Cervical Spine

Question 1

Cervical AROM

Answer 1

– Nodding (variable)
– Flexion (45-50°)
– Extension (85°)
– Lateral flexion (40°)
– Rotation (90°)

Question 2

Cervical PROM

Answer 2

– Nodding -> tissue stretch
– Flexion -> tissue stretch
– Extension -> tissue stretch
– Lateral flexion -> tissue stretch
– Rotation -> tissue stretch

Question 3

Cervical Spine

Answer 3

• Resting Position:
– Slight extension

• Close Packed Position:
– Full extension

• Capsular Pattern:
– Lateral flexion and rotation equally limited
– Extension

Question 4

Upper Limb Myotomes

Answer 4

C4: shoulder shrugs
C5: shoulder abduction and external rotation; elbow flexion
C6: wrist extension
C7: elbow extension and wrist flexion
C8: thumb extension and finger flexion
T1: finger abduction

Question 5

Upper Limb DTRs

Answer 5

Biceps C5-C6
Brachioradialis C6
Triceps C7

Question 6

Kemp’s Test: Cervical Spine

Answer 6

• Purpose:
– This test is designed to provoke radicular symptoms in patients with suspected cervical radiculopathy
– This test can also be used to stress the I/L facet joints and disc

• Procedure:
– Patient is sitting
– Practitioner stands slightly behind the patient
– The practitioner laterally flexes and rotates the patient’s head to the homolateral side
– The patient’s neck is then gently taken into extension
– The practitioner notes any changes or manifestations in signs and symptoms

• Positive:
– Production of pain that radiates into the arm in a dermatomal distribution on the side of lateral flexion and rotation
– I/L neck pain without referral may indicate local mechanical neck pain

• Indication of positive: – Cervical radiculopathy
– Cervical radicular pain
– Transient brachial plexopathy
– I/L Facet pathology
– I/L Disc pathology

Question 7

Maximal Foraminal Compression Test

Answer 7

• Purpose:
– This test is designed to provoke symptoms in patients with suspected cervical radiculopathy

• Procedure:
– Patient is sitting
– Practitioner stands slightly behind the patient
– The patient laterally flexes their and rotates their head to the homolateralside
(Part 1)
– The practitioner places the secondary hand on the patient’s I/L shoulder and places the primary contact on the top of the
patient’s head
– The patient’s neck is then taken extension (as well as the lateral flexion and rotation) and the practitioner applies a caudally
directed compressive force through the cervical spine. (Part 2)

• Positive:
– Production of pain that radiates into the arm in a dermatomal distribution on the side of lateral flexion and rotation
– Pain in the neck without radiation is not considered a positive test
– The practitioner notes any changes or manifestations in signs and symptoms

• Indication of Positive:
– Cervical radiculopathy
– Transient brachial plexopathy
• Clinical note:
– The asymptomatic side is always assessed first
– The second part of the test maximally closes the IVF
– The second part of the test may also stress the vertebral artery

Question 8

Spurling’s Test

Answer 8

• Also known as the ‘Foraminal compression test’

• Purpose:
– This test is designed to provoke radicular symptoms in patients with suspected cervical radiculopathy

• Procedure:
– Patient is sitting
– The examiner stands behind the patient and places their hands on top of the patient’s head
– The patient then laterally flexes and extends their head and the practitioner then gently applies a caudally directed compressive
force through the patient’s laterally flexed and extended cervical spine

• Positive:
– Production of pain that radiates into the arm in a dermatomal distribution on the side of lateral flexion
– Pain in the neck without radiation is not considered a positive test
– The practitioner notes any changes or manifestations in signs and symptoms

• Indication of positive:
– Cervical radiculopathy
– Transient brachial plexopathy

• Clinical note:
– The asymptomatic side is always assessed first
– Various authors recommend performing the procedure in a stepwise approach by increasing the provocative force over several
movements:

• Neutral compression -> Half lateral-flexion, extension and compression -> Full lateral flexion, extension and compression
– Patient’s may experience on the C/L side which is referred to as a ‘reverse Spurling’s Sign’
– B/L symptoms during this procedure indicate possible myelopathy

Question 9

Jackson’s Compression Test

Answer 9

• Purpose:
– This test is designed to provoke radicular symptoms in patients with suspected cervical radiculopathy
– Especially important if the patient complains of radicular symptoms with neck rotation

• Procedure:
– Patient is sitting
– The practitioner stands behind the patient
– The patient rotates their head to the affected side
– The practitioner then places their hands on the patient’s head and gently applies a caudally directed
compressive force through the cervical spine

• Positive:
– Production of pain that radiates into the arm in a dermatomal distribution on the side of rotation

• Indication of positive:
– Cervical radiculopathy

• Clinical note: – The asymptomatic side is always assessed first
– Patient’s may experience I/L or C/L facet joint symptoms

Question 10

Cervical Compression Test

Answer 10

• Purpose:
– This test is designed to provoke radicular symptoms in patients with radiculopathy

