PRACTICAL 4: CERVICAL SPINE

Cervical Trapezius
Splenius Capitis
Splenius Cervicis
Semispinalis Capitis and
Cervicis
Longissimus Capitis
Cervical Multifidus
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 TENEGRITY
Tensile integrity”
“The ability of the body to absorb impacts without
being damaged. The mechanical energy flows away
from the site of impact through the tensegrous living
matrix”
Not just a network, but a “webwork”
Cytoskeletons behave as tensegrity structures

The more flexible and balanced the network (i.e. the

better the tensional integrity) the more readily it
absorbs shocks and converts them into information
rather than damage.
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 GOOD TENSEGRITY

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 CERVICALGIA

There is no direct relationship between

extent of X-ray changes and the appearance
of neck pain unless there are also objective
neurological signs (Heller et al 1983 BMJ 287:1276-1278)
“Everyone with persistant pain in the neck
whether due to cervical spondylosis or…non
specific pain, has exquisitely tender trigger
points in the muscles of the neck and
shoulder girdle” Baldry 1993

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 WHIPLASH
 “Whiplash” is not innocuous
 40% of patients who sustain a whiplash
injury in a MVA develop whiplash
associated disorders like headache,
dorsalgia, neck pain.
 16% of these will not return to their former
employment.
 The major factor here is the changes in
central pain processing.

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 SPINAL SEGMENTAL SENSITIZATION
Characterized by:

Narrowed disc space and neural foramen on

imaging.
Narrowed space between spinous processes.
A tender (sprained) supraspinous ligament
on palpation.
Palpable paraspinal muscle spasm.
Radicular compression and dysfunction with
"spinal segmental sensitization (SSS)

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 GOOD READING ON SSS

Lidbeck,J. 2002. Central hyperexcitability in chronic

musculoskeletal pain. Pain research and management
7:81-92

Herren-Gerber, R et al. 2004. Modulation of central

hypersensitivity by nociceptive input in chronic pain
after whiplash injury. Pain med. 5:366-376

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 CERVICOGENIC MIGRAINES

The following S&S suggest cervicogenic

cause of migraines.

All point to spondylosis or old cervical sprain

Hooshmand, 1993 Chronic Pain

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 CERVICOGENIC MIGRAINES

• Affected by changes in barometric pressure

• Starts or worsens at end of long working day
• Shooting pain to occiput or behind the eye
• Suffers migraine with history of thoracic
outlet, carpal tunnel, rotator cuff tears
• Has remission then resurgence, often at
menopause or after 45
• Patient identifies pain as starting in sub-
occipital or C2-4 area.

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 Anatomy of the Cervical Spine

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 Vertebral Arteries

Deep Cervical Arteries

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Sternocleidomastoid

Splenius Capitis

Cervical Trapezius

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Trapezius removed

Semispinalis Capitis

Splenius Capitis

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 POSTERIOR CERVICAL SPINE
X-SECTION

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 SURFACE ANATOMY

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 SURFACE ANATOMY

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 NO NEEDLES C2 TO OCCIPUT!

PROTECT VERTEBRAL ARTERIES

CAPTURE INSERTIONS
OF MOST OF SUBOCCIPITALS
WITH THE RAKE TECHNIQUE

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 SUBOCCIPITALS ARE HEADACHE
GENERATORS

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 RAKE TECHNIQUE

• Due to the vertebral artery and vascular supply

in the suboccipital triangle, no needling is
performed here.

• The “Rake technique is a method to catch the

insertion edges of various upper cervical
muscles in order to treat neck pain and
headache producers including most of the
suboccipital insertions

• This treatment mimics the myofascial cranial

base release.
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 PERIOSTEAL PECKING

Don’t forget to check

out and clear
attachments of
affected muscles
Superficial needling
into the area if acute
Periosteal pecking in
chronic myofascial
syndromes

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 RAKE TECHNIQUE

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 SPLENIUS CAPITIS
REFERRAL AND CHARACTERISTICS
Commonly activated
with whiplash, poor
sustained postures,
cold draft
Pain with neck flexion
and rotation
Limited rotation to
same side
Capitis:
Pain referral to vertex
of head
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 SPLENIUS CERVICIS
REFERRAL AND CHARACTERISTICS

Pain referral:
intense pain
behind eye
Blurring of vision
on same side
Pain to posterior
angle of neck and
shoulder girdle

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 Splenius Capitis Technique
Starting position Prone or contralateral side lying

Check that neck is in enough upper and lower cervical flexion to facilitate
palpation

Palpation landmarks Spinous processes C7-T4, mastoid process, superior nuchal line

Take care to apply gel to skin in hairline

Possible Needle sizes 0.25X25mm

Possible Grip Flat palpation approx. 1 cm away from spinous process in lower Cx area, and
2cm in the C2/3 area– palpate for MTrP as you palpate upward and outward,
toward mastoid process.

