Figure 5.1
The cervical spine
Introduction
Neck pain is one of the most common reasons people visit manual therapists, with 54% of Americans visiting complementary therapists for either neck or back pain compared to 37% seeking conventional care (Wolsko et al 2003). Another study by Bassols et al (2002) found that 29.4% would seek complementary help, compared to 22.8% who self-medicated.
Vernon et al (2007) found moderate to high evidence that manual therapy to chronic neck pain not due to whiplash-associated disorders (WAD) and without arm pain or headaches had clinically reported improvements in the patients’ symptoms. However, the research did not report the same for massage as a stand-alone treatment modality.
In their study ‘Effectiveness of manual therapies: the UK evidence report’ Bronfort et al (2010) found that there are several studies supporting the beneficial effects of manual therapy including articulation of the cervical spine in the treatment of mechanical neck disorders (MND), WAD and chronic neck pain. There is also evidence to suggest that cervical spine articulation and exercise can be beneficial in relieving pain and increasing the range of motion in MND and WAD (Allison et al 2002, Hoving et al 2002, 2006, Jull et al 2002, Korthals-de Bos et al 2003). Persson and Lilja (2001) found that manual therapy was more beneficial in relieving patients’ symptoms than surgery or immobilizing the neck in a collar. Gross and colleagues (2007) found strong evidence for the sustained reduction of pain, improvement in mobility and a positive mental attitude change in response to exercise with manual therapy. The clinical practice guidelines for neck pain from the Orthopaedic Section of the American Physical Therapy Association (Childs et al 2008) ‘concluded that the most beneficial manipulative interventions for patients with mechanical neck pain with or without headaches should be combined with exercise to reduce pain and increase patient satisfaction’.
Studies by Hall et al (2010) and Zito et al (2006) have shown that articulation to the atlas–axis (C1–C2) can have a beneficial effect on headaches, neck pain and range of movement. This is of particular importance because 39–45% of cervical rotation occurs at C1–C2 with only 4–8% rotation occuring at each other cervical segment (Hall & Robinson 2004, Ogince et al 2007). Dunning et al (2012) found in their study that treating into the upper thoracic spine as well as the cervical spine achieved better outcomes in pain levels and range of movement than treating into the cervical spine alone.
One of the main concerns that therapists and patients have with treating the cervical spine is the risk of vertebrobasilar stroke. In a study by Cassidy et al (2008) no evidence was found that there is an excessive risk of vertebrobasilar stroke with manual therapy of the cervical spine. In addition, Carlesso et al (2010) found no strong evidence of any link between manual therapy of the cervical spine and the occurrence of serious adverse events. Haldeman et al (1999) found the groups that had the highest risk of adverse reaction were patients with hypertension or migraines, those using oral contraceptives, and smokers, but they found that these risk factors were roughly the same or lower than in the general population. Although the risks of adverse reactions for manipulation or high-velocity thrusts to the cervical spine are viewed to be low by most studies, some studies advise that articulation is the preferred method of treatment with lower potential risk factors than manipulation or high-velocity thrusts (Di Fabio 1999, Hurwitz et al 2005).
Anatomy
The cervical spine consists of the first seven vertebrae (C1–C7) of the spinal column, beginning just below the skull and ending just above the thoracic vertebrae. It includes the atlanto-occipital joint (A–O or C0–C1 joint), the atlanto-axial joint (A–A or C1–C2 joint) and the lower cervical joints (C3–C7). It is the shortest section of the spinal column, but it is the most mobile segment of the entire spine and supports a high degree of movement. It plays several important functions in the body, such as providing support to the skull, allowing full range of motion of the head, and protecting the spinal cord, vertebral artery and nerve roots. In addition, the craniocervical junction (i.e. the junction between the skull and the upper cervical spine (C0–C2)) and its muscles are vital to maintain equilibrium with precise muscle activity coordination in order to position one’s head in space (Bogduk 2005).
This part of the spine has a great deal of flexibility. Its movements are usually three-dimensional: the range of motion is up to 90° of rotation to both sides, about 80° to 90° of flexion, 70° of extension and 20° to 45° of lateral flexion (Windle 1980). However, motion of the cervical spine does not follow a simple mechanism; it is complex. Motion in one segment at the cervical spine involves other individual vertebrae and requires complementary motion between cervical levels (Van Mameren et al 1989). This confounds the kinematics of the cervical segment and the resulting mechanisms.
