Basics
Description
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Anatomy:
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The cervical spine contains 7 cervical vertebrae, from which arise 8 nerve roots.
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The normal cervical spine has a lordotic curvature.
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Intact functional cervical vertebrae are vital because they protect both the spinal cord and the vertebral artery.
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Of the 8 nerve roots that arise from the cervical vertebrae, all but 1 (C8) exit above their numbered vertebral body through the vertebral foramina; C8 exits below its numbered vertebral body.
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Vertebral anatomic structures consist of 2 lamina, 2 arches, 2 pedicles, 2 transverse processes, a spinous process, and a body.
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C1 and C2 are unique in that C1 (atlas) lacks a vertebral body and C2 (axis) has a bony protrusion on the superior side of the body called the odontoid process.
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Most flexion and extension occurs at the atlanto-occipital joint, whereas rotation occurs mostly at the atlantoaxial joint .
Diagnosis
Signs and Symptoms
Physical Exam
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The cervical spine provides support and stability to the head while allowing for a wide ROM.
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A thorough neck examination should evaluate the soft tissues and bony structures while also testing neurologic function.
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Motor examination:
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Levator scapulae: Resisted elevation (C3, C4, sometimes C5)
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Deltoids: Shoulder abduction (C5)
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Biceps: Arm flexion (C6)
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Wrist extension (C6)
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Triceps: Elbow extension (C7)
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Wrist flexion (C7)
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Finger extension (C7)
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Finger flexion and thumb adduction (C8)
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Deep tendon reflexes:
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An abnormal reflex response may be indicative of spinal stenosis or nerve root compression.
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Reflex amplification is a symptom of spinal stenosis with myelopathy, whereas diminished reflexes indicate nerve root compression.
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Biceps (C5)
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Brachioradialis (C6)
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Triceps (C7)
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Sensation:
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When tracing abnormal sensation, patients should be asked to be as specific as possible.
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C2, C3, and C4 sensation should move from the posterior to the anterior neck.
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C5-T2 has very specific dermatomes on the arm, wrist, and fingers.
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C5: Lateral shoulder
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C6: Radial 2 digits
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C7: Middle finger
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C8: Ulnar 2 digits
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T1: Medial forearm
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Inspection: It is important to evaluate
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Posture of the head
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Posture of the body, motion, gait
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Pain
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Scars on the anterior or posterior neck
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Bony palpation: Anterior
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Note any abnormalities such as tenderness, lumps, asymmetries, or misalignments.
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May use surface landmarks to localize cervical spine level:
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Hyoid bone: C3 vertebral body
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Superior notch of thyroid cartilage: C4 vertebral body
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1st cricoid ring: C6 vertebral body (swallowing allows easier palpation.)
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Carotid tubercle: C6 transverse process (the 2 carotid tubercles of the C6 vertebra should be palpated separately because simultaneous palpation can restrict the flow of both carotid arteries).
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Trachea: Make sure no deviations are present from the midline and palpate for abnormalities.
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Bony palpation: Posterior
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Occiput:
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Inion: The lower, most palpable part of the occiput
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Spinous processes:
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C7 and T1 are the most prominent.
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All the spinous processes should be aligned.
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Any deviation may be secondary to a unilateral facet dislocation.
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C3-C5 may be bifid.
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Facet joints: Approximately 2.5 cm lateral to the spinous processes, the most common joint involved in osteoarthritis is C5-C6 .
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Soft-tissue palpation: Anterior
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Sternocleidomastoid
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Parotid gland
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Lymph nodes
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Thyroid gland: Symmetric and smooth
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Carotid pulse
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Supraclavicular fossa: Palpate for bulges or cervical ribs.
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Soft-tissue palpation: Posterior
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Trapezius: Evaluate for lymph nodes, palpable only because of pathologic causes
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Greater occipital nerves: If palpable, may be secondary to whiplash injury.
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Ligamentum nuchae: Inion to C7 spinous process
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ROM:
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Active ROM is a crucial part of the cervical neck examination and includes flexion, extension, lateral bending, and rotation of the neck.
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Flexion and extension:
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50% occurs between the occiput and C1, and the remainder is distributed from C2-C7.
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Slightly greater motion occurs at the C5-C6 level.
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Tests sternocleidomastoid muscle (flexor) and paravertebral extensor and trapezius (extensors).
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Rotation:
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50% occurs between C1-C2, and the remainder is evenly distributed in the remainder of the cervical spine.
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To examine, rotate the chin 60-80° to the right and left.
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Tests sternocleidomastoid muscle (primary rotator).
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Lateral bending:
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Evenly distributed throughout the cervical spine and usually not a pure movement but, rather, functions in conjunction with rotation
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To examine, touch the ear to the ipsilateral shoulder without moving the shoulder; normal lateral bending is 45°.
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Tests scalene muscles.
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Special maneuvers to help to identify the cause of the cervical spine symptoms:
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Modified Spurling maneuver:
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Extend the neck and rotate the head to 1 side as axial pressure is applied.
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A positive test is specific for cervical root compression but with low sensitivity.
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Distraction test:
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Apply vertical traction to the head in slight flexion and extension.
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Symptoms of compressed nerve roots may regress temporarily.
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Lhermitte test :
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Patient flexes head forward.
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If shooting pain is noted down the arms and/or legs, an anterior compressive lesion may be present.
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Hoffmann test:
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Rapidly flex the nail of the middle finger.
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If muscles of the hand and thumb flex, then a positive sign exists, indicative of an upper motor neuron lesion (myelopathy).
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Static/dynamic Romberg test:
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The patient stands with hands out and palms up (arms in 90° of flexion).
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Proprioceptive deficit is present if the patient loses balance with the eyes closed or if the arms rise slowly above the parallel.
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Tests
Imaging
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Radiography:
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AP and lateral views are used to screen for most conditions.
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Oblique views are used to detect facet dislocation and subluxation.
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The open-mouth view is used to detect odontoid and Jefferson burst fractures (for patients with neck pain who have struck their heads).
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When viewing radiographs of young children, ossification centers may be present and should not be mistaken for fractures.
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MRI is used to detect and define disc herniation, facet hypertrophy, or ligamentum flavum hypertrophy that may be impinging on the spinal cord or cervical nerve root foramen.
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CT is used to define the anatomy of the osseous cervical spinal structures.
Miscellaneous
FAQ
Q: What is a commonly made mistake when reading a radiograph of a young child’s cervical spine?
A: Ossification centers may still be present in young children and should not be confused with a fracture.
Q: What does the Hoffmann sign evaluate?
A: The Hoffmann sign evaluates for an upper motor neuron lesion, such as cervical spinal stenosis with myelopathy.