MTrP is typically more lateral than you expect!

Direction of insertion Towards the Lamina of the same level (remember the concept of a clock‡ ).
Inferio-medial insertion

Special precautions The neck is richly supplied with proprioceptive and ANS fibres. The
patient may easily become dizzy. The needles may need to be left in situ
even after LTR to achieve full relaxation. Somatoemotional release
following needling here is not uncommon.

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 SPLENIUS CAPITIS

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 SPLENIUS CERVICIS TECHNIQUE
Starting position Prone or contralateral side lying

Check that neck is in enough upper and lower cervical flexion to facilitate
palpation

Palpation landmarks Spinous processes T3-T6, posterior transverse processes of C1-3

Possible Needle sizes 0.25X25mm

Possible Grip Flat palpation approx. 1 cm away from spinous process in lower Cx area,
and 1.5-2cm in the C2/3 area– palpate for MTrP as you palpate upward
and outward, toward mastoid process.

MTrP is typically more lateral than you expect!

Direction of insertion Towards the Lamina of the same level (remember the concept of a
clock‡ ). Inferio-medial insertion

Special precautions The neck is richly supplied with proprioceptive and ANS fibres. The
patient may easily become dizzy. The needles may need to be left in
situ even after LTR to achieve full relaxation. Somatoemotional
release following needling here is not uncommon.

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 SPLENIUS CERVICIS

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 SEMISPINALIS AND DEEP GROUP
REFERRAL AND CHARACTERISTICS
Pain referred strongly
into base of shoulder
and neck
May create a band like
pattern of pain above
the orbit
Pain and marked
restriction of head May trap the occipital
and neck flexion nerve causing occipital
neuralgia at level C4,5
Activation: Whiplash where the nerve penetrates
and posture the semispinalis muscle
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 Deep Layer Technique: Semispinalis
CapitIs & CervicIs; Multifidi
Starting position Prone or contralateral side lying

Check that neck is in enough upper and lower cervical flexion to

facilitate palpation

Palpation landmarks Transverse processes C7-T7, occipital bone

Possible Needle sizes 0.3X40mm-0.35x50mm

Possible Grip Flat palpation approx. 1 cm away from spinous process

Direction of insertion Towards the Lamina of the same level (remember the concept of a
clock‡ )

Minimal “fishing” in this area to minimize risk to deep cervical vessels

Special precautions
The neck is richly supplied with proprioceptive and ANS fibres.
The patient may easily become dizzy. The needles may need to be
left in situ even after LTR to achieve full relaxation.
Somatoemotional release following needling here is not
uncommon.

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 DEEP LAYER NEEDLING

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 DEEP LAYER NEEDLING

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 PRACTICAL 5: SPINO-SCAPULAR
MUSCLES

Trapezius
Levator Scapulae
Rhomboids Major &
Minor
Thoracic Small needles

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 Anatomy
of the Spino-scapular Muscles

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Trapezius:
Upper
Mid
Lower

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Rhomboids Minor
Major Levator Scapulae

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 HOW & WHY OF DDN GRIPS

• Flat – aiming for patients bone OR shallow

insertion in dangerous areas
• Pincer – true or modified, aim for your finger
• Split finger block – block the way into chest
wall, aim for patient’s bone
• Rib block – bracket the intercostal space
either side, aim for rib
• Guide – Bracket the muscle, use shallow
insertion in dangerous spot.

