CERVICAL

SPINE
Prepared by: Ms. Sarah A. Ligaya, PTRP

 Scanning examination
Mobility

ANATOMY

2 divisions
Cervicoencephalic/Cervicocranial
upper cervical spine
C0-C2
Cervicobrachial for the lower cervical
spine.
Lower cervical spine
C3-C7

Cervicoencephalic/
Cervicocranial
upper cervical spine
C0-C2
Injuries in this area lead to symptoms of:
Headache
Fatigue
Vertigo
Poor concentration
Hypertonia of sympathetic nervous system, and
Irritability
Cognitive dysfunction, cranial nerve dysfunction and
sympathetic system dysfunction.

LIGAMENTS
ANTERIOR ATLANTO-OCCIPITAL MEMBRANE
is strengthened by the anterior longitudinal ligament.

POSTERIOR ATLANTO-OCCIPITAL MEMBRANE

replaces the ligamentum flavum between the atlas and occiput.

TECTORIAL MEMBRANE
is a broad band covering the dens and its ligaments
is found within the vertebral canal
is a continuation of the posterior longitudinal ligament.

ALAR LIGAMENTS
two strong rounded cords found on each side of the upper dens passing
upwards and laterally to attach on the medial sides of the occipital condyles
limit flexion and rotation
play a major role in stabilizing C1 and C2, especially in rotation
Lateral Flexion Alar Ligament Stress Test
Rotational Alar Ligament Stress Test

ATLANTO-OCCIPITAL
JOINTS (C0 TO C1)
are the two uppermost joints.
The principal motion of these two joints is:
Flexion-extension (15 to 20) or nodding of the
head.
Side flexion is approximately 10, whereas rotation
is negligible.

ATLANTO-AXIAL
JOINTS (C1 TO C2)
Pivot/trochoid joint
Most mobile articulation of the spine
FL-EX (10 deg.)
Side flexion (5 deg.)
Rotation (50 deg.)
Ligament: transverse ligament of the atlas
which holds the dens of the axis against the anterior
arch of the atlas.
It is this ligament that weakens or ruptures in
rheumatoid arthritis.
Transverse Ligament Stress Test.
cruciform ligament of the atlas

The Cervicobrachial Area

Symptoms include
neck and/or arm pain
Headaches
Restricted range of motion (ROM)
Paresthesia
Altered myotomes and dermatomes
and radicular signs.
Sympathetic dysfunction may be.
Injury to both areas, if severe enough,
may result in psychosocial issues.
For C3 to C7, the main ligaments are
the:
ALL
PLL
Ligamentum flavum
Supraspinal and
Interspinal ligaments

UNCINATE JOINTS OR
JOINTS OF LUSCHKA
C3 TO T1
not seen until age 6 to 9 years and
are not fully developed until 18 years
of age.
The uncus gives a saddle form to the
upper aspect of the cervical vertebra,
which is more pronounced
posterolaterally; it has the effect of
limiting side flexion.
Extending from the uncus is a joint
that appears to form because of a
weakness in the annulus fibrosus.

FACET ORIENTATION
The superior facets
of the cervical
spine face:
upward, backward,
and medially (PSM)
The inferior facets
face:
downward, forward,
and laterally.

 This plane facilitates flexion and extension

C5 and C6 where greatest flexion-extension of the
facet joints occurs.
Because of this mobility, degeneration is more likely to
be seen at these levels.
there is almost as much movement at C4 to C5 and C6
to C7.
Coupled movement with rotation and side flexion
Between C0 and C2, as well as C7 and T1, the two
movements occur in opposite directions
Between C2 and C7, they occur in the same direction.
These joints move primarily by gliding and are classified as
synovial (diarthrodial) joints.
Capsule: Lax

Cervical Spine
Resting position: Midway between flexion and extension
Close packed position: Full extension
Capsular pattern: Side flexion and rotation equally
limited extension

IVD
make up approximately 25% of the
height of the cervical spine.
No disc is found between the atlas and
the occiput (C0 to C1) or between the
atlas and the axis (C1 to C2).
give the cervical spine its lordotic
shape.
The nucleus pulposus
functions as a buffer to axial
compression in distributing
compressive forces
annulus fibrosus acts to withstand
tension within the disc.

NERVE
ROOTS
- Eight cervical nerve roots.
- Each nerve root is named
for the vertebra below it.
- As an example, C5 nerve
root exists between the C4
and C5.
- In the rest of the spine,
each nerve root is named
for the vertebra above; the
L4 nerve root,
- for example, exists
between the L4 and L5
vertebrae

VERTEBRAL
ARTERY
passes through the transverse
processes of the cervical
vertebrae
usually starting at C6 but entering
as high as C4supplies 20% of
the blood supply to the brain
ICA (80%)
The vertebral and internal
carotid arteries are
Vertebral arteries and ICA are
stressed primarily by rotation,
extension, and traction
movements.

VERTEBRAL ARTERY
lies close to the facet joints and vertebral body where it
may be compressed by osteophyte formation or injury to
the facet joint.
OLDER PEOPLE
may contribute to altered blood flow in the arteries:
atherosclerotic changes and
other vascular risk factors (e.g., hypertension, high
fat or cholesterol levels, diabetes, smoking)
Rotation and extension of as little as 20 have
significantly decrease vertebral artery blood flow.
Dutton reports that the most common mechanism for nonpenetrating injury to the vertebral artery is neck
extension, with or without side flexion or rotation.

