Physical Examination of the
Cervical Spine
William C. Scott, D.O.
Dept. of Physical Medicine and
Rehabilitation
Louisiana State University
Our agenda
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Review tissue texture changes associated with
acute versus chronic soft tissue dysfunctions.
Review basic anatomy, and palpable anatomical
bony and soft tissue structures of the anterior
and posterior cervical spine.
Review principles of ROM and apply this to
ROM testing of C-Spine
Review special physical exam tests and clinical
correlations.
Review principles and technique Muscle Energy.
INTRODUCTION
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The cervical Spine provides:
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Head stability and support
Head ROM secondary to vertebral facets
Protection of spinal cord and houses vertebral
artery
Is the final area for a compensatory
pattern to maintain the eyes on a
horizontal plane.
INSPECTION
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Expose neck and upper extremities
Note patients head posture
Examine the skin for deformity, blisters,
scars
Look for symmetry
PALPATION

EXAMINING THE PATIENT IN
A SUPINE POSITION
ALLOWS RELAXATION OF
THE PARAVERTEBRAL
MUSCLES – THIS ENABLES
MORE EFFECTIVE
PALPATION.

A good alternative is to have
the patient lean forward in a
seated position and place their
forehead on their folded arms.
This position facilitates
inspection and palpation.
PITFALLS OF PALPATON
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Lack of concentration
Too much pressure
Excessive movement
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Blind individuals rely on palpation to discover their world, and
hence develop a heightened awareness of palpation. This
brings information to the blind that is not otherwise recognized.
Physicians who respect, value, and practice palpation can also
develop a heightened awareness of what they feel on palpation,
furthering the information they obtain on physical exam.
Otherwise, the quality and quantity of information gathered is
mitigated, and value of the physical exam is diminished.
Chronic versus acute tissue
texture changes
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Is related to the amount of sympathetic
activity
Sympathetic innervation of the head and
neck comes from T1-T4
Tissue Texture Changes
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Acute
History - recent; often an
injury
Vascular – vessels
injured, release of
endogenous peptides =
chemical vasodilatation,
inflammation.
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Chronic
History - Long
standing
Vascular – vessels
constricted due to
sympathetic tone
Tissue Texture Changes

Skin – warm, moist, red,
inflamed (via vascular
and chemical changes)
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Skin – cool, pale )via
chronic sympathetic
vascular tone increase.

Sympathetics –
Systemically increased
sympathetic activity but
local effect overpowered
by bradykinins so there is
local vasodilatation due
to chemical effect.

Sympathetics – has
vasoconstriction due to
hypersympathetic tone.
Regional sympathetic
activity. Systemic
sympathetic tone may be
reduced to normal.
Tissue Texture Changes

Musculature – local
increase in muscle
tone, muscle
contraction, spasm,
increased tone of the
muscle spindle
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Musculature –
decreased muscle
tone, flaccid, mushy,
limited range of
motion due to
contracture.
Tissue Texture Changes

Mobility – range often
normal, quality is sluggish

Tissues – boggy edema,
acute congestion, fluids
from vessels and from
chemical reactions in the
tissues - extravasation

Limited range with normal
quality in the motion that
remains.
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Tissues – chronic
congestion, doughy,
stringy, fibrotic, ropy,
thickened, increased
resistance, contracted,
contractures.
Tissue Texture Changes
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Skin – moist, no
trophic changes
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Skin – pimples, scaly,
dry, folliculitis,
pigmentation (trophic
changes)
Summary – Tissue Texture
Changes: Acute vs Chronic
ANTERIOR NECK PALPATION
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Stand at patients side
With the cephalad hand support the base
of the neck and with the caudal hand
palpate the anterior structures.
HYOID PALPATION
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SITUATED ABOVE THE
THYROID CARTILAGE;
HORSESHOE SHAPED
ON THE SAME
HORIZONTAL PLANE
OF C3 VERTEBRAL
BODY.
PALPATE WHILE THE
PATIENT SWALLOWS
TO DETECT
MOVEMENT OF THE
HYOID
PALPATION-THYROID
CARTILAGE

