Cervical Spine Cervical Spine Anatomy and Anatomy and

Clinical EvaluationClinical EvaluationOrthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith LabPET 5609CPET 5609C

Clinical AnatomyClinical Anatomy Cervical Spine:Cervical Spine:

Greatest range Greatest range of motionof motion

↑ ↑ risk of injury Vertebral bodies:Vertebral bodies:

Smaller than other vertebral sections

7 vertebrae:7 vertebrae: 11stst – Atlas – Atlas 22ndnd – Axis – Axis

Clinical AnatomyClinical Anatomy Cervical Spine:Cervical Spine:

Atlas:Atlas: No vertebral bodyNo vertebral body Transverse processesTransverse processes No true spinous No true spinous

processprocess Supports the weight Supports the weight

of the skull through 2 of the skull through 2 facet surfaces facet surfaces (atlanto-occipital joint (atlanto-occipital joint or C0-C1 articulation)or C0-C1 articulation)

Flexion and extension Flexion and extension (primary movement)(primary movement)

Lateral flexion (slight)Lateral flexion (slight)

Clinical AnatomyClinical Anatomy Atlanto-occipital joint Atlanto-occipital joint

dislocation: dislocation: (15% of all fatal spinal (15% of all fatal spinal

trauma)trauma) MOI: high speed motor MOI: high speed motor

accident; Pt. accident; Pt. unconscious at the unconscious at the scene, respiratory arrest scene, respiratory arrest en route to hospitalen route to hospital

Lateral cervical spine Lateral cervical spine radiograph:radiograph:

Prevertebral soft-tissue Prevertebral soft-tissue swelling (white arrow) swelling (white arrow)

Malalignment between Malalignment between the skull and the the skull and the cervical spine with cervical spine with widening of the atlanto-widening of the atlanto-occipital joints (black occipital joints (black arrow)arrow)

Clinical AnatomyClinical Anatomy Cervical Spine:Cervical Spine:

Axis:Axis: 22ndnd cervical cervical

vertebraevertebrae Small body with a Small body with a

superior projection superior projection (Dens)(Dens)

Atlanto-axial joint:Atlanto-axial joint: Dens and atlas Dens and atlas

articulationarticulation Rotation of the Rotation of the

skullskull

Clinical AnatomyClinical Anatomy Cervical ligaments:Cervical ligaments:

Anterior and posterior Anterior and posterior longitudinal ligaments:longitudinal ligaments:

Limit extension and flexionLimit extension and flexion Ligamentum nuchae:Ligamentum nuchae:

Limits flexionLimits flexion Interspinous ligaments:Interspinous ligaments:

Between spinous processesBetween spinous processes Limit flexion and rotationLimit flexion and rotation

Ligamentum flavum:Ligamentum flavum: Connect laminaeConnect laminae Limits flexion and rotationLimits flexion and rotation

Clinical AnatomyClinical Anatomy Brachial Brachial

Plexus: C5 – T1Plexus: C5 – T1 7 cervical 7 cervical

vertebraevertebrae 8 cervical 8 cervical

nerves:nerves: 11stst 7: exit above 7: exit above

the the corresponding corresponding vertebraevertebrae

C8: exits below C8: exits below the 7the 7thth cervical cervical vertebraevertebrae

Clinical AnatomyClinical Anatomy Muscular Anatomy:Muscular Anatomy:

Cervical extension and flexion → Cervical extension and flexion → bilateral contraction of cervical bilateral contraction of cervical musclesmuscles

Side bending and rotation → unilateral Side bending and rotation → unilateral contractioncontraction

Superficial cervical musculature:Superficial cervical musculature: Splenius capitisSplenius capitis Splenius cervicisSplenius cervicis Upper trapeziusUpper trapezius SternocleidomastoidSternocleidomastoid

Clinical AnatomyClinical Anatomy Splenius capitis:Splenius capitis:

O: Lower half of O: Lower half of ligamentum nuchaeligamentum nuchae

I: Mastoid process I: Mastoid process and adjacent occipital and adjacent occipital bonebone

A: Lateral bending A: Lateral bending Splenius cervicis:Splenius cervicis:

O: C7 spinous O: C7 spinous process through T6process through T6

I: Transverse I: Transverse processes of C2 – C4 processes of C2 – C4

A: Rotation, A: Rotation, extensionextension

Clinical AnatomyClinical Anatomy Upper trapezius:Upper trapezius:

O: Occipital O: Occipital protuberance, nuchal protuberance, nuchal line, upper portion of line, upper portion of ligamentum nuchaeligamentum nuchae

I: Lateral 1/3 of I: Lateral 1/3 of clavicle, acromion clavicle, acromion processprocess

