The joints of the lower cervical segment consist of the interbody joint anteriorly and the two zygapophyseal joints posteriorly. The interbody joint is made up of the intervertebral joint and the uncovertebral joints. When stacked, the joints can be considered to form three pillars in a triangular formation, the vertebral bodies and uncinate processes forming the anterior column and the two articular pillars formed by the zygapophyseal joints arranged posteriorly (Mercer & Bogduk 1999).

The intervertebral joint is a symphysis formed between the relatively avascular intervertebral disc and the adjacent vertebral bodies. The disc contributes to mobility and, as it ages, assists the uncovertebral joints in providing translatory glide to the movements of flexion and extension (see below).

The uncovertebral joints (joints of Luschka) are formed between the unciform processes and corresponding facets on the vertebral body above (Fig. 8.3), though their existence has been challenged (Mercer & Bogduk 1999). They may be true synovial joints or adventitious fibrous joints which have developed through clefts or fissures in the lateral corners of the annulus fibrosis of the intervertebral disc originally described by Hurbert von Luschka in 1858 (Prescher 1998). These fissures are absent in young children and appear to develop in conjunction with the development of the unciform process.

Once formed, the fissures in the annulus develop a pseudocapsule in which vascularized synovial folds have been seen. Prescher (1998) relates the development of these fissures and the uncovertebral ‘joint’ to the development of the cervical lordosis resulting in a change in configuration and the magnitude of the loads transmitted through the cervical spine. This results in strong shear forces being transmitted through the intervertebral disc, particularly during rotation and side flexion. C3–C5 are the most loaded segments and it is at these levels that the fissures in the disc first appear.

The uncovertebral joints also contribute to mobility by providing a translatory gliding component to flexion and extension as well as stabilizing the spine by limiting the amount of side flexion. The gliding component produces shear which extends horizontal fissuring of the disc medially from the uncovertebral joints. This, together with the degenerative process, may eventually produce a bipartite disc (see below) (Taylor & Twomey 1994, Mercer & Bogduk 1999).

The position of the uncovertebral joints gives bony protection to the nerve root from posterolateral disc displacement. As synovial ‘joints’, degenerative changes can have an effect on the uncovertebral joints. Osteophyte formation on the uncinate process occurs predominantly in the lower cervical segments. Posterior osteophytes can encroach on the intervertebral canal leading to compression of the emerging spinal nerve root, whereas anterior osteophytes may compress the vertebral artery.

The zygapophyseal joints are synovial plane joints with relatively lax fibrous capsules to facilitate movement. The articular facets are angled at approximately 45° to the vertical so that side flexion and rotation of the lower cervical spine occur as a coupled movement. This angle of inclination adds to the component of translatory glide during flexion and extension (Taylor & Twomey 1994).

A number of intra-articular structures have been described, particularly vascular synovial folds, similar to the alar folds of the knee, as well as fat pads and meniscoid structures. All are highly innervated and can be a potential source of pain (Taylor & Twomey 1994, Oliver & Middleditch 2006). As synovial joints, the zygapophyseal joints are prone to degenerative changes and, being placed near the exiting nerve root, osteophyte formation may affect the size of the intervertebral foramen.

Orthopaedic medicine treatment was traditionally based on the discal model, but it should be remembered that any structure that receives a nerve supply can be a potential source of pain. Since the cervical spine is made up of individual motion segments, a lesion of one part of the segment will tend to influence the rest of that segment. Similarly, treatment directed to one part of a segment will affect the segment as a whole.

There are six cervical discs which facilitate and restrain movement as well as transmit load from one vertebral body to the next (Fig. 8.4). Cervical discs are approximately 5 mm thick (Palastanga et al 2006) and the thinnest of all the intervertebral discs. Each forms part of the anterior wall of the intervertebral foramen and is thicker anteriorly, contributing to the cervical lordosis. The intervertebral disc consists of an annulus fibrosus, nucleus pulposus, and transitional superior and inferior vertebral end-plates.

The difference in function between the lumbar and cervical spine and the traditionally accepted view that cervical discs are smaller versions of lumbar discs does not hold true. Mercer & Bogduk (1999) acknowledged this in their investigation of the form of the human adult intervertebral cervical disc and its ligaments. At birth the nucleus consists of no more than 25% of the entire disc and it undergoes rapid degeneration with age so that, by the age of 30, the nucleus is undistinguishable as such.

The structure of the annulus fibrosus, described by Mercer & Bogduk (1999), is different anteriorly and posteriorly (Fig. 8.5). The anterolateral annulus forms a crescent shape when viewed from above, thicker in the median plane and thinner laterally, tapering out to the unciform processes. It forms a dense, anterior interosseous ligament. The fibres arise from the superior surface of the lower vertebra, fanning out in an alar fashion laterally, but in the midline form a tightly interwoven pattern with fibres from opposite sides, not the true laminate structure as seen in the lumbar spine. A distance of 2–3 mm from the surface of the anterior annulus, collagen fibres have been found embedded with proteoglycans and forming a fibrocartilaginous mass which has a pearly appearance and the consistency of soap.

On a deeper plane, the fibrocartilaginous mass becomes more homogeneous and less laminated, forming what the authors interpret as the nucleus of the disc. Clefts, presumably the uncovertebral ‘joints’, are seen to extend into the fibrocartilaginous core laterally at the uncovertebral region, partially into the core in younger patients but totally transecting the posterior two-thirds of the disc in older specimens (bipartite disc). Covering the clefts in the uncovertebral region is thin periosteofascial tissue, the annular fibres being deficient here.

The posterior annulus demonstrates different features to the anterior annulus. It consists of a thin layer of one set of vertically oriented collagen fibres, not more than 1 mm thick, passing between adjacent vertebrae and extending out as far as the unciform process on each side where no oblique posterior annular fibres were found. Deep to this is the fibrocartilaginous core. It would appear that the deep layer of the posterior longitudinal ligament, with short fibres spanning each intervertebral joint, compensates for the lack of annular fibres in the posterior part of the disc, supporting the nucleus posteriorly. Posterolaterally the alar fibres of the posterior longitudinal ligament alone contain the nucleus and these may become torn or stretched by a bulging disc, or nuclear material may herniate under or through them.

