This book chapter has been provided for use by Physiopedia Plus

members. Please do not publish or share this document.

Grieve’s Modern Musculoskeletal

Physiotherapy, 4th Edition

Authors: Gwendolen Jull, Ann Moore, Deborah Falla, Jeremy Lewis, Chris McCarthy,
Michele Sterling
Published Date: 23rd June 2015
Imprint: Elsevier
eBook ISBN: 9780702066511

Since the third edition of Grieve’s Modern Manual Therapy was published in 2005, the
original concepts of manipulative therapy have grown to embrace new research-
generated knowledge. Expansions in practice have adopted new evidence which include
consideration of psychological or social moderators. The original manual therapy or
manipulative therapy approaches have transformed into musculoskeletal physiotherapy
and this is recognized by the change in title for the new edition – Grieve’s Modern
Musculoskeletal Physiotherapy. Grieve’s Modern Musculoskeletal
Physiotherapy continues to bring together the latest state-of-the-art research, from both
clinical practice and the related basic sciences, which is most relevant to practitioners.
The topics addressed and the contributing authors reflect the best and most clinically
relevant contemporary work within the field of musculoskeletal physiotherapy.

Purchase at: https://www.elsevier.com/books/grieves-modern-musculoskeletal-

physiotherapy/jull/978-0-7020-5152-4

Functional Anatomy
CHAPTER OUTLINE
Ch 9.1  The Cervical Spine  93
Gail Forrester-Gale • Ioannis Paneris
CHAPTER 9.1  ■  THE CERVICAL SPINE
Gail Forrester-Gale • Ioannis Paneris
INTRODUCTION
The following chapter aims to review and highlight
the key anatomical and biomechanical features of the
craniocervical region that are relevant to and support
clinical practice.
The occiput, atlas, axis and surrounding soft tissues
are collectively referred to as the craniocervical region.
It is a unique spinal region that exhibits highly specialized
anatomy and considerable mobility in comparison to
other spinal regions. Of particular note are the atypical,
modified vertebrae (the atlas and axis), the absence of
intervertebral discs, the presence of an odontoid peg and
the configuration of double convex joints bilaterally at
the C1–C2 articulation.1
The atlas (C1) and axis (C2) together with the occiput
form a unique triad of articulations referred to as the
occipito–atlantoaxial (O-AA) complex. This complex is
responsible for approximately one-third or 20° of the
total cervical sagittal plane movements of flexion and
extension.2–8 In vivo movement analysis studies report
that 4–7° of flexion and 17–21° of extension occur across
this complex with the majority of this movement occur-
ring specifically at the atlanto-occipital joint (C0-C1).4–8
The atlanto-occipital joint (A-O joint) configuration is
specifically designed to facilitate upper cervical flexion
and extension (retraction and protraction). The lack of
intervertebral disc along with the congruous joint sur-
faces, which are long and thin and orientated in a
posterior–anterior direction, facilitate the nodding move-
ment of the head on neck.2,5,8
Clinically, in situations where craniocervical spine
(CCS) pain is associated with movements of upper
cervical flexion and extension, the A-O joint should be
a primary consideration in terms of assessment and
treatment.
Axial rotation is the largest range of motion available
across the O-AA complex.1 Studies consistently show that
the atlanto-axial joint (A-A joint; Fig. 9-1) provides 60%
of the total cervical rotation, which amounts to approxi-
mately 38–56° to each side.1,5,9–11 This is unsurprising,
CHAPTER 9 
Ch 9.2  Lumbar Spine  101
Michael Adams • Patricia Dolan
as anatomically the A-A joint is specifically designed
for rotation. It has a central pivot joint between the odon-
toid peg and the osseoligamentous ring formed by the
transverse ligament and anterior arch of the atlas, double
convex joints bilaterally and it lacks an intervertebral
disc.1,12,13 In addition to its large range of rotation, in vivo
studies on asymptomatic subjects have shown that the
A-A joint plays a key role in the initiation of cervical
rotation.9,14 Cervical rotation has been shown to start at
the C1–C2 level and to continue sequentially down the
cervical spine with each joint moving only once the pre-
ceding joint has completed its range of movement.1,14
CRANIOCERVICAL-COUPLED
MOVEMENTS AND CLINICAL
IMPLICATIONS
Alongside movement analysis studies exploring the range
and direction of CCS mobility, there is a growing body
of evidence from in vivo three-dimensional computed
tomography (3D CT) scan studies demonstrating the
coupling of movements occurring in the CCS.15–19
A recent study by Salem et al. carried out on 20
Superior articular surface
(for occipital condyle)
Articular facet for dens
Atlas (CI)
Axis (CII)
FIGURE 9-1  ■  The atlanto-axial joint. (Adapted from Drake et al.
Grey’s Anatomy for Students. Edinburgh: Churchill Livingstone;
2005.)
93
94 PART II  Advances in Theory and Practice
asymptomatic participants used up-to-date imaging tech-
niques (3D CT kinematic analysis) to explore the coupled
motion patterns of the CCS in maximal axial rotation.1
This study found that rotation in the CCS was consis-
