Osteopathic Approach to

Neck Pain

David C. Mason, DO, FACOFP

Chair Department of OMM
 Learning Objectives
• Review Anatomy and Biomechanics of
Cervical Spine
• Discuss Evaluation of Patient with Neck
Pain
• Incorporate Osteopathic Principles and
Manipulative Treatment into Care Plan for
Patients with Neck Pain
 OUTLINE
• Anatomy
• Biomechanics
• Clinical Presentations
• Indications/Contraindications
• Diagnosis
• OMT Techniques
 Significance
• 8-24% prevalence with a 71% lifetime rate.
• Second most common reason to seek
manual medical treatment.
• Most common complaint after MVA.
• 1/3 of patients report complete resolution.
• 1/2 of acute neck pain sufferers report pain
at 12 months.
 Significance
• Millions in health care dollars and lost
employment
• 10% of patients become permanently
disabled after MVA due to neck pain
• Severe pain at onset and previous episodes
have worst prognosis.
 NOMENCLATURE
• Vertebral motion of the more superior
vertebrae on the inferior vertebrae.
– EX:C2 actually denotes C2 on C3
• Intervertebral Disc
– EX: C5-C6 denotes the disc or disc space
between the vertebral body of C5 and C6
• Forwardbending=FB=Flexion
• Backward bending=BB=Extension
• Lateral Flexion=Sidebending=SB
 CERVICAL LORDOSIS
• Least distinct of spinal curves
• Begins to develop before birth.
• Most noticeable as child lifts head at 3-4
mo.
• Helps absorb loads applied to the spine
 CHARACTERISTICS OF
CERVICAL SPINE
1. More muscles in this region of spine than
any other (more than thoracic or lumbar).
2. Most mobile region of vertebral column.
3. Required to support weight of head and
neck.
 Typical and Atypical
• Typical Cervical Spine are C2-7
• Atypical Cervical Spine OA and AA
 Typical Cervical Spine
• C2-7 can be Neutral, Flexed or Extended
• C2-7 somatic dysfunctions have
sidebending and rotation to the same side
(NON-Fryette Mechanics)
• C2-7 make up approximately 50% of
Flexion/Extension of Cervical Spine
• C2-7 Make up approximately 50% of
rotation of Cervical Spine
 Uncovertebral joints.
Uncovertebral joints in the cervical spine of an 18-year-old man, anterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Zygapophyseal (intervertebral facet) joints.
Cervical region, left lateral view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Typical Cervical Spine
• The upper Typical Cervicals tend to have
more rotation and less sidebending.
• The lower Typical Cervicals tend to have
more sidebending and less rotation.
Bony structures of the neck. Left lateral view.
Cervical spine.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Atypical Cervical Spine
OA
• The OA joint makes up approximately 50%
of the Flexion/Extension of the Cervical
Spine.
• The flexion and extension is primarily a
gliding motion on the cervical condyles.
• The OA joint somatic dysfunctions are
found with Flexion or Extension and with
Sidebending and Rotation to OPPOSITE
Sides. (Non-Fryettes mechanics)
 Craniovertebral joints
Atlas and axis, posterosuperior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Craniovertebral joints
Posterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Dissection of the craniovertebral joint ligaments.
Posterior view.
Nuchal ligament and posterior atlantooccipital membrane.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Atypical Cervical Spine
AA
• The AA joint (C1-C2) is purely a rotational
joint.
• Approximately 50% of the Rotation of the
entire cervical spine is found here.
 ATLAS
Vertebral Foramen of Atlas
greater AP diameter
very large as it approaches foramen magnum
Transverse processes
very long
between angle of mandible and mastoid
“lever”
muscles attached to it rotate the head
foramen
vertebral artery, vertebral veins, and vertebral
artery sympathetic plexus course through this.
ATLAS

