Cervical Spine Examination

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Sequence

Observation

  • Posture
  • Carriage of head
  • Symmetry of shoulders

Active Movements

  • Active movements - rotation, flexion, rotation in flexion, extension, rotation in extension, side bending.
  • Passive movements - rotation, flexion, rotation in flexion, extension, rotation in extension, side bending.

Palpation

Landmarks

  • Occipital protuberance
  • Superior insertion Trapezius
  • Nuchal line
  • Mastoid process and sulcus
  • Attachment sternocleidomastoid
  • Transverse process CI
  • C2 spinous process
  • CI - C2 Articular pillars
  • C2 - C5 spinous processes
  • C6 C7 spinous processes (differentiate)
  • Articular pillars C3 C6/7
  • TI/2 spinous processes
  • Angle of first rib
  • Upper surface Ist rib
  • Superomedial border of scapula
  • Sternomastoid and Trapezius
  • C2 coupling rotation
  • C2 coupling sidebending
  • C3 - C7 as above
  • C7 -TI motion testing

First Rib

  • Tender points
  • Posterior angle
  • Below sternoclavicular joint
  • Scalene insertion
  • Motion testing active breathing
  • Motion testing passive springing

Muscles

  • Short extensors of the neck
  • Scalenes
  • Sternomastoid
  • Splenius/Semispinalis
  • Trapezius
  • Levator scapulae

Special Tests

  • Sharp Purser
  • Spurling's test
  • C0-C2 axial rotation test[1]
    • Patient is seated with the neck in a neutral position. Stabilise the second cervical vertebra with the clinician's index finger and thumb against the articular pillar and spinous process of C2. Passively rotate the head left and right isolating movement to segmental levels above C2.
    • Fixation does not allow normal motion, and normal range during fixation is 30° combined rotation to each side
    • Reliability and Validity: At least moderate reliability[2]
    • False Positives: This does not require endrange flexion of the lower cervical spine and so can be used to assess C0-C2 rotation mobility in the presence of lower cervical spine pain and dysfunction.
  • Flexion rotation test (FRT)[3][1]
    • Lie the patient supine with the cervical spine and thoracic spine in complete flexion. Assess range of motion with rotation to the left and right.
    • This passive test assesses movement dysfunction at the C1/2 segment. The C1/2 segment comprises around 60% of the total cervical range of motion regardless of age. By maximally flexing the neck, theoretically all structures below C2 are constrained and therefore have limited ability to contribute to rotation. Range of motion reduces with age by about 4-7° per decade. Normal values are 44° to each side.
    • Reliability and Validity: It has been shown to be accurate and reliable.
    • False Positives: Painful joints in the lower cervical spine may give a false positive as this reduces the normal range to 37.5°.
  • Craniocervical flexion test (CCFT)
    • Lie the patient in supine crook lying position with the head in neutral position, the line of the face should be horizontal (use towels if necessary)
    • Place the deflated biofeedback unit behind the neck so it abuts the occiput, inflate to 20mmHg
    • Patient slowly performs cranio-cervical flexion, until they reach a pressure increase of 2mmHg, hold for 10 seconds, then return to the starting position. If the patient has an apical breathing pattern, the nod is performed in exhalation.
    • Repeat this for each 2mmHg increment, until 30mmHg is reached (5 stage)
    • The stage the patient is able to achieve and hold for 10 seconds with correct cranio-cervical flexion is the baseline measure

Segmental pain

  • C0 CI Zones of irritation
  • Pinch roll brow,cheek,yoke,scalp
  • Palpation spinous prcss
  • Segmental Translation supine

Segmental restriction

  • CO-CI Inclination (seated & supine)
  • CO-CI Reclination (seated & supine)
  • CO-C1 Sidebending
  • C1 -C2 Rotation (seated & supin
  • C2 -C7 Rotation (seated)
  • C2 -C7 Sidebending, (seated & supine)

Cervicothoracic junction

  • Segmental pain
  • C7 - T2 Dorsal springing
  • Lateral shift

Neurological Examination

Supine

  • Palpation of articular pillars and paraspinal musculature
  • Segmental movement, quality of movement, end feel.
  • Translatory movement

Side Lying

  • Articulation/Segmental mobility

Diagnostic Validity

  • Cervicogenic Headache
    • Reduced cervical extension, impaired craniocervical flexion test, and segmental dysfunction is predictive of positive C2/3 or C3/4 block[4]
    • Impaired flexion-rotation test suggests C1-2 source.

Paediatric Examination of the Whole Spine

A consensus approach to the MSK examination in children was developed by Foster et al in 2011.[5] They did not differentiate between cervical, thoracic, and lumbar spine. The underlined components are those that are additional to the adult examination. The italicised components are those that the doctor should be aware of but not necessarily competent in.

With the patient standing:

  • Look at the spine from the side and from behind
  • Look at the skin and natal cleft
  • Look at limb and trunk proportions
  • Look at the face and jaw profile
  • Feel the spinal processes and paraspinal muscles and Temporomandibular joints (TMJs)
  • Assess movement: lumbar flexion and extension and lateral flexion; cervical flexion, extension, rotation and lateral flexion, thoracic rotation
  • Assess TMJ opening
  • Options – Schober’s test, “stork test”

With the patient sitting on couch (standing in younger child):

  • Assess thoracic rotation

With the patient lying on couch:

  • Perform straight leg raising and dorsi-flexion of the big toe
  • Assess limb reflexes

References

  1. 1.0 1.1 Satpute et al.. The C0-C2 axial rotation test: normal values, intra- and inter-rater reliability and correlation with the flexion rotation test in normal subjects. The Journal of manual & manipulative therapy 2019. 27:92-98. PMID: 30935342. DOI. Full Text.
  2. Satpute et al.. The C0-C2 axial rotation test - Reliability and correlation with the flexion rotation test in people with cervicogenic headache and migraine. Musculoskeletal science & practice 2021. 51:102286. PMID: 33187891. DOI.
  3. Schäfer, Axel Georg Meender, et al. “Upper Cervical Range of Rotation during the Flexion-Rotation Test Is Age Dependent: An Observational Study.” Therapeutic Advances in Musculoskeletal Disease, Jan. 2020, Full Text
  4. Getsoian et al.. Validation of a clinical examination to differentiate a cervicogenic source of headache: a diagnostic prediction model using controlled diagnostic blocks. BMJ open 2020. 10:e035245. PMID: 32376753. DOI. Full Text.
  5. Foster et al.. Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach. Arthritis care & research 2011. 63:1503-10. PMID: 21954040. DOI.