Cervical Spine Anatomy and Examination - TeachMe Orthopedics (2024)

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

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> Table of Contents > Cervical Spine Anatomy and Examination

Cervical Spine Anatomy and Examination

Sergio A. Glait BS

Sanjog Mathur MD

A. Jay Khanna MD

Cervical Spine Anatomy and Examination - TeachMe Orthopedics (2)Basics

Description

  • Anatomy:

    • The cervical spine contains 7 cervical vertebrae, from which arise 8 nerve roots.

      • The normal cervical spine has a lordotic curvature.

      • Intact functional cervical vertebrae are vital because they protect both the spinal cord and the vertebral artery.

      • 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.

  • Vertebral anatomic structures consist of 2 lamina, 2 arches, 2 pedicles, 2 transverse processes, a spinous process, and a body.

  • 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.”

  • Most flexion and extension occurs at the atlanto-occipital joint, whereas rotation occurs mostly at the atlantoaxial joint (1).

Cervical Spine Anatomy and Examination - TeachMe Orthopedics (3)Diagnosis

Signs and Symptoms

Physical Exam

  • The cervical spine provides support and stability to the head while allowing for a wide ROM.

  • A thorough neck examination should evaluate the soft tissues and bony structures while also testing neurologic function.

  • Motor examination:

    • Levator scapulae: Resisted elevation (C3, C4, sometimes C5)

    • Deltoids: Shoulder abduction (C5)

    • Biceps: Arm flexion (C6)

    • Wrist extension (C6)

    • Triceps: Elbow extension (C7)

    • Wrist flexion (C7)

    • Finger extension (C7)

    • Finger flexion and thumb adduction (C8)

  • Deep tendon reflexes:

    • An abnormal reflex response may be indicative of spinal stenosis or nerve root compression.

    • Reflex amplification is a symptom of
      spinal stenosis with myelopathy, whereas diminished reflexes indicate
      nerve root compression.

      • Biceps (C5)

      • Brachioradialis (C6)

      • Triceps (C7)

  • Sensation:

    • When tracing abnormal sensation, patients should be asked to be as specific as possible.

    • C2, C3, and C4 sensation should move from the posterior to the anterior neck.

    • C5–T2 has very specific dermatomes on the arm, wrist, and fingers.

      • C5: Lateral shoulder

      • C6: Radial 2 digits

      • C7: Middle finger

      • C8: Ulnar 2 digits

      • T1: Medial forearm

  • Inspection: It is important to evaluate:

    • Posture of the head

    • Posture of the body, motion, gait

    • Pain

    • Scars on the anterior or posterior neck

  • Bony palpation: Anterior (2):

    • Note any abnormalities such as tenderness, lumps, asymmetries, or misalignments.

    • May use surface landmarks to localize cervical spine level:

      • Hyoid bone: C3 vertebral body

      • Superior notch of thyroid cartilage: C4 vertebral body

      • 1st cricoid ring: C6 vertebral body (swallowing allows easier palpation.)

      • 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).

      • Trachea: Make sure no deviations are present from the midline and palpate for abnormalities.

  • Bony palpation: Posterior (2)

    • Occiput:

      • Inion: The lower, most palpable part of the occiput

    • Spinous processes:

      • C7 and T1 are the most prominent.

      • All the spinous processes should be aligned.

      • Any deviation may be secondary to a unilateral facet dislocation.

      • C3–C5 may be bifid.

    • Facet joints: Approximately 2.5 cm lateral to the spinous processes, the most common joint involved in osteoarthritis is C5–C6 (3).

  • Soft-tissue palpation: Anterior:

    • Sternocleidomastoid

    • Parotid gland

    • Lymph nodes

    • Thyroid gland: Symmetric and smooth

    • Carotid pulse

    • Supraclavicular fossa: Palpate for bulges or cervical ribs.

  • Soft-tissue palpation: Posterior:

    • Trapezius: Evaluate for lymph nodes, palpable only because of pathologic causes

    • Greater occipital nerves: If palpable, may be secondary to whiplash injury.