The vertebral end-plate offers protection by preventing the disc from bulging into the vertebral body. It acts as a semipermeable membrane which, by diffusion, facilitates the exchange of nutrients between the vertebral body and the disc.

Cyriax (1982) stated that ‘from a clinical point of view nuclear protrusions form only a small minority of cervical disc displacements’. He postulated that a true nuclear disc lesion occurs only in adolescents and young adults, presenting as an acute torticollis. His hypothesis would seem to be substantiated by Taylor & Twomey (1994) who suggested that early degeneration of the cervical nucleus makes nuclear protrusion in the cervical spine unlikely, unless precipitated by severe trauma. A central bar-like protrusion of the annulus was more likely to occur in the cervical spine. This appeared to be refuted by the work of Mercer & Bogduk (1999) described above, given the relatively deficient posterior cervical annulus identified. Perhaps, like lumbar discs, herniated cervical discs may consist of degenerate nuclear material. Posterolateral herniation of the disc could be possible through the weak supporting alar fibres of the posterior longitudinal ligament in the uncovertebral region. Indeed, one specimen from the Mercer & Bogduk study (1999) illustrates a disc bulge and a herniation, both below their respective alar fibres.

The position of the uncovertebral joints and the large vertebral canal in the cervical spine may both also exert a protective influence on disc movement. Degenerate cervical discs may prolapse directly posteriorly, encroaching on the dura through the posterior longitudinal ligament, rather than laterally at the uncovertebral region, to affect the dural nerve root sleeve and underlying nerve root in the intervertebral canal. Alternatively, discal material may be reflected posterolaterally in the vertebral canal by the stronger median part of the posterior longitudinal ligament to cause unilateral pressure on the dura.

The triangular vertebral canal is at its largest in the cervical spine and, even though the cervical cord is enlarged in this region, there may be room for a prolapse to be accommodated. Posterolateral prolapse through the weaker alar portion in the uncovertebral region may encroach on the dural nerve root sleeve and underlying nerve root. However, it would seem that only a very large posterolateral prolapse would be able to compress the nerve root at the same level, unless there is canal stenosis caused by osteophyte formation, an infolding ligamentum flavum or congenital factors.

Since the extent of pain referral is thought to be related to the amount of pressure on the dural nerve root sleeve (Mooney & Robertson 1976), brachial pain is not as commonly associated with cervical disc lesions as sciatica is with lumbar disc lesions. Dural pressure due to a cervical disc tends to produce central or unilateral scapular pain.

It is assumed that cervical discs are innervated in a similar way to lumbar discs, since no studies have refuted this as yet. Bogduk (1994a) acknowledged the paucity of data on cervical discs but claimed that the few studies that had been done had been positive, demonstrating that the cervical discs do have an innervation. In that respect, the data on cervical discs are in accord with those on lumbar discs. At least the outer third and possibly the outer half of the annulus fibrosis receives a nerve supply from branches of a posterior longitudinal plexus, derived from the cervical sinuvertebral nerves, as well as from a similar plexus formed from cervical sympathetic trunks and the vertebral nerves, and from penetrating branches from the vertebral nerve (Bogduk 1994a). Mendel et al (1992) found evidence of nerve fibres and mechanoreceptors in the posterolateral region of the annulus.

The cervical disc may produce either primary disc pain, pain due to the mechanical effect of secondary compression of pain-sensitive structures, or pain associated with chemical or ischaemic effects. The mechanism of pain produced by disc displacement is covered in greater detail in Chapter 13 since much of the investigative work on pain production has been performed in the lumbar region and no studies have been identified that relate to the cervical spine. If findings can be extrapolated to the cervical spine, disc material is thought to undergo a process of degradation which contributes to its herniation. The chemical mediators of inflammation may play a role in the pathophysiology of cervical radiculopathy which renders the nerve root pain-sensitive (Kang et al 1995).

There are eight cervical spinal nerves, each approximately 1 cm long. Each nerve, together with the dorsal root ganglion, occupies a large, funnel-shaped intervertebral foramen (Fig. 8.6). The spinal nerve is composed of one dorsal or posterior nerve root and one anterior or ventral nerve root, the ventral nerve root emerging more caudally from the dura mater (Tanaka et al 2000). The dorsal nerve root carries sensory fibres and the ventral nerve root, motor fibres.

The spinal nerve occupies one-fourth to one-third of the intervertebral foramen diameter and carries with it an investment of the dura mater, the dural nerve root sleeve. The dural nerve root sleeve is sensitive to pressure and produces pain in a segmental distribution. Cervical spinal nerves generally emerge horizontally and therefore the nerve roots are vulnerable to pressure only from the disc at that particular level, producing signs and symptoms in one segment only (Fig. 8.7). Indication of more than one nerve root involvement should be considered suspicious until proved otherwise.

However, Tanaka et al (2000), in a cadaver study, showed that the roots below C5 reached their intervertebral foramen with increasing obliquity making compression of more than one nerve root below this level possible. At the C7–T1 disc, 78% of specimens showed that the C8 nerve roots did not have any contact with the disc at the entrance of the intervertebral foramen, which probably accounts for the low frequency of C8 radiculopathy.

Nerve root compression was found to occur at the en-trance of the intervertebral foramen and was determined to be due to herniated discs and osteophytes in the uncovertebral region anteriorly, and to the superior articular process, ligamentum flavum and periradicular fibrous tissue posteriorly (Tanaka et al 2000). Motor impairment, therefore, is suggestive of anterior compression from a disc prolapse or degenerative changes in the uncovertebral region, whereas sensory change is indicative of compression due to changes in the posterior structures. Of course a large disc prolapse or gross degenerative change, anteriorly or posteriorly, may compress both elements of the nerve root.

After it leaves the intervertebral foramen, the spinal nerve root immediately divides into ventral and dorsal rami. The sinuvertebral nerve is a mixed sensory and sympathetic nerve, receiving origin from the ventral ramus and the grey ramus communicans of the sympathetic system (Fig. 8.8). The nerve returns through the intervertebral foramen and gives off ascending, descending and transverse branches to supply structures at, above and below the segment (Oliver & Middleditch 2006, Palastanga et al 2006, Standring 2009). The structures it supplies include the dura mater, posterior longitudinal ligament and the outer part of the annulus of the intervertebral disc (Bogduk 1994b).