A: Cervical extension, A: Cervical extension, cervical spine cervical spine bending, scapular bending, scapular elevation, upward elevation, upward scapular rotationscapular rotation

Clinical AnatomyClinical Anatomy Levator scapulae:Levator scapulae:

O: Spinous process O: Spinous process of C7, transverse of C7, transverse processes of C1 processes of C1 through C4through C4

I: Superior medial I: Superior medial border of scapulaborder of scapula

A: Extension of A: Extension of cervical spine, cervical spine, scapular elevation scapular elevation and downward and downward rotationrotation

Clinical AnatomyClinical Anatomy Scalenes:Scalenes:

Anterior scalene:Anterior scalene: O: Anterior portion of transverse processes C3-C6O: Anterior portion of transverse processes C3-C6 I: Sternal attachment of 1I: Sternal attachment of 1stst rib rib

Middle scalene:Middle scalene: O: Anterior portion of transverse processes C2-C7O: Anterior portion of transverse processes C2-C7 I: Lateral to insertion of anterior scalene on 1I: Lateral to insertion of anterior scalene on 1stst rib rib

Posterior scalene:Posterior scalene: O: Anterior portion of transverse processes C5-C6O: Anterior portion of transverse processes C5-C6 I: Medial portion of 2I: Medial portion of 2ndnd rib rib

Action: Lateral bending of cervical spineAction: Lateral bending of cervical spine

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy SternocleidomastSternocleidomast

oid:oid: O: Medial O: Medial

clavicular head, clavicular head, superior sternumsuperior sternum

I: Mastoid I: Mastoid processprocess

A: Flexion of A: Flexion of cervical spine, cervical spine, rotation to rotation to opposite side, opposite side, lateral bendinglateral bending

Clinical EvaluationClinical Evaluation History:History:

Location of pain:Location of pain: Localized pain:Localized pain:

Muscle strain, Muscle strain, ligament sprain, ligament sprain, vertebral fracture, vertebral fracture, facet syndromefacet syndrome

Radiating pain:Radiating pain: Trauma to cervical Trauma to cervical

nerve root or spinal nerve root or spinal cordcord

Onset of pain:Onset of pain: Acute, chronic, Acute, chronic,

insidiousinsidious

Clinical EvaluationClinical Evaluation History:History:

Mechanism of Injury:Mechanism of Injury: Insidious onset:Insidious onset:

Overuse and postural conditionsOveruse and postural conditions Acute onset:Acute onset:

Axial load (compression fracture)Axial load (compression fracture) Flexion (compression of anterior vertebral Flexion (compression of anterior vertebral

body and intervertebral disc; facet joint body and intervertebral disc; facet joint sprain; posterior muscle strain)sprain; posterior muscle strain)

Extension (compression of posterior vertebral Extension (compression of posterior vertebral body and intervertebral disc; anterior body and intervertebral disc; anterior longitudinal ligament sprain)longitudinal ligament sprain)

Lateral bending (nerve root compression, Lateral bending (nerve root compression, facet joint compression)facet joint compression)

Clinical EvaluationClinical Evaluation History:History:

Mechanism of Injury:Mechanism of Injury: Acute onset:Acute onset:

Rotation (disc trauma, ligament sprain, vertebral Rotation (disc trauma, ligament sprain, vertebral dislocation)dislocation)

Consistency of pain:Consistency of pain: Inflammatory induced pain: consistent painInflammatory induced pain: consistent pain Mechanical pain (i.e. nerve compression): varies Mechanical pain (i.e. nerve compression): varies

in intensity, moving spine may ↑ or ↓ painin intensity, moving spine may ↑ or ↓ pain History:History:

Previous injuryPrevious injury Scar tissue formationScar tissue formation Injured discInjured disc Osteophyte within intervertebral foraminaOsteophyte within intervertebral foramina

Clinical EvaluationClinical Evaluation Inspection:Inspection:

Cervical Cervical curvature:curvature:

Lordotic Lordotic curvature – curvature – normalnormal

Lateral bending Lateral bending posture - posture - ↓ ↓ pressure on pressure on nerve roots away nerve roots away from the bendfrom the bend

Clinical EvaluationClinical Evaluation Inspection:Inspection:

Position of head on Position of head on the shoulders:the shoulders:

Unilateral spasm – Unilateral spasm – lateral flexion of head lateral flexion of head towards involved sidetowards involved side

Torticollis: Wry neckTorticollis: Wry neck Rotation of chin Rotation of chin

opposite the side of opposite the side of the tiltthe tilt

Congenital or Congenital or acquired spasm of acquired spasm of the SCMthe SCM

Clinical EvaluationClinical Evaluation Inspection:Inspection:

