Cervical spine

1
Chapter 23

• Cervical spine

2
Overview

• The cervical spine consists of 37 joints, which
  allow for more motion than any other region of
  the spine
• However, this degree of mobility comes with a
  cost. With stability being sacrificed for
  mobility, the cervical spine is rendered more
  vulnerable to both direct and indirect trauma

3
Anatomy

• Cervical curve
• The cervical spine forms a lordotic curve that
  develops secondary to the response of an upright
  posture, which initially occurs when the child
  begins to lift the head at 3-4 months.
• The presence of the curve allows the head and
  eyes to remain oriented forward, and provides a
  shock-absorbing mechanism to counteract the axial
  compressive force produced by the weight of the
  head

4
Anatomy

• Cervicothoracic Junction
• The cervicothoracic junction (CTJ) comprises the
  C 7-T 1 segment, although functionally it
  includes the seventh cervical vertebra, the first
  two thoracic vertebrae, the first and second
  ribs, and the manubrium
• In addition, the CTJ forms the thoracic outlet,
  through which the neurovascular structures of the
  upper extremities pass

5
Anatomy

• Vertebra
• Compared with the rest of the spine, the
  vertebral bodies of the cervical spine are small
  and consist predominantly of trabecular
  (cancellous) bone
• The third to sixth cervical vertebrae can be
  considered typical, while the seventh is atypical

6
Anatomy

• Vertebra
• Each pair of vertebrae in this region is
  connected by a number of articulations a pair of
  zygapophyseal joints, the uncovertebral joints,
  and the IVD
• The structure of the cervical vertebrae, combined
  with the orientation of the zygapophyseal facets,
  provides very little bony stability, and the lax
  soft tissue restraints permit large excursions of
  motion

7
Anatomy

• Zygapophyseal joints
• There are 14 zygapophyseal joints from the
  occiput to the first thoracic vertebra. These
  joints are typical synovial joints and are
  covered with hyaline cartilage
• The average horizontal angle of the joint planes
  is approximately 45, with the upper cervical
  levels closer to 35º, and the lower levels at
  approximately 65

8
Anatomy

• Uncovertebral Joints
• Extend from C 3-T 1 there is usually a total of
  ten saddle-shaped, diarthrodial articulations
• Formed between the uncinate process found on the
  lateral aspect of the superior surface of the
  inferior vertebra, and the beveled
  inferior-lateral aspect of the superior vertebra

9
Anatomy

• Uncovertebral Joints
• Penning and Wilmink highlighted a possible
  correlation between uncovertebral joint
  configuration and the coupled cervical segmental
  motion of side bending and axial rotation
• A more recent study of the C 5-6 segment level by
  Clausen et al. found that both the zygapophyseal
  joints and Luschka joints are the major
  contributors to coupled motion in the lower
  cervical spine, and that the uncinate processes
  effectively reduce motion coupling and primary
  cervical motion

10
Anatomy

• Intervertebral foramina
• Serve as the principal routes of entry and exit
  for the neurovascular systems to and from the
  vertebral canal
• This region is vulnerable to narrowing with
  certain motions, or with osteophyte growth
• As the dimensions of the intervertebral foramen
  decrease with full extension and ipsilateral side
  bending of the cervical spine, uncovertebral
  osteophytes may compress the nerve root and
  cervical cord posteriorly

11
Anatomy

• Ligaments
• Both the function and location of the ligaments
  in this region are similar to that of the rest of
  the spine
• Anterior longitudinal. This ligament is narrower
  in the upper cervical spine but is wider in the
  lower cervical spine than it is in the thoracic
  region
• Posterior longitudinal. This ligament is broader
  and considerably thicker in the cervical region
  than in the thoracic and lumbar regions

12
Anatomy

• Muscles
• Trapezius
• Most superficial back muscle
• Traditionally divided into middle, upper, and
  lower parts according to anatomy and function
• The innervation for the trapezius comes from the
  accessory nerve (CN XI) and fibers from the
  ventral rami of the third and fourth cervical
  spinal nerves

13
Anatomy

• Muscles
• Sternocleidomastoid (SCM)
• Largest muscle in the anterior neck
• Attached inferiorly by two heads, arising from
  the posterior aspect of the medial third of the
  clavicle and the manubrium of the sternum. From
  here it passes superiorly and posteriorly to
  attach on the mastoid process of the temporal
  bone
• Motor supply is from the accessory nerve (CN IX),
  while the sensory innervation is supplied from
  the ventral rami of C 2 and C 3

14
Anatomy

• Muscles
• Levator scapulae
• The levator is the major stabilizer and elevator
  of the superior angle of the scapula
• With the scapula stabilized, the levator produces
  rotation and side bending of the neck to the same
  side while acting bilaterally, cervical
  extension is produced

15
Anatomy

• Muscles
• Rhomboids
• Although the rhomboid minor, with its attachment
  to the spinous processes of C 7 and T 1, has a
  slight association with the cervical spine, the
  rhomboid major, arising from the spinous
  processes of T 1 through T 5, is inactive during
  isolated head and neck movements

16
Anatomy

• Muscles
• Scalenes
• The scalenes extend obliquely like ladders
  (scala means ladder in Latin) and share a
  critical relationship with the subclavian artery
• Adaptive shortening of these muscles will affect
  the mobility of the upper cervical spine and, due
  to their distal attachments to the 1st and 2nd
  ribs they can, if in spasm, elevate the ribs and
  be implicated in the thoracic outlet syndrome

