Chapter 23
Cervical spine
Overview
 The cervical spine consists of 37
joints, which allow for more motion
than any other region of the spine
 However, this degree of mobility
comes with a cost. With stability being
sacrificed for mobility, the cervical
spine is rendered more vulnerable to
both direct and indirect trauma
Anatomy

Cervical curve
– The cervical spine forms a lordotic curve that
develops secondary to the response of an
upright posture, which initially occurs when the
child begins to lift the head at 3-4 months.
– The presence of the curve allows the head and
eyes to remain oriented forward, and provides a
shock-absorbing mechanism to counteract the
axial compressive force produced by the weight
of the head
Anatomy

Cervicothoracic Junction
– The cervicothoracic junction (CTJ) comprises the
C 7-T 1 segment, although functionally it
includes the seventh cervical vertebra, the first
two thoracic vertebrae, the first and second ribs,
and the manubrium
– In addition, the CTJ forms the thoracic outlet,
through which the neurovascular structures of
the upper extremities pass
Anatomy

Vertebra
– Compared with the rest of the spine, the
vertebral bodies of the cervical spine are
small and consist predominantly of
trabecular (cancellous) bone
– The third to sixth cervical vertebrae can
be considered typical, while the seventh
is atypical
Anatomy

Vertebra
– Each pair of vertebrae in this region is connected
by a number of articulations: a pair of
zygapophyseal joints, the uncovertebral joints,
and the IVD
– The structure of the cervical vertebrae,
combined with the orientation of the
zygapophyseal facets, provides very little bony
stability, and the lax soft tissue restraints permit
large excursions of motion
Anatomy

Zygapophyseal joints
– There are 14 zygapophyseal joints from
the occiput to the first thoracic vertebra.
These joints are typical synovial joints
and are covered with hyaline cartilage
– The average horizontal angle of the joint
planes is approximately 45°, with the
upper cervical levels closer to 35º, and
the lower levels at approximately 65°
Anatomy

Uncovertebral Joints
– Extend from C 3-T 1 there is usually a
total of ten saddle-shaped, diarthrodial
articulations
– Formed between the uncinate process
found on the lateral aspect of the
superior surface of the inferior vertebra,
and the beveled inferior-lateral aspect of
the superior vertebra
Anatomy

Uncovertebral Joints
– Penning and Wilmink highlighted a possible
correlation between uncovertebral joint
configuration and the coupled cervical segmental
motion of side bending and axial rotation
– A more recent study of the C 5-6 segment level
by Clausen et al. found that both the
zygapophyseal joints and Luschka joints are the
major contributors to coupled motion in the
lower cervical spine, and that the uncinate
processes effectively reduce motion coupling and
primary cervical motion
Anatomy

Intervertebral foramina
– Serve as the principal routes of entry and exit for
the neurovascular systems to and from the
vertebral canal
– This region is vulnerable to narrowing with
certain motions, or with osteophyte growth
– As the dimensions of the intervertebral foramen
decrease with full extension and ipsilateral side
bending of the cervical spine, uncovertebral
osteophytes may compress the nerve root and
cervical cord posteriorly
Anatomy

Ligaments
– Both the function and location of the ligaments
in this region are similar to that of the rest of the
spine
– Anterior longitudinal. This ligament is narrower
in the upper cervical spine but is wider in the
lower cervical spine than it is in the thoracic
region
– Posterior longitudinal. This ligament is broader
and considerably thicker in the cervical region
than in the thoracic and lumbar regions
Anatomy

Muscles
– Trapezius
Most superficial back muscle
 Traditionally divided into middle, upper, and
lower parts according to anatomy and
function
 The innervation for the trapezius comes from
the accessory nerve (CN XI) and fibers from
the ventral rami of the third and fourth
cervical spinal nerves

Anatomy

Muscles
– Sternocleidomastoid (SCM)



Largest muscle in the anterior neck
Attached inferiorly by two heads, arising from the
posterior aspect of the medial third of the clavicle and
the manubrium of the sternum. From here it passes
superiorly and posteriorly to attach on the mastoid
process of the temporal bone
Motor supply is from the accessory nerve (CN IX),
while the sensory innervation is supplied from the
ventral rami of C 2 and C 3
Anatomy

Muscles
– Levator scapulae
The levator is the major stabilizer and
elevator of the superior angle of the scapula
 With the scapula stabilized, the levator
produces rotation and side bending of the
neck to the same side; while acting bilaterally,
cervical extension is produced

Anatomy

Muscles
– Rhomboids

Although the rhomboid minor, with its
attachment to the spinous processes of C 7
and T 1, has a slight association with the
cervical spine, the rhomboid major, arising
from the spinous processes of T 1 through T
5, is inactive during isolated head and neck
movements
Anatomy

Muscles
– Scalenes
The scalenes extend obliquely like ladders
(‘scala’ means ladder in Latin) and share a
critical relationship with the subclavian artery
 Adaptive shortening of these muscles will
affect the mobility of the upper cervical spine
and, due to their distal attachments to the 1st
and 2nd ribs they can, if in spasm, elevate
the ribs and be implicated in the thoracic
outlet syndrome