Position of the Position of the head on the head on the shoulders: shoulders: TorticollisTorticollis

18 years age male with congenital 18 years age male with congenital torticollis with the left SCMM tight torticollis with the left SCMM tight as a band unabeling him to turn his as a band unabeling him to turn his head to the righthead to the right

Infant with torticollis: The attitude of the head and neck results from a combination of head tilt and rotation. A tight SCM muscle causes head tilt towards the tight side with rotation of the chin to the opposite side

Clinical EvaluationClinical Evaluation Inspection:Inspection:

Bilateral soft tissue Bilateral soft tissue comparison:comparison:

Trapezius and other Trapezius and other musculature:musculature:

Hypertrophy, atrophyHypertrophy, atrophy Level of the shoulders:Level of the shoulders:

Height of Height of acromioclavicular jointsacromioclavicular joints

DeltoidsDeltoids ClaviclesClavicles

Clinical EvaluationClinical Evaluation Palpation:Palpation:

Anterior Anterior Structures:Structures:

Hyoid bone:Hyoid bone: Have patient Have patient

swallow noting swallow noting superior and superior and inferior movement inferior movement

Level of 3Level of 3rdrd cervical vertebraecervical vertebrae

Thyroid cartilage:Thyroid cartilage: Adam’s appleAdam’s apple Level of 4Level of 4thth and 5 and 5thth

cervical vertebraecervical vertebrae Cricoid cartilage:Cricoid cartilage:

Level of 6Level of 6thth cervical vertebraecervical vertebrae

Clinical EvaluationClinical Evaluation Palpation:Palpation:

Anterior structures:Anterior structures: SternocleidomastoiSternocleidomastoi

d:d: Have patient Have patient

rotate headrotate head Scalenes:Scalenes:

Posterior to SCM Posterior to SCM (C3-C6 level)(C3-C6 level)

Carotid arteryCarotid artery Lymph nodesLymph nodes

Clinical EvaluationClinical Evaluation Palpation:Palpation:

Posterior and Posterior and Lateral Structures:Lateral Structures:

Occiput and Occiput and superior nuchal superior nuchal lineline

Transverse Transverse processesprocesses

Spinous processes:Spinous processes: Have patient flex c-Have patient flex c-

spinespine C7 and T1C7 and T1

TrapeziusTrapezius

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Active neck flexion and extension:Active neck flexion and extension: Test position: patient can be standing or Test position: patient can be standing or

seatedseated Motion: Atlanto-occipital jointMotion: Atlanto-occipital joint Flexion: patient touches chin to chest (45Flexion: patient touches chin to chest (4500)) Extension: patient looks up towards ceiling Extension: patient looks up towards ceiling

(45(4500)) Active neck lateral flexion:Active neck lateral flexion:

Test position: patient seated or standingTest position: patient seated or standing Patient takes ear to shoulders (45Patient takes ear to shoulders (4500))

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Active rotation:Active rotation: Test position: patient seated, head held Test position: patient seated, head held

upward and facing forwardupward and facing forward Patient attempts to look over each Patient attempts to look over each

shouldershoulder Motion: Atlanto-axial joint (45Motion: Atlanto-axial joint (4500))

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Passive flexion:Passive flexion: Patient position: supinePatient position: supine ATC: grab patient’s head (under occiput) ATC: grab patient’s head (under occiput)

and attempt to bring chin to chestand attempt to bring chin to chest Passive extension:Passive extension:

Patient position: supine, head off end of Patient position: supine, head off end of tabletable

ATC: grasp patient’s head and move into ATC: grasp patient’s head and move into extensionextension

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Passive lateral flexion:Passive lateral flexion: Patient position: supine, head in Patient position: supine, head in

neutral positionneutral position ATC: one hand under occiput, tilt ATC: one hand under occiput, tilt

head/neck to bring ear to shoulderhead/neck to bring ear to shoulder Passive rotation:Passive rotation:

Patient position: supinePatient position: supine ATC: grasp patient’s forehead and ATC: grasp patient’s forehead and

occiput, rotate head and neckocciput, rotate head and neck

Clinical EvaluationClinical Evaluation

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Resisted range of motion: FlexionResisted range of motion: Flexion Patient: supine with cervical spine and Patient: supine with cervical spine and

head in neutral positionhead in neutral position Stabilization: superior aspect of Stabilization: superior aspect of

sternumsternum Resistance: to the foreheadResistance: to the forehead Muscles tested: SCM and anterior Muscles tested: SCM and anterior

scalenesscalenes

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Resisted range of motion: ExtensionResisted range of motion: Extension Patient: prone with cervical spine and Patient: prone with cervical spine and

head in neutral positionhead in neutral position Stabilization: superior aspect of Stabilization: superior aspect of

thoracic spinethoracic spine Resistance: to the skull over the occiputResistance: to the skull over the occiput Muscles tested: trapezius (upper 1/3, Muscles tested: trapezius (upper 1/3,

levator scapulae, cervical paraspinal levator scapulae, cervical paraspinal muscles)muscles)

