Cervical Spine Examination

• Cervical Spine Examination by Adam Squires

Objectives

• Demonstrate basic cervical physical examination procedures
• Understand and demonstrate selected passive accessory intervertebral (PAIVM) movements
• Understand and demonstrate selected passive physiological intervertebral movements (PPIVM)
• Understand and be able to apply the Canadian Cervical Spine rule for imaging

Overview

• Subjective Exam
• Outcome Measures
• Physical Exam
• Canadian C-Spine Rules

Subjective Exam

• Note where the pain is, fill it out on a body chart and create an initial hypothesis based on this
• Note what makes it worse and what makes it better
• Take a history including MOI and timeframe

Specific Questions

• Determine if the patient is experiencing any Ns and Ds
• Ask about Cervical Artery (Vertebral or Internal Carotid Artery) Dissection
• Have the patient had any, even minor, trauma to the head or neck in the last month?
• Determine if there is a Cervical Artery dissection
• Are they experiencing any loss of balance or coordination in your arms and legs?
• Determine if there is Cervical myelopathy
• What neck/arm positions relieve or aggravate symptoms?
• Determine if there is Cervical radiculopathy

Screening: Upper Quarter Red Flag Screening Questions

• Systemic Constitutional Symptoms:
  • Any recent fever, chills, or night sweats, could be an infection or cancer
  • Any recent infections can cause increased risk for infection
• Medications
  • Any long-term use of steroids or corticosteroids could cause osteoporosis or increases the risk of fracture
  • Anticoagulants, increases bleeding risk
  • Immunosuppressants, increases the risk for infection
• Cancer
  • Any previous history of cancer?
  • Any recent unexplained changes in weight could indicate cancer of infection
• Other Exam Findings: Age > 50, Pain Worse at Night & Not Related to Posture, Position, Activity, or Variance with Time of Day, Symptoms Not Relieved with Rest, Symptoms Do Not Improve w/in 30 Days of Conservative Care
• Cervical Artery Dissection
  • Any dizziness, drop attacks, dysphagia, dysarthria, or diplopia? (5 D's)
  • Any ataxia (AND)
  • Any nausea, numbness, or nystagmus (3 N's)
• Cervical Myelopathy
  • Any numbness or tingling in the hands and/or feet?
  • Any recent changes in your walking or balance while on your feet?
  • Any recent clumsiness in the hands?

Outcome Measures

• Neck Disability Index (NDI)
• Patient Specific Functional Scale (PSFS)
• Numeric Pain Rating Scale (NPRS)

Neck Disability Index

• Measures how neck pain affects daily life
• Similar to ODI
• Scored between 0-50
  • A higher score indicates greater disability
• MCID - 7.5
• Research has shown a 50% reduction

Physical Exam Overview

• Cervical AROM with overpressure
  • Flexion, Extension, Lateral Flexion, Rotation
• Repeated Motions
• Shoulder Screen
• Dermatomes
• Myotomes
• Joint Assessment

Cervical Flexion ROM

• Patient is sitting
• "Bring your chin down to your chest as far as you can"
• If full ROM without symptoms, perform overpressure
  • Stabilize at CTJ, apply pressure through top of the head toward the opposite hand
  • Hold for 5 seconds

Cervical Extension ROM

• Patient sitting, feet on the floor
• "Look up as far as you can"
• If full ROM without symptoms, perform overpressure
  • One hand cupping and supporting chin, opposite hand on head with fingers on forehead and elbow pointed straight down to table
  • Force is directly down to the table
  • Hold 5 seconds

Cervical lateral flexion

• Patient sitting, feet on floor
• "Bring your ear to your shoulder"
• If full ROM without symptoms, perform overpressure
  • One hand on top of head with fingers on opposite temporal bone and elbow straight down toward table/ipsilateral shoulder
  • Stabilize opposite shoulder
  • Force is directly inferior, do NOT induce more lateral flexion
  • Hold 5 seconds

