S1 disk, sponding asymmetry of the pedicles and the row of see Figure 3.18). transverse processes, etc., indicates that the devia- tion observed is simply asymmetry and not rotation. Evaluation of function from X-rays Scoliosis should always be assessed according to the principles of body statics. In order to evaluate radiographic films from the point of view of function, they must be taken under The lateral view is used to assess lordosis, standard conditions. The film must be taken with kyphosis and ventral or dorsal shift. If an appar- the patient standing erect, and if possible using ently blocked position is found, this can also be the technique described in Section 3.3.1. A func- significant. Slight shifting (ventrally or dorsally) is tional evaluation of the lumbar spine can only be a sign of instability. This may become more marked done if the pelvis, hip joints and pubic symphysis during ante- or retroflexion. However, very slight, are included on the film. A 30 × 40 format is there- proportional shifts in ante- or retroflexion, espe- fore recommended for both projections, so that cially in young patients, may be normal. There are the entire sacrum and hip joints can also be seen two potential pitfalls to beware of: 1. Incongruence of the end-plates of two adjacent vertebrae, most frequently observed between L5 and S1 in the lateral view. In such cases the superior end-plate of S1 is usually slightly longer than the inferior end- plate of L5, and the shift that is observed can be seen either only at the dorsal or ventral edge of the adjacent vertebra. 2. Slight rotation in patient positioning: here the shadows of the anterior and posterior borders form a double contour which can be mistaken for a shift. Slight shifts due to hypermobility or slight instability need to be distinguished from true spondylolisthesis (with spondylolysis) and from degenerative ‘pseu- dospondylolisthesis or spondylotic listhesis’ as described by Junghanns (1930), in which the superior articular process of the adjacent vertebra below (most frequently L5) is bent in the ventral direction, so that the vertebra above it (usually L4) glides ventrally over it. 57

Manipulative Therapy Radiographic movement studies jointed, connection to the relatively rigid thoracic cage. The narrowness of the intervertebral disks Films taken in erect posture may not always pro- is the morphological expression of this minimal vide any clues to disturbed function, which only mobility. In the frontal plane the joint spaces are becomes evident in movement studies. These are almost vertical, but laterally they fall away ante- usually performed to study ante- and retroflexion riorly, as if on the periphery of a circle (cylinder) and side-bending. In the normal case, movement is whose center is ventral to the vertebral body. This fluid and all segments of the lumbar spine partici- arrangement would allow for considerable rotation pate. Where there is disturbed function, it is possi- in the thoracic region were it not for the ribs and ble to distinguish segments of reduced or increased the intervertebral disks. mobility. We find a sign of reduced mobility at a block vertebra position, and the segment concerned Side-bending, and to some degree also anteflexion, does not participate in the movement. Where there are similarly limited by the thoracic cage. Anteflexion is increased mobility, local ventral or dorsal shifts is also held in check by the tension of the inter- and may be observed in ante- and retroflexion. In young supraspinal ligaments. Retroflexion is limited mainly and hypermobile subjects, slight step-like shifting by the articular and the spinous processes, which of vertebrae and shifting that occurs to an equal overlie each other in the manner of tiles on a roof. degree in all segments may be considered normal At a certain point in retroflexion this arrangement (Jirout 1956). Even the formation of an exaggerated therefore obstructs bending in this direction. sharp bend is a sign of local hypermobility. How- ever, if this sharp bend is accompanied by a ventral Transitional regions narrowing of the disk in anteflexion, without a cor- responding dorsal widening, this is indicative of a One important reason for the significance of the disk lesion. The same can be said if it is accompa- thoracolumbar junction is that there is a sudden nied by dorsal narrowing of the disk without a cor- change in joint structure occurring in the region of responding widening ventrally (Jirout 1965). a single vertebra (T12): whereas the articular proc- esses above this point are those of the thoracic In the lumbosacral segment a ‘paradoxical’ shift spine, those below it have the form and mechani- sometimes occurs; instead of the ventral shift in cal features of the lumbar spine. During walking on anteflexion and dorsal shift in retroflexion that is the spot, the thoracolumbar junction acts as a fixed observed in the other segments, there is a ventral point, where scoliosis of the lumbar spine to one shift during retroflexion and dorsal shift during side changes to scoliosis of the thoracic spine to the anteflexion (Jirout 1957). This presumably occurs opposite side. as a kind of leverage mechanism. The anatomists’ view that trunk rotation takes Movement studies are mainly indicated where place mainly in the thoracolumbar junction was there is a clinical reason for doing so; usually where refuted by Singer & Giles (1990). They demon- particular movements give rise to symptoms. These strated directly by means of CT during trunk rota- studies are particularly important in order to find tion that the rotation occurring in this segment was out whether or not spondylolisthesis is already hardly any greater than that in the neighboring tho- fixed. In side-bending, the main object is to look for racic and lumbar motion segments. We confirmed asymmetry and to assess the relationship between these findings using AP films of trunk rotation flexion and rotation. taken in the sitting position with fixed pelvis. We demonstrated that scoliosis with rotation occurs in 3.4 The thoracic spine the entire lumbar spine (see Figure 3.19). 3.4.1 Functional anatomy Just as side-bending (scoliosis) of the trunk is combined with rotation, so rotation of the trunk is The thoracic spine is the longest section of the spi- accompanied by side-bending. In principle, nal column, but also the one with the least mobi­ movement of the spine occurs by coupled lity. The main reason for this is its firm, though movements in all three planes. 58

Functional anatomy and radiology of the spinal column Chapter 3 The ribs Figure 3.19 • Right rotation with right lumbar scoliosis The ribs articulate with the vertebrae at the cos- during right rotation of the trunk in the sitting position, with tovertebral and costotransverse joints. The head of fixed pelvis. the rib articulates with the superior border of the body of the corresponding vertebra and with the Another transition region which is commonly the inferior border of the next vertebral body above. site of dysfunctions is the cervicothoracic junc- The tip of the head of the rib (crista capituli) is tion down to T3/T4; this is where movements of attached to the intervertebral disk by ligaments. the head and neck end, as is most clearly seen in The third rib therefore articulates with the bodies ante- and retroflexion. The same is true for side- of T2 and T3, and is attached to the T2 interver- bending and rotation, though it is evident only in tebral disk. Exceptions to this rule are the first rib, erect posture. One possible reason for the fre- which articulates exclusively with the body of the quency of dysfunctions in this region may be that it first thoracic vertebra, and the last two floating is the point of transition between the most mobile ribs, which are attached simply by a syndesmosis to section of the spine and the least mobile section. the rudimentary transverse processes of the corre- Another is that this is the site where the powerful sponding last thoracic vertebrae. muscles and tendons of the upper limbs have their origin. Rib movement occurs about an axis running from the head of the rib through the neck of the The middle thoracic spine is an important tran- rib to the costotransverse joint. In the upper tho- sitional region, because this is where the cervical racic spine, this axis is horizontal in the frontal erector spinae muscle ends and the lumbar portion plane. The movement about this axis causes the of the muscle begins. Around T5, therefore, the thorax to rise and fall and the sternum to undergo apex of the thoracic curvature of the spine, is the a pumping motion. In the inferior thoracic spine, weakest point of the muscles of the back. the axis runs in an oblique, laterodorsocaudal direc- tion, and produces a wing-like movement. At the All transitional regions are rich in anomalies. last floating ribs there is no joint, so there will be no There may be rudimentary ribs at T12 or lumbar motion restriction here. If pain occurs here it is due ribs at L1; cervical ribs at C7 or enlarged transverse to muscle attachments, especially that of the quad- processes at C7 are quite common. It is rare, on the ratus lumborum. The articulation between the ribs other hand, for the first rib at T1 to be absent. The and sternum is often painful; this too is usually due uncinate process at C7 may sometimes be absent to muscle attachments with TrPs in the pectoralis on one or both sides. and scalene muscles. 3.4.2 X-ray anatomy of the thoracic spine X-ray imaging of the thoracic spine demonstrates the structural details less clearly than imaging of the lumbar spine. In the AP view (see Figure 3.20) the vertebral bodies, pedicles, and spinous proc- esses can be clearly seen. The joint spaces are not visible because they lie in the frontal plane; the laminae of the vertebral arches and the superior and inferior articular processes can also not be seen. The spinous processes are angled downward. As a result, from about T4 to T10 the tip of the spinous process is projected onto the body of the next ver- tebra below. The characteristic feature of the thoracic spine is the costovertebral joint. The head of the rib can 59

Manipulative Therapy Figure 3.20 • Anatomical structures of the thoracic spine. (A) AP radiograph. (B) Dorsal aspect of the thoracic spine. 1, Spinous process; 2, pedicle; 3, rib; 4, transverse process; 5, costotransverse joint. be seen in close contact with the intervertebral disk if the lateral projection is set up accurately. The and, laterally to it, the neck and tubercle of the rib joint space and articular processes are clearly visual- are superimposed on the transverse process. The ized. The ribs are superimposed on the laminae and costotransverse joint space usually runs at a steep the greater part of the spinous processes, although angle from dorsocranial to ventrocaudal, so is dif- the tips of the spinous processes can be seen if the ficult to visualize much or at all. Sometimes, espe- image is good. The superior portion of the thoracic cially in the lower thoracic region, the joint space spine (approximately above T3) is completely hid- runs more dorsoventrally and horizontally, and is den in the lateral projection and can only be dem- then easily seen. In this case the superimposed rib onstrated using oblique views or by tomography. lies approximately on the transverse process. It can sometimes be difficult to identify which The first rib articulates only with the first tho- thoracic vertebra is which in the lateral view, as T1 racic vertebra. The two last ribs only contact the cannot be seen and it is hard to be sure of identify- rudimentary transverse processes of the last tho- ing T12, because the last rib can sometimes be rudi- racic vertebrae. The sternum and sternocostal joints mentary. It is therefore useful to look for the inferior are not generally visualized when the usual tech- angle of the scapula (which is usually at the level of nique is used. T7), the bifurcation of the trachea (approximately at T5), the arch of the aorta (level with T4), and the In the lateral view (see Figure 3.21) the ribs and dome of the diaphragm (usually level with T10). structures of the lungs are superimposed on the vertebral bodies and disks. At the vertebral arches 3.4.3 Evaluating functional this superimposition is still more troublesome. aspects Nevertheless, if the film is technically successful enough to give good visualization, the pedicles and The curvatures of the spine are important here intervertebral foramen are easily seen. The foramen as they are in all sections of the spinal column. opens ventrally at an angle of approximately 15° to the frontal plane, but there need be little distortion 60