VERTEBRAL ARTERY
The greatest stresses are placed on the vertebral arteries in
four places:
where it enters the transverse process of C6
within the bony canals of the vertebral transverse processes
between C1 and C2
and between C1 and the entry of the arteries into the skull
Given the type of injury possible, symptoms may be delayed.
Symptoms related to the vertebral artery include:
Vertigo
Nausea
Tinnitus
drop attacks (falling without fainting)
visual disturbances, or,
in rare cases, stroke or death.

Signs and Symptoms of Vertebrobasilar

Artery Insufficiency*

Dizziness
Giddiness
Drop attacks
Syncope (loss of consciousness)
Stroke
Diplopia, blurred vision
Visual hallucination
Tinnitus (ringing in the ears)
Flushing
Sweating
Lacrimation (tearing)
Rhinorrhea (runny nose)
Scotomata (visual defect in
defined area of eye[s])
Hiccups
Myotonic jerks

Tremor and rigidity

Disorientation
Vertigo
Photophobia (sensitivity to light)
Numbness and tingling
Quadriparesis (weakness in all
four limbs)
Dysphagia (difficulty swallowing)
Dysarthria (difficulty articulating)
Photopsia (sensation of flashing
lights)
Visual anosognosia (unawareness
of visual defect)
Nystagmus
Ataxia (lack of voluntary muscle
coordination)

OBSERVATION

Head and Neck Posture.

Shoulder Levels.
Normally
With injury?
Poking chin will cause shoulders to be?...

Muscle Spasm or Any Asymmetry.

Is there any atrophy of the deltoid muscle
(_______nerve palsy)
- Torticollis?

Facial Expression.
Such observation should give the examiner an idea of how much the
patient is subjectively suffering.

Bony and Soft-Tissue

Contours.
If the cervical spine is injured, the head tends to be tilted
and rotated away from the pain, and the face is tilted
upward.
If the patient is hysterical, the head tends to be tilted and
rotated toward the pain, and the face is tilted down.

Evidence of Ischemia in
Either Upper Limb.
The examiner should note any altered coloration of the skin, ulcers, or
vein distention as evidence of upper limb ischemia.

Normal Sitting Posture.

The nose should be in line with the manubrium and xiphoid
process of the sternum.
From the side, the ear lobe should be in line with the
acromion process and the high point on the iliac crest for
proper postural alignment.
The normal curve of the cervical spine is a lordotic type of
curve.
Referred pain from conditions, such as spondylosis, tends
to occur in the shoulder and arm rather than the neck.

ACTIVE MOVEMENTS
PASSIVE MOVEMENTS
RESISTED ISOMETRIC MOVEMENTS

SCANNING EXAMINATION

Active Movements of
the Cervical Spine
Flexion
Extension
Side flexion left and right
Rotation left and right
Combined movements (if necessary)
Repetitive movements (if necessary)
Sustained positions (if necessary)

Passive overpressure - differentiating between physiological

(active) end range and anatomical (passive) end range.

Flexion
palpate
the relative movement between the mastoid and
transverse process of C1
posterior arch of C1 and the lamina of C2
Posterior bulging of SP of C2 Forward
subluxation of atlas
Sharp Purser test
MAX ROM is normally found when the chin is able to
reach the chest with the mouth closed;
however, up to two finger widths between chin and
chest is considered normal.
SCM compensation
IV foramen: 20-30% larger inflexion than in extension

Extension

The examiner can lift the occiput at the same time.

70 deg
No anatomic block to stop the movement
Atlas tilts upward posterior compression between the
atlas and occiput

Side, or lateral,
flexion
20 to 45 deg
palpate adjacent transverse
processes on the convex side

Rotation
70 to 90

NORMAL ROM VALUES

Repetitive Movements
Or Sustained Postures

Passive Movements of
the Cervical Spine

If pt does not have full ROM

If PT does not apply overpressure to determine end-feel
Greater in supine > sitting
End feels: Tissue stretch

A.
B.
C.
D.

FLEXION
EXTENSION
SIDE FLEXION
ROTATION

A. FLEXION
palpates between the mastoid process and the transverse
process for movement between C0 and C1
between the arch of C1 and spinous process of C2
The rest, palpate between SP

B. SIDE FLEXION
C. ROTATION
palpating the adjacent transverse
processes on each side while doing the
movement
the TP on the side to which the head is
rotated will seem to disappear (bottom
one) while the other side (top one)
seems to be accentuated in the normal
case.
If (-) disappearance/accentuation: there is
restriction of movement between C0 and
C1 on that side.

Resisted Isometric Movements

of the Cervical Spine
Dont let me move you,

A.
B.
C.
D.

FLEXION
EXTENSION
SIDE FLEXION
ROTATION

Peripheral Joint Scan

Temporomandibular Joints.
Open mouth
Close mouth

Shoulder Girdle.
Abduction
Flexion
Scaption
Apleys scratch test (right and
left)
Rotation in 90 abduction

Elbow joints
Flexion
Extension
Supination
Pronation
Wrist and hand joints
Flexion
Extension
Abduction
Adduction
Opposition of thumb
and little finger

Myotomes
Resisted isometric contractions with joint at or near resting
position (5 sec.)
Dont let me move you,
Cervical Myotomes
Neck flexion: C1 to C2
Neck side flexion: C3 and cranial nerve XI
Shoulder elevation: C4 and cranial nerve XI
Shoulder abduction/shoulder lateral rotation: C5
Elbow flexion and/or wrist extension: C6
Elbow extension and/or wrist flexion: C7
Thumb extension and/or ulnar deviation: C8
Abduction and/or adduction of hand intrinsics: T1