tently coupled with contralateral lateral flexion, which is
in contrast to the ipsilateral coupling pattern found in the
sub-axial cervical spine.20
SYNOVIAL FOLDS IN THE
CRANIOCERVICAL SPINE
The synovial folds of the CCS are formed by wedge-
shaped folds of synovial membrane.21–24 They have an
abundant vascular network and are innervated.21,25 The
composition of the synovial folds varies across the cra-
niocervical region possibly due to the different amounts
of mechanical stress they are subjected to at each level.
The synovial folds found at the A-O joint do not project
between the joint surfaces and are therefore unlikely to
be exposed to mechanical stresses. They are composed of
adipose-type synovial membrane. The synovial folds of
the A-A articulation, however, project as far as 5 mm
between the articular surfaces and will therefore be
exposed to mechanical stresses. They are formed of a
stronger more fibrous type of synovial membrane.21,24,25
The synovial folds have been suggested to perform
various functions in the CCS. They have been described
as ‘passive space fillers’ serving to fill non-congruent
areas of the joint and thus enhance joint congruity and
stability. They may also help to protect or lubricate the
articular surfaces and assist in weight bearing or shock
absorption.21 Additionally, the CCS synovial folds may
have a proprioceptive role providing mechanosensory
information important for sensorimotor control in the
upper cervical spine.25
THE ANATOMY OF CRANIOCERVICAL
STABILITY AND CLINICAL
IMPLICATIONS
CCS stability is provided through a combination of
mechanical restraint from the ligamentous system
and sensorimotor control from the neuromuscular
system.26–33
Ligamentous System
The chief mechanical restraints of the craniocervical
region are generally recognized as the transverse and alar
ligaments with other ligaments such as the tectorial
membrane, capsular ligaments, ligamentum flavum, A-A
ligaments, ligamentum nuchea, posterior atlanto-occipital
membranes and atlanto-axial membranes acting as sec-
ondary stabilizers (Fig. 9-2).15,17,34–36
Clinical Anatomy and Biomechanics
of the Alar Ligaments
There is consensus in the literature that the alar liga-
ments provide the main passive restraints to contralateral
axial rotation and lateral flexion across the O-AA
complex.16,17,37,38 They are strong, collagenous cords
approximately 1 cm in length, which run from the pos-
terolateral aspect of the odontoid peg to the medial
surface of the occipital condyles.15 Due to their posterior
attachment on the odontoid peg, they are wound around
the process during contralateral axial rotation and become
maximally tightened at 90° cervical rotation. Further
stretch can be added to these ligaments with the addition
of upper cervical flexion.16,17,34
Clinical Anatomy and Biomechanics of
the Transverse Ligament and Relevance
to Clinical Testing
Magnetic resonance imaging (MRI) studies on healthy
participants have confirmed findings from cadaveric
studies that the transverse ligament is a broad collage-
nous band, approximately 2.5 mm thick, which extends
across the atlantal ring directly behind the odontoid peg
and attaches to the medial aspect of each lateral mass of
the atlas.16,31 It acts like a sling and serves to hold the
odontoid peg against the anterior arch of the atlas. In this
way it restricts forward translation of the atlas in relation
to the axis particularly during movements of cervical
flexion.35,39
Clinical Anatomy and Biomechanics of
the Tectorial Membrane and Relevance
to Clinical Testing
Combined findings from in vitro cadaveric studies and in
vivo MRI scan studies concur that the tectorial mem-
brane is a broad fibroelastic band, approximately 5–7.5 cm
in length, 1.5–3 cm in width and 1–1.5 mm thick.37,40
Recent anatomical and radiological studies have con-
firmed that it originates on the posterior surface of the
C2 body and runs vertically upwards, as a specialized
cranial continuation of the posterior longitudinal liga-
ment, attaching to the basilar grove of the occipital
bone.35,37 It is adherent to the anterio superior dura
mater that may be of clinical relevance in patients with
whiplash-associated disorder (WAD) or other disorders
presenting with head, neck or facial pain and altered
response to neurodynamic testing such as passive neck
flexion.36,40–42 The tectorial membrane becomes taught at
15° of craniocervical flexion; however, anatomical studies
suggest that its primary role is not to limit craniocervical
flexion but to prevent posterior migration of the odon-
toid peg into the cervical spinal canal.37,40 Due to its high
elastin content it is thought that the membrane acts as a
hammock, stretching and tightening over the odontoid
peg in craniocervical flexion thus assisting the transverse
ligament in preventing a posterior movement of the
odontoid peg into the spinal canal and preventing
impingement of the peg onto the spinal cord.36,40
Craniocervical Muscles and Their
Clinical Significance
The key muscles acting directly on the CCS are the
suboccipital muscle (SOM) group posteriorly and the
craniocervical flexor (CCF) muscle group anteriorly.
 9  Functional Anatomy 95

