Unit 3, Lecture 3 Moorified

Which of the following is not an important function of Folic Acid? a. Red blood cell metabolism b. Neural tube formation c. Gluten absorption d. Synthesis of serine

d. Synthesis of serine slide 4

What is the recommended amount of folic acid during the 1st trimester of a normal pregnancy? A) 400mcg B) 800mcg C) 1000mg D) 200mcg E) it is not safe to give folic acid during the first trimester

slide 3

A 35-year-old male patient presents to your office after a lifting competition. After explaining to you how great of a job he did considering he did not train as long as many of the other competitors, he begins to explain his complaint of a sore back. Upon history you determine that the patient did not use the proper lifting technique of crouching, straightening his back, and using his buttocks and lower limbs to help support the weight during his competition which likely led to him experiencing which of the following conditions? (Page 495, Blue Boxes) A) Nerve impingement from over-extension B) Back strain due to overly strong muscular contractions C) Quadratus lumborum tear due to excessive use with lifting D) Reduced blood supply to his back muscles

B) Back strain due to overly strong muscular contractions BB 495 "*Back sprain is an injury in which only ligamentous tissue, or the attachment of ligament to bone, is involved*, without dislocation or fracture. It results from excessively strong contractions related to movements of the vertebral column, such as excessive extension or rotation. *Back strain *is a common injury in people who participate in sports; it results from overly strong muscular contraction. The *strain involves some degree of stretching or microscopic tearing of muscle fibers*. The muscles usually involved are those producing movements of the lumbar IV joints, especially the erector spinae. If the weight is not properly balanced on the vertebral column, strain is exerted on the muscles."

A 52 yo male is brought in on a stretcher after a three car pile up. He was not wearing his seat belt, but remained in the car and had to be cut out by the jaws of life. On exam you note he has no sensation or motor ability in either leg. He is able to bend both his arms at his elbow, but can not make a fist. At what level was the spinal cord likely severed? A. C4-C5 B. C6-C8 C. T1-T9 D. L2-L3

B. C6-C8 *Spinal Cord Injuries Pg 506 "Transection of the spinal cord results in loss of all sensation and voluntary movement inferior to the lesion. Transection between the following levels will result in the indicated effects: (see pic)"

Which of the following do NOT make up the deep layer of the instrinsic back muscles? A. Multifidus B. Iliocostalis C. Semispinalis capitis D. Rotatores

B. Iliocostalis slide 17 of lecture

If the splenius muscles are unilaterally activated, what is the resulting action? A. Extension of head B. Lateral flexion and rotation of head C. Lateral flexion of spine D. Extension of spine

B. Lateral flexion and rotation of head (slide 14)

The intrinsic back muscles are enclosed by fascia that attach to all of the following except; A. Nuchal ligament B. Scapular spine C. Tips of spinous processes D. Supraspinous ligament E. Median crest of sacrum

B. Scapular spine slide 10

Which of the following intrinsic back muscles is NOT correctly matched with its layer? A. Splenis cervicis--Superficial B. Semispinalis capitis--Superficial C. Longissimus--Intermediate D. Spinalis--Intermediate E. Multifidus--Deep

B. Semispinalis capitis--Superficial **Page 9/slide 17. Semispinalis capitus is a deep muscle

A 27 year old male comes into your clinic complaining of recurring headaches that began a week ago and states that the pain is becoming unbearable. While taking a history, you discover that the patient is a PA student and has been very stressed. It is finals week and he has been hitting the books like crazy. He spends hours reading his textbooks without taking a break. You complete a physical exam that is unremarkable except that you note the patient has decreased range of motion of the neck. Based on the history and physical exam, what is your most likely diagnosis? a. Flexion-extension injury b. Cervical vertebra fracture c. Migraine headaches d. Tension headaches

d. Tension headaches

In order to handle the stress of PA school, you decide to take up yoga. You forget to warm up one day and after holding triangle pose (which requires you to flex laterally), your lower back suddenly becomes painful. The pain remains after you stop doing the pose. What muscle(s) are you worried you strained? A. Iliocostalis B. Longissimus C. Spinalis D. All of the above E. None of the above

D. All of the above **Page 8/slides 15-16 in powerpoint, Moore p 495

Why is L5 is the most commonly compressed spinal nerve? A. The lumbar spinal nerves increase in size from L1 to L5 B. The IV foramina decrease in size from L1 to L5 C. The size of the sacrum puts too much force on L5 D. Both A and B E. A, B, and C

D. Both A and B *Compressions of Lumbar Spinal Nerve Root Pg. 505 pic 462 BB 505 "Compression of Lumbar Spinal Nerve Roots: The lumbar spinal nerves increase in size from superior to inferior, whereas the IV foramina decrease in diameter. Consequently, the L5 spinal nerve roots are the thickest and their foramina, the narrowest. This increases the chance that these nerve roots will be compressed if osteophytes (bony spurs) develop (see Fig. B4.9B), or herniation of an IV disc occurs."