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Resisted range of motion: Lateral Resisted range of motion: Lateral flexionflexion

Patient: seated with cervical spine and Patient: seated with cervical spine and head in neutral positionhead in neutral position

Stabilization: over the AC joint on the side Stabilization: over the AC joint on the side toward the motiontoward the motion

Resistance: over the temporal and parietal Resistance: over the temporal and parietal bones on the side toward the motionbones on the side toward the motion

Muscles tested: SCM, scalenes, paraspinal Muscles tested: SCM, scalenes, paraspinal muscles on the side being testedmuscles on the side being tested

Clinical EvaluationClinical Evaluation Range of Motion:Range of Motion:

Resisted range of motion: RotationResisted range of motion: Rotation Patient: seated with cervical spine and Patient: seated with cervical spine and

head in neutral positionhead in neutral position Stabilization: over the anterior shoulder Stabilization: over the anterior shoulder

on the side toward the rotationon the side toward the rotation Resistance: over the temporal bone on Resistance: over the temporal bone on

the side toward the motionthe side toward the motion Muscles tested: SCM, multifidus, Muscles tested: SCM, multifidus,

rotatorsrotators

Clinical EvaluationClinical Evaluation

C1-C2C1-C2 Neck flexionNeck flexionC3C3 Neck lateral flexionNeck lateral flexionC4C4 Shoulder shrugShoulder shrugC5C5 Shoulder abduction, ERShoulder abduction, ERC6C6 Elbow flexion, wrist Elbow flexion, wrist

extensionextensionC7C7 Elbow extension, wrist Elbow extension, wrist

flexionflexionC8C8 Thumb extensionThumb extensionT1T1 Finger abduction and Finger abduction and

adductionadduction

Clinical EvaluationClinical Evaluation Neurological Neurological

Screening:Screening: Nerve root: C5 Nerve root: C5

(Biceps brachii)(Biceps brachii) Patient: seated Patient: seated

and relaxedand relaxed ATC: thumb ATC: thumb

placed over biceps placed over biceps tendon, strike the tendon, strike the thumb nail with thumb nail with reflex hammerreflex hammer

Clinical EvaluationClinical Evaluation Neurological Neurological

Screening:Screening: Nerve root: C6 Nerve root: C6

(Brachioradialis)(Brachioradialis) Patient: seated Patient: seated

and relaxedand relaxed ATC: taps the ATC: taps the

brachioradialis brachioradialis with reflex with reflex hammerhammer

Clinical EvaluationClinical Evaluation Neurological Neurological

Screening:Screening: Nerve root: C7 Nerve root: C7

(Triceps)(Triceps) Patient: seated Patient: seated

and relaxedand relaxed ATC: support arm ATC: support arm

in position of in position of extension and extension and abduction, tap the abduction, tap the triceps tendon with triceps tendon with reflex hammerreflex hammer

Clinical EvaluationClinical Evaluation Babinkski Test:Babinkski Test:

Athlete:  Supine with shoes Athlete:  Supine with shoes and socks removedand socks removed

ATC:  At the foot of the ATC:  At the foot of the athlete holding a blunt tool athlete holding a blunt tool

Procedure:  ATC runs the Procedure:  ATC runs the tool up bottom of athlete’s tool up bottom of athlete’s foot starting at the calcaneus foot starting at the calcaneus and ending at the great toeand ending at the great toe

Positive test:  Great toe Positive test:  Great toe extends while other toes extends while other toes splaysplay

Implications:  Lesion of Implications:  Lesion of upper motor neurons, may be upper motor neurons, may be caused by trauma to the caused by trauma to the brainbrain

Comments:  This reflex Comments:  This reflex occurs naturally in occurs naturally in newborns.  However, this newborns.  However, this reflex should cease quickly reflex should cease quickly after birthafter birth

Clinical EvaluationClinical Evaluation Oppenheim Test:Oppenheim Test:

Test: Upper motor neuron lesions Test: Upper motor neuron lesions Patient position: supinePatient position: supine ATC: at patient’s sideATC: at patient’s side Procedure: examiner’s fingernail is Procedure: examiner’s fingernail is

run along the crest of the run along the crest of the anteromedial tibiaanteromedial tibia

Positive test: great to extends and Positive test: great to extends and the other toes splaythe other toes splay