Cervical Spine Anatomy
Cervical Spine
Orthopedics DX 611
James J. Lehman, DC, MBA, DABCO
University of Bridgeport College of Chiropractic
James J. Lehman, DC, MBA, DABCO
Orthopedic Examination of the
Cervical Spine
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Involves the taking of a
history, performance of
physical examination
procedures and
laboratory evaluation,
which may include
imaging studies.
James J. Lehman, DC, MBA, DABCO
History Taking Process
James J. Lehman, DC, MBA, DABCO
Chief Complaint Interview
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James J. Lehman, DC, MBA, DABCO
History Taking Process
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The history should
precede all physical
exam procedures but
include observation.
James J. Lehman, DC, MBA, DABCO
The O, P, Q, R, S, T
process is suggested
for all patients
presenting with
neuromusculoskeletal
conditions.
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Establishing rapport
Listening and
questioning
Observation
Integration
James J. Lehman, DC, MBA, DABCO
1
Obstacles to History Taking
1.
2.
3.
4.
5.
6.
Fear
Antagonism
Mental cloudiness
Incoherence
Language barriers
Rambling and
talkativeness
James J. Lehman, DC, MBA, DABCO
Mental Status
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Appearance
Alert
Cooperative
Oriented x3 / Memory
Vital Signs
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Chief complaint
History of present illness (OPQRST)
Past, family, social, and occupational
history
Systems review (SHEENT)CR, GI, GU,
MS, NS, VD, and OB
James J. Lehman, DC, MBA, DABCO
History Taking and
Observation
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Rust’s sign
Dejerine’s sign
Lhermitte’s sign
Barre-Lieou sign
http://library.med.utah.edu/neurologicexam/html/me
ntalstatus_normal.html
James J. Lehman, DC, MBA, DABCO
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History Taking Process
Height
Weight
Blood pressure
Pulse rate
Respiration rate
Temperature
James J. Lehman, DC, MBA, DABCO
James J. Lehman, DC, MBA, DABCO
Patient Preparation
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Why should the
patient be gowned
prior to evaluation?
James J. Lehman, DC, MBA, DABCO
2
Prepare Patient
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Environment
Gowned
Explain procedures
James J. Lehman, DC, MBA, DABCO
Inspection Involves Five Special
Senses
Allegory of Five Senses
Theodore Rombouts
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Sight
Hearing
Touch
Taste
Smell
James J. Lehman, DC, MBA, DABCO
Inspection
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Nutrition
Stature
Body temperature
Breath odors
James J. Lehman, DC, MBA, DABCO
Inspection
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General inspection is
a series of accurate
and meaningful
observations
James J. Lehman, DC, MBA, DABCO
Inspection
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Posture
Body movements
Gait
Speech
Surface scars and
wounds
James J. Lehman, DC, MBA, DABCO
Palpation
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Static palpation
Flat palpation
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Superficial
Deep
James J. Lehman, DC, MBA, DABCO
3
Motion Palpation
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Technique evaluation
includes motion
palpation
James J. Lehman, DC, MBA, DABCO
Palpation Objectives
Palpation
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James J. Lehman, DC, MBA, DABCO
Percussion
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Detect abnormal
tissue textures
Evaluate symmetry
Detect and assess
movements
Detect and evaluate
changes in findings
James J. Lehman, DC, MBA, DABCO
Superficial tissues
Deep tissues
Joint play
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Stroking with the
reflex instrument
Spinous processes
Interspinous
ligaments
Paravertebral
muscles
James J. Lehman, DC, MBA, DABCO
Instrumentation
Instrumentation
Dynamometer
Inclinometer
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Elbow flexion to 90
degrees
Record 3 readings
with each hand
Record dominant
hand
James J. Lehman, DC, MBA, DABCO
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Most accurate
mensuration of spinal
or joint motion
Record 3 readings
Impairment ratings
and independent
medical exams
James J. Lehman, DC, MBA, DABCO
4
Instrumentation
Instrumentation
Reflex Hammer Babinski
Goniometer
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Easiest to utilize for
most joint range of
motion examinations
James J. Lehman, DC, MBA, DABCO
Instrumentation
Buck Reflex Hammer
James J. Lehman, DC, MBA, DABCO
Instrumentation
Taylor Reflex Hammer
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James J. Lehman, DC, MBA, DABCO
DTR Testing
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Identify the grade of
reflex being tested
James J. Lehman, DC, MBA, DABCO
Patient position
Doctor position
Relaxed patient and
doctor
Stroke tendon for
rebound
James J. Lehman, DC, MBA, DABCO
Diagnostic Instruments
Tuning Forks
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C128 and C 256 are
utilized with
orthopedic
examinations
James J. Lehman, DC, MBA, DABCO
5
Diagnostic Instruments
Tuning Forks
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Test for osseous
fracture pain and
perception of vibration
Safety Pin
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James J. Lehman, DC, MBA, DABCO
Instrumentation
Cotton Balls
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Test for light touch
Superficial reflexes
James J. Lehman, DC, MBA, DABCO
Half Time
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Sterile
Large enough
Test for sharp and
dull
James J. Lehman, DC, MBA, DABCO
Instrumentation
Paper Clips
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Test for two-point
discrimination but not
for pain
James J. Lehman, DC, MBA, DABCO
Cervical Range of Motion
Testing
Who is going to win?
