Cervical Spine Examination

Cervical Spine Examination Objectives

• Demonstrate basic cervical physical examination procedures.
• Understand and perform passive accessory (PAIVM) and physiological (PPIVM) intervertebral movements.
• Apply the Canadian Cervical Spine rule for imaging.

Cervical Spine Examination Overview

• Subjective examination
• Outcome Measure
• Physical examination
• Canadian C-Spine Rules

Subjective Examination Details

• Identify the location of pain using a body chart and propose an initial hypothesis.
• Determine factors that worsen the pain, including specific activities or positions, and how long it takes for the pain to increase.
• Identify factors that alleviate the pain and how long it takes for the pain to decrease.
• Gather history, including mechanism of injury (MOI) and timeframe.

Specific Questions for Cervical Issues

• Determine if the patient is experiencing any Ns (nausea, numbness) and Ds (dizziness, drop attacks, dysphagia, dysarthria, or diplopia).
• Rule out cervical artery dissection of the vertebral or internal carotid artery.
• Ask about any trauma to the head or neck in the past month, as it can be a sign of cervical artery dissection.
• Inquire about any loss of balance or coordination in the arms and legs, possibly indicating cervical myelopathy.
• Ask about specific neck or arm positions that relieve or aggravate symptoms, indicating cervical radiculopathy.

Screening

• Check for systemic constitutional symptoms like fever, chills, or night sweats.
• Inquire about a history of cancer, recent unexplained weight changes, and any recent infections, indicating increased risk for infection.
• Determine long-term medication use, specifically steroids/corticosteroids (osteoporosis/fracture risk), anticoagulants (bleeding risk), or immunosuppressants (increased risk for infection).
• Key to also note any pain worse at night, and not being improved with rest!

Outcome Measures

• Utilize the Neck Disability Index (NDI) to measure the impact of neck pain on daily life.
• The NDI is scored from 0-50, where a higher score indicates greater disability and is similar to ODI
• A Minimally Clinically Important Difference (MCID) of the NDI is 7.5, while research shows a 50% reduction.
• Apply the Patient Specific Functional Scale (PSFS) which helps the patient identify goals of the therapy
• Assess with the Numeric Pain Rating Scale (NPRS) of 0-10, with 0 indicating no pain and 10 indicating worst pain imaginable

Physical Examination Overview

• Perform cervical AROM with overpressure, including flexion, extension, lateral flexion, and rotation.
• Assess repeated motions.
• Conduct a shoulder screen.
• Evaluate dermatomes.
• Evaluate myotomes.
• Perform a joint assessment.

Cervical Range of Motion (ROM)

• Cervical Flexion ROM
  • Patient is sitting: "Bring your chin down to your chest as far as you can"
  • With full ROM and without symptoms, perform overpressure.
  • Stabilize at CTJ, and apply pressure through the top of the head toward the opposite hand
  • Hold for 5 seconds
• Cervical Extension ROM
  • Patient is sitting and both feet are on the floor: "Look up as far as you can"
  • With full ROM and without symptoms, perform overpressure.
  • Hand placement: One hand cupping and supporting the chin, the opposite hand on the head with the fingers on the forehead and elbow pointing straight down to the table
  • A downward force applied to the table
  • Hold for 5 seconds
• Cervical Lateral Flexion
  • Patient is sitting and both feet are on the floor: "Bring your ear to your shoulder"
  • With full ROM and without symptoms, perform overpressure.
  • Hand placement: One hand on top of the head with fingers on the opposite temporal bone and elbow straight down toward the table/ipsilateral shoulder
  • Stabilize the opposite shoulder
  • Direct force inferiorly, without inducing more lateral flexion
  • Hold for 5 seconds
• Cervical Rotation ROM
  • Patient is sitting and both feet are on the floor: "Turn your head as far as you can to the right/left"
  • With full ROM and without symptoms, perform overpressure.
  • Block the ipsilateral scapula with your forearm
  • Use both hands to apply pressure into more rotation
  • Hold for 5 seconds

Repeated Motions

• Perform 5-10 repetitions in one direction.
• Observe for centralization vs. peripheralization, where symptoms either concentrate towards the center or spread out.

Shoulder ROM Assessment

• Perform active ROM in each direction with overpressure if necessary.
• Active ROM and overpressure in flexion, abduction, ER in 90 degrees of abduction, IR/Extension, and horizontal adduction.
• This will be covered in more detail in UE management.

Upper Extremity Dermatomes

• Test light touch sensation from C3-T1 and compare bilaterally.
  • C3: Neck, posterior-lateral side
  • C4: Shoulder, upper trapezius
  • C5: Lateral cubital fossa
  • C6: Thumb
  • C7: Middle finger
  • C8: Little finger
  • T1: Medial cubital fossa

Cervical and UE Myotomes

• C3 through T1 require stabilization proximally.
• Apply moderate force and hold for 5 seconds while assessing for weakness.
• Weakness is indicative of nerve root or other motor neuron pathology (upper vs. lower motor neuron lesions?).

Joint Assessment

• Use Central Posterior-Anterior (PA) and Unilateral.
• Perform glide assessments with the patient prone.
• Stack thumbs with MCPs flexed and DIPs/PIPs straight, ensure broad contact, and position nose over the area being assessed.
• Slowly sink into the tissue without poking with fingers
• Assess for pain provocation and resistance in a systematic manner to maintain consistency in joint assessment
• Palpate C2 and move laterally to articular pillar
• With the thumb of one hand, apply anterior directed force to block movment of C2
• While in this position, assess how much rotation happens at C1/2.

Canadian C-Spine Rules

• Used to determine the necessity of radiographs, not to predict fractures (high sensitivity, low specificity).

Canadian C-Spine Rules - High Risk Factors

• Age ≥ 65 years
• Dangerous mechanism -Fall from ≥ 1 meter/5 stairs -Axial load to head, e.g., diving -MVC high speed (>100 km/hr), rollover, ejection -Motorized recreational vehicles -Bicycle Collision
• Paresthesias in extremities

Canadian C-Spine Rules - Low Risk Factors

• Simple rear-end motor vehicle collision
• Sitting position in the emergency department
• Ambulatory at any time
• Delayed onset of neck pain
• Absence of midline cervical-spine tenderness