•Transverse Processes(long)
•Transverse Foramen
•vertebral artery
•sympathetic plexus
•Groove (trough)
•formed by 2 elements of
transverse process
•cervical nerve passes
posterior to vertebral artery
 Ligaments of the craniovertebral joints
Ligaments of the median atlantoaxial joint, superior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Ligaments of the craniovertebral joints
Posterosuperior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Dissection of the craniovertebral joint ligaments.
Posterior view.
Cruciform ligament of atlas.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 EMBRYOLOGY OF ATLAS AND AXIS
• Apical Dental Ligament(suspensory lig)
– portion of notochord that normally becomes
nucleus pulposus
– connects dens with occiput
• Dens
– actually that portion of the body of atlas,C1
– dens dissociates from atlas and fuses with body of
2nd cervical vertebrae
• C1 (“Atlas”)
– has no body- ant and post arches of atlas fuse
forming ring-shaped atlas
ATLAS: develops from 3 primary centers of ossification
lateral masses(2), anterior arch(1)
 AXIS
Pedicles-very thick
superior articular facets
“smoothed out” portions of pedicles
allows for C1 to rotate on C2.
Atlanto-Axial articulation (AA joint)
inferior articular facets of atlas
superior articular facets of axis
*anterior to other pillars of C spine
Transverse processes
very small
attachment site for many muscles
foramen-vertebral artery,v,sympathetics
 AXIS
Odontoid Process
peg-shaped
1.5 cm
ant surface – hyaline lined
articulates with post surface of anterior arch of the
atlas.
post. Surface
groove at base(transverse atlantal lig.)
transverse atlantal ligament forms a synovial joint
“trochoid or pivot” joint
between atlas, odontoid, & transverse lig.
ATLANTO-AXIAL JOINT
Cruciform ligament (horizontal & vertical portion)
can see if remove tectorial membrane
horizontal portion- “transverse ligament of atlas”
gives integrity to AA joint
if torn- sudden death secondary to compression of
medulla or cord
superior and inferior limbs
CERVICAL INTERVERTEBRAL DISCS
Annulus Fibrosus
load bearing structure of intervertebral disc
ant aspect is stronger
post-lat is weaker (common to herniate)
pain sensitive
Nucleus Pulposus
thickest in lumbar
2nd thickest in cervical
thinnest in thoracic
centrally placed in cervical
gelatinous substance (absorbs majority of fluid)
Cartilaginous end plate
attached to IVD and 2 vertebral bodies
prevent vertebral bodies from undergoing pressure atrophy
keep annulus fibrosus and nucleus pulposus within
anatomic borders
Pathology
lateral herniations are not as common because of
uncinate processes.
posterior herniations not common because of thick
tectoral membrane

*Nerve Root Compression

degeneration of joints of Lushka anteriorly
hypertrophic osteoarthritis of synovial joints
posteriorly at intervertebral foramen
Discs of C spine move away from area of motion
EX: if FB, disc moves posteriorly
 Ligaments of the cervical spine
Midsagittal T2-weighted MRI, left lateral view.

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Clinical: Proximity of spinal nerve and vertebral artery to
the uncinate process
Fourth cervical vertebra, superior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Anterior longitudinal ligament.
Anterior view with base of skull removed.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Clinical: Proximity of spinal nerve and vertebral artery to
the uncinate process
Cervical spine, anterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Brachial plexus. Right side, anterior view.
Structure of the brachial plexus.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Brachial plexus. Right side, anterior view.
Course of the brachial plexus.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Anterior shoulder: Deep dissection.
Right limb, anterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Backward bending, Sidebending, and Rotation
reduces size of intervertebral foramen on same side
Underberg or Wallenburg Test (“vertibrobasilar insufficiency test”)
backward bending, sidebending, and rotation to same side
assesses functional vascular adequacy
Cervical Root Pressure
most common causes:
degeneration of joints of Lushka
hypertrophic arthritis of intervertebral synovial joints
EX: Pt prefers forward bending and dislikes BB, SB,
or rotation to that side because these motions
reduce size of intervertebral foramen
Cervical Disc Herniation
Pt prefers BB and slight sidebending to side of herniation.
keeps nucleus pulposus away from neural structures.
dislikes FB and sidebending away from side of herniation.
PALPATION OF CERVICAL SPINE
Must feel through:
skin
SQ (fat)
Muscle
Articular Pillars or Columns
2-3 cm from spinous processes
lateral edge of semispinalis muscle
Suboccipital Triangle
1. occipital bone (superior)
2. tip of transverse process of atlas (lateral)
3. ligamentum nuchae & spinous process of axis (medial)

*triangle important in finding somatic dysfunction

MUSCLES IN THE CERVICAL SPINE
POSTERIOR MUSCLES
1. Trapezius – extends over back of neck & upper thorax
origin: external occipital protuberance
ligamentum nuchae
spinous processes (SP) of C7-T12
insertion: lat 1/3 of clavicle, spine of scapula, base of
scapular spine.
Function: elevate shoulder, depress & retract scapula
steadies scapula on thorax
extend, laterally flex, & contralaterally rotate head

