Physical Examination

of Neck
NANANG ZULKARNAIN
111 2015 0113

Supervisor: dr. Muh. Alihasti, SpOT

Advisor: dr. William Limoa
Anatomy of Spine

GENERAL INFORMATION

• 33 Vertebrae; 7 Cervical, 12 thoracic,

5 lumbar, 5 sacral (fused), 4
coccygeal (fused).
• Cervical C1-C2; a unique bones allow
stabilization of occiput to spine and
rotation of head. Motion: rotation
and flexion/extension
GENERAL INFORMATION
The cervical spine has three
functions;
1. Furnishes support and
stability of the head.
2. Its articulating vertebral
facets allow for the head’s
range of motion.
3. It provides housing and
transport for the spinal cord
and the vertebral artery.
Anatomy of Neck (C1-
C2)
Anatomy of Neck (C3-
C4)
Anatomy of Neck (C4-
C7)
Anatomy of Neck
(Joints)
Anatomy of Neck (Anterior
Muscles)
Anatomy of Neck (Posterior
Muscles)
The Nerves
Physical Examination of Plexus
Brachialis
 Clinical
Assessment
Referred pain or
Where did it start? radicular pain?
ONSE PAIN
T
Acute, subacute,
How did it start? Chronic or recurrent
pain?
DEFORMIT
Y
Appears a wry neck? HEADAC
HE
The only symptom
STIFFNE
or any else?
SS
Intermittent or
continuous?
 PHYSICAL
EXAMINATIONS
LOOK
• Posture of neck
• Deformity
• Scars

Look for any deformity or superficial blemish which

might suggest a disorder affecting the cervical spine
 PHYSICAL
EXAMINATIONS
FEEL

The back of the neck is most easily and reliably felt with
the patient lying prone over a pillow; this way muscle
spasm is reduced the neck is relaxed.
The front of neck is felt with the patient seated
and the examiner standing behind him.
PHYSICAL
EXAMINATIONS
 FEEL
(SOFT TISSUE)

Zone 1 – Anterior Aspect

 M. Sternocleidomastoideus
 Lymph Node Chain
 Carotid Pulse
 PHYSICAL
EXAMINATIONS
 FEEL
(SOFT TISSUE)

Zone 2 – Posterior Aspect

 M. Trapezius
 Greater Occipital nerves
 PHYSICAL
EXAMINATIONS
MOVE

Flexion Extension
(Chin on Chest) (Look up at the Ceiling)
 PHYSICAL
EXAMINATIONS
MOVE

Lateral Flexion Lateral Rotation

(tilt your ear towards (Look over your Shoulder)
your shoulder)
 Normal Range of
Movement

Flexion Extension

Lateral
Rotation
Flexion
Physiological Reflex in Upper Limb.

 BICEPS REFLEX
 BRACHIORADIALIS REFLEX
 EXTENSOR CARPI RADIALIS
REFLEX
 PRONATOR TERES REFLEX
 TRICEPS REFLEX
 1. BICEPS REFLEX

 Spinal Root: 5th Cervical

 Look for : Elbow Flexion or
biceps activation.
 Efferent Limb: C5, C6,
Musculocutaneous nerve.
 2. BRACHIORADIALIS REFLEX

 Spinal Root: 6th Cervical

 Look for: Brachioradialis
activation during elbow flexion.
 Efferent Limb: C6, Radial nerve.
 3. EXTENSOR CARPI RADIALIS
REFLEX

 Spinal Root: 6th Cervical

 Look for: Wrist Extension.
 Efferent Limb: C5, C6, C7, Radial
nerve.
 4. PRONATOR TERES REFLEX

 Spinal Root: 6th Cervical

 Look for: Forearm pronation.
 Efferent Limb: C6, C7, median
nerve.
 5. TRICEPS REFLEX

 Spinal Root: 7th Cervical

 Look for: Elbow Extension.
 Efferent Limb: C7, Radial nerve.
Patological Reflex in Upper Limb.

 HOFFMAN’S SIGN
 TROMNER’S SIGN
 1. HOFFMAN’S SIGN
HOW TO PERFORM:
1. Ask the patient to relax the hand
with palm facing down.
2. Examiner grasps the distal phalanx
of the long finger, passively extending
at the metacarpophalangeal (MCP)
joint and flexing at the
interphalangeal (IP) joints.
3. Examiner slips thumb over the tip
of the patient’s long finger in a
proximal to distal direction.
POSITIVE TEST: Thumb flexes
(other finger may also flex).
 2. TROMNER’S SIGN
HOW TO PERFORM:
1. Ask the patient to relax the hand
with palm facing down.
2. Tapping or flicking the volar
surface of the distal phalanx of the
middle finger held partially flexed
between the examiner’s finger and
thumb.

POSITIVE TEST: Thumb and index

finger are flexes.
Various Special Reflex.

 SNOUT REFLEX
 GRABELLAR REFLEX
 PALMOMENTAL REFLEX
 1. SNOUT REFLEX
• Reflex test: Examiner taps the
patient 3–5 times gently over the
upper lip.
• Positive test: Puckering of the lips
occurs.
• Consistent with: Frontal lobe
dysfunction in adults.
 2. GLABELLAR REFLEX
• Reflex test: Tap the patient 5–10
times with mild force in the midline
of the forehead. Patient’s blinking
should extinguish after several
seconds of tapping.
• Positive test: Patient continues to
blink and is unable to suppress
blinking.
• Consistent with: This is a primitive
reflex that can be seen in
neurodegenerative disorders,
Parkinson’s disease, and individuals
with frontal lobe pathology.
Persistent blinking is called
Myerson’s sign.
 3. PALMOMENTAL REFLEX
• Reflex test: Examiner scratches the
patient’s midline palm with her
fingernail.
• Positive test: Ipsilateral twitching of
the chin or lower lip.
• Consistent with: May be normal, but
may indicate ipsilateral cerebral
(frontal lobe) pathology.

*Note: Frequently (although not

always) consistent with upper motor
neuron pathology. Evaluate for
bilateral responses.
 Various Orthopedic tests
applied to the cervical region.

 DISTRACTION TEST
 COMPRESSION TEST
 VALSALVA TEST
 SWALLOWING TEST
 ADSON TEST
 1. DISTRACTION TEST

 HOW TO PERFORM:
Place the open palm of one under
the patient’s chin, and the other
hand upon his occiput.

 MECHANISM:
This test demonstrates the effect
of the neck traction might have in
relieving pain. Distraction relieves
pain due to narrowing of the
neural foramen.
 2. COMPRESSION TEST

 HOW TO PERFORM:
Press down upon the top of the
patient’s head while he is either
sitting or lying down.

 MECHANISM:
A narrowing of the neural
foramen, pressure on the facet
joints, or muscle spasm can cause
increased pain upon compression.
 3. VALSALVA TEST

 HOW TO PERFORM:
The patient hold his breath and
bear down as if he we were
moving his bowels.

 MECHANISM:
This test increases intrathecal
pressure. If a space-occupying
lesion, is present in cervical canal,
the patient may develop pain.
 4. SWALLOWING TEST

 MECHANISM:
Difficulty or pain upon swallowing
can sometimes be caused by
cervical spine pathology due to
hematomas, infection, or tumor in
the anterior portion of the
cervical spine.
 5. ADSON TEST

 HOW TO PERFORM:
Take the patient ‘s radial pulse at
the wrist. As you continue to feel
the pulse, abduct, extend, and
externally rotate his arm.

 MECHANISM:
This test is used to determine the
state of the subclavian artery. If
there is compression, you will feel
a marked diminution or absence
of radial pulse.