CERVICAL SPINE PARTS OF CERVICAL CHARACTERISTICS FEATURES

REVIEW OF RELATED ANATOMY VERTEBRAE

- 7 Cervical Vertebrae Vertebral Body Small, Broad

Spinous Process Short, Slender; Bifid
- 3 Atypical Vertebrae
Transverse Process (+) Transverse Foramen
• C1 (Atlas) – no body, no pedicle, no
lamina, no spinous process Vertebral Foramen Triangular – shaped
(Spinal Canal) Largest in the spine
• C2 (Axis) – (+) odontoid process (dens),
short transverse process, large bifid Facet Joints SUPERIOR ARTICULAR FACET;
spinous process (Zygoapophyseal faces superior & posterior,
joints/ Z-joints) slightly medially
• C7 (vertrabrae Prominens) – spinous INFERIOR ARTICULAR FACET;
process is long, slender, not befid faces inferior & anterior,
slightly laterally
- (+) FORAMEN TRANVERSARIUM (Transverse
Foramen): Passageway from vertebral artery Angle of Facet Joint 45 (transverse/frontal plane)
Pedicles Short, projects posterolaterally
Laminae Long, Narrow, Thinner above
than below

ATYPICAL CERVICAL VERTEBRAE

ANATOMY OF THE CERVICAL SPINE

TYPICAL CERVICAL VERTEBRAE

CERVICAL SPINE - • No IV disc found between C0-C1, C1-C2
- SecXons of the Cervical Spine - • CLINICAL SIGNIFICANCE OF IV DISC:
• Upper Cervical Spine: Atlas & Axis (C1 & ♦ InnervaXon is at outer 1/3 porXon only →
C2) pain sensiXve
• Lower Cervical Spine: C3 – C7
♦ Fluid content in nucleus pulposus diminishes
- Center of Gravity of the Cervical Spine: Level of with age → ↓ shock absorbing capability, ↑ risk
sella turcica, posiXoned slightly anterior to the of tearing
C0 – C1 and C1 – C2 joints.
8 Cervical Nerve Roots
RESTING POSITION: Midway between flexion and
extension - Each nerve root in the cervical spine is named
for the vertebra BELOW it (e.g. C5 nerve root,
CLOSED PACKED POSITION: Full Extension exits between C4 – C5 vertebrae)
CAPSULAR PATTERN: Equal limitaXon of side flexion - C1 Nerve Root: exits between the occiput & C1
& rotaXon > Extension
- C8 Nerve Root: exit between C7 – T1 Vertebra
JOINTS OF THE CERVICAL SPINE
1. Atlanto – Occipital Joint (C0 – C1)
- “yes” joint; Cervical Flexion & Extension
(nodding) some side flexion & rotaXon
2. Atlantoaxial joint
- “no” joint, Cervical rotaXon and some flexion,
extension, & side flexion
3. Facet (Zygoapophyseal Joint)
- Allow cervical flexion, extension, side flexion,
rotaXon (depends on orientaXon of facets) •
CLINICAL SIGNIFICANCE: common site of BLOOD VESSELS & NERVES IN THE NECK & CERVICAL
degeneraXve changes 2° to its weightbearing REGION
funcXons
A. Main Blood Vessels in the Neck:
4. JOINTS OF LUSCHKA (UNCOVERTEBRAL) JOINTS
1. CaroVd Arteries – Common CaroXd Artery
- Allow cervical flexion & extension -> External & Internal CaroXd
- • Limit lateral flexion (C3-C7 segments) 2. Jugular Veins – External, Anterior, Inferior
Jugular Veins
- • Prevent posterior linear translaXon
movements of the vertebral bodies B. Brachial Plexus
- • CLINICAL SIGNIFICANCE: MUSCLES OF THE NECK

♦ Important in providing stability and guiding - Platysma

the moXon of the cervical spine - SCM
♦ High tendency for developing degeneraXve - Suprahyoid (Digastric, Geniohyoid, Stylohyoid,
changes → vertebral artery compression Mylohyoid)