In high school, Amy worked at the local ski area teaching ski lessons to all the tourists. On busy weekends, however, she was often sent to the bunny hill to do "maintenance" which meant helping lift large men off the snow and back in their ski boots. Despite knowing that she really should protect her back, Amy often would forget to lift with her knees and instead would use her back as a lever to get the Texans back on the slopes. As a protective mechanism, the back muscles can spasm, cramp, and interfere with function. What nerve innervates the majority of the intrinsic back muscles Amy was not protecting? A. Dorsal Rami of Suboccipital nerves B. Dorsal Rami of Subarachnoid nerves C. Dorsal Rami of Sural nerves D. Dorsal Rami of Spinal nerves

D. Dorsal Rami of Spinal nerves (Slide 16) pic 467 yellow 496 "The superficial extrinsic back muscles are axio-appendicular muscles that serve the upper limb. Except for the trapezius— innervated by CN XI—the extrinsic back muscles are innervated by the *anterior rami* of spinal nerves. The deep intrinsic back muscles connect elements of the axial skeleton, are mostly innervated by *posterior rami* of spinal nerves, and are arranged in three layers: superficial (splenius muscles), intermediate (erector spinae), and deep (transversospinalis muscles)."

A patient presents to his PCP for back pain. He states that he was helping his son move over the weekend and was doing a lot of heavy lifting and that the pain didn't start until the following morning. He rates the pain as 7/10, constant, and describes it as a tightness. He has limited range of motion in extension of the back and states that it makes the tightness worse when he tries to stand up straight. Upon physical exam you decide to treat the patient conservatively for spasmodic contractions of the erector spinae muscles due to overuse. Which of the following actions is LEAST likely to be involved in causing this man's symptoms? A. Lateral flexion of vertebral column B. Extension of vertebral column C. Extension of head D. Lateral rotation of head

D. Lateral rotation of head Moore p. 486 "Erector spinae: Iliocostalis, Longissimus, Spinalis Acting bilaterally: extend vertebral column and head; as back is flexed, control movement via eccentric contraction Acting unilaterally: laterally flex vertebral column"

In the deep layer of intrinsic back muscles, the transversospinalis muscle group has all of these main functions EXCEPT A. Extend neck and thoracic region B. Stabilize Vertebra C. Rotation of localized areas D. Rotate head C1 on C2 E. Aid in lateral flexion

D. Rotate head C1 on C2 *** Answers found on lecture slides 18 & 23 *** Yellow 496 "The deep intrinsic back muscles connect elements of the axial skeleton, are mostly innervated by posterior rami of spinal nerves, and are arranged in three layers: superficial (splenius muscles), intermediate (erector spinae), and deep (transversospinalis muscles). *The intrinsic muscles provide primarily extension and proprioception for posture*, and work synergistically with the muscles of the anterolateral abdominal wall to stabilize and produce movements of the trunk."

Name the innervation of superficial, deep, and intrinsic back muscles. A) All by dorsal rami of spinal nerves B) All by ventral rami of spinal nerves C) Mix of dorsal and ventral rami of spinal nerves D) Spinus erectus nerve

A) All by dorsal rami of spinal nerves pic 484 pg 482 "The intrinsic back muscles (muscles of back proper, deep back muscles) are innervated by the posterior rami of spinal nerves and act to maintain posture and control movements of the vertebral column" Yellow 496 "Except for the trapezius— innervated by CN XI—the extrinsic back muscles are innervated by the *anterior rami* of spinal nerves. The deep intrinsic back muscles connect elements of the axial skeleton, are mostly innervated by *posterior rami* of spinal nerves, and are arranged in three layers: superficial (splenius muscles), intermediate (erector spinae), and deep (transversospinalis muscles)."