• Procedure:
– The patient is sitting with the head in neutral
– The practitioner stands behind the patient and places their hands on top of the patient’s head
– The practitioner gently applies a caudally directed compressive force through the patient’s cervical spine

• Positive:
– The test is considered positive if the patient’s radicular symptoms are provoked by the compressive force

• Indication of positive:
– Cervical radiculopathy

• Clinical note:
– Apply the compression slowly and then gently return the patient’s head to the pretest position
– The practitioner may perform the test in varying degrees of flexion or extension depending on what type of information the practitioner is trying to elicit
– Pain on compression may also indicate vertebral body, disc or facet joint pathology

Question 11

Shoulder Depression Test

Answer 11

• Purpose:
– Used to evaluate for brachial plexus injury and radiculopathy

• Procedure:
– The patient is sitting
– The practitioner places one hand on the patient’s head and the other hand on the patient’s shoulder
– The practitioner laterally flexes the patient’s head to one side while applying downward pressure on the patient’s opposite shoulder

• Positive:
– An increase of pain on the side of the compression indicates irritation/compression of nerve roots
– An increase of pain on the side of the being stretched indicates irritation/stretching of nerve roots

• Indication of positive:
– Brachial plexopathy
– Transient brachial plexopathy
– Radiculopathy

Question 12

Tinel’s Tap or Doorbell Sign

Answer 12

• Purpose:
– To test for brachial plexopathy

• Procedure:
– The patient is sitting with neck slightly flexed
– The practitioner stands behind the patient
– Using one finger, the practitioner taps (Tinel’s Tap) or applies firm
pressure (Doorbell sign) along the roots and trunks of the brachial plexus

• Positive:
– Tingling sensation or pain distal to the contact points in a dermatomal
distribution in response to the tapping/pressure

• Indication of Positive:
– Brachial plexopathy
– Radiculopathy
– Transient brachial plexopathy

Question 13

Cervical Distraction Test

Answer 13

Purpose:
– This test is designed to relieve radicular symptoms in patients who demonstrate radicular signs during the examination

• Procedure:
– The patient is sitting
– The practitioner stands adjacent to the patient and places their hand under the patient’s chin with one hand and under the
patient’s occiput with the other hand and slowly lifts the patient’s head which creates traction through the cervical spine

• Positive:
– The test is considered positive if the patient’s radicular symptoms are relieved by the traction which indicates that pressure on
the nerve roots has been removed temporarily by the procedure

• Indication of positive:
– Cervical radiculopathy

• Clinical note:
– Increased pain on distraction may occur due to m. spasm/strain, lig. strain, facet joint irritation, or disc herniation
– In some instances it can take a few minutes for neurological symptoms to abate
– Apply the traction slowly and then gently return the patient’s head to the pretest position
– The test procedure relieves radicular symptoms that the patient is experiencing during the examination

Question 14

Shoulder Abduction (Relief) Sign

Answer 14

• Also known as Bakody’s Sign

• Purpose:
– To test for radicular symptoms, specifically symptoms arising from compression of the C4, C5, or C6 nerve roots
– Particularly useful if the patient has indicated that placing the arm or hand on the head relieves the symptoms
– The test procedure relieves radicular symptoms that the patient is experiencing during the examination

• Procedure:
– The patient is sitting
– The practitioner is positioned such that they can observe the patient’s response to arm abduction
– The patient is asked to place their forearm or hand on top of their head. Alternatively, the practitioner can passively
move the patient’s forearm or hand into this position

• Positive:
– A decrease in or relief of radicular symptoms

• Indication of positive:
– Cervical radiculopathy - specifically C4/C5/C6 nerve roots

• Clinical note:
– The test can be performed sitting or supine, however the test is more effective in the sitting position
– In some cases it may take a few minutes for symptoms to abate

Question 15

Sharp-Purser Test

Answer 15

• Purpose:
– To determine potential subluxation (medical) of the atlas on the axis
– This indicates a possible insufficiency of the transverse ligament which maintains the position of the odontoid process relative to C1
– If the transverse ligament is torn, C1 will translate forward on C2 during flexion of the cervical spine
– This test may also be positive in individuals with a fracture of the odontoid process

• Procedure:
– Patient is sitting
– The examiner stands to the side of the patient and places their secondary contact on the patient’s forehead
– The examiner places the thumb of their primary contact over the spinous process of C2 to stabilize that segment
– The patient is then asked to slowly flex their head
– The practitioner then applies a slow, gentle, measured AP force on the patient’s forehead creating a relative ‘posterior shear’
of the atlas on the axis

• Positive:
– The test is considered positive is the practitioner feels the head slide posteriorly as the secondary contact applies pressure
– The posterior slide, which may be associated with a ‘clunk’, indicates a relocation of the subluxated atlas
– The patient may also experience the symptoms associated cervical instability as the head is flexed

• Indication of positive:
– Cervical instability -> Potential rupture of the transverse ligament
– Odontoid fracture

