Chapter 23

At the completion of this chapter, the reader will be able to:

1. Describe the anatomy of the vertebrae, ligaments, muscles, and blood and nerve supply that comprise the craniovertebral segments.

2. Describe the biomechanics of the craniovertebral joints, including coupled movements, normal and abnormal joint barriers, and kinesiology.

3. Perform a comprehensive history and systems review for the craniovertebral region.

4. Perform a detailed examination of the craniovertebral musculoskeletal system, including palpation of the articular and soft tissue structures, specific passive mobility tests, passive articular mobility tests, and stability tests.

5. Evaluate the total examination data to establish a diagnosis.

6. Apply appropriate manual techniques to the craniovertebral joints, using the correct grade, direction, and duration.

7. Describe intervention strategies based on clinical findings and established goals.

8. Evaluate intervention effectiveness in order to progress or modify intervention.

9. Plan an effective home program and instruct the patient in this program.

10. Help the patient to develop self-reliant intervention strategies.

The craniovertebral region is a collective term that refers to the occiput, atlas, axis, and supporting ligaments, which accounts for approximately 25% of the vertical height of the entire cervical spine. Injuries to this region have the potential to involve the brain, brain stem and spinal cord, resulting in a myriad of symptoms ranging from headache and vertigo to cognitive and sympathetic system dysfunction.1 Craniovertebral injuries that involve cognitive and sympathetic system dysfunction demonstrate a poorer prognosis and a lengthy recovery.

The craniovertebral region is considered as a separate entity from the rest of the cervical spine because of its distinct embryology and anatomical structure. Kapandji2 notes that the occiput, atlas, and axis actually form a primary kyphotic curve and that this curve serves as a delineation between the craniovertebral region and the cervical spine proper.

### Foramen Magnum

The general shape of the foramen magnum is oval, with the longer axis oriented in the sagittal plane (Fig. 23-1).3 The margin of the foramen is relatively smooth and serves as the most superior attachment for a variety of the ligaments of the vertebral column. The smaller anterior region of the foramen magnum is characterized by a pair of tubercles to which the alar ligaments attach. The posterior portion of the foramen magnum houses the brain stem–spinal cord junction.

###### Figure 23-1

Bony structures of the craniovertebral joints. A. The atlas (C 1). B. The axis.

On either side of the anterolateral aspect of the foramen magnum are two ovoid projections, called occipital condyles (Fig. 23-1). The long axis of these paired occipital condyles is situated in a posterolateral to anteromedial orientation. The occipital condyles articulate with the first cervical vertebra.

### Atlas

The atlas is a ring-like structure that is formed by two lateral masses, which are interconnected by anterior ...

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