The cervical spine involves a complex system of ligaments, tendons and muscles to support and stabilize the neck and spinal column, as well as for facilitating normal joint motion. It relies heavily on ligaments for the stability of the spine as well as for movement; for example, the craniocervical junction requires many ligaments for stabilization because it accommodates a wide variety of motions (Steilen et al 2014). The ligaments in the cervical spine are usually divided into two columns: anterior and posterior. The anterior column provides stability during extension, and the posterior column provides stability during flexion (Austin et al 2014). This over-reliance on ligamentous tissues predisposes the cervical spine to a number of serious injuries, including the odontoid fracture, hangman’s fracture (acute spondylolysis of C2), C1 ring fractures, atlanto-occipital dislocation (AOD), paralysis of the arms, legs and diaphragm to name a few.
Types of cervical spine
The cervical vertebrae consist of two functionally and anatomically different segments, namely the superior or suboccipital cervical (C0–C2) segment and the inferior cervical (C3–C7) segment.
Superior cervical segment (C0–C2)
The superior cervical segment has unique anatomical features; it is quite different from the rest of the cervical spine. It consists of the occiput (C0) and the first two cervical vertebrae: the atlas (first vertebra or C1) and the axis (second vertebra or C2). These two cervical vertebrae are more specialized than other cervical vertebrae as they support the weight and movement of the head (Steilen et al 2014).
The atlas is ring-shaped and does not contain a vertebral body. It articulates superiorly with the occipital condyles and forms the atlanto-occipital joint. The primary motions of the atlas are flexion and extension. The axis has a prominent vertebral body, known as the odontoid process (dens), which works as a pivot point for the atlas. The axis articulates with the atlas via its superior articular facets and forms the atlantoaxial joint (Driscoll 1987).
The range of motion of the superior cervical spine is shown in Table 5.1.
The atlanto-axial joint (C1–C2) is responsible for 50% of all cervical rotation (White & Panjabi 1990).
Inferior cervical segment (C3–C7)
Superior cervical joint | Movement type | Range of motion (°) |
Atlanto-occipital / C0–C1 | Flexion and extension | 25 |
Axial rotation | 5 | |
Lateral bending | 7 | |
Atlanto-axial / C1–C2 | Flexion and extension | 15 |
Axial rotation | 30 | |
Lateral bending | ≤ 4 |
Table 5.1
Superior cervical range of motion
Data from Tubbs et al (2010, 2011)
The inferior cervical segment is from the inferior axis surface to the superior surface of vertebra T1. It consists of five cervical vertebrae, C3–C7, which are quite similar to each other but very different from the first two cervical vertebrae, C1 and C2. Each of these vertebrae has a vertebral body that is convex on its lower surface and concave on its upper surface.
An intervertebral disc – a piece of fibrocartilage that resists spinal compression – lies between adjacent vertebrae. These discs provide more stability in the lower cervical vertebrae. They are more fibrous in the cervical segment than other segments of the spine and, as a result, they herniate less often compared to those in the lumbar spine (Frobin et al 2002).
The degree of cervical range of motion is proportional to the height of the intervertebral disc: a greater degree of cervical range of motion will result from a greater height of intervertebral disc. Degeneration of the discs consequently leads to decline in range of motion (Muhle et al 1998).
The inferior cervical segment’s range of motion is greatest at C4–C5 and C5–C6 (see Table 5.2). The extension and flexion primarily take place in the central cervical vertebrae, with most of the flexion taking place around C4–C6 and extension at C5–C7. Lateral bending takes place at close proximity to the head, particularly at C2–C3 and C3–C4. According to Steilen et al (2014), 50% of total neck flexion, extension and rotation takes place at the upper cervical segment (C0–C2), and the remaining 50% takes place at the inferior cervical segment, especially at C2–C3, C3–C4 and C4–C5.
