High Yield Topics
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Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Cervical Spine Anatomy and Examination
Cervical Spine Anatomy and Examination
Sergio A. Glait BS
Sanjog Mathur MD
A. Jay Khanna MD
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).
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:
See AlsoAn anatomical study of the spinous process of the seventh cervical vertebrae based on the three-dimensional computed tomography reconstructionAnatomy, Head and Neck: Cervical VertebraeLevator 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 rotationTo 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.Fig. 1. Radiographs of an adult patient showing a normal lateral cervical spine radiograph (A) and bilateral C5–C6 facet dislocation (B).
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.
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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