Cervical Spine Anatomy and Clinical Evaluation

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Cervical Spine Anatomy and Clinical Evaluation

• Orthopedic Assessment III Head, Spine, and
  Trunk with Lab
• PET 5609C

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Clinical Anatomy

• Cervical Spine
• Greatest range of motion
• ? risk of injury
• Vertebral bodies
• Smaller than other vertebral sections
• 7 vertebrae
• 1st Atlas
• 2nd Axis

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Clinical Anatomy

• Cervical Spine
• Atlas
• No vertebral body
• Transverse processes
• No true spinous process
• Supports the weight of the skull through 2 facet
  surfaces (atlanto-occipital joint or C0-C1
  articulation)
• Flexion and extension (primary movement)
• Lateral flexion (slight)

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Clinical Anatomy

• Atlanto-occipital joint dislocation
• (15 of all fatal spinal trauma)
• MOI high speed motor accident Pt. unconscious
  at the scene, respiratory arrest en route to
  hospital
• Lateral cervical spine radiograph
• Prevertebral soft-tissue swelling (white arrow)
• Malalignment between the skull and the cervical
  spine with widening of the atlanto-occipital
  joints (black arrow)

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Clinical Anatomy

• Cervical Spine
• Axis
• 2nd cervical vertebrae
• Small body with a superior projection (Dens)
• Atlanto-axial joint
• Dens and atlas articulation
• Rotation of the skull

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Clinical Anatomy

• Cervical ligaments
• Anterior and posterior longitudinal ligaments
• Limit extension and flexion
• Ligamentum nuchae
• Limits flexion
• Interspinous ligaments
• Between spinous processes
• Limit flexion and rotation
• Ligamentum flavum
• Connect laminae
• Limits flexion and rotation

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Clinical Anatomy

• Brachial Plexus C5 T1
• 7 cervical vertebrae
• 8 cervical nerves
• 1st 7 exit above the corresponding vertebrae
• C8 exits below the 7th cervical vertebrae

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Clinical Anatomy

• Muscular Anatomy
• Cervical extension and flexion ? bilateral
  contraction of cervical muscles
• Side bending and rotation ? unilateral
  contraction
• Superficial cervical musculature
• Splenius capitis
• Splenius cervicis
• Upper trapezius
• Sternocleidomastoid

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Clinical Anatomy

• Splenius capitis
• O Lower half of ligamentum nuchae
• I Mastoid process and adjacent occipital bone
• A Lateral bending
• Splenius cervicis
• O C7 spinous process through T6
• I Transverse processes of C2 C4
• A Rotation, extension

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Clinical Anatomy

• Upper trapezius
• O Occipital protuberance, nuchal line, upper
  portion of ligamentum nuchae
• I Lateral 1/3 of clavicle, acromion process
• A Cervical extension, cervical spine bending,
  scapular elevation, upward scapular rotation

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Clinical Anatomy

• Levator scapulae
• O Spinous process of C7, transverse processes
  of C1 through C4
• I Superior medial border of scapula
• A Extension of cervical spine, scapular
  elevation and downward rotation

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Clinical Anatomy

• Scalenes
• Anterior scalene
• O Anterior portion of transverse processes
  C3-C6
• I Sternal attachment of 1st rib
• Middle scalene
• O Anterior portion of transverse processes
  C2-C7
• I Lateral to insertion of anterior scalene on
  1st rib
• Posterior scalene
• O Anterior portion of transverse processes
  C5-C6
• I Medial portion of 2nd rib
• Action Lateral bending of cervical spine

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Clinical Anatomy
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Clinical Anatomy

• Sternocleidomastoid
• O Medial clavicular head, superior sternum
• I Mastoid process
• A Flexion of cervical spine, rotation to
  opposite side, lateral bending

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Clinical Evaluation

• History
• Location of pain
• Localized pain
• Muscle strain, ligament sprain, vertebral
  fracture, facet syndrome
• Radiating pain
• Trauma to cervical nerve root or spinal cord
• Onset of pain
• Acute, chronic, insidious

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Clinical Evaluation

• History
• Mechanism of Injury
• Insidious onset
• Overuse and postural conditions
• Acute onset
• Axial load (compression fracture)
• Flexion (compression of anterior vertebral body
  and intervertebral disc facet joint sprain
  posterior muscle strain)
• Extension (compression of posterior vertebral
  body and intervertebral disc anterior
  longitudinal ligament sprain)
• Lateral bending (nerve root compression, facet
  joint compression)

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Clinical Evaluation

• History
• Mechanism of Injury
• Acute onset
• Rotation (disc trauma, ligament sprain, vertebral
  dislocation)
• Consistency of pain
• Inflammatory induced pain consistent pain
• Mechanical pain (i.e. nerve compression) varies
  in intensity, moving spine may ? or ? pain
• History
• Previous injury
• Scar tissue formation
• Injured disc
• Osteophyte within intervertebral foramina

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Clinical Evaluation

• Inspection
• Cervical curvature
• Lordotic curvature normal
• Lateral bending posture - ? pressure on nerve
  roots away from the bend

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Clinical Evaluation

• Inspection
• Position of head on the shoulders
• Unilateral spasm lateral flexion of head
  towards involved side
• Torticollis Wry neck
• Rotation of chin opposite the side of the tilt
• Congenital or acquired spasm of the SCM