Anatomy

Neurology
– The cervical spine is the only region that has
more nerve roots than vertebral levels
– In general, structures supplied by the upper
three cervical nerves can cause neck and head
pain, whereas the mid to lower cervical nerves
can refer symptoms to the shoulder, anterior
chest, upper limb, and scapular area
Biomechanics



The only significant arthrokinematic
available to the zygapophyseal joint is an
inferior, medial and posterior glide of the
inferior articular process of the superior
facet during extension, and a superior,
lateral and anterior glide during flexion
Segmental side bending is, therefore,
extension of the ipsilateral joint and flexion
of the contralateral joint
Rotation, coupled with ipsilateral side
bending, involves extension of the ipsilateral
joint and flexion of the contralateral
Examination

The examination of the acute and
recently traumatized neck is
necessarily different from the routine
examination of a more chronic and
less irritable condition, because of the
potential for the examination itself to
be harmful
Examination


Where possible, the patient should first be
examined for central and peripheral
neurological deficit, neurovascular
compromise and serious skeletal injury such
as fractures or craniovertebral ligamentous
instability
The examination must be graduated and
progressive so that the testing can be
discontinued at the first signs of serious
pathology
Examination
 Clinical signs and symptoms of serious
pathology include:
Unexplained weight loss
Night pain
Involvement of more than 1 nerve root
Expanding pain
Weak and painful resisted testing
4 findings and their interpretations
Spasm with PROM
T1 palsy
Examination

History
– The history often gives the clinician clues
as to the source of the patient’s
symptoms, the nature and location of the
involved structure, the severity of the
condition, and the activities or positions
that appear to aggravate or improve the
patient’s condition
Examination

Systems Review
– Symptoms that show no predictable response to
mechanical stimuli are unlikely to be mechanical
in origin, and their presence should alert the
clinician to the possibility of a more sinister
disorder or one of central initiation, autonomic,
or affective nature
– The systems review must include questions that
will elicit any symptoms that might suggest a
central nervous system condition, or a vascular
compromise to the brain
Examination
Upper Quarter Scan
 AROM, passive overpressure, resistance
C 1-4
C 5
C 6
C 7
C 8
T 1
 DTR
 Sensation
Examination

Tests and Measures
– Observation
A major contributor to cervicogenic pain is a
lack of postural control due to poor
neuromuscular function
 Static observation of general posture, as well
as the relationship of the neck on the trunk,
and the head on the neck, is observed while
the patient is standing and sitting, both in the
waiting area, and in the examination room

Examination

AROM
– The clinical examination of the mobility of the
cervical spine should consist of a comparison
between active and passive ranges and coupled
movements of the cervical spine


Active motion induced by the contraction of the
muscles determines the so-called physiologic ROM
Passively performed movement causes stretching of
non-contractile elements, such as ligaments, and
determines the anatomic ROM
Examination

Key Muscle Testing
– During the resisted tests, the clinician
looks for relative strength and fatigability
Examination
Specific key muscles for the various levels
C 2
C 3
C 4
C 5
C 6
C 7
 C 8-T 1
Examination

Combined motion testing
– Using a biomechanical model


A restriction of cervical extension, side bending and
rotation to the same side as the pain is termed a
closing restriction. This restriction is the most common
pattern producing distal symptoms. However, a
limitation in cervical flexion accompanied by the
production of distal symptoms can also occur
A restriction of cervical flexion, side bending and
rotation to the opposite side of the pain is termed an
opening restriction
Examination
Neurological examination
 MOTOR LOSS
 Spinal nerve root
 Peripheral nerve
Long thoracic
Thoracodorsal
Subscapular
Suprascapular
Dorsal scapular
Medial pectoral
Lateral pectoral
Axillary
Musculocutaneous
Radial
Median
Ulnar
Examination
Neurological examination
 SENSORY LOSS
 Spinal nerve root
 Peripheral nerve
Musculocutaneous
Axillary
Radial
Median
Ulnar
Examination

Palpation
– Palpation is performed to:




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Check for any vasomotor changes such as an increase
in skin temperature
Localize specific sites of swelling
Identify specific anatomical structures and their
relationship to one another
Identify sites of point tenderness
Identify soft tissue texture changes or myofascial
restriction
Locate changes in muscle tone resulting from, trigger
points, muscle spasm, hypertonicity, or hypotonicity
Examination
 Stability (Stress) testing
Transverse
Anterior - posterior
Torsion
Vertical
Lateral shear
Examination
Special Tests
 Foraminal compression
 Axial distraction
 Upper limb neural tension
 Median
 Ulnar
 Radial
Examination
Special Tests
 Thoracic Outlet Syndrome
Vascular
Neurological
Traction
Intervention Strategies

Physical therapy interventions that
have included postural re-education,
neck-specific strengthening and
stretching exercises, and ergonomic
changes at work, have been shown to
be beneficial in reducing neck pain and
improving mobility
Intervention Strategies

Acute Phase
– Goals:
To
 To
 To
 To
 To
 To

encourage patient involvement
provide mechanoreceptor stimulation
control pain and inflammation
promote healing
maintain the newly attained ranges
provide neuromuscular feedback
Intervention Strategies

Functional Phase
– Goals:
Correction of imbalances of strength and
flexibility
 Incorporate neuromuscular re-education
 Strengthening of entire kinetic chain
 Postural correction and retraining