Superior longitudinal band Jugular foramen

of cruciform ligament
Anterior edge of
foramen magnum
Transverse process of atlas
Alar ligament
Transverse ligament of atlas Ends of membrana tectoria

Anterior capsule of atlanto-axial joint Posterior longitudinal ligament

Inferior longitudinal band
A of cruciform ligament

Temporal bone
petrous part Internal acoustic meatus

Foramen magnum Occipital bone basilar part

posterior border Membrana tectoria
Anterior atlanto-occipital membrane
Apical ligament of dens
Superior longitudinal band
of cruciform ligament
Vertebral artery Dens
First cervical nerve Anterior arch of atlas
Posterior arch of atlas Bursal space in fibrocartilage
Transverse ligament of atlas Remains of intervertebral disc
Inferior longitudinal band
Body of atlas
of cruciform ligament
Ligamentum flavum
Posterior longitudinal ligament
Anterior longitudinal ligament
B
FIGURE 9-2  ■  The craniocervical ligamentous system.

Both groups are composed of short, deep segmental

muscles that largely function to provide segmental control
and support to the craniocervical joints.18,43–46 Both
Rectus
muscle groups have been shown to contain a high density capitis
of muscle receptors, particularly muscle spindles, with anterior
the largest concentration of muscle spindles being found
Longus capitis
in the SOM.18,19,46–48 This would suggest that both these C2
muscle groups are likely to act primarily as sensory recep- Upper part
tors monitoring and controlling the position, direction, C3
amplitude and velocity of craniocervical joint movement C4
Longus
and therefore have an important role in the maintenance colli
Middle part
of dynamic stability in the CCS. In addition, afferent C5
information from the SOM and CCF muscle spindles is C6
integrated with information from the vestibular and Lower part
C7
visual apparatus via the vestibular nuclei and is thus
involved in various postural reflexes in the control of T1
balance.49–51 T2
The CCF muscle group include longus capitis (LCap), T3
rectus capitis anterior (RCA), rectus capitus lateralis
FIGURE 9-3  ■  The craniocervical flexor muscle group. (Adapted
(RCL) and longus colli (Fig. 9-3). The first three muscles from Palastanga et al. Anatomy and Human Movement. Edinburgh:
all have an attachment in the CCS. LCap arises from the Churchill Livingstone; 2006.)
transverse processes of the third to sixth cervical verte-
brae and ascends to insert onto the inferior surface of
the occiput. It is narrow subaxially but broad and thick
in the CCS.3,13,44
96 PART II  Advances in Theory and Practice
The RCA muscle is a short, flat muscle, situated
immediately behind the upper part of the LCap. It arises
from the anterior surface of the lateral mass of the atlas,
and passes obliquely upward and medially to insert on the
inferior surface of the occiput in front of the foramen
magnum. The RCL is another short, flat muscle, which
arises from the upper surface of the transverse process of
the atlas, and is inserted onto the undersurface of the
jugular process of the occiput.3,13,51–53
Acting as a group, the CCF muscle group provides
support to the cervical lordosis and segmental stability to
the cervical spine as a whole. RCA and LCap in particular
provide stability to the upper cervical motion segments.54
In addition to their proprioceptive role, they serve to
produce flexion of the upper cervical spine or a nodding
movement of the head on the neck.55
The SOM group includes rectus capitis posterior
major (RCPmajor), rectus capitis posterior minor (RCP-
minor), obliqus capitis superior (OCS) and obliqus capitis
inferior (OCI) (Fig. 9-4).13,52,53
RCPminor is stated to be the only muscle with a direct
attachment to the atlas (C1). It is documented to arise
from the posterior arch of the atlas (C1) and to insert
onto the occipital bone below the inferior nuchal line
lateral to the midline and medial to RCPmajor.20
The RCPmajor muscle is commonly cited to arise
from the spinous process of the axis (C2) and to ascend
to its insertion on the lateral part of the inferior nuchal
line of the occiput.13 However, Scali et al. carried out an
anatomical and histological study on 11 cadavers primar-
ily to explore the atlanto-axial interspace.56 They found
in all 11 cadavers examined that the RCPmajor muscle
was firmly attached to the spinous process of the atlas
(C1). It would therefore appear that both RCPmajor and
RCPminor have an attachment onto the atlas (C1).
The main actions of RCPmajor and RCPminor are
extension, side flexion and rotation of the O-AA joint
Oblique capitis
superior
Rectus capitis
posterior minor
Rectus capitis
posterior major
Obliquus capitis
inferior
FIGURE 9-4  ■  The suboccipital muscle group. (Adapted from
Middleditch & Oliver. Functional Anatomy of the Spine. Edinburgh:
Butterworth Heinnemann; 2005.)
complex. However, studies have shown that both muscles,
in particular the RCPminor, have a high density of muscle
spindles suggesting that they have a more important role
in CCS proprioception than in movement and may help
to stabilize the atlas in relation to the occiput.18,19,47 This
has been supported by a recent electromyographic study
on RCPminor muscles that demonstrated activity in the
muscle with the head in a neutral position but signifi-
cantly increased activity with the head in a retracted
position.46
Anatomical connections between the anterior surfaces
of RCPmajor and RCPminor muscles and the posterior
cervical spinal dura mater through fibrous connective
tissue or myodural bridges have been consistently
reported.56–58 These connections may provide a form of
anchorage for the dura mater but more importantly,
due to findings of proprioceptive fibres throughout the
myodural connections, are believed to be involved in
the monitoring and controlling of dural tension during
flexion and extension movements of the head and neck.46,56
Additionally, the fibrous bridge may provide propriocep-
tive information regarding the position of the AO and
AA joints to help prevent infolding of the pain-sensitive
dura mater during head and neck movements.46,56 Clini-
cally, the myodural bridges between the SOM and the
cervical spinal dura may be of relevance in relation to
cervicogenic headache.46,56,59–61
The OCS is a small muscle arising from the lateral
mass of the atlas (C1) ascending to attach onto the lateral
half of the inferior nuchal line on the occiput. It acts at
the A-O joint to extend and side flex the head. The OCI
muscle is the larger of the two oblique craniocervical
muscles. It lies deep to semispinalis capitus, arising from
the apex of the spinous process of the axis (C2) and
passing laterally and upwards to insert on the posterior
aspect of the transverse process of the atlas (C1). It is
responsible for rotation of the A-A joint.13 Similarly to
RCPmajor and RCPminor, both OCS and OCI have a
high density of Golgi tendon organs and muscle spindles
indicating that proprioception is likely to be the primary
role of these and indeed all the SOM allowing for accu-
rate positioning of the head on the neck.
MID TO LOW CERVICAL SPINE
Although the first, second and seventh vertebrae have
special features, the rest of the vertebrae of the cervical
spine are almost identical with the sixth having only
minor distinguishing features.62
The Vertebral Body
The typical vertebra consists of two parts: the vertebral
body and the vertebral arch. The body of the typical
vertebra is a relatively small and broad mass of trabecular,
spongy bone covered by a layer of cortical bone.63 The
shape of the cervical vertebral body is oval with the trans-
verse diameter being greater than the anteroposterior
diameter and height.63 The cervical intervertebral joints
are saddle-shaped and they consist of two concavities
facing each other at 90°.64 The opposing surfaces of the

