Clinical examination of the cervical spine

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Clinical examination of the cervical spine

Chapter contents

History

History taking in patients with problems in the neck, trapezius or shoulder region should be as detailed as possible and great care should be taken to define every symptom precisely. Especially when a controversial treatment, such as manipulation, is to be considered, it is vital that nothing has been forgotten that could constitute a contraindication.

Age may be important, because some disorders do not occur before or do typically occur at a certain period of life. For instance, torticollis in a baby is probably congenital. The same clinical picture in a 5-year-old child is more likely to be caused by contracture of the sternocleidomastoid muscle after, for example, glandular swelling or abscess formation. During and after adolescence it is more probably the result of a disc protrusion.

The same argument applies to root pain. Under the age of 35 it is scarcely ever caused by a disc except after trauma, in which it may occur from 30 years upward. Radicular pain in a young person is usually the result of a neurofibroma, while in the elderly it is commonly the result of compression by an osteophyte or invasion from secondary deposits in the spine, rather than a disc protrusion.

Early morning headache is typical in the elderly and is often the result of contracture in upper cervical ligaments. Headache from temporal arteritis also occurs late in life.

Whenever symptoms appear in a patient of the ‘wrong’ age group, further investigation should be requested in order to exclude more serious disorders.

The patient’s work, hobbies or preferred sport may give an idea of postures, movements or strains that may be causative or provocative.

Cervical spine lesions may lead to the following symptoms: pain, paraesthesia, vertigo or symptoms related to the vertebral artery, and incoordination and spasticity.

Pain

Pain is the most common symptom. Its localization may give an idea of the position of the lesion. Details about its evolution and behaviour help to determine the nature of the disorder.

If this is the patient’s first presentation with a problem in the cervical spine, questions are asked about the current complaints (see below). In a recurrence, a detailed and chronological reconstruction of the past history should be made.

The patient may present with acute, subacute, chronic or recurrent pain. Acute and subacute episodes are characterized by difficulty in moving the head without exacerbation of the pain. Except in young people with torticollis or after injury, acute lesions are not as common as more chronic complaints. Chronic lesions come and go for months or years without any tendency towards spontaneous recovery. Most problems in the cervical spine, however, are recurrent, which implies that the course is characterized by definite attacks of short duration. The examiner should then find out whether the patient is totally free from pain in between the attacks, for how long the symptoms last and whether the pain is always felt on the same side.

Onset

Next, the following questions are asked about the onset of the pain.

• Where did it start?

Pain of cervical origin very often starts at the cervical spine but frequently spreads or shifts to another region quite quickly, so that the cervical source may pass unnoticed.

Interscapular onset of pain is typical of a lower cervical disc lesion that compresses the dura. In contrast, it is very unusual for pain to begin in the arm. Should this occur, the possibility of a neurofibroma, compressing a nerve root, has to be considered in young people. In the elderly, an osteophyte or even a malignant process is more probable.

• When did it start?

Pain of cervical origin may occur in discrete attacks, especially when a disc lesion is responsible. It is important to encourage the patient to recall the first episode and to ask for a chronological account. In discal root pain, a normal period of spontaneous relief should be recognizable.

• How did it start?

The origin may be spontaneous, either acute or chronic, but may also be the consequence of injury. In the latter case, more details should be sought about the type of injury (e.g. a fall or whiplash). It is then necessary to seek further investigations to exclude fractures or luxations.

Evolution

More detailed information is then obtained about the development of the complaints in relation to localization, duration and intensity.

The localization may change, either because the pain shifts to another place or because it spreads. Pain that spreads and gradually expands over a larger area is typical of an expanding lesion and should always arouse suspicion. On the other hand, pain that shifts from the scapular area to the upper limb is highly indicative of a shifting lesion (or disc lesion). The fragment of disc substance first displaces posterocentrally and compresses the dura mater, which results in central, bilateral or unilateral scapular pain; it then moves laterally and impinges on the dural investment of a nerve root. The scapular pain disappears and is replaced by a radicular pain down the upper limb. In order to interpret the distribution and evolution of the pain correctly, the mechanism of dural pain should be understood. Because the anterior aspect of the dura mater is innervated by a dense network of branches of sinuvertebral nerves originating at several levels, extrinsic compression and subsequent irritation of the dura may give rise to pain felt in several dermatomes. This phenomenon is called ‘multisegmental pain’ and is described in Chapter 1. Because the dural investment of the nerve root is only innervated from its own recurrent nerve, irritation here results in pain strictly felt in the corresponding dermatome, thus strict segmental pain.