Sensory Scanning
Examination
Accomplished by running relaxed hands over all aspects
of the arm.
(+) difference = use pinwheel, pin, cotton batting, or brush
(or a combination of these) to map out the exact area of
sensory difference
May include:
deep tendon reflexes
Pathological reflexes
Neurodynamic tests

Reflexes
Common Reflexes Checked in Cervical
Spine Assessment
Biceps (C5, C6)
Brachioradialis (C5-C6)
Triceps (C7, C8)
Hoffmann sign (if upper motor neuron lesion
suspected)
Jaw Jerk (CNV)

DEEP TENDON REFLEXES

Pathologic Reflexes
Hoffman (Digital) Reflex
ELICITATION:
Flicking of terminal phalanx of index, middle, or ring
finger
POSITIVE RESPONSES:
Reflex flexion of distal phalanx of thumb and of distal
phalanx of index or middle finger (whichever one was not
flicked), interphalangeal joint of the thumb of the same
hand flexes/adducts.
PATHOLOGY:
Increased irritability of sensory nerves in tetany
Pyramidal tract lesion

Sensory Distribution
Of The Peripheral Nerves

Dermatome Pattern Of
The Various Nerve Roots

Brachial Plexus Dermatomes

All based upon anatomical position

C5 lateral arm
C6 lateral forearm, thumb, index finger
C7 posterior forearm, middle finger
C8 medial forearm, ring and little fingers
T1 medial arm

Referral of symptoms from the cervical spine

to areas of the spine, head, shoulder girdle,
and upper limb.

Muscles
and their
referred
pain
patterns

Muscles
and their
referred
pain
patterns

Referred pain
patterns suggested
with pathology of
the apophyseal
joints.

Signs of Headaches Having a

Cervical Origin

Occipital or suboccipital component to headache

Neck movement alters headache
Painful limitation of neck movements
Abnormal head or neck posture
Suboccipital or nuchal tenderness
Abnormal mobility at C0C1
Sensory abnormalities in the occipital and suboccipital areas

Bakodys sign
The patient may state that the pain and referred symptoms are
decreased or relieved by placing the hand or arm of the
affected side on top of the head
it is usually indicative of problems in the C4 or C5 area.

Bilateral tingling symptoms

usually indicate either systemic disorders (e.g., diabetes,
alcohol abuse) that are causing neuropathies or central space
occupying lesions.

DIZZINESS?
Semicircular canal problems
vertebral artery problems.
Falling with no provocation while remaining conscious is
sometimes called a drop attack.
Has
the patient experienced any Disturbances
such

VISUAL
DISTURBANCES?

diplopia (double vision),

Nystagmus (dancing eyes)
scotomas (depressed visual field)
loss of acuity

may indicate severity of injury, neurological injury, and

sometimes increased intracranial pressure

Pain on swallowing

may indicate soft- tissue swelling in the throat

vertebral subluxation
osteophyte projection
or disc protrusion into the esophagus or pharynx.

In addition, swallowing becomes more difficult and the voice

becomes weaker as the neck is extended.

 Breathing
Swallowing
Looking up at the Ceiling
40 to 50 of neck extension is usually
necessary for everyday activities
Looking down at Belt Buckle or Shoe Laces
At least 60 to 70 of neck flexion is
necessary.
Shoulder Check

At least 60 to 70 of cervical rotation is necessary.

Tuck Chin IN
Poke Chin OUT
Neck Strength
Paresthesia

FUNCTIONAL ASSESSMENT

FUNCTIONAL ASSESSMENT

Special Tests
For cervical muscle (deep neck flexors) strength:
Craniocervical flexion test (CCF)
Deep neck flexor endurance test
For neurological symptoms:
Brachial plexus lesions
Brachial plexus tension test
Shoulder depression test
Tinel Sign for Brachial Plexus lesions
Distraction test (if symptoms are severe)
Foraminal compression/Spurlings test (three stages) (if symptoms are absent or mild)
Maximum cervical compression test
Upper limb neurodynamic (tension) tests
Shoulder Abduction or Relief Test
Radicular symptoms at C4 C5 nerve roots
For myelopathy:
Romberg test
Lhermittes
10 Second Step Test

Special Tests

For cervical instability

Anterior shear stress test
Lateral flexion alar ligament stress test
Lateral shear test
Rotational alar ligament stress test
Transverse ligament stress test
For cervical spine mobility:
Cervical flexion rotation test
Pettmans Distraction Test.
For first rib mobility:
First rib mobility
For vascular signs:
Hold planned mobilization/manipulation position for at least 30
seconds watching for vertebral-basilar artery signs
For Vertigo and Dizziness:
Dizziness Test
Hallpike-Dix Test
Temperature/Caloric Test

Outcome Measures
Whiplash Disability Questionnaire (WDQ) (Figure 3-30)
to assess the impact of whiplash associated disorders
including social and emotional problems.
Page 181

Neck Disability Index (NDI) (Figure 3-31), which is a

modification of the Oswestry low back pain index.
Page 183

CERVICAL SPINE
CONDITIONS

Tzietzes Syndrome
Aka Costal chondritis
Painful inflammation of the costochondral junction

