Neuro Anatomy. Cervical Spine. Spinal Nerves. Cervical Nerve Roots. Brachial Plexus

Transcription

1 Neur Anatmy Cervical Spine Spinal Nerves Spinal nerves emerge frm dura mater as ventral (anterir) and drsal (psterir) nerve rts The ventral nerve rt carries mtr infrmatin away frm the spine The drsal nerve rt carries sensry infrmatin frm the bdy t the spine The drsal rt ganglin cntains the cell bdies f the sensry neurns The drsal rt ganglin is particularly sensitive and is ften the cause f radicular pain The tw nerve rts then cme tgether as they g thrugh intervertebral framen They will then split int ventral and drsal rami t becme peripheral nerves Drsal rami supplies psterir back muscles Ventral rami prgress, frming a plexus supplying the rest f the bdy Cervical Nerve Rts Althugh there are 7 cervical vertebrae there are 8 cervical nerve rts The nerve exiting at C0-C1 is named the C1 Nerve rt Each nerve rt is named in relatin t the vertebrae belw, i.e C4 nerve rt is between C3-C4 The nerve rt between C7- T1 is the C8 nerve rt Frm T1 dwn the nerve rt is named by the vertebrae abve Brachial Plexus Frmed by the ventral rami f the lwer fur cervical nerves and first thracic nerve Frms just utside the intervertebral framen in between scalenus anterir and medius Cllectively named the rts f the plexus Upper tw rts (C5,6) - > Upper trunk C7 rt -> Middle Trunk Lwer tw rts (C8, T1) -> Lwer trunk (frms very clse t the subclavian artery and first rib) All trunks are between the scalenes and clavicle Each trunk then divides int anterir and psterir divisins Upper, Middle and Lwer trunk psterir divisins -> psterir crd Upper, Middle trunk anterir divisins -> lateral crd Lwer trunk anterir divisin -> medial crd All crds pass int the axilla psterlateral t the axillary artery They then mve int their named psitins (psterir, lateral, medial) relative t the axillary artery when psterir t pectralis minr The brachial plexus is susceptible t injury frm tractin r even cmpressin 1

2 Nerves Frm The Brachial Plexus Branches frm the Rts Drsal scapular nerve (C5) Lng thracic nerve (C5,6,7) Branches frm the Trunks Subclavius nerve (C4,5,6) Suprascapular nerve (C4,5,6) Branches frm the Crds Medial Crd Medial pectral nerve (C8, T1) Medial cutaneus nerve f the frearm (C8, T1) Medial cutaneus nerve f the arm (T1) Ulnar nerve (C7,8,T1) Medial part f the median nerve (C8,T1) Psterir Crd Upper subscapular nerve (C4,5,6,7) Thracdrsal nerve (C6,7,8) Lwer subscapular nerve (C5,6) Axillary nerve (C5,6) Radial nerve (C5,6,7,8,T1) Lateral Crd Lateral pectral nerve (C5,6,7) Musculcutaneus nerve (C5,6,7) Lateral part f the median nerve (C5,6,7) Axillary Nerve Frm Psterir crd f brachial plexus Rt Value C5,6 Anatmy Descends psterir t axillary artery but anterir t subscapularis Passes int quadrilateral space supplying shulder jint Divides int anterir and psterir branches Anterir branch winds arund surgical neck f humerus t anterir deltid Psterir branch cntinues psterirly t teres minr and psterir deltid 2

3 Muscles Supplied Deltid Teres Minr Cutaneus branch Upper lateral cutaneus nerve f the arm Supplies the skin ver lwer part f deltid and lateral head f triceps Musculcutaneus Nerve Frm Lateral crd f brachial plexus Rt Value C5,6,7 Anatmy Descends laterally between axillary artery and cracbrachialis Pierces cracbrachialis and runs distally inbetween biceps and brachialis t lateral arm Surfaces at elbw between biceps and brachiradialis Extends as lateral cutaneus nerve f frearm t lateral frearm and base f thumb Muscles Supplied Cracbrachialis Biceps Brachii Brachialis ( 2 / 3) Cutaneus Branch Lateral cutaneus nerve f frearm Ulnar Nerve Supplies skin ver lateral half f frearm t base f thumb Frm Medial crd f brachial plexus Rt Value C7,C8,T1 Anatmy Descends medial t axillary artery and then anterir t triceps Pierces the medial intermuscular septum t pass int psterir cmpartment f the arm Passes between the medial epicndyle f humerus and lecrann f ulna Than passes int anterir cmpartment f frearm medially Travels laterally past the pisifrm 3