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.21 • Anatomical structures of the thoracic spine. (A) Lateral aspect of the thoracic spine. (B) Radiograph, lateral view. 1, Inferior articular process; 2, joint space; 3, superior articular process; 4, intervertebral foramen; 5, pedicle; 6, rib; 7, transverse process. Scoliosis and increased kyphosis are the most fre- Figure 3.22 • Schematic drawing to illustrate rotation of a quent findings. It is always useful to know whether vertebra. the curvatures are in static equilibrium. For this, the films must be taken under static conditions. It is important to note that the greater the curvature, the less the mobility and the greater the stability. Conversely, if the curve is flat, this indicates hyper- mobility and a tendency to instability. Dysfunctions may be associated with rotation, in which a sudden deviation is found in the line of the spinous processes (see Figure 3.20). The asymmetri- cal position of the spinous process is insufficient on its own to enable a diagnosis of rotation to be made; for this, there must also be a shift in the position of the pedicles in the same direction (see Figure 3.22). In the lateral view of the thoracic spine it is rare to see shifts between two adjacent vertebrae, or a lordotic or kyphotic deviation between neighboring vertebrae in cases of simple dysfunction. Kyphotic deformity, on the other hand, whose cause is morphological, does frequently occur here in the 61

Manipulative Therapy context of juvenile osteochondrosis (Scheuermann’s the patient is supine. Positioning is done using the fol- disease), following a traumatic compression frac- lowing technique, so as to represent the patient’s pos- ture, or as a consequence of osteoporosis. ture accurately: the patient begins by sitting on the X-ray table, intergluteal cleft exactly on the midline Dysfunctions of the ribs can be recognized by of the table and legs extended, symmetrically side by changes in the spaces between them. side. Only then is the patient requested to lie down. Ask your patient to do so without use of the arms, 3.5 The cervical spine looking straight ahead and in a completely natural manner. To check that the finding is representative The cervical spine is the most mobile section of the rather than chance, this procedure may be repeated. If whole spinal column; it is also the most vulnerable. the head regularly deviates to one side, this must not This region is the richest in afferent propriocep- be corrected; instead you should adjust the cassette tive nerves, which exercise an effect on the entire and the X-ray tube accordingly. If you correct the head locomotor system. Dysfunctions here are therefore position you might either correct or artificially produce particularly important, and their treatment is cor- cervical scoliosis and at the same time induce axis rota- respondingly rewarding. tion and lateral deviation of the atlas. 3.5.1 X-ray technique The film format used is either 18 × 24 cm or 15 × 40 cm; it can be helpful to include the upper A suitable and effective technique is essential in thoracic spine as well. Position the cassette so as to order to obtain pictures that can be evaluated for be able to assess the upper margin of the foramen function. The usual technique, which usually pro- magnum, the front incisors and, caudally, at least duces very poor visualization of the upper portion T1. This is usually achieved when the upper edge of the cervical spine in the lateral view and does not of the cassette is aligned slightly craniad to the visualize it at all in the AP one, is not even adequate patient’s external ear. for morphological diagnosis and is completely use- less for the evaluation of function. Ask the patient to open her mouth as wide as possible and place a cork between her front teeth. The Sandberg–Gutmann technique (Sandberg The patient should then draw in her chin until 1955) (see Figure 3.23A) best meets the requirements the forehead (glabella) and upper lip (filtrum) are for a successful image in the AP projection. For this, on the same horizontal plane. For this, a pillow beneath the head is often necessary, except when the patient is a child. Figure 3.23 • X-ray technique for the cervical spine according to Sandberg–Gutmann. (A) Alignment of the central ray for the AP projection with the aid of a string. (B) Alignment for the lateral view of the cervical spine. 62

Functional anatomy and radiology of the spinal column Chapter 3 Now the X-ray tube can be centered. The cen- 1.5 meters or more. This produces an undistorted tral ray must be aligned through a point one finger’s image of the cranial base and the entire cervical breadth below the upper premolars to a point one spine and also evens the exposure; the density of finger’s breadth above the palpable inferior border of the cranial base means that it demands more irra- the occiput (posterior margin of the foramen mag- diation than the cervical spine. num) in the midline. Either a light field indicator or a piece of string running from the center of the focal X-ray films of the cervical spine that do not provide spot to the appropriate position on the patient’s face good visualization of the atlanto-occipital and can be used for this alignment. The X-ray tube is then atlantoaxial joints and cranial base and of the aligned so that the line of the central ray is an exten- cervicothoracic junction are inadequate for the sion of that of the string (or light) (see Figure 3.23A). evaluation of function. For edentulous patients, the central ray is aligned through a point one finger’s breadth below the max- 3.5.2 Assessment of X-ray films illa to the border of the occipital squama, and in infants who do not yet have teeth, from the inferior The technique described here provides suffi- border of the maxilla to the border of the occipital cient criteria to evaluate all the images and to squama. Finally, correct any rotation of the patient’s repeat them for comparison, even if all struc- head since this would make the film hard to evaluate. tures are asymmetrical. In the AP projection (see Figure 3.24) the first task is to make sure that both This projection can also be taken with the patient seated, aligning the beam in an analogous manner. This Figure 3.24 • Anatomical structures of the craniocervical approach is slightly more difficult but has the advan- junction, anteroposterior view. 1, Inferior border of the clivus; tage of being performed under static conditions. Nev- 2, foramen magnum; 3, occipital condyle; 4, inferior border ertheless, there can be an advantage in having taken of the anterior arch of the atlas; 5, lateral triangle; 6, foramen the AP projection with the patient supine and the lat- transversarium of the axis; 7, inferior contour of the occipital eral one with the patient seated, if the findings reveal squama; 8, medial lucency of the atlas; 9, transverse discrepancies. It is always possible then to perform an process of the atlas; 10, inferior border of the posterior arch additional AP view taken in the sitting position. of the atlas; 11, pedicle of the arch of the axis; 12, lamina of the axis (superior border). One objection to the open-mouth technique is that the mandible is superimposed on the mid-cervical spine. This problem can be avoided if the patient rapidly opens and shuts her mouth while the film is being taken; in this way the shadow of the mandible is blurred. The risk in this case is that there will be slight associated movement of the head, which might cause blurring of the image at the craniocervical junction. For the lateral view the patient is seated relaxed in front of a vertical stand (see Figure 3.23B). The film may be 18 × 24 cm or 24 × 30 cm, and must be placed so that the image demonstrates the cranial base as far as the sella turcica, and the cervical spine down to the cervicothoracic junction. In subjects with very tapering shoulders it will also be possible to include the first thoracic vertebra. The patient’s gaze should be fixed on a distant object at eye level, maintaining the hard palate horizontal. Take care that there is no inclination or rotation of the patient’s head, so that the two mandibles are exactly superimposed. This is necessary for accurate assessment of the film. Do not align the central ray on the mid-cervical region as is usually done, but on the tip of the mas- toid process. The light field indicator can be used for this. It is best to use a film-focus distance of 63

Manipulative Therapy occipital condyles, the atlas, and the axis are well important that the line of the hard palate should be visualized, and whether it is possible to look into horizontal. Fineman et al (1963) showed that a dif- both foramina transversaria (which give passage to ference of only 10° in inclination of the head is suf- the vertebral artery). At the caudal end, ensure that ficient to change lordotic to linear posture, or even at least the first thoracic vertebra is included in the to change it to the extent that lordosis becomes image. Next the centering should be checked, to kyphosis. It is important that the two halves of the make sure that the image is straight. If the position- mandible should overlie each other exactly. If the ing is correct, the middle point between the incisors vertical borders of the rami appear projected side should be vertically in line with the middle of the by side, the head is rotated to one side. Projection dens of the axis and of the occipital squama. The of the horizontal line of the mandible one above the tip of the chin will be projected onto the middle other indicates that the head is inclined to one side. of the cervical spine, which must run symmetrically Another sign of rotation is if the shoulders are pro- between the two rami of the mandible. jected apart. The position of the mastoid processes should also The oblique projection (for which the patient be symmetrical. In order to evaluate the inferior adopts a position turned at an angle of 45°) gives the part of the cervical spine, it is necessary to ensure clearest imaging of the intervertebral foramina. This that the superior thoracic spine is not rotated. projection is indicated especially for radicular syn- dromes and vertebral artery syndrome. As recom- In the lateral projection (see Figure 3.25), first mended by Gutmann (1956), this projection should ensure that the cranial base, including the sella be taken with the patient’s head in retroflexion, turcica and hard palate, can all be seen. If possible because this more clearly displays any narrowing of the cervical spine should be shown as far down as the intervertebral foramen. It is also recommended C7, although this is often not possible in heavily to take it not with the patient’s back to the cas- built patients or those with high shoulders. Check sette, but with the patient facing toward it (see that the alignment is perfect before beginning to Figure 3.26). evaluate the findings on the film. It is particularly Figure 3.25 • Lateral view of the cervical spine, indicating Figure 3.26 • Oblique view of the cervical spine showing a the plane of the foramen magnum, of the atlas and of the narrowed intervertebral foramen of C5/6. axis. Dotted lines indicate the clivus and basion (white), and the posterior border of the spinal canal (black). 64

