CERVICAL SPINE

CONTENTS
• Anatomy
• Biomechanics
• Common conditions
• Assessment
 History
Observation
Palpation
Examination
• General Vertebral Anatomy
• Body
• Vertebral Arch
• Pedicles
• Laminae
• Vertebral Foramen
• Spinous Process
• Facets
• Superior Articulating Surface
• Inferior Articulating Surface
• Transverse Process
• Intervertebral Foramen
 ARTICULATION OF CERVICAL SPINE
• Atlanto-occipital joint
• Occipital condyles of skull and superior articulating surface of
atlas
• A joint between the atlas & axis is called as ATLANTO-AXIAL
JOINT
• Body-to-body articulation (INTERVERTEBRAL JOINTS)
• Fibrocartilagenous Intervertebral Disk
• Annulus fibrosus
• Nucleus pulposus
LIGAMENTS OF CERVICAL SPINE
• Transverse ligament
• Alar ligament
• Anterior longitudinal ligament
• Posterior longitudinal ligament
• Ligamentum flavum
• Intertransverse ligaments
• Interspinous ligaments
• Ligamentum nuchae
 MUSCLES OF CERVICAL SPINE
• FLEXORS- longus colli, sternomastoid, scalenus anterior, longus
capitis, rectus capitis anterior
• EXTENSORS- levator scapulae, splenius cervicis, trapezius, splenius
capitis, errector spinae, rectus capitis posterior major and minor and
superior oblique
• LATERAL FLEXORS- scalenus anterior, medius and
posterior,levator scapulae, sternomastoid, splenius capitis, trapezius,
errector spinae
• ROTATORS – semispinalis cervicis, multifidus, splenius anterior,
splenius cervicis & capitis, sternomastoid, inferior oblique, rectus
capitis posterior major.
 BIOMECHANICS OF CERVICAL
SPINE
• KINEMATICS:
• The cervical spine is designed relatively for a large amount
of mobility. Normally the neck moves 600 times every hour
whether awake or asleep.
• The motions of flexion and extension, lateral flexion and
rotation are permitted in the cervical region. These motions
are accompanied by translations that increase in magnitude
from C2 to C7.
 CERVICAL RANGE OF MOTION
• According to AAOS (American Association of Orthopaedic
Surgeons) the normal ROM :
• C. Flexion – 0 to 45 deg
• C. Extension – 0 to 70 deg
• C. Lateral flexion – 0 to 40 deg
• C. Rotation – 0 to 80 deg
• Cervical motion has six degrees of freedom, translations in each
plane and rotations in each axis.
• These motion are coupled such that motions around one axis are
consistently associated with motion around another axis.
• COUPLED MOTION
• C1 can move independently,but motion below C1 involves the
entire cervical spine because the vertebrae are attached to each
other functionally in motion segments.
Flexion – Extension is coupled with TRANSVERSE
(HORIZONTAL) TRANSLATION
Lateral flexion with ROTATION
Rotation with AXIAL (VERTICAL) TRANSLATION
COUPLED MOVEMENTS
KINETICS
• Loads on the cervical spine are produced mainly by the
weight of the head, the activity of the surrounding
muscle, the inherent tension of the adjacent ligament and
the application of the external loads.
• These loads are minimal during upright relaxed standing
& sitting.
• Rotation & lateral flexion increases the loads moderately.
• During extreme flexion & extension these loads are
increased maximally.
• STATIC LOADS ON THE CERVICAL SPINE WITH
VARIOUS POSITION OF THE HEAD
• The load on the junction between occipital bone and C1 is
lowest during extreme extension.
• It is highest during extreme flexion and slightly increase when
the neck was in neutral position.
• The load on the C7 and T1 motion segment was low with the
neck in the neutral position but became even lower when the
head was held upright with the chin tucked in.
• The load increased some what during extreme extension and
substantially during slight flexion. The greatest loads were
produced during extreme flexion.
• DYNAMICS OF CERVICAL SPINE DURING EXCESSIVE
LOADIING
• The structure of the head and neck, which is essentially that of a
large mobile ball atop a slender pivot makes the cervical spine and
surrounding soft tissues particularly vulnerable to dynamic injury.
• Excessive loading and motion of the relatively heavy head upon its
“pivot” can easily create stresses & strains that exceed the strength
of the stabilizing structures.
• Mechanisms responsible for excessive loading of the spine have
received considerable attention because of the importance of
preventing spine trauma & its grave consequences. Example :
whiplash injuries, facetal dislocations, wedge compression etc..
 ASSESSMENT
• Patient History
• What is the patient’s age?
• What are the symptoms, and which are most severe?
• What was the mechanism of injury?
• Has the patient had neck pain before?
• What is the patient’s usual activity or pastime?
• Did the head strike anything, or did the patient lose
• consciousness?
• Did the symptoms come on right away?
• What are the sites and boundaries of the pain?
• Is there any radiation of pain?
• Is the pain affected by laughing, coughing, sneezing, or
• straining?
• Does the patient have any headaches? If so, where? How
• frequently do they occur?
• Does a position change alter the headache or pain?
• Is paresthesia (a “pins and needles” feeling) present?
• Does the patient experience any tingling in the extremities?
• Does the patient experience dizziness, faintness, or seizures?
• Which activities aggravate the problem? Which activities
• ease the problem?
COMMON CONDITIONS
 PAIN HISTORY
Quality of pain
Intensity of pain
I1-Mild pain
I2-More than mild but tolerable
I3-Moderately severe pain
I4- Severe pain
I5-Intolarable
Frequency/ periodicity
Aggravating factor
Reliving factor
Severity and irritability of symptoms
Temporal variations
• Signs and Symptoms Arising from Cervical Spine Pathology
SIGNS SYMPTOMS
Anesthesia (lack of Arm and leg pain
sensation)
Ataxia Dizziness
Atrophy Headache
Asymmetry Insomnia
Dysesthesia Pain
Falling Paresthesia
Nystagmus Poor balance
Upper limb weakness Stiff neck
 OBSERVATION