4 Muscles Supplied Flexr carpi ulnaris Flexr digitrum prfundus Palmaris brevis Abductr, flexr and ppnens digiti minimi Medial 2 lumbricals Palmar and drsal interssei Adductr pllicis Cutaneus branches Palmar cutaneus branch Drsal branch Superficial branch Digital branch Supplies skin ver medial palmar and drsal wrist t 5 th digit and the medial aspect f the 4 th digit Radial Nerve Frm Psterir crd f brachial plexus Rt Value C5,6,7,8,T1 Anatmy Passes psterir t axillary artery, but anterir t subscapularis, latissums drsi and teres majr tendns Nerve passes psterirly t humerus and wrap arund the radial grve f humerus between medial and lateral triceps heads Nerve then pierces the intermuscular septum t anterir cmpartment f between brachialis and brachiradialis Passes anterir t lateral epicndyle, divides int superficial and deep branches int lateral frearm, thumb and digits 2-4 Muscles Supplied Triceps Ancneus Brachialis (lateral third) Brachiradialis Wrist extensrs Extensr indicis Abductr pllicis lngus 4

5 Cutaneus branches Psterir cutaneus nerve f the arm Lwer lateral cutaneus nerve f the arm Psterir cutaneus nerve f the frearm Superficial radial branch Supplies skin ver lateral and psterir aspect f upper arm, psterir middle aspect f frearm, drsal wrist and hand, nt int finger tips Median Nerve Frm Medial and lateral crds f the brachial plexus Rt Value C5,6,7 (lateral crd) C8,T1 (medial crd) Anatmy Descends under biceps brachii and int elbw under cubital fssa Passes thrugh the anterir frearm and enters the hand deep t the flexr retinaculum Cntinues t thumb and 2 nd -4 th digits Muscles Supplied Prnatr teres Wrist Flexrs Oppnens pllicis Lateral 2 lumbricals Cutaneus branches Palmar cutaneus branch Lateral and medial branches Digital branches Supplies skin ver palmar aspect f lateral wrist, thumb, digits 2, 3 and half f 4. Drsal finger tips f digits 1-3 and half f 4 5

6 Neurdynamics The Neurdynamic System Refers t the interactin f the nervus system with its surrunding structures Made up f 3 cmpnents Mechanical Interface All the structures that surrund the nervus system, i.e tendns, ligaments, fascia, bld vessels, disc etc Neural Structures Brain, spinal crd, dura mater, nerve rtlets, nerve rts, peripheral nerves Innervated Tissues Any structure that is innervated by a nerve If there is a restrictin r alteratin in any neural structure MTrP s can develp in the muscles it may supply Sensry AND mtr functins can be inhibited. Abnrmal Neurdynamic System Can be the result f ne r a cmbinatin f the fllwing three cmpnents Tensin As the nervus system is cnnected at bth ends it will act like a piece f string with certain mvements taking up the slack increasing the amunt f tensin Sliding The nervus system will slide in relatin t the mechanical interface. There can be areas where the nervus system will struggle t slide thrugh r between structures Cmpressin The mechanical interface can physically cmpress the nervus system Mvement f the Nervus System Generally as a jint mves the neural structures mve twards the jint distally and prximally. This temprarily increases the slack f the nerve surrunding the jint, allwing tensin t be increased as the jint mves The sequence f mvements can affect the lcalizatin f stress The first regin t be mved r mved strngest will increase the chance f a respnse in this area 6

7 Assessing Neurdynamics Start with standard Upper Limb Tensin Test Change the mechanical interface E.g ipsilateral cervical rtatin and side flexin will clse the intervertebral framen Check neural structures sliding and tensiners Check the innervated tissues Dermatme, Mytme and Deep Tendn Reflexes Als check anatmical muscular cntractin vs muscular cntractin under neural lad Median Nerve Tensin Test Psitin 1. Client supine 2. Therapist standing t side facing cephalad 3. Therapists clsest hand abve clients shulder ready t depress 4. Therapists furthest hand pistl grip with clients thumb extended Prcedure 1. Glenhumeral abductin t resist scapular elevatin 2. Glenhumeral external rtatin 3. Frearm supinatin and wrist and finger extensin 4. Elbw extensin Ulnar Nerve Tensin Test Psitin 1. Client supine 2. Therapist standing t side facing cephalad 3. Therapists clsest hand abve clients shulder ready t depress Prcedure 1. Shulder depressin 2. Wrist and finger extensin 3. Frearm prnatin 4. Elbw flexin 5. Glenhumeral external rtatin 6. Glenhumeral abductin 7