Top portion on the
same horizontal
plane as C4 and the
lower portion at
level of C5.
Palpation - FIRST CRICOID
RING
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Opposite C6
Immediately inferior to
the lower order of the
thyroid cartilage
Is immediately above the
site for emergency
tracheostomy.
Becomes palpable when
the patient swallows.
Palpation - CAROTID
TUBERCLE
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Move laterally one inch
from the first cricoid ring
Carotid tubercle is the
anterior tubercle of C6
transverse process
Can be felt by pressing
posteriorly
IS THE INJECTION SITE FOR
THE STELLATE GANGLION AND
IS OFTEN THE ANATOMIC
LANDMARK FOR ANTERIOR
C5/C6 SURGICAL APPROACH
Palpation – POSTERIOR
ASPECT
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Patient is supine, with
arms and hands at
their side
Physician seated at
the head of the table
with hands cupped
beneath the occiput.
Palpation - Inion
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Lies in the midline of the occiput marks the
center of the superior nuchal line.
Superior Nuchal line – Small transverse
ridge extending on either side of the inion.
Palpation – Mastoid Processes
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Palpate laterally from the superior nuchal
line and feel the rounded mastoid
processes.
C/T/L-Spine Segmental Anatomy

C-Spine –
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Foramina in
transverse process for
vertebral arteries
Uncal process form
the joints of Luschka –
increase lateral
stability
Spinous process is
bifid and directed
posterior and inferiorly
Palpation – Spinous processes of
the cervical spine
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Lie along the
posterior midline of
the cervical spine.
Begin at the base of
the skull – C2 spinous
process is the first
that is palpable.
Note the lordosis as
you palpate the Cspine.
Palpation – Facet Joints
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From C-2 spinous
process, move one inch
laterally to palpate the
vertebral facet joints.
Not always clearly
palpable, lies beneath
trapezius.
Feels like small domes of
tissue
C5/6 facet most often
involved in OA
In C-spine facet
posterior and superior
Soft Tissue Palpation Of The
Neck - Sternocleidomastoid
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Extends from sternoclavicular joint to mastoid
processes
There are two heads – medial and lateral
Frequently stretched in neck hyperextension
injuries during mva’s
Palpate for hematomas
Torticolis – hypertonic scm, with neck side bent
towards and rotated away from the dysfunctional
side.
Soft Tissue Palpation Of The
Neck –lymph node chain
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Situated along medial border of scm
Usually no palpable, but may be enlarged
with URI’s
Soft Tissue Palpation Of The
Neck – Thyroid gland
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Anterior and midline of the neck
Same horizontal plane of C4/C5
Overlies the cartilage with an “H” pattern
with a thin isthmus in between.
Feel for nodules/soft tissue prominences.
Soft Tissue Palpation Of The
Neck – Supraclavicular fossa
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Lies superior to the clavicle and lateral to
the suprasternal notch.
Palpate for edema which may be
secondary to clavicular fractures
Palpate for lymph nodes
Look for pancoast tumors, cervical ribs.
Soft Tissue Palpation Of The
Neck – Trapezius Muscle
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Broad Origin – from the inion to T12
Inserts laterally on the clavicle, the acromion,
and the scapula.
MVA – causes flexion injuries to the trapezius,
frequently with hematomas and tender points
near the inion and spine of the scapula
Embryologicaly the trapezius and scm form as
one muscle, but split into two later in
development – share CNXI – spinal Accessory
Soft Tissue Palpation Of The
Neck – posterior lymph nodes
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Not normally palpable
Lie along the anterolateral border of the
trapezius.
Can be enlarged and palpable with
infections, lymphoma etc.
Soft Tissue Palpation Of The
Neck – Greater Occipital Nerves
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Distinctly palpable
with inflammation as
a result of trauma
sustained in whiplash
injury. Results in
headache
Palpable on either
side of the inion
Soft Tissue Palpation Of The
Neck – Superior Nuchal Ligament
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Rises from the inion and extends to the C7
spinous process
Tenderness may indicate stretched
ligament secondary to neck flexion injury.
NORMAL ROM OF CERVICAL
SPINE
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Flexion – 60 degrees
Extension – 75 degrees
Lateral flexion (SB) - 45 degrees
Rotation – 80 degrees
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Und B, Schlbom H, Nordwall A Normal range of motion in cervical spine, Arch
Phys Med Rehabil 1989; 70:692-695
Pain felt on the side to which the joint moves
suggests facet pathology, whereas pain on the
opposite side is more likely muscle spasm.
Segmental Motion testing
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Each Joint in the body has a:
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Physiologic barrier
Pathologic Barrier
Restrictive Barrier
Barriers
Physiologic Barrier
 Has
normal palpable resiliency.
 Functional limits within the anatomic ROM.
 Has soft tissue tension accumulation which
limits the voluntary motion of an
articulation.
 The joint at which a patient can actively
move any given joint.
 Further motion toward the anatomic barrier
can still be induced passively.
Pathologic Barrier
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Is a functional limit within the anatomic
range of motion, which abnormally
diminishes the normal physiologic range.
May be associated with somatic
dysfunction
This term is sometimes used instead of
restrictive barrier.
Anatomic Barrier
The limit of motion imposed by anatomic structure.
The point at which a physician can passively
move any given joint.
ANY movement beyond the anatomical barrier will
cause ligament, tendon, or skeletal injury.
Barriers – Depicted in Vertebral
Movement
OA
AA Joint
Range of Motion
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50% of flexion and extension occurs
between the occiput and Atlas (C1)
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Occipital-atlantal joint (OA)
50% of rotation occurs between the
Atlas (C1) and Axis (C2)
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Atlantal-axial joint (AA)
SEGMENTAL ROM OF
CERVICAL SPINE

