Practical Cervical Flashcards
Upper extremity dermatomes
Palpation of cervical spine
We look for:
- pain
- temperature
- swelling
- deformity
- muscle tone
BUT we also palpate individual segments for RANGE and END FEEL to see if these segments are HYPOmobile or HYPERmobile
Hypermobility Rx = strengthening and stabilization
Hypomobility Rx = mobilization (Maitland)
We palpate the patient’s cervical spine in SITTING and PRONE positions
Sitting position: some muscles are active (palpate them)
- upper trapezius
-sternocleidomastoid
- Levator scapulae
- rhomboids
NOTE: any difference in pain or tone or trigger points
- palpate mastoid process and TMJ
- palpate for C6-C7 interspinous space and flex head to feel increase gapping and extend for approximation ( this is done by cupping head around forehead to flex and extend while other hand palpates spinous processes . Upper cervical = nodd range. Middle/Lower cervical = chin to chest)
Prone position:
TOP to DOWN
- palpate the occipital prominence . Move distally and you’ll feel a gap = C1 (atlas) which does not have a spinous process (or palpate mastoid then go medial and palpate occipital condyles then go medial to find dip = C1)
- after that palpate C2 spinous process under C1 and keep on palpating the spinous processes and spaces till you reach C7
- when palpating C5,C6, and C7 vertebrae, passively bring head into extension (C6 will disappear while c5 and c7 remain palpable)
- palpate transverse processes of C1 and C2
PAIVMS (central, unilateral)
- central PA on spinous process
- unilateral PA on side of vertebra (transverse process) for both sides (one thumb over the other)
-place finger at C7 SP and other on EOP and note: contour, shape, symmetry
- palpate few segments of the thoracic spine using PA
C1 to C2 myotome
Neck flexion
Muscles:
- Rectus lateralis
- Rectus capitis anterior
- longus capitis
- sternocleidomastoid
- etc
C3 or cranial nerve 11 (accessory) myotome
Neck side flexion
Muscles:
- longus capitis
- scalenus medius
- trapezius
- etc
C4 Myotome (CNXI Accessory Nerve)
Shoulder elevation
Muscles:
- trapezius
- diaphragm
- Levator scapulae
- scalene muscles
- etc
C5 myotome
Shoulder abduction
Elbow flexion
Muscles:
- deltoid
- biceps
- rhomboids
- Supraspinatus
- infraspinatus
- etc .
C6 myotome
Wrist extension
Elbow flexion
Muscles:
- extensor carpi radialis longus
- biceps
- brachialis
- serratus anterior
- etc.
C7 myotome
Elbow extensors
Wrist flexors
Muscles:
- triceps
- flexor digitorum superficialis
- etc
C8 Myotome
Thumb extension
Ulnar deviation
Finger flexion
Muscles:
- extensor pollicis longus & brevis
- flexor carpi ulnaris
- etc.
T1 Myotome
Finger abduction
Hand intrinsics
Muscles:
- intrinsic muscles of hand (dorsal interosseous)
- flexor digitorum profundus
- etc
T1 Myotome
Finger abduction
Hand intrinsics
Muscles:
- intrinsic muscles of hand (dorsal interosseous)
- flexor digitorum profundus
- etc
Upper extremity reflexes
C5, C6 = biceps (elbow flexion)
C6, C7 = Brachioradialis (supination)
C7, C8 = triceps (elbow extension)
Hoffmann’s sign
- Patient is sitting / standing
- sit besides patient and support patient hand so that it is completely relaxed with fingers partially flexed
- cradle patient’s hand and grasp proximal to the DIP of the middle finger
- flick the patient’s nail
POSITIVE SIGN: quick adduction of thumb and flexion of index finger (so index or index&thumb are moving into a “pinch” )
INTERPRETATION: upper motor neuron lesion, cervical cord compression
Gross cervical spine ROM
Watch out for “apparent movements” and substitutions/compensations
Ex: for neck flexion patient does forward protrusion THEN flexion
What is the capsular pattern for the cervical spine ?
What is the treatment
- Full flexion
- Limited extension
- Symmetrically limited side flexion and rotation
Rx: mobilization
What are we checking when we test dermatome, myotome, and reflexes?
