Cervical Spine Disorders in Physical Therapy

Physical Therapy for Cervical Spine Disorders

• Objectives: Students should be able to memorize clinical anatomy and biomechanics of the cervical spine, identify red flags of cervical spine disorders, and understand the classification and treatment of cervical disorders.

Functional Anatomy

• Cervical spine is divided into two groups based on structure and function.
• Lower cervical vertebrae (C2-C7) have similar structure to thoracic and lumbar vertebrae with distinct vertebral bodies and spinous processes.
• Transverse processes have foramina allowing passage for the vertebral artery.
• From C3-T1, there are 10 saddle-shaped, diarthrodial articulations between the uncinate process and the adjacent body, known as uncovertebral joints (or joints of Luschka). These joints aid in mobility of the lower cervical spine.
• Articular facet joints in lower cervical spine are in the sagittal plane, tilting forward by approximately 45 degrees. This allows the facet joints to support weight and guide the motion of the segment.

The Atlas

• The atlas (C1) has a thin, wide ring shape with a well-developed transverse process, but no spinous process.
• It has concave joint surfaces above and below, serving a disc-like function.
• The atlanto-occipital joint is a convex-on-concave joint in the spine. Superior articular facet surfaces of the atlas are oval and concave.

The Axis

• The axis (C2) has an inferior articular facet similar in form and function to lower cervical facets.
• The superior articular facets of C2 align in the horizontal plane and allow for rotation.
• The dens (odontoid process) of C2 acts as a pivot for the atlas.

Ligaments

• Anterior and posterior longitudinal ligaments, ligamentum flavum are found throughout the cervical spine, functioning similarly to the thoracic and lumbar spine.
• Interspinous and supraspinous ligaments blend with the nuchal ligament of the cervical spine.
• Nuchal ligament originates from spinous processes of the cervical spine and inserts on the occiput.
• It prevents overflexion of the neck.
• Tectorial ligament is a thickening of the posterior longitudinal ligament, arising from C2, and inserting on the occiput. It becomes tight with flexion of the head.
• Cruciform ligament lies deep to the tectorial ligament, having both vertical and transverse portions that originate on C2 and insert similarly to the tectorial ligament.
• Transverse ligament of the atlas has origins and insertions on the posterior aspect of the anterior ring of the atlas, housing the dens. It is lined with synovial membrane and articular cartilage for lubrication during rotation.
• Alar ligaments are wing-like structures originating from the lateral borders of the dens and inserting on the occiput. They are a major component of the stabilization system for the upper cervical spine.

Muscles

• Muscles involved in the cervical spine are grouped into superficial posterior, deep posterior, superficial anterior, and deep anterior functional groups.
• Proper flexibility and balance in these groups are needed for normal cervical spine function in upright posture.
• Longus colli, semispinalis cervicis, and multifidus provide support and posture function.
• Rectus capitus anterior, rectus capitus lateralis are capital flexors, while suboccipital extensors, semispinalis, and splenius capitis are capital extensors.

Vertebral Artery

• Vertebral arteries pass upwards through the lateral foramina of cervical vertebrae.
• A redundant portion allows for full rotation of the atlas in both directions, and the vertebral arteries enter the cranium at the foramen magnum and join to form the basilar artery.
• Occlusion of vertebral artery can damage brainstem and cerebellum, causing dizziness, nystagmus, slurred speech, loss of consciousness.
• Manipulation techniques on the upper cervical spine should be carefully evaluated due to potential vascular damage.

Testing Ligamentous Instability

• Sharp-Purser test and Lateral flexion/alar ligament stress test assess potential ligamentous instability.

Cervical Red Flags

• Sensory disturbance in hands, muscle wasting of hand intrinsic muscles, unsteady gait, hyperreflexia, bowel/bladder disturbances, multisegmental weakness/sensory changes, are possible signs of cervical myelopathy.

Neoplastic Conditions

• Age greater than 50 years, history of cancer, unexplained weight loss, constant pain with no relief from bed rest, and night pain may indicate neoplastic conditions.

Upper Cervical Ligamentous Instability

• Common symptoms include occipital headaches and numbness, and severe limitations during neck active range of motion (AROM).

Inflammatory or Systemic Disease

• Symptoms include fever >37°C, blood pressure >160/95, resting pulse >100 bpm, resting respiration > 25 bpm, and fatigue.

Classification of Cervical Spine Disorders

• Acute Pain and Whiplash Associated Disorders
• Clinical Instability
• Cervical Radiculopathy
• Hypomobility
• Cervicogenic Headache

Management

• Relative rest, physical modalities, intermittent use of a cervical collar, gentle AROM, and activity modification are generally recommended treatments.

• Specific treatments for each condition may also involve gentle manual therapy/exercise or avoidance of pain-inducing manual therapy or exercises.

• For Clinical Instability, postural education, cervical stabilization exercise programs, and ergonomic corrections are important.

• For Cervical Radiculopathy, traction and exercises are likely interventions along with thoracic spine manipulation.

• For Hypomobility, AROM exercises, cervical and thoracic mobilization, and manipulation including isometric techniques are likely interventions.

• Cervicogenic headache management may involve cervical and thoracic mobilization/manipulation, strengthening neck and postural muscles, and postural education.