The facet joints
The facet joints of the cervical vertebrae, also known as zygapophyseal joints, are complex biomechanical structures located in the spine. They join the inferior articular process of the upper vertebra, with the exception of C0–C1, and the superior articular process of the lower vertebra (Steilen et al 2014).
At each vertebra, there are two sets of joint surfaces – a superior and an inferior articulating surface. One pair faces upwards and one downwards. The lower vertebra’s superior facet is relatively flat in the cervical and thoracic segments and more convex in the lumbar segment. In contrast, the upper vertebra’s inferior facet is concave and makes an arch with its apex directing towards the vertebral body (Jaumard et al 2011).
Motion unit | Movement type | Range of motion (°) |
C2–C3 | Flexion and extension | 8 |
Rotation | 9 | |
Lateral bending | 10 | |
| C3–C4 | Flexion and extension | 13 |
Rotation | 12 | |
Lateral bending | 10 | |
C4–C5 | Flexion and extension | 19 |
Rotation | 12 | |
Lateral bending | 10 | |
C5–C6 | Flexion and extension | 17 |
Rotation | 14 | |
Lateral bending | 8 | |
C6–C7 | Flexion and extension | 16 |
Rotation | 10 | |
Lateral bending | 7 |
Table 5.2
Inferior cervical range of motion
Data from Schafer & Faye (1990)
Anatomically, the cervical facet joints are diarthrodial synovial joints with fibrous capsules, and they function in a way similar to the knee joint. These joint capsules hold adjacent vertebrae to one another. In addition, the capsular joints in the inferior cervical segment are relatively more lax than in other segments of the spine; thus, they facilitate mobility and allow more gliding movements of the facets (Milligram & Rand 2000).
The cervical facet joints play a significant role in the overall stability and behavior of the spine. They guide vertebral motion and facilitate transmission of loads applied to the spine (Kalichman & Hunter 2007). Their mechanical behavior has an influence on the spinal response through their relationship with the intervertebral discs and via their anatomical orientation. However, their behavior is also reliant on the overall spine responses (Jaumard et al 2011). Moreover, they resist torsion relatively less than the lumbar spine, and they are involved in a certain amount of weight bearing. Since the facet joints help to integrate the essential structure of the spine, injury to their mechanical integrity can cause cervical spine instability. Lee and Sung (2009) suggest that injury or trauma to the facet joints can have a direct impact on a motion segment’s mechanical behavior and even on the overall spine.
Epidemiology
Chronic neck pain
Chronic neck pain often pinpoints cervical spine instability and has been identified as a common symptom of a variety of conditions, such as cervical spondylosis, post-concussion syndrome, disc herniation, whiplash injury and associated disorders, Barré–Liéou syndrome and vertebrobasilar insufficiency.
Numerous epidemiological studies have shown that the incidence of chronic neck pain in the overall population is high and could be a common source of disability. The prevalence has been reported to be in the range of 30–50%, with women of 50 years of age and above identified as the larger portion (Hogg-Johnson et al 2008). Croft et al (2001) estimated that about one in every five persons in the United Kingdom had suffered from a new neck pain episode within the previous year.
Cases of chronic neck pain usually require minimal intervention, and they often resolve with time, but the recurrence rate is high. In a population-based cohort study of 1100 adults, Côté et al (2004) found around 22.8% of participants with recurrent episodes of pain. An epidemiological study reported that only 6.3% of participants with mechanical neck disorders in the previous year were free of recurrent episodes (Picavet & Schouten 2003).
Cervical spine injury
A fracture of the cervical vertebrae caused by trauma or injury – for example, from a fall, a car or diving accident that causes trauma, a blow to the head or any other serious cervical injury – may lead to damage to the spinal cord. Spinal cord damage leads to cervical pain and poor functioning of the spine depending on which vertebra of the cervical spine has been affected (Torretti & Sengupta 2007).
