Physical Examination of the Cervical Spine

Introduction

The annual prevalence of neck pain is estimated to range between 30% and 50%, and nearly half of all individuals will experience neck pain in their lifetime. History and physical examination can provide important clues in determining the etiology of symptoms. Many specialized provocative tests have been described for physical examination of the neck and cervical spine. These tests are routinely performed by clinicians with varying experience and skill. This may lead to error in both the technique and the interpretation of findings.

Several key principles exist in examination of the cervical spine: (1) The exam should be systematic to avoid missing key steps. (2) Generally, exam maneuvers should be done in a stepwise manner so that less painful movements are performed first and most painful movements are completed last; this ensures the least amount of pain carryover, which may confound exam findings. (3) Of crucial concern for any examination of the cervical spine is the ability to differentiate pathologies that merely cause pain from those that adversely affect sensitive neural tissues associated with the cervical spinal cord and its nerve roots.

This chapter provides a comprehensive overview of the physical examination of the cervical spine. For each test, the original description, currently performed technique, reliability, validity, and clinical significance are discussed, based on a comprehensive search of the existing literature. The goal is not necessarily to learn every examination maneuver performed for neck pain but rather to understand the limitations, reliability, and scientifically proven validity of some of the commonly used tests.

Inspection

Inspection should begin by noting the position of the head in relation to the line of gravity, which passes through the external auditory meatus; odontoid process; the cervical, thoracic, thoracolumbar, and lumbosacral spine; and the sacral promontory. One should carefully assess not only the upper cervical region but also the relative curvature of the thoracolumbar and lumbosacral spines because the relative positioning of the cervical spine may be influenced by the curvature below. The forward-head position can also be the direct cause of the loss of cervical motion. Caillet reported a 25% to 50% loss of head rotation with a forwardly protruded head and a significant increase in the gravity-induced weight of the head brought on by this postural abnormality. The forward-head posture thus increases the work requirements of the capital and cervical musculature. Additional features associated with damage to the neural structures may be noted by observation/inspection, including limb muscle atrophy, clumsiness, and balance problems on gait.

Palpation

Palpation is a common component of cervical spine evaluation. It should be systematic and focus on palpation of the midline spinous processes, the paraspinal musculature, and the underlying zygapophyseal joints (z-joints), as well as the associated cervical spinal musculature. Studies have addressed the accuracy of palpation in identifying the structure or level of the spine and interexaminer reliability. In a study of 69 patients, experienced anesthesiologists were asked to identify the C7 spinous process by palpation, which was then compared with fluoroscopy. The C7 level was chosen because it was believed to be the most prominent and easiest level to identify. The physicians in this study were only able to correctly identify the C7 spinous process 47.9% of the time when compared with fluoroscopy. This was increased to 77.1% with the addition of neck flexion-extension. Additional concerns with the reliability of the cervical spine palpatory examination have been highlighted in a systematic comprehensive review of the literature, which showed overall poor interexaminer reliability for all palpation. Reviewers also found that the level of clinical experience did not improve the reliability in that experienced clinicians fared no better than students in terms of palpatory reliability. Segmental range of motion as assessed by palpation was also found to have very low reliability. Additionally, palpation for soft tissue had very low reliability in all regions tested. Reviews of the literature on manual palpation of trigger points have shown poor reproducibility; however, the majority of studies had poor methodological quality.

Studies on the validity of palpation in the cervical spine are lacking. In 1995, Sandmark and Nisell found in a study of 75 patients with self-reported pain that palpation over the facet joints was the most appropriate screening to corroborate self-reported neck dysfunction. This was based on a reported sensitivity of 82% and a specificity of 79%, in which a single-blinded physiotherapist performed palpation over the cervical z-joints on subjects with and without neck pain. Subjects were then instructed to answer “yes” or “no” if pain had been elicited. Unfortunately, additional studies that compare a palpatory examination to known cervical spine pathology are few; thus, evaluation of the validity of this test is limited.

Collectively, palpation appears to have low interrater reliability and not even perfect intrarater reliability. It also fails to identify the correct target tissue in a significant percentage of cases. However, it still has utility in determining anatomic regions of pain and establishing rapport with the patient. Additionally, studies have shown that palpation is useful for assessing for hypersensitivity to pain and other nonorganic causes of pain. Sobel and associates reported that pain with light touch or pinching of the skin over the cervical region or complaints of widespread tenderness with local palpation in the cervical or upper thoracic region were associated with nonorganic disease. Therefore palpation remains a standard part of the examination, and to accomplish these numerous goals, clinicians must have a thorough understanding of both structural and functional anatomy.