17
Anatomy

• Neurology
• The cervical spine is the only region that has
  more nerve roots than vertebral levels
• In general, structures supplied by the upper
  three cervical nerves can cause neck and head
  pain, whereas the mid to lower cervical nerves
  can refer symptoms to the shoulder, anterior
  chest, upper limb, and scapular area

18
Biomechanics

• The only significant arthrokinematic available to
  the zygapophyseal joint is an inferior, medial
  and posterior glide of the inferior articular
  process of the superior facet during extension,
  and a superior, lateral and anterior glide during
  flexion
• Segmental side bending is, therefore, extension
  of the ipsilateral joint and flexion of the
  contralateral joint
• Rotation, coupled with ipsilateral side bending,
  involves extension of the ipsilateral joint and
  flexion of the contralateral

19
Examination

• The examination of the acute and recently
  traumatized neck is necessarily different from
  the routine examination of a more chronic and
  less irritable condition, because of the
  potential for the examination itself to be
  harmful

20
Examination

• Where possible, the patient should first be
  examined for central and peripheral neurological
  deficit, neurovascular compromise and serious
  skeletal injury such as fractures or
  craniovertebral ligamentous instability
• The examination must be graduated and progressive
  so that the testing can be discontinued at the
  first signs of serious pathology

21
Examination

• Clinical signs and symptoms of serious pathology
  include
• Unexplained weight loss
• Night pain
• Involvement of more than 1 nerve root
• Expanding pain
• Weak and painful resisted testing
• 4 findings and their interpretations
• Spasm with PROM
• T1 palsy

22
Examination

• History
• The history often gives the clinician clues as to
  the source of the patients symptoms, the nature
  and location of the involved structure, the
  severity of the condition, and the activities or
  positions that appear to aggravate or improve the
  patients condition

23
Examination

• Systems Review
• Symptoms that show no predictable response to
  mechanical stimuli are unlikely to be mechanical
  in origin, and their presence should alert the
  clinician to the possibility of a more sinister
  disorder or one of central initiation, autonomic,
  or affective nature
• The systems review must include questions that
  will elicit any symptoms that might suggest a
  central nervous system condition, or a vascular
  compromise to the brain

24
Examination
Upper Quarter Scan

• AROM, passive overpressure, resistance
• C 1-4
• C 5
• C 6
• C 7
• C 8
• T 1
• DTR
• Sensation

25
Examination

• Tests and Measures
• Observation
• A major contributor to cervicogenic pain is a
  lack of postural control due to poor
  neuromuscular function
• Static observation of general posture, as well as
  the relationship of the neck on the trunk, and
  the head on the neck, is observed while the
  patient is standing and sitting, both in the
  waiting area, and in the examination room

26
Examination

• AROM
• The clinical examination of the mobility of the
  cervical spine should consist of a comparison
  between active and passive ranges and coupled
  movements of the cervical spine
• Active motion induced by the contraction of the
  muscles determines the so-called physiologic ROM
• Passively performed movement causes stretching of
  non-contractile elements, such as ligaments, and
  determines the anatomic ROM

27
Examination

• Key Muscle Testing
• During the resisted tests, the clinician looks
  for relative strength and fatigability

28
Examination
Specific key muscles for the various levels

• C 2
• C 3
• C 4
• C 5
• C 6
• C 7
• C 8-T 1

29
Examination

• Combined motion testing
• Using a biomechanical model
• A restriction of cervical extension, side bending
  and rotation to the same side as the pain is
  termed a closing restriction. This restriction
  is the most common pattern producing distal
  symptoms. However, a limitation in cervical
  flexion accompanied by the production of distal
  symptoms can also occur
• A restriction of cervical flexion, side bending
  and rotation to the opposite side of the pain is
  termed an opening restriction

30
Examination
Neurological examination

• MOTOR LOSS
• Spinal nerve root
• Peripheral nerve
• Long thoracic
• Thoracodorsal
• Subscapular
• Suprascapular
• Dorsal scapular
• Medial pectoral
• Lateral pectoral
• Axillary
• Musculocutaneous
• Radial
• Median
• Ulnar

31
Examination
Neurological examination

• SENSORY LOSS
• Spinal nerve root
• Peripheral nerve
• Musculocutaneous
• Axillary
• Radial
• Median
• Ulnar

32
Examination

• Palpation
• Palpation is performed to
• Check for any vasomotor changes such as an
  increase in skin temperature
• Localize specific sites of swelling
• Identify specific anatomical structures and their
  relationship to one another
• Identify sites of point tenderness
• Identify soft tissue texture changes or
  myofascial restriction
• Locate changes in muscle tone resulting from,
  trigger points, muscle spasm, hypertonicity, or
  hypotonicity

33
Examination

• Stability (Stress) testing
• Transverse
• Anterior - posterior
• Torsion
• Vertical
• Lateral shear

34
Examination
Special Tests

• Foraminal compression
• Axial distraction
• Upper limb neural tension
• Median
• Ulnar
• Radial

35
Examination
Special Tests

• Thoracic Outlet Syndrome
• Vascular
• Neurological
• Traction

36
Intervention Strategies

• Physical therapy interventions that have included
  postural re-education, neck-specific
  strengthening and stretching exercises, and
  ergonomic changes at work, have been shown to be
  beneficial in reducing neck pain and improving
  mobility

37
Intervention Strategies

• Acute Phase
• Goals
• To encourage patient involvement
• To provide mechanoreceptor stimulation
• To control pain and inflammation
• To promote healing
• To maintain the newly attained ranges
• To provide neuromuscular feedback

38
Intervention Strategies

• Functional Phase
• Goals
• Correction of imbalances of strength and
  flexibility
• Incorporate neuromuscular re-education
• Strengthening of entire kinetic chain
• Postural correction and retraining