Anatomically the vertebral artery is divided into the following four sections, which include two right-angled bends where it is vulnerable to internal and external factors which tend to compromise blood flow (Fig. 8.9) (Oliver & Middleditch 2006, Standring 2009):

Anatomical anomalies and variations exist and commonly one vertebral artery is narrower than its partner. Clinically it is important to recognize vertebrobasilar signs and symptoms since these contraindicate certain cervical manoeuvres. The artery is elastic, particularly in its first and third sections, which allow it to accommodate to movement. Degenerative changes in the artery itself, in the intervertebral canal, uncovertebral joints and zygapophyseal joints make it vulnerable to blockage as well as possibly distorting its pathway.

The internal carotid artery arises from the bifurcation of the common carotid artery in the anterior cervical spine (Fig. 8.9). It supplies most of the ipsilateral cerebral hemisphere, the eye and accessory organs, the forehead and part of the nose. It ascends to enter the cranial cavity via the carotid canal and turns anteriorly to end by dividing into the anterior and middle cerebral arteries, which anastomose into the circle of Willis.

The internal carotid arteries together provide the most significant proportion of blood to the brain, 80%, compared with 20% passing through the posterior vertebral artery system. Blood flow is known to be influenced by neck movements, particularly extension and less so rotation (Rivett et al 1999, Kerry & Taylor 2006).

An understanding of the anatomy at the cervical spine, together with a detailed history and examination of the patient, will help with the selection of patients suitable for manual treatment and contribute to safe practice. The two areas of danger in this region are the cervical arteries and the spinal cord, and certain signs and symptoms will become evident on examination which would exclude some patients from manual treatment techniques.

Similarly, there are other causes of neck pain in which manual treatment techniques are either contra-indicated or not as appropriate. The following section will be divided into two parts. The first covers mechanical lesions, which present a set of signs and symptoms that help to establish diagnosis and to rationalize treatment programmes. The second covers the other causes of neck pain and associated signs and symptoms. On the whole, these patients are not appropriate for treatment with manual orthopaedic medicine treatment techniques and require suitable referral.

As well as being a primary source of pain, the disc, through prolapse into the vertebral or intervertebral canal, can have a secondary effect on any pain-sensitive structure lying within. This effect can be mechanical through compression and distortion, chemical through the inflammatory process and ischaemic through the pressure of oedema. For further information on these theories, the reader is referred to Chapter 13. Although the differences in the anatomy and function of the cervical and lumbar spine must be acknowledged, few studies have been unearthed to reflect patterns of radicular pain production specific to the cervical spine, although conclusions have been drawn in relation to myofascial pain patterns based on clinical observation. For the time being, cervical radicular pain patterns have been extrapolated from the lumbar model.

A central herniation of cervical disc material produces central and/or bilaterally referred symptoms. A unilateral herniation produces unilaterally referred symptoms. Reference of pain arising from compression of the central structures is characteristically multisegmental, i.e. over many segments (see Ch. 1). Involvement of the unilateral structures, dural nerve root sleeve and/or the nerve root produces segmentally referred signs and symptoms.

Since the disc degenerates early in the cervical spine, disc lesions tend to produce a pattern of symptoms which indicate a progression of the same condition. The symptoms are age-related with a pattern of increasing frequency and severity. Eventually the nerve root may become involved.

The anatomy of the zygapophyseal joint with its intra-articular structures makes it susceptible to possible mechanical derangement. It is difficult to differentiate pathology in the absence of neurological signs or symptoms, and primary disc lesions and zygapophyseal joint lesions appear to be similar in their presentation. Referral pain patterns arising from the zygapophyseal joints in symptomatic subjects have been looked at by Cooper et al (2007) who found that there was referral into the neck but minimal reference into the arm. As mentioned above, there are no similar studies for primary or secondary disc pain.

While acknowledging the zygapophyseal and other pain-sensitive somatic structures as possible causes of pain, the approach in orthopaedic medicine is traditionally based on the discal model.

Disc lesions in the cervical spine need to be reduced to prevent them contributing further to the degenerative process. A central prolapse in particular may cause osteophyte formation through ligamentous traction which may eventually threaten the spinal cord. Cyriax (1982) was emphatic in pointing out the danger of not reducing an early, minor cervical disc lesion for this reason as there comes a time when manipulation will not have an effect and a point at which it may be dangerous. Elderly patients with osteophytic cord compression often report the onset of paraesthesia associated with cervical extension and for that reason it would seem that particular attention should be paid to restoring cervical extension which would act as an indicator that reduction had been effected.

Cervical lesions produce a pattern of signs and symptoms and a set of clinical models has been established to aid diagnosis and establish treatment programmes. These are outlined later in this chapter. The models should be used as a general guide to the clinical diagnosis and treatment of cervical lesions. All show a non-capsular pattern on examination.

The following terminology will be used to describe disc lesions:

Generally, this group of conditions does not respond to the manual techniques described in this chapter and indeed some may be absolute contraindications. There may, however, be some overlap, particularly with the degenerative conditions, and the techniques may be attempted provided contraindications have been eliminated.

Arthritis in any joint presents with the capsular pattern. Arthritis occurs in synovial joints in the cervical spine and involves the zygapophyseal and uncovertebral joints. In the cervical spine the capsular pattern is demonstrated by the cervical spine as a whole. The limited movements have the ‘hard’ end-feel of arthritis. The pattern of symmetrical limitation of the side flexions and rotations is distinctive when compared with the asymmetrical pattern of limitation seen in disc lesions. The early degeneration of the cervical intervertebral disc occurs concurrently with degenerative changes within the other joints. The history will indicate the type of arthritis: degenerative osteoarthrosis, inflammatory or traumatic.

Serious, non-mechanical conditions may present with signs and symptoms similar to those of a mechanical presentation. For this reason, careful examination is necessary to eliminate serious disease which would be contraindicated for orthopaedic medicine treatment. Patients may present with local symptoms which are rarely provoked by movement or posture. On examination it may be difficult to reproduce the symptoms. Other more generalized features may also be present, such as increasing and unrelenting pain, night pain, weight loss, general malaise, fever, raised erythrocyte sedimentation rate or other symptoms, e.g. cough.

