CERVICAL SPINE

Published on 16/03/2015 by admin

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CHAPTER 2

CERVICAL SPINE

image

Précis of the Cervical Spine Assessment*

History (sitting)

Observation (sitting or standing)

Examination

Active movements

Passive movements

Resisted isometric movements (as in active movements but in the resting position of the joint)

Scanning examination

Special tests

Reflexes and cutaneous distribution

Examination, supine

Passive movements

Special tests

Note 1: The following tests should be performed if the examiner anticipates treating the patient by mobilization or manipulation. In this case, they are called clearing tests for treatment:

Note 2: If any of the previous tests are positive, mobilization or manipulation should be performed only with extreme care, and the level exhibiting the positive signs should be stabilized during the treatment.

Joint play movements

Palpation

Examination, prone

Diagnostic imaging


*The précis is shown in an order that limits the amount of moving the patient must do but ensures that all necessary structures are tested. After any examination, the patient should be warned that symptoms may be exacerbated as a result of the assessment.

(end feel)

Movements involve the whole cervical spine (general techniques)

§Movements involve individual segments of the cervical spine (specific techniques)

SELECTED MOVEMENTS

ACTIVE MOVEMENTS19 image

GENERAL INFORMATION

While the patient performs the active movements, the examiner looks for limitation of movement and possible reasons for pain, spasm, stiffness, or blocking, and also the pattern of movement. The movements should be done in a particular order so that the most painful movements are done last; this ensures that no residual pain is carried over from the previous movement. With a very acute condition of the cervical spine, only some movements—those that give the most information—are done to prevent undue exacerbation of symptoms. As the patient reaches the full range of active movement, passive overpressure may be applied very carefully, but only if the movement appears to be full and not too painful (see discussion of passive movement later in the chapter). The overpressure helps the examiner to determine the end feel of the movement and to differentiate between physiological (active) end range and anatomical (passive) end range. The examiner must be careful when applying overpressure during rotation or any combination of rotation, side flexion, and extension. In these positions, the vertebral artery often is compressed, which can lead to a reduction in the blood supply to the brain; also, the movements can cause narrowing of the spinal and intervertebral canals.

Flexion—Upper Cervical Spine

CLINICAL NOTES/CAUTIONS

• As the patient flexes (nods) the head, the examiner can palpate the relative movement between the mastoid and transverse process of C1 on each side, comparing the two sides for hypomobility or hypermobility between C0 and C1. The examiner also can palpate the posterior arch of C1 and the lamina of C2 during the nodding movement to compare the relative movement.

• As the patient forward-flexes, the examiner should look for a posterior bulging of the spinous process of the axis (C2). This bulging may result from forward subluxation of the atlas, which allows the spinous process of the axis to become more prominent. If this sign appears, the examiner should exercise extreme caution during the remainder of the cervical assessment. To verify the subluxation, the Sharp-Purser test may be performed (see that test under Special Tests for Cervical Instability); however, it must be done with extreme care.

• The mastoid process moves away from the C1 transverse process on flexion and extension.

Flexion—Lower Cervical Spine

Side Flexion/Side Bend—Lower Cervical Spine

Rotation—Lower Cervical Spine

CLINICAL NOTES

PASSIVE MOVEMENTS4,5,1013 image

Flexion—Upper Cervical Spine

Side Flexion/Side Bend—Upper Cervical Spine

TEST PROCEDURE

The examiner palpates the transverse processes of C1. First the examiner must find the mastoid process on each side and then move the fingers inferiorly and anteriorly until a hard bump (i.e., the transverse process of C1) is palpated on each side (usually below the earlobe and just behind the jaw). The examiner palpates between the occiput and C1 to feel the relative amount of movement on each side. After C0-C1 motion has been tested, the fingers are moved caudally to the transverse process of C2 to test C1-C2 motion. To test side bend between the occiput (C0) and C1, the examiner holds the patient’s head in position and then side-bends the head in the desired direction. Care must be taken to side-bend only at the upper cervical region. A common mistake is to side-bend the entire cervical region. The examiner side-bends the patient’s head until movement is felt at the C1 transverse process. This procedure is repeated for testing of C1-C2 motion.