5. INTERVERTEBRAL JOINTS - Infrahyoid (Thyrohyoid, Omohyoid, Sternohyoid,

Sternothyroid)
- ArXculaXons between vertebral bodies & the IV
disc in between - Scalene (Anterior, Middle, Posterior)
 - Rectus CapiXs (Anterior, Lateralis, Posterior) - A.k.a “Wry Neck”
- Longus CapiXs & Longus Colli - Scoliosis in the Cervical Spine
- Obliquus CapiXs & Superior & Inferior TYPES:
- Splenius CapiXs & Cervicis ▪ CONGENITAL/INFANTILE TORTICOLLIS
➢Seen in young children (females; 6mos-3yrs)
IMPORTANT LANDMARKS IN THE CERVICAL REGION
➢Cause: Unilateral contracXon of SCM muscle due
to ischemic
Vertebral IdenXficaXon of Cervical Vertebra Level
changes
Level
➢S/Sx: side flexion to affected side & rotaXon to
2 Fingers widths below occipital opposite side
C1
protuberance
3 Fingers widths below occipital ▪ ACUTE/ACQUIRED TORTICOLLIS
C2 ➢Occurs in 20yrs or older
protuberance
➢Cause: trauma or muscle strain; URTI, poor
C3 Hyoid posture
Superior notch (top) of Thyroid CarXlage ➢S/Sx: mms spasm of one or more muscles (SCM,
C4
(Adam’s Apple) Splenius,
Semispinalis, Scalenus Ant.); pain; ↓ ROM
C5 Inferior Border of Thyroid CarXlage
➢Resolves within 7 days to 2 weeks
C6 Cricoid CarXlage
Base of Neck; Prominent posterior
C7
spinous process

PATIENT HISTORY
SubjecVve
- What is the Chief Complaint (c/c)
- What is the Mechanism of Injury (MOI) WHIPLASH (ACCELERATION) INJURY

- Look for presence of Red Flag or Yellow Flag ▪ AcceleraXon-deceleraXon injury of the neck → cervical
signs for the cervical region sprain or sprain
▪ Head goes into flexed combined with rotaXon,
CondiVons that afflict the Neck and Cervical Region followed very rapidly by extension
▪ Common Cause: MVA
- TorXcollis
▪ S/Sx: neck pain, headache (occipital area)
- Whiplash injury
CERVICAL SPINE INSTABILITY
- Cervical Spine Instability
Failure to maintain correct vertebral alignment due to
- Facet Joint Syndrome
bony changes, neuromuscular pathology, or
- Cervical Radiculopathy ligamentous damage
▪ Cause: trauma, surgery, tumor, arthriXc/degeneraXve
- Cervical Myelopathy changes, long-term corXcosteroid use, congenital
- Disc HerniaXon malformaXons
▪ S/Sxs: Severe muscle spasm, paXent does not want to
- Cervical Spondylosis move head (especially into flexion), lump in throat, lip
or facial paresthesia, severe headache, dizziness,
- Cervical Spinal Stenosis
nausea, vomiXng, sot end-feel, nystagmus, pupil
TORTICOLLIS changes
 ▪ S/Sx: numbness, weakness, paresthesia (leg, foot, arm)
FACET JOINT SYNDROME ▪ Most common sx: Xngling of the hand

Pain at the joint between the two vertebrae of the spine

▪ Cause: trauma, disc degeneraXon
▪ S/Sx: neck pain, tenderness, muscle spasm, pain & BRACHIAL PLEXUS INJURIES OF THE CERVICAL SPINE
limitaXon of neck extension & rotaXon, radiaXng pain
BRACHIAL LANDMARK
PLEXUS INJURY
CERVICAL RADICULOPATHY
ERB-DUCHENNE Injury to upper nerve roots (C5-C6)
▪ Injury to the nerve roots in the cervical spine PARALYSIS • Affects shoulder & elbow muscles
▪ S/Sxs: unilateral motor/sensory sxs in the UE; reflex • Affects sensaXon over deltoid area &
hypoacXvity radial surfaces of FA & hand
KLUMPKE Injury to lower nerve roots (C8-T1)
CERVICAL MYELOPATHY (DEJERINE- • (+)Atrophy & weakness in triceps, FA
KLUMPKE) & hand muscles
Injury to the spinal cord itself PARALYSIS • FuncXonless hand
▪ S/Sxs: spasXc weakness, paresthesia, incoordinaXon in • (+) Sensory loss on ulnar side of FA &
LE, propriocepXve dysfuncXon hand
BURNERS & Transient injuries to the brachial plexus
DISC HERNIATION STINGERS due to trauma (compression/tracXon
neck injury) combined with factors,
▪ A.k.a. slipped disc
such as stenosis or a degeneraXve disc
▪ A condiXon affecXng the spine in which a tear in the
(spondylosis)
outer, fibrous ring of an intervertebral disc allows the
• (+) SXnging and burning pain
sot, central porXon to bulge out beyond the damaged
spreading from shoulder to hand
outer rings
▪ Affects males, 30 y/o
▪ Most commonly affected: C5-C6, C6-C7 RED FLAG FINDINGS
▪ Most common direcXon: posterolateral MANDATORY QUESTIONS:
▪ S/Sxs: pain, limited ROM, radicular pain in unilateral 1. Any dizziness (verXgo), blackouts, or drop avacks?
UE, headache 2. Any history of rheumatoid arthriXs (RA) or other
inflammatory arthriXs or treatment by systemic steroid?
3. Any neurological symptoms in arms and legs? ➢If
posiXve → serious pathology → referral to physician/
specialist

