Chapter 23

Chapter 23Chapter 23

Cervical spineCervical spine

OverviewOverview

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

AnatomyAnatomy

Cervical curveCervical curve– The cervical spine forms a lordotic curve The cervical spine forms a lordotic curve

that develops secondary to the response of that develops secondary to the response of an upright posture, which initially occurs an upright posture, which initially occurs when the child begins to lift the head at 3-4 when the child begins to lift the head at 3-4 months.months.

– The presence of the curve allows the head The presence of the curve allows the head and eyes to remain oriented forward, and and eyes to remain oriented forward, and provides a shock-absorbing mechanism to provides a shock-absorbing mechanism to counteract the axial compressive force counteract the axial compressive force produced by the weight of the headproduced by the weight of the head

AnatomyAnatomy

Cervicothoracic JunctionCervicothoracic Junction– The The cervicothoracic junctioncervicothoracic junction (CTJ) (CTJ)

comprises the C 7-T 1 segment, although comprises the C 7-T 1 segment, although functionally it includes the seventh functionally it includes the seventh cervical vertebra, the first two thoracic cervical vertebra, the first two thoracic vertebrae, the first and second ribs, and vertebrae, the first and second ribs, and the manubriumthe manubrium

– In addition, the CTJ forms the thoracic In addition, the CTJ forms the thoracic outlet, through which the neurovascular outlet, through which the neurovascular structures of the upper extremities pass structures of the upper extremities pass

AnatomyAnatomy

VertebraVertebra– Compared with the rest of the spine, Compared with the rest of the spine,

the vertebral bodies of the cervical the vertebral bodies of the cervical spine are small and consist spine are small and consist predominantly of trabecular predominantly of trabecular (cancellous) bone(cancellous) bone

– The third to sixth cervical vertebrae The third to sixth cervical vertebrae can be considered typical, while the can be considered typical, while the seventh is atypicalseventh is atypical

AnatomyAnatomy

VertebraVertebra– Each pair of vertebrae in this region is Each pair of vertebrae in this region is

connected by a number of articulations: a connected by a number of articulations: a pair of zygapophyseal joints, the pair of zygapophyseal joints, the uncovertebral joints, and the IVD uncovertebral joints, and the IVD

– The structure of the cervical vertebrae, The structure of the cervical vertebrae, combined with the orientation of the combined with the orientation of the zygapophyseal facets, provides very little zygapophyseal facets, provides very little bony stability, and the lax soft tissue bony stability, and the lax soft tissue restraints permit large excursions of motionrestraints permit large excursions of motion

AnatomyAnatomy

Zygapophyseal jointsZygapophyseal joints– There are 14 zygapophyseal joints from There are 14 zygapophyseal joints from

the occiput to the first thoracic the occiput to the first thoracic vertebra. These joints are typical vertebra. These joints are typical synovial joints and are covered with synovial joints and are covered with hyaline cartilagehyaline cartilage

– The average horizontal angle of the The average horizontal angle of the joint planes is approximately 45°, with joint planes is approximately 45°, with the upper cervical levels closer to 35º, the upper cervical levels closer to 35º, and the lower levels at approximately and the lower levels at approximately 65° 65°

AnatomyAnatomy

Uncovertebral JointsUncovertebral Joints– Extend from C 3-T 1 there is usually Extend from C 3-T 1 there is usually

a total of ten saddle-shaped, a total of ten saddle-shaped, diarthrodial articulationsdiarthrodial articulations

– Formed between the uncinate Formed between the uncinate process found on the lateral aspect process found on the lateral aspect of the superior surface of the inferior of the superior surface of the inferior vertebra, and the beveled inferior-vertebra, and the beveled inferior-lateral aspect of the superior lateral aspect of the superior vertebravertebra

AnatomyAnatomy

Uncovertebral JointsUncovertebral Joints– Penning and Wilmink highlighted a possible Penning and Wilmink highlighted a possible

correlation between uncovertebral joint correlation between uncovertebral joint configuration and the coupled cervical configuration and the coupled cervical segmental motion of side bending and axial segmental motion of side bending and axial rotationrotation