Range of Motion

The amount of motion that occurs between contiguous vertebrae in the cervical spine is dictated mainly by the anatomic orientation of the z-joints. Paired superior and inferior articular processes project from each pedicle–lamina junction. The superior articular processes of each vertebra articulate with the inferior articular processes of the next higher vertebra to form hyaline cartilage–covered synovial z-joints. These joints are true synovial joints with hyaline cartilage, synovial lining, and a joint capsule that encloses the joint space. They are also known sources of pain because mechanoreceptors and nociceptors richly innervate each cervical zygapophyseal joint. The z-joint capsule for the subatlantoaxial zygapophyseal joints are generally sufficiently lax to permit gliding movements of the facet joints in planes compatible with their facing direction. The atlantooccipital (AO) and atlantoaxial (AA) joints are not true z-joints. True joints extend from C2/C3 to the C7/T1 level. Biomechanical studies have identified flexion and extension motion of the AO joint to be approximately 13 degrees. Lateral bending motion at the AO joint averages 8 degrees with negligible rotation. The AA joint articulates at three locations creating a medial atlantodental and two lateral AA joints. Rotation is the key movement of the AA joint, which averages 47 degrees and is limited by the lateral atlantoaxial joint capsule and the opposite alar ligament. The AA joint accounts for 50% of the total rotation of the cervical spine. There are 10 degrees of total flexion and extension at the AA joint with a negligible amount of lateral bending. Distal to C2, the superior articular processes of the z-joints are oriented in a posterior and superior direction, at a 45-degree angle from the horizontal plane. Flexion and extension are greatest at the C5/C6 and C6/C7 interspaces, where they amount to 17 degrees and 16 degrees, respectively. Lateral bending and rotation of the five lower cervical z-joints tend to be most extensive at the C3/C4 and C4/C5 levels, averaging 11 to 12 degrees.

In a clinical setting where spinal instability is not a concern, range of motion should ideally be initially assessed actively with the patient standing or in a seated posture. This can proceed to passive range of motion in the supine position if an abnormality is identified. By splitting the range of motion exam into active and passive components, the practitioner can assess for a true restriction with a firm end feel versus those reductions in range that are due to pain.

When specific measurements are needed, a goniometer is placed at the external auditory meatus for flexion and extension, at the top of the head for rotation, and at the nares for side-bending ( Fig. 3.1 ). Cervical flexion has been identified to range between 54 and 69 degrees, with extension ranging between 73 and 93 degrees. Youdas and coworkers identified extension to range between 20 and 74 degrees with a mean of 52 degrees in patients older than 90 years and a range of 61 to 106 degrees with a mean of 86 degrees in patients between 11 and 19 years. Lateral bending ranged between 11 and 38 degrees, while rotation ranged between 26 and 74 degrees in those older than 90 years. In patients between 11 and 19 years, lateral bending ranged between 30 and 66 degrees, whereas rotation ranged between 50 and 94 degrees. Intraclass correlation coefficients range from 0.84 to 0.95 for intratester reliability of goniometric assessment, and the intertester reliability ranged between 0.73 and 0.92.

Some studies have suggested that diminished range of motion is related to cervical pathology and physical impairment. However, diminished range of motion may also be found in the asymptomatic population. It is well known that motion of the cervical spine decreases with age due to degenerative changes, which are not always symptomatic.

Neuromuscular Evaluation

The neuromuscular screen is perhaps the most important portion of the examination and should be performed on all patients with neck complaints. The comprehensive neuromuscular examination should include a detailed motor examination ( Table 3.1 ), assessment of reflexes ( Table 3.2 ), and possibly a sensory examination ( Table 3.3 ). The results of these tests should be considered in the context of the patient’s complaints and in conjunction with the remainder of the examination.