2. Levator scapulae
origin: transverse processes of C1,C2,C3,C4
insertion: superior angle of scapula
Function: elevates scapula
Posterior muscles of the shoulder and arm.
Deep dissection. Right side, posterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 MUSCLES IN THE CERVICAL SPINE

• POSTERIOR MUSCLES
• 3.Splenius Capitis
– origin: lower portion of ligamentum nuchae
• Spinous processes of C7-T3
– insertion: lat aspect of nuchal line on rough area of occipital
bone and on mastoid
– function: extend head
• laterally flex and rotate head to same side
• 4. Splenius cervicis
– origin: SP of T3-T6
– insertion: TP of C1-C3
– function: laterally flex and rotate neck to same side
•
 Muscles in the nuchal region.
Posterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
SUBOCCIPITAL MUSCLES
1. Rectus capitus posterior major
origin: SP C2
insertion: occiput
function: extend occiput on C2
sl rotation to same side
2. Rectus capitus posterior minor
origin: Posterior tubercle C1
insertion: occiput
function: extend occiput of C1
3. Obliquus capitus inferior
origin: SP C2
insertion: TP C1
function: rotate C1 to same side
4. Obliquus capitus superior
origin: TP C1
insertion: Occiput
function: lat flex and extend occiput on C1
Short nuchal and craniovertebral joint muscles
Suboccipital muscles, posterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
POSTERIOR MUSCLES, cont
5. Semispinalis capitis
origin: TP of C7-T6
insertion: occiput
function: extend head
6. Rotatores cervicis
a. longus
origin:TP
insertion:SP of 2 vertebrae above
function: lat flex and rotate vertebrae to opposite side
b. brevis
origin: TP
insertion: SP of adjacent vertebrae
function: lat flex and rotate vertebrae to opposite side
7. Longisimus capitis
origin: articular pillars C4-C7
inserion:mastoid process
function: lat flex and extend head
POSTERIOR MUSCLES, cont.
8. Spinalis Capitis
origin: articular pillars(columns) C4-C6
insertion: occiput
function: lateral flexion and extension of head
 Short nuchal muscles. Posterior view.
Course of the short nuchal muscles.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Short nuchal and craniovertebral joint muscles
Suboccipital muscles, left lateral view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Short nuchal muscles. Posterior view.
Origins (red) and insertions (blue) in the suboccipital region.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
ANTEROLATERAL MUSCLES OF CERVICAL SPINE

1. Sternocleidomastoid muscle
origin: mastoid
insertion: sternum
function: tilt head to ipsilateral shoulder
rotates head to opposite shoulder
2. Scalenes (scalenius)
a. anterior
origin: TP of C3-C6
insertion: 1st rib
func: flex and SB to same side, rotate to opposite side
b. posterior (smallest and deepest scalene)
origin: TP of C4-C6
insertion: 2nd rib
function: SB to same side, elevates 2nd rib
c. middle (medius), (largest scalene)
origin: TP of C2-C6
insertion: 1st rib
function: SB to same side, elevates 1st rib
Brachial plexus. Right side, anterior view.
Course of the brachial plexus.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
ANTERIOR MUSCLES OF CERVICAL SPINE
1. Longus colli
origin: vertebral bodies of lower cervicals
vertebral bodies of lower thoracics
TP lower cervicals
insertion: anterior upper cervical bodies
TP mid and lower cervicals
ant. Tubercle C1
function: flexion of spine
some lat flexion
2. Longus capitus
origin: TP C3-C6
insertion: ant occiput
function: flex spine, some lat flexion
3. Rectus capitus lateralis
origin: TP C1
insertion: occiput
function: flex head
ANTERIOR CERVICAL MUSCLES, cont.

4. Rectus capitus anterior

origin: lat mass C1
insertion: occiput
function: lat flex occiput on C1
 Prevertebral muscles
Prevertebral muscles, anterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Prevertebral muscles
Anterior view.

