INTRODUCTION

Neck discomfort commonly appears after sudden and unusual motion of the neck because the cervical spine is the most mobile segment of the spine. Many delicate and vital structures pass through the cervical spinal column, including the carotid and vertebral arteries, the spinal cord, and the spinal nerves, all of which require great protection.

Normal function of the cervical spine requires that all movements be accomplished without injury to the spinal cord and the millions of nerve fibers that pass through it. The spinal cord has the capacity to adapt itself to marked alteration in the length of the cervical spinal canal. Flexion of the neck lengthens the spinal canal, and extension shortens it. The thickness of the cervical spinal cord and the diameter of the spinal canal vary considerably from person to person.

The nerve roots in the neck are particularly vulnerable to injury because of their relatively horizontal position in comparison with those of the lumbar spine. Stretching of the spinal cord itself is greatest at the cervical spine, which also predisposes the cord and nerve roots to trauma (Tables 3-1 and 3-2).

TABLE 3-1 CERVICAL SPINE CROSS-REFERENCE TABLE BY SYNDROME OR TISSUE

TABLE 3-2 CERVICAL SPINE CROSS-REFERENCE TABLE BY SYNDROME OR TISSUE

Many provocative tests can be used for the cervical spine. The anatomic structures commonly tested are dural tension, foraminal and vertebral canal patency, and muscle, tendon, or ligamentous injuries (Table 3-3). During investigation of the upper extremity, the examiner must differentiate between canal or nerve root lesions by physical examination and, if necessary, electrodiagnostic studies. Cervical spine canal stenosis, whether of bony or soft-tissue origins, can cause lower-extremity signs and symptoms. Most notable is long tract pain, or rhizalgia, appearing in an ipsilateral leg with a cervical nerve root lesion (Table 3-4).

TABLE 3-3 COMMON PROVOCATIVE TESTS TO EVALUATE THE SPINE

TABLE 3-4 CLASSIFICATION OF POST–SPINAL CORD INJURY PAIN STATES

ESSENTIAL CLINICAL ANATOMY

The atlas consists of a pair of strong lateral masses that are linked by the anterior arch and the posterior arch. The posterior arch of the atlas is attached to the posterior rim of the foramen magnum by the atlantooccipital membrane.

Children often have lax ligaments, which increases spinal motion. This characteristic most commonly occurs in the cervical region. Increased motion seen during physical or X-ray examination should be differentiated from pathologic subluxation. On imaging of the cervical spine, the predental space should not exceed 3 mm. A predental space greater than 3 mm has been found in 20% of normal patients younger than 8 years and can be tracked on patients into early adulthood.

Pathologic subluxation of the atlas on the axis that compromises the spinal cord (compressive myelopathy) is associated with rheumatoid arthritis and ankylosing spondylitis. The common characteristic of these disorders is the destructive weakening of the atlantooccipital ligament system, with resultant translation of the structures.

The costal element in C7 is one of the most common from which accessory ribs may form (e.g., a cervical rib). Abnormal positioning of a cervical rib heightens the risk of compression of the nerves and vessels.

The articulations of the vertebral column are of great importance. The vertebral column supports much weight; serves as an axis for movement of the limbs, trunk, head, and neck; and protects the spinal cord from trauma.

The intervertebral discs are fibrocartilaginous flattened structures interposed between adjacent vertebral bodies. Each disc consists of a gelatinous inner region (i.e., the nucleus pulposus), surrounded by a solid ring of stiffer material (i.e., the annulus fibrosus).

The vertebral artery is closely related to the cervical spine and is the first branch of the subclavian artery. It enters the foramen of the transverse process of C6 and ascends through the remaining foramina of the tops of the cervical vertebrae. The vertebral artery passes beneath the posterior atlantooccipital membrane. The union of the two vertebral arteries forms the basilar artery.

ESSENTIAL MOTION ASSESSMENT

During a cervical spine range-of-motion assessment, the examiner should examine active then passive movements. For flexion, the patient brings the chin onto the chest; for extension, the patient bends the head backward as far as possible. For lateral flexion, the patient brings an ear toward the shoulder, first on one side and then on the other. For rotation, the patient looks over one shoulder and then the other. Repeating the movements while applying gentle pressure over the vertex of the skull may trigger pain or paresthesia in the arm if a critical degree of narrowing exists at an intervertebral foramen. In evaluating cervical spine range of motion, the examiner observes not only the total range of movement, but also the smoothness and comfort with which the patient accomplishes the motions (Figs. 3-1 to 3-8).

FIG. 3-1 Flexion. A, To assess cervical range of motion, the examiner has the patient sit with the head upright. B, The examiner then instructs the patient to tuck the chin in toward the chest. The expected range of motion is 80 to 90 degrees. Excessive range is when the chin can reach the chest while the patient’s mouth is closed. Two finger widths’ distance between the chin and the chest can be considered normal. Forty degrees or less of retained cervical flexion is an impairment of neck function in the activities of daily living.

FIG. 3-2 Flexion assessed with an inclinometer. The patient flexes the head and neck forward. The examiner records both angles. The T1 inclination is subtracted from the cranial inclination to determine the cervical flexion angle. The expected range of motion is 60 degrees or greater from the neutral position.