Observation views of head and neck. A, Anterior view. B, Posterior view. C, Lateral or side
view. With normal posture, the ear should be in line with the shoulder and the forehead
vertical.
• Upper crossed syndrome
• Head and neck posture
• Shoulder levels
• Muscle spasm or any asymmetry
• Facial expressions
• Bony and Soft-Tissue Contours
• Evidence of Ischemia in Either Upper Limb
• Normal Sitting Posture
• Cock-robin" posture
 PALPATION
• Tenderness
• Trigger points
• Muscle spasm ( muscle hardness tester, Neutone)
• Myoton pro for tone,elasticity,stiffness
• Texture of the skin and surrounding bony and soft tissues on the
posterior, lateral, and anterior aspects of the neck.
• POSTERIOR ASPECT
• External Occipital Protuberance.
• Spinous Processes and Facet Joints of Cervical Vertebrae.
• Mastoid Processes (Below and Behind Ear Lobe)
• LATERAL ASPECT
• Transverse Processes of Cervical Vertebrae.
• Lymph Nodes and Carotid Arteries
• Temporomandibular Joints, Mandible, and Parotid Glands.

• ANTERIOR ASPECT
• Hyoid Bone, Thyroid Cartilage, and First Cricoid Ring
• Paranasal Sinuses
• First Three Ribs
• Supraclavicular Fossa
 EXAMINATION
• Active movements

Active movements of the cervical spine. A, Anterior

nodding (upper cervical spine). B, Flexion. C,
Extension. D, Posterior
nodding (upper cervical spine). E, Side flexion. F,
Rotation
RANGE OF MOTION

Digital inclinometer Bubble inclinometer

• Opto electronic scanners
Movement Restriction and Possible Causes
• Movement Restriction • Possible Causes
[Link] and right side bending [Link] extension hypomobility, Left
flexor muscle tightness, Anterior
[Link] and right side bending capsular adhesions ,Right subluxation,
[Link] and right side bending Right small disc protrusion
restriction greater than extension 2. Left flexion hypomobility,Left
and left side bending extensor muscle tightness
[Link] and right side bending [Link] posterior capsular adhesions,Left
restriction equal to extension and subluxation,Left capsular pattern
left side flexion (arthritis, arthrosis)
[Link] bending in neutral, flexion, [Link] arthrofibrosis (very hard capsular
and extension end feel)
[Link] hypomobility or
anomaly
• PASSIVE MOVEMENTS