Functional anatomy and radiology of the spinal column Chapter 3 3.5.3 Functional anatomy of often observed. In retroflexion there is a slight caudad the cervical spine shift. This too is associated with the inclination of the joints. Penning (1968) describes this motion as a rota- The cervical spine has two distinct sections: the tion of the upper vertebra relative to the lower one, atlanto-occipital and atlantoaxial joints, and the rest around a frontal axis in the dorsal part of the vertebral of the cervical spine from C3 to C7; nevertheless it body. Experience shows this motion to be physiological, is a functional unity, since all the movements it per- as long as it occurs evenly in the motion segments of forms originate at the atlanto-occipital and atlantoax- the cervical spine. It is regularly seen in young subjects ial joints, these movements being anticipated by eye with good mobility. If it is not observed in less mobile, movements. The anatomical description will accord- older patients, this absence is not pathological. The shift ingly be treated in separate sections. The function of is greatest between C2/C3 (see Figure 3.32 B and D) the cervical spine will then be dealt with as a whole. where the range of motion is least in adulthood. Functional anatomy of C3–C7 It is also important to note that the cervical spi- nal canal lengthens considerably during anteflex- As in other parts of the spinal column, the degree ion, shortening during retroflexion. This produces of mobility in the cervical spine corresponds to the a significant movement of the meninges and dural thickness of the intervertebral disk, which is great- sheaths of the nerve roots relative to the spinal est in the segments C3/C4 and C4/C5. The char- cord, which becomes longer and thinner in ante- acteristic feature of the cervical spine is the raised flexion and shorter and thicker in retroflexion. lateral margins of the vertebral bodies, the uncinate processes. The disk therefore thins laterally, with the The course of the vertebral artery also has an consequence that thinning of the disk brings about important role. This enters its bony canal at C6, pass- contact in this lateral region. This is where early ing upward through the intervertebral foramina in degenerative changes occur, tending to form unco­ close contact with the intervertebral joints and unc- vertebral joints (neoarthroses). The position of these inate processes almost at right angles to the course is very close to the intervertebral foramen. The sig- of the nerve roots. Therefore, as the intervertebral nificance for cervical function is that the shape of foramen (canal) narrows in retroflexion, this may the vertebrae with their lateral margins limits side- affect both the nerve root and the vertebral artery. bending and favors ante- and retroflexion. Functional anatomy of the The intervertebral joints are almost parallel, craniocervical junction inclined at an angle of about 45° from ventrocranial to dorsocaudal. The angle is greatest at C2/C3. In In order to understand function it is important to this segment the joints are frequently not parallel look first at the anatomy of the individual articu- but arranged as if on the circumference of a cylin- lar structures and ligaments. The superior articular der with its center behind the vertebra; it is there- surfaces of the atlas run obliquely from dorsolateral fore not pathological if the joint space at C2/C3 is to ventromedial. The facets are oval in shape, con- less clearly delineated than in the other segments verging anteriorly like a section of the surface of a of the cervical spine in the lateral projection. As a sphere with its center located above both articu- general principle, laterally the joints in the lordotic lar surfaces. The most important movement of section of the cervical spine are inclined slightly the atlanto-occipital joint is ante- and retroflex- posteriorly and in the kyphotic section slightly ion of about 16° (see Figure 3.27). Gliding of the anteriorly. According to Janda (2002) the transition from the one to the other occurs roughly at C3/ Figure 3.27 • Diagram to illustrate ante- and retroflexion C4. The inclination of the intervertebral joints in between the occipital condyles and the atlas. the sagittal plane means that side-bending produces rotation, the two kinds of movement being coupled. Similarly, rotation brings about side-bending, always to the same side (see Figure 3.30A and B). During anteflexion, a slight ventral shift of the cra- nial partner vertebra relative to its caudal neighbor is 65

Manipulative Therapy Figure 3.28 • AP X-rays of an isolated axis: (A) in neutral position and (B–H) in various positions of rotation. These images provide a suitable reference for evaluating X-ray films. occipital condyles occurs in the dorsal direction Figure 3.29 • X-ray film of rotation between atlas and axis. during anteflexion and in the ventral direction dur- With the subject erect and head fixed, the subject’s body ing retroflexion. Very slight rotation is also possible, was turned in maximum rotation counter to the sagittal which Jirout (1981) was able to demonstrate as a beam (here at 40° axis rotation). synkinetic movement during side-bending of the head. Slight side-bending is also possible, coupled Ante- and retroflexion between atlas and axis with rotation in the opposite direction. is considerable, amounting on average to 15°. The anterior arch of the atlas slides up and down on the The atlantoaxial joint is made up of the articula- dens of the axis, while the atlas itself performs a tion between the anterior arch of the atlas and the tipping motion (see Figure 3.29). dens of the axis, between the dens and the trans- verse ligament of the atlas with its articular carti- Kinematics of the cervical spine lage, and between the lateral mass of the atlas and the body of the axis. Its main function is that of Rotation rotation, and it also performs ante- and retroflex- ion. All these articulations participate in rotation. Rotation begins between the atlas and the axis On one side the lateral mass of the atlas glides and the movement takes place mainly there until ventrally on the body of the axis, rising as it does so, while on the other side the lateral mass of the atlas glides dorsally and downward. The rotation is limited by the joint capsules and the strong alar ligaments, which have their attachment to the mar- gins of the foramen magnum. The average range of motion of this rotation (our own results) is 25° in each direction, although we have found a range of motion up to as much as 40° (see Figure 3.28). Dvorák, using CT, even obtained average meas- urements of 41.1° to the right and 44° to the left. Huguenin, on the other hand, in measurements made using CT, obtained figures corresponding to our own. 66

Functional anatomy and radiology of the spinal column Chapter 3 the range of motion in this segment is exhausted, of the head (see Figure 3.31). Side-bending of the that is to about 25° to each side. Up to this head involves rotation of the head about a sagit- point the head rotates about a vertical axis in tal axis at the level of the root of the nose. This the horizontal plane. From this point onwards creates a pull on the spinous process of the axis, the other segments participate in succession in which causes rotation of the axis with simultane- the rotation movement, from C2/C3 to C6/C7, as ous tipping in the sagittal direction. This tipping long as the cervical spine is in a position of slight motion in the sagittal plane, which takes place both kyphosis. If the neck is completely upright the in side-bending and in rotation, is, according to Jir- cervicothoracic junction also rotates, down to and out (1968), the joint play of the cervical spine. The including T3. In passive rotation there is still some sideways shift of the spinous process can easily be slight additional rotation between the atlas and the palpated, and occurs as soon as the subject’s head occiput. The moment rotation below C2 begins, inclines to the side even to a slight degree. Inter- the inclined course of the intervertebral joints estingly, Gaymans (1973) demonstrated that a brings about simultaneous lateroflexion to the same shifting of the spinous process of the axis (rotation side unless the subject deliberately resists this of the axis) occurs even on mere leaning against synkinesis. slight resistance in the neutral position and with minimum pressure, thus simply through the pull Side-bending of the muscles. He obtained radiological evidence of this. Side-bending can be studied only by X-ray, hence the decision to deal with it under functional radio­ Rotation of the axis on side-bending of the graphic studies (see Figure 3.30). Like rotation, cervical spine is not simply the combined it begins at the atlanto-occipital and atlantoaxial result of rotation movements of the individual joints. This can be demonstrated by looking at vertebrae, due to the inclination of the the craniocervical region in passive side-bending zygapophysial joints of C7, C6, etc.; on the contrary (‘side-nodding’). This shows that side-bending it results from the inclination of the head itself, in starts with rotation of the axis relative to the which the head rotates about a sagittal axis and atlas. At the same time we find a synkinesis in exerts a pull on C2. If there is no rotation of the which the atlas shifts relative to the occipital con- axis, there is also no rotation of the other vertebrae dyles and C2 in the direction of the side-bending of the cervical spine during side-bending. At the (see Figure 3.30C). same time there is a tipping motion in the sagittal plane, so that the movement occurs in a coupled During this side-bending the cervical spine way in all three planes. rotates, maximum rotation occurring at C2. Jirout (1968) demonstrated that this rotation is absent Anteflexion and retroflexion in the lower cervical spine during side-bending to the right, but during side-bending to the left it Two distinct kinds of anteflexion should be distin- continues down into the upper thoracic spine. He guished. The first is a nodding movement limited explains this as being due to the stronger pull of to the atlanto-occipital and atlantoaxial joints. The the muscles of the shoulder girdle on the right side, other is a forward flexion involving the entire cer- whose attachment to the spinous processes exerts vical spine. This distinction does not exist for ret- a pull to the right and so brings about left rotation. roflexion. The two kinds of anteflexion of the head This combination of side-bending and rotation is are to some extent mutually exclusive. If we draw consistent with the positioning of the interverte- the chin in toward the chest (forward nodding), bral joints, although this cannot be the true cause, this usually inhibits full anteflexion. If we drop the as is usually thought, because the side-bending head far forward in anteflexion, this renders nod- originates at the axis. This rotates even with the ding more difficult except in hypermobile subjects. slightest side-bending, followed by the other seg- The explanation lies in the tipping mechanism of ments. If rotation of the axis does not take place, the atlas. there is no rotation of the rest of the cervical spine (see Figure 3.47B) According to Jirout (1968), the forces that bring about axis rotation are the product of side-bending 67

Manipulative Therapy Figure 3.30 • AP X-ray of the cervical spine of a healthy subject, to compare the (asymmetrical) neutral position, active side-bending, and passive ‘side-nodding.’ (A) In neutral position the atlas is to the right in relation to the condyles and axis; the plane of the condyles and that of the axis therefore converge on the right, with the axis rotated about 5° to the left. (B) In active side-bending to the left the atlas is still slightly to the right, and the plane of the condyles and that of the axis still converge to some extent to the right, while the axis is now more markedly rotated (about 10°) to the left. (C) In passive ‘side-nodding’ to the left, the atlas is now clearly to the left of the condyles and the plane of the condyles and that of the axis are parallel. The axis is rotated about 10° to the left. Transmission of the axis rotation to the next vertebra below can clearly be seen. (D) Diagram to illustrate the rotation of C2. 68

