AO and AA joints and neck pain The anatomy of atlantooccipital (AO) and atlantoaxial (AA) is uniquely different in the cervical spine. The AO joint is a synovial articulation between the convex occipital condyles of the skull and C1. The AA joint consists of the lateral articulations between C1 and C2 and the median articulation between the odontoid process and the posterior surface of the anterior arch of the atlas anteriorly and the transverse ligament posteriorly. The AO and AA joints provide mechanical stability between the head and cervical spine while allowing for significant movement. Approximately 33% of cervical spine flexion and extension comes from the AO joint. Over 50% of cervical spine rotation occurs at the AA joint. Pain related to AO or C0–C1 dysfunction tends to occur at the occipito-cervical region, in the retro-mastoid region, and in the upper cervical area. Pain related to dysfunction in C1– C2 most often occurs in the suboccipital area with radiation up to the back and head and down into the upper neck (Hurley et al., 2022). Self-Assessment Quiz Question #33 Another name for the articulation between the occipital condyles of the skull and C1 is: a. Atlanto-axial joint. b. Atlanto-occipital joint. c. Axial-occipital joint. d. C1-C2. Self-Assessment Quiz Question #34 The structure that runs posterior to the dens and provides stability to the C1/C2 articulation via the den is: a. Transverse ligament. b. Atlas ligament. Mr. Barnes presents to physical therapy with complaints of neck pain. When asked to show you where the pain is, he puts his hand on the upper cervical spine and says, “Right here.” Based on this basic information, it seems that upper cervical dysfunction may explain his symptoms. Question What tests can you use to determine if upper cervical spine dysfunction is present? What symptom might accompany the presence of upper cervical spine dysfunction if it is present? Discussion Tests that can be used to determine if upper cervical dysfunction is present include (1) the head nod test, which isolates motion at the C0/C1 joints; (2) the flexion rotation test, which isolates motion at the C1/C2 joints; and (3) palpation of the upper cervical facet joints to determine if they are painful and/or demonstrate restricted motion, which can indicate involvement of these joints. c. Atlantis ligament. d. Vertebral ligament. Case Study: Ben Barnes
C2 to C7 facet joints and neck pain Specific physical examination findings can be used to confirm a differential diagnosis of neck pain originating from the cervical spine. Hurley et al. (2022) identified the following exam findings as useful for diagnosing facet joint pain in the cervical spine: ● Cervical spine range of motion . Assessment of cervical flexion and extension, bilateral lateral flexion or side bend, and rotation can identify facet joint restrictions. Gross motion of the cervical spine is accomplished via the segmental contributions of each facet joint. Limitations in cervical range of motion should be noted. In addition, the patient should report any pain response elicited by these maneuvers. ● Extension–rotation testing. For this test, the patient is seated and asked to fully extend their head followed by rotation to both sides. Patients are asked to report any pain occurring at end range. When painful, this is considered a positive test for facet joint dysfunction ● Manual spine examination . With the patient prone and the spine in neutral, a posterior-to-anterior directed force is applied over the articular pillars from C2–C3 to C6–C7 on each side. This test is considered positive when the patient reports pain or when resistance to motion is noted at any of the segments. ● Palpation for segmental tenderness . With the patient prone, the segmental muscles overlying the facet joints from C2–C3 to C6–C7 are palpated bilaterally. These muscles have the same nerve supply as the painful joint, and joint dysfunction can cause tenderness and spasm in these muscles. This test is positive if the patient reports pain when the joint (or joints) is palpated. Pain patterns C2–C3 to C6–C7 facet joints The referral pain patterns from the facet joints at various levels in the cervical spine have been mapped out. In general, dysfunction at a specific level can refer pain both superiorly and inferiorly, with the upper levels also referring into the head: ● C2–C3 pain pattern . The pain pattern from this level is a band of pain in the posterior neck from the C2 to C3 level with extensions superior into the inferior aspect of the skull and inferiorly to the mid portion of the neck. It may extend laterally toward the mastoid region. Pain may also extend from the occiput across the parietal and upper temporal regions of the skull to the forehead or orbit. C2–C3 pain typically does not encompass the ear (Cooper et al., 2007). ● C3–C4 pain pattern . The pain pattern from this level includes the posterolateral neck from occiput to shoulder. Pain may also be referred into the suboccipital and occipital regions or into the forehead of the cranium. ● C4–C5 pain pattern . Pain at this level tends to be more focal and is centered in the lower posterior quadrant of the neck. It may spread inferiorly into the proximal shoulder girdle or superiorly into the suboccipital areas. Typically, it does not refer to the head. ● C5–C6 pain pattern . This level has pain that is often centered around the junction of the base of the neck and the top of the shoulder. It can extend up into the suboccipital area and/or laterally across the top of the shoulder girdle. Infrequently, it may cause pain in the scapular region. It does not cause pain in the head. ● C6–C7 pain pattern . Facet joint dysfunction at this level is typically focused on the junction of the neck and shoulder girdle. It tends to spread inferiorly and medially to the central and medial aspects of the scapula. It does not refer to the head.
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