CERVICAL SPINE
osteophyte formation, vertebral body
Applied Anatomy
 The cervical spine is divided into two
areas: cervicoencephalic (C0 – C2)
and cervicobrachial (C3 - C7).
Atlanto-occipital jt
 Flex-ext: 15-20° (nodding of the head)
 Side flex: 10°
Atlanto-axial jt
 Most mobile articulations of the spine
 Flex-ext: 10°
 Side flex: 5°
 Rotation: 50°
Facet jts (Apophyseal)
 14 in the cervical spine, upper four
facet jts of the thoracic vertebrae are
often included in examination of
cervical
 Sup: sup, post, medial. Inf: inf, ant,
lateral
 Greatest flex-ext occurs in C5-C6,
followed by C4-C5 and C6-C7
Uncovertebral/Uncinate jts
 Also known as the joints of Luschka
 More pronounced posterolaterally,
limits side flexion
Intervertebral Discs
 Make up ~25% of the height of the
cervical spine and gives the cervical
spine its lordotic shape
o Nucleus Pulposus – buffer to
axial compression
o Annulus Fibrosus – withstand
tension w/in the disc
Conditions
Cervical Spondylosis/Osteoarthritis
 Vertebral osteophytosis 2° to
degenerative disc dse d/t osteophytic
formations that occur with progressive
spinal segment degeneration
 Commonly affects the C5-C6, C6-C7,
and C4-C5 IV discs and facet jts, may
progress to: disk herniation,
o Triceps brachii- resist elbow
degeneration, SC compression, or
cervical spondylotic myelopathy
 25% of adults < 40 y/o, 50% of adults
> 40 y/o, and 85% of adults > 60 y/o;
showed in 70% of women and 95% of
men at age 60 and 65
 Risk factors: age, gender, occupation
 Non-specific neck pain – localized to
SC
 Cervical radiculopathy – complaints
in a dermatomal/myotomal
distribution often occurring in the
arms. May be numbness, pain, or loss
of function
 Cervical myelopathy – cluster of
findings d/t intrinsic dmg to SC
 Signs: poorly-localized tenderness,
limited ROM, minor neurological
changes
 Symptoms: cervical pain aggravated
by movement, referred pain (occiput,
between the shoulders blades, upper
limbs), retro-orbital/temporal pain,
cervical stiffness, vague numbness,
tingling, or weakness in UE,
dizziness/vertigo, poor balance, rarely,
syncope, triggers migraines
 Outcome measures to evaluate neck
pain:
o Visual analogue scale (VAS)
o Short Form 36 (SF-36)
o Neck Disability Index
 Provocation tests: Spurling’s Test (A),
Bakody’s Test (shoulder and release
test B)
 Muscle atrophy of affected side in UE,
shoulders, and scapula are compared
with the unaffected side
 Muscle strength in 4 muscles
(myotomes C5-C8)
o Deltoid- resist FLEX, AND and
EXT
o Biceps brachii- resist elbow
FLEX hile forearm is SUP
EXT from 90° elbow FLEX
o Dorsal interosseous- reists
separation of 2nd – 5th fingers
 Sensitivity to light touch and pain are
tested for dermatomes
 Pharmacology:
o NSAIDs – in theory, will ↓
inflammation, ↓ sensitivity to
compression
o Opioid analgesics – ineffective
in neuropathic pain, addictive
nature
o Muscle relaxants – for
associated spasm of trapezius,
max. of 2 weeks
o Corticosteroids – limited
evidence
 Surgery:
o Progression of s/sx that don’t
respond to conservative tx
o Presence of myelopathy for 6
mos+
o Transverse area of SC 40mm2
or less
 PTMx:
o Manual therapy – reduce
pain, improve function, ↑ ROM,
address thoracic hypomobility
o Thrust manipulation – prone,
supine, or sitting. Can include
cervical traction
o Non-thrust manipulation –
PA glides in prone. Retract,
rotate, lateral glide in ULTT1
position.