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.31 • Mechanism of side-bending of the cervical atlanto-occipital and atlantoaxial joints are in spine according to Jirout (1968). During side-bending the maximum anteflexion. head inclines about a sagittal axis (x) passing through the anterior cranial fossa. The diagram shows how the cranial • In maximum anteflexion (see Figure 3.32C), base, together with the occipital condyles, shifts relative to the cervical spine is almost horizontal; there is a the atlas in the opposite direction to the side-bending, and proportional slight ventral shift of the individual how the axis, together with the lower cervical vertebrae, is cervical vertebrae up to C2. Anteflexion brought into rotation in the direction of the side-bending, between C1 and C2 is at its maximum. In while the axis is tilted ventrally by a cranial pull on the contrast to the situation in the erect posture and spinous process. in forward nodding there is now retroflexion of the head relative to the atlas, which can be greater than in retroflexion with the subject seated. Anteflexion of the atlanto-occipital and atlantoaxial joints is thus reduced as compared to forward nodding, closer to the degree of anteflexion in the erect posture. Consequently the angle between the clivus and dens is usually the same with the head erect as during maximum anteflexion. There is also a forward shift of the clivus (basion), together with the atlas, relative to the tip of the dens. • In maximum retroflexion with the subject seated (see Figure 3.32D), there is maximum retroflexion of the atlas (relative to the axis). Retroflexion of the cranium, on the other hand, is seldom at its maximum (it is usually very little greater than during anteflexion of the head). Here, too, we see a proportional dorsal shift of the individual cervical vertebrae from C7 to C2 and of the clivus and atlas relative to the tip of the dens. • In passive retroflexion with the subject side- lying and so without the effect of gravity (see Figure 3.32E), there is now maximum retroflexion of the head relative to the atlas, while retroflexion of the atlas relative to C2 is even less than in the erect posture. There is no dorsal shift of the basion with the atlas. The following changes can be observed in The mechanism underlying these processes, which X-ray studies of anteflexion and retroflexion (see appear paradoxical at first sight, has been termed Figure 3.32): the tipping of the atlas. It is based on the follow- ing (see Figure 3.33): in anteflexion with the sub- • In the erect posture (see Figure 3.32A), the ject sitting, as soon as the center of gravity of the atlas is already in a position of slight retroflexion head shifts ventrally, the occipital condyles exert with an average angle of about 5°. pressure on the anterior, rising part of the concave articular surface of the atlas. This causes the atlas • During forward nodding (see Figure 3.32B), to tip forward and downward. There is an analogous anteflexion of the atlas increases only process in retroflexion with the subject sitting: the slightly. This movement causes an anteflexion atlas tips backward. This does not happen, however, of the head (the plane of the foramen with the subject lying on one side, which explains magnum); in the erect posture the head why in this case retroflexion of the occiput relative had been in a position of anteflexion to the atlas attains its maximum. relative to the atlas. In this position the 69

Manipulative Therapy Figure 3.32 • Ante- and retroflexion of the cervical spine. (A) Erect posture. (B) Forward nodding. (C) Maximum anteflexion. (D) Maximum retroflexion. (E) Passive retroflexion. 70

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.33 • Diagram to illustrate tipping of the atlas: 1, in erect posture; 2, in ‘forward nodding’; 3, in maximum anteflexion; 4, in maximum retroflexion; 5, in passive retroflexion. 3.5.4 X-ray anatomy of the at the cranial end of the cervical spine. Its superior cervical spine border is formed by the clivus and its lateral part by the occipital condyles. Beneath the condyles lie Anteroposterior view the two articulations of the atlanto-occipital joint, meeting at an angle of about 125–130°. Below the The AP view (see Figures 3.34 and 3.35) shows the condyles, to either side of the dens of the axis, arc of the anterior margin of the foramen magnum, can be seen the lateral masses of the atlas. These are wedge shaped, tapering towards their medial Figure 3.34 • The cervical spine (ventral aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP X-ray. 1, Anterior margin of the foramen magnum; 2, inferior border of the anterior arch of the atlas; 3, foramen transversarium; 4, intervertebral foramen; 5, course of the vertebral artery; 6, uncinate process; 7, pedicle of the vertebral arch. 71

Manipulative Therapy Figure 3.35 • The cervical spine (dorsal aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP X-ray. 1, Foramen transversarium; 2, inferior border of the posterior arch of the atlas; 3, lateral mass of the atlas with lateral triangle, 4; 5, joint space; 6, spinous process. border. Close to this border we often see a medial much higher medially than laterally. Beneath the lucency which should be interpreted as a normal unciform processes lies the shadow of the point- finding. Laterally to the lateral mass, the transverse like pedicles. The spinous processes can be seen in processes can be seen. It is sometimes possible to the midline and the lateral contour is formed by the see into the foramen transversarium, which gives transverse processes. The intervertebral foramen passage to the vertebral artery. The spindle-like is visible, but less clearly. Rarely, the intervertebral posterior arch (broadest in its medial portion) can joint space can be seen. be traced from one transverse process to the other. It separates the ‘lateral triangle’ from the lateral Lateral view mass. Sometimes the anterior arch can also be seen, projected across the tip of the dens. The lateral view (see Figure 3.36) offers an undis- torted image of the cranial base and the atlanto- The inferior contour of the lateral mass forms occipital and atlantoaxial joints. The clivus can be the superior articular surface of the joint between followed in its entirety down from the sella turcica C1 and C2. At the medial border of the joint facet to the anterior margin of the foramen magnum of the axis there is a tiny notch marking the border (basion) which is situated directly above the tip of the dens. The tip of the dens usually lies well of the dens. The posterior margin of the foramen below the superior border of the foramen magnum. magnum (opisthion) cannot always be clearly dis- Just below the lateral end of the superior joint tinguished from the squama of the occipital bone; facets of the axis is the foramen transversarium. it helps to follow the posterior margin of the cervi- Medial to this foramen, the point-like projection cal spinal canal from caudad to craniad. Where the of the pedicles of the axis can be seen. From here arc-shaped prolongation of this margin meets the can be traced the shadow of the arch of the axis on occiput is the opisthion. both sides, through to the spinous process. If there is hyperlordosis it is sometimes possible to see into The mastoid process frequently overlaps the con- the spinal canal above the arch of the axis. dyle and atlanto-occipital joint; therefore this joint is not always visualized in the lateral view, although Below the axis can be seen the typical cervical it is often clearly seen (see Figure 3.37). vertebrae with their characteristic uncinate process either side. This causes the intervertebral disk to be 72

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.36 • The cervical spine (lateral aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) Lateral X-ray. 1, Transverse process; 2, width of the spinal canal; 3, joint space; 4, inferior articular process; 5, intervertebral foramen; 6, superior articular process. The plane of the foramen magnum can be The plane of the axis lies on a straight line linking established by drawing a line from the basion the inferior border of the transverse processes to the opisthion on the posterior margin of the and the inferior border of the spinous process. foramen magnum. The plane of the atlas cor- These lines are used to determine the ante- or responds to a straight line through the middle retroflexion of the occiput, atlas, and axis (see of the anterior and posterior arches of the atlas. Figures 3.25 and 3.38). Figure 3.37 • Atlanto-occipital joint, lateral view. Figure 3.38 • Anteflexion of the atlas (relative to the axis). 73

Manipulative Therapy The dens of the axis is projected just behind Figure 3.39 • Typical forward-drawn position of the head. the anterior arch of the atlas. The tip of the dens is usually at the same level as the superior border of the atlanto-occipital and atlantoaxial joints, and the anterior arch of the atlas. It should not be much tension in the short extensor muscles of the neck. above the palato-occipital line; this is the case in basilar impression. In order to demonstrate the patient’s natural posture radiographically, lateral projections should In this section of the spinal column, unlike the be taken with the subject seated in a relaxed man- others, the pedicles and transverse processes are ner, in a backless chair, as described by Gaizler projected onto the vertebral bodies in the lateral (1973). It is important to ensure that the patient view but not in the AP view, because here the spi- remains relaxed, with gaze fixed on an object at eye nal canal is wider than the vertebral bodies. The level, so that there is no anteflexion of the head superior border of the transverse processes lies despite the natural posture. We took projections slightly above the superior end-plate of the ver- of a group of 50 patients with the patients in erect tebral bodies, which can cause them to appear posture (kneeling), and sitting both upright and somewhat blurred. In the lower cervical spine the relaxed. Whereas with the subject sitting upright shadow of the transverse processes lies more in the external auditory meatus was projected almost the dorsal direction and in the superior cervical exactly above the anterior border of C7, in the spine more ventrally; at C2 the position of this erect posture it was 7 mm in front of C7, and sit- shadow of the transverse process is such that its ting relaxed it was projected forward by 16 mm; in anterior border overlies the anterior border of the individual cases even by 5 cm. This was particularly vertebral body. the case where a patient’s relaxed sitting position involved lumbar kyphosis. The shadows of the articular processes and joint spaces are projected behind the vertebral bodies. If In addition to disturbances of statics, localized the projection is well executed, all that can be seen irregularities can be observed. Examples of these is a lucency, showing that the joints are essentially are slight relative shifts in neighboring vertebrae parallel. This need not be so at C2/C3, where it or local lordotic or kyphotic deviations. In the can be quite normal to see some fuzziness of out- line. The posterior margin of the spinal canal cor- responds to a line linking the bases of the spinous processes (posterior border of the vertebral arch) – a rule that thus also applies to the atlas, which does not have a spinous process. If, however, this shadow is absent at the atlas, this is a sign of spina bifida atlantis, a frequently-found anomaly. 3.5.5 Evaluation with respect to functional implications The most characteristic disturbance of statics in the cervical region is the forward-drawn posture (see Figure 3.39). Even when statics are normal, the centre of gravity of the head is slightly in front of its support, so that electromyographic studies reveal a slight degree of muscular activity in the nuchal muscles even with the subject in normal erect pos- ture. As soon as there is any forward inclination (not flexion!), whether of the entire body or of the neck alone, tension can immediately be palpated in the muscles of the back of the neck. The forward- drawn position therefore creates overload of the cervical spine and compensatory hyperlordosis at 74