vertebral bodies are gently curved in the sagittal plane
with the anterior part of the vertebra sloping downwards
partially overlapping the anterior surface of the interver-
tebral disc. The superior surface of the vertebral body is
also curved on the coronal plane forming a concavity of
which its sides are the uncinate processes.62
The uncinate processes are projections that arise from
most of the circumference of the upper margin of the
vertebral body of C3 to C7. Although the uncinate pro-
cesses are present in utero, they start to enlarge gradually
between the ages of 9 to 14 years reaching their maximum
height.63,65 In mature spines the uncinate processes artic-
ulate with the superior vertebra at its incisures forming
the uncovertebral joints or joints of Luschka. The size of
the uncinate processes varies slightly from level to level.
Their average height ranges from 3–6.1 mm and the
anteroposterior length from 5–8.3 mm,66 and they are
significantly higher at C4 to C6 compares to C3 and C7
levels.67
The uncinate processes and the uncovertebral joints
limit side flexion of the cervical spine and stabilize the
intervertebral disc in the coronal plane during axial rota-
tion.5 The uncovertebral joints play a stabilizing role
primarily in extension and side flexion followed by
torsion.68 The uncinate processes, by forming the saddle
shape of the superior surface of the vertebra, working
together with the zygapophyseal joints dictate the cou-
pling movement of side flexion and ipsilateral rotation of
the vertebrae of the low cervical spine on an the axis
perpendicular to the plane of the facet joints.64,69
The Vertebral Arch
The vertebral arch consists of the pedicles and the
laminae. The pedicles are short, projecting posterolater-
ally and arising midway between the discal surfaces of the
vertebral bodies making the superior and inferior verte-
bral notches of similar depth. The laminae are longer and
thinner and project posteromedially. They have a thinner
superior border compared to the inferior and they are
slightly curved. The junction of the laminar forms the
spinous process which is short and bifid and the two
tubercles being often of unequal size.
The junction of the pedicle with the ipsilateral lamina
bulges laterally forming the superior and inferior articu-
lar processes. The articulations between the superior and
inferior processes (facet or zygapophyseal joints) form the
articular pillar (lateral mass) on each side. The superior
articular processes are flat, oval-shaped and face supero-
posteriorly. Small morphological differences exist for the
superior articular processes of the C3 which, in addition
to facing superiorly and posteriorly, also face medially to
about 40°. Also, the superior articular facets of C3 lie
slightly inferiorly in relation to their vertebral body com-
pared to the rest of the typical cervical levels.64 This
morphological specificity of the superior processes of the
C3 lead to alteration of the biomechanical behaviour at
the C2–C3 level. Indeed, the expected coupling of ipsi-
lateral rotation and side flexion does not seem to exist at
this level. The medial orientation on the facets at this
level serves to minimize rotation, thus stabilizing the C2
during rotational movements of the neck.14 On average
9  Functional Anatomy 97
a contralateral rotation and side flexion pattern seem to
take place on C2.64 The orientation of the superior facets
in relation to the transverse plane seems to change gradu-
ally from posteromedially at C3 to posterolaterally at C7
to T1. However this change could be either gradual or
sudden and the level of change of the orientation was not
constant, occurring at any level of the lower cervical spine
with the most common being the level of C5–C6.70 The
shape of the superior articular facets gradually changes
from almost circular at the level of C3, to oval with an
elongated transverse diameter at C7.70
The cervical zygapophyseal joints were found to be
the most common source of pain after whiplash injury.71
This could be due to the mechanical compressional and
shear forces applied to the dorsal part of the joints during
this form of impact.72–74 Further, the absence of articular
cartilage, especially at the dorsal part of the joint, could
lead to impingement and bone to bone contact and
trauma.75 The facet joint capsule consists of bundles of
dense, regularly arranged, collagen fibres, containing
elongated nuclei of fibroblasts and loose connective tissue
with areas of adipose-like tissue.76,77 Fibroblasts with
ovoid and round nuclei are found within the loose con-
nective tissue.76 The capsule of the lower cervical spine
is also covered by an average of 22.4% by muscle fibres,
possibly by the semispinalis and multifidi, suggesting a
potential path for loading of the facet capsule.78 A number
of animal and human cadaveric studies have verified the
presence of mechanoreceptors and nociceptors in the
capsules of the cervical facet joints.76,77,79–81 The dorsal
part of the cervical facet joint is innervated by the dorsal
ramus via its middle branch.41
Intra-articular inclusions, or synovial folds, are present
in the majority of the zygapophyseal joints. Because of
the location, to the ventral and dorsal parts of the joints,
it has been hypothesized that they act as space fillers
protecting the parts of the cartilage that become exposed
during translatory movements by maintaining a film of
synovial fluid between themselves and the cartilage. In
addition, and due to their fibrous consistency, it has also
been hypothesized that meniscoids could play a role in
mechanical stress distribution.82 Although, an earlier
study has indicated that intra-articular meniscoids are
features of cervical spine in the first two decades of life,83
more recent cadaveric studies have confirmed their pres-
ence in the majority of facet joints of cervical spines of
advanced age.82,84
Ligaments
The main ligaments that are associated with the interver-
tebral and zygapophyseal joints are the anterior longitu-
dinal ligament, the posterior longitudinal ligament and
the ligamentum flavum.
The anterior longitudinal ligament (ALL) is attached
to the anterior surfaces of the vertebral bodies and discs.62
The ALL is comprised of four layers with distinguishable
patterns of attachment.85 The fibres of the superficial
layer of the ALL run longitudinally crossing several seg-
ments and they are attached to the central areas of the
anterior surfaces of the vertebral bodies. They cover
roughly the middle two-quarters of the anterior vertebral
98 PART II  Advances in Theory and Practice
