Week 2 Study Quide Q A

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.
 the first branch from the subclavian trunk, becomes closely related to
the spine entering the transverse foramen of the 6th cervical vertebral
level.
 It passes through the transverse foramen from C6- C1 lying directly in
front of the cervical nerves and medial to intertransverse muscles.
 It accompanies vertebral plexus, veins, cervical nerves (sympathetic
fibers arising from inferior stellate ganglion.
 After leaving C2 it passes with the artery through the transverse
foramen of the atlas. Then around the posterior lateral aspect of the
superior articular process of C1.
 As the nerve travels posterior, it passes the atlanto-occipital joint
capsule and through the arcuate foramen
 Then turning upward its runs through the foramen magnum into the
cranial cavity.
 It then passes the lower pons where it joins the other vertebral artery to
become the basilar artery.
 Branches from the vertebral artery also supply facet joint structures,
NRs, and dorsal root ganglia.
Q2. What is the Circle of Willis and what does it supply?
 The basilar artery splits to make the circle of Willis, joined anteriorly by
internal carotid arteries.
 At the foramen magnum, a branch comes off at each vertebral artery to
unite with the anterior surface of the cord. These branches give off
posterior spinal arteries that supply the cord down to T4.
 Another branch of the vertebral artery, posterior inferior cerebellar
artery (PICA) leaves the vertebral artery and runs along the medulla.
 The vertebrobasilar system supplies the inner ear, the cerebellum, pons
and brainstem and the posterior portion of the cerebral hemisphere e.g.
visual cortex.
Q3. What is the incidence of manipulation- associated Vertebral Artery Injury

and Stroke VAD and VBA?
- 1.3 in 1000 cases of stroke per year

- General population dissection rate = approx 0.97 to 1.2 per 100,000
individuals.
The estimated incidence of VBAI stroke following or occurring 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?
45 yrs of age or less, apparently healthy, suffer from a MSK complaint such as
head, neck, shoulder pain no significant history of hypertension or
hypotension.
Q5. Currently is there established history and physical examination findings

that predict whether a patient will develop VAD?
- No there isn’t
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?
- Aim to provoke signs of VBAI by inducing extension and extreme

rotation of the neck
- However they don’t provided diagnostic value so are no longer used for
care screening procedures
Q7. What are the potential warning signs or risk factors for cervical artery
dissection (CAD)? According to Triano J Kawchuck
Sudden severe pain in the side of the head or neck which is different from any
pain the patient has had before.
2.Dizziness, unsteadiness, giddiness and vertigo
3. Age <45 yrs
4. Migraine
5. Connective tissue disease
 Autosomal dominate polycystic kidney disease
 Ethers-Danlos Type IV
 Marfans syndrome
 Fibromuscular dystrophy
6.Recent infection, particularly upper respiratory
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? What are the other steps to follow with possible post manipulative
stroke patient?
1. Do not adjust patient again

2. Do not allow patient to get up and start walking, keep them comfortable
3. note all physical and vital signs (pallor, sweating, vomiting, heart and
respiratory rate, blood pressure and temperature)
4. check the pupils for size shape and equality
5. check the eyes for light and accommodation reflexes.
6. Test then lower cranial nerves (facial numbness, paresis, swallowing, gag
reflex, slurred speech and palatal elevation)
7. Test cerebellar function (dysmetria of extremities, nystagmus, and
tremor)
8. Test for strength and tone
9. Test sensation to pinprick
10. Test muscle stretch and pathologic reflexes
11. 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?
- Serious neurological condition due to an occlusion of the basilar artery

with conservation 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.
- Atlanta-occipital and atlanto-axial articulations
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?
Allows concentration of the applied testing vector to cause rotation on the x

axis in the joint. Resulting in 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?
Each condyle rests in a matching concavity on the superior aspect of the lateral
mass of C1. The depth of these concavities is responsible for the stability of the
atlanto-occipital joint. The side walls prevent the occiput from slipping
sideways and the A- P walls prevent translation.
Q13. Where is the foramen transversarium found in the neck.
- Within the transverse processes

