Cervical Spine CYRIAX
Cervical Spine CYRIAX
Cervical Spine CYRIAX
CHAPTER CONTENTS which it may occur from 30 years upward. Radicular pain in a
History . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 young person is usually the result of a neurofibroma, while in
the elderly it is commonly the result of compression by an
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . 119 osteophyte or invasion from secondary deposits in the spine,
Paraesthesia . . . . . . . . . . . . . . . . . . . . . . 121 rather than a disc protrusion.
Vertigo or symptoms related to the vertebral . Early morning headache is typical in the elderly and is often
artery . . . . . . . . . . . . . . . . . . . . . . . . . 122 the result of contracture in upper cervical ligaments. Headache
Incoordination and spasticity . . . . . . . . . . . . . 122 from temporal arteritis also occurs late in life.
Medication . . . . . . . . . . . . . . . . . . . . . . 122 Whenever symptoms appear in a patient of the wrong age
group, further investigation should be requested in order to
Inspection . . . . . . . . . . . . . . . . . . . . . . . . . 122
exclude more serious disorders.
Functional examination . . . . . . . . . . . . . . . . . . 123 The patients work, hobbies or preferred sport may give an
Neck movements . . . . . . . . . . . . . . . . . . . 123 idea of postures, movements or strains that may be causative
or provocative.
Scapular movements . . . . . . . . . . . . . . . . . 125
Cervical spine lesions may lead to the following symptoms:
Arm tests . . . . . . . . . . . . . . . . . . . . . . . 127 pain, paraesthesia, vertigo or symptoms related to the vertebral
Technical investigations . . . . . . . . . . . . . . . . . 131 artery, and incoordination and spasticity.
Pain
History
Pain is the most common symptom. Its localization may give
History taking in patients with problems in the neck, trapezius an idea of the position of the lesion. Details about its evolution
or shoulder region should be as detailed as possible and great and behaviour help to determine the nature of the disorder.
care should be taken to define every symptom precisely. Espe- If this is the patients first presentation with a problem in
cially when a controversial treatment, such as manipulation, is the cervical spine, questions are asked about the current com-
to be considered, it is vital that nothing has been forgotten that plaints (see below). In a recurrence, a detailed and chronologi-
could constitute a contraindication. cal reconstruction of the past history should be made.
Age may be important, because some disorders do not occur The patient may present with acute, subacute, chronic or
before or do typically occur at a certain period of life. For recurrent pain. Acute and subacute episodes are characterized
instance, torticollis in a baby is probably congenital. The same by difficulty in moving the head without exacerbation of the
clinical picture in a 5-year-old child is more likely to be caused pain. Except in young people with torticollis or after injury,
by contracture of the sternocleidomastoid muscle after, for acute lesions are not as common as more chronic complaints.
example, glandular swelling or abscess formation. During and Chronic lesions come and go for months or years without any
after adolescence it is more probably the result of a disc tendency towards spontaneous recovery. Most problems in
protrusion. the cervical spine, however, are recurrent, which implies that
The same argument applies to root pain. Under the age of the course is characterized by definite attacks of short dura-
35 it is scarcely ever caused by a disc except after trauma, in tion. The examiner should then find out whether the patient
Copyright 2013 Elsevier, Ltd. All rights reserved.
The Cervical Spine
is totally free from pain in between the attacks, for how long dermatomes. This phenomenon is called multisegmental pain
the symptoms last and whether the pain is always felt on the and is described in Chapter 1. Because the dural investment of
same side. the nerve root is only innervated from its own recurrent nerve,
irritation here results in pain strictly felt in the corresponding
dermatome, thus strict segmental pain.
Onset Also the duration of the pain is informative. Most benign
Next, the following questions are asked about the onset of the cervical disorders are intermittent. If pain progressively
pain. worsens, then the presence of an irreversible lesion such as
Where did it start? metastases must be borne in mind, particularly in the elderly.
Pain of cervical origin very often starts at the cervical Root pain as the result of a disc protrusion lasts for a variable
spine but frequently spreads or shifts to another region but limited period and then ceases as spontaneous remission
quite quickly, so that the cervical source may pass takes place (see Ch. 8). Hence, root pain that lasts longer than
unnoticed. 6 months should arouse suspicion of another, possibly progres-
Interscapular onset of pain is typical of a lower cervical
sive cause.