bodies and, in contrast to the upper cervical levels, at the
lower cervical segments the fibres of the ALL are less
densely packed and the ligament expands laterally. The
fibres of the second layer also run longitudinally. At this
layer the fibres cover one intervertebral disc and attach
to the anterior surfaces of the inferior and superior ver-
tebrae but never further than half way up or down that
surface. The fibres of the third layer are similar to the
ones of the second one in orientation, but these fibres are
shorter, covering one intervertebral disc and attaching
just cranial of caudal to the margins of the adjacent ver-
tebrae. The fibres of the fourth layer are of more alar
disposition. They arise from the anterior surface of the
vertebra above, close to its inferior margin, and passing
inferiorly and laterally insert to the vertebra below just
inferiorly to its superior margin. The most lateral of these
fibres reach the summit of the uncinate processes.85
The posterior longitudinal ligament (PLL) covers the
entire posterior surface of the vertebral bodies in the
vertebral canal, attaching to the central posterior surfaces
of the vertebral bodies and has three distinct layers.85 The
superficial layer contains longitudinal fibres that bridge
three to four vertebrae and lateral extensions that extend
inferolaterally from the central band to cross an interver-
tebral disc and attach to the base of the pedicle one or
two levels below.85 The fibres of the intermediate layer
are longitudinal, span only one intervertebral disc and
occupy a narrow area close to the midline of the posterior
surface of the vertebral body. The deep layer consists of
fibres that cover one intervertebral disc and arise from
the inferior margin of the cephalad vertebra and extend
inferiorly and laterally to the superior margin of the
caudal vertebrae. The most lateral fibres extend in an alar
fashion to the posterior end of the base of the uncinate
process.85 In the cervical spine the ALL and the deep
layer of the PPL are continuous, surrounding the entire
vertebral body while the superficial layer of the PPL sur-
rounds the dura matter, nerve root and the vertebral
artery suggesting a dual role for this structure: as a con-
ventional ligament; and as a protective membrane for the
soft tissues inside the vertebral canal.86
The ligamentum flavum (LF) connects the laminae of
the adjacent vertebra and extends from the facet joint
capsules to the point where the laminae fuse to form the
spines.62 In the low cervical spine the majority of liga-
menta flava do not fuse at the midline,87 leaving gaps that
admit veins connecting the internal and posterior exter-
nal venous plexuses.62 The LF consists of yellow elastic
and collagen fibres that are longitudinal in orientation
connecting the anterior surface and lower margin of the
lamina above to the posterior surface and upper margin
of the lamina below. At the cervical spine the LF is thin,
broad and long and it limits separation of the laminae in
flexion and assists restoration of the neutral posture after
flexion.62 The LF becomes thinner in cervical flexion and
thicker and shortened in extension protruding in the
spinal canal to an average of 3.25 mm approximately.88
At the levels of C6–C7 and C7–T1 the LF is uniquely
thick in extension, which may predispose to cord
compression.
From the rest of the ligaments of the cervical
spine, the ligamentum nuchae (LN) commands the most
attention, especially in the mid and low cervical seg-
ments. Despite the fact that in most anatomical texts the
LN is described as a ligament homologous to the supra-
spinous and interspinous ligaments, the LN is not a liga-
ment but a structure that consists of a dorsal nuchal raphe
and a midline fascial septum.89 The dorsal raphe and the
ventral fascial portions of the LN are a single entity and
consist of muscular aponeurotic fibres and in the mid-
cervical spine; they are derived from the trapezius and
splenius capitis. The aponeurotic fibres decussate at the
midline, forming a triangular body representing the
dorsal raphe which becomes progressively larger caudally
with a progressive increase in aponeurotic fibres. The
decussate fibres then project ventrally to attach to the
spinous processes of the C2 to C5 vertebrae forming
the ventral portion of the LN. At the C6, C7 levels the
two portions of the LN are not distinguishable and
the LN is formed by horizontal aponeurotic fibres of the
trapezius, rhomboideus minor, serratus posterior minor
and splenius capitis.90
The Intervertebral Disc
The intervertebral disc of the cervical spine shows dis-
tinct morphological and histological differences to the
rest of the discs of the spinal column. The intervertebral
disc consists of the nucleus pulposus and the annulus
fibrosus as in the rest of the sections of the spine. However,
the nucleus pulposus at birth constitutes no more than
25% of the entire disc and quickly changes from gelati-
nous to fibrocartilagenous in consistency by the middle
of the second decade of life.65
The annulus fibrosus has a crescentic form anteriorly
with a thick anterior part in the sagittal plane, which
becomes progressively thinner when traced to the unci-
nate processes. The posterior part consists only of a
thin layer of collagen fibres. The anterior part of the
annulus is covered by a thin layer of collagen fibres.
This is a transitional layer between the deepest layers
of the anterior longitudinal ligament and the annulus.
The fibres of the transitional layer pass inferiorly and
diverge laterally, whereas more laterally they pass infe-
riorly and laterally in a more alar disposition attaching
to the edges of the vertebral bodies. The fibres of the
annulus fibrosus proper arise laterally from the apex
and anterior surface of the uncinate process and the
superior part of the inferior disc and run medially to
insert on the inferior surface of the vertebrae above.
Towards the midline the fibres interweave with the fibres
coming from the opposite side. Deeper layers of the
annulus progressively originate closer to the midline
maintaining the interweaving pattern. At its deepest
(2–3  mm), the fibres of the annulus are embedded with
proteoglycans to form a fibrocartilagenous mass increas-
ingly becoming less laminated, forming the nucleus of
the disc.85 The posterior part of the annulus is about
1  mm thin and covers a small posteromedial section.
Its fibres run vertically between the facing surfaces of
the adjacent vertebral bodies. The rest of the posterior
fibrocartilagenous core to the uncus either side is covered
by periosteofascial tissue.65,85