2. The deep layer of the intrinsic back muscles are innervated by the dorsal rami of spinal nerves. What is not one of their main functions? A. Extend lumbar region B. Stabilize vertebra C. Rotation of localized areas D. Aid in lateral flexion

A. Extend lumbar region slide 17

A young man decided to try playing rugby. He played football when he was in 7th grade and figured it should be basically the same. He tried tackling another player and ended up with a herniated disk in his neck. The disk compressed the spinal nerve that exits between C5 and C6. Which spinal nerve is affected? A. C5 B. C6 C. C7 D. C8 E. T1

B. C6 *** Answers found on lecture slide 2 ***

The superficial, intrinsic, and deep intrinsic back muscles are innervated by which of the following? A. Ventral Rami of the Spinal Nerves B. Dorsal Rami of the Spinal Nerves C. Both a & b D. Neither a or b

B. Dorsal Rami of the Spinal Nerves (Slides 15-18) pic 467

You are seeing a patient after he fell down the stairs and obtained an injury to his neck. He denies paresthesia or weakness, so you rule out a nerve injury. You have him perform a series of head movements to try and pinpoint the injured muscle. He is able to extend the head and neck with ease, but was unable to laterally flex and rotate his head to the left side. On palpation he notes muscle tenderness just lateral to the C3 vertebra. What muscle was injured based on the movements and location of tenderness? A. Right splenius capitis B. Left splenius capitis C. Right splenius cervicis D. Left obliquus inferior

B. Left splenius capitis slide 26 pic 494 485 "The splenius muscles (L. musculi splenii) are thick and fl at and lie on the lateral and posterior aspects of the neck, covering the vertical muscles somewhat like a bandage, which explains their name (L. splenion, bandage) (Figs. 4.29 and 4.30). The splenius muscles arise from the midline and extend superolaterally to the cervical vertebrae (splenius cervicis) and cranium (splenius capitis). The splenius muscles cover and hold the deep neck muscles in position."

A 23 year old woman comes into your office and suspects she is pregnant. After a positive hCG test and asking her about her menstrual cycle, you determine she is 6 weeks into her first trimester. In order to decrease the risk of neural tube defects, this woman needs folic acid. What directions can you give this patient to fulfill her high need during the first trimester? A) Take 1 prenatal vitamin everyday which contain 400 mcg folic acid. B) Take 2 prenatal vitamins everyday during the first trimester which contain 400 mcg x2 pills. C) Take 1 prenatal vitamin which contain 400 mcg plus a separate 400 mcg dose of folic acid everyday for a total of 800 mcg. D) Take 1 prenatal vitamin containing 400 mcg plus a separate 800 mcg of folic acid everyday.

C) Take 1 prenatal vitamin which contain 400 mcg plus a separate 400 mcg dose of everyday for a total of 800 mcg. slide 3

What muscles are referred to as the "long muscles" of the back? A. Splenius muscles B. Transversospinalis muscle group C. Erector spinae muscles D. Intermediate extrinsic back muscles

C. Erector spinae muscles Pg. 485 "The erector spinae are often referred to as the "long muscles" of the back. In general, they are dynamic (motion producing) muscles, acting bilaterally to extend (straighten) the flexed trunk. The muscles of the *intermediate layer of intrinsic* muscles are illustrated in isolation in Figure 4.31"

Which muscle does NOT cause ipsilateral/left rotation of the head? A. Left obliquus capitis inferior B. Left rectus capitis posterior C. Left sternocleidomastoid D. Left splenius capitis E. Left longissimus capitis: intermediate layer

C. Left sternocleidomastoid *** Answer found on lecture slide 24 *** pic 494

A patient comes into your emergency department after a hard fall on the back of her head and neck while snowboarding. She was not wearing a helmet, and is having difficulty making postural movement with her head. A quick X-ray and CT show rule out bleeding and fractures. You know that the suboccipital muscle group play a large role in posture, and one of them may have been torn. Where are the origins for the muscles in the suboccipital group located? A. Occiput B. Mandible C. Spine D. Scapula

C. Spine Muscles of the back slide 22 492 "The four small muscles of the suboccipital region lie deep (anterior) to the semispinalis capitis muscles and consist of two rectus capitis posterior (major and minor) and two obliquus muscles. All four muscles are innervated by the posterior ramus of C1, the *suboccipital nerve*.

The Rotatores are attached to the transverse process and what part of the superior vertebrae? A. Lamina B. Transverse process C. Spinous process D. Vertebral body

C. Spinous process Muscles of the back slide 17 "Intrinsic Back Muscles: Deep Layer: Made up of Transversospinalis Muscle Group: Attached to *transverse process of vertebrae to spinous process of more superior vertebra*. Occupy area between transverse and spinous processes and attach to processes, laminae and ligaments" pic 488

What muscles are involved on your right side as you rotate your head to the left? A. Splenius Capitis B. Sternocleidomastoid C. Semispinalis capitis D. A&B E. B&C

D. A&B Slide 28 pic 494

Which of the following is the function of the intermediate layer of extrinsic back muscles? A. Controlling upper limb movements B. Maintaining posture C. Rotating the spinal column D. Controlling respiration

D. Controlling respiration (slide 8) 482 "The intermediate extrinsic back muscles (serratus posterior) are thin muscles, commonly designated as superficial respiratory muscles, but are more likely proprioceptive rather than motor in function (Vilensky et al., 2001). ... The serratus posterior superior lies deep to the rhomboid muscles, and the serratus posterior inferior lies deep to the latissimus dorsi. Both serratus muscles are innervated by intercostal nerves, the superior by the first four intercostals and the inferior by the last four."