Injury | Anatomical changes and severity of the injury |
Hyperextension | Distracts the anterior column Includes the unstable compressing injuries, such as Jefferson fracture and diving injury, and the unstable but decompressed injury, such as hangman’s fracture |
Hyperflexion | Distracts or overstretches the anterior column Accounts for up to 46% of overall cervical spinal injuries Ranges from mild stable injuries, such as clay-shoveler’s fracture and wedge fractures, to severe unstable injuries, such as facet joint fractures |
Compression | Forms small spinal canal, and commonly manifests as a cervical burst fracture Relatively stable injury but can impair the spine with disc fragments |
Clinically minor injuries | Include injuries that are clinically insignificant or do not considerably affect the cervical spine |
Table 5.3
Cervical spine injuries
Data from Austin et al (2014)
Cervical spine injury can affect between 2% and 5% of blunt trauma victims (Crosby & Lui 1990); this risk increases dramatically if there is a focal neurological deficit, decreased level of consciousness, or head or facial injury (Hackl et al 2001). Certain demographic factors are also found to influence blunt cervical spine injury. These include age over 65 years, male sex and white ethnicity (Lowery et al 2001).
Types of cervical spine injury include hyperextension, hyperflexion, compression and clinically minor injuries (see Table 5.3).
In the upper cervical region, the atlanto-axial joints have been identified as the most common site of injury; in the subaxial cervical spine, C6–C7 has been found to be the most commonly injured level (Goldberg et al 2001). Impairment depends on the cervical vertebra(e) injured (see Table 5.4).
Cervical spine examination
Medical history
A detailed patient history is vital for cervical spine examination. The healthcare provider must listen to the patient’s past medical history and history of present illness very carefully. In most cases, the narrative provided by the patient will consist of information critical to determine red flags and facilitate the cervical examination. In addition, the healthcare provider must ask the patient whether they have pain or other symptoms in other parts of the body, such as the shoulder or thoracic spine, to inform the cervical examination. The completion of medical screening forms is useful.
Red flags
While questioning patients, be on the lookout for red flags in their narrative (see Table 5.5). Review completed medical screening forms.
Investigation
• Radiological considerations are as follows:
• A referral for imaging is needed if the patient is positive on the Canadian C-spine rule.
• A cervical spine radiograph or cervical CT (more sensitive) should be performed to rule out fractures.
• A referral for cervical multiplanar reformatting (MPR) should be considered if the patient shows rapidly worsening neurological signs and symptoms.
• A referral for diagnostic imaging procedures should be given if the patient is with certain red flags, such as possible instability or having a history of cancer.
Cervical vertebra | Type of impairment |
C1, C2 or C3 | Functional loss of the diaphragm (a ventilator is required to facilitate breathing) |
C4 | Functional loss of control of the shoulders and biceps |
C5 | Functional loss of the wrists and hands Partial functional loss of the shoulders and biceps |
C6 | Complete functional loss of the hand Partial functional loss of the wrist |
C7 | Reduced use of the hands and fingers Limited arm use |
Table 5.4
Type of impairment from cervical vertebra injury
Physical examination
Observation
The therapist should observe the patient’s posture when he or she sits and stands. Postural deviations can be rectified in order to note the effect on signs and symptoms. Common deviations of posture may include:
Condition | Signs and symptoms |
Cervical myelopathy | Hands show sensory disturbances Intrinsic muscle wasting of hand Clonus Babinski Hoffman’s reflex Unsteady gait Bladder and bowel disturbances Inverted supinator sign Hyperreflexia Multisegmental sensory changes Multisegmental weakness |
Inflammatory or systemic disease | Temperature above 100 °F (37.8 °C) Blood pressure above 160/95 mmHg Resting pulse above 100 bpm Fatigue Resting respiration above 25 bpm |
Neoplastic conditions | Over 50 years of age Patient has a previous history of cancer Constant pain that does not subside even with rest Unexplained weight loss Night pain |
Upper cervical ligamentous instability | Post trauma Occipital numbness and headache Severe limitation during the neck’s active range of motion (AROM) in every direction Down’s syndrome, rheumatoid arthritis (RA) Signs of cervical myelopathy |
Vertebral artery insufficiency | Dizziness Drop attacks Ataxia Nausea Dysphasia Dysarthria Positive cranial nerve signs Diplopia |
Table 5.5
Red flags for neck pain during cervical spine examination
• rounded shoulders or protracted shoulder girdle
• forward head posture or protracted cervical spine
• upper thoracic spine
• flexed or kyphotic
• extended or lordotic
• middle thoracic spine.