Functional anatomy and radiology of the spinal column Chapter 3 craniocervical region the atlas may be in a posi- of the atlanto-occipital and atlantoaxial joints, lat- tion of ante- or retroflexion in relation to the axis. eral shifting, an asymmetrical position of the con- The older expressions ‘atlas superior’ or ‘atlas infe- dyles relative to the atlas, and of the atlas in relation rior,’ which were adopted by chiropractors, are to the axis. This is often described as a shift of the less appropriate because they refer to the position atlas to one side relative to the condyles and to the of the atlas relative to the occiput rather than axis, which is not quite appropriate: the description the axis, whereas the criterion being assessed in should always be given in terms of the upper ele- the rest of the spine is always the position of the ment relative to the lower. The description in this upper of two vertebrae relative to the one below case would not be of the atlas to the right relative it. The tipping of the atlas means that the atlas is to the condyles and axis, but of the atlas to the usually in a slightly retroflexed position if there right relative to the axis, and the condyles to the is cervical lordosis, with the occiput in anteflex- left relative to the atlas (see Figures 3.41–3.43). ion; if the posture is kyphotic the atlas would be in anteflexion and the occiput in retroflexion Isolated rotation of the atlas in relation to both (see Figures 3.33, 3.39 and 3.40). the occiput and the axis is fairly uncommon. The joint space between atlas and axis is narrower on Other frequent findings are the rotation of sev- the side of rotation, the lateral triangle of the lat- eral vertebrae (see Figure 3.46) and, in the region eral mass becomes larger, the center of the poste- rior arch is shifted in the opposite direction to the rotation, and the lateral mass becomes larger on the side opposite to rotation. Much more frequent than rotation of the atlas is axis rotation in neutral posture (see Figure 3.44). A 5° or occasionally even 10° rotation of the axis is not unusual. Interestingly, the rotation of the axis is caudally transmitted, down to the rest of the cer- vical vertebrae and even down as far as the cervi- cothoracic junction, particularly when rotation is to the left. This can happen even in the simple case of lateral deviation of the spinous process. The mecha- nism clearly seems to be the same as that discussed in connection with side-bending, which brings about left rotation of the lower cervical spine and cervico- thoracic junction. Figure 3.40 • Kyphotic posture of the mid-cervical spine Figure 3.41 • Diagram to illustrate the asymmetrical position with balanced body statics: the external auditory meatus of the atlas relative to the occipital condyles and the axis. and the dens of the axis are not projected in front of the anterior border of C7. The position of C7 is consistent with a flat thoracic spine. 75

Manipulative Therapy Figure 3.42 • (A) Asymmetrical position of the atlas relative Figure 3.44 • Dextrorotation of the axis. (A) X-ray. to the occipital condyles and axis. (B) After manual therapy (B) Diagram. the position is symmetrical. Figure 3.43 • Dextrorotation of the atlas. (A) X-ray. (B) Diagram. 76

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.46 • Rotation of the cervical spine: X-ray, lateral view. The joint spaces, articular processes and transverse processes are projected apart. Figure 3.45 • Schematic drawing to illustrate the rotation together with the articular processes and transverse of a cervical vertebra in the AP view. processes. At C2 one transverse process is projected in front of the vertebral body (see Figure 3.46). The characteristic features of axis rotation in the AP view are the deviation and position of the pedi- An important sign of static disturbance is dis- cles and the spinous process to that of rotation. The crepancy between the AP view taken with the foramen transversarium widens on the side of rota- patient supine and the lateral view with the patient tion and the joint space narrows on the opposite side. sitting, in particular if there is rotation in the view taken sitting and none at all in the AP view with the Rotation of the other cervical vertebrae is char- patient supine. The cause may be an oblique plane acterized not only by the deviation of the spinous below the cervical spine. process and rotation of the pedicles to the oppo- site side, but also by distortion of the unciform 3.5.6 Movement studies processes (see Figure 3.45). In the lateral view, the structures that usually overlap are projected Radiographic movement studies are used to inves- apart. This applies particularly to the joint spaces, tigate restrictions and hypermobility. X-rays are taken in ante- and retroflexion and side-bending. Rotation is less studied by this method because interpretation is difficult. 77

Manipulative Therapy The physiological reaction of the cervical find that if there is no rotation of the axis, there spine during side-bending has been described in will be none in the rest of the cervical spine Section 3.5.3. The study of side-bending is use- (see Figure 3.47). Even if, on side-bending, an ful in the diagnosis of movement restrictions. We asymmetrical spinous process of the axis fails to Figure 3.47 • (A) Neutral position. (B) Side-bending with absence of axis rotation. Rotation of the other motion segments is also absent. (C) After treatment, rotation of the axis is restored and the other motion segments now also rotate. The extent of side-bending has also increased. 78

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.48 • Schematic drawing to illustrate the effect It is not usually difficult to demonstrate a of asymmetry of the spinous process of C2 on the caudad restriction of side-bending between the atlas and vertebrae during side-bending. (A) Neutral posture with axis. When this is done, rotation is (also) seen to be spinous process of the axis to the right of the midline. blocked (see Figures 3.47 and 3.49). The radiologi- (B) On inclination to the right the axis rotates to the right cal evidence of restriction in the other motion seg- in the normal way, but the asymmetrical spinous process ments of the cervical spine is much more difficult travels no further than the midline. The vertebrae below to achieve. According to Jirout (1971) side-bending therefore remain in the central position and do not rotate. is accompanied by slight synkineses in the sagittal plane, consisting of ante- and retroflexion move- reach any further than the midline, the rest of the ments that can be recognized by a change in the cervical spine will not rotate. This demonstrates position of the spinous processes relative to the ver- that the rotation is transmitted through the spinous tebral bodies. Comparison of the films taken before processes in a caudal direction. Lack of rotation and after manipulation found a more marked reac- in the lower cervical spine does not in any way tion of these synkineses in restrictions than actual impair rotation above the restriction (Jirout 1972) side-bending as seen radiographically. (Figure 3.48). To summarize: Although lateral shifting of the atlas occurs in side-bending, this shifting can sometimes be • Lateroflexion of the head against the cervical absent without implying any movement restric- spine (side-bending; ‘side-nodding’) is mainly tion, especially if there is marked asymmetry. More performed by means of rotation of the axis importantly, the shifting may still be seen in the relative to the atlas. Normalization of side- radiographic image even in cases where there is bending at the atlanto-occipital and atlantoaxial restriction. If there is restriction blocking axis rota- joints also normalizes this rotation. tion, no side-bending occurs at the atlanto-occipital and atlantoaxial joints (see Figure 3.49). This is in • Lateroflexion between occiput and atlas can keeping with the fact that in cases of atlas assimi- be established radiographically and clinically lation, side-bending at the craniocervical junction only if the more mobile segment (C1/C2) is occurs in the normal way. locked, that is if the head and atlas are rotated by at least 45°. The movement restriction This raises the question as to whether restric- between occiput and atlas does not affect side- tion between occiput and atlas on side-bending can bending in the frontal plane or the synkinesis be demonstrated radiographically at all. We have between occiput and atlas during side-bending shown this to be possible (Lewit & Krausová 1967) in the sense of a lateral shift accompanied by with the head rotated to the side, locking the atlas/ simultaneous rotation of the axis. axis motion segment. This is necessary to obtain an accurate diagnosis. • Ante- and retroflexion is the movement most frequently examined by X-ray. The disadvantage of this examination from the point of view of manipulation therapy is that this is the movement most frequently and preferentially performed and so the least susceptible to dysfunction. Hypermobility, on the other hand, is more readily revealed here. This can reveal increased shift between neighboring vertebrae, increased lordosis or kyphosis between neighboring vertebrae, and the following signs of hypermobility at the craniocervical junction: - Laxity of the transverse ligament of the atlas and a widening of the joint space between the anterior arch of the atlas and the dens of the axis, especially the superior part (see Figure 3.50). As a consequence the basion also shifts anteriorly. During anteflexion the distance between the anterior arch of the atlas 79

Manipulative Therapy Figure 3.49 • Restriction of side-bending between atlas and axis. (A) In the neutral posture the position of the atlas is slightly asymmetrical, to the left relative to the condyles. (B) On attempted left lateroflexion there is almost no side-bending at the craniocervical junction, although the atlas has moved markedly to the left. (C) After manipulation, normal lateroflexion is restored, with (slight) rotation of the axis. (D) Spontaneous side-bending to the left; position analogous to (C) with acute cervical myalgia. 80

Functional anatomy and radiology of the spinal column Chapter 3 Figure 3.50 • Increased distance between the anterior arch of the atlas and the dens of the axis, especially in the superior part, with anterior shift of the basion. and the dens and the angle between the clivus Figure 3.52 • Hypermobility between the occiput and and the dens decreases. This happens not only atlas during ante- and retroflexion of the head. (A) During on forward-nodding, but also anteflexion anteflexion, the basion lies above the anterior arch of the (see Figure 3.51). atlas and the opisthion above the posterior arch. (B) On retroflexion the occiput is shifted posteriorly by about 2 cm. - Hypermobility between the occipital condyles and the atlas without laxity of the transverse ligament of the atlas can be recognized by a shift of the basion and opisthion in relation to the dens of the axis (see Figure 3.52). Figure 3.51 • Hypermobility of the atlas on anteflexion of the head with slackening of the transverse ligament of the atlas. (A) Neutral posture. The articular facet of the anterior arch of the atlas lies parallel to the dens of the axis. (B) On maximum anteflexion the anterior arch of the atlas and dens of the axis create a gap that is open cranially, the basion shifts anteriorly, and the angle between the clivus and dens (obtuse) becomes noticeably smaller than in the neutral posture. 81

