CHAPTER 48 Examination of the Cervical Spine
SCOPE AND LIMITATIONS
For example, cervical spinal range of motion is perhaps the most commonly performed assessment, common to most if not all practitioners, in the assessment of the patient presenting with neck pain. Notwithstanding the popularity of this examination component, there is a wide range of intra-subject variability depending upon the time of day it is measured. In addition, within a given individual, motion in a particular plane differs according to where the starting point of the motion is measured. Accordingly, establishing normal ranges for spinal motion is challenging.1,2
This has led to the development of various devices and technologies that can measure spinal range of motion more precisely.3–7 While certain devices have shown improved reliability as compared to manual physical examination techniques, the use of such devices is not commonplace in clinical practice, leaving the practitioner to rely upon manual techniques to guide clinical decision-making.
Compounding these reliability issues is the notion that impaired spinal range of motion correlates with impaired spinal function. In spite of evidence demonstrating a lack of correlation between loss of range of spinal motion and spinal dysfunction,8,9 the use of range of motion as a diagnostic tool remains well engrained in medical culture. Accordingly, range of motion models are regularly used as the basis upon which spinal impairment is rated.
Even more problematic is the attempt to establish whether a particular spinal motion segment, within the multiarticulated spine, has an abnormally restricted or lax range of motion. Despite numerous descriptions of techniques for the palpation of spinal structures, the inter-rater reliability and validity for motion palpation are both lacking in literature support.10–13
The quest for sources of anatomic pain generators has led examiners to teach provocative maneuvers that are designed to provoke local or referred pain.14 As a result, many syndromic diagnoses have included reproduction of a patient’s habitual pain as an essential diagnostic element. Nevertheless, the combination of the subjectivity of the pain response to palpation and the inherent biases of both examiner and examinee, have limited the predictive value of this aspect of the examination.15,16
WHY EXAMINE THE SPINE AT ALL?
Finally, non-specific spinal pain implies pain of non-ominous and non-neurogenic origin. In general, this diagnostic category is consistent with a more benign prognosis than the other two categories. The anatomic origin, if detectable by alternate means, may be discrete or diffuse. The spinal examination is often non-specific and exhibits wide variability among patients in this descriptive category.
PHYSICAL EXAMINATION
Since there is often an overlap in the symptoms associated with upper limb conditions and neck conditions referring to the upper limb, evaluation of the cervical spine should not only include a detailed neurological evaluation of the upper limbs, but also an examination of the upper limb joints that could potentially be the source of the presenting symptoms. Symptoms referable to the shoulder often mirror presenting complaints frequently seen in the cervical spine. The examination of the upper limb joints is outside the scope of the present chapter, so the focus will be on the remaining elements of the cervical spinal evaluation. For further information on the shoulder, please refer to Chapter 49.
Inspection
Poor posture, in particular, poor sitting posture, is considered to be a significant contributor in back and neck pain.17 When sitting in a slumped or unsupported position, there is a loss of lumbar lordosis, which results in a compensatory thoracic kyphosis. Consequently, there is a resultant compensatory forward inclination of the head with flexion of the lower cervical spine and hyperextension of the upper cervical pole to level the head horizontally.
Range of motion
The patient should be given simple commands such as, ‘Touch your chin to your chest,’ ‘Look up to the sky,’ etc. By placing one hand on the head or chest, the examiner can also provide proprioceptive cues to guide the patient through his active motion (Fig. 48.1). In this way the unrehearsed patient is easily able to perform the requested active range of motion with confidence, and without the need for the examiner to demonstrate the required maneuver.