As a protective mechanism, the back muscles go into spasm after an injury in response to what? A. Hemorrhage B. Pathogens C. Infection D. Inflammation E. Temperature change

D. Inflammation BB 495 "As a protective mechanism, the back muscles go into spasm after an injury or in response to inflammation (e.g., of ligaments). A spasm is a sudden involuntary contraction of one or more muscle groups. Spasms are attended by cramps, pain, and interference with function, producing involuntary movement and distortion."

Which of the following is NOT one of the main functions of the deep layer of the intrinsic back muscles? A: Aids in lateral flexion B: Stabilizes Vertebra C: Extends neck and thoracic region D: Rotates the neck and head

D: Rotates the neck and head Slide 18 in "Muscles of the Back" lecture Made up of Transversospinalis Innervated by Dorsal Rami of Spinal Nerves Main Functions: Extend neck and thoracic region Stabilize Vertebra Rotation of localized areas Aid in lateral flexion pic 486

A patient reports to your office with a medical history of a recent cervical lymph node biopsy. She complains of having shoulder weakness. During exam you notice her right shoulder is lower than the her left. Which nerve was damaged? A) Accessory nerve B) Thoracodorsal nerve C) Dorsal scapula nerve D) Greater occipital nerve E) Great auricular nerve

A) Accessory nerve 482: "The superficial extrinsic back muscles (trapezius, latissimus dorsi, levator scapulae, and rhomboids) are posterior axio-appendicular muscles that connect the axial skeleton (vertebral column) with the superior appendicular skeleton (pectoral girdle and humerus) and produce and control limb movements (Fig. 4.28A; see also Table 6.4, p. 700). Although located in the back region, for the most part these muscles receive their nerve supply from the anterior rami of cervical nerves and act on the upper limb. *The trapezius receives its motor fibers from a cranial nerve, the spinal accessory nerve (CN XI)*. More from Moore: BB pg 1082 "SPINAL ACCESSORY NERVE Because of its nearly subcutaneous passage through the posterior cervical region, iatrogenic (physician-caused) injury of CN XI may occur during surgical procedures such as *lymph node biopsy*, cannulation of the internal jugular vein, and carotid endarterectomy (see Chapter 8).

Which of the following is the correct origin and insertion for the splenius cervicis? (Slide 13) A) Spinous processes of C6-T7 to tubercle of transverse process of C1-C3/C4 B) Nuchal ligament to mastoid process of temporal bone of cranium and lateral third of occipital bone C) Transverse processes of C7 to occipital condyles D) Spinous processes of T10-T12 to transverse process of C3-C4

A) Spinous processes of C6-T7 to tubercle of transverse process of C1-C3/C4 Splenius cervicis: Spinous process of C6-T7 to tubercle of transverse process of C1-C3/4 Splenius Capitis: Nuchal Ligament to mastoid process of Temporal Bone of cranium and lateral third of Occipital Bone

After spending months slouched over in a chair studying, a PA student gets ready to move to her next apartment after her lease is up. As she's lugging heavy boxes up to her new place, she is definitely wishing she had spent more time at the gym or at the yoga studio. This would have been way easier if she was fitter...and she was lifting correctly. Shortly after she feels dull and achy continuous pain running up and down her back and sitting through lecture the next day sounds like about as much fun as running on a treadmill laden with legos. What is she likely suffering from? A. Back strain B. Back bruising C. Back sprain D. Back spasm E. None of the above

A. Back strain Moore 495-496 (Blue Box): Back strains are often caused by repetitive movements, especially when using the back as a lever. Sprains are often caused by jolting movements such as "excessive extension or rotation"-Moore. Back spasms are uncontrolled contractions. Bruising might result from a fall or blow. "*Back sprain is an injury in which only ligamentous tissue, or the attachment of ligament to bone, is involved*, without dislocation or fracture. It results from excessively strong contractions related to movements of the vertebral column, such as excessive extension or rotation. *Back strain* is a common injury in people who participate in sports; it results from overly strong muscular contraction. The *strain involves some degree of stretching or microscopic tearing of muscle fibers*. The muscles usually involved are those producing movements of the lumbar IV joints, especially the erector spinae. If the weight is not properly balanced on the vertebral column, strain is exerted on the muscles.