Manipulative Therapy 3.5.7 Morphological changes growth. This anomaly could easily be confused with the consequences of childhood rheumatoid arthri- It is not the task of this book to deal in detail with tis (Still’s disease). The difference lies in the oblit- morphological and structural changes; nor is it nec- eration of the joints, while the vertebral arches and essary to do so, since this field forms the subject of spinous processes are normally developed. textbooks of radiology and orthopedics. Therefore only certain aspects, the limited number of those Cervicothoracic transitional vertebra that are particularly important from the point of view of manual medicine, are touched on here. A transitional C7 cervicothoracic vertebra with a very large transverse process or with a cervical rib Anomalies is another frequent anomaly. There may also be an absence of the unciform process on one or both Block vertebrae sides. A transitional T1 vertebra is however rare. Block vertebrae lead to a compensatory hypermo- Spinal canal stenosis bility in the neighboring segments. The coalescence may be complete or partial, or sometimes simply A narrow spinal canal is particularly important clini- consist of a hypoplastic intervertebral disk, in which cally, because it is the most important cause of cer- case the vertebral bodies adjacent to the hypoplas- vical myelopathy. From the practical point of view tic disk are narrower (see Figure 3.53). This occurs in diagnosis it is more helpful to look at the change because the adjacent end-plates – between which in the proportions of the individual anatomical the hypoplastic disk lies – are also the zone of structures than to measure the sagittal diameter of the spinal canal; the proportions of the structures can be seen at first glance. Normally, in the cervical spine, the spinal canal is wider than the vertebral bodies. In spinal canal stenosis this is not so; also (if there is no rotation in the radiograph) the articu- lar processes overlie the entire width of the spinal canal (see Figure 3.54). Figure 3.53 • Incomplete block vertebra (congenital Figure 3.54 • Spinal canal stenosis. The spinal canal coalesence) of C5/C6 with a hypoplastic intervertebral disk is markedly narrower than the vertebral bodies, and the and narrowing of the vertebral bodies in the region of the articular processes cover its entire width. narrowed disk. The articular processes and vertebral arches are normally developed. 82

Functional anatomy and radiology of the spinal column Chapter 3 Basilar impression well above the line between the mastoid processes and digastric muscles (see Figure 3.55B). At the As a region of transition, the craniocervical junction, same time the foramen magnum may be narrower the region of the atlanto-occipital and atlantoaxial than usual, unless there is also an Arnold–Chiari joints, is the site of many anomalies. Probably the malformation, in which case displacement of the most important of these is basilar impression (see tonsils of the cerebellum below the foramen mag- Figure 3.55), which is the result of hypoplasia of num has the effect of widening it. These changes the basiocciput. In this condition the occipital part can cause syndromes associated with compression of the clivus is shortened and therefore the dens of the medulla oblongata, similar to those of spinal axis appears as if shifted into the foramen magnum, canal stenosis in the cervical region. so as to lie above the palato-occipital line in the lat- eral view (see Figure 3.55A). In the AP view the Frequently basilar impression is accompanied by dens can be above the occipital condyles, placing it hypoplasia or assimilation of the atlas to the occipi- tal bone and its condyles. Less frequently there can Figure 3.55 • Basilar impression. (A) The lateral view shows hypoplasia of the clivus, and the dens high in the foramen magnum. (B) In the AP view the dens of the axis is again seen in a high position. (C) Diagram: a, sphenoid part of the clivus; b, occipital part of the clivus; c, palato-occipital line; d, distance (according to Klaus 1974) of the dens of the axis from a line joining the tuberculum sellae and the internal occipital protuberance; e, plane of the foramen magnum. 83

Manipulative Therapy be a block vertebra involving coalescence of the axis Hypoplasia of the dens of the axis with a lateral mass of the atlas. Hypoplasia of the dens or especially the os All the anomalies listed here are frequently odontoideum leads to pathological instability (see asymmetrical, so that lateral displacement of the Figure 3.56). Another anomaly deserving of men- atlas and also rotated positions of the axis can be tion is reclination of the dens (Gutmann 1981), found simultaneously. In addition there can also which results in retroflexion of the atlas and there- be hyperlordosis. It is therefore little wonder that fore places increased strain on the transverse liga- these anomalies often also lead to dysfunctions ment of the atlas during head anteflexion. which in turn cause pain. Figure 3.56 • Os odontoideum, lateral view in neutral position (B). Pathological shift of the atlas relative to the axis (A) during retroflexion and (C) during anteflexion. Figure 3.57 • Spondylarthrosis in a case with a horizontal course of the articular facets. (A) Joint spaces well visualized in the AP projection as a result of the horizontal direction of the beam; also the condensation. (B) The lateral view provides clear evidence of the horizontal course; the condensation and extension of the articular processes can clearly be seen. 84

Functional anatomy and radiology of the spinal column Chapter 3 Degenerative changes Degenerative changes can be of clinical significance, Figure 3.58 • Difference in the inclination of the articular especially if they affect the intervertebral foramen, facets in the C3/C4 segment. if they are closely associated with the nerve root and the vertebral artery, or if they cause additional upper of two neighboring vertebrae, relative to the narrowing of an already narrow spinal canal. These caudally adjacent one, during retroflexion, and con- changes mainly develop in the region of the unci- sequent narrowing of the intervertebral foramen on nate processes when there is thinning of the disk, the side of the rotation (see Figure 3.58). bringing the uncinate processes into close contact with the body of the vertebra above. This can lead to the formation of uncovertebral joints (neoar- throses) and osteophytes. Degeneration of the articular processes also has an effect on the intervertebral foramina. Arthroses of the zygapophysial joints often occur as a con- sequence of their horizontal position, whether this has come about as an anomaly or in the case of hyperlordosis. In such cases the joint facets, rather than the end-plates of the vertebral bodies, become the weight-bearing structures. This causes a broad- ening and condensation of these joints, and they can therefore be clearly seen in the AP view (see Figure 3.57) as well as the lateral view. Finally, the significance of a divergent course of the paired joints in the cervical spine needs to be highlighted. This change can clearly be seen in a well-centered lateral view. It causes rotation of the 85

Chapter Four 4 Diagnosis of dysfunctions of the locomotor system Chapter contents   4.5.3 Pelvic distortion . . . . . . . . . . 102   4.5.4 Pelvic tilt . . . . . . . . . . . . . . 103 4.1 Patient history . . . . . . . . . . . . . . . 88   4.5.5 Restriction of the sacroiliac joint . 103   4.5.6 S hear dysfunction (Greenman) 4.1.1 Course of the disease . . . . . . . . 88 4.1.2 Localization . . . . . . . . . . . . . 89 (upslip and downslip) . . . . . . . 106 4.1.3 Trauma . . . . . . . . . . . . . . . . 89   4.5.7 Outflare and inflare . . . . . . . . . 106 4.1.4 Load, posture, and position . . . . 89   4.5.8 T he pelvic floor and coccygeus 4.1.5 Non-mechanical factors . . . . . . 90 4.1.6 Psychological factors . . . . . . . . 90 muscle . . . . . . . . . . . . . . . 106 4.1.7 Paroxysmal character . . . . . . . . 90   4.5.9 The painful coccyx . . . . . . . . . 107 4.1.8 The significance of patient age . . . 90 4.2 The inspection: posture . . . . . . . . . . 90 4.5.10 Ligament pain . . . . . . . . . . . 107 4.6 Examination of the lumbar spine . . . . . 108 4.2.1 The dorsal aspect . . . . . . . . . . 91 4.2.2 The lateral aspect . . . . . . . . . . 91 4.6.1 Screening examination of active 4.2.3 The ventral aspect . . . . . . . . . . 92 movement . . . . . . . . . . . . . 108 4.2.4 Inspection of the seated patient . . 93 4.3 Palpation (soft-tissue examination) . . . . 93 4.6.2 E xamination of individual motion segments . . . . . . . . . . . . . . 109 4.3.1 Hyperalgesic zones . . . . . . . . . 93 4.3.2 Subcutaneous tissue and fasciae . 94 4.7 Examination of the thoracic spine . . . . 112 4.3.3 Trigger points . . . . . . . . . . . . 94 4.3.4 Periosteal pain points . . . . . . . . 96 4.7.1 Screening examination of active 4.3.5 Radicular syndromes . . . . . . . . 96 movement . . . . . . . . . . . . . 112 4.3.6 Conclusion . . . . . . . . . . . . . 100 4.4 Mobility testing . . . . . . . . . . . . . . 100 4.7.2 Palpation of mobility . . . . . . . . 113 4.7.3 Anteflexion . . . . . . . . . . . . . 113 4.4.1 Active mobility . . . . . . . . . . . 100 4.7.4 Side-bending . . . . . . . . . . . . 114 4.4.2 Movement against resistance . . . 100 4.7.5 Rotation . . . . . . . . . . . . . . . 114 4.4.3 Passive mobility . . . . . . . . . . 100 4.8 Examination of the ribs . . . . . . . . . . 115 4.5 Examination of the pelvis . . . . . . . . . 101 4.8.1 Screening examination . . . . . . 115 4.5.1 Screening examination . . . . . . 101 4.8.2 Examination of the first rib . . . . 116 4.5.2 Pelvic obliquity . . . . . . . . . . . 102 4.9 Examination of the cervical spine . . . . 116 4.9.1 Screening examination . . . . . . 116 4.9.2 E xamination of passive mobility . . . . . . . . . . . . . . . 117 4.9.3 E xamination of the motion segments . . . . . . . . . . . . . . 118