Cervical Rotation

• Patient sitting, feet on floor
• "Turn your head as far as you can to the right/left"
• If full ROM without symptoms, perform overpressure
  • Block with ipsilateral scapula with your forearm
  • Apply pressure into more rotation using both hands
  • Hold 5 seconds

Repeated Motions

• 5-10 repetitions in one direction
• Centralization vs peripheralization

Shoulder ROM

• Active ROM in each direction with some overpressure if necessary
• In-depth coverage in UE management in future course
• Motions to assess
  • Shoulder flexion
  • Shoulder abduction
  • Shoulder ER in 90 deg abduction
  • Shoulder IR/Extension
  • Horizontal Adduction

UE Dermatomes

• Test light touch sensation from C3-T1
• Compare bilaterally
• C3’s innervated area is the Neck, posterior-lateral side
• C4’s innervated area is the Shoulder, upper trapezius
• C5’s innervated area is the Lateral cubital fossa
• C6’s innervated area is the Thumb
• C7’s innervated area is the Middle finger
• C8’s innervated area is the Little finger
• T1’s innervated area is the Medial cubital fossa

Cervical and UE Myotomes

• C3 through T1
• Stabilize proximally
• Apply moderate force and hold for 5 seconds
• Assess for weakness, indicative of nerve root or motor neuron pathology
  • check for Upper motor neuron vs lower motor neuron lesions

Myotomes

• C1, C2 - Cervical flexion
• C3 - Cervical side flexion
• C4 - Scapula elevation
• C5 - Shoulder abduction
• C6 - Elbow flexion and wrist extension
• C7 - Elbow extension and wrist flexion
• C8 - Thumb extension
• T1 - Finger Abduction
• L1, L2 - Hip flexion
• L3 - Knee extension
• L4 - Ankle dorsiflexion
• L5 - Big toe extension
• S1 - Ankle plantiflexion
• S2 - Knee flexion

Joint Assessment

• Central Posterior-Anterior (PA) and Unilateral PA glides
• Patient prone
• Thumbs stacked, MCPs of fingers flexed but DIP and PIPs straight
• Broad contact
• Nose over area assessing
• Slowly sink into tissue – lower body, DON'T poke with fingers
• Assess for pain provocation and resistance
• Be systematic so that you are consistent

Joint Assessment C1/2

• C1/2 rotation assessment
• Patient sitting
• Palpate C2 and move laterally to articular pillar
• Using thumb of one hand, apply anterior directed force to block movement of C2
• Other hand rotates the head until resistance is felt
  • How much rotation happens at C1/2?

Canadian C-spine Rules

• Developed to determine if radiograph is needed
• Does NOT predict if there is a fracture
• Very high Sensitivity (99-100%) but low Specificity (42-45%)

Dangerous Mechanism

• Fall From ≥1 Meter/5 Stairs
• Axial Load to Head, eg, Diving
• MVC High Speed (>100 km/hr), Rollover, Ejection
• Motorized Recreational Vehicles
• Bicycle Collision

Simple Rear-end MVC Excludes

• Pushed Into Oncoming Traffic
• Hit by Bus/Large Truck
• Rollover
• Hit by High-Speed Vehicle

Delayed

• Not Immediate Onset of Neck Pain

Cases

• Discuss with a partner - Radiograph or no?
  • Patient is a 53 year old farmer complaining of neck pain after a car rear-ended him, while he was driving his tractor on a 2-lane highway. On physical exam, he can only turn his head 20 degrees to the right and 60 degrees to the left.
  • Patient is a 63 year old woman who fell down 2 steps coming out of her house and began getting neck pain that night and presents 24 hours after the fall. She can turn her head about 65 degrees each way and is tender along the spinous processes of C3-5.
  • Patient is a 16 year old male riding his bike at the local skate park earlier today and crashed while trying to land a jump. He presents with pain in his neck and right elbow.