The following conditions are not serious but should be considered as part of the clinical reasoning required in differential diagnosis:

Before proceeding with the history, a general observation of the patient’s face, posture and gait is made, noting the posture of the neck and the carriage of the head. Neck posture will give an immediate indication of the severity and possible irritability of the condition, e.g. a wry neck associated with acute pain in which the patient has developed an antalgic posture.

The box above lists the ‘red flags’ for the possible presence of serious pathology that should be listened for and identified throughout the subjective and objective examination. In isolation, many of the flags may have limited significance but it is for the clinician to consider the general profile of the patient and to decide whether contraindications to treatment exist and/or whether onward referral is indicated.

The history is particularly important at the spinal joints. Selection of patients for orthopaedic medicine treatment techniques relies on the discal model of diagnosis and certain aspects of the history will assist in this diagnosis as well as highlighting patients with contraindications to treatment.

The age, occupation, sports, hobbies and lifestyle of the patient may give an indication of the nature of onset and its relationship to habitual postural problems associated with a particular lifestyle.

The age of the patient is important, particularly at the cervical spine, since the type of cervical disc lesion is related to age. In the young patient, child or adolescent, neck pain may be associated with an acute torticollis, possibly a true nuclear disc lesion.

Disc lesions tend to occur in the middle-age group, with posterior or posterolateral herniation; zygaphophyseal joint lesions are also prevalent in this age group. Referred arm pain, due to a large posterolateral disc prolapse, usually occurs over the age of 35, through progressive prolapse. Arm pain presenting under the age of 35 may be indicative of serious pathology and this should be excluded. Degenerative changes in the intervertebral, uncovertebral and zygapophyseal joints occur in the older neck.

Occupation, sports, hobbies and lifestyle of the patient may contribute to the patient’s signs and symptoms. Habitual postures can contribute to postural adjustment, altered biomechanics and muscle imbalance. Examples are provided by the head-forward posture of the visual display unit operator, the side-flexed posture of holding the telephone in the crook of the neck to leave the hands free, the flexed and rotated posture of the plumber or builder, or the head-extended posture allowing the arms to be used above the head in the painter or electrician. Athletes may assume certain postures related to their sport which may precipitate or contribute to their problem.

The site and spread of the symptoms give important clues to diagnosis in the cervical spine and highlight the importance of understanding the mechanisms of referred pain in a segmental or multisegmental pattern. Pain may be localized to the neck or occur in association with symptoms felt in the scapular area, chest, upper limb or head. The sole presentation of internal carotid artery dysfunction may be unilateral upper cervical or anterolateral neck pain and headache and/or sensitivity in the frontotemporal region (Kerry & Taylor 2006).

Nerve root compression in the cervical spine can only occur at the levels at which the nerve root can be compressed. In the mid and lower cervical regions the roots are under threat from the intervertebral discs, uncovertebral joints and zygapophyseal joints which form the boundaries of the intervertebral foramen. C1 and 2 nerve roots do not run in intervertebral foramina, therefore compression of these nerve roots is not the mechanism for upper cervical pain.

It is important to establish the nature of the onset and duration of the symptoms, not just of this current episode of pain, but of all previous episodes. Cervical disc lesions tend to be a progression of the same incident, and establishing a history of increasing and worsening episodes of pain assists diagnosis.

The onset may be sudden or gradual. It may be precipitated by a single incident, such as a whiplash injury due to a motor vehicle accident, or a sudden unguarded movement, such as missing a footing. If traumatic in onset, the exact mechanism should be established: was it hyperflexion, hyperextension or excessive rotation? If the condition developed gradually, is it associated with habitual postures, or a change in posture, such as sleeping in a different bed?

The patient with whiplash injury without serious bony complications presents with pain felt at the time of the trauma which settles. Twenty-four hours later, pain and stiffness develop due to the ligamentous involvement and muscular strain. The whiplash patient who has severe pain from the time of the trauma may have more serious underlying pathology, e.g. fracture and/or dislocation.

Headache of sudden onset may be an indication of internal carotid artery dysfunction (Taylor & Kerry 2005, Kerry & Taylor 2006).

The duration of the symptoms helps to give a prognosis of the patient’s condition as well as providing an indicator for serious pathology, being always on the alert for possible contraindications to treatment. Generally, the patient who presents with a short duration of symptoms responds better to treatment. Disc pathology tends to be self-limiting and generally symptoms will resolve spontaneously. With repeated episodes, however, this tends to take longer and longer. Nerve root compression may follow a mechanism of spontaneous recovery in 3 or 4 months, providing the patient loses the central symptoms.

Recurrent symptoms may indicate a cervical disc lesion or degenerative arthrosis which tends to present with periods of exacerbation of symptoms. Inflammatory arthritis may present a similar picture, but it has usually manifested itself in other joints before involving the cervical spine.

The symptoms and behaviour need to be considered. The behaviour of the pain will give an indication of the irritability of the condition. Make a note of the daily pattern of the pain. If it is easier first thing in the morning and worse as the day goes on, easing up again with rest, this could indicate a compression problem or a postural problem. If it is uncomfortable and stiff in the morning and painful on certain movements, this is indicative of an active arthritis. It may be due to an acute episode of degenerative osteoarthrosis, or inflammatory arthritis such as rheumatoid arthritis or ankylosing spondylitis. Pain not at all relieved by rest and with unrelenting night pain indicates serious pathology such as tumour.

Of what other symptoms does the patient complain? Coughing, sneezing or straining cause an increase in the intrathecal pressure, and neck pain produced with any of these may indicate disc compression or tumour. With regard to the latter, pain produced in the arm on coughing or sneezing is considered to be a ‘red flag’, i.e. a sign of serious spinal pathology, that warrants further investigation, and would provide a contraindication to treatment.

Paraesthesia may be related to nerve root compression. Sympathetic symptoms such as hot and cold feelings, heaviness, puffiness or circulatory symptoms may be related to nerve root compression or thoracic outlet syndrome, reflex sympathetic dystrophy or work-related upper limb disorder.

Other causes of neck pain and associated symptoms should be eliminated, such as thoracic outlet syndrome, which may produce similar symptoms to upper cervical syndromes. Symptoms may include facial pain, tinnitus, auditory and visual disturbances.