What muscles make up the Erector Spinae? A. Iliocostalis, Longissimus, Spinalis B. Spinalis, Semispinalis Capitis, Multifidus C. Quadratus Lumborum, External Oblique, Transversus D. Longissimus, Psoas Major, Rectus Abdominis

A. Iliocostalis, Longissimus, Spinalis (slide 15) pic 486

A patient presents to the clinic reporting frequent symptoms of light-headedness and dizziness. You know that these symptoms can indicate interference with the blood supply to the brainstem. After looking in the patient's chart, you note that this patient has known arteriosclerosis of vertebral arteries. What motion can aggravate these symptoms in this patient? A. Prolonged turning of the head B. Prolonged extension of the head C. Prolonged flexion of the head D. Abrupt rotation of the head E. Abrupt extension of the head

A. Prolonged turning of the head (pg. 496: Reduced blood supply to the brainstem) "The winding course of the vertebral arteries through the foramina transversarii of the transverse processes of the cervical vertebrae and through the suboccipital triangles becomes clinically significant when blood fl ow through these arteries is reduced, as occurs with arterio sclerosis (hardening of arteries). Under these conditions, *prolonged turning of the head*, as occurs when backing up a motor vehicle, may cause light-headedness, dizziness, and other symptoms from the interference with the blood supply to the brainstem." pic 882

Which muscle is not a component of the the deep layer transversospinalis muscle group? A. Spinalis B. Semispinalis C. Multifidus D. Rotatores E. All of the above are components of the transversospinalis muscle group

A. Spinalis

Ms. Agnes Schuster is a 87 year old female with complaints of lightheadedness. Upon obtaining your history you learn that she experiences lightheadedness and dizziness upon turning her head at stoplights or when she backs up her car into her garage. You ask Ms. Schuster to complete testing for arteriosclerosis. One of your concerns is the interference of the blood supply to the brain, in particular which blood vessel(s) can have significant reduction in blood flow to the brain as they cross through the transverse processes of the cervical vertebrae? A. vertebral arteries B. spinal veins C. anterior vertebral canal branch D. ascending cervical arteries E. internal vertebral venous plexus

A. vertebral arteries p. 496

1. A 66-year-old female presents to clinic reporting she has had recent intermittent symptoms of dizziness and lightheadedness. Upon further questioning, you learn she has these symptoms mostly when she turns her neck to the side for a prolonged period of time. Interestingly, she notes she recently has been avoiding parking her car in spaces she would need to back out of because she does not want to have to look behind her. She also adds that does not want to get a car with a "fancy back up camera" and would just like you to help fix her symptoms. Thinking back to a Moore Blue Box, you remember reading about a scenario just like hers. What is most likely going on? A. She has nuchal rigidity and this is causing her transient lightheadedness B. She has arteriosclerosis of the vertebral artery which is interfering with blood supply to the brainstem C. She strained her semispinalis capitis and this will not allow for full rotation of her head D. She likely has tension headaches which are made worse when she turns her head

B. She has arteriosclerosis of the vertebral artery which is interfering with blood supply to the brainstem pic 882 BB 496 "The winding course of the vertebral arteries through the foramina transversarii of the transverse processes of the cervical vertebrae and through the suboccipital triangles becomes clinically significant when blood flow through these arteries is reduced, as occurs with *arteriosclerosis* (hardening of arteries). Under these conditions, *prolonged turning of the head*, as occurs when backing up a motor vehicle, may cause light-headedness, dizziness, and other symptoms from the interference with the blood supply to the brainstem." More from moore: pg 882 "Although it accounts for only about 2.5% of body weight, the brain receives about one sixth of the cardiac output and one fifth of the oxygen consumed by the body at rest. The *blood supply to the brain is derived from the internal carotid and vertebral arteries* (Fig. 7.39), the terminal branches of which lie in the subarachnoid space. Venous drainage from the brain occurs via cerebral and cerebellar veins that drain to the adjacent dural venous sinuses"

Spring finally arrives and you decide to spend the evening looking up at the stars. After your night of star gazing you notice that your neck is pretty stiff. You attribute your stiffness to the hour your neck spent in extension. What group of muscles is responsible for extension of your neck? A. Sternocleidomastoid, scale muscles, splenius capitis, trapezius B. Trapezius, splenius capitis, splenius cervicis, semispinalis C. Semispinalis, sternocleidomastoid, trapezius, splenius cervicis D. Splenius capitis, Splenius cervicis, semispinalis, semicapitis