Table 3.1

Motor Examination

Spine Level	Nerve	Muscle	Testing
C5/C6	Axillary	Deltoid	Arm abducted to the side
C5/C6	Musculocutaneous	Biceps	Elbow flexion
C5–C7	Radial	Triceps	Elbow extension
C6/C7	Median	Pronator teres	Pronation of extended forearm
C6/C7	Radial	Extensor carpi radialis	Wrist extension
C8/T1	Ulnar	Abductor digiti minimi	Abduction of the fifth digit

Table 3.2

Reflex Examination

Spine Level	Reflex
C5/C6	Biceps
C5/C6	Brachioradialis
C6/C7	Pronator teres
C7/C8	Triceps

Table 3.3

Sensory Examination

Spine Level	Sensation
C3	Supraclavicular fossa
C4	Tip of acromion
C5	Lateral epicondyle
C6	Thumb
C7	Middle digit
C8	Fifth digit

Cervical Spine Tests That Provide or Relieve Pain

Spurling Neck Compression Test

Spurling and Scoville first described the Spurling neck compression test, also known as the foraminal compression test, neck compression test, or quadrant test, in 1944 as “the most important diagnostic test and one that is almost pathognomonic of a cervical intraspinal lesion.” Their observations were based on the presentation of 12 patients with “ruptured cervical discs” verified during surgery in 1943 at Walter Reed Army Hospital. They originally described “the neck compression test” as follows:

Tilting the head and neck toward the painful side may be sufficient to reproduce the characteristic pain and radicular features of the lesion. Pressure on the top of the head in this position may greatly intensify the symptoms. Tilting the head away from the lesion usually gives relief ( ).

Since originally described, several modifications of this test have been suggested. Anekstein and associates performed a prospective study of 67 patients to assess ability of six variations of the Spurling test to reproduce symptoms of cervical radiculopathy. The variations included (1) lateral bending and compression; (2) lateral bending, rotation, and compression; (3) extension and compression; (4) extension and lateral bending; (5) extension, lateral bending, and compression; and (6) extension, rotation, and compression. Results found that maneuvers 5 and 6 were associated with the highest elicited pain and paresthesia, respectively. Methodological flaws in this study prevent conclusive recommendations. Some authors advocate performing the components of the test in a staged manner and halting with the onset of radicular symptoms, preferably reproducing the patient’s presenting symptoms. Radicular symptoms are described as pain or paresthesias occurring distant from the neck, in the distribution of a cervical spinal nerve root. Currently, this test is performed by extending the neck and rotating the head and then applying downward pressure on the head ( Fig. 3.2 ). The test is considered positive if pain radiates into the limb ipsilateral to the side at which the head is rotated.

Viikari-Juntura conducted a prospective study assessing the interexaminer reliability of common tests performed in the clinical examination of patients with neck and radicular pain. Two blinded expert examiners, who were trained together in the identical performance of the clinical tests, independently examined 52 patients referred for cervical myelography. The neck compression test was performed with each patient in both supine and sitting positions. The patient’s neck was passively flexed laterally and slightly rotated ipsilaterally, and the head was then compressed with approximately 7 kg of pressure. A positive test result was considered to be the appearance or aggravation of pain, numbness, or paresthesias in the shoulder or upper extremity. For the sitting position, κ values ranged from 0.40 to 0.77, which was considered to be “fair to excellent,” and the proportion of specific agreement was found to be 0.47 to 0.80, which was also considered to be “fair to excellent.” For the supine position, κ values ranged from 0.28 to 0.63, which was considered to be “poor to good,” and the proportion of specific agreement was found to be 0.36 to 0.67, which was also considered to be “poor to good.” The author concluded that this test has good reliability when performed in the sitting position. This is one of the only studies in the literature assessing interexaminer reliability for the Spurling neck compression test and other provocative test maneuvers of the cervical spine. However, the results are analyzed according to the area of symptom radiation (eg, “right shoulder or upper arm,” “right forearm or hand,” “left shoulder or upper arm,” “left forearm or hand”), instead of classifying the test result as positive or negative. This fragments statistical analysis and makes interpretation difficult.

In 1989, Viikari-Juntura and coworkers published a prospective study assessing the validity of the Spurling neck compression test in diagnosing cervical radiculopathy, along with the axial manual traction and shoulder abduction tests. Forty-three patients who presented for myelography were interviewed and examined before performing the procedure. The Spurling neck compression test was performed with the patient sitting as previously described. The criterion standard used was myelography combined with neurologic exam findings. Based on the study population’s myelographic and clinical findings, statistical analysis was performed only for cervical roots C6 to C8. Sensitivity ranged from 40% to 60% and specificity was 92% to 100%. The authors concluded that the test has high specificity but low sensitivity. The results are presented in a manner making interpretation difficult.