TORTICOLLIS
Is the head tilted or
rotated to
one side or the other
d/t
muscle spasm,
tightness, or
prominence of the
sternocleidomastoid
muscle)

TORTICOLLIS
MECHANISM OF INJURY:

CONGENITAL/ MUSCULAR:
- ABN position of head in utero
- prenatal injury
- fibroma in the muscle
- rupture of SCM fibers during birth with hematoma and scar formation
ACUIRED:
Acute Traumatic or Inflammatory
Chronic Infectious or Neoplastic
Arthritic
Circatricial
Paralytic
Hysterical Spasmodic

ACUIRED MECHANISMS OF INURY OF TORTICOLLIS

Acute Traumatic or Inflammatory

Cervical Injures
Atlanto-axial rotatory subluxation
Mm inflammations
Cervical lymph nodes inflammation

Chronic Infectious or Neoplastic

Osteomyelitis
TB
Tumors of spine or SC

Arthritic

RA
Ankylosing spondylitis
OA

Circatricial

Contracture or scar tissue after burn

Paralytic

Asymmetrical flaccid or spastic

paralysis of the neck muscles

Hysterical

Psychogenic inability of patients to

control neck muscles

Spasmodic

CNS or cervical nerve root lesion

resulting to involuntary contraction of
the neck muscles

TORTICOLLIS
DISTINGUISHING SIGNS AND SYMPTOMS

Chin is rotated AWAY from the side of shortened

muscle and head is displaced and tilted toward the
side of shortening
Shoulder elevation on affected size
LOM: Restricted rotation and lateral bending of the
neck BUT N FL-EX ROM
Cervicodorsal Scoliosis
Flattening and shortening of the face on the side to
which the neck is tilted
C/L Occipital flattening
Orbital asymmetry

TORTICOLLIS
ASSESSMENT
History: Painless deformity since birth
(-) X-RAY findings of C-spine
MANAGEMENT
Passive stretching of the shortened muscle into overcorrected position
Direct gaze: I/L superior direction
Use of skull shaping orthotics
Positioning: head during sleep
Active exercises
Modalities:
Hot applications
Gentle massage
Horizontal and vertical traction
Cervical Orthosis
Functional strengthening of C/L neck muscles
Lateral AND Ant head righting reactions
Surgery: Successful resectioning of fibrotic SCM

Klippel-Feil syndrome
- congenital fusion of some
cervical vertebra, from C2C7; usually C3 to C5 (MC
radiographic findings)
MOST COMMON CLINICAL
FINDINGS:
- Short neck
- Low posterior headline
- LOM on neck motions

ASSOCIATED FINDINGS
- Deafness
- Scoliosis (Alone or with
kyphosis

POKING CHIN
result in adaptive
shortening of the
occipital muscles.
It also causes the
cervical spine to
change alignment
resulting in
increased stress
of the facet joints
and posterior
discs and other
posterior elements

FLAT NECK

Exaggerated military posture

Increase in flexion of AO joint
Decrease in cervical lordosis, <20 DEGREES
Mandible protrusion

FORWARD HEAD
Increased extension of AO joint and upper cervical vertebrae
Increased flexion of lower cervical and upper thoracic
Retrusion of mandible

UPPER CROSSED
SYNDROME

MYOFASCIAL PAIN
SYNDROMES

Demonstrate generalized aching and

at least three trigger points,
which have lasted for at least 3 months
with no history of trauma.

Cervical Spondylosis
Pain:

Unilateral

Distribution of pain:

Into affected dermatomes

Pain on extension

Increases

Pain on flexion

Decreases

Pain relieved by rest

No

Age group affected

60% of those older than 45 years

85% of those older than 65 years

Instability

Possible

Levels commonly affected

C5C6, C6C7

Onset

Slow

Diagnostic imaging

Diagnostic

Cervical Disc Herniation

Pain:

May be unilateral (most common) or bilateral

Distribution of pain:

Into affected dermatomes

Pain on extension

May increase (most common)

Pain on flexion

May increase or decrease (most common)

Pain relieved by rest

No

Age group affected

17 to 60 years

Instability

No

Levels commonly affected

C5C6

Onset

Sudden

Diagnostic imaging

Diagnostic (be sure clinical

signs support)

Cervical Disc Herniation

commonly cause severe neck pain that may
radiate into the shoulder, scapula and/or arm,
limit ROM, and
an increase in pain on coughing, sneezing, jarring,
or straining

Cervical radiculopathy
injury to the nerve roots in the cervical spine
presents primarily with:

Unilateral motor and sensory symptoms into the upper limb,

with muscle weakness (myotome),
sensory alteration (dermatome),
reflex hypoactivity, and

Acute radiculopathies are commonly associated with disc

herniations, whereas chronic types are more related to
spondylosis.

Cervical radiculopathy

Arm pain in dermatome distribution

Pain increased by extension and rotation or side flexion
Pain may be relieved by putting hand on head (C5, C6)
Sensation (dermatome)
Affected gait not affected
Altered hand function
Bowel and bladder not affected
Weakness in myotome but no spasticity
DTR hypoactive
Negative pathological reflex
Negative superficial reflex
Atrophy (late sign), hard to detect early

WHIPLASH-TYPE (ACCELERATION)
INJURY OR WHIPLASH ASSOCIATED
DISORDER (WAD)
WHIPLASH INURY
MC cause of cervical
ligament sprain and mm
strain

Caused by: Trauma

MOI: ACCELERATIONDECCELERATION
d/t rear end MVA
30-50 year old females
MC affected ligament?
ASSESSMENT:
ST: (+) reverse Spurlings
sign
(-) NEUROLOGIC FINDINGS

WHIPLASH-TYPE (ACCELERATION)
INJURY OR WHIPLASH ASSOCIATED
DISORDER (WAD)
lead to hypertonia of the sympathetic nervous system.
Some of the sympathetic signs and symptoms the examiner may
elicit are:

ringing in the ears (tinnitus),

dizziness,
Blurred vision,
photophobia,
rhinorrhea,
sweating,
lacrimation,
and loss of strength.