Question 16

Rotational Alar Ligament Stress Test

Answer 16

• Purpose:
– To test for instability at the atlanto-axial joint and to test the integrity of the alar ligament
– The test was first designed to assess instability in patients with Rheumatoid Arthritis
– Performed if a practitioner suspects either cervical instability, odontoid fracture or odontoid dysplasia

• Procedure:
– Patient is seated with the head in neutral
– Practitioner stands to the side of the patient
– The practitioner gently grips the patient’s lamina and spinous process of C2 with the primary contact
– The practitioner places the secondary contact on top of the patient’s head
– While stabilizing the patient’s C2, the practitioner tries to passively rotate the patient’s head which forces the C1 vertebrae to rotate on the fixated C2 vertebrae

• Positive:
– More than 20°-30° of rotation without C2 movement indicates injury to the contralateral alar ligament
– If this test is positive, the lateral flexion alar ligament stress test should be positive in the same direction

• Indication of positive:
– Cervical instability
– Alar ligament disruption
– Dens fracture
– Odontoid dysplasia

• Note:
– The alar ligament serves to restrain rotation

Question 17

Transverse Ligament Stress Test

Answer 17

• Purpose: – To determine potential subluxation (medical) of the atlas on the axis which may indicate either cervical instability, odontoid fracture, atlanto-axial hypermobility or transverse ligament disruption

• Procedure:
– Patient is supine
– The examiner stands at the head of the table supporting the patient’s occiput with the palms and fingers of both hands
– The examiner places the index finger of both the primary and secondary contacts over the posterior arch of C1
– While keeping the patient’s head in neutral, the practitioner simultaneously lifts the head and the C1 contacts anteriorly
– This position, which creates an anterior shear of C1 on C2, is then held for 10-20 seconds to see if any symptoms are produced

• Positive:
– Production of cervical instability symptoms e.g. lump in the throat sensation

• Indication of Positive: – Cervical instability
– Potential rupture of the transverse ligament
– Odontoid fracture
– Atlanto-axial hypermobility

Question 18

Atlantoaxial Lateral Shear Test

Answer 18

• Purpose:
– To assess for possible instability at the atlanto-axial articulation, odontoid process fracture, transverse ligament tear, odontoid dysplasia

• Procedure:
– The patient is supine with the head supported on a pillow
– The examiner is positioned at the head of the treatment table facing in a caudal direction
– The examiner places one index finger contact on the transverse process of C1 and an index finger contact on the contralateral transverse process of the C2
– The examiner then carefully pushes both contacts in a L-M direction causing a relative shear of one vertebra on the other

• Positive:
– The test is considered positive if there is excessive movement between the two vertebrae and/or symptoms are produced that are indicative of cervical instability e.g. Paraesthesia in the lips

• Indication of Positive:
– Cervical instability
– Potential rupture of the transverse ligament
– Odontoid fracture
– Atlanto-axial hypermobility

• Clinical Note:
– Explain to the patient that in order to perform this procedure correctly it is necessary to contact on the sides of the traverse processes which may be a little
painful
– This test can be performed from C1-C7

Question 19

Lateral Flexion Alar Ligament Stress Test

Answer 19

• Purpose:
– To test for instability at the atlanto-axial joint and to test the integrity of the alar ligament
– Performed if a practitioner suspects either cervical instability, odontoid fracture or odontoid dysplasia

• Procedure:
– Patient is supine with the head in neutral
– Practitioner is positioned at the head of the table facing caudally
– The practitioner uses a firm pincer grip with the secondary hand to stabilize C2
– The practitioner’s primary contact is placed on the top of the patient’s head
– The practitioner then attempts to laterally flex the patient’s head (occiput and C1) while stabilizing the C2 vertebrae

• Positive:
– Excessive movement or a reproduction of instability type symptoms indicates a positive test

• Indication of Positive:
– Cervical instability
– Alar ligament disruption
– Dens fracture
– Odontoid dysplasia

Question 20

Sagittal Stress Test

Answer 20

• Purpose:
– To test the integrity of the supporting structures, ligaments and joint capsules, of the cervical spine when the practitioner suspects either
cervical instability, cervical myelopathy or cervical spondylolisthesis
– The test is designed to move an unstable superior segment relative to an stable inferior segment

• Procedure:
– Patient is supine with head resting in the neutral position on a pillow
– Practitioner stands at the head of the table facing caudally
– The practitioner places an index contact bilaterally on the articular pillar of the segment to be tested
– The practitioner then slowly and carefully applies and anteriorly directed force through both contacts which causes an anterior shear or the
segment above on the segment below
– The practitioner should feel a tissue stretch followed by an abrupt stop in a normal cervical spine

• Positive:
– The test is considered positive if there excessive movement between the two vertebrae and/or symptoms are produced that are indicative of
cervical instability e.g. nystagmus

• Indication of Positive:
– Cervical instability
– Cervical myelopathy
– Cervical spondylolisthesis

• Clinical Note:
– This test can be performed from C1-C7
– Excessive force is not required to provoke symptoms