As cervical disorders are frequently episodic, the patient
disc lesion that compresses the dura. In contrast, it is
should be asked to describe previous episodes in as detailed a
very unusual for pain to begin in the arm. Should this
way as possible. Often a recurrence can be ascribed to instabil-
occur, the possibility of a neurofibroma, compressing a
ity of the affected structure. Once an intervertebral disc frag-
nerve root, has to be considered in young people. In
ment has displaced, it may do so again, because the cartilage
the elderly, an osteophyte or even a malignant process
remains unhealed. Further displacement may be in a different
is more probable.
direction and it is thus possible for the pain to be variable and
When did it start?
not on the same side. Therefore, pain that changes sides from
Pain of cervical origin may occur in discrete attacks,
one attack to another very strongly suggests the presence of a
especially when a disc lesion is responsible. It is disc lesion. Also the duration of the previous bouts may have
important to encourage the patient to recall the first some prognostic value, as it can give an idea of how long the
episode and to ask for a chronological account. In discal current symptoms may be expected to last. The patient should
root pain, a normal period of spontaneous relief should be questioned about previous successful treatment because, if
be recognizable. the present episode is a recurrence, it is very likely that it will
How did it start? respond to the same treatment. Has the patient been totally
The origin may be spontaneous, either acute or chronic, free of pain between attacks? Freedom from symptoms indi-
but may also be the consequence of injury. In the latter cates that the patient went into complete remission and this
case, more details should be sought about the type of result could be obtained again. Failure of complete remission
injury (e.g. a fall or whiplash). It is then necessary to requires a search for the reason: possibly previous treatments
seek further investigations to exclude fractures or have not been completed. Alternatively, age may be a factor in
luxations. that some conditions have a tendency to become more persist-
ent with advancing years.
Evolution
Current pain
More detailed information is then obtained about the develop-
ment of the complaints in relation to localization, duration and After the patient has given a thorough description of the onset
intensity. and evolution, the moment has come to ask for details about
The localization may change, either because the pain shifts the pain experienced at present: its localization, the influence
to another place or because it spreads. Pain that spreads and of posture and movements, and how it is affected by cough.
gradually expands over a larger area is typical of an expanding
Localization
lesion and should always arouse suspicion. On the other hand,
pain that shifts from the scapular area to the upper limb is The localization may vary: headache, pain in the face, neck,
highly indicative of a shifting lesion (or disc lesion). The frag- scapular area, pectoral area or down the upper limb are all
ment of disc substance first displaces posterocentrally and possible.
compresses the dura mater, which results in central, bilateral Headache
or unilateral scapular pain; it then moves laterally and impinges If headache is referred from the cervical spine, the patient will
on the dural investment of a nerve root. The scapular pain usually mention an association between the symptoms and
disappears and is replaced by a radicular pain down the upper certain postures and/or movements. The pain may be bilateral
limb. In order to interpret the distribution and evolution of the or unilateral, and can be either segmental or multisegmental.
pain correctly, the mechanism of dural pain should be under- Segmental pain originates from the upper cervical segments
stood. Because the anterior aspect of the dura mater is inner- (C1 and C2). Disorders at the joints between occiput and atlas,
vated by a dense network of branches of sinuvertebral nerves or between atlas and axis, may give rise to pain felt at the
originating at several levels, extrinsic compression and subse- centre of the upper neck and spreading to the occiput, the
quent irritation of the dura may give rise to pain felt in several vertex (C1) and/or the temples and forehead. As the pain is
120
Clinical examination of the cervical spine C H A P T E R 6
not always felt in the neck, localization to the head only can
divert attention from the cervical spine. Multisegmental head-
ache results from irritation of the dura at any cervical level.
The pain often radiates from the mid-neck up to the temple,
the forehead and behind one or both eyes, but rarely to the
bridge of the nose. If, apart from this distribution, there is also
downward reference of pain to the scapular area, the dural
origin is clear.
Some types of headache can be recognized by paying atten-
tion to the history.