OUTCOME MEASURES RELEVANT TO THE NECK &

CERVICAL REGION
CERVICAL SPONDYLOSIS
A.k.a. cervical arthriXs OUTCOME DESCRIPTION
▪ Age-related degeneraXve disease of the cervical spine MEASURE
▪ Affects the IV disc → degeneraXon, due to damage or NECK DISABILITY Contains 10 items (7 related to ADLs, 2
poor nutriXon INDEX (NDI) related to pain, 1 related to
▪ Areas most commonly affected: C5-C6, C6-C7 concentraXon)
▪ Age: 35-55 y/o • Each item is scored 0 – 5; total score
▪ S/Sx: pain, tenderness, sXffness, limited ROM is expressed in percentage
▪ CERVICAL OSTEOARTHRITIS – late stage • Higher scores correspond to greater
disability
CERVICAL SPINAL STENOSIS
Narrowing of space in the spine
▪ Dx: sagival diameter of spinal canal is <13mm
PATIENT-SPECIFIC Asks paXents to list 3 acXviXes that
FUNCTIONAL are difficult as a result of their
SCALE (PSFS) symptoms/injury/disorder
• The paXent rates each acXvity on a
scale of 0 – 10 (0 represents inability
to perform the acXvity; 10 represents
ability to perform the acXvity as well
as they could prior to the onset of
symptoms)
• The 3 acXvity scores are averaged
for a final score
WHIPLASH Provide informaXon on the impact the UPPER CROSSED SYNDROME
DISABILITY whiplash injury and symptoms have ▪ TIGHT MUSCLES:
QUESTIONNAIRE upon the paXent’s lifestyle pectoralis major/minor, upper trapezius, levator
(WDQ) • A 13-item quesXonnaire scored from scapulae
0 (no disability) to 130 (complete ▪ WEAK MUSCLES:
disability) deep neck flexors, rhomboids, serratus anterior, lower
trapezius
COPENHAGEN A self-administered quesXonnaire
NECK developed to measure the level of
FUNCTIONAL funcXonal disabiliXes in paXents with
DISABILITY SCALE neck pain
(CNFDS) • Consists of 15 items (Good funcXon
= 0; Poor funcXon = 2; ‘Occasionally’=
1)
NORTHWICK PARK Measures neck pain and consequent
NECK PAIN paXent disabiliXes (how it affects
QUESTIONNAIRE ADLs)
(NPQ) • Each parameter is divided in 5
answer possibiliXes with points from 0
– 4 (0 = no pain; 4 = worst pain);
Minimum score = 0; maximum score =
36 (if all 9 quesXons were answered)
& 32 (if only the first 8 quesXons were
answered). RANGE OF MOTION (ROM) ASSESSMENT
• The higher the percentage, the CERVICAL ROM: ACTIVE & PASSIVE MOTIONS
greater the disability and the pain ▪Cervical Flexion
▪Cervical Extension
▪Cervical Lateral Flexion
▪Cervical RotaXon

OBSERVATION
NORMAL ROM VALUE
CERVICAL SPINE (GONIOMETER)
CERVICAL SPINE
Flexion 0-45˚
▪ Normal Standing & Si{ng Posture
Extension 0-45˚
▪ Head and Neck Posture
Lateral Flexion 0-45˚
▪ Shoulder should be level
RotaXon 0-60˚
▪ (+/-) Muscle spasm or any asymmetry
CERVICAL SPINE (TAPE MEASURE)
▪ Facial Expression
Flexion 1-4.3cm
▪ Bony and Sot Xssue contours
Extension 18.5-22.4cm
▪ Evidence of Ischemia in either UE
Lateral Flexion 10.7-12.9cm
RotaXon 11-13.2cm
FUNCTIONAL ASSESSMENT C8 Livle finger (dorsal surface of proximal phalanx)
FUNCTIONAL ASSESSMENT OF THE CERVICAL SPINE
ASSESS ADLs, which may include:
▪ Breathing
▪ Swallowing
▪ Looking up at the ceiling
▪ Looking down at belt buckle or shoe laces
▪ Shoulder check
▪ Tuck chin in
▪ Poke chin out
▪ Neck strength
▪ Paresthesia