From the history, specific questions must be asked to eliminate vertebrobasilar and carotid artery problems and problems of instability in the upper cervical joints, which would contraindicate treatment. A description of unilateral frontotemporal headache as ‘unlike any other’ should raise concerns of internal carotid dysfunction (Kerry & Taylor 2006). It is important to consider any risk factors for vascular disease, specifically atherosclerosis, that may help in differential diagnosis to distinguish pain associated with cervical artery dissection or to guide treatment selection to minimize the potential risk from cervical techniques.

The risk factors for atherosclerosis include: hypertension, raised blood cholesterol, lipids and free radicals, diabetes mellitus and genetic clotting disorders or propensity to thrombus formation (taking oestrogen or recent long-haul flight or surgery). Smoking, infection and direct vessel trauma also provide an increased risk of atherosclerosis (Kerry & Taylor 2006). The list is extensive and it could be argued that the risk factors apply to a large proportion of the population. The advice is to consider the patient’s profile but to maintain a wise balance between ensuring patient safety and applying appropriate treatment.

Explore any complaint of dizziness, nausea, faintness, tinnitus or visual problems. Ask specific questions about drop attacks, i.e. ‘Do you ever fall to the ground without losing consciousness?’. Establish the presence of pins and needles and numbness and note exactly where. Consider whether the distribution of these symptoms fits with segmental referral or is more a sympathetic feature. It may be pertinent to ask about headaches, fatigue and stress, or blurred or dull vision.

Other joint involvement will give an indication of previous problems which may or may not be related. Look for evidence of rheumatoid arthritis, usually in the smaller joints, remembering that the disease process may be quiet in the cervical spine. Ankylosing spondylitis usually starts in the sacroiliac joint(s) and lumbar spine or hips. Note the presence of generalized degenerative osteoarthrosis.

Ask about past medical history and consider any serious illness or operations. It is advisable to ask about previous trauma involving the neck: a history of whiplash is considered a risk factor in vascular accidents (Kleynhans & Terret 1985). Explore previous similar episodes of neck pain and any previous treatment.

Check the medications currently taken by the patient, as anticoagulants and long-term systemic steroid use may present a contraindication to the treatment techniques. Ask about any pain-relieving drugs to give an indication of how much pain control is required by the patient. As antidepressants may also be prescribed for chronic pain they may give an indication of the patient’s general pain profile. Antistatins and antihypertensive drugs should also be noted in relation to potential risk factors for diagnosis and treatment selection.

The patient should undress down to underwear to the waist, and be in a good light. A general inspection will reveal any bony deformity. The general spinal curvatures are appreciated, assessing for any increased or decreased cervical lordosis, tilt or rotation, abnormalities in the cervicothoracic junction and upper thoracic kyphosis, scoliosis, or the presence of an antalgic posture. Abnormal fatty tissue sometimes develops over C7, in association with postural deformity at the cervicothoracic junction, and this is known as a ‘dowager’s hump’. Similar fatty tissue can often be seen in rugby players in the front row of the scrum. The head carriage is also noted, looking for excessive protraction or retraction.

Colour changes and swelling would not be expected in the cervical spine unless associated with a history of direct trauma.

A neuritis would give the appropriate wasting of the muscles supplied by the nerve involved and the neck, shoulder and scapular area should be assessed for obvious muscle wasting. Some unusual nerve pathologies produce bizarre patterns of bilateral asymmetrical wasting, e.g. neuralgic amyotrophy. In disc pathology with nerve root compression, muscle wasting may not be obvious on inspection.

Before any movements are performed, the state at rest is established to provide a baseline for subsequent comparison.

The suggested sequence for the objective examination will now be given, followed by a commentary including the reasoning in performing the movements and the significance of the possible findings.

The routine examination of the cervical spine includes active, passive and resisted movements. Since the spinal joints are considered to be a potential focus for ‘emotional’ symptoms, six active movements are conducted assessing willingness to move, range of movement and pain. The capsular or non-capsular pattern may also emerge from these active movements.

In a non-capsular pattern of the cervical spine, some movements are limited and/or painful and others are full and pain-free. The presence of a non-capsular pattern indicates a possible disc displacement. Normally movements at the cervical spine do not occur in isolation, but the examination procedure is conducted simply by assessing the individual movements. It should, however, be remembered that flexion and extension occur with a component of translatory glide, while side flexion and rotation occur as a coupled movement.

The passive movements are assessed to determine the true limitation of range of movement and the end-feel. The pattern of limited movements should be the same as that found on active movements, although the range may be slightly more. Normally passive extension has a hard end-feel, passive rotations an elastic end-feel and passive side flexions an elastic end-feel due to tissue tension. Passive flexion is not assessed because it would tend to aggravate the symptoms of disc lesion.

The resisted tests are not part of the routine examination at the cervical spine, but should be applied if there is a history of trauma, e.g. for a muscle lesion, suspected serious pathology such as fracture or metastases, or illness behaviour. The resisted tests also assess the C1 and 2 nerve roots. Resisted flexion may produce pain in a disc lesion since it causes compression.

The shoulder joint complex is eliminated as a cause of pain by active elevation. If this is full range and pain-free, the shoulder can be eliminated from the examination.

Assessment for objective root signs is conducted by a series of resisted tests for the myotomes, looking for a pattern of muscle weakness which would indicate nerve root compression. Since it is also important to eliminate other causes of arm pain, the muscle groups are also assessed, looking for alternative causes of pain. This explains why the sequence appears to test the same nerve roots several times.

A quick check of skin sensation to light touch is made looking for differences. Paraesthesia commonly affects the distal end of the dermatomes and these are assessed, followed by the biceps, brachioradialis and triceps reflexes.

The plantar response is assessed by stroking up the lateral border of the sole of the foot and across the metatarsal heads. If the response is extensor, i.e. upgoing, it is indicative of an upper motor neuron lesion. The normal response is flexor.

The objective examination sequence provides a basic assessment framework to glean important information towards the selection of patients appropriate for the treatment techniques used in orthopaedic medicine. It also highlights possible contraindications and provides a guide for the specific treatments to be used.