Also the duration of the pain is informative. Most benign cervical disorders are intermittent. If pain progressively worsens, then the presence of an irreversible lesion such as metastases must be borne in mind, particularly in the elderly. Root pain as the result of a disc protrusion lasts for a variable but limited period and then ceases as spontaneous remission takes place (see Ch. 8). Hence, root pain that lasts longer than 6 months should arouse suspicion of another, possibly progressive cause.

As cervical disorders are frequently episodic, the patient should be asked to describe previous episodes in as detailed a way as possible. Often a recurrence can be ascribed to instability of the affected structure. Once an intervertebral disc fragment has displaced, it may do so again, because the cartilage remains unhealed. Further displacement may be in a different direction and it is thus possible for the pain to be variable and not on the same side. Therefore, pain that changes sides from one attack to another very strongly suggests the presence of a disc lesion. Also the duration of the previous bouts may have some prognostic value, as it can give an idea of how long the current symptoms may be expected to last. The patient should be questioned about previous successful treatment because, if the present episode is a recurrence, it is very likely that it will respond to the same treatment. Has the patient been totally free of pain between attacks? Freedom from symptoms indicates that the patient went into complete remission and this result could be obtained again. Failure of complete remission requires a search for the reason: possibly previous treatments have not been completed. Alternatively, age may be a factor in that some conditions have a tendency to become more persistent with advancing years.

Current pain

After the patient has given a thorough description of the onset and evolution, the moment has come to ask for details about the pain experienced at present: its localization, the influence of posture and movements, and how it is affected by cough.

Localization

The localization may vary: headache, pain in the face, neck, scapular area, pectoral area or down the upper limb are all possible.

Headache

If headache is referred from the cervical spine, the patient will usually mention an association between the symptoms and certain postures and/or movements. The pain may be bilateral or unilateral, and can be either segmental or multisegmental. Segmental pain originates from the upper cervical segments (C1 and C2). Disorders at the joints between occiput and atlas, or between atlas and axis, may give rise to pain felt at the centre of the upper neck and spreading to the occiput, the vertex (C1) and/or the temples and forehead. As the pain is not always felt in the neck, localization to the head only can divert attention from the cervical spine. Multisegmental headache results from irritation of the dura at any cervical level. The pain often radiates from the mid-neck up to the temple, the forehead and behind one or both eyes, but rarely to the bridge of the nose. If, apart from this distribution, there is also downward reference of pain to the scapular area, the dural origin is clear.

Some types of headache can be recognized by paying attention to the history.

Early morning headache in elderly patients is a typical example. The patient wakes every morning with headache and/or occipital pain. After some hours the symptoms ease and have completely disappeared by midday. Symptoms do not recur until the next morning. The sequence is repeated daily without fail and, as the years go by, pain tends to last longer into the day. This type of headache responds spectacularly to manipulative treatment (see p. 201).

Migraine is another typical history. Symptoms usually start during adolescence and may persist for many years. The vascular origin of this disorder has been widely accepted and the following features are well known: an ‘aura’ which frequently includes visual hallucinations, photophobia, nausea, vomiting and other bizarre experiences, often precedes an attack; pain is severe, unilateral and well localized, though may change sides for each attack and is usually described as throbbing or bursting.

Cluster headache is very severe, is more common in men, and occurs on a regular basis. The pain is always felt on the same side, mainly above the eye, and may be accompanied by a partial Horner’s syndrome.

Pain in the face

This may either have a local origin or be referred. Local causes include sinusitis, dental problems, temporomandibular lesions, lesions of the facial bones, neuralgia and arteritis. Referred pain may be a segmental C2 pain or a multisegmental dural pain. The latter should always be borne in mind because, if a local cause is not found, treatment to the cervical spine may be curative.