FIG. 3-3 Extension. Extension range of motion is 70 degrees. In extension, the plane of the nose and forehead should be nearly horizontal. Fifty degrees or less of retained cervical extension is an impairment of neck function in the activities of daily living.

FIG. 3-4 Extension assessed with an inclinometer. The T1 inclination is subtracted from the occipital inclination to determine the cervical extension angle. The expected range of motion is 75 degrees or greater from the neutral position.

FIG. 3-5 Lateral flexion. Lateral flexion of the cervical spine is normally approximately 20 to 45 degrees to the right and left. Most lateral flexion occurs between the occiput and C1 and between C1 and C2.

FIG. 3-6 Lateral flexion assessed with an inclinometer. A, With the patient seated and the cervical spine in a neutral position, the examiner places one inclinometer on the T1 spinous process in the coronal plane. The examiner places the second inclinometer at the superior aspect of the occiput, or on top of the head, also in the coronal plane. Both instruments are then zeroed. B, The patient laterally flexes the head and neck to one side. The examiner records the angles of both instruments. The T1 inclination is subtracted from the occipital inclination to determine the cervical lateral flexion angle.

FIG. 3-7 Rotation. Normal rotation of the cervical spine is 70 to 90 degrees. The patient’s chin does not often reach the plane of the shoulder.

FIG. 3-8 Rotation assessed with an inclinometer. A, With the patient in a supine position, the examiner places the inclinometer at the crown of the head in the coronal plane. The instrument is zeroed. B, The patient rotates the head to one side, and the examiner records the angle indicated on the instrument.

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

The muscles of the vertebral column are often in an increased state of contraction, which stiffens the vertebral column to serve as a platform for movement of the head or limbs.

ORTHOPEDIC GAMUT 3-6 CERVICAL SPINE MUSCLE STRENGTH

To evaluate cervical spine muscle strength, the patient takes the following actions:

1. Pushes a cheek against the examiner’s hand (This maneuver also tests the motor function of cranial nerve XI [sternocleidomastoid muscle].) (Fig. 3-9)

2. Pushes the back of the head against the examiner’s hand

3. Pushes the forehead against the examiner’s hand (Figs. 3-10 to 3-12)

FIG. 3-9 Examining the strength of the sternocleidomastoid and trapezius muscles. A, Rotation against resistance. B, Flexion with palpation of the sternocleidomastoid muscle. C, Extension against resistance.

FIG. 3-10 Posterolateral head and neck extensors. The patient tries a posterolateral extension with the face turned toward the side tested. The examiner applies pressure in an anterior direction against the posterolateral aspect of the head.

FIG. 3-11 Anterolateral head and neck flexors. The patient attempts anterolateral neck flexion. The examiner applies pressure to the temporal region of the head in an obliquely posterior direction.

FIG. 3-12 Anterior head and neck flexors. The patient tries to flex the cervical spine by lifting the head from the table toward the sternum while keeping the mouth closed and the chin depressed. The examiner applies pressure to the forehead in a posterior direction.

The intrinsic longitudinal vertebral muscles, placed more superficially, are collectively called the erector spinae. The cervical region contains elongated muscles originating from the spinous process (the splenius muscles) and others from the transverse processes (the semispinalis muscles). The suboccipital muscles are a special group of muscles linking the atlas, the axis, and the base of the skull.

ESSENTIAL IMAGING

BAKODY SIGN

SHOULDER ABDUCTION RELIEF SIGN/TEST—CERVICAL FORAMINAL COMPRESSION TEST

Assessment for Cervical Nerve Root Compression

Comment

Cervical radiculopathy is more common than cervical myelopathy. Cervical radiculopathy consists of pain and neurologic dysfunction produced by irritation or injury to a spinal nerve. The injury may be caused by a herniated cervical disc, cervical foraminal stenosis, tumors, fractures, or dislocations. The pathognomic characteristic of cervical radiculopathy is pain in the distribution of nerve (Table 3-6).

TABLE 3-6 CLINICAL FINDINGS ASSOCIATED WITH THE CERVICAL NERVE ROOTS

ORTHOPEDIC GAMUT 3-9 CERVICAL NERVE ROOT COMPRESSION SYMPTOMS

• Proximal (root) pain and neck pain

• Distal paresthesia in dermatome patterns

• Muscle weakness in one or several muscles supplied by a single root

• Loss of deep-tendon reflexes

• Muscle fasciculation

• Radiating pains that are further aggravated by movements of the neck

PROCEDURE

FIG. 3-13 The hand is placed on top of the head. If this position relieves radicular pain, it suggests a nerve root syndrome.

BARRÉ-LIÉOU SIGN

PROCEDURE

FIG. 3-14 A VA syndrome is suggested by vertigo, blurred vision, nausea, syncope, or nystagmus. These symptoms may occur singly or in combination.

BIKELE SIGN

PROCEDURE

FIG. 3-15 The arm is fully extended at the elbow, and the patient attempts to reach behind. In the presence of radiculopathy or plexopathy, this maneuver produces the radicular pain.

BRACHIAL PLEXUS TENSION TEST

PROCEDURE

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