The Intervertebral Foramina
and Spinal Nerves
The cervical spinal nerves exit the spinal cord in an
oblique orientation towards their respective neural
foramen.91 The intervertebral foramen is shaped as a
funnel with its narrowest part medially and its borders
are comprised by the pedicles of the superior and inferior
vertebrae, the facet joint posteriorly and the disc and
uncovertebral joint anteriorly.91,92 The foramina are also
larger in the upper cervical spine becoming gradually
narrower at lower levels with the narrowest at the C7–T1
level.91 The anatomical cadaveric study of Tanaka et al.92
provided significant findings regarding the anatomy of
the cervical nerve roots that have clinical implications.
The spinal nerve is comprised of the ventral and dorsal
nerve roots. The ventral nerve root lies caudal to the
dorsal root and courses along the caudal border of
the dorsal nerve root in the intervertebral foramen. The
ventral root is approximately two-thirds the size of the
dorsal root.
Further, at the level of C4-C5 intervertebral foramen
the majority of the C5 nerve roots are situated caudal or
just anterior to the intervertebral disc. The majority of
the C6 and C7 nerve roots lie cephalad to the interver-
tebral disc while the vast majority of the C8 nerve roots
have no contact with the disc. Furthermore, below the
level of C5 the nerve rootlets, which comprise the ventral
and dorsal nerve roots, pass downwards with increased
obliquity reaching their corresponding intervertebral
foramina, with the dorsal rootlets of C5, C6 and C7
forming a number of intra-dural connections. The con-
sequence is that whichever nerve root is going to be
compressed, the dorsal, the ventral or perhaps both,
depends upon the compressing structure (disc, superior
facet joint or ligamentum flavum) and its anatomical rela-
tionship to the nerve root. In addition, the course of the
rootlets and the interconnections between the dorsal
rootlets can explain the spread of clinical signs and symp-
toms in more than one nerve root from disc herniations,
as well as the variation and overlapping sensory symp-
toms cause by nerve root compression.92
The spinal nerves at the lower cervical spine have
significant connective tissue attachments posteriorly to
the medial end of the intervertebral foramina, the cap-
sules of the zygapophyseal joints, the periosteum of the
inferior pedicles and anteriorly to the vertebral bodies,
the intervertebral discs and the posterior longitudinal
ligament.93 All the above structures are innervated by the
sinuvertebral nerve (intervertebral discs, posterior longi-
tudinal ligament and ventrolateral spinal canal perios-
teum) and by the cervical dorsal ramus (zygapophyseal
joints). The potential of those structures to evoke pain
could render the findings of the neural tension tests more
difficult to interpret.93
REFERENCES
1. Salem W, Lenders C, Mathieu J, et al. In vivo three-dimensional
kinematics of the cervical spine during maximal axial rotation. Man
Ther 2013;18:339–44.
2. Chancey V, Ottaviano D, Myers B, et al. A kinematic and anthro-
pometric study of the upper cervical spine and the occipital con-
dyles. J Biomech 2007;40:1953–9.
9  Functional Anatomy 99
3. Jull G, Sterling M, Falla D, et al. Whiplash, Headache and
Neck Pain. Research-Based Direction for Physical Therapists.
Edinburgh: Churchill Livingstone; 2008.
4. Amiri M, Jull G, Bullock-Saxton J. Measurement of upper cervical
flexion and extension with the 3-space fastrak measurement system:
a repeatability study. J Man Manip Ther 2003;11(4):
198–203.
5. Panjabi M, Crisco J, Vasavada A, et al. Mechanical properties of the
human cervical spine as shown by three-dimensional load displace-
ment curves. Spine 2001;26(24):2692–700.
6. Ordway N, Seymour R, Donelson R, et al. Cervical flexion, exten-
sion, protrusion and retraction: a radiographic segmental analysis.
Spine 1999;24(3):240–7.
7. Panjabi M, Dvorak J, Duranceau J, et al. Three-dimensional move-
ments of the upper cervical spine. Spine 1988;13(7):
726–30.
8. Bogduk N, Mercer S. Biomechanics of the cervical spine. I: normal
kinematics. Clin Biomech 2000;15:633–48.
9. Ishii T, Mukai Y, Hosono N, et al. Kinematics of the cervical spine
in rotation in vivo three-dimensional analysis. Spine 2004;29(7):
139–44.
10. Iai H, Moriya H, Goto S, et al. Three-dimensional motion analysis
of the upper cervical spine during axial rotation. Spine 1993;
18(16):2388–92.
11. Mimura M, Moriya H, Watanabe T, et al. Three dimensional
motion analysis of the cervical spine with special reference to axial
rotation. Spine 1989;14(11):1135–9.
12. Palastanga N, Field D, Soames R. Anatomy and Human Move-
ment. Structure and Function. 5th ed. Butterworth Heinnemann,
Elsevier; 2006.
13. Standring S. Gray’s Anatomy. 40th ed. Churchill Livingstone;
2008.
14. Hino H, Abumi K, Kanayama M, et al. Dynamic motion analysis
of normal and unstable cervical spines using cineradiography. An
in vivo study. Spine 1999;24(2):163–8.
15. Crisco J, Panjabi M, Dvorak J. A model of the alar ligaments of the
upper cervical spine in axial rotation. J Biomech 1991;24(7):