Rotation—Upper Cervical Spine

TEST PROCEDURE

The examiner palpates the transverse processes of C1. First the examiner must find the mastoid process on each side and then move the fingers inferiorly and anteriorly until a hard bump (i.e., the transverse process of C1) is palpated on each side (usually below the earlobe and just behind the jaw). The examiner palpates between the occiput (C0) and C1 to feel the relative amount of movement on each side. After C0-C1 motion has been tested, the fingers are moved caudally to the transverse process of C2 to test C1-C2 motion. To test rotation between C0 and C1, the examiner holds the patient’s head in position and then rotates the head while palpating the transverse processes. Normally, the transverse process on the side to which the head is rotated seems to disappear (bottom one), whereas the transverse process on the other side (top one) seems to be accentuated. This procedure is repeated for testing of C1-C2 motion.

Flexion—Lower Cervical Spine

Extension—Lower Cervical Spine

Side Flexion/Side Bend—Lower Cervical Spine

Rotation—Lower Cervical Spine

RESISTED ISOMETRIC MOVEMENTS image

TEST PROCEDURE (SITTING)

Flexion. The examiner places the palm of the hand on the patient’s forehead and the other hand on the patient’s upper back for stabilization (A).

Extension. The examiner places the palm of the hand on the patient’s occipital region and the other hand on the sternum for stabilization (B).

Side flexion. The examiner places the palm of the hand on the patient’s temporal region and the other hand on the contralateral shoulder for stabilization (C).

Rotation. The examiner places both hands on the patient’s temples (D).

The examiner tests resisted isometric strength by applying force to the head through the palm of the hand. The patient should be instructed, “Don’t let me move you,” rather than, “Contract the muscle as hard as possible.” In this way, the examiner makes sure the movement is as isometric as possible and that minimal movement occurs while at the same time gauging the strength of the movement.

PERIPHERAL JOINT SCANNING EXAMINATION

PERIPHERAL JOINT SCAN14 image

Temporomandibular Joints (TMJs)

Shoulder Girdle

MYOTOME TESTING image

TEST PROCEDURE

Myotomes are tested by resisted isometric contractions with the joint at or near the resting position. As with the resisted isometric movements previously mentioned, the examiner should position the joint being tested and instruct the patient, “Don’t let me move you,” so that an isometric contraction is obtained. The contraction should be held at least 5 seconds, because myotome weakness commonly takes time to develop.

C1-C2 myotome (neck flexion). The patient’s head should be slightly flexed (a nod). The examiner applies pressure to the patient’s forehead while stabilizing the patient’s trunk with a hand between the scapulae (A). The examiner should make sure the patient’s neck does not extend when pressure is applied to the forehead.

C3 myotome and cranial nerve XI (neck side flexion). The examiner places one hand above the patient’s ear and applies a side-flexion force to the head while stabilizing the patient’s trunk with the other hand on the opposite shoulder (B). Both right and left side flexion must be tested.

C4 myotome and cranial nerve XI (shoulder elevation). The examiner asks the patient to elevate the shoulders to about half of full elevation. The examiner applies a downward force on both of the patient’s shoulders while the patient attempts to hold them in position (C). The examiner should make sure the patient is not “bracing” the arms against the thighs if testing is done with the patient sitting.

C5 myotome (shoulder abduction). The examiner asks the patient to elevate the arms to about 75° to 80° in the scapular plane with the elbows flexed to 90° and the forearms pronated or in neutral. The examiner applies a downward force on the humeral shaft while the patient attempts to hold the arms in position (D). To prevent rotation, the examiner places his or her forearms over the patient’s forearms while applying pressure to the humerus.

C6 and C7 (elbow flexion and extension). The examiner asks the patient to put the arms by the sides with the elbows flexed to 90° and the forearms in neutral. The examiner applies a downward isometric force to the forearms to test the elbow flexors (C6 myotome) (E) and an upward isometric force to test the elbow extensors (C7 myotome) (F). For testing of wrist movements (extension, flexion, and ulnar deviation), the patient has the arms by the side, the elbows at 90°, the forearms pronated, and the wrists, hands, and fingers in neutral. The examiner applies a downward force to the hands to test wrist extension (C6 myotome) (G) and an upward force to test wrist flexion (C7 myotome) (H).

C8 myotome (thumb extension). The patient extends the thumb just short of full ROM. The examiner applies an isometric force to bring the thumb into flexion (I). A lateral force (radial deviation) to test ulnar deviation may also be performed to test the C8 myotome. The clinician stabilizes the patient’s forearm with one hand and applies a radial deviation force to the side of the hand.

T1 myotome (finger abduction/adduction). To test hand intrinsics (T1 myotome), the examiner may have the patient squeeze a piece of paper between the fingers (usually the fourth and fifth fingers) while the examiner tries to pull it away. Alternatively, the patient may squeeze the examiner’s fingers, or the patient may abduct the fingers slightly with the examiner isometrically adducting the fingers (J).