B. Trapezius, splenius capitis, splenius cervicis, semispinalis Table 490

You are on rotation in the emergency department when a victim of a car accident is rushed in. It is reported to you that their vehicle was driving up Hwy 61. They were taking in the views of the north shore when a bull moose ran in front of their car. On impact the individual was thrown from their car. The patient has been nonresponsive since being airlifted from the scene. They are currently in a c-collar and on a back board. On imaging it is observed that the C4 vertebra is fractured and a large amount of blood has begun pooling in the neck. An EEG is performed and no brain activity is observed. What artery(s) has likely been severed with the fracture of C3? A. Subclavian artery B. Vertebral arteries C. Superficial temporal artery D. Basilar artery E. Segmented arteries

B. Vertebral arteries *** Answer found on lecture slide 23 *** pic 882

As a PA in the OB/Gyn Unit, you are aiding in the birth of a first-time mother who is 39 weeks along and in good health. She requests the use of spinal anesthesia before progressing into labor any farther. Your supervising doctor injects the spinal anesthesia and the birth of her baby boy is relatively stress and complication free. You receive a call the next day from the mother after she has been home for several hours and she reports that her only complication is that she is experiencing a moderate headache that is persistent. You educate and tell her that this is normal following being given spinal anesthesia and that it most likely results from which of the following: A: Spinal nerves being pinched when given the anesthesia B: Leakage of CSF through the lumbar puncture C: The lingering of the spinal anesthesia metabolites in her body D: The loss of blood following the birth of her son.

B: Leakage of CSF through the lumbar puncture BB 506 "Spinal Anesthesia: An anesthetic agent is injected into the subarachnoid space. Anesthesia usually occurs within 1 min ute. A headache may follow spinal anesthesia, which likely results from the leakage of CSF through the lumbar puncture. (See also the blue box "Anesthesia for Childbirth," p. 397.)"

An 85 year-old woman with a history of cardiovascular disease and hypothyroidism presents to the emergency room. She was at the hair salon when she started to feel extremely dizzy and lightheaded. After asking more questions about the onset on symptoms, it started while she had her neck bent back in the sink as her hairdresser was washing her hair. What could be a potential cause of her symptoms based on the presented history? A. Spasm of the neck muscles, causing ischemia of the vertebral arteries B. Rupture of the alar ligament while placing head in the sink to quickly C. Hyperextension of the neck interfering with blood supply to the brainstem D. Vertebral body fracture from osteoporosis and menopause E. Idiopathic cause that is leads to lightheadedness and dizziness

C. Hyperextension of the neck interfering with blood supply to the brainstem Slide 25 BB 496 "Reduced Blood Supply to the Brainstem The winding course of the vertebral arteries through the foramina transversarii of the transverse processes of the cervical vertebrae and through the suboccipital triangles becomes clinically significant when blood flow through these arteries is reduced, as occurs with arterio sclerosis (hardening of arteries). Under these conditions, *prolonged turning of the head*, as occurs when backing up a motor vehicle, may cause light-headedness, dizziness, and other symptoms from the interference with the blood supply to the brainstem."

1. Which muscle is NOT a part of the transversospinalis muscle group? A. Multifidus B. Semispinalis C. Longissimus D. Rotatores

C. Longissimus pic 488 485 "Deep to the erector spinae is an obliquely disposed group of much shorter muscles, the transversospinalis muscle group consisting of the semispinalis, multifidus, and rotatores. These muscles originate from transverse processes of vertebrae and pass to spinous processes of more superior vertebrae. They occupy the "gutter" between the transverse and the spinous processes and are attached to these processes, the laminae between them, and the ligaments linking them together"

Which of the following muscles is NOT a part of the Erector Spinae? A. Spinalis B. Longissimus C. Semispinalis D. Iliocostalis

C. Semispinalis Muscles of the Back Powerpoint Slides 15-18; Moore pgs. 485-489 The Semispinalis is a part of the Transversospinalis Muscle Group. pic 495

A 68 year old female presents with a complaint that she becomes light-headed and dizzy while backing up her car. She has a history of hypertension and hyperlipidemia. She doesn't have a handy back-up camera in her 1972 impala and must physically turn her head to before backing up. What is causing her chief complaint? A. She pinched nerve in her neck B. She has a bulging disc in her neck C. She has interference of blood supply to the brainstem D. She has a spinal cord injury

C. She has interference of blood supply to the brainstem (Moore p.496)

Which of the following muscles are NOT part of the Transversospinalis muscle group? A. Multifidus B. Seminspinalis Capitis C. Spinalis Cervicis D. Rotatores

C. Spinalis Cervicis (= Erector spinae) Slide 17 pic 488

A 45 year old male presents with complaints of back spasms. He states that he just helped one of his friends move to a new house last week and did lots of lifting. He admits to not always using the best form as they were moving heavier items and first noticed a spasm as they were lifting a very heavy safe. What should be on the top of your differential? A. Herniated disc B. Spinal cord injury C. Strained back muscles D. Spinal stenosis

C. Strained back muscles BB 495 "*Back sprain* is an injury in which only ligamentous tissue, or the attachment of ligament to bone, is involved, without dislocation or fracture. It results from excessively strong contractions related to movements of the vertebral column, such as excessive extension or rotation. *Back strain* is a common injury in people who participate in sports; it results from overly strong muscular contraction. The strain involves some degree of stretching or microscopic *tearing of muscle fibers*. The muscles usually involved are those producing movements of the lumbar IV joints, especially the erector spinae."