James J. Lehman, DC, MBA, DABCO
James J. Lehman, DC, MBA, DABCO
6
Range of Motion Evaluation
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Symmetrical motion
Free of restriction or aberrant
Pain free or provocative
Passive, active, and restricted isometric
movements
James J. Lehman, DC, MBA, DABCO
Cervical Spine Assessment Protocol
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History
Observation
Physical examination
Orthopedic Maneuvers
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Anatomical structure tests
Dural tension
Foraminal canal patency
 Spinal canal patency
 Ligamentous
 Muscle
 Tendon
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James J. Lehman, DC, MBA, DABCO
Rust’s Sign
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Inspection
 Palpation
 Range of motion
 Orthopedic maneuvers
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James J. Lehman, DC, MBA, DABCO
Rust’s Sign
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Suspect upper
cervical spine
instability
History of roll-over
MVA or blow to head
James J. Lehman, DC, MBA, DABCO
May grab head upon
removal of cervical
collar
May use hand to lift
head when rising from
supine position
James J. Lehman, DC, MBA, DABCO
Shoulder Abduction Test
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Bakody’s sign for
nerve root irritation
James J. Lehman, DC, MBA, DABCO
7
Valsalva Maneuver
Cervical Distraction Test
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Valsalva maneuver
for IVD syndrome or
tumor (space
occupying lesion)
James J. Lehman, DC, MBA, DABCO
Soto-Hall Test
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Non-specific test for
cervical spine injury
or lesion
Passive flexion of
neck with sternum
stabilized
Contraindicated with
severe injury
James J. Lehman, DC, MBA, DABCO
Cervical Compression Tests
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Maximal foraminal
compression (active)
Jackson’s
Spurling’s
Maximums cervical
rotary compression
Extension/Flexion
James J. Lehman, DC, MBA, DABCO
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Distraction test for
nerve root, facet, or
myospasm
Positive test relieves
pain
Negative test
increases pain
James J. Lehman, DC, MBA, DABCO
Swallowing Test
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Difficulty swallowing
might be related to a
space occupying
lesion anterior to the
cervical spine.
James J. Lehman, DC, MBA, DABCO
Common Cervical Provocative Tests
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All of them test for
dural sheath, nerve
root, or spinal nerve
involvement
Positive findings all
indicate radicular pain
James J. Lehman, DC, MBA, DABCO
8
Cervical Orthopedic Tests
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Nerve Injuries
Don’t memorize the tests
Practice them with comprehension
Discuss the tests and practice
Marinate, practice and discuss the
relevance of the tests and signs
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James J. Lehman, DC, MBA, DABCO
James J. Lehman, DC, MBA, DABCO
Pathological Neurological
Responses
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Neuropraxia
Axonotmesis
Neurotmesis
Severe Pathological Neurological
Responses
Most benign
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Dysesthesia, paresthesia
Brachial plexopathy or neuropraxia
 Motor or reflex changes
 Atrophy or denervation
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James J. Lehman, DC, MBA, DABCO
James J. Lehman, DC, MBA, DABCO
Most Severe Pathological
Neurological Responses
Neuropraxia
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Hemiparesis or
neurotmesis
 Transient
quadriparesis
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James J. Lehman, DC, MBA, DABCO
Axonotmesis
Cervical cord
neuropraxia
Cervical stenosis
Cervical myelopathy
This is the physiological interruption of an
anatomically intact nerve. In this condition
there is minimal damage. The axons are
intact but conduction is lost because of
segmental demyelination.
James J. Lehman, DC, MBA, DABCO
9
Neuropraxia
"Identify Cause"
Neuropraxia
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This is a transient
lesion and recovery is
spontaneous after a
few days or weeks.
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James J. Lehman, DC, MBA, DABCO
James J. Lehman, DC, MBA, DABCO
Neuropraxia
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Neuropraxia
Otherwise, “Wallerian Degeneration”
would likely result. Therefore, it is imperative
that the mechanism of compression be
identified to insure optimal recovery.
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James J. Lehman, DC, MBA, DABCO
Axonotmesis is characterized by axonal
and myelin sheath damage that results in
loss of continuity with the cell body and its
end organ. There is preservation of the
endoneurium, perineurium, and
epineurium.
James J. Lehman, DC, MBA, DABCO
Neuropraxia may be
caused by a ligamentous
structure, extended
pressure, or repetitive
motion.
James J. Lehman, DC, MBA, DABCO
Axonotmesis
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In neuropraxic insult, the
offending compressive
agent, must be eliminated
to protect the nerve from
further damage.
Axonotmesis
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A complete absence of sensory modalities can be
expected. The prognosis for recovery is
good,. However, occasionally, the possible loss of some
cell bodies inhibits complete recovery. This is due to
retrograde neuronal degeneration.
James J. Lehman, DC, MBA, DABCO
10
Myelopathy
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Cervical spondylotic myelopathy is the most common
cause of spinal cord dysfunction in older persons. The
aging process results in degenerative changes in the
cervical spine that, in advanced stages, can cause
compression of the spinal cord. Symptoms often develop
insidiously and are characterized by neck stiffness, arm
pain, numbness in the hands, and weakness of the
hands and legs.
James J. Lehman, DC, MBA, DABCO
Neurotmesis
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Implies complete
disruption of all the axon
and supporting
connective tissue
structures.
James J. Lehman, DC, MBA, DABCO
Myelopathy
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The differential diagnosis includes any condition that can
result in myelopathy, such as multiple sclerosis,
amyotrophic lateral sclerosis and masses (such as
metastatic tumors) that press on the spinal cord. The
diagnosis is confirmed by magnetic resonance imaging
that shows narrowing of the spinal canal caused by
osteophytes, herniated discs and ligamentum flavum
hypertrophy. (Am Fam Physician 2000;62:106470,1073.)
James J. Lehman, DC, MBA, DABCO
Neurotmesis
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Without surgical repair,
this injury has a very poor
prognosis.
James J. Lehman, DC, MBA, DABCO
End of Cervical Orthopedic
Tests
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Thank you for your
attention and enjoy
the day…
James J. Lehman, DC, MBA, DABCO
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