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Cervical Spine

Anatomy and
Clinical Evaluation
Orthopedic Assessment III
Head, Spine, and Trunk
with Lab
PET 5609C

Clinical Anatomy

Cervical Spine:

Greatest range
of motion

risk of injury

Vertebral bodies:
Smaller than
other vertebral
sections
7 vertebrae:

1st Atlas
2nd Axis

Clinical Anatomy

Cervical Spine:

Atlas:

No vertebral body
Transverse processes
No true spinous
process
Supports the weight
of the skull through 2
facet surfaces
(atlanto-occipital joint
or C0-C1 articulation)

Flexion and extension


(primary movement)
Lateral flexion (slight)

Clinical Anatomy

Atlanto-occipital joint
dislocation:

(15% of all fatal spinal


trauma)
MOI: high speed motor
accident; Pt.
unconscious at the
scene, respiratory arrest
en route to hospital
Lateral cervical spine
radiograph:

Prevertebral soft-tissue
swelling (white arrow)
Malalignment between
the skull and the
cervical spine with
widening of the atlantooccipital joints (black
arrow)

Clinical Anatomy

Cervical Spine:

Axis:
2nd cervical
vertebrae
Small body with a
superior projection
(Dens)

Atlanto-axial joint:
Dens and atlas
articulation
Rotation of the
skull

Clinical Anatomy

Cervical ligaments:

Anterior and posterior


longitudinal ligaments:

Ligamentum nuchae:

Limits flexion

Interspinous ligaments:

Limit extension and flexion

Between spinous processes


Limit flexion and rotation

Ligamentum flavum:

Connect laminae
Limits flexion and rotation

Clinical Anatomy

Brachial
Plexus: C5 T1

7 cervical
vertebrae
8 cervical
nerves:

1st 7: exit above


the
corresponding
vertebrae
C8: exits below
the 7th cervical
vertebrae

Clinical Anatomy

Muscular Anatomy:
Cervical extension and flexion
bilateral contraction of cervical
muscles
Side bending and rotation unilateral
contraction
Superficial cervical musculature:

Splenius capitis
Splenius cervicis
Upper trapezius
Sternocleidomastoid

Clinical Anatomy

Splenius capitis:

O: Lower half of
ligamentum nuchae
I: Mastoid process
and adjacent occipital
bone
A: Lateral bending

Splenius cervicis:

O: C7 spinous process
through T6
I: Transverse
processes of C2 C4
A: Rotation, extension

Clinical Anatomy

Upper trapezius:

O: Occipital
protuberance, nuchal
line, upper portion of
ligamentum nuchae
I: Lateral 1/3 of
clavicle, acromion
process
A: Cervical extension,
cervical spine
bending, scapular
elevation, upward
scapular rotation

Clinical Anatomy

Levator scapulae:

O: Spinous process
of C7, transverse
processes of C1
through C4
I: Superior medial
border of scapula
A: Extension of
cervical spine,
scapular elevation
and downward
rotation

Clinical Anatomy

Scalenes:

Anterior scalene:

Middle scalene:

O: Anterior portion of transverse processes C2-C7


I: Lateral to insertion of anterior scalene on 1 st rib

Posterior scalene:

O: Anterior portion of transverse processes C3-C6


I: Sternal attachment of 1 st rib

O: Anterior portion of transverse processes C5-C6


I: Medial portion of 2nd rib

Action: Lateral bending of cervical spine

Clinical Anatomy

Clinical Anatomy

Sternocleidomast
oid:

O: Medial
clavicular head,
superior sternum
I: Mastoid
process
A: Flexion of
cervical spine,
rotation to
opposite side,
lateral bending

Clinical Evaluation

History:

Location of pain:

Localized pain:

Radiating pain:

Muscle strain,
ligament sprain,
vertebral fracture,
facet syndrome
Trauma to cervical
nerve root or spinal
cord

Onset of pain:

Acute, chronic,
insidious

Clinical Evaluation

History:

Mechanism of Injury:

Insidious onset:

Overuse and postural conditions

Acute onset:

Axial load (compression fracture)


Flexion (compression of anterior vertebral
body and intervertebral disc; facet joint
sprain; posterior muscle strain)
Extension (compression of posterior vertebral
body and intervertebral disc; anterior
longitudinal ligament sprain)
Lateral bending (nerve root compression,
facet joint compression)

Clinical Evaluation

History:

Mechanism of Injury:

Acute onset:

Consistency of pain:

Rotation (disc trauma, ligament sprain, vertebral


dislocation)
Inflammatory induced pain: consistent pain
Mechanical pain (i.e. nerve compression): varies
in intensity, moving spine may or pain

History:

Previous injury
Scar tissue formation
Injured disc
Osteophyte within intervertebral foramina

Clinical Evaluation

Inspection:

Cervical
curvature:
Lordotic
curvature
normal
Lateral bending
posture -
pressure on
nerve roots away
from the bend

Clinical Evaluation

Inspection:

Position of head on
the shoulders:
Unilateral spasm
lateral flexion of head
towards involved side
Torticollis: Wry neck

Rotation of chin
opposite the side of
the tilt
Congenital or
acquired spasm of
the SCM

Clinical Evaluation

Inspection:

Position of the
head on the
shoulders:
Torticollis

18 years age male with congenital


torticollis with the left SCMM tight
as a band unabeling him to turn his
head 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

Clinical Evaluation

Inspection:

Bilateral soft tissue


comparison:

Trapezius and other


musculature:

Hypertrophy, atrophy

Level of the shoulders:

Height of
acromioclavicular joints
Deltoids
Clavicles

Clinical Evaluation

Palpation:

Anterior
Structures:

Hyoid bone:

Thyroid cartilage:

Have patient
swallow noting
superior and
inferior movement
Level of 3rd cervical
vertebrae
Adams apple
Level of 4th and 5th
cervical vertebrae

Cricoid cartilage:

Level of 6th cervical


vertebrae

Clinical Evaluation

Palpation:

Anterior structures:

Sternocleidomastoi
d:

Have patient
rotate head

Scalenes:

Posterior to SCM
(C3-C6 level)

Carotid artery
Lymph nodes

Clinical Evaluation

Palpation:

Posterior and
Lateral Structures:
Occiput and
superior nuchal line
Transverse
processes
Spinous processes:

Have patient flex cspine


C7 and T1

Trapezius

Clinical Evaluation

Range of Motion:

Active neck flexion and extension:


Test position: patient can be standing or
seated
Motion: Atlanto-occipital joint
Flexion: patient touches chin to chest (45 0)
Extension: patient looks up towards ceiling
(450)

Active neck lateral flexion:


Test position: patient seated or standing
Patient takes ear to shoulders (45 0)

Clinical Evaluation

Range of Motion:

Active rotation:
Test position: patient seated, head held
upward and facing forward
Patient attempts to look over each
shoulder
Motion: Atlanto-axial joint (450)

Clinical Evaluation

Range of Motion:

Passive flexion:
Patient position: supine
ATC: grab patients head (under occiput)
and attempt to bring chin to chest

Passive extension:
Patient position: supine, head off end of
table
ATC: grasp patients head and move into
extension

Clinical Evaluation

Range of Motion:

Passive lateral flexion:


Patient position: supine, head in
neutral position
ATC: one hand under occiput, tilt
head/neck to bring ear to shoulder

Passive rotation:
Patient position: supine
ATC: grasp patients forehead and
occiput, rotate head and neck

Clinical Evaluation

Clinical Evaluation

Range of Motion:

Resisted range of motion: Flexion


Patient: supine with cervical spine and
head in neutral position
Stabilization: superior aspect of
sternum
Resistance: to the forehead
Muscles tested: SCM and anterior
scalenes

Clinical Evaluation

Range of Motion:

Resisted range of motion: Extension


Patient: prone with cervical spine and
head in neutral position
Stabilization: superior aspect of
thoracic spine
Resistance: to the skull over the occiput
Muscles tested: trapezius (upper 1/3,
levator scapulae, cervical paraspinal
muscles)

Clinical Evaluation

Range of Motion:

Resisted range of motion: Lateral


flexion
Patient: seated with cervical spine and
head in neutral position
Stabilization: over the AC joint on the side
toward the motion
Resistance: over the temporal and parietal
bones on the side toward the motion
Muscles tested: SCM, scalenes, paraspinal
muscles on the side being tested

Clinical Evaluation

Range of Motion:

Resisted range of motion: Rotation


Patient: seated with cervical spine and
head in neutral position
Stabilization: over the anterior shoulder
on the side toward the rotation
Resistance: over the temporal bone on
the side toward the motion
Muscles tested: SCM, multifidus,
rotators

Clinical Evaluation
C1-C2
C3
C4
C5
C6
C7
C8
T1

Neck flexion
Neck lateral flexion
Shoulder shrug
Shoulder abduction, ER
Elbow flexion, wrist
extension
Elbow extension, wrist
flexion
Thumb extension
Finger abduction and

Clinical Evaluation

Neurological
Screening:

Nerve root: C5
(Biceps brachii)
Patient: seated
and relaxed
ATC: thumb
placed over biceps
tendon, strike the
thumb nail with
reflex hammer

Clinical Evaluation

Neurological
Screening:

Nerve root: C6
(Brachioradialis)
Patient: seated
and relaxed
ATC: taps the
brachioradialis
with reflex
hammer

Clinical Evaluation

Neurological
Screening:

Nerve root: C7
(Triceps)
Patient: seated
and relaxed
ATC: support arm
in position of
extension and
abduction, tap the
triceps tendon with
reflex hammer

Clinical Evaluation

Babinkski Test:

Athlete: Supine with shoes


and socks removed
ATC: At the foot of the
athlete holding a blunt tool
Procedure: ATC runs the tool
up bottom of athletes foot
starting at the calcaneus and
ending at the great toe
Positive test: Great toe
extends while other toes
splay
Implications: Lesion of
upper motor neurons, may be
caused by trauma to the
brain
Comments: This reflex
occurs naturally in
newborns. However, this
reflex should cease quickly
after birth

Clinical Evaluation

Oppenheim Test:
Test: Upper motor neuron lesions
Patient position: supine
ATC: at patients side
Procedure: examiners fingernail is
run along the crest of the
anteromedial tibia
Positive test: great to extends and
the other toes splay