A 28-year-old PA student was packing up their suitcase to go home for a 5-day Easter Break. In the excitement, the student bent over to pick-up the suitcase and forgot to use safe technique when lifting the heavy object. When standing upright, the student cried out in pain. Frustrated, the student shuffled back to the school to get some help from classmates. The student denied leg pain or weakness. Ibuprofen relieved the pain somewhat, and the pain was aggravated by any movement of the abdomen. On examination, the student had decreased torso movement. Neurological exam was unremarkable... besides the general craziness that all PA students suffer from studying hours on end, that is. The class suspected that the student had strained the erector spinae muscles. Which of the following functions is least likely to be affected by the muscle strain? A. Lateral Flexion of the Vertebral Column B. Extension of the Vertebral Column C. Extension of the Head D. Rotation of localized areas. E. Prevention of hyperflexion and falling during spinal flexion.

D. Rotation of localized areas. Muscles of the Back Powerpoint Slides 15-18; Moore pgs. 485-489 Rotation of localized areas of the spine is a function of the Transversospinalis Muscle Group.

A 38 year old woman is brought to the ER with a large laceration to the back of the neck sustained in a machete juggling incident. You note that the laceration is deep and extends beyond the superficial muscles but is contained above the level of C2. What muscle are you not concerned about? A. Rectus capitis posterior minor B. Rectus capitis posterior major C. Obliquus capitis inferior D. Semispinalis cervicis E. Splenius capitis

D. Semispinalis cervicis Pg. 493

Which set of muscles is involved in maintaining posture and controlling movements of the vertebral column? a) intrinsic back muscles b) extrinsic back muscles c) superficial back muscles d) suboccipital muscles

a) intrinsic back muscles page 482, slide 10 482 "The intrinsic back muscles (muscles of back proper, deep back muscles) are innervated by the posterior rami of spinal nerves and act to maintain posture and control movements of the vertebral column" 484 "The intrinsic back muscles are grouped into superficial, intermediate, and deep layers according to their relationship to the surface." Superficial Layer: Splenius cervicis and Capitis Intermediate Layer: Erector Spinae Deep Layer: Transversospinalis

You are caring for a patient who sustained a deep laceration to the left posterior neck, just below the base of the skull. Luckily, bleeding is controlled but there appears to be a slight motor deficit and the patient is having difficulty turning their head to the left. Which of the following muscles do you NOT suspect may be responsible for this deficit? a. Semispinalis capitis b. Obliquus capitis inferior c. Longissimus capitis d. Splenius capitis

a. Semispinalis capitis (slide 25 - semispinalis capitis injury would affect rotation to the contralateral side, the rest contribute to ipsilateral rotation)

2. A 25-year old man presents to clinic having trouble rotating and extending his head after a weekend of moving into his new house and lifting heavy boxes. The muscles injured were in the suboccipital triangle. Which nerve innervates these muscles? a. Suboccipital nerve b. Accessory nerve XI c. C8 d. Recurrent Meningeal nerve

a. Suboccipital nerve pic 493 492 "The four small muscles of the suboccipital region lie deep (anterior) to the semispinalis capitis muscles and consist of two rectus capitis posterior (major and minor) and two obliquus muscles. All four muscles are innervated by the posterior ramus of C1, the suboccipital nerve."

A 60-year-old male presents to your clinic with complaints of recent dizziness. He has a past medical history significant for hypertension and obesity. He is not currently taking any medications other than ibuprofen on rare occasions for knee pain. His BP is 167/93 on his R arm while sitting, HR is 72bpm, RR is 16 breaths per minute, and O2 sat is 98% on room air. After taking a thorough history you discover that the patient experiences lightheadedness only when turning his head around to look behind him for prolonged periods of time. Based on the information as stated above, what is the most likely cause of his dizziness? Moore page 496 a. Vertigo b. Reduced blood flow through the vertebral arteries c. Orthostatic hypertension d. Uncontrolled hypertension

