EXAMINATION OF THE CERVICAL SPINE (NECK) At this station you will practice the examination of the cervical spine. Station learning objectives: 1. Describe the applied clinical anatomy of the cervical spine. 1. Demonstrate with a clear commentary the examination of the cervical spine. using inspection (look), palpation (feel) and assessing movements (move). Relevant anatomy The human spine is made up of 24 vertebrae. These small bones each contain a hole or foramen, through which the spinal cord passes. The vertebrae are grouped into three sections according to location: cervical spine: neck thoracic spine: middle back lumbar spine: lower back Soft tissues surround and support the spine: mainly the ligaments (tough connective tissue that connects bones) and muscles. Seven vertebrae form the cervical spine. This section of the spine connects the base of the head to the thorax (trunk and shoulders) and, with the help of soft tissues, supports the head. Acknowledgements: www. hughston.com/hha/a.cspine.htm. The cervical spine can conveniently be divided into anterior and posterior columns: The anterior column consists of the cervical vertebral bodies sandwiched between supporting disks. This column s anterior surface is reinforced by the anterior and posterior longitudinal ligaments, both of which run from the axis to the sacrum. The posterior column consists of: The neural arch (pedicles and lamina) The transverse and spinous processes, which arise from the neural arch. These posterior column is similarly reinforced by a number of ligaments, as illustrated in the diagram below: ligamentum flavum, interspinous ligament, supraspinous ligament, intertransverse ligament.
Acknowledgements: www. Spineuniverse.com/article 1268.html The articulations (joints) of the cervical spine include: The articulation between each disk and vertebral body. This is a cartilaginous joint. The facet joints, which are situated laterally between the upper and lower facets of the neural arches of adjacent vertebrae. These are synovial joints. The unco-vertebral joints (joints of Luschka, neurocentral joints, lateral interbody joints) are only found on C3-C7. The upper border of the body lateral to the origin of the pedicles is elongated to form a so-called uncal process on each side, which articulates with the body of the vertebra above. These joints are sometimes synovial. Note the following relationships beween anatomy and movement: The intervertebral disk is thicker anteriorly, contributing to the normal cervical lordosis. The unco-vertebral joints, located as they are on the lateral side of the cervical body, both allow and limit the degree of lateroflexion of the cervical spine. The facet joints are oriented 45 degrees to vertical, so they allow a sliding motion forward as the joint capsule is weakest posteriorly. The vertebral artery runs part of its course through foramina in the transverse processes, as illustrated in the diagram below. The same diagram demonstrates hw the cervical nerve roots pass through the intervertebral foramina.
Acknowledgements: www. coventrypain.clinic.org.uk/images/spine.ce Clinical examination The patient should be adequately exposed for this examination i.e. both upper limbs and the trunk need to be bared, up to the waist. NB: The cervical spine can be difficult to see. The patient s hair must be lifted out of the way, if it is obscuring any part of the neck. A neurological examination of the upper and lower limbs forms a key part of the examination of cervical spine. You will learn to do this in detail later in the year. As always in orthopaedic examinations we follow the three steps: A. Look B. Feel C. Move A. LOOK (inspection) a. Look first at the patient as a whole! Observe the patient as s/he undresses as well as his/ her general posture. Start with patient standing and you inspect from the front, the back and the sides. Remember each joint and bone has three dimensions. Look if the patient wears a surgical collar. b. Observe the skin: Scars Sinuses (mainly around the cervical lymph nodes) Swellings (thyroid, abscesses and cervical nodes) Changes of colour (inflammation)