607–14.
16. Dvorak J, Schneider E, Saldinger P, et al. Biomechanics of the
craniocervical region; the alar and transverse ligaments. J Orthop
Res 1988;6:452–61.
17. Dvorak J, Panajabi M. Functional anatomy of the alar ligaments.
Spine 1987;12(2):183–9.
18. McPartland J, Brodeur R. Rectus capitus posterior minor: a small
but important suboccipital muscle. J Bodyw Mov Ther 1999;
3(1):30–5.
19. Boyd Clark L, Briggs C, Galea M. Comparative histochemical
composition of muscle fibres in a pre and post-vertebral muscle of
the cervical spine. J Anat 2001;199:709–16.
20. Cook C, Hegedus E, Showalter C, et al. Coupling behaviour of the
cervical spine: a systematic review of the literature. J Manipulative
Physiol Ther 2006;29(7):570–5.
21. Mercer S, Bogduk N. Intra-articular inclusions of the cervical syno-
vial joints. Br J Rheumatol 1993;32(8):705–10.
22. Friedrich K, Reiter G, Pretterklieber M, et al. Reference data for
in vivo MRI properties of meniscoids in the cervical zygapophyseal
joints. Spine 2008;33(21):E778–83.
23. Webb A, Darekar A, Sampson M, et al. Synoival folds of the lateral
atlanto-axial joints: in vivo quantitative assessment using MRI in
healthy volunteers. Spine 2009;34(19):E697–702.
24. Tang X, Liu L, Yang H, et al. Anatomic study of the synovial folds
of the O-AA joints. Clin Anat 2007;20(4):376–81.
25. Inami S, Shiga T, Tsujino A, et al. Immunohistochemical demon-
stration of nerve fibres in the synovial folds of the human cervical
facet joint. J Orthop Res 2001;19:593–6.
26. Goel V, Winterbottom J, Schulte K, et al. Ligamentous laxity
across C0-C1-C2 complex. Axial torque-rotation characteristics
until failure. Spine 1990;15(10):990–6.
27. Panjabi M, Dvorak J, Duranceau J, et  al. Three-dimensional move-
ments of the upper cervical spine. Spine 1988;13(7):726–30.
28. Panjabi M. The stabilising system of the spine. Part I. Function,
dysfunction, adaptation and enhancement. J Spinal Disord 1992a;
5(4):383–9.
29. Panjabi M. The stabilising system of the spine. Part II. Neutral
zone and instability hypothesis. J Spinal Disord 1992b;5(4):
390–7.
100 PART II  Advances in Theory and Practice
30. Panjabi M, Abumi K, Duranceau J, et al. Spinal stability and inter-
segmental muscle forces: a biomechanical model. Spine
1989;14:194–200.
31. Panjabi M, Lydon C, Vasavada A, et al. On the understanding of
clinical instability. Spine 1994;19(23):2642–50.
32. Panjabi M, Cholewicki J, Nibu K, et al. Critical load of the human
cervical spine: an in vitro experimental study. Clin Biomech
1998;13:11–17.
33. Brolin K, Halldin P. Development of a finite model of the upper
cervical spine in a parameter study of ligament characteristics.
Spine 2004;29(4):376–85.
34. Goel V, Winterbottom J, Schulte K, et al. Ligamentous laxity
across C0-C1-C2 complex. Axial torque-rotation characteristics
until failure. Spine 1990;15(10):990–6.
35. Krakenes J, Kaale B, Nordli H, et al. MR analysis of the transverse
ligament in the late stage of whiplash injury. Acta Radiol 2003;
44:637–44.
36. Krakenes J, Kaale B, Moen G, et al. MR analysis of the tectorial
and posterior antlanto-occipital membranes in the late stage of
whiplash injury. Neuroradiology 2003;45:585–91.
37. Krakenes J, Kaale B. Magnetic resonance imaging assessment of
craniovertebral ligaments and membranes after whiplash trauma.
Spine 2006;31(24):2820–6.
38. Dvorak J, Hayek J, Zehnder R. CT-functional diagnostics of the
rotatory instability of the upper cervical spine: 2. An evaluation on
healthy adults and patients with suspected instability. Spine
1987;12:726–31.
39. Dickman C, Mamourian A, Sonntag V, et al. Magnetic resonance
imaging of the transverse atlantal ligament for the evaluation of
atlantoaxial instability. J Neurosurg 1991;75:221–7.
40. Tubbs S, Kelly D, Humphrey R, et al. The tectorial membrane:
anatomical, biomechanical and histological analysis. Clin Anat
2007;20:382–6.
41. Krakenes J, Kaale B, Rorvik J, et al. MRI assessment of normal
ligamentous structures in the craniovertebral junction. Neuroradi-
ology 2001;43:1089–97.
42. Kaale B, Krakenes J, Albreksten G, et al. Whiplash associated dis-
orders impairment rating: neck disability index score according to
severity of MR-findings of ligaments and membranes in the upper
cervical spine. J Neurotrauma 2005;22(4):466–75.
43. Schomacher J, Falla D. Function and structure of the deep cervical
extensor muscles in patients with neck pain. Man Ther 2013;18:
360–6.
44. Falla D. Unravelling the complexity of muscle impairment in
chronic neck pain. Man Ther 2004;9(3):125–33.
45. Jull G, Falla D, Treleaven J, et al. A therapeutic exercise approach
for cervical disorders. In: Boyling J, Palastanga N, editors.
Grieves’ Modern Manual Therapy. 3rd ed. Edinburgh: Churchill
Livingstone; 2004.
46. Hallgren R, Pierce S, Prokop L, et al. EMG activity of rectus
capitus posterior minor muscles associated with voluntary head
retraction. Spine J 2014;14:104–12.
47. Boyd Clark L, Briggs C, Galea M. Muscle spindle distribution,
morphology and density in longus colli and multifidus muscles of
the cervical spine. Spine 2002;27(7):694–701.