Testing passive movement in the cervical spine. A, Position testing for occipito-atlantal
joint. B, Position testing for atlanto-axial
joint. C, Flexion testing of C2–T1, Side flexion, Rotation
• RESISTED ISOMETRIC MOVEMENTS

Positioning for resisted

isometric movement. A,
Flexion. B, Extension. C,
Side flexion (left side flexion
shown). D, Rotation (left
rotation shown).
• PASSIVE ACCESSORY MOVEMENTS
Joint Play Movements of the Cervical Spine
• Side glide of the cervical spine (general)
• Anterior glide of the cervical spine (general)
• Posterior glide of the cervical spine (general)
• Traction glide of the cervical spine (general)
• Rotation of the occiput on C1 (specific)
• Posteroanterior central vertebral pressure (specific)
• Posteroanterior unilateral vertebral pressure (specific)
• Transverse vertebral pressure (specific)
Vertebral pressures to the cervical spine. A, Posteroanterior central vertebral pressure on tip of spinous process. B,
Posteroanterior unilateral vertebral pressure on posterior aspect of transverse process. C, Transverse vertebral
pressure on side of spinous process.
 • Functional Strength Testing of the Cervical Spine
Starting Position Action Functional Test
Supine lying Lift head keeping chin tucked in (neck 6 to 8 repetitions: Functional
flexion) 3 to 5 repetitions: Functionally fair
1 to 2 repetitions: Functionally poor
0 repetitions: Nonfunctional
Prone lying Lift head backward (neck extension) Hold 20 to 25 seconds: Functional
Hold 10 to 19 seconds: Functionally fair
Hold 1 to 9 seconds: Functionally poor
Hold 0 seconds: Nonfunctional

Side lying (pillows under head so Lift head sideways away from pillow Hold 20 to 25 seconds: Functional
head is not side flexed) (neck Hold 10 to 19 seconds: Functionally fair
side flexion) (must be repeated for other Hold 1 to 9 seconds: Functionally poor
side) Hold 0 seconds: Nonfunctional

Supine lying Lift head off bed and rotate to one side Hold 20 to 25 seconds: Functional
keeping head off bed or pillow (neck Hold 10 to 19 seconds: Functionally fair
rotation) (must be repeated both ways) Hold 1 to 9 seconds: Functionally poor
Hold 0 seconds: Nonfunctional
• Craniocervical flexion test
 SPECIAL TESTS
NEUROLOGICAL UPPER MOTOR VASCULAR SIGN CERVICAL
SYMPTOMS NEURON LESION INSTABILITY
Foraminal compression( Romberg’s test Cervical quadrant test Rust’s sign
spurlings)
Jackson’s compression Lhermitte’s sign Havtant test Sharp purser test
Distraction Soto hall sign Naffziger’s test Transverse ligament
stress test
ULTT(Elvey) Pettman’s distraction test
Doorbell sign Anterior shear/saggital
stress test
Bakody’s sign Lateral ( transverse)shear
test
Scalene cramp test Lateral flexion alar
ligament stress test
Valsalva Rotational alar ligament
stress test
Tinnel’s sign
Jackson’s compression test Door bell sign Scalene cramp test
Lhermitte sign. A, Patient in long
sitting position. B, Examiner
flexes patient’s head and hip
simultaneously
Vertebral artery (cervical quadrant) test Positioning for Hautant’s test. A, Forward flexion of both
arms to 90°. B, Rotation and extension of neck with arms
forward flexed to 90°

Naffziger test (compression

of jugular veins)
Anterior sagittal stress test Lateral flexion alar ligament Rotational alar ligament stress test
stress test
The Sharp-Purser test for Pettman’s distraction test. A, First position. B, Second
subluxation of the atlas on (flexed) position
the axis.
 FUNCTIONAL SCALES
• Neck disability index
• Whiplash disability questionnaire
• Japanese orthopaedic association cervical myelopathy evaluation
REFRENCES
• Oatis CA, Beattie PF. Kinesiology: The Mechanics &
Pathomechanics of Human Movement, 2004. Philidelphia:
Lippincott Williams & Wilkins.;2.
• Magee DJ. Orthopedic physical assessment-E-Book. Elsevier
Health Sciences; 2014 Mar 25.
• Cook C, Hegedus EJ. Orthopedic physical examination tests: an
evidence-based approach.
THANK YOU