CHRONIC POST
WHIPLASH SYNDROME
Can lead to anxiety, pain catastrophizing (negative or
heightened orientation toward pain), and other adverse
psychosocial factors over time, and it can play a major role in
the symptoms felt by the patient.

BRACHIAL PLEXUS INJURIES OF THE

CERVICAL SPINE

INJURIES TO CERVICAL NERVE ROOTS

AND BRACHIAL PLEXUS

PATHOLOGY
(a) neuropraxia (Sunderland I), or a stretch injury that results in
a temporary nerve conduction block;
(b) axonotmesis (Sunderland I I-IV), or varying degrees of
rupture of the neural axon in which tile neural sheath remains
intact but internal elements are disrupted;
(c) neurotmesis (Sunderland V), or complete rupture of the axon
and the encapsulating connective tissue;
(d) avulsion, in which tile nerve roots tear away from the spinal
cord.

DX:
Currently, neurophysiological studies appear to underestimate
the severity of the injury and falsely provide optimism about
recovery.

PROGNOSIS
Preganglionic or Postganglionic lesions?
Preganglionic lesions are avulsions from tile cord tl1at
do not spontaneously recover
- Better prognosis if Axonotmesis: axon regrowth (1
mm/day)
- Poor prognosis C5-C7
Recovery : 4-6 months upper arm; 6-9 months lower
arm
Recovery continue until 2 years upper arm; until 4
years lower arm

PROGNOSIS
Infants who recover partial antigravity upper trunk muscle
strength during the first 2 months of life should show full
recovery over the first 1 to 2 years of life.
Microsurgical reconstruction of the brachial plexus is
indicated for infants who do not recover antigravity
strength by 5 to 6 months of age, because successful
surgery results in a better outcome than natural history
alone.
Infants who have partial recovery of CS-C6-C7
antigravity strength at 3 to 6 months of age have
permanent, progressive limitations of motion and strength.

Erb-Duchenne Paralysis.
UPPER NERVE ROOT INJURY
(C5,C6)
Cause:
Compression
Stretching
Most common impairments:
paralysis of the rhomboid,
levator scapulae,
serratus anterior,
subscapularis,
deltoid,
supraspinatus,
infraspinatus,

teres minor,
biceps brachialis,
brachioradialis, and
supinator muscles.

Erb-Duchenne Paralysis.
Therefore the shoulder usually is
held in extension,
medial rotation, and adduction with
elbow extension and forearm
pronation.
Although grasp function is intact,
sensory loss usually is present
sensation over the radial surfaces
of the forearm and hand and the
deltoid area are affected.

Dejerine-Klumpke
Paralysis.
Lower BPI (C8-T1)
Atrophy and weakness are evident in the muscles of the
forearm and hand as well as in the triceps. The obvious
changes are in the distal aspects of the upper limb.
The resultant injury is a functionless hand. Sensory loss
occurs primarily on the ulnar side of the forearm and
hand.
paralysis of tile wrist flexors and extensors and the
intrinsic muscles of the wrist and hand.
Clinically, hand grasp is poor, although more proximal
muscles are intact.

Brachial Plexus Birth

Palsy.
These injuries to the brachial plexus occur in 0.1% to 0.4% of
births with the majority showing full recovery within 2 months.
Those infants who have not recovered within 3 months are at
considerable risk to decreased strength and range of motion in
the upper limb.

Burners or stingers
These are transient injuries to the brachial plexus typically occur from a blow
to part of the brachial plexus or from stretching or compression of the
brachial plexus.
combined with factors, such as stenosis or a degenerative disc spondylosis).

Erbs Point

st
1

MOI

nd
2

MOI

rd
3

MOI

INJURIES TO THE CERVICAL NERVE ROOTS

AND BRACHIAL PLEXUS
ETIOLOGY
The peak incidences of brachial plexus injuries are:
at birth
20 to 40 years of age, as a result of motor vehicle accidents or knife
or bullet wounds.
Surgery
median sternotomy for open heart surgery
shoulder reconstruction
axillary arteriography
venous cannulation
administration of regional anesthetic blocks
Positioning during surgical procedures
Neoplastic Disease
Pancoast tumor/ superior sulcus tumors
Breast tumors
Athletic injuries
Defensive players

INJURIES TO THE CERVICAL NERVE ROOTS AND

BRACHIAL PLEXUS
CLINICAL PRESENTATION
Transient weakness of the shoulder musculature accompanied by upper
extremity paresthesia.
sensation is a lightning-like, burning pain into the shoulder and arm,
followed by a period of heaviness or loss of function in the arm
Immediately after injury, weakness can be found in the biceps, deltoid,
supraspinatus, and infraspinatus muscles.
DTR of biceps may also be diminished
Acute syndrome symptoms usually last several seconds to a few minutes
and are followed by complete recovery.
Neck pain may or may not be present
Symptoms often ca n be reproduced by cervical extension and side
flexion toward the involved extremity or lateral flexion away from the
extremity
Any restriction of cervical movement or spinal pain should alert the
examiner to the possibility of cervical spine injury.
Restriction of shoulder range of motion should alert the clinician to the
possibility of a clavicular fracture or acromioclavicular separation .