Any other assessment procedures may be included throughout the sequence or explored separately afterwards, including vestibular apparatus tests for benign paroxysmal positional vertigo (BPPV), either to elicit extra information for the purposes of the application of other treatment modalities, or to confirm findings necessitating patient referral.

It is impossible to be absolutely definitive about all contraindications and nothing can substitute for a rigorous assessment of the presenting signs and symptoms and an accurate diagnosis of a mechanical cervical lesion.

‘Red flags’ are signs and symptoms found in the patient’s subjective and objective examination that may indicate serious pathology and provide contraindications to cervical manipulation (Greenhalgh & Selfe 2006, Sizer et al 2007) (see Red flags p. 194).

The absolute contraindications are highlighted in the discussion below but there are several relative contraindications that should be considered as well. It may be useful to use the mnemonic ‘ COINS’ (a contraction of ‘contraindications’), as an aide-mémoire to be able to create mental categories for the absolute contraindications: Circulatory, Osseous, Inflammatory, Neurological and suspicious features indicating Serious pathology. If the first and last two letters are pushed together as ‘ CONS’, the crucial need for consent is emphasized.

The treatment regime discussed in this chapter is absolutely contraindicated in the absence of informed patient consent. The patient should be given all details of their diagnosis together with the proposed treatment regime and a discussion of the risks and benefits should ensue to enable them to give their informed consent (Oppenheim et al 2005). Consent is the patient’s agreement, written or oral, for a health professional to provide care. It may range from an active request by the patient for a particular treatment regime to the passive acceptance of the health professional’s advice. The process of consent, within the context of orthopaedic medicine, is ‘fluid’ rather than one instance in time when the patient gives their consent. The patient is constantly monitored and feedback is actively requested. The treatment procedures can be progressed or stopped at the patient’s request or in response to adverse reactions. Reassessment is conducted after each technique and a judgment made about proceeding. The patient has a right to refuse consent and this should be respected and alternative treatment options discussed. For further information on consent, the reader is referred to the Department of Health website: www.dh.gov.uk/consent.

Drop attacks are an absolute contraindication to the orthopaedic medicine cervical mobilization procedure, including manipulation, since these may be indicative of upper cervical instability or related to transient ischaemic attacks. Similarly, patients with a history of cerebrovascular accident, transient ischaemic attacks or other upper motor neuron lesions would be contraindicated and other treatment modalities should be considered if neck pain is a feature in these patients. Upper cervical spine instability is also associated with Down’s syndrome and active cervical rheumatoid arthritic changes. Ligamentous laxity may be a feature of pregnancy, making pregnancy a relative contraindication to manipulation.

A gradual onset of increasing pain over 3 months may be indicative of inflammatory arthritis, which may be a relative contraindication. Ankylosing spondylitis and other spondyloarthropathies, for example, may not affect the cervical spine, in which case the cervical mobilization regime discussed below would not be contraindicated and individual judgments would need to be made for each case. Rheumatoid arthritis, which usually affects the smaller joints symmetrically, may be progressing subclinically in the cervical spine; therefore the techniques discussed below would be contraindicated.

A subjective examination will screen a patient for symptoms of vertebrobasilar insufficiency and, if present, the treatment regime discussed below would be absolutely contraindicated. However, dizziness, a major symptom of vertebrobasilar insufficiency, is more commonly a symptom of cervical dysfunction. Reid & Rivett (2005) conducted a systematic review of the effectiveness of manual therapy for cervicogenic dizziness and found that there was some evidence, though acknowledged as limited, to support the use of manual therapy in treating cervicogenic dizziness. Therefore accurate diagnosis is essential here in order to prevent a large group of patients being denied a worthwhile treatment regime. The merits of the testing procedure for vertebrobasilar insufficiency will be discussed below and currently it is advisable to conduct a recognized test before applying manipulation. A positive vertebrobasilar test would be an absolute contraindication to manipulation. If the cause of dizziness cannot be ascertained, it would be wise to err on the side of caution.

Suspicious features indicative of non-mechanical lesions would be an absolute contraindication to the orthopaedic medicine treatment regime. These symptoms should not be considered in isolation but in the general context of the whole examination procedure and may include unexplained weight loss, poor general health, pain unaffected by posture or activity, constant pain of which night pain is a feature and double root palsy and cord signs such as spastic gait and/or abnormal plantar response. The patient with a past history of primary tumour is not strictly contraindicated, but diagnosis of a mechanical lesion must be certain before proceeding with the treatment regime since the pain of bony metastases may mimic mechanical pain. Suspicious findings occur in Pancoast’s tumour (a tumour in the apex of the lung) which may affect the lower trunks of the brachial plexus resulting in medial arm pain and C8 and/or T1 palsy that may be evident as atrophy of the ulnar border of the hand and a reduced triceps reflex (Pitz et al 2004). Objective examination may reveal provocation of pain by side flexion away from the painful side as the only positive cervical sign and this would be an unusual finding in a cervical disc lesion. Consider risk factors for atherosclerosis and symptoms that could be associated with internal carotid artery dysfunction, including headache described as ‘unlike any other’ (Kerry & Taylor 2006).

Symptoms of cervical disc lesions can generally be traced back to show a history of increasing and worsening episodes. Therefore cervical radiculopathy generally affects the over 35 age group. Of course, this can also occur in the younger age group, but diagnosis is again paramount, since this can be a suspicious feature associated with tumour. As in the lumbar spine, for the arm symptoms to be indicative of a mechanical lesion, the central symptoms are expected to subside considerably at the onset of arm pain. The nerve roots emerge horizontally, certainly in the upper cervical spine (see discussion in the anatomy section); therefore multiple nerve root involvement should be considered suspicious until the screening procedures in the subjective and objective examination confirm a mechanical diagnosis. Similarly, double nerve root involvement is unusual, particularly as the vertebral canal in the cervical region is large and can more readily accommodate a disc prolapse than in the lumbar spine. Bilateral arm signs and symptoms would therefore be an unusual presentation of a mechanical lesion. If, during the application of manual traction, the patient experiences an onset of paraesthesia in a multisegmental distribution, i.e. both hands, then the procedure should be stopped. Cyriax & Cyriax (1993) suggested this phenomenon is due to adherent dura, presumably therefore having implications for the mobility of the spinal cord, and alternative treatment options should be explored.