Manipulative Therapy 4.9.4 T esting of mobility between   4.20.3 T he pathomechanisms of occiput and atlas . . . . . . . . . . 122 chain reactions . . . . . . . . . 159 4.10 Examination of the limb joints . . . . . 124 4.20.4 Causes of chain reactions . . . 160 4.10.1 The shoulder . . . . . . . . . . . 124 4.20.5 The role of the diaphragm . . . 160 4.10.2 The elbow . . . . . . . . . . . . 126 4.10.3 The wrist . . . . . . . . . . . . . 127 4.20.6 Rotation of the trunk . . . . . . 161 4.10.4 The hip . . . . . . . . . . . . . . 127 4.10.5 The knee . . . . . . . . . . . . . 128 4.20.7 Unilateral chains of dysfunction 161 4.10.6 The foot . . . . . . . . . . . . . 129 4.11 Examination of the 4.20.8 Analysis of chain reactions . . . 161 temporomandibular joint . . . . . . . . 130 4.21 Differential diagnosis . . . . . . . . . . 162 4.12 Examination of disturbances of balance . . . . . . . . . . . . . . . . . 130 4.21.1 Problems . . . . . . . . . . . . . 162 4.13 Examination of muscle function . . . . 132 4.21.2 Case studies . . . . . . . . . . . 163 4.13.1 General principles . . . . . . . . 132 4.21.3 Common differential diagnoses 164   4.13.2 E xamination of muscles with a 4.21.4 Conclusions . . . . . . . . . . . 165 tendency to weakness . . . . . 133   4.13.3 E xamination of muscles with a As in every other field of medicine, examination starts with taking the patient history. The model tendency to shortening . . . . . 136 we shall take here is the diagnosis of vertebrogenic 4.14 Examination of hypermobility . . . . . . 140 disturbances, which are among the most frequent type of dysfunction. Dysfunctions should not sim- 4.14.1 The spinal column . . . . . . . . 140 ply be diagnosed by a process of elimination; if we 4.14.2 The joints of the upper limb . . 143 approach the task by ruling out all other possible 4.14.3 The joints of the lower limb . . . 144 causes of the lesions (especially pathomorphol- 4.15 Examination of coordinated movements ogy) we cannot expect to arrive at helpful findings. (motor stereotypes) . . . . . . . . . . . 145 Instead, diagnosis should be based on characteristic symptoms. Precise criteria for the patient history   4.15.1 E xamination with the patient have been laid down by Gutzeit (1951). sitting . . . . . . . . . . . . . . . 145 Following the patient history, the next step   4.15.2 E xamination with the patient is the physical examination. There is no clinical standing erect . . . . . . . . . . 149 field in the whole of our experience in which the purely clinical examination plays such a decisive   4.15.3 M ovement patterns of role; nor does any other make such high demands respiration . . . . . . . . . . . . 150 as the examination of motor function. The exami- nation begins the moment the patient enters – the 4.16 Syndromes . . . . . . . . . . . . . . . . 151 very first steps into the room, the way the patient sits down, even the way the patient undresses. It   4.16.1 The lower crossed syndrome . . 151 is important that patients should undress for the   4.16.2 The upper crossed syndrome . 152 first examination (to their underwear, since most   4.16.3 S tratification syndrome patients feel more at ease if they can keep their undergarments on, and so move more naturally). (according to Janda) . . . . . . 152 Present-day knowledge of functional inter-relation- 4.17 Retesting . . . . . . . . . . . . . . . . . 153 ships shows it to be essential to study the entire locomotor system at the initial examination. 4.18 D ysfunctions and the course of examination . . . . . . . . . . . . . . . 153 4.1 Patient history 4.19 Adjusting our thinking to the 4.1.1 Course of the disease functional approach . . . . . . . . . . . 154 Unless we are dealing with a young patient, symp- 4.20 Chain reactions of dysfunctions and toms will usually have been present for some time; motor programs . . . . . . . . . . . . . 155   4.20.1 Function and chain reactions . . 155   4.20.2 C hain reactions in the light of developmental kinesiology . . . 157 88

Diagnosis of dysfunctions of the locomotor system Chapter 4 in most cases for years or decades, though sometimes it ‘only’ affects the limbs, affects the spinal column. in mild form, interspersed with periods of complete This is particularly so in the case of head injury. Nev- absence of pain. The frequency, duration, and inten- ertheless, it is well known that many patients tend to sity of the individual episodes are all relevant, but forget ‘minor’ injuries, serious as the consequences such details can often only be discovered by careful, often turn out to be. Children who wrench their neck specific questioning. For example, female patients in an awkwardly performed somersault in a gymnas- will tend not to recall or mention low-back pain dur- tics lesson at school, or fall and sit down heavily, sel- ing menstruation unless specifically asked, because dom suffer any painful consequences at the time; if they consider this irrelevant. In contrast to this pat- they do, they compensate quickly. However there can tern, a short, progressive course should give rise to be consequences, but they often appear very much concern, especially if the patient is advanced in age. later. It is therefore advisable not to accept straight away an answer that your patient cannot remem- 4.1.2 Localization ber ever having had any accident. Instead, it should become a routine question to ask patients what sports Over the course of years, pain may occur in various they practice. To give a typical example: a patient different parts of the spine and locomotor system; it who answered a direct question about injury by say- is exceptional for dysfunctions to remain confined to ing that he ‘never suffered any trauma’ replied to one a single region. Again, specific questioning is usually about sport by saying that he had been a boxer! needed to elicit this information. Patients presenting with headache will have little idea that there might 4.1.4 Load, posture, and be a connection between this and their low-back pain, position any more than patients with lumbago will associate this with vertigo originating from the spinal column. Function and its disturbances in the locomotor sys- tem are influenced by movement, load, posture, Patients may suffer from a number of complaints and position, especially if the position maintained that might, if taken individually, be seen as having a is stressful. Therefore one of the most important variety of different causes, yet all have a common points in recording the case history is to discover denominator in the spinal column or locomotor sys- under what conditions the pain occurs. This is not tem. The greater the number of complaints a patient only useful in arriving at a diagnosis, but also impor- has – all of which, however different, could have a tant from the point of view of prevention. vertebral origin – the greater the likelihood that these are indeed vertebrogenic dysfunctions. This serves to Details in the history such as these are essential, confirm Gutzeit’s (1951) view that the spinal column but often very difficult to discover from the patient. is the link that runs like a bright red thread through a It does little good to ask what happened just before thoroughly varied list of different complaints. the onset of symptoms, because patients will give an answer based on all sorts of theories they have Vertebrogenic pain is typically asymmetrical heard or formed for themselves. What we need to as between sides and often unilateral. This applies know are the circumstances in which pain was ini- both to radicular pain and to reflex, referred pain tially felt and which cause it to recur on a regular such as headache or pseudovisceral pain. The asym- basis. Patients often find this very difficult to recall, metry usually increases as a patient’s condition dete- thinking that it would not help to say, for example: riorates, and decreases as it improves. If (in the case ‘when I got up from my chair …’; ‘I was shaving, of dysfunctions) a unilateral pain spreads to become and when I tried to look more closely in the mirror bilateral, this does not usually indicate deterioration. …’; ‘… getting out of bed in the morning …’; ‘I was going to pick up a piece of paper from the floor …’; 4.1.3 Trauma yet these are significant details. As has already been emphasized (in the discussion It is also important to ask which position or of pathogenesis), trauma is a significant factor in the movement gives relief. It is important to know etiology of vertebrogenic disturbances. If an acci- whether pain is provoked by sudden movements, by dent features in the previous history it becomes all an extended period of sustained, strenuous effort, the more likely that the presenting complaint has a or by an enforced position. Even apparently irrel- vertebral origin. Almost any kind of trauma, even if evant details can be important. The point that has 89

Manipulative Therapy to be identified is whether a particular pain symp- of the locomotor system. Signs that a problem is tom occurs on bending slightly forward, as when caused by purely psychological factors are these: if working at a desk, or on maximum flexion, as when the patients are unable to localize the pain, if they stooping to wipe a floor, or while straightening up constantly change their account, or if they cannot from a stooping position. The mechanism behind describe the pain. They are often confusing their the problem is very different in each case. psychological suffering with the pain. In this context too it is necessary to find out 4.1.7 Paroxysmal character about patients’ work and sporting activities. 4.1.5 Non-mechanical factors Gutzeit (1951) is entirely right when he describes the paroxysmal character of vertebrogenic com- Dysfunctions of the locomotor system are not sim- plaints, especially if the symptoms involved are ply a mechanical problem, but involve every aspect autonomic and vasomotor in nature: examples are that affects the reactive capacity of the body. The headache, vertigo, pseudocardiac or other pseudo- nervous system in particular plays a role, as can be visceral problems. If the pain has the same, sus- seen in susceptibility to changes in the weather, to tained intensity, for example headache, this tends chills, and infectious diseases. This is especially so to suggest another cause rather than a vertebral if these cause raised body temperature. Hormo- one. At the same time it should be pointed out nal disturbances, the clearest effects of which are that patients often speak of pain as being ‘constant’ those experienced by women during menstruation, when they are never completely free of it, although can also be important; allergy can likewise have an its intensity rises and falls paroxysmally with a cer- effect. tain frequency. 4.1.6 Psychological factors 4.1.8 The significance of patient age Since, as we know, the locomotor system is sub- ject to human will, and pain is the most frequent For differential diagnosis it is important to bear in symptom of dysfunction, it is hardly surprising mind that the age of the patient plays an important that psychological factors play an important part. role. In adolescents we might expect to find ‘ordi- Psychological involvement in no way excludes, but nary’ restrictions or juvenile osteochondrosis, and in rather corroborates, the diagnosis of vertebrogenic slightly older patients, ankylosing spondylitis. In the dysfunction. It must be stressed that appropriate middle-age group, the most common serious condi- treatment of the dysfunction is the best means of tions are herniated disc and ‘ordinary’ dysfunctions. easing the pain. It also provides the practitioner In older age groups, osteoporosis is the most impor- with the best means of dealing with the psycho- tant, especially in women; also osteoarthritis, espe- logical problems. It is ultimately the course of the cially of the hip and knee joints. In this older age illness that indicates how significant the psycho- group, malignant disease must also be considered, logical factor is in the particular case. The psycho- especially if the patient is over 50 years of age and logical problems may ease when the patient’s pain the disease has followed a progressive course. True is relieved, or may persist; they may even cause vertebrogenic disease tends to decrease after the relapse as a result of increased muscle tension, and age of 60, accompanied by a rise in the incidence of an inability to relax. This is particularly the case in osteoarthritis of the limb joints. masked depression. 4.2 The inspection: posture One general principle needs to be stressed: we should guard against categorizing pain as psycholog- The inspection usually begins with the dorsal ical if patients are able to localize it accurately and aspect. The plumb line is positioned so as to fall if they give the same account of the symptoms each between the heels. This is followed by the lat- time they describe them. The conclusion we should eral and finally the frontal aspects. If possible the draw in this case, assuming that no pathomorpho- logical lesion is found, is that there is a dysfunction 90