Test | Procedure | Positive sign | Interpretation |
Cervical AROM | Using an inclinometer, the practitioner measures neck flexion, extension and rotation. The practitioner uses a universal goniometer to assess cervical motion while sitting. The practitioner may apply passive overpressure at the end of the motion assessment for end feel and pain response. | Decreased range of motion and weakness | Foraminal encroachment |
Cervical and thoracic segmental mobility | With the patient positioned in prone, the practitioner uses his or her thumb to contact each spinal process by applying oscillatory posterior to anterior force. | Pain and hypermobility or hypomobility | Upper cervical joint dysfunction in patients suffering from headaches |
Passive OA joint testing (flexion/extension) | The patient lies supine and the practitioner stands at the head of the patient. The practitioner rotates the patient’s head 20–30° to the right. The occiput is translated anteriorly to the superior facet C1 and then posteriorly. The procedure is repeated on the left side. | Pain and reproduction of symptoms | Foraminal encroachment |
AA mobility testing | The practitioner cradles the patient’s head with both hands and contacts the posterior aspect of C1 using his or her fingertips. The practitioner then flexes the cervical spine, maintaining the flexion during passive rotation. | Pain | C1 or C2 dysfunction |
Table 5.6
Movement patterns in cervical spine examination
Activity limitations or movement related to the patient’s neck pain can be used to evaluate how an episode of care affects his or her level of function. Activities should be reproducible and measurable, such as looking over the shoulder as if to check the blind spot while driving to note the point at which motion symptoms arise. These activities can be used again to see if intervention improves symptoms and enhances range of motion, thus eliciting improvement in function.
Movement patterns
See Table 5.6.
Palpation
With the patient lying supine, the practitioner palpates the bilateral sternoclavicular joints, the acromioclavicular joint and suboccipital muscles, upper trapezius, levator scapula and pectoralis minor in order to assess tenderness. An increase in tenderness/fluid accumulation, fibrosis or reproduction of symptoms will indicate inflammatory disease.
Special tests
Special tests for the cervical spine are summarized in Table 5.7.
Test | Procedure | Positive sign | Interpretation |
Cranial cervical flexion (CCF) test | The patient lies supine. Towels may be required to be placed under the occiput for a neutral position. With the occiput kept stationary, the patient is instructed to perform CCF in five increments in a graded manner while attempting to hold each position for 10 seconds with 10 seconds’ rest between stages. The practitioner palpates the neck while the patient performs CCF to monitor unrequired activation of the more superficial cervical muscles. | Inability to increase pressure to at least 6 mmHg Inability to hold the generated pressure for a period of 10 seconds Using sudden chin movements of forceful pushing of the neck against the pressure device Using superficial neck muscles for CCF | Inflammatory disease |
Upper limb tension test | The patient lies supine and the practitioner tests the patient’s response to pressure applied in the median nerve. The practitioner introduces scapular depression, shoulder abduction to 90° with the patient’s elbow flexed, forearm supination, wrist and finger extension, shoulder lateral rotation, elbow extension and contralateral and ipsilateral cervical side bending. | Reproduction of symptoms Radicular pain Increase of patient’s symptoms with contralateral side bending Decrease in patient’s symptoms with ipsilateral side bending | Dural or meningeal irritation or nerve root compression |
Spurling’s test | With the patient seated, the practitioner stands behind the patient with his or her hands interlocked on the crown of the patient’s head. The patient laterally flexes the cervical spine and the practitioner applies a compressive force along the cervical spine. | Pain and reproduction of symptoms radiating down the patient’s arm | Foraminal encroachment |
Valsalva test | The patient is seated and the practitioner asks the patient to take a deep breath and hold the breath while trying to exhale for 2–3 seconds. | Reproduction of symptoms | Presence of lesion, herniated disc, osteophyte or tumor in the cervical canal |
Distraction test | The patient is positioned in supine to relax the cervical spine postural muscles. The practitioner stands at the head of the patient and places one hand on the occiput and the other on top of the forehead to stabilize the head. The practitioner then flexes the patient’s cervical spine to a position of comfort. Force is applied to the skull to produce distraction of the cervical spine. | Pain decreases or disappears | Nerve root compression may exist during normal posture/positioning |