    • Ligamentum nuchae: Inion to C7 spinous process

  • ROM:

    • Active ROM is a crucial part of the
      cervical neck examination and includes flexion, extension, lateral
      bending, and rotation of the neck.

    • Flexion and extension:

      • 50% occurs between the occiput and C1, and the remainder is distributed from C2–C7.

      • Slightly greater motion occurs at the C5–C6 level.

      • Tests sternocleidomastoid muscle (flexor) and paravertebral extensor and trapezius (extensors) (4)

    • Rotation:

      • 50% occurs between C1–C2, and the remainder is evenly distributed in the remainder of the cervical spine.

      • To examine, rotate the chin 60–80° to the right and left.

      • Tests sternocleidomastoid muscle (primary rotator) (4)

    • Lateral bending:

      • Evenly distributed throughout the
        cervical spine and usually not a pure movement but, rather, functions
        in conjunction with rotation

      • To examine, touch the ear to the ipsilateral shoulder without moving the shoulder; normal lateral bending is 45°.

      • Tests scalene muscles (4).

  • Special maneuvers to help to identify the cause of the cervical spine symptoms:

    • Modified Spurling maneuver (5):

      • Extend the neck and rotate the head to 1 side as axial pressure is applied.

      • A positive test is specific for cervical root compression but with low sensitivity.

    • Distraction test (2):

      • Apply vertical traction to the head in slight flexion and extension.

      • Symptoms of compressed nerve roots may regress temporarily.

    • Lhermitte test (2):

      • Patient flexes head forward.

      • If shooting pain is noted down the arms and/or legs, an anterior compressive lesion may be present.

    • Hoffmann test:

      • Rapidly flex the nail of the middle finger.

      • If muscles of the hand and thumb flex, then a positive sign exists, indicative of an upper motor neuron lesion (myelopathy).

    • Static/dynamic Romberg test (2):

      • The patient stands with hands out and palms up (arms in 90° of flexion).

      • Proprioceptive deficit is present if the
        patient loses balance with the eyes closed or if the arms rise slowly
        above the parallel.

        Cervical Spine Anatomy and Examination - TeachMe Orthopedics (4)

        Fig. 1. Radiographs of an adult patient showing a normal lateral cervical spine radiograph (A) and bilateral C5–C6 facet dislocation (B).

        Cervical Spine Anatomy and Examination - TeachMe Orthopedics (5)

        Fig.
        2. Sagittal T2-weighted MRI scan showing severe stenosis at C3–C4 and
        C4–C5 secondary to large disc herniations with cord signal change at
        C4–C5.

P.65

Tests

Imaging

  • Radiography (Fig. 1):

    • AP and lateral views are used to screen for most conditions.

    • Oblique views are used to detect facet dislocation and subluxation.

    • The open-mouth view is used to detect
      odontoid and Jefferson burst fractures (for patients with neck pain who
      have struck their heads).

    • When viewing radiographs of young children, ossification centers may be present and should not be mistaken for fractures (6).

  • 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 (Fig. 2).

  • CT is used to define the anatomy of the osseous cervical spinal structures.

References

1. Aptaker RL. Neck pain. Part 1: Narrowing the differential. Phys Sportsmed 1996;24:37–46.

2. Albert
TJ, Vaccaro AR. Physical examination of the cervical spine. In:
Physical Examination of the Spine. New York: Thieme, 2005:13–63.

3. Hunt WE, Miller CA. Management of cervical radiculopathy. Clin Neurosurg 1986;33:485–502.

4. Tachdjian
MO. The neck and upper limb. In: Clinical Pediatric Orthopaedics: The
Art of Diagnosis and Principles of Management. Stamford, CT: Appleton
and Lange, 1997:263–324.

5. Viikari-Juntura
E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis
of root compression in cervical disc disease. Spine 1989;14:253–257.

6. Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med 1989;7:133–142.

Cervical Spine Anatomy and Examination - TeachMe Orthopedics (6)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.

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