Diagnosis of dysfunctions of the locomotor system Chapter 4 patient should also be assessed in the sitting posi- trunk up to the axilla. The superior border tion, again from all sides. of the shoulders is formed by the deltoid and superior portion of the trapezius, and medially The inspection is the quickest way of gaining an to these by the levator scapulae. The inspection overall impression so that the manual stage can be should note whether the superior contour takes carried out in as targeted and economical a way as a concave or convex (hypertonic) course and possible. observe whether there is symmetry • the neck: note whether the neck deviates to one 4.2.1 The dorsal aspect side or the other, and observe whether it is long, slim, or stocky The inspection begins with an assessment of overall • the hair line: note whether this is well above the posture, looking for any deviation from the plumb shoulders or low down as in basilar impression line and any asymmetries. • the head: look for any deviation. Does it deviate to the same side as the neck, or to the opposite The next stage is the systematic inspection. side? Working upward from the feet, the specific points to examine are: 4.2.2 The lateral aspect • the shape (roundness) and position of the heels • the shape of the foot Inspection of the lateral aspect also begins with an • the shape and thickness of the Achilles tendons assessment of posture as a whole. The center of gravity of the head should normally be above the and the calves, observing their medial and lateral shoulder girdle; more precisely the external audi- contours tory meatus should be vertically above the pel- • the position of the knees vic girdle and this in turn above the feet, so that • the shape of the thighs a plumb line from the external auditory meatus • the height of the gluteal folds falls approximately 2 cm in front of the ankles and • the tone of the gluteal muscles touches the scaphoid of the foot (navicular bone). • the course of the intergluteal cleft During this inspection the patient’s gaze should be • the shape of the hips: whether symmetrical or directed at an object at eye level. projecting to one side • the waist It is extremely important to register a forward- • the distance of the pendant arms from the trunk drawn position, in which the head is in front of the on either side. shoulder girdle, and this in front of the pelvic girdle, Further details to examine are: with the pelvis above the anterior part of the foot. • the rhomboid of Michaelis between the dimples situated at the posterior superior iliac spines It is important for diagnosis to note any tension (PSIS), and further craniad, the prominence of of the muscles of the back, and especially of the the erector spinae muscles. Between these lie the back of the neck, which disappears on sitting. spinous processes, set within a groove between these muscles. This may follow a vertical course, When carrying out the systematic inspection, the or may be found to deviate from the vertical examiner again works upward from the feet. Points • the apex of the lordosis and the transition to to assess are: kyphosis • the shape of the lower leg and especially the • the position of the shoulder blades: how high, and, if prominent, how symmetrical knee: genu recurvatum is a sign of laxity • the relative height and shape of the shoulders • the shape of the buttocks • the quadratus lumborum and latissimus dorsi • the lumbar curvature: note whether the apex muscles; these form the lateral contour of the of the lordosis is located at or above the lumbosacral junction. In cases of increased lordosis with flabby posture, the abdomen is seen to protrude; this is not always a sign of adiposity. This protrusion may be at its maximum at the navel; however, if there is a drooping belly the level may be much lower 91

Manipulative Therapy • the level of the transition from lumbar lordosis • the sternum and pectoral muscles. It is mainly to thoracic kyphosis: note whether the patient in male patients that these are easily seen has a flat or round back; if the thoracic spine is flat there is frequently increased kyphosis at the • the clavicles, noting how they move during cervicothoracic junction inhalation and exhalation and the extent to which they participate in the movements of • the shape of the spinal column respiration (markedly or little). The depth of • the position of the shoulders: whether drawn the supraclavicular fossae is important; these are deeper when the thoracic cage remains in an forward or protruding. inspiratory position, as happens in emphysema, for example, or where there is a functional Cervical lordosis largely depends on the shape problem of faulty breathing. In this case there of the thoracic spine. If the thoracic spine is flat, is also hypertonus of all the other upper fixators cervical lordosis may be completely absent. This is of the shoulder girdle, which is manifested as a particularly seen in individuals of the athletic type ‘Gothic shoulders’ posture with broad shoulders and a flat thoracic cage; simi- larly in ballet dancers. If the back is round, on the • the position of the shoulders: asymmetry is other hand, the thoracic kyphosis often continues almost the general rule into the lower cervical spine, with only the upper part of the cervical spine showing lordosis. • the jugular fossa in the neck region between the medial ends of the clavicles, and the In flabby posture, exaggerated cervical lordosis is sternoclavicular joint: one joint is often found sometimes seen; the thyroid cartilage (and trachea) to be more prominent than the other, although may protrude, giving the impression of an enlarged this need not be clinically significant. The thyroid gland. This, however, disappears in the sternocleidomastoids can be seen either side of supine position. the jugular fossa; the lateral attachment of this muscle on the clavicle is usually less distinct. In a forward-drawn posture there is frequently Between the sternocleidomastoids and the hyperlordosis in the craniocervical region. trapezius, some bundles of the scaleni may be visible in slim patients 4.2.3 The ventral aspect • the thyroid cartilage: this can be seen more At inspection of the ventral aspect the most striking distinctly in males. Any lateral shift in its features are asymmetries between one side and the position is clinically very significant, since other, especially those that fall into the category of this indicates tension in one of the digastric hemihypertrophy. Working from caudal to cranial, muscles, drawing the hyoid to one side along the points to observe are: with the thyroid cartilage. This observation is • the position of the feet and their transverse and accompanied by distortion and asymmetry of the floor of the mouth, which is shallower on longitudinal arching one side and deeper on the other • the knees: varus or valgus alignment • the thighs • hyperactivity of the masticatory muscles: • the lower abdomen. Note a protruding abdomen this can often also be seen at rest. Another manifestation is that the patient’s mouth hardly and also the navel; the position of the navel is opens during speech. important. Specific points to note are whether it is central, and whether it lies on the surface • the face: facial asymmetry is very frequent, or at some depth. If the patient has a large and can be combined with asymmetry of bite abdominal circumference and the navel is and even ‘facial scoliosis.’ This in turn can be deep-lying, this indicates corpulence, but if the associated with scoliosis of the spinal column abdomen is enlarged and the navel ‘floats’ in a and hemiatrophy. superficial position, it is indicative of muscle weakness. The lateral contours of the abdominal To summarize: inspection of the dorsal and ventral wall are normally concave, but if the abdominal aspects enables the practitioner to detect muscles are weak, the contour is convex bulging asymmetries, either in the sense of relative • the epigastric angle: this may be obtuse or acute 92

Diagnosis of dysfunctions of the locomotor system Chapter 4 weakness of one side (hemihypogenesis), or and movement. It is registered using not only our simply of the marked dominance of one side. pressure receptors but also, simultaneously, our Dominance is clearly recognized by the arm proprioceptors. that is more powerful. In the lower limbs, the stance leg is more powerful and solid, though Further, touch constantly evokes a reaction from it is the swing leg that is dominant. the patient, and this reaction must also be regis- tered. Feedback operates between the examiner 4.2.4 Inspection of the and the patient, and is extremely important in diag- seated patient nosis; a non-reproducible process of feedback is taking place between two systems. Examination of the patient in the relaxed, sitting posi- tion can produce very different results from those Palpation is a method that reveals a great deal obtained with the patient standing. This is particularly to the experienced examiner; a host of informa- so with hypermobile subjects, in whom lumbar hyper- tion that a technological instrument is incapable of lordosis standing changes to a kyphotic posture when providing. The fact that it is not reproducible fre- seated and relaxed. This is accompanied by a forward- quently leads to its rejection as too subjective: how- drawn neck and hyperlordosis at the atlanto-occipital ever this is not only absurd on practical grounds but and atlantoaxial joints. This is particularly important also theoretically untenable; computers that proc- in subjects whose profession is mainly sedentary. ess information are in essence no more than imper- fect copies of the nervous system. The information Inspection from above would reveal rotation of that we obtain from them is uncritically accepted the shoulder girdle in relation to the pelvic girdle as ‘objective’ while the original, the human brain and the feet. and the hands that provide the sensory input of information, are rejected as unreliable. Yet there is already radiological evidence to demonstrate ‘palpa- tory illusions’ (see Figure 4.11). 4.3 Palpation (soft-tissue The palpating hand has receptors to sense heat examination) and cold, to distinguish pressure, motion, position, and tissue quality. No technological instrument is Palpation is extremely important in the diagno- able to detect and integrate all these factors sis of painful structures of the locomotor system simultaneously. There is also a feedback process and essential for all manipulative techniques. This between practitioner and patient, both during examination therefore follows next, immediately diagnosis and during treatment. after the inspection. 4.3.1 Hyperalgesic zones The first step in palpation is to place a hand (fin- ger) onto the surface of the patient’s body, and then The quickest, most elegant method of finding a to focus one’s attention on the aspect to be tested: hyperalgesic zone (HAZ) is to run one’s fingers warmth, moisture, consistency (whether the sur- very lightly over the surface of the skin: heightened face is rough or smooth), mechanical properties friction is felt at an HAZ on account of increased (resistance, mobility, stretch capacity), and whether sweat production. The lighter the touch of the fin- the examination causes the patient to feel pain. gers, the more readily this is detected. The ‘barrier’ phenomenon is used when examining all the tissues Given that palpation is associated with touch, and of the locomotor system other than bones (see this in turn with pressure, we might think that an Figure 2.3). The points to note are: objective way to perform it would be to use a pres- • the point at which the first resistance is felt sure gauge. Sadly this idea is misleading; palpation is never a matter of mere (static) pressure, but a proc- on moving away from the neutral position: ess that involves movement of the hands (fingers). on stretching or folding the skin, stretching a subcutaneous fold, or displacing muscles relative Whether attempting to penetrate down from the to the bone surface to underlying layers, or to examine some aspect of the tissue by feel, we are constantly mov- ing tissue aside or drawing it apart. Palpation there- fore involves a combination of alternating pressure 93