48. Kettler A, Hartwig E, Schultheib L, et al. Mechanically stimulated
muscle forces strongly stabilise intact and injured upper cervical
spine specimens. J Biomech 2002;35:339–46.
49. Armstrong B, McNair P, Taylor D. Head and neck position sense.
Sports Med 2008;38(2):101–17.
50. Treleaven J. Sensorimotor disturbances in neck disorders affecting
postural stability, head and eye movement control. Man Ther
2008;13(1):2–11.
51. Kristjansson, E. The Cervical spine and proprioception. In: Boyling
J, Jull G, editors. Grieve’s Modern Manual Therapy. 3rd ed.
Churchill Livingstone; 2004.
52. Middleditch A, Oliver J. Functional Anatomy of the Spine.
2nd ed. Edinburgh: Elsevier Butterworth Heinnemann; 2005.
53. Taylor J, Twomey L. Functional and applied anatomy of the cervical.
In: Spine IN, Grant R, editors. Physical Therapy of the Cervical and
Thoracic Spine. 3rd ed. New York: Churchill Livingstone; 2002.
54. O’Leary S, Falla D, Jull G. The relationship between superficial
muscle activity during the craniocervical flexion test and clinical
features in patients with chronic neck pain. Man Ther 2011;
16:452–5.
55. Kelly M, Cardy N, Melvin E, et al. The craniocervical flexion test:
an investigation of performance in young asymptomatic subjects.
Man Ther 2013;18:83–6.
56. Scali F, Pontell M, Enix D, et al. Histological analysis of the rectus
capitus posterior major’s myodural bridge. Spine J 2013;13:
558–63.
57. Hack G, Koritzer R, Walker L. Anatomic relation between the
rectus capitus posterior minor muscle and the dura mater. Spine
1995;20:2484–6.
58. Scali F, Marsili E, Pontell M. Anatomical connection between the
rectus capitis posterior major and the dura mater. Spine 2011;
36:E1612–14.
59. Alix M, Bates D. A proposed etiology of cervicogenic headache: the
neurophysiological basis and anatomic relationship between the
dura mater and rectus capitis minor muscle. J Manipulative Physiol
Ther 1999;22:534–9.
60. Hack G, Hallgren R. Chronic headache relief after section of sub-
occipital muscle dural connections: a case report. Headache
2004;44:84–9.
61. Haldeman S, Dagenais S. Cervicogenic headaches: a critical review.
Spine J 2001;1(1):31–46.
62. Standring S. Standring S, editor. Gray’s Anatomy. The Anatomical
Basis of Clinical Practice. 39th ed. Oxford: Elsevier, Churchill
Livingstone; 2005.
63. Levangie PK, Norkin CC. Joint Structure and Function. A Com-
prehensive Analysis. 3ed ed. Philadelphia: F. A. Davis Company;
2001.
64. Bogduk N, Mercer S. Biomechanics of the cervical spine. I: normal
kinematics. Clin Biomech (Bristol, Avon) 2000;15(9):633–48.
[Epub 2000/08/18].
65. Mercer SR, Jull GA. Morphology of the cervical intervertebral disc:
implications for McKenzie’s model of the disc derangement syn-
drome. Man Ther 1996;1(2):76–81.
66. Tubbs RS, Rompala OJ, Verma K, et al. Analysis of the uncinate
processes of the cervical spine: an anatomical study. J Neurosurg
Spine 2012;16(4):402–7. [Epub 2012/01/24].
67. Ebraheim NA, Lu J, Biyani A, et al. Anatomic considerations for
uncovertebral involvement in cervical spondylosis. Clin Orthop
Relat Res 1997;334:200–6. [Epub 1997/01/01].
68. Kotani Y, McNulty PS, Abumi K, et al. The role of anteromedial
foraminotomy and the uncovertebral joints in the stability of the
cervical spine. A biomechanical study. Spine (Phila Pa 1976)
1998;23(14):1559–65. [Epub 1998/07/31].
69. Penning L. Differences in anatomy, motion, development and
aging of the upper and lower cervical disk segments. Clin Biomech
1988;3(1):37–47.
70. Pal GP, Routal RV, Saggu SK. The orientation of the articular
facets of the zygapophyseal joints at the cervical and upper tho-
racic region. J Anat 2001;198(Pt 4):431–41. [Epub 2001/
05/01].
71. Barnsley L, Lord SM, Wallis BJ, et al. The prevalence of chronic
cervical zygapophysial joint pain after whiplash. Spine (Phila Pa
1976) 1995;20(1):20–5, discussion 6. [Epub 1995/01/01].
72. Bogduk N, Yoganandan N. Biomechanics of the cervical spine Part
3: minor injuries. Clin Biomech (Bristol, Avon) 2001;16(4):267–75.
[Epub 2001/05/19].
73. Stemper BD, Yoganandan N, Pintar FA. Gender dependent cervical
spine segmental kinematics during whiplash. J Biomech 2003;
36(9):1281–9. [Epub 2003/08/02].
74. Stemper BD, Yoganandan N, Pintar FA. Gender- and region-
dependent local facet joint kinematics in rear impact: implications
in whiplash injury. Spine (Phila Pa 1976) 2004;29(16):1764–71.
[Epub 2004/08/11].
75. Yoganandan N, Knowles SA, Maiman DJ, et al. Anatomic study of
the morphology of human cervical facet joint. Spine (Phila Pa 1976)
2003;28(20):2317–23. [Epub 2003/10/16].
76. Kallakuri S, Singh A, Chen C, et  al. Demonstration of substance
P, calcitonin gene-related peptide, and protein gene product 9.5
containing nerve fibers in human cervical facet joint capsules.
Spine (Phila Pa 1976) 2004;29(11):1182–6. [Epub 2004/05/29].
77. Kallakuri S, Li Y, Chen C, et al. Innervation of cervical ventral facet
joint capsule: histological evidence. World J Orthop 2012;3(2):10–
14. [Epub 2012/04/04].
78. Winkelstein BA, McLendon RE, Barbir A, et al. An anatomical
investigation of the human cervical facet capsule, quantifying