Pain in the neck

Local pain in the upper neck is usually the outcome of a local lesion: one of the ligaments of the upper cervical segments or one of the upper facet joints. Rarely, the muscular insertions on the occiput are responsible. However, upper cervical pain may also have a multisegmental dural origin. Mid- or lower cervical pain is most often caused by a mid- or lower cervical discodural conflict, especially if the pain is felt centrally or bilaterally. Unilateral and lower cervical pain that is well localized often originates from a facet joint.

Pain in the trapezioscapular area

This is the most common pain reference for cervical lesions. The majority of pain in the trapezius or scapular area has a cervical origin, and must usually be considered as the multisegmental reference of a discodural conflict (Fig. 6.1). The pain may be unilateral, bilateral or interscapular. Depending on the patient’s age, it may be intermittent or constant; the older the patient, the more likely the pain will last over longer periods. Upper scapular pain or pain in the trapezius area may also have a C4 segmental origin. Other sources of trapezioscapular pain are a thoracic lesion, a local scapular lesion or a shoulder girdle problem.

Fig 6.1 Multisegmental scapular pain.

Pain in the pectoral area

Another rare manifestation of multisegmental dural reference is pain in the pectoral area. Because the pain is usually felt deeply and there is a strong popular association between pectoral (retrosternal) pain and cardiac disease, the pectoral discomfort can be initially misjudged as angina.

Pain down the upper limb

Dural pain never presents down the arms. Therefore, upper limb pain is always segmental in origin and is referred within its dermatomal borders. If the lesion is discoradicular, the normal time sequence of the symptoms must be appreciated: neck pain first, followed by unilateral scapular pain and then finally segmental pain. It is therefore important to ask whether or not the arm pain has been preceded by neck and/or scapular pain. If not, a non-discogenic origin of the pain is to be considered.

Exacerbation of pain by cough

This is uncommon in cervical lesions but may occur in a disc prolapse, when the pain is usually felt in the scapular region. Pain in the arm on coughing is one of the symptoms that draws attention to a neuroma (see Ch. 9).

Paraesthesia

Paraesthesia is a very common symptom which may originate from any nerve fibre in the cervicoscapular area or in the arm (Table 6.1). Paraesthesia is often experienced as a ‘pins and needles’ sensation. In other instances, the patient may describe the feeling as ‘numbness’. The moment the patient mentions the presence of such symptoms, the examiner should carefully determine how proximal they are because, as has been explained in Chapter 2, the point of compression always lies proximal to that of the paraesthesia. The lesion may lie at any one of a number of different levels but the vaguer the distribution of the pins and needles, the more proximally the lesion needs to be sought.

Table 6.1

Level	Cause/site of cause	Symptoms
Cervical	Myelopathy:	No pain
	Intrinsic	Multisegmental paraesthesia on neck flexion
	Extrinsic	Lhermitte’s sign
	Nerve root	Pain
		Segmental paraesthesia
		Compression phenomenon
Shoulder girdle	Brachial plexus	Vague paraesthesia
		Release phenomenon
Arm	Nerve trunk	Defined area of paraesthesia
		Specific tests
	Nerve ending	Cutaneous analgesia
		(Paraesthesia)

At the cervical spine

Spinal cord

External pressure on the spinal cord is characterized by painless paraesthesia in the upper and/or lower limbs felt distally and in a multisegmental distribution. The paraesthesia comes and goes in a wholly irregular way, most marked by day. Neck flexion usually increases the symptoms, or Lhermitte’s sign may be present: an electric shock sensation in the trunk and/or upper limbs following forceful passive flexion of the cervical spine. Differential diagnosis has to be made from pernicious anaemia, diabetes and peripheral neuritis.

Nerve root

When a nerve root is affected, paraesthesia appears distally in the corresponding dermatome. The pins and needles come and go in an erratic fashion and do not last for more than an hour at a time. Pain resulting from external pressure on the dural sleeve may precede or accompany the paraesthesia.

At the shoulder girdle

Lesions of the brachial plexus at the thoracic outlet give rise to paraesthesia in one or both hands and affect all digits. When there is external pressure and because of the release phenomenon, pins and needles are only felt after the compression has ceased (see Ch. 2). They are often nocturnal, waking the patient after some hours’ sleep.

In the arm

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