Early morning headache in elderly patients is a typical
example. The patient wakes every morning with headache and/
or occipital pain. After some hours the symptoms ease and
have completely disappeared by midday. Symptoms do not Fig 6.1 Multisegmental scapular pain.
recur until the next morning. The sequence is repeated daily
without fail and, as the years go by, pain tends to last longer
into the day. This type of headache responds spectacularly to
manipulative treatment (see p. 201). a C4 segmental origin. Other sources of trapezioscapular pain
Migraine is another typical history. Symptoms usually start are a thoracic lesion, a local scapular lesion or a shoulder girdle
during adolescence and may persist for many years. The vascular problem.
origin of this disorder has been widely accepted and the follow- Pain in the pectoral area
ing features are well known: an aura which frequently includes Another rare manifestation of multisegmental dural reference
visual hallucinations, photophobia, nausea, vomiting and other is pain in the pectoral area. Because the pain is usually felt
bizarre experiences, often precedes an attack; pain is severe, deeply and there is a strong popular association between pec-
unilateral and well localized, though may change sides for each toral (retrosternal) pain and cardiac disease, the pectoral dis-
attack and is usually described as throbbing or bursting. comfort can be initially misjudged as angina.
Cluster headache is very severe, is more common in men,
Pain down the upper limb
and occurs on a regular basis. The pain is always felt on the
Dural pain never presents down the arms. Therefore, upper
same side, mainly above the eye, and may be accompanied by
limb pain is always segmental in origin and is referred within
a partial Horners syndrome.
its dermatomal borders. If the lesion is discoradicular, the
Pain in the face normal time sequence of the symptoms must be appreciated:
This may either have a local origin or be referred. Local causes neck pain first, followed by unilateral scapular pain and then
include sinusitis, dental problems, temporomandibular lesions, finally segmental pain. It is therefore important to ask whether
lesions of the facial bones, neuralgia and arteritis. Referred pain or not the arm pain has been preceded by neck and/or scapular
may be a segmental C2 pain or a multisegmental dural pain. pain. If not, a non-discogenic origin of the pain is to be
The latter should always be borne in mind because, if a local considered.
cause is not found, treatment to the cervical spine may be
curative. Exacerbation of pain by cough
Pain in the neck This is uncommon in cervical lesions but may occur in a disc
Local pain in the upper neck is usually the outcome of a local prolapse, when the pain is usually felt in the scapular region.
lesion: one of the ligaments of the upper cervical segments or Pain in the arm on coughing is one of the symptoms that draws
one of the upper facet joints. Rarely, the muscular insertions attention to a neuroma (see Ch. 9).
on the occiput are responsible. However, upper cervical pain
may also have a multisegmental dural origin. Mid- or lower Paraesthesia
cervical pain is most often caused by a mid- or lower cervical
discodural conflict, especially if the pain is felt centrally or Paraesthesia is a very common symptom which may originate
bilaterally. Unilateral and lower cervical pain that is well local- from any nerve fibre in the cervicoscapular area or in the arm
ized often originates from a facet joint. (Table 6.1). Paraesthesia is often experienced as a pins and
Pain in the trapezioscapular area needles sensation. In other instances, the patient may describe
This is the most common pain reference for cervical lesions. the feeling as numbness. The moment the patient mentions
The majority of pain in the trapezius or scapular area has a the presence of such symptoms, the examiner should carefully
cervical origin, and must usually be considered as the multi- determine how proximal they are because, as has been explained
segmental reference of a discodural conflict (Fig. 6.1). The pain in Chapter 2, the point of compression always lies proximal to
may be unilateral, bilateral or interscapular. Depending on the that of the paraesthesia. The lesion may lie at any one of a
patients age, it may be intermittent or constant; the older the number of different levels but the vaguer the distribution of
patient, the more likely the pain will last over longer periods. the pins and needles, the more proximally the lesion needs to
Upper scapular pain or pain in the trapezius area may also have be sought.
121
The Cervical Spine
122
Clinical examination of the cervical spine C H A P T E R 6
123
The Cervical Spine
(a) (b)
(c) (d)
(e) (f)
Fig 6.2 Active movements: flexion (a), extension (b), rotation (c, d) and lateral flexion (e, f ) of the head.
124
Clinical examination of the cervical spine C H A P T E R 6
Left
flexion
Right Flexion
side flexion side flexion The patient bends the head and the examiner gently assists it
into greater flexion. Excessive pressure should be avoided.
