CERVICAL SPINE EXAMINATION. PART 1: BASIC STEPS

CERVICAL SPINE EXAMINATION. PART 1: BASIC STEPS

Cervical spine examination is especially important in patients with neck pain, headache, arm pain, nerve dysfunction in the upper or lower extremities, or bowel and/or bladder dysfunction. Because all of these symptoms can result from conditions involving the cervical spine, cervical blood vessels, spinal cord, or nerve roots, it is important to ask questions regarding these types of symptoms when taking history. Care should be taken to exclude myelopathy (signs/symptoms of spinal cord compression). If the patient complains of radicular symptoms (pain, altered sensation, or muscle weakness of the nerve root distribution), an attempt should be made to determine which root is affected during examination and examination. Finally, always ask the appropriate questions (red flags) to rule out a tumor or infection (nocturnal pain, fever, chills, sweating, or unexplained weight loss).

Basic musculoskeletal examination steps include Look - Feel - Move

LOOK

Look at the patient sitting and waiting, head, neck, and upper limb positions. Does the patient bow forward or to the side? Does the patient support the head with his hands or is he wearing a neck brace? Arms relaxed next to the torso or held for protection? Can the patient use his or her hands? The patient has reached out to shake hands. Observe the patient's facial expression to see the level of pain.

Observe the patient standing up and note the position. Pay attention to the posture of the head, cervical spine, and hunchback in the thoracic spine. The posture of the shoulders and hand strokes when walking.

View when exposed: head, neck, and upper back position (alignment). Observe the symmetry of the bones (clavicle, sternum, shoulder blade), muscles, and folds. Assess for muscle atrophy in the shoulder-hand area, abnormalities such as swelling, color change, incisions, scars, etc.

Figure: The cervical spine from the back, with skeletal and neural anatomy on the left side (great occipital nerve) and muscle anatomy on the right side (trapezoid muscle)

TOUCH

Start touching in a standing position. If the patient has difficulty standing, the patient can be seated in a chair with his back to the examiner. For easier palpation, the patient can be placed in a relaxed position (supine or supine).

Touch The Back

Palpation detects temperature changes in the skin, displacement, pain, swelling, and muscle tension...

Palpation of bone structures:

External occipital (inion), occipital bone, spinous processes, small facet joints…

Touch the external occipital ridge

Figure: Palpate the spinous processes, with the thumb in the anterior midline and fingers encircling the posterior aspect of the spine, palpated from top to bottom (C2 to T1)

Palpation of Soft Tissue Structures:

Feel the soft tissues along the spine (ligaments), paraspinal muscles, and shoulder blades…

Trapezoid muscles, suboccipital muscles, cervical and spondylolisthesis, great occipital nerve, cervical ligament, levator scapula.

Picture: Touching the trapezius muscle

Touch the ladder muscle

Palpate the suboccipital muscles and the great occipital nerve

Longitudinal palpation of the nuchal ligament

Note about shoulder levator/levator scapulae: The levator scapulae is attached to the transverse processes of C1-C4 and the medial superior border of the scapula. This muscle can act as a shoulder lifter or a side tilt of the neck. Pain and tenderness may be detected at the attachment of the muscle to the medial superior border of the scapula. Shoulder levator palpation can be facilitated by asking the patient to rotate to the opposite side (which further tenses this muscle and relaxes the trapezius).

Touch The Front

Bone structures:

Hyoid/hyoid bone (at C3-C4 body level), thyroid cartilage (C4-C5 level), sternum, clavicle, sternoclavicular joint, ribs...

Picture: Palpate the hyoid bone in the anterior neck

Picture: Palpation of the thyroid cartilage in front

Soft tissue structures:

Steroid mastoid muscle: To facilitate palpation of the sternocleidomastoid muscle, ask the patient to tilt his or her head to the side that is being palpated and to turn the face to the other side. You can use your hands to create resistance in the head so that the muscle contraction will be more clearly palpable. Touching from the bottom clinging to the end (breast-beat) gradually up to the origin.

The sternocleidomastoid muscle is the anterior border of the cervical triangle; The superior trapezius muscle is the posterior border and the lower clavicle. This muscle is a useful landmark for palpating the lymph nodes.

Figure: Components of the supraclavicular pit

The trapezius muscles, the cervical chain, and the carotid vessels

Palpate the sternocleidomastoid muscle and scalene

Pain Points Spread:

Location of spreading the pain of small facet joint of the cervical spine

Trigger point upper trapezius

Trigger point trapezius medial-inferior

Trigger point sternocleidomastoid muscle

MOTOR

Active Movement

Observe the patient Bend- Back, Tilt Right- Tilt Left, and Rotate Right- Rotate left for ease and range of motion.

(If the motion is painless at the end of the range, additional compression can be applied to “exclude” the joint. Or the patient may be asked to hold the position for 15 seconds to see if symptoms recur.)

Active movement of the cervical spine

Active Neck Bend/Bend

Ask the patient to bring his chin to his chest, usually 2 fingers apart.

Measure neck flexion with an inclinometer

Leaning/ Active Neck Extension

Ask the patient to lift their chin and look up at the ceiling. Usually, the forehead and nose form a horizontal line.

Measure neck extension with an inclinometer

Active side tilt

Ask the patient to tilt the head to the side, bringing the ear to the shoulder (do not raise the shoulder instead). The distance between the jaw and the apex of the shoulder can be measured.

Active neck rotation

Ask the patient to rotate the head in a horizontal plane to bring the chin to the shoulder (do not rotate the torso). Rotate both sides. Can measure the chin-to-shoulder distance to compare the two sides.

Upper cervical spine

Chin extension and Chin retraction (chin tuck, flexion of the upper cervical spine, and extension of the lower cervical spine).

Need to check more Shoulder Mobility and Thoracic Spine Mobility

Passive Movement

The article only presents physiological movements, not mentioning auxiliary movements (joint games, joint play).

When performing a passive motor examination, note the difference in mobility and range of motion with active movement. Assess the level of pain at the end of the range, feeling the end of the range as a firm, soft or hard. With caution in patients with a history of trauma, do not perform passive range of motion until fractures or severe ligament damage have been ruled out.

Bowing - Passive neck tilt

Rotate Right/Rotate Left Passive

Tilt right/Tilt left passive

Resistance Movement:

Folding neck with resistance

Sternocleidomastoid muscle (main), trapezius, intrinsic muscle of the neck (auxiliary).

Neck stretch with resistance:

The major extensor muscles are the trapezius (upper bundle), semi-spinacus, semi-spinous cervical, and cervical knee (splenius cervicis) muscles.

Neck extensor muscle

Neck rotation with resistance: 

The left sternocleidomastoid muscle rotates the head to the right.

Side tilt with resistance:

The main muscles are the trapezius muscles and the intrinsic muscles of the neck support. Lateral tilt is not a simple movement that occurs in coordination with the rotation of the cervical spine.

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