8 Radial Nerve Tensin Test Psitin 1. Client supine 2. Therapist standing caudad 3. Web space f therapists clsest hand ver shulder ready t depress Prcedure 1. Scapular Depressin 2. Elbw extensin 3. Glenhumeral internal rtatin 4. Frearm prnatin 5. Glenhumeral abductin 6. Wrist thumb and finger flexin Determining The Outcme Of A Test Neurdynamic tests are never psitive r negative They are best described as nrmal r abnrmal Abnrmal results include Reprductin f clients familiar symptms (pain r radiculpathy) that is altered thrugh structural differentiatin Reduced OR Increased range f mvement cmpared t nrmal side Reprductin f pain r radiculpathy in an area that they wuld nt be expected cnfirmed by structural differentiatin Therefre when writing patient ntes the fllwing can be used ULTT Ulnar Nerve Right- Abnrmal- Restricted ROM (unable t reach head with hand)- Familiar pain reprted little finger- Decreased with cntralateral cervical flexin 8

9 Structural Differentiatin T determine whether symptms reprted during testing is due t the neurdynamic system structural differentiatin must be used This is dne in the fllwing way Elicit a respnse using a test and hld this psitin Mve a jint that is at least 2 steps away frm the area f symptms If this increases/decreases symptms the neurdynamic system is the structure at fault Shuld symptms remain exactly the same there is a mechanical cause t the clients symptms during testing E.G E.G 2 Radial Nerve testing reprduces familiar lateral frearm and thumb pain Cervical cntralateral flexin is intrduced (2 steps away) This INCREASES symptms Ipsilateral cervical flexin is perfrmed This DECREASES symptms This wuld indicate the neurdynamic system is dysfunctinal Ulna Nerve testing prduces shulder pain Finger flexin is intrduced (2 steps away) Symptms remain the same Wrist flexin is intrduced Symptms remain the same This wuld indicate a mechanical dysfunctin f the shulder Dermatme Testing Test the dermatme patterns f the cervical spine bilaterally simultaneusly Abnrmalities require further investigatin which can be cmpleted with sharp r blunt testing N.B there is cnsiderable verlapping f dermatme patterns which ften differ between texts Dermatme abnrmalities that fail t respnd t physitherapy require investigatin by a spinal r neurlgical specialist C1: tp f head C2: side and back f the head, upper half f the ear, cheek and upper lip, nape f the neck C3: entire neck, lwer mandible, chin, lwer half f the ear C4: epaulette area f the shulder C5: anterlateral aspect f the arm and frearm as far as the base f the thumb C6: anterlateral aspect f the arm and frearm, thenar eminence, thumb and index finger C7: psterir aspect f the arm and frearm, index, middle and ring fingers C8: medial aspect f the frearm, medial half f the hand, middle, ring and little fingers T 1: medial aspect f the frearm, upper bundary uncertain 9

10 Mytme Testing Test the mytmes f the cervical spine bilaterally and simultaneusly where pssible Maintain resistance fr 5 secnds at least Nerve rt weakness will be evident after 5 secnds, peripheral nerve weakness is evident immediately Mytmal weakness requires further investigatin by a spinal r neurlgical specialist As with dermatmes there is sme verlap and differences between texts C1/2: Cervical Flexin/ Extensin C3: Cervical Lateral Flexin C4: Scapular Elevatin C5: Shulder Abductin, Shulder Lateral Rtatin C6: Elbw Flexin, Wrist Extensin C7: Elbw Extensin, Wrist Flexin C8: Thumb Adductin/ Extensin T1: Finger Adductin Management Sft Tissue Release While hlding the limb in a psitin that represents the abnrmal tensin test perfrm sft tissue release alng the pathway f the peripheral nerve frm the cervical spine t the fingers Mbilisatins The neurdynamic system can be mbilised by either sliders r tensiners Sliders Tensin is never increased thrugh the nerve Pint A and B f a nerve will always stay the same distance frm ne anther E.g Median Nerve testing- scillate between wrist flexin/elbw extensin and wrist extensin/elbw flexin Sliders are the treatment f chice fr very irritable symptms Tensiners Pint A and B f a nerve will increase in distance frm ne anther E.G Medial Nerve testing- Grade II Physilgical Elbw Extensin Mbilisatin This can be dne int resistance r symptms, r can be cmpleted befre the nset f symptms Hme Exercise Prgramme Clients can be instructed f self- mbilisatins t cmplete at hme Cautin-ensure crrect technique f sliders and tensiners etc t avid aggravatin f symptms Mnitr symptm respnse frm neurdynamic hme exercise prgrammes as regular self-mbilisatins may aggravate symptms if dne t aggressively and regularly 10