c. Observe the soft tissue: Inspect the main observable muscles of the neck: The sternocleidomastoid (SCM) (anteriorly). The trapezius (laterally). The upper portion of the erector spinae and associated nuchal muscles (posteriorly) In both cases you observe them for symmetry. For example, they will be asymmetrical when the muscle is in spasm on one side: Spasm of the sternomastoid e.g. torticolis ( wry neck ) is found congenitally in children, or there can be contracture due to a prolapsed intervertebral disc. Spasm of the trapezius e.g. caused by pain due to trauma. d. Observe the bone (i.e. the vertebrae): Look at the posture (position) of the neck. Note any abnormality: Loss of normal cervical lordosis or flexion deformity (acute lesions, rheumatoid arthritis). Increased lordosis (ankylosing spondylitis). Lateral flexion (cock robin position): due to erosion of lateral mass of the atlas in RA. Any bone deformity: trauma, tumours. B. FEEL (Palpation) We are referring here to examination of the cervical spine not the neck in general. You are therefore feeling mainly for the following structures: The vertebrae, which are only palpable posteriorly (the spinous processes) and laterally (the transverse processes). The muscles: SCM, trapezius, erector spinae and nuchal muscles. Any swellings or tumours of other soft tissue structures around the cervical spine. Position for examination: You examine the front of the neck from behind. The examiner stands behind the patient, with the patient seated. The back of the neck is examined with the patient lying prone and resting his/ her head over a pillow to relax any muscle spasm. You systematically palpate the whole area covered by the trapezius and SCM, including the space between the two (which is the posterior neck triangle) and the vertebrae posteriorly:
Think carefully what you are doing all the while and remember the underlying anatomy. Always compare the two sides. a. Soft tissue Feel for spasm in the muscles e.g. (commonly) tender nodules in the trapezius. Feel for the presence of tenderness and any swellings in the area described above: Comment on the characteristics of any swelling that is felt. Make sure you have palpated the soft tissues in the supraclavicular and suprascapular regions. b. Bone Begin by palpating the spinous processes: are they in a straight line? Is there any tenderness? Is the gap between any of them unduly large? Then move to the facet joints, which are about a finger s breath from the spine laterally on both sides (of course!). Feel for any tenderness. NB Referred muscle pain is common in almost all chronic spine disorders. This means that if there is a disease condition affecting the spine, the overlying muscles will usually be tense, tender and painful. C. MOVE As usual you test movement by using active and passive movements. a. Active movements there are 4 of these. For this examination it is useful to have the patient sit in a chair with a straight back. You must help patient to do some movements. Flexion ( chin on chest ) Ask the patient to bend the neck forward, to put his/ her chin on the chest. In full flexion the chin normally touches the chest. Extension ( look up at the ceiling ) The patient is instructed to sit completely upright and look up at the ceiling, bending the neck backwards as far as possible. In full extension the occipitomental line (from the posterior occipital protuberance or inion to the chin) forms an angle of at least 45 o with the horizontal plane. In young people the angle is usually over 60 o.
Lateral rotation ( look over your shoulder ) Ask the patient to look over each shoulder as far as possible, to each side in turn, keeping the thorax still. Note the angle that the chin makes with the shoulders on each side. Rotation should be equal in both directions. Lateral flexion ( rest your ear on your shoulder ) Ask the patient to carry out this movement to the left and right sides. Make sure the shoulder remains horizontal and doesn t move upward. Lateral flexion should be equal in both directions. In full flexion: the chin should touch the chest In full extension: the occipito-mental line forms an angle of at least 45 degrees with the horizontal and usually over 60 degrees in young people.
NB: For every movement look at the face of the patient and note any pain. b. Passive movements there are two particular tests here: The compression test This is a test which diagnoses narrowed intervertebral discs and foramina, with nerve root entrapment. The patient sits on a chair, head straight up, looking forward. The examiner stands behind the patient. The examiner puts both hands (one on the top of the other) on top of the patient s head, and presses firmly downward, gradually increasing the pressure. If the patient complains of discomfort, pain, or a change of sensation in an arm, it means a nerve root is being trapped. The pressure is stopped and the problem noted. The traction test This test distinguishes between neck pain due to nerve root compression, and neck pain due to muscle spasm. The patient sits on the edge of a bed, head straight up, looking forward. The examiner stands in front of the patient. The examiner cups the patient s head in her/ his hands, under the ears (i.e. from the occiput to the jaw), and tries to lift the patient s head upwards. If the pain is due to nerve root pressure it will be relieved (intervertebral spaces increase in width); if it is due to muscle spasm it will get worse.