Nerve integrity
MMT
Opening restriction
Spasm, shortening, tendon inflammation etc
Rx: stretching
Closed restriction
Joint problem, impingement
Rx: mobilization
Clear peripheral joints and upper thoracic spine
Shoulder
Elbow
Wrist
Hand
Upper T/S (cross arms and rotate to each side)
Observation
Posture standing/sitting/walking
Ant/lat/post
Facial responses and expressions
Deformities / scars
Gait etc
Vertebral artery test
Original version:
- Patient supine with head off table and supported by therapist hand.
- extend the neck while asking the patient to keep their eyes open
- rotate to one side . Check for nystagmus. And then the other side and check
POSITIVE: dizziness, lightheadedness, difficulty swallowing or speaking, numbness, visual changes, nystagmus, strabismus
IF POSITIVE = CONTRADICTION TO MANIPULATION, MOBILIZATION, TRACTION, and EXERCISE
MODIFIED VERSION: (do this)
- patient supine
- lift neck into extension ask patient to count backwards from 15 while you check for nystagmus or strabismus
- then do full rotation one side with 30 seconds hold and check again
- repeat on other rotation side
- ask patient to stick out tongue and check for deviations
POSITIVE could indicate missed fracture or compression of the artery
Sharp-Purser
It’s a 2-step test
- Patient is sitting.
- Ask patient to flex CS to midrange actively
- Ask for pain/numbness/tingling or reproduction of symptoms ?
If yes ?
- pinch C2 spinous process to stabilize it while other hand on forehead pushing to the back
(Should be firm end feel)
- ask if symptoms are gone? Or if end feel is soft?
Reproduction of symptoms or soft end feel = POSITIVE SIGN
Interpretation: ligament instability (ruptured/laxity) causing subluxation of the atlas on the axis due to rupture or laxity of TRANSFER LIGAMENT (which checks cervical flexion) , therefore the dens (odontoid) process is compressing
C2 Kick test (Alar ligament test)
This test is to check the integrity of the alar ligament . C2 is the origin of the Alar ligament
NOTE: this ligament is made up of 2 bundles that limit rotation and check sidebending
SO if one bundle is ruptured = excessive Contralateral sidebending
- Patient is supine. You sit at the end where patient’s head is.
- You grasp and stabilize the spinous process of C2 with one hand
- While other hand bends the head and atlas to the side and assess ROM and END FEEL
- If alar lig is intact, little to no sidebending will occur AND end feel is intact = NEGATIVE
- Significant side bending and soft end feel = POSITIVE
( side bend head to R and you feel the SP of C2 Kick over to L)
- Repeat the test with rotation and the ROM and END FEEL is assessed again
- excessive ROM compared to other side or soft end feel = POSITIVE
Shear test (lateral displacement test)
For upper cervical spine instability due to alar ligament laxity or damage
- Patient in supine position . You sit at head of bed. Patient’s head is against your chest to offer some axial compression
- PIP of one hand = block the SP of C2
- PIP of other hand = glide C1
- Then switch hands for other side
(Sliding C1 left is to check the right alar ligament and vice versa)
POSITIVE = lateral translation occurs between segments because it is absent in healthy individuals with firm end feel
Causes :
- fracture in odontoid ruptures ligament
- trauma (whiplash injury)
- laxity (inflammatory conditions)
Tips: superficial hand moves C1, while further hand stabilizes C2
Spurling test
For radiculopathy (pinching of nerves at root) or space-occupying lesion
Designed to provoke patient symptoms by reducing the diameter of the intervertebral foramen
- Patient is sitting
- Patient neck is in extension + lateral bending to affected side
- Apply axial compression GRADUALLY
POSITIVE: shooting pain radiating to Ipsilateral arm
Distraction test
Best to be done after spurling test
Patient is sitting . Cup the mastoid processes and perform upward traction by extending knees
(Alternative method: patient is supine, one hand under the chin while the other is behind the head. Apply cephalic traction)
POSITIVE:
- pain relief = narrowing of foramen (cervical root compression) or irritated facet joints so pain subsides by decreasing pressure to nerve roots or facet impingement
- Pain increase = ligament problem
Valsalva test
In sitting position , Ask patient to hold breath for 15 seconds while bearing down or slouching like they are having a bowel movement
This will increase the intrathecal pressure (intra-abdominal pressure)
POSITIVE: increase in pain (whether in spine or extremities ) indicates a space occupying lesion such as a disk
Shoulder abduction test
patient is asked to place their hands on top of the head by abducting the arm (same arm as symptoms) and hold for 5 to 10 seconds.
POSITIVE: if pain is relieved or reduced due to reduced tension of the affected nerve root
INTERPRETATION: radicular pathology or space -occupying lesion