– A more recent study of the C 5-6 segment level A more recent study of the C 5-6 segment level by Clausen et al. found that both the by Clausen et al. found that both the zygapophyseal joints and Luschka joints are zygapophyseal joints and Luschka joints are the major contributors to coupled motion in the the major contributors to coupled motion in the lower cervical spine, and that the uncinate lower cervical spine, and that the uncinate processes effectively reduce motion coupling processes effectively reduce motion coupling and primary cervical motion and primary cervical motion

AnatomyAnatomy

Intervertebral foraminaIntervertebral foramina– Serve as the principal routes of entry and Serve as the principal routes of entry and

exit for the neurovascular systems to and exit for the neurovascular systems to and from the vertebral canalfrom the vertebral canal

– This region is vulnerable to narrowing with This region is vulnerable to narrowing with certain motions, or with osteophyte growthcertain motions, or with osteophyte growth

– As the dimensions of the intervertebral As the dimensions of the intervertebral foramen decrease with full extension and foramen decrease with full extension and ipsilateral side bending of the cervical ipsilateral side bending of the cervical spine, uncovertebral osteophytes may spine, uncovertebral osteophytes may compress the nerve root and cervical cord compress the nerve root and cervical cord posteriorly posteriorly

AnatomyAnatomy

LigamentsLigaments– Both the function and location of the Both the function and location of the

ligaments in this region are similar to that ligaments in this region are similar to that of the rest of the spineof the rest of the spine

– Anterior longitudinal. This ligament is Anterior longitudinal. This ligament is narrower in the upper cervical spine but is narrower in the upper cervical spine but is wider in the lower cervical spine than it is in wider in the lower cervical spine than it is in the thoracic regionthe thoracic region

– Posterior longitudinal. This ligament is Posterior longitudinal. This ligament is broader and considerably thicker in the broader and considerably thicker in the cervical region than in the thoracic and cervical region than in the thoracic and lumbar regions lumbar regions

AnatomyAnatomy

MusclesMuscles– TrapeziusTrapezius

Most superficial back muscleMost superficial back muscle Traditionally divided into middle, upper, Traditionally divided into middle, upper,

and lower parts according to anatomy and lower parts according to anatomy and functionand function

The innervation for the trapezius comes The innervation for the trapezius comes from the accessory nerve (CN XI) and from the accessory nerve (CN XI) and fibers from the ventral rami of the third fibers from the ventral rami of the third and fourth cervical spinal nerves and fourth cervical spinal nerves

AnatomyAnatomy

MusclesMuscles– Sternocleidomastoid (SCM)Sternocleidomastoid (SCM)

Largest muscle in the anterior neckLargest muscle in the anterior neck Attached inferiorly by two heads, arising from Attached inferiorly by two heads, arising from

the posterior aspect of the medial third of the the posterior aspect of the medial third of the clavicle and the manubrium of the sternum. clavicle and the manubrium of the sternum. From here it passes superiorly and posteriorly to From here it passes superiorly and posteriorly to attach on the mastoid process of the temporal attach on the mastoid process of the temporal bonebone

Motor supply is from the accessory nerve (CN Motor supply is from the accessory nerve (CN IX), while the sensory innervation is supplied IX), while the sensory innervation is supplied from the ventral rami of C 2 and C 3 from the ventral rami of C 2 and C 3

AnatomyAnatomy

MusclesMuscles– Levator scapulaeLevator scapulae

The levator is the major stabilizer and The levator is the major stabilizer and elevator of the superior angle of the elevator of the superior angle of the scapulascapula

With the scapula stabilized, the levator With the scapula stabilized, the levator produces rotation and side bending of produces rotation and side bending of the neck to the same side; while acting the neck to the same side; while acting bilaterally, cervical extension is bilaterally, cervical extension is producedproduced

AnatomyAnatomy

MusclesMuscles– RhomboidsRhomboids

Although the rhomboid minor, with its Although the rhomboid minor, with its attachment to the spinous processes of attachment to the spinous processes of C 7 and T 1, has a slight association C 7 and T 1, has a slight association with the cervical spine, the rhomboid with the cervical spine, the rhomboid major, arising from the spinous major, arising from the spinous processes of T 1 through T 5, is inactive processes of T 1 through T 5, is inactive during isolated head and neck during isolated head and neck movementsmovements

AnatomyAnatomy

MusclesMuscles– ScalenesScalenes

The scalenes extend obliquely like ladders The scalenes extend obliquely like ladders (‘scala’ means ladder in Latin) and share a (‘scala’ means ladder in Latin) and share a critical relationship with the subclavian critical relationship with the subclavian arteryartery