Resisted movements
After active and passive tests, resisted movements are per-
formed. Conduction of both rotations suffices. The other
movements are only carried out in case of doubt and for the
purpose of differential diagnosis. Pain and/or weakness are
rotation rotation
ascertained. Interpretation of positive resisted movements
must be done in the light of the overall clinical picture. The
response can be obscured in acute lesions, where the slightest
effort augments the pain as the result of transmitted stress.
Muscular and tendinous lesions are extremely uncommon at
the cervical spine. The movement also gives information on
extension motor conduction of the first cervical nerve root.
125
The Cervical Spine
(a) (b)
(c) (d)
Fig 6.6 Secondary resisted movements: extension (a), flexion (b) and lateral flexion (c, d).
126
Clinical examination of the cervical spine C H A P T E R 6
Fig 6.7 Active elevation of the shoulders. Fig 6.8 Resisted elevation of the shoulders.
Resisted movement
The patient is asked to keep the shoulders elevated while
the examiner applies a downward force on them (Fig. 6.8).
This tests the trapezii muscles and the motor conduction in
C2C4. Normally the trapezii are stronger than the downward
pressure.
Arm tests
Arm movements test the integrity of the muscular system.
If pain is elicited, alternative causes of pain down the upper
limb should be sought. When one or more movements are
weak a neurological problem is responsible. The pattern pre-
sented will indicate the possible level.
Active elevation
The patient is asked to elevate both arms sideways, as high as
possible (Fig. 6.9). This is a swift scan for shoulder and shoul-
der girdle problems. If there is pain and/or limitation, a com-
plete shoulder examination should follow (see Ch. 12).
Resisted movements
Isometric resisted tests are done bilaterally, so that strength
may be compared. These are mainly tests for motor conduction
and so strength is noted, but, if the test elicits pain, the pos-
sibility of a local lesion should be considered.
The tests are illustrated in Figures 6.106.13. Detailed
execution of the different tests is discussed in the relevant
chapters on the shoulders, elbow and wrist. Fig 6.9 Active elevation of the arms.
127
The Cervical Spine
(a) (b)
Fig 6.10 (a) Resisted abduction of the shoulder tests the C5 nerve root and the abductor muscles. (b) Resisted external (or lateral)
rotation of the shoulder tests the C5 nerve root and the external (or lateral) rotators.
(a) (b)
Fig 6.11 (a) Resisted flexion of the elbow tests the C5 and C6 nerve roots and the elbow flexors. (b) Resisted extension of the elbow
tests the C7 nerve root and the elbow extensors.
128
Clinical examination of the cervical spine C H A P T E R 6
(a) (b)
Fig 6.12 (a) Resisted extension of the wrist tests the C6 nerve root and the wrist and finger extensors. (b) Resisted flexion of the wrist
tests the C7 nerve root and the wrist and finger flexors.
(a) (b)
Fig 6.13 (a) Resisted extension of the thumb tests the C8 nerve root and the thumb extensors. (b) Resisted adduction of the fifth finger
tests the T1 nerve root and the intrinsic muscles of the hand.
129
The Cervical Spine
communis). The elbow is held in extension. The patient resists Brachioradialis reflex
the examiners attempt to flex the wrist. The patients elbow is held at a right angle and is well relaxed.
Resisted flexion of the wrist The hammer taps on the distal end of the radius. This tests the
C5 nerve root. The reaction is elbow flexion (Fig. 6.16).
This test examines nerve root C7 and the flexors of the wrist
(flexores carpi) and fingers (flexores digitorum). The elbow is Triceps reflex
held in extension. The examiners attempt to extend the wrist The patients elbow is 90 flexed and well relaxed. The hammer
is resisted. strikes the triceps tendon, just proximal to the olecranon.
Resisted extension of the thumb The C7 nerve root is tested. The reaction is elbow extension
(Fig. 6.17).
The C8 nerve root is tested, as well as the extensors of the
thumb (extensores pollicis). The examiners attempt to flex Plantar reflex
the thumb is resisted. To test the plantar reflex, the examiner uses the sharp end of
Resisted adduction of the fifth finger the reflex hammer to stroke the sole of the patients foot,
starting at the lateral aspect of the heel and moving along the
This tests the T1 nerve root and the intrinsic muscles of the
hand, i.e. the adductors of the little finger. The patient squeezes
the examiners finger between the fourth and fifth fingers. The
examiner assesses the strength.