o Postural education,
thermotherapy, soft tissue
mobilization in ABD and ER,
home exercises: cerv RETRACT
& EXT, deep cerv FLEX
strengthening, scapular
strengthening, chest muscle
stretching
Thoracic Outlet Syndrome altered/absent sensation, weakness,  Relax shortened
 Compression of neurovascular fatigue, heaviness in arm or hand, muscles
structures as they exit through the blotchy/discolored skin, different  Aerobic exercises
thoracic outlet temp, worse when arm is ABD
 Ant: ant scalene overhead and ER with head rotated Observation & Examination
 Post: middle scalene  When C5-7 is involved, pain in side of Differential Diagnosis of Spondylosis,
 Inf: first rib the neck and may radiate to ear and Stenosis, and Disc Herniation
face. From ear post to rhomboids and Spondylo Herniatio
 Areas of compression: Stenosis
ant over clavicle and pectorals, sis n
o Interscalene triangle Uni(m/c)/bil
o Costoclavicular triangle laterally down radial nerve, headaches Pain Unilateral Uni/Bilat
at
o Subcoracoid/sub-pectoralis are not uncommon Affected Several Affected
Distrib
minor space  Pts with C8-T1 involvement have dermatom dermatom dermatome
of Pain
symptoms present in ant and post es es s
 Affects ~8% of the population Pain on
shoulder and radiate down ulnar side
 3-5x more frequent in women than extensi ↑ ↑ May ↑
of forearm into hand, and ring and on
men between 20-50 y/o
small fingers Pain on May ↓
 Women have less developed muscles, ↓ ↓
 Observation: Posture, cyanosis, flexion (m/c) or ↑
greater tendency for drooping Pain
edema, paleness, atrophy
shoulders, narrowed TO, lower relieve
o Special Tests: - + -
sternum d by
 Adson Maneuver rest
 Almost all cases of TOS (95-98%)
 Military Brace 60% > 45
affect the brachial plexus, other 2-5% 11-70 y/o
Test/Costoclavicular Syndrome Age y/o
m/c: 30- 17-60 y/o
affect vascular structures (subclavian group 85% > 65
Test 60 y/o
AV) y.o
 Halstead Maneuver
 Congenital factors: Instabil
Possible - -
 Roos Test ity
o Cervical rib, prolonged
 Palpation: temp changes, Levels
transverse process of C7, commo
supraclavicular fossa, scalene C-C6, C6-
anomalous muscles, fibrous nly Varies C5-C6
tenderness C7
anomalies, (transversocostal, affecte
 MMT & flexibility of: scalenes, d
costocostal), abnormalities in
pectorals, levator scapulae, SCM, and Onset Slow Slow Sudden
scalene insertion, fibrous
SA
muscular bands, exostosis of
 PTMx: Signs: Anesthesia, ataxia, atrophy,
first rib, cervicodorsal scoliosis,
o Stage 1: ↓ symptoms, pt asymmetry, drop attack, dysesthesia, falling,
congenital uni/bilateral
elevated scap, subclavian AV education fasciculation, hyperesthesia, nystagmus,
location o Stage 2: address tissues that pathological gait, reflex changes, spastic gait,
create LOM and compression sweating/lack of, tender bones, tender
 Acquired:
 Massage, strengthening muscles, tender scalp, transient loss of
o Postural factors, dropped
levator scapulae, SCM, hearing, consciousness, sight, UE weakness
shoulder, wrong work posture,
and upper traps (opens Symptoms: Arm and leg pain/ache, auditory
heavy mammaries, trauma,
the TO by raising the disturbance, cough, depressed mood,
clavicle/rib fx, hypertext neck
scapula & opening diarrhea, diplopia, dizziness, fatigue, gait
injury, whiplash, repetitive
costoclavicular space) disturbance, headache, insomnia, muscle
stress injuries
 Stretching pectorals, twitch, nausea, paresthesia, poor balance,
 S/sx: pain anywhere between the
lower traps, and restless arms and legs, sneeze, speech
neck, face, and occipital region/into
scalenes
chest. Shoulder, UE, and paresthesia,
 Postural correction
disturbance, stiff neck, threatened faint, Immunosuppression Osteophyt
tinnitus, torticollis, vertigo, visual disturbance IV drug use es
Neurologic Progressive Swelling cervical spine
Injury neurologic deficit with Depression of
UE and LE symptoms trauma shoulder
Bowel/bladder Spondylosi
dysfunction s
Yellow Flags (Fear-Avoidance)
Cervical Sensory disturbance Contribut
Attitudes and Beliefs: Pain is harmful or Congenital
Myelopathy of hands ing TOS
disabling resulting in guarding and fear of defects
Wasting of intrinsic factors
movement, all pain must be abolished before hand muscles Pain Sharp,
returning to activity, expectation of increased Sharp, burning
Unsteady gait burning in
pain with activity/work, lack of ability to in almost all arm
Hoffman reflex affected
predict capabilities, catastrophizing, pain is dermatomes,
Hyperreflexia dermatom
pain in traps
uncontrollable, passive attitude to rehab Bowel/bladder es
Behaviors: Extended rest, ↓ activity level disturbances Paresthe Affected
All or most arm
with significant withdrawal from daily Multisegmental sia dermatom
dermatomes
activities, avoidance of normal activity and weakness/sensory es
changes Tenderne Over
progressive substitution of lifestyle away Over affected
Upper cervical Occipital headache ss affected
from productive activity, extremely high pain brachial plexus/
ligamentous and tenderness post
intensity, excessive reliance on aids, sleep lateral to
instability Severe limitation cervical
quality ↓, high intake of alcohol or other cervical spine
during neck active spine
substances since onset of back pain, smoking ROM ROM ↓ usually
Signs of cervical ↓ returns rather
Red Flags myelopathy quickly
Potential Cause Clinical Vertebral artery Drop attacks Weaknes Transient
Transient muscle
Characteristics insufficiency Dizziness/lightheaded s paralysis
weakness
Fracture Clinically relevant ness related to neck Myotome
Myotomes
trauma movement may be
affected
Minor trauma in Dysphasia affected
elderly Dysarthria DTR Affected
Ankylosing spondylitis Diplopia nerve root May be
Neoplasm Pain worse at night (+) cranial nerve sign may be depressed
Unexplained weight Inflammatory or Temp > 37°C depressed
loss systemic BP > 160/95 mmHg Provocati Side flex,
History of neoplasm disease Resting pulse > 100 ve test rotation, Side flex w/
Age > 50 or < 20 bpm ext compression
Previous history of Resting respiration > Cervical (opp)/stretch(sa
cancer 25 cpm traction ↓ me)
Constant pain, no Fatigue symptoms ULTT may be (+)
relief Differential Diagnosis of Nerve Root and (+) ULTT
Infection Fever, chills, night Brachial Plexus Lesion
sweats Nerve Brachial
Unexplained weight Root Plexus Lesion Spondylosis Disease Process
loss Lesion
History of recent Early Cause
spondylosis – degen changes
Disc w/in
Stretching of IV discs
systemic infection – desiccation ofherniation
disc – disccervical
heightspine
loss and a
Recent invasive reduction in Stenosis
the ability Compression
of the disc of to
procedure maintain/bear additional axial loads  transfer