Cervical Spine Anatomy and Examination - TeachMe Orthopedics (2024)

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 Also

  Neck Pain: Initial Evaluation and ManagementNeck & Upper Extremity Spine Exam - SpineOverview of Neck and Back Pain - Overview of Neck and Back Pain - MSD Manual Professional Edition

  • 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.

      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.

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.