The Cervical Spine

CHAPTER 9

The Cervical Spine

Introduction

Cervical spine manipulation (CSM) has been used for years to treat a multitude of head and neck disorders, including upper back pain, neck pain and stiffness, cervical disc problems, headaches and migraine. Practitioners of this therapy consider it a safe and effective manipulative procedure because of its relatively low adverse effects (Killinger, 2004). However, multiple recent studies have reported a range of serious and at times fatal complications following CSM, and suggested that the potential health risks associated with the procedure might offset the benefits (Di Fabio, 1999; Ernst, 2007; Leon-Sanchez, Cuetter and Ferrer, 2007; Gouveia, Castanho and Ferreira, 2009; Puentedura et al., 2012).

In contrast, some authors suggested that the incidence of serious adverse events after CSM is predictable, and might be attributed to poor knowledge of body biomechanics, inappropriate skills to use the techniques and inadequate examination and judgement by the practitioner (Refshauge et al., 2002; Haneline and Triano, 2005). Taken together, it can be said that it is of critical importance for a practitioner to have proper knowledge and appropriate skill before performing a first-line cervical manipulation.

Therefore, this chapter is written to describe the various joints of the cervical spine, the range of motion in these joints and appropriate special tests to diagnose serious pathology in the region. In addition, this chapter will also describe some of the common injuries to the cervical spine and the red flags for CSM.

Joints

The cervical spine is made up of the first seven vertebrae (C1–C7) of the spinal column, beginning just below the skull and ending just above the thoracic spine. It is divided into two functionally different segments: the superior cervical segment (O–C2) and the inferior cervical segment (C3–C7). The superior segment is highly specialised and includes the occiput (O), atlas (C1) and axis (C2). The inferior cervical segment consists of more classic vertebrae, having a body, spinous processes, laminae, pedicles and facet joints (Dodwad, Khan and An, 2014).

Table 9.1 The joints of the cervical spine
Joint name	Description	Function
Atlanto-occipital joint (O–C1)	•A synovial joint of ellipsoid variety •Forms due to articulation between the atlas and the occipital condyles •Made up of a pair of condyloid joints	•Responsible for 50% of total neck flexion and extension •Serves to maintain and support the weight and movement of the head and neck
Atlantoaxial joint (C1–C2)	•A complex joint consisting of three synovial joints •Forms due to articulation between the atlas and axis •Made up of a pair of plain joints (lateral joints) and a pivot joint (median joint)	•Responsible for 50% of all cervical rotation •Serves to maintain and support the weight and movement of the head and neck
Lower cervical joints (C3–C7)	•Originate from the inferior surface of the axis and end at the superior surface of the first thoracic vertebra (T1) •Articulations include the uncovertebral joints, disc-vertebral body and facet joints	•Responsible for 50% of total neck flexion, extension and rotation
Sources: White and Panjabi (1990); Johnson (1991); Standring (2008)

Range of Motion

The cervical spine is the most mobile segment of the entire spine and supports a high degree of movement. However, movements in the cervical spine are complex, as motion in one individual joint involves not just complementary but also unequal motion between cervical levels (Van Mameren et al., 1989). In general, the range of motion of the cervical spine is three-dimensional:

Rotation	Up to 90° (both sides)
Flexion	80° to 90° (approximately)
Extension	70° (approximately)
Lateral flexion	20° to 45° (approximately)
Source: Adapted from Swartz, Floyd and Cendoma (2005)

Table 9.2 Range of motion between different cervical joints
Motion unit	Range of motion
O–C1	•25° of flexion and extension •5° of axial rotation •7° of lateral bending
C1–C2	•15° of flexion and extension •30° of axial rotation •4° or less of lateral bending
C2–C3	•8° of flexion and extension •9° of rotation •10° of lateral bending
C3–C4	•13° of flexion and extension •12° of rotation •10° of lateral bending
C4–C5	•19° of flexion and extension •12° of rotation •10° of lateral bending
C5–C6	•17° of flexion and extension •14° of rotation •8° of lateral bending
C6–C7	•16° of flexion and extension •10° of rotation •7° of lateral bending
Sources: Tubbs et al. (2010, 2011); Schafer and Faye (1990)

Common Injuries

A major injury to the cervical spine is often caused by a fall or motor vehicle accident. Such injuries usually lead to a fracture in the cervical vertebra, and subsequently to pain and poor spinal functioning, depending on the severity of the injury (Torretti and Sengupta, 2007). Two of the most predominantly affected cervical levels are craniocervical junction (the junction between O and C2) and the C6–C7 segment. However, most fatal cervical injuries frequently occur at the atlantoaxial joints (Trafton, 1982).

Table 9.3 Common injuries of the cervical joints
Injury	Characteristics
Atlanto-occipital dislocation	•A highly unstable craniocervical injury that is associated with significant neurological morbidity and mortality •May occur due to severe extension or flexion at the atlanto-occipital level •Disrupts all ligamentous and/or bony connections between O and C1
Jefferson fracture	•A bony fracture of the atlas caused by a compressive downward force •Causes fracture of one or both of the anterior or posterior arches •May cause fracture of all four aspects of the atlas ring
Odontoid fracture	•A fracture that occurs at the base of the dens •The displacement of the fractured segment may occur anteriorly, posteriorly or laterally
Atlantoaxial subluxation	•A disorder of the C1–C2 complex that impairs neck rotation •Occurs when the transverse ligament is disrupted and a rotatory component at the superior cervical segment is absent during flexion •May cause neurological injury because of cord compression between the odontoid and posterior arch of atlas
Hangman fracture	•An unstable fracture caused by hyperextension of C2 •Commonly occurs due to motor vehicle collisions and results in bilateral fractures through the C2 pedicles
Sources: Hall et al. (2015); Trafton (1982); Goldberg et al. (2001)

Red Flags

Red flags for CSM help practitioners to make sound clinical judgements as part of the examination process. If a red flag symptom is found in a patient, the practitioner should prioritise sound clinical reasoning and exercise utmost caution, so that the patient is not placed at risk of an undue adverse event following CSM.

Table 9.4 Red flags for cervical spine manipulation
Condition	Signs and symptoms
Cervical myelopathy	•Sensory disturbances in the hand •Intrinsic muscle wasting of hand •Clonus •Babinski sign •Hoffman’s reflex •Unsteady gait •Bladder and bowel disturbances •Inverted supinator sign •Hyperreflexia •Multisegmental sensory changes •Multisegmental weakness
Inflammatory or systemic disease	•Gradual onset of symptoms •Family history •Fatigue •Temperature above 100°F •Blood pressure above 160/95 mmHg •Resting pulse above 100bpm •Resting respiration above 25bpm
Neoplastic conditions	•Over 50 years of age •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 syndrome
Other serious cervical pathology	•Previous diagnosis of vertebrobasilar insufficiency •Dizziness/vertigo •Drop attacks •Ataxia •Nausea •Dysphasia •Dysarthria •Diplopia
Sources: World Health Organization (2005); Puentedura et al. (2012)

Special Tests

Table 9.5 Special tests for assessing serious pathology in the cervical spine

Vertebral artery test

The patient is placed in either supine lying or sitting position. The examiner slowly but passively extends and/or rotates the patient’s head and neck to the maximum range of motion, keeping the patient in either supine or upright position. The examiner sustains all positions for a minimum of ten seconds while observing for symptoms associated with vertebrobasilar insufficiency.

•Dizziness

•Nausea and vomiting

•Drop attacks

•Temporary vision or hearing loss

•Pins and needles

•Double vision

•Pallor and sweating

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