Cord signs, which may be associated with cervical myelopathy, are an absolute contraindication to cervical manipulation. A central disc prolapse may encroach on the dura mater producing bilateral symptoms; therefore central techniques might be appropriate, but rotatory techniques under traction would not. The importance of reducing small uncomplicated disc lesions is important to prevent future degenerative changes threatening the spinal cord (Ombregt et al 2003).

The acute cervical lesion is too irritable for manipulation but may well respond to mobilization, particularly the bridging or manual traction technique described below. An antalgic posture indicates severity. In radiculopathy with minimal, stable neurological signs, manipulation is not contraindicated but may not be effective. Increasing unstable neurological signs are a contraindication as the prolapse could be increased.

A history of recent trauma has been identified as a risk factor in vertebrobasilar insufficiency due to damage to the lining of the vertebral artery; therefore manipulation is contraindicated. Past history of trauma, head injury, fracture and previous surgery are all relative contraindications and judgments will have to be made on individual cases.

The drug history will identify the contraindication of anticoagulation therapy to manipulation due to the risk of intraspinal bleed. The long-term use of systemic steroid medication predisposes the patient to osteoporosis; this and a known diagnosis of osteoporosis is a contraindication to manipulation. Patients considered susceptible to osteoporosis may be relatively contraindicated and individual judgments will need to be made. Caution should be exhibited with patients who have blood clotting disorders.

Patients with psychosocial components, the so-called ‘yellow flags’, may be unsuitable for manipulation and even the mobilization regime may present a relative contraindication; again judgments will need to be made on individual cases.

Safety recommendations for spinal manipulative techniques are included in Appendix 2.

It is important to emphasize that the treatment techniques in this section will be described carefully in a step-by-step fashion to enable their application. However, the professional judgment and existing skill of the operator will allow each technique to be adapted.

The order of the techniques as they appear here merely provides a guide towards the development of skills at each stage and it is not necessarily an order of efficacy. It is important to reassess the patient’s comparable signs constantly and to decide on the next step in the light of patient response. In this way the orthopaedic medicine approach can properly be integrated into existing practice as fresh decisions are made and the underlying hypothesis is modified. It is traditional to start each session with manual traction as this technique seems to achieve the greatest response; if progression is required then the other techniques are carried out, with a vertebrobasilar artery test conducted prior to the application of manipulation in each session of treatment.

Manipulation as such, defined as a minimal amplitude, high velocity thrust at the end of range, is only carried out if judgment deems it necessary. The mobilization procedure suggested is usually sufficient to reduce most uncomplicated cervical lesions, i.e. with no neurological signs or symptoms.

The benefit of this cervical mobilization procedure outweighs the small risk of vertebrobasilar complications but that is not to take the risk lightly. The appropriate steps to minimize this risk, suggested in the guidelines below, should always be taken, but debate continues on the true incidence of complications from cervical manipulation, and it has been ascertained that the tests themselves carry a degree of risk. The reader is recommended to check for the most recent developments before applying the techniques, as safety issues are in a state of change and the most up-to-date guidelines should be adhered to.

The techniques involve traction, slight extension of the head and sometimes rotation, and these are the positions that have been implicated in causing compromise of the vertebral arteries. However, it should be emphasized that this is not the only area of danger in this region. The spinal cord is vulnerable to central disc herniation and these same positions assist centralization of the herniated disc material and aim to prevent further central displacement that could potentially endanger the cord.

It is not possible to say how many times each technique is to be attempted since the process of reassessment is the basis for each clinical decision and the circumstances vary in every clinical encounter. Nonetheless, a balance must be found between sidestepping the question and providing a recipe for treatment. Some guidance will be given in terms of expectations, with respect to the different states and stages of the conditions presented.

Generally, the more acutely painful lesions require gentle treatment, but reassurance and advice may be more appropriate in the early stages without the application of passive treatment. For the subacute or less irritable states, if the technique is helping, it is repeated; if no change occurs after a few attempts, the next technique is chosen; if the patient’s signs and symptoms are abolished, treatment should be stopped. Once improvement plateaus in each session, or if the progress is uncertain, the treatment is either modified to an alternative modality or ceased, with the patient being reassessed at the next session when a new status quo will have emerged.

In general, lesions producing central or bilateral pain should be treated with central techniques, i.e. manual traction, traction with leverage, anteroposterior glide. Lesions producing unilateral pain are treated with manual traction, progressing to rotational mobilizations under traction and manipulation if necessary. The monitoring that takes place during this step-by-step progression of forces is most important to safety.

The guidance for pre-manipulative testing (Barker et al 2001) aims to identify patients with a potential risk of vascular accident if the vertebral artery is compromised. Rather than testing for vertebrobasilar insufficiency, it aims to be a predictor of the ability of the collateral circulation to maintain perfusion of the brain should the cervical arteries be occluded. A detailed history, together with the objective examination, establishes a diagnosis. If manipulation is the treatment of choice, the clinician should discuss the risks and benefits of the proposed technique with the patient to gain informed consent. The flowchart (see Fig. 8.43) is self-explanatory, and it is currently advised that a recognized pre-manipulative test is conducted in each treatment session that is to include cervical manipulation. Some clinicians choose to apply the testing procedure prior to other cervical mobilization techniques, but this is not currently mandatory. Local policy sometimes drives the decision and justification should be available if the policy is challenged. The decision should be based on clinical judgment in the light of best available evidence and the reader is advised to keep abreast of developments occurring in the intervening time.

Any recognized pre-manipulative testing procedure can be applied. Positions can include extension, combined extension and rotation, the pre-manipulative position or rotation alone (Kerry & Taylor 2006). Kerry et al (2008) observe that the extension element of testing has been removed from the new Australian Physiotherapy Association protocol (2006) and appears to have taken into account that extension has been reported as the most influential movement for internal carotid artery flow. The test described below places the patient’s cervical spine in the simulated position for the manipulative procedures. However, this is a combined position, which is not exactly the same as the position for the individual techniques, nor can the manipulative thrust be simulated.

Position the patient in supine lying with the shoulders level with the end of the couch. Support the head comfortably. Place the head into a degree of extension (not full extension), with side flexion and rotation of the cervical spine (Fig. 8.44). Keep the patient talking and the eyes open while maintaining the position for 30 s unless symptoms are evoked before this time. Allow the patient to rest in neutral before repeating the test to the other side.