Tong and Haig reported a sensitivity of 30% and specificity of 93% utilizing electrodiagnostic studies as a criterion standard in 224 patients. Sandmark and Nisell reported a specificity of 92%, sensitivity of 77%, positive predictive value of 80%, and negative predictive value of 91%. However, their study used neck pain symptoms as the criterion standard, and the Spurling neck compression test was considered to be positive if neck pain, not radicular symptoms, was produced. This interpretation is inconsistent with the original and commonly accepted descriptions of the Spurling sign. Because of these methodological issues, the results should be viewed cautiously. Uchihara and associates reported a sensitivity of 28% and a specificity of 100%. However, the criterion standard used was spinal cord deformity on magnetic resonance imaging (MRI) in 65 patients.

In summary, there are few methodologically sound studies that assess the interexaminer reliability, sensitivity, and specificity of the Spurling neck compression test. The literature appears to indicate high specificity but low sensitivity for this test.

Shoulder Abduction Test

In 1956 Spurling was reported to have first described the shoulder abduction test, also known as the shoulder abduction relief sign and Bakody sign. In a review on the examination maneuver, Davidson and coworkers described Spurling’s initial description as follows: “raising the arm above the head sometimes brings relief of radicular symptoms caused by cervical intervertebral disc pathology.” The shoulder abduction relief test is currently described as: “active or passive abduction of the ipsilateral shoulder so that the hand rests on top of the head, with the patient either sitting or supine [ Fig. 3.3 ]. Relief or reduction of ipsilateral cervical radicular symptoms is indicative of a positive test ( ).” History alone may predict a positive test result because patients often describe raising their arms to alleviate radicular symptoms.

Davidson and associates described 22 patients who presented with severe cervical radicular pain, sensory and motor symptoms, initially unresponsive to outpatient measures. All were found to have large lateral extradural lesions on myelography. Fifteen (68%) of these patients experienced relief of their radicular symptoms with ipsilateral shoulder abduction. The authors hypothesized that reduced nerve root tension is the most likely cause for symptom relief with shoulder abduction. They concluded that the shoulder abduction relief sign is indicative of nerve root compression and predictive of an excellent response to surgical treatment.

Beatty and colleagues described this sign to be indicative of radiculopathy secondary to cervical disc pathology but not from cervical spondylosis. Ellenberg and Honet described the shoulder abduction relief sign as helpful in distinguishing cervical radiculopathy from shoulder pathology, when present. In their experience, the sign is “frequently not present” with cervical radiculopathy, though no statistical data were presented.

Viikari-Juntura prospectively studied the interexaminer reliability of the shoulder abduction relief test in 31 patients with radicular pain, paresthesias, or numbness. It was performed in the seated position with the patient instructed to “lift” the hand above the head. The decrease or disappearance of radicular symptoms indicated a positive test. Kappa scores were poor to fair and ranged from 0.21 to 0.40. The proportion of specific agreement was fair to good, ranging from 0.57 to 0.67. Overall, the test’s reliability was described as “fair.” Viikari-Juntura and coworkers later investigated the validity of the shoulder abduction relief test on 22 patients. Sensitivity ranged from 43% to 50%, and specificity ranged from 80% to 100%. The authors concluded that the test is highly specific for cervical radiculopathy with low sensitivity.

Similar to the Spurling maneuver, the literature seems to indicate high specificity with low sensitivity for the shoulder abduction relief test. However, the only available prospective study examined a small number of subjects for this test. The only investigation of interexaminer reliability concluded the test to be “fair.” Interestingly, incorporation of the abduction maneuver into a nonsurgical treatment program is reported as beneficial for patients with a positive test result.

Neck Distraction Test

The neck distraction test is also described as the axial manual traction test. The origin of this maneuver is uncertain, but it is well described in the current literature:

To perform the distraction test, the examiner places one hand under the patient’s chin and the other hand around the occiput, then slowly lifts the patient’s head. The test is classified as positive if the pain is relieved or decreased when the head is lifted or distracted, indicating pressure on nerve roots that has been relieved ( ).