Sensory conduction
The examiner passes his fingers over the patients skin in the
different dermatomes (Fig. 6.14). The patient is asked if the
sensation is the same over all areas.
One arm is compared with the other, and each dermatome
is compared with the others in the same limb.
Testing reflexes
The main reflexes are tested and note is taken of whether they
are normal, diminished, absent or inverted. Each side is always
compared with the other.
Biceps reflex
The patients elbow is held at a right angle and is well relaxed.
The tendon is stretched by the pressure of the examiners Fig 6.15 Testing the biceps reflex: C5 and C6 nerve roots. The
thumb on which the hammer is tapped. The C5 and C6 nerve reaction is elbow flexion.
roots are tested. The reaction is elbow flexion (Fig. 6.15).
Fig 6.14 Testing sensory conduction. Fig 6.16 Testing the brachioradialis reflex: C5 nerve root. The
reaction is elbow flexion.
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Clinical examination of the cervical spine C H A P T E R 6
Fig 6.17 Testing the triceps reflex: C7 nerve root. The reaction is Fig 6.18 Testing the plantar reflex: central nervous system. The
elbow extension. reaction is flexion of the toes.
Hoffmanns sign
The hand is supported and pronated so that wrist and fingers
fall into slight flexion. The middle finger is firmly grasped and
partially extended. The nail is then flicked by the examiners Fig 6.19 Hoffmanns sign is elicited by flicking the distal phalanx
thumbnail. This flicking should be done with considerable of the long finger. Flexion of the thumb at the interphalangeal joint
force. The sign is considered to be positive when quick flexion is a positive response.
of both the thumb and the index finger results.3 A positive sign
is indicative of possible pyramidal tract pathology (Fig. 6.19).4 X-ray, computed tomography (CT) or magnetic resonance
A summary of the neurological deficit at each level is given imaging (MRI), does not reveal the source of the pain but only
in Table 6.2. shows anatomical changes that may or may not be consistent
A summary of the functional examination is given in with the patients description of the pain. Most of these ana-
Box 6.2. tomical alterations reflect painless degenerative changes that
are normal at certain ages and which may also be present in
asymptomatic individuals. The examiner should constantly
Technical investigations keep in mind the fact that the presence of anatomical and
morphological changes does not automatically imply causality.
Technical investigations have become a routine measure in the For example: CT and MRI are widely used to demonstrate the
evaluation of patients with neck pain for several reasons: to existence of discal disorders, which also exist in a large number
assist diagnosis, to complement the clinical diagnosis, to meet of asymptomatic people. Boden5 cites a figure between 14 and
the patients request for radiography, or for medicolegal 28% and Teresi6 a figure of 23%. According to Matsumoto
reasons. et al, degeneration is present in 86% of the discs of asympto-
During recent decades there has been a tendency to reduce matic individuals of over 60 years of age. Posterior disc protru-
the time spent on history taking and clinical examination sion is observed in 7.6% of asymptomatic subjects.7
and to proceed immediately with technical investigations in However, technical procedures may be of great help in
order to detect the anatomical changes that are held to be complementing the clinical findings, i.e. to confirm a tentative
responsible for a patients condition. This trend not only has diagnosis or to exclude serious disorders. The examiner should
serious financial consequences but also leads to diagnostic always remember, however, that a clinical diagnosis is a basic
errors. It is important to realize that imaging, whether it is requirement and that imaging techniques should never be used
131
The Cervical Spine
132
Clinical examination of the cervical spine C H A P T E R 6
root palsies, which can easily be detected by clinical testing. It The results must be evaluated with great care and only in
can have a certain importance in cases with medicolegal the light of the clinical picture.
implications. In doubtful cases, clinical evaluation will be more
important than technical investigations.
Conclusions Treatment decisions should never be taken on the
outcome of imaging studies alone.
Technical investigation should not replace clinical
examination.
It may be used to clarify the clinical picture or to exclude Access the complete reference list online at
a serious disorder. www.orthopaedicmedicineonline.com
133
Clinical examination of the cervical spine CHAPTER 6
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