The presence of dizziness, nausea, vomiting, sweating, pallor, blurred vision, dysarthria, fainting, tinnitus or paraesthesia in the head or arm or nystagmus constitutes a positive test.

The main symptoms and signs of a positive vertebrobasilar artery test can be remembered using the five Ds: dizziness, diplopia, drop attacks, dysarthria and dysphagia – a useful aide-mémoire attributed to Coman (Grant 1988, Kerry & Taylor 2006).

If the test is found to be positive, slide the patient back onto the couch to remain lying in supine to recover. Help the patient to sit up steadily and check by questioning and observation that the symptoms have subsided before terminating the session, or continuing with a suitable alternative treatment modality.

Following the recommended guidance is the current basis for ensuring maximum safety and preparation for the unexpected. The clinician must take all due care while applying the test and the treatment techniques.

These are stronger manoeuvres and it is definitely recommended that they should be applied only after attending an orthopaedic medicine course.

Cyriax did not advocate the use of cervical traction to the same extent as lumbar and was of the opinion that it was used ‘far too often’ (Cyriax 1982). A systematic review of the literature on the efficacy of traction for neck and back pain was presented by van der Heijden et al (1995), but most of the selected studies proved to be of poor quality. No clear indications of the effectiveness or ineffectiveness of traction could be ascertained from this study. Peake & Harte (2005) reviewed trials conducted between 1966 and 2004, to update the review of van der Heijden et al (1995) but remarked that the evidence had not changed substantially since the earlier review. They were unable to establish evidence either for or against the application of cervical traction. In spite of the lack of evidence to support the technique, the authors suggest that apparent benefits might be due to mobilization of the muscle and connective tissue, increased venous and lymphatic flow or psychological improvement, irrespective of any effect on the spinal joints.

Hickling (1972) described the application of sustained cervical traction in either sitting (cervical suspension) or lying, and various studies have been published to explore the merits or disadvantages of each. Cervical suspension, the application of vertical traction with the patient sitting, appeared to be the choice of Cyriax, but it may also be applied in supine lying (long traction) or inclined half-lying. Colachis & Strohm (1965) quoted the paper of Gartland which mentioned Krusen’s list of advantages of cervical suspension over long or horizontal traction:

• Convenience of application

• Elimination of friction

• Accuracy of measurement

• Facilitation of manipulation.

Stoddard (1954) was critical of cervical suspension since he observed that his patients found it difficult to relax in this position. He also believed that sustained traction impaired blood flow, and favoured intermittent traction. Deets et al (1977) mention that Maitland had the opposite view and preferred traction in sitting since his patients found it more comfortable. They also report that Crue found that greater foraminal separation was observed in the supine position than in sitting.

Colachis & Strohm (1965), in a study of 10 normal medical students, found that the separation of the cervical vertebrae under traction increased with the angle of flexion to the horizontal of the rope applying the pull. They found that the poundage applied had a comparatively greater effect on the joint separation and the maximum of 30 lb (14 kg) used in their investigation had the greatest effect. Judovitch (1952) studied radiographs of the cervical spine under different poundages of traction and found that 25 lb (11 kg) of vertical traction straightened the cervical lordosis, while at 45 lb (20.5 kg) a mean stretch of 5 mm was achieved in the cervical spine. Deets et al (1977) cite a further study of Colachis & Strohm which demonstrated that the greatest elongation of the posterior portion of the disc was observed with the angle of rope pull at 35° to the horizontal.

Hickling (1972) recounted Cyriax’s suggestion that cervical suspension should be just sufficient to lift the patient’s buttocks from the chair, implying that forces of near body weight were being applied. However, this was for a short duration of 1–5 min. In lying, average treatments ranged from 15 to 25 lb (7–11 kg), according to the size and overall response of the patient. The traction was applied horizontally or in slight flexion at an unspecified angle but with consideration for patient comfort and preference.

Readers must weigh up for themselves the pros and cons of applying traction in the sitting versus supine position. The characteristics of the individual patients encountered will form part of the decision-making process.

Another factor in the application of cervical traction is the length of time for which it should be applied. Colachis & Strohm (1965) noted that no further increase of intervertebral separation occurred after 7 s of sustained traction and Judovitch (1952) stated that the time of application should be decreased as greater forces were applied. Hickling (1972) suggested that traction of 15–25 lb (7–11 kg) should be continued for between 15 and 25 min. This recommendation is based on empirical findings and more work needs to be done to establish the optimum duration of treatment.

The literature is unclear in its support of either sustained or intermittent traction. Moeti & Marchetti (2001) used intermittent traction for patients with radicular symptoms and demonstrated that patients with symptoms of more than 12 weeks’ duration had minimal improvement, and those with symptoms for less than 12 weeks had a better outcome. Improved circulation, reduction of adhesions and reduction of pain via presynaptic inhibition at spinal cord level have been suggested as possible mechanisms for improvement due to intermittent traction (Wong et al 1997). Chung et al (2002) used MRI to evaluate the reducibility of cervical disc herniation under traction on 29 patients and seven healthy volunteers. Using a traction device which essentially consisted of a portable inflatable ‘accordion’-shaped neck collar to produce 30 lb of traction force over 10 min, an increase in length of the vertebral column was demonstrated in both groups, and 21 patients had complete or partial reduction of the disc herniation.

These are largely the same as for cervical manipulation and the reader is referred to the discussion on contraindications above.

Care should be taken in applying traction to the elderly and they must be thoroughly questioned for the presence of any contraindications.

Most traction beds and mobile traction equipment of modern design have the facility to apply cervical and lumbar traction.

A cervical harness is required to rest under the occiput and chin, with straps or cord passing to a spreader bar above the head. There are several types of harness which nowadays are made of washable materials, which also have the advantage of being pliable to give comfortable support. The simplest uses two padded rectangles which mould to the head as the traction is applied, but others are made of more substantial materials and have adjustable clasps to accommodate the differing shapes of patients.

The straps to the spreader bar should be long enough to give safe clearance above the head. A rope passes from the central point of the spreader bar via a pulley or pulleys to a fixing cleat in manually applied units, or directly into the housing of the automatic device.