Q14. List the unique features of the C2 (axis)
Superior surface of the body carries the odontoid process centrally which acts
as a pivot for atlanto-odontoid joint.
- Laterally possess 2 articular facets facing superior and laterally
- Facets are convex AP and flat transversely
- Posterior arch consists of narrow laminae
- The cartilage lined inferior articular process corresponds to the superior
articular process of C3.
Q15. Describe why the atlantoaxial joint is so unique.
It is a plane synovial joint and comprises of 3 mechanically linked joints

- The central joint is the atlanto-odontoid joint
- Two lateral joints-atlanto-axial joints
- Is synovial trochoid /pivot joint
- Joint surfaces - anterior articular facet of odontoid and posterior
articular facet of the anterior arch of the atlas
Q16. Explain the movements that occur at the atlantoaxial joint.
Flexion- The point of contact is between two convex surface moves forward
interspace of atlanto-axial joint opens superiorly
Extension – The Interspace of atlanto-axial joint opens inferiorly

NB. Radiological findings does not show opening of interspaces
This is due to transverse ligament and keeps the anterior arch and odontoid
process in close contact
During flexion and extension the inferior surface of atlas rolls and sides over
superior articular surface of axis.
Left to right rotation - The left lateral mass of the atlas moves forward
Right lateral mass recedes in rotation from left to right and vice versa from
right to left.
Q17. How do the occipital condyles move differently at the atlanto occipital
joint?
Flexion the occipital condyles recede on the lateral masses of the atlas. The
occipital bone moves away from the posterior arch of the atlas
Extension the occipital condyles slides anteriorly on the lateral masses of the
atlas. The occipital bone moves nearer to the posterior arch of the atlas.
Lateral flexion movement only occurs between C0-C1 and C2-C3.

Slipping of occipital condyles of the atlas on opposite side to movement of the
atlas (Left lateral flexion = slipping of occipital condyles on right of atlas)
Rotation when the occiput rotates on atlas its rotation is secondary to rotation
of atlas on axis. Vertical axis passing through the centre of odontoid causes
right anterior displacement of right occipital condyle on right lateral mass of
the atlas
Q18. Discuss the tissues that are influenced with the movement of flexion in
the mid neck region.
- upper vertebral body tilts and slides anteriorly Intervertebral space is

compressed anteriorly and opened wide posteriorly.
- The nucleus pulposus is driven posteriorly.
- The posterior fibers of annulus fibrosis is stretched
limited by the tension developed in the posterior longitudinal ligament
By the capsular ligament ligamentum flavum, ligamentum nuchae
Q19. Name the muscles that help in maintaining the cervical lordosis.
- Splenius Cervicis, Semispinalis Cervicis, Leavator Scapulae, Transverso

Spinalis, Longismus Capiis, Spenius Capitis, Trapezius
Q20. What functions do the Alar ligaments serve in the cervical spine
- Prevents anterior displacement of C1 on C2.

- Axial rotation of head and neck tightens both alar ligaments
- Prevents distraction of C1 on C2.

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CHIR12006

Week 2 Study Guide Questions

Cerebral Artery Injury and Cerebrovascular Events.

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

- 1.3 in 1000 cases of stroke per year

The estimated incidence of VBAI stroke following or occurring during cervical

Q5. Currently is there established history and physical examination findings

- Aim to provoke signs of VBAI by inducing extension and extreme

1. Do not adjust patient again

Q9. What is locked in syndrome?

- Serious neurological condition due to an occlusion of the basilar artery

Cervical Biomechanics Study Guide Questions

- Atlanta-occipital and atlanto-axial articulations

Q11. The occipital condyles and are angled anteromedially.

Allows concentration of the applied testing vector to cause rotation on the x

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

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

- Within the transverse processes

Q15. Describe why the atlantoaxial joint is so unique.

It is a plane synovial joint and comprises of 3 mechanically linked joints

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

Extension – The Interspace of atlanto-axial joint opens inferiorly

Lateral flexion movement only occurs between C0-C1 and C2-C3.

- upper vertebral body tilts and slides anteriorly Intervertebral space is

- Splenius Cervicis, Semispinalis Cervicis, Leavator Scapulae, Transverso

- Prevents anterior displacement of C1 on C2.

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