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 UPPER TRAPEZIUS FIBRES
REFERRAL AND CHARACTERISTICS
Most common muscle to
have trigger points
Pain may be referred to
cervical area, ear, face and
give temporal headaches
Dizziness and vertigo
Common causes:
whiplash, stress, scapular
instability

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 MID & LOWER TRAPEZIUS FIBRES
REFERRAL AND CHARACTERISTICS

 Middle traps: may

cause symptoms of  Lower traps: may refer to
brachial neuralgia paradorsal, high cervical
and subdeltoid area, and the medial
bursitis. border of the scapula
and acromion.
 Middle traps strongly
retracts the scapula
so instability often
seen

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Dynamic scapula control
 TRAPEZIUS TECHNIQUE
Starting position All: Contralateral Sy Ly, shoulders relaxed =/- 60 degrees F

UFT alternative: Supine arms up

Position scapula to slacken fibers to facilitate pincer grip

Palpation landmarks Spine of scapula, T12, Occiput

Possible Needle sizes UFT & LFT: 0.3X25mm-0.35x40mm

Mid: 0.25x25mm-0.25x30mm

Possible Grip UFT: Lumbrical grip taking care to lift tissue cephalad and posterior

Mid: Modified pincer if possible or flat palpation with fingers either side of target
and very oblique insertion toward scapula

LFT: Modified pincer grip Try to passively retract scapula and so relax LFT

Direction of insertion UFT: Into pincer grip

Mid and Lower: Horizontal into pincer, or Inferomedial toward scapula shallow
insertion

Special precautions Beware pleura. Patient must be advised of additional risk of pneumothorax
injury and be advised what to do in case the symptoms arise.

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 UPPER TRAPEZIUS

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 MID-TRAPEZIUS

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 MID-TRAPEZIUS

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 LOWER TRAPEZIUS

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 LOWER TRAPEZIUS

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 LEVATOR SCAPULAE

•Most commonly affected of the neck muscles

•Pain usually felt as being “at the base of the
neck” or “in the corner of the neck”
•Referred pain may be felt along course of 4 th

and 5th intercostal nerves, mimicking angina,

pleural pain or even intercostal nerve
entrapment.
•Note also referral into the upper limb which
mimics ulnar nerve pathology

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 LEVATOR SCAPULAe
“Stiff Neck”
Common finding
restricted rotation
Activation:
Sustained elevation of
the shoulders
Cramped positioning
e.g.flying
Cold wind
Sustained neck rotation

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 LEVATOR SCAPULAE TECHNIQUE
Starting position Contralateral side lying (Belly) or Ipsilateral side lying (Insertion)

Check that scapula is elevated and retracted

Palpation landmarks Origin of spine of scapula, transverse processes C1-C4

Possible Needle sizes 0.3X30mm-0.35x50mm

Possible Grip Belly: Pincer grip using tips of fingers

Insertion onto scapula: Flat palpation with finger either side of long axis of origin

Direction of insertion Towards your finger or toward the superomedial border of the scapula (insertion)

Dorsal scapular artery lies deep to the insertion. Aim at the bone to avoid
unnecessary bruising

Special precautions Beware pleura. Patient must be advised of additional risk of pneumothorax
injury and be advised what to do in case the symptoms arise.

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 LEVATOR SCAPULAE INSERTION

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 LEVATOR SCAPULAE BELLY

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 LEVATOR SCAPULAE BELLY

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 RHOMBOID MAJOR AND MINOR
REFERRAL AND CHARACTERISTICS

• Usually postural cause

• Occurs with pectoral TrP’s

• Abducted scapula

• Look at scapular rhythm

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 RHOMBOIDS MAJOR AND MINOR
TECHNIQUE
Starting position Contralateral side lying (Belly) or ipsilateral side lying (Insertion)

Check that scapula is elevated and retracted

Palpation landmarks Origin of spine of scapula, transverse processes C7-T5

Possible Needle sizes 0.25x13mm-0.3x30mm

Possible Grip Insertion onto scapula: Flat palpation with finger either side of long axis of
origin

Direction of insertion Towards your finger or toward the medial border of the scapula (insertion)

Dorsal scapular artery lies deep to the insertion. Aim at the bone to avoid
unnecessary bruising

Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the
symptoms arise.

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 RHOMBOIDS MINOR CONTRALATERAL

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 RHOMBOIDS MAJOR IPSILATERAL

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 RHOMBOIDS MAJOR CONTRALATERAL

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 THORACIC MULTIFIDUS

• No more than 1 finger breadth from spinous

process
• Use small needles - .25x25mm longest
• Always direct needle inferior and medially
CAUTION! Look after the lung.

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 THORACIC MULTIFIDUS NEEDLING

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 THORACIC MULTIFIDUS NEEDLING

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