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Clinical Evaluation

• Inspection
• Position of the head on the shoulders
  Torticollis

Infant with torticollis The attitude of the
head and neck results from a combination of head
tilt and rotation. A tight SCM muscle causes head
tilt towards the tight side with rotation of the
chin to the opposite side
18 years age male with congenital torticollis
with the left SCMM tight as a band unabeling him
to turn his head to the right
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Clinical Evaluation

• Inspection
• Bilateral soft tissue comparison
• Trapezius and other musculature
• Hypertrophy, atrophy
• Level of the shoulders
• Height of acromioclavicular joints
• Deltoids
• Clavicles

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Clinical Evaluation

• Palpation
• Anterior Structures
• Hyoid bone
• Have patient swallow noting superior and inferior
  movement
• Level of 3rd cervical vertebrae
• Thyroid cartilage
• Adams apple
• Level of 4th and 5th cervical vertebrae
• Cricoid cartilage
• Level of 6th cervical vertebrae

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Clinical Evaluation

• Palpation
• Anterior structures
• Sternocleidomastoid
• Have patient rotate head
• Scalenes
• Posterior to SCM (C3-C6 level)
• Carotid artery
• Lymph nodes

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Clinical Evaluation

• Palpation
• Posterior and Lateral Structures
• Occiput and superior nuchal line
• Transverse processes
• Spinous processes
• Have patient flex c-spine
• C7 and T1
• Trapezius

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Clinical Evaluation

• Range of Motion
• Active neck flexion and extension
• Test position patient can be standing or seated
• Motion Atlanto-occipital joint
• Flexion patient touches chin to chest (450)
• Extension patient looks up towards ceiling
  (450)
• Active neck lateral flexion
• Test position patient seated or standing
• Patient takes ear to shoulders (450)

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Clinical Evaluation

• Range of Motion
• Active rotation
• Test position patient seated, head held upward
  and facing forward
• Patient attempts to look over each shoulder
• Motion Atlanto-axial joint (450)

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Clinical Evaluation

• Range of Motion
• Passive flexion
• Patient position supine
• ATC grab patients head (under occiput) and
  attempt to bring chin to chest
• Passive extension
• Patient position supine, head off end of table
• ATC grasp patients head and move into
  extension

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Clinical Evaluation

• Range of Motion
• Passive lateral flexion
• Patient position supine, head in neutral
  position
• ATC one hand under occiput, tilt head/neck to
  bring ear to shoulder
• Passive rotation
• Patient position supine
• ATC grasp patients forehead and occiput,
  rotate head and neck

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Clinical Evaluation
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Clinical Evaluation

• Range of Motion
• Resisted range of motion Flexion
• Patient supine with cervical spine and head in
  neutral position
• Stabilization superior aspect of sternum
• Resistance to the forehead
• Muscles tested SCM and anterior scalenes

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Clinical Evaluation

• Range of Motion
• Resisted range of motion Extension
• Patient prone with cervical spine and head in
  neutral position
• Stabilization superior aspect of thoracic spine
• Resistance to the skull over the occiput
• Muscles tested trapezius (upper 1/3, levator
  scapulae, cervical paraspinal muscles)

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Clinical Evaluation

• Range of Motion
• Resisted range of motion Lateral flexion
• Patient seated with cervical spine and head in
  neutral position
• Stabilization over the AC joint on the side
  toward the motion
• Resistance over the temporal and parietal bones
  on the side toward the motion
• Muscles tested SCM, scalenes, paraspinal
  muscles on the side being tested

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Clinical Evaluation

• Range of Motion
• Resisted range of motion Rotation
• Patient seated with cervical spine and head in
  neutral position
• Stabilization over the anterior shoulder on the
  side toward the rotation
• Resistance over the temporal bone on the side
  toward the motion
• Muscles tested SCM, multifidus, rotators

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Clinical Evaluation
C1-C2 Neck flexion
C3 Neck lateral flexion
C4 Shoulder shrug
C5 Shoulder abduction, ER
C6 Elbow flexion, wrist extension
C7 Elbow extension, wrist flexion
C8 Thumb extension
T1 Finger abduction and adduction
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Clinical Evaluation

• Neurological Screening
• Nerve root C5 (Biceps brachii)
• Patient seated and relaxed
• ATC thumb placed over biceps tendon, strike the
  thumb nail with reflex hammer

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Clinical Evaluation

• Neurological Screening
• Nerve root C6 (Brachioradialis)
• Patient seated and relaxed
• ATC taps the brachioradialis with reflex hammer

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Clinical Evaluation

• Neurological Screening
• Nerve root C7 (Triceps)
• Patient seated and relaxed
• ATC support arm in position of extension and
  abduction, tap the triceps tendon with reflex
  hammer

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Clinical Evaluation

• Babinkski Test
• Athlete  Supine with shoes and socks removed
• ATC  At the foot of the athlete holding a blunt
  tool
• Procedure  ATC runs the tool up bottom of
  athletes foot starting at the calcaneus and
  ending at the great toe
• Positive test  Great toe extends while other
  toes splay
• Implications  Lesion of upper motor neurons, may
  be caused by trauma to the brain
• Comments  This reflex occurs naturally in
  newborns.  However, this reflex should cease
  quickly after birth

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Clinical Evaluation

• Oppenheim Test
• Test Upper motor neuron lesions
• Patient position supine
• ATC at patients side
• Procedure examiners fingernail is run along
  the crest of the anteromedial tibia
• Positive test great to extends and the other
  toes splay