IMPAIRMENTS
Weak AB-ER
Common contractures of the upper extremity include:
scapular protraction
Shoulder extension, and
wrist and finger flexion.
Medial rotation and Add contracture
absent or abnormal sensation may lead to neglect, and injuries to the skin often
go unnoticed
The primary functional limitations involve:
reaching and grasping,
manipulation of objects, and
bilateral hand use;
Resultant delayed motor activities may include:
getting into and out of positions over the involved side,
protective extension using the involved side, and
delayed balance reactions.
Creeping may be delayed or replaced by scooting,
Significant functional limitations in hand to head, hand to mouth, and
overhead activities

INJURIES TO THE CERVICAL NERVE ROOTS

AND BRACHIAL PLEXUS
ACUTE MANAGEMENT

Resting the extremity

Ice
Transcutaneous electrical nerve stimulation (TENS)
Ultrasound
Anti-inflammatory medications if pain and tenderness of the
cervical spine and shoulder persist.
Neck and shoulder strengthening exercises
Padded neck rolls and shock-absorbing shoulder pads that
should restrict cervical extension and side bending

Rehabilitation Management:
Evaluation, Intervention, and
Clinical Implications

Reflexes
Developmental milestones
MMT
Sensory Test
Motor function of UE
AROM/PROM
PT: Acute -> preventive (first few months)
Goals over first few years:
Achieving and maintaining full range of motion,

muscle extensibility,
normal motor control,
strength,
functional bilateral activities, and
developmental skills

Rehabilitation Management:
Evaluation, Intervention, and
Clinical Implications
2 years of age, goals should include:
achievement of age-appropriate self-care skills (e.g., dressing and grooming using
either extremity) and
active participation in age-appropriate movement activities and preschool
program.
Family education:
passive ROM exercises,
goals of the home program,
risk of contractures,
importance of joint integrity,
precautions to prevent overstretching and joint dislocation,
precautions with regard to sensory loss, and
how to position the infant in all activities to maintain range of motion and regain
muscle strength

Rehabilitation Management:
Evaluation, Intervention, and
Clinical Implications
Facilitation of fill1ctional development through therapeutic play activities,
such as:
hand to mouth;
reaching,
grasping, and
manipulating objects;
propping on the elbows;
hands to midline;
rolling to each side; and
Bilateral hand activities.
Facilitation of a normal scapulothoracic and glenohumeral relationship should
be emphasized.
A variety of play activities should be used to promote strengthening of
weakened muscles.
To develop motor control throughout the range of motion, the clinician should
control time to fatigue, allowing the child to be successful by initially
challenging the involved extremity in a gravity neutral position.

Rehabilitation Management:
Evaluation, Intervention, and
Clinical Implications

Activities should involve toys of different sizes, shapes, and textures and should
incorporate:
hand to mouth,
transferring items from one hand to the other,
weight shifting in prone position,
quadruped or sitting,
creeping, and
reaching for toys at various angles and distances.
Constraining the opposite extremity for brief periods or occupying the opposite
hand with another object can be extremely helpful in focusing and encouraging the
child to use the involved extremity.
Transitional movements over the involved extremity,
Pulling to stand using bilateral hands,
Challenging balance reactions while sitting on a lap or therapy ball, and
Performing bilateral upper extremity activities (e.g., catching a large ball, clapping
to music, or opening a jar)
Weight-bearing activities such a s wheelbarrow walking, bear crawling, crab
walking and wall push-ups are important for the development of shoulder girdle
strength and stability as well as to improve proprioception and body awareness.

Potential Cause: Fracture

Clinical Characteristics
Clinically relevant trauma in adolescent or adult
Minor trauma in elderly patient
Ankylosing spondylitis

Potential Cause: Neoplasm

Clinical Characteristics
Pain worse at night
Unexplained weight loss
History of neoplasm
Age of more than 50 or less than 20 years
Previous history of cancer
Constant pain, no relief with bed rest

Potential Cause: Infection

Clinical Characteristics
Fever, chills, night sweats
Unexplained weight loss
History of recent systemic infection
Recent invasive procedure
Immunosuppression
Intravenous drug use

Potential Cause:
Neurologic injury
Clinical Characteristics
Progressive neurologic deficit
Upper and lower extremity symptoms
Bowel or bladder dysfunction

Potential Cause: Cervical

myelopathy
Clinical Characteristics
Sensory disturbance of the hands
Muscle wasting of hand intrinsic muscles
Unsteady gait
Hoffman reflex
Hyperreflexia
Bowel and bladder disturbances
Multisegmental weakness and/or sensory changes

Cervical Myelopathy
Motor Changes
Initial Symptoms (Predominantly Lower Limbs)
Spastic paraparesis
Stiffness and heaviness, scuffing of the toe, difficulty climbing stairs
Weakness, spasms, cramps, easy fatigability
Decreased power, especially of flexors (dorsiflexors of ankles and toes;
flexors of hips)
Hyperreflexia of knee and ankle jerks, with clonus
Positive Babinski sign, extensor hypertonia
Decreased or absent superficial abdominal and cremasteric reflexes
Drop foot, crural monoplegia
Later Symptoms (In Order of Occurrence)
Various combinations of upper and lower limb involvement
Mixed picture of upper and lower motoneuron dysfunction
Atrophy, weakness, hypotonia, hyper-reflexia to hyporeflexia, and absent
deep tendon reflexes