CERVICAL MMT
▪ Capital Extension
▪ Cervical Extension
▪ Combined Neck Extension
▪ Capital Flexion
▪ Cervical Flexion
▪ Combined Neck Flexion
▪ IsolaXon of SCM
▪ Cervical RotaXon UE MYOTOME TESTING
NERVE TEST ACTION
SPECIAL TESTS ROOT
▪ Tests for Neurological Symptoms
▪ Tests for Upper Motor Neuron Lesions C1-C2 Neck flexion, extension
▪ Tests for Vascular Signs C3 Neck side flexion
▪ Tests for VerXgo & Dizziness
▪ Tests for Cervical Instability C4 Shoulder elevaXon (shoulder shrug)
▪ Tests for Upper Cervical Spine Mobility C5 Elbow flexion (Biceps, Brachialis)
▪ Tests for First Rib Mobility
C6 Wrist Extension (ECRL, ECRB)
NEUROLOGIC ASSESSMENT C7 Elbow Extension (Triceps)
COMMON REFLEXES CHECKED IN CERVICAL SPINE
C8 Finger flexion (FDP)
ASSESSMENT
▪ BICEPS (C5, C6) T1 Finger AbducXon (Abductor DigiX Minimi)
▪ TRICEPS (C7, C8)
▪ BRACHIORADIALIS (C5, C6) PALPATION
▪ JAW REFLEX (CN V) ▪ Hyoid bone
▪ HOFFMAN SIGN (checked if UMNL is suspected) ▪ Thyroid CarXlage
SENSORY TESTING: DERMATOMES ▪ Cricoid CarXlage (1st Cricoid Ring)
C1 Vertex of skull ▪ Thyroid Gland
▪ External Occipital Protuberance
C2 External Occipital Protuberance ▪ Inion (“Bump of Knowledge”)
C3 Supraclavicular fossa ▪ Superior Nuchal Line (lateral to the inion)
▪ Mastoid Process (at the lateral edge of superior nuchal
C4 Acromion process line)
C5 Lateral side of antecubital fossa (proximal to ▪ C2 Spinous Process (1st one that is palpable at the
elbow crease) base of the skull)
▪ Spinous Processes C6, C7 (largest spinous process), T1
C6 Thumb (dorsal surface of proximal phalanx) ▪ Facet joints (palpated 0.5-1 inch/1.3-2.5cm lateral to
C7 Middle finger (dorsal surface of proximal spinous processes; common cause of pain, C5-C6 oten
phalanx) involved in OA)
▪ Mastoid Processes (below and behind ear lobe)
▪ Transverse Processes of cervical vertebrae Cervical RA/OA
▪ Lymph node chains in the neck (in the medial border - RA C3,C4,C5 (SYSTEMIC)

of SCM; anterolateral aspect of trapezius muscle) • Juvenile (C1-C2)

▪ CaroXd Pulse (situated next to the caroXd tubercle, C6)

▪ Superior Nuchal Ligament
- OA C5 - C6 (DEGENERATIVE)

▪ Supraclavicular Fossa
▪ SCM
▪ Trapezius WHIPLASH
- Traumatic injury

SUPRACLAVICULAR FOSSA - MVA

▪ Lies superior to the clavicle & lateral to the - Ligaments that control spine are injures

suprasternal notch • Supraspinous & Interspinous (flexion)

▪ STRUCTURES: • ALL (extension) (rare)

➢Platysma muscle - No fracture

➢Cupola (dome) of the lung – injured by puncture

wounds, fracture of the clavicle, or biopsy of BURNER/STINGER
enlarged lymph node
- Neurologic Conditions
➢Cervical rib (if present) - Brachial Plexus

▪ Swelling (edema) due to trauma (i.e. clavicular

- Traumatic Brachial Plexus Injury

fracture)
▪ Small lumps due to enlargement of the lymph glands - Self limiting

in the fossa

CERVICAL DISC STENOSIS

HERNIATION

Disc Protrudes outwards Narrowing (less than the

normal range of 10-12 mm)

Pain @ Flexion Pain @ Extension

Extension Exercises Flexion Exercises

C5 - C6 most affected

HOFFMANN SIGN: EQUIVALENT OF BABINSKI

CERVICAL SPINE
CERVICAL SPONDYLOSIS
- Initial start of OA of cervical spine
- Degenerative change
- C5 - C6 (most moved)
- Pain management & strengthening

CERVICAL SPONDYLOLYSIS
- Pars Interariticularis defect
- Facet/Zygaopohyseal/Lushka Jt

- Scottie dog w/Collar

- Splinting & Brace

CERVICAL SPONDYLOLYSTHEIS
- Fracture of Pars interarticularis

- Decapitated Scottie dog

- Brace & ORIF