Many cineradiographic studies have been
performed to demonstrate spinal motion.

Fielding JW: "Normal and selected abnormal motion of cervical
spine from second cervical vertebra based on
cineroentgenography." J Bone and Joint Surg 46-A:1779, 1964.

Ochs CW: "Radiographic examination of the cervical spine in motion." US
Navy Med 64:21, 1974.
Wallace H, Wagnon R, Pierce W: "Inter-examiner reliability using
videofluoroscope to measure cervical spine kinematics: a sagittal plane
(lateral view)." Proceedings of the International Conference on Spinal
Manipulation May 1992, pages 7-8.

Evaluating the cervical spine
Segment
Main motion
OA
Flexion &
Extension
Rotation
AA
Rotation and
sidebending
Opposite sides
Opposite sides
Upper cervical Rotation
Same sides
Lower cervical Sidebending
Same sides
COUPLED MOTION OF CERVICAL
SPINE
NEUROLOGICAL EXAM
Special Tests – For C- Spine
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Distraction Test
Compression Test (Spurling)
Swallowing Test
Adsons Test
Special Tests – Distraction
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Patient seated, physician standing
Place open palm of one hand under
patients chin, and the other on his occiput
Lift the head to remove weight from the
neck.
Distraction relieves pain secondary to NF
narrowing and nerve root compression by
widening the foramen
Special Tests – Compression test,
aka Spurling maneuver
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Patient seated, physician standing
Press down on patients head and if there is a
distribution of pain that follows a dermatome
than it is a positive test.
This can be done in various positions of
flexion/ext and SB/Rot.
Narrowing of the NF can produce pain on
compression in a dermatomal distribution to the
UE.
Special Tests – Swallowing Test

Difficulty or pain on swallowing can be
caused by cervical spine pathology such
as bony protuberances, osteophytes,
retropharyngeal soft tissue swelling due to
infection, hematoma, abscess.
Special Tests – Adson’s test
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Used to eval subclavian
artery insufficiency
Causes include cervical
rib compression,
hypertonic anterior and
medial scalenes.
Patient upright, feel radial
pulse at wrist, while
abducting extending and
External rotating the UE.
Decreased or absent
radial pulse indicates
subclavian artery
compression.
Muscle Energy
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An Active and Direct Technique.
Utilizes the Golgi tendon organ
 GTO prevent too much pull from excessive muscle
tension by continually monitoring muscle force
 They lie within the muscle tendons
 They are in series with the extrafusal muscle
fibers so they will be pulled when the muscle
contracts
 They respond to changes in force, not changes in
length
Muscle Energy-How Does It
Work?
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A patient provides a contraction in a already
tight muscle, acting against equal resistance
provided by the physician, results in pulling
on the Golgi tendon receptors producing a
reflex relaxation of that muscle’s extrafusal
muscle mass through the Golgi tendon reflex
mechanism.
When the patient is completely relaxed, the
operator advances the joint to the new
restrictive barrier and at each new length the
Golgi receptor is stretched again and the
muscle’s length is again increased.
Muscle Energy Schematic
Muscle Energy - Goals
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Treatment of individual joints
For stretching the muscle – increasing ROM
For activation of muscle pumps to move fluid
For preparation to manipulate somatic
dysfunction by some other method, especially if
there is much spasm as a component of the
somatic dysfunction.
Muscle energy of c-spine