Cervical Myelopathy
Sensory Changes
Headache and head pain
Neck, eye, ear, throat, or sinus pain
Sensory symptoms in the pharynx and larynx
Paroxysmal hoarseness and aphonia
Rotary vertigo
Tinnitus synchronous with pulse or continuous whistling noises
Deafness
Oculovisual changes (e.g., blurring, photophobia, scintillating scotomata,
diplopia, homonymous hemianopsia, and nystagmus)
Autonomic disturbance (e.g., sweating, flushing, rhinorrhea, salivation,
lacrimation, nausea, and vomiting)
Weakness in one or both legs, drop attacks with or without loss of consciousness
Numbness on one or both sides of the body
Dysphagia or dysarthria
Myoclonic jerks
Hiccups
Respiratory changes (e.g., Cheyne-Stokes respiration, Biot respiration, or ataxic
respiration)

Cervical Myelopathy
(+) pathological reflexes (e.g.
Babinski, Hoffman)
Hyperreflexia of DTRs
Clonus
(+) lhermittes sign
sharp, electric shock-like pain down
the spine and into the upper or
lower limbs
INDICATION: dural or meningeal
irritation in the spine or possible
cervical myelopathy.
Romberg test = (+) UMNL
Ten Second Step Test: Ave:19-20 steps

Potential Cause: Upper

cervical ligamentous
instability
Clinical Characteristics
Occipital headache and numbness
Severe limitation during neck active
ROM in all directions
Signs of cervical myelopathy

Potential Cause: Vertebral

artery insufficiency
Clinical Characteristics
Drop attacks
Dizziness or lightheadedness related
to neck movement
Dysphasia
Dysarthria
Diplopia
Positive cranial nerve signs

Potential Cause: Inflammatory

or systemic disease
Clinical Characteristics
Temperature more than 37 C
Blood pressure more than
160/95 mm Hg
Resting pulse more than 100 bpm
Resting respiration more than 25 bpm
Fatigue

Cervical Spine Injuries

Cervical Sprains
Cervical Strains
Cervical Spinal Stenosis
Cervical Fractures and Dislocations

Cervical Spinal Stenosis

Pain:

Unilateral or bilateral

Distribution of pain:

Usually several dermatomes

affected

Pain on extension

Increases

Pain on flexion

Decreases

Pain relieved by rest

Yes

Age group affected

11 to 70 years
Most common: 30 to 60 years

Instability

No

Levels commonly affected

Varies

Onset

Slow (may be combined with

spondylosis or disc herniation)

Diagnostic imaging

Diagnostic

SPINAL STENOSIS
Narrowing of spinal canal
N diameter: 17 mm Spinal canal
10 mm Spinal cord
RELATIVE STENOSIS: 12 mm
ABSOLUTE STENOSIS: 10 mm
ETIOLOGY:
Facet joint hypertrophy
Ligamentum flavum hypertrophy
Disc protrusion4Spur formation
Position:
Avoid: Extension
Ideal: Flexion

CERVICAL STRAIN AND

SPRAINS
CERVICAL STRAIN Musculotendinous injury produced
by an overload injury resulting from forces imposed on
the cervical spine
CERVICAL SPRAIN Overstretching or tearing injuries
of the spinal ligaments
EPIDEMIOLOGY
Muscular strains > ligamental sprains
MC type of injuries to MVA
MC cause of pain after noncatastrophic sports injures
MC in women ages 30-50 years old

CERVICAL STRAIN AND

SPRAINS
PATHOPHYSIOLOGY
ALL tears
Traumatic blows
Repetitive motions
Thoracic kyphosis, cervical lordosis and extension -> levscap,
SCM, scalene and suboccipital mm strain
Acceleration-decceleration injuries
100 ms after rear end impact S-shaped curvature excursion
of spine
90-120 ms activation of posterior neck muscles
200 250 ms head initiates forward flexion of neck
Neck eccentrically contract to decelerate head

CERVICAL STRAIN AND

SPRAINS
DIAGNOSIS
- Headache: Sharp/ dull localized to cervical/ shoulder
girdle mm
- History of MVA
- Neck Fatigue and stiffness aggravated by
PROM/AROM
- Dec. ROM
- MC invovled areas: SCM, Trapz
- (-) Neuro signs
- Give way weakness

CERVICAL STRAIN AND

SPRAINS
TREATMENT
Initial Care:
- Control Pain and Inflammaition
- NSAIDS and acetaminophen
PT Modalities
- Massage
- Superficial and deep heat
- Soft cervical collar
Gradual return to activities (2-4 weeks after inury)
Postural reeducation program
Proper movement patterns
Proprioceptive, balance and postural conditioning
Mobilization and stretching exercises

CERVICAL RADICULOPATHY
AND RADICULAR PAIN
CERVICAL RADICULOPATHY
- Pathologic process involving neurophysiologic dysfunction of the
nerve root
- Reflex and strength deficits marking a hypofunctional nerve root as
a result of pathologic changes