b. Reduced blood flow through the vertebral arteries 882 "*The blood supply to the brain* is derived from the internal carotid and vertebral arteries (Fig. 7.39), the terminal branches of which lie in the subarachnoid space. *Venous drainage from the brain* occurs via cerebral and cerebellar veins that drain to the adjacent dural venous sinuses." more from moore: "The vertebral arteries begin in the root of the neck (the prevertebral parts of the vertebral arteries) as the first branches of the first part of the subclavian arteries (Fig. 7.39). The two vertebral arteries are *usually unequal in size, the left being larger than the right*. The *cervical parts* of the vertebral arteries ascend through the transverse foramina of the first six cervical vertebrae. The *atlantic parts* of the vertebral arteries (parts related to the atlas, vertebra C1) perforate the dura and arachnoid and pass through the foramen magnum. The *intracranial parts* of the vertebral arteries unite at the caudal border of the pons to form the basilar artery (Figs. 7.29A, 7.39, 7.42 and 7.43C). The vertebrobasilar arterial system and its branches are *often referred to clinically as the posterior circulation of the brain*."

A 22 year old male decided to attempt a risky trick after uttering the solemn last words of so many young men: "hold my beer and watch this!" The result was over-rotation of the C1-C2 spinal column area, which, along with causing dangerous nerve damage, also can restrict blood supply to the brain via which unpaired artery that resides in this area? a) vertebral artery b) cranial artery c) basilar artery d) Artery of Robinson e) occipital artery

c) basilar artery slide 25 882 "The intracranial parts of the vertebral arteries unite at the caudal border of the pons to form the basilar artery. The basilar artery, so-named because of its close relationship to the cranial base, ascends the clivus, the sloping surface from the dorsum sellae to the foramen magnum, through the pontocerebellar cistern to the superior border of the pons. It ends by dividing into the two posterior cerebral arteries." pic 884

1. What is the function of the Intermediate Extrinsic back muscles? a. Connect upper limbs to trunk b. Control arm movement c. Help control respiration d. Maintain posture and control movements of the spinal cord and head

c. Help control respiration side 8 pic 486 482 "The intermediate extrinsic back muscles (serratus posterior) are thin muscles, commonly designated as superficial respiratory muscles, but are more likely proprioceptive rather than motor in function. ... The serratus posterior superior lies deep to the rhomboid muscles, and the serratus posterior inferior lies deep to the latissimus dorsi. Both serratus muscles are innervated by intercostal nerves, the superior by the fi rst four intercostals and the inferior by the last four."

Which of the following muscles is/are not part of the superficial extrinsic back? Lecture slide 8 a. Rhomboids b. Latissimus dorsi c. Serratus posterior d. Trapezius

c. Serratus posterior (= Intermediate Extrinsic Back Muscles) 482 "The intermediate extrinsic back muscles (serratus posterior) are thin muscles, commonly designated as superficial respiratory muscles, but are more likely proprioceptive rather than motor in function. The serratus posterior superior lies deep to the rhomboid muscles, and the serratus posterior inferior lies deep to the latissimus dorsi. Both serratus muscles are innervated by intercostal nerves, the superior by the first four intercostals and the inferior by the last four." pic 486

Which of the following about the intrinsic back muscles (muscles of back proper, deep back muscles) are TRUE? a. innervated by the posterior rami of spinal nerves b. act to maintain posture and control movements of the vertebral column c. extend from the pelvis to the cranium d. are enclosed by deep fascia e. all of the above

e. all of the above moore 482 "The intrinsic back muscles (muscles of back proper, deep back muscles) are innervated by the posterior rami of spinal nerves and act to maintain posture and control movements of the vertebral column (Figs. 4.28B and 4.29). These muscles, which extend from the pelvis to the cranium, are enclosed by deep fascia that attaches medially to the nuchal ligament, the tips of the spinous processes of the vertebrae, the supraspinous ligament, and the median crest of the sacrum."

Bria, in the 7th hour of a hot vinyasa yoga class on the top of Mount Kilimanjaro, suddenly has the urge to do Pungu Mayurasana (Wounded Peacock). Well, it's aptly named because now Bria's Spinalis, Longissimus and Iliocostalis muscles are are in constant spasm. What action(s) will Ms. Wounded Peacock Schurke struggle to perform MOST? a. Looking over her shoulder b. looking down, while she sulks c. turning her torso left or right d. bending over to tie her shoes e. standing back up after tying her shoes

e. standing back up after tying her shoes 485 "The massive erector spinae muscles lie in a "groove" on each side of the vertebral column between the spinous processes centrally and the angles of the ribs laterally (Fig. 4.29). *The erector spinae are the chief extensors of the vertebral column* and are divided into three columns: The iliocostalis forms the lateral column, the longissimus forms the intermediate column, and the spinalis forms the medial column."