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CHIR12006

Week 2 Study Guide Questions

Cerebral Artery Injury and Cerebrovascular Events.

Q1. Describe the course of the vertebral artery commencing from the
subclavian Artery in the body.
- Arise from subclavian arteries bilaterally proximal to the thyrocervical
trunk and distal to the common carotid artery
- Divided into 4 segments as they ascend the cervical spine
1. From subclavian artery to transverse foramen of C6
2. Remains within transverse foramen from C6-C2.
3. From superior of C2 foramen to the dura.
4. From the dura into the cranium.

Q2. What is the Circle of Willis and what does it supply?


The Circle Of Willis is a circular formation of blood vessels in the brain which
supply the following structures:
- Posterior spinal arteries supply spinal cord to T4
- The cerebellum
- Pons
- Brainstem
- Inner ear
- Visual cortex

Q3. What is the incidence of manipulation- associated Vertebral Artery Injury


and Stroke VAD and VBA?
VBAI is currently 1.3 in 1000 stroke cases per year. Dissection rate is
approximately 0.97-1.2 per 100 000 individuals.

During cervical manipulation less than 1 in 2 million to 1 in 3.8 million to 5.8


million cervical manipulations.

Q4. According to the literature what is the patient profile of those who have
developed post manipulative VBA strokes?
It is patients which are younger than 45 and do not have a history circulatory
issues and complain of head, neck and shoulder pain for no apparent reason. It
is common for these patients to seem quite healthy also.

Q5. Currently is there established history and physical examination findings


that predict whether a patient will develop VAD?
There is no current test or screening which can be taken to determine whether
a patient may be suffering from VBI/VAD.

Q6. There are a number of functional tests for the vertebral arteries e.g.
(Georges, de Klyens, Hautants, Houles, Wallenberg tests). They all aim to
what? Are they used in clinical practice today?
These various tests involve taking the cervical spine into deep extension and
rotation which ultimately is aimed at provoking signs involved in VBI. Due to
the risks involved in these tests, they are no longer used in clinic today.

Q7. What are the potential warning signs or risk factors for cervical artery
dissection (CAD)? According to Triano J Kawchuck
Initially, a patient may present with dizziness, unsteadiness, migraines,
giddiness or vertigo which may encourage them to see a chiropractor. In
addition to this, a sudden onset of indifferent pain in the head and in particular
patterns may also be suspicious.

A history of connective tissue diseases in the family such as Marfans syndrome,


or fibromuscular dystrophy can also be suspicious. Also, this occurs generally in
people under the age of 45 yrs.

Q8. It is absolutely imperative that the clinician be able to recognise the signs
of VBI and take appropriate steps to minimise the pathological effects. If they
do occur, specific steps must be followed. A) The most important first step is
what? Do not adjust the patient again! An adjustment is only to be taken once
the previous effects have resided.
B) What are the other steps to follow with possible post manipulative stroke
patient?
1. Do not allow patient to stand or walk. Keep them comfortable.
2. Note all physical and vital signs.
3. Check pupils and size shape and equality.
4. Check eyes for light and reflexes.
5. Test lower cranial nerves for anything abnormal. (EG. paresis, swallowing,
gag reflex, numbness, slurred speech)
6. Test cerebellar function (nystagmus, tremor, dysmetria of extremities)
7. Strength and tone test.
8. Sensation to pinprick.
9. Muscle stretch and pathologic reflexes.
10. If condition does not abate referral is necessary, medical emergency
transport patient to hospital, relay all findings recommend MRA and consider
anticoagulant therapy within 3 hours to effectively dissolve an offending clot.

Q9. What is locked in syndrome?


A neurological condition which can result from a stroke that damages the
basilar artery with se of only the vertical ocular motility and blinking ability.

Cervical Biomechanics Study Guide Questions

Q10. Name the joints in the neck that do not have IVD.
Atlanto-occitpital (AO) and atlanto-axial (AA) joint complexes.

Q11. The occipital condyles and are angled anteromedially.


about 30- 40 degrees, thus converging towards the front of the patient. What
are the clinical implications of this angulation?
This allows for a concentration of the applied testing vector to cause rotation
about the x axis in the joint and thus a more accurate assessment of any
flexion and extension fixation in the sagittal plane.

Q12.What are some of the features of the antlanto-occipital joint that


provide it with stability?
The superior condyle has a deep concavity in which it allows the inferior
segment to ‘rest’ in – Atlas or C1. In addition to this, the side walls prevent the
occiput from slipping sideways.

Q13. Where is the foramen transversarium found in the neck.


The transverse processes possess foramen transversarium.

Q14. List the unique features of the C2 (axis)


- Contains odontoid process (dens), 2 articular facets which face laterally
and superiorly and these facets convexly face A-P and transversely.
- Plays an important role in rotation of the head with the majority of
movement occurring around the dens and at the atlanto-axial joint.
- Superior articulation carries centrally the odontoid process
- Posterior arch contains laminae.

Q15. Describe why the atlantoaxial joint is so unique.


- Classified as plane synovial joint
- 3 mechanically linked joints which are atlanto-odontoid, synovial
trochoid and atlanto-axial
- Anterior articular facet of dens and posterior articular facet of anterior
arch of atlas

Q16. Explain the movements that occur at the atlantoaxial joint.


Flexion: between two convex surfaces, interspace of atlanto-axial joint opens
superiorly.
Extension: Interspace of atlanto-axial joint opens inferiorly. Cannot be seen in
radiographic imaging due to the transverse ligament keeping in close contact
with its surroundings. Inferior surface of atlas rolls and slides over surperior
articular surface of axis.
Rotation: lateral mass of atlas moves forward – contralateral mass moves
forward. Ipsilateral mass recedes.

Q17. How do the occipital condyles move differently at the atlanto occipital
joint?
The occipital condyles on the atlanto-occipital joint only allows for three slight
degrees of motion and these are:
Lateral flexion (z axis)
Axial rotation (y axis)
Flexion/extension (x axis)

Q18. Discuss the tissues that are influenced with the movement of flexion in
the mid neck region.
During flexion, the upper vertebral body tilts and slides anteriorly while the
intervertebral space is closed anteriorly and opened posteriorly. The nucleus
pulposus is pushed posteriorly. This movements is limited by the ligaments
including ligamentum flavum, ligamentum nuchae and posterior longitudinal
ligament.

Q19. Name the muscles that help in maintaining the cervical lordosis.
The muscles which aid in maintaining cervical lordosis are:
- Splenius Cervicis
- Semispinalis Cervicis
- Levator Scapulae
- Transverso Spinalis
- Longismus Capiis
- Spenius Capitis
- Trapezius
The muscles which aid in straightening the cervical spine while holding it
upright are:
- Rectus capitis minor
- Longus cervicis
- Rectus capitis major
Muscles which support cervical spine at rest are:
- Suprahyoid
- Infrahyoid
- SCM
- Scalenes (anterior, posterior and medius)

Q20. What functions do the Alar ligaments serve in the cervical spine
The main function of the alar ligament in the cervical spine is to prevent
displacement or slipping of C1 on C2. Therefore, it also prevents distraction of
C1 on C2.
Note: Axal rotation of the neck tightens the alar ligaments.

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