Illustrator: Karl Wesker

Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
 Physical Exam
• Visually inspect
– Anterior Head Carriage
– Eyes, Ears, OA, Cervical Curves
• ROM
– Active Flexion/Extension, Rotation, Sidebending
 Physical Exam
• Palpation
– OA
– C1 Transverse Processes
– Cervical Pillars
– Hand Placement
• Segmental Motion Testing
– Gliding OA on Condyles
– AA Rotation with Flexion of C2-7
– Translation
 Translation
• Sidebending and Rotation coupled
• Lower C spine Prefers Sidebending
• Upper C spine Prefers Rotation
Controlled Segmental Rotation
and Sidbending
 Radiological studies
• Use common sense.
• Plain x-rays of the spine help rule out
fracture or dislocation. As well as diagnose
osteoarthritis.
• MRI to diagnose soft tissue injuries and
herniated discs.
• CT scan for occult fractures, some soft
tissues.
MRI Cervical Spine
 Relative Contraindications
• Recent trauma without workup.
• Fracture or suspected fracture.
• Open wounds.
• Skin infections.
• Rheumatoid Arthritis.
• Down Syndrome.
Why Relative Contraindication in
RA and Down Syndrome?
 Contraindications
• Make sure patient is not having an acute
neurological event such as ruptured berry
aneurysm or arteriovenous malformation.
Cervical Case Presentations
David C. Mason, DO, FACOFP
Chair
Department of Osteopathic Manipulative Medicine
UNTHSC-TCOM
 Case 1
• 42 year old male in MVA yesterday
complains of neck pain that started 8 hours
after accident.
• Struck from behind while stopped at a light.
• Restrained no airbag.
All of the anterior
structures of the
neck are
stretched.
The muscle are
strained.
Micro trauma sets
up an
inflammatory
reaction.
Palpate
individual
muscles in
the anterior
neck
following their
fibers
between
origin and
insertion.
Deep muscles and
anterior ligaments
are involved.
Anterior
longitudinal
ligament.
 Case 2
• 28 year old female in MVA two days ago.
• Hit a patch of ice on road and struck a tree
head on at 25 miles per hour.
• Neck pain and headache.
• No LOC, no head trauma.
• Restrained by seatbelt, no airbag.
 Myofascial Techniques
• Longitudinal stretch
• Perpendicular stretch
• Mobilization (figure eight, traction)
• Suboccipital tension release
 Soft Tissue Techniques
• OA Suboccipital Release
• Longitudinal Stretching
• Perpendicular Stretching
Suboccipital Tension Release
Longitudinal
Stretch
Perpendicular Stretch
 Case 3
• 40 year old female complains of left arm
pain with parasthesias after her dog pulled
her off balance.
 Exam and Treatment
• Use range of motion to determine restricted
motion.
• Correlate findings with knowledge of
anatomy and palpatory exam.
• Palpate all accessible portions of the
muscles involved.
• Use myofascial release, deep inhibitory
pressure, strain-counterstrain or other
techniques.
 Muscle Energy for AA
• AA is rotational only
• Flatten AP curve.
• Rotate to barrier.
• Patient rotates into ease (dysfunction.)
AA Rotated Right
 HVLA for AA
• Flatten AP curve ( DO NOT Flex.)
• Rotate to barrier.
• Short Thrust through rotational barrier.
AA Rotated Right
HVLA AA Rr
OA Range of Motion Testing

Positive
Restriction
Equals
Flexion
Dysfunction
OA Range of Motion Testing

Positive
Restriction
Equals
Flexion
Dysfunction
 MET for OA
• Same set up as HVLA into all three planes
of motion.
• 3-5 seconds of isometric contraction.
• Post isometric relaxation stretching.
• Repeat.
• Final stretch.
 HVLA for OA
• Glide head on condyles into Flexion or
Extension barrier.
• Sidebend to barrier.
• Rotate to barrier.
• Short rotational thrust though barrier in
direction of ipsilateral eye.
OA Flexed Sidebent Left Rotated
Right
HVLA OA Joint FSblRr
OA Flexed Sidebent Right Rotated
Left
 References
• Greenspan, Adam, Orthopedic Imaging: A Practical
Approach, LWW 1st edition 2011
• Hoppenfeld, Stanley, MD; Physical Exam of the Spine and
Extremities; 1976. pp105-132.
• Netter, Frank, MD; Atlas of Human Anatomy; CIBA 1989.
plates 23-30.
• Greenman, Philip E. DO; Principles of Manual Medicine,
3rd edition. 2003. pp 540-544.
• Seffinger, Michael, Raymond Hruby, Evidence-Based
Manual Medicine: a problem oriented approach, Suanders
Elsevier 1st edition 2007.
• Thieme Altas of Neck and Visceral Organs, 2006.
• Ward, DO; Foundations of Osteopathic Medicine 3rd
edition. 2003. pp1046.
 Additional Optional Resources
• AOA Position paper on OMT for Cervical
Spine 2004.
• JAOA Somatic Connection JAOA Vol 111
No1 January 2011.