CERVICAL RADICULAR PAIN

- Hyperexcitable state of the afferent nerve root

EPIDEMIOLOGY:
Decreasing frequency of involvement:
C7 C6 C8 C5

CERVICAL RADICULOPATHY
AND RADICULAR PAIN
PATHOPHYSIOLOGY
- Cervical nerve root injury most commonly caused by cervical IVD
herniation
- Next MC cause: Cervical spondylosis
- CERVICAL SPONDYLOSIS
- Degenerative OA changes
- Manifested by:
- ligamentous hypertrophy
- Hyperostosis
- Disk generation
- Z joint arthopathy
- Hypertrophy of Zygapophyseal joints and uncovertebral joints IV
foramina stenosis and nerve root impingement
- Vertebral body osteophytes and dsik material can form a disk that can
also compress adjacent nerve root

CERVICAL RADICULOPATHY
AND RADICULAR PAIN
DIAGNOSIS
- History and PE
- Hx of cervical pain that is followed by an expulsive onset of
upper limb pain
- Spondylitic radicular pain presents more gradually
- Cervical radicular pain can masquerade as deep dull ache or
lancinating pain
- Exacerbating factors:
- Coughing, sneezing, valsalva
- Cervical extension: significant stenosis is present
- (+) Bakody sign

CERVICAL RADICULOPATHY
AND RADICULAR PAIN
DIAGNOSIS
- Atrophy severe or longstanding lesions
- Mm testing has greater specificity
- Altered sensation to pinprick, light touch and vibration
- Long tract signs Hoffmans and Babinski signs : SC involvement
- Spurlings maneuver highly specific but not sensitive
- Root tension more sensitive, less specific
- Lhermittes sign SC involvement, tumor, spondylosis or MS

- Imaging studies
- Plain cervical radiography
- CT Myelography
- MRI Cervical radicuolpathy
- Contrast enhanced CT Scan disk pathology

CERVICAL RADICULOPATHY
AND RADICULAR PAIN
TREATMENT
Primary Objectives:
- Pain resolution
- Improve myotome weakness
- Avoid SC complications
- Prevent recurrence
SURGICAL APPROACH Progressive neuro fdeficit
Pt educ, activity modiification, pain relief
Avoid repetitive heavy lifting
Modalities
TENS
COLD,
Superficial heat but Avoid deep heat!

CERVICAL RADICULOPATHY
AND RADICULAR PAIN
TREATMENT
Cervical Orthosis (1-2 weeks)
Cervical Traction
distract midcervical segment 25 lb weight applied for 25
minutes at 24 degree angle of pull
Cerviothoracic stabilization
- restore biomechanics, limit pain, max function, prevent
recurrence and progression
Cervical strengthening
Medications
NSAIDs
Mm relaxants
Low dose tricyclic antidepressants
Opiate

CERVICAL JOINT PAIN

EPIDEMIOLOGY
- 30-60% prevalence
- MC in C2-C3; then C5-C6 & C6-C7
- Cervical Z joints are common source in chronic post traumatic neck pain
- Associated with symptomatic IVD at the same level
- Traumatically induced lower cervical pain attributable to a Z joint MC
involves C5-C6
DIAGNOSIS
- Unilateral occipital headaches
- Unilateral paramidline neck pain with or without periscapular symptoms,
that is more painful than any associated headache
- Localized spot of maximal pain
- Focal tenderness to palpation
- Painful C1-C2 = Increase suboccipital pain that is exacerbated with 45
degrees of cervical flexion and sequential axial rotation

CERVICAL JOINT PAIN

IMAGING STUDIES
Plain Radiography = Joint subluxation
CT Scan = Fracture
TREATMENT
Acute Phase
NSAIDS
Superficial cryotherapy (20 mins initially 3-4x a day)
ST mobilization and massage
Soft cervical collar worn up to 72hours after initial injury
Pt education on proper positioning

CERVICAL INTERNAL
DISK DISRUPTION

IVD has lost its N internal architecture but remains a preserved

external contour in the absence of nerve root compression
EPIDEMIOLOGY
- 20% of traumatically induced neck pain
- 41% CIDD + concomitant Z joint injury
DIAGNOSIS
SYMPTOM COMPLEX
- Posterior neck pain
- Interscapular and periscapular pain
- Upper trapezial pain
- Occipital and subociipital pain
- Nonradicular arm pain
- Vertigo, tinnitus, ocular dysfunction
- Dysphasia, facial pain
- Anterior chest wall pain

CERVICAL INTERNAL
DISK DISRUPTION

DIAGNOSIS
- Hx of trauma with acute onset
- With absence of precipitating event, symptoms of CIDD can start spontaneously or
gradually, or explosively
- If (+) referred pain: axial pain associated with nondescript upper limb symptoms
- Exacerbating factors: prolonged sitting, coughing, sneezing or lifting
- Alleviating factors: lying supine with head support
- Subtle ROM restrictions
- If (+) cervical spondylosis cervical extension and side bending more restricted than
flexion and axial rotation
- (+) pain on palpation over cervical SP of involved level.
IMAGING
- MRI
- Plain films hyperostosis and disk space collapse but frequently do not correlate with
pain symptoms
- MARKERS OF DISK DEGENERATION:
- Disk dessication
- Loss of disk height
- Annular fissure
- Osteophytosis
- Reactive end plate changes

CERVICAL INTERNAL
DISK DISRUPTION
TREATMENT
- SIMILAR WITH CERVICAL RADICULOPATHY
- NSAIDS
- Modalities
- Traction should be used cautiously
- Cervical collars help comfortable positioning

Active stretching and flexibility program with transition

conditioning and stabilization