Adaptive shortening of these muscles will Adaptive shortening of these muscles will affect the mobility of the upper cervical affect the mobility of the upper cervical spine and, due to their distal attachments to spine and, due to their distal attachments to the 1st and 2nd ribs they can, if in spasm, the 1st and 2nd ribs they can, if in spasm, elevate the ribs and be implicated in the elevate the ribs and be implicated in the thoracic outlet syndromethoracic outlet syndrome

AnatomyAnatomy

NeurologyNeurology– The cervical spine is the only region that The cervical spine is the only region that

has more nerve roots than vertebral levelshas more nerve roots than vertebral levels – In general, structures supplied by the In general, structures supplied by the

upper three cervical nerves can cause upper three cervical nerves can cause neck and head pain, whereas the mid to neck and head pain, whereas the mid to lower cervical nerves can refer symptoms lower cervical nerves can refer symptoms to the shoulder, anterior chest, upper limb, to the shoulder, anterior chest, upper limb, and scapular area and scapular area

BiomechanicsBiomechanics

The only significant arthrokinematic available The only significant arthrokinematic available to the zygapophyseal joint is an inferior, to the zygapophyseal joint is an inferior, medial and posterior glide of the inferior medial and posterior glide of the inferior articular process of the superior facet during articular process of the superior facet during extension, and a superior, lateral and anterior extension, and a superior, lateral and anterior glide during flexionglide during flexion

Segmental side bending is, therefore, Segmental side bending is, therefore, extension of the ipsilateral joint and flexion of extension of the ipsilateral joint and flexion of the contralateral jointthe contralateral joint

Rotation, coupled with ipsilateral side Rotation, coupled with ipsilateral side bending, involves extension of the ipsilateral bending, involves extension of the ipsilateral joint and flexion of the contralateraljoint and flexion of the contralateral

ExaminationExamination

The examination of the acute and The examination of the acute and recently traumatized neck is recently traumatized neck is necessarily different from the necessarily different from the routine examination of a more routine examination of a more chronic and less irritable chronic and less irritable condition, because of the condition, because of the potential for the examination potential for the examination itself to be harmfulitself to be harmful

ExaminationExamination

Where possible, the patient should first Where possible, the patient should first be examined for central and peripheral be examined for central and peripheral neurological deficit, neurovascular neurological deficit, neurovascular compromise and serious skeletal injury compromise and serious skeletal injury such as fractures or craniovertebral such as fractures or craniovertebral ligamentous instabilityligamentous instability

The examination must be graduated The examination must be graduated and progressive so that the testing can and progressive so that the testing can be discontinued at the first signs of be discontinued at the first signs of serious pathologyserious pathology

ExaminationExamination

Clinical signs and symptoms of serious pathology include:Unexplained weight lossNight painInvolvement of more than 1 nerve rootExpanding painWeak and painful resisted testing

4 findings and their interpretationsSpasm with PROMT1 palsy

ExaminationExamination

HistoryHistory– The history often gives the clinician The history often gives the clinician

clues as to the source of the clues as to the source of the patient’s symptoms, the nature and patient’s symptoms, the nature and location of the involved structure, location of the involved structure, the severity of the condition, and the the severity of the condition, and the activities or positions that appear to activities or positions that appear to aggravate or improve the patient’s aggravate or improve the patient’s conditioncondition

ExaminationExamination

Systems ReviewSystems Review– Symptoms that show no predictable response Symptoms that show no predictable response

to mechanical stimuli are unlikely to be to mechanical stimuli are unlikely to be mechanical in origin, and their presence mechanical in origin, and their presence should alert the clinician to the possibility of should alert the clinician to the possibility of a more sinister disorder or one of central a more sinister disorder or one of central initiation, autonomic, or affective natureinitiation, autonomic, or affective nature

– The systems review must include questions The systems review must include questions that will elicit any symptoms that might that will elicit any symptoms that might suggest a central nervous system condition, suggest a central nervous system condition, or a vascular compromise to the brainor a vascular compromise to the brain

ExaminationExaminationUpper Quarter Scan

AROM, passive overpressure, resistanceC 1-4C 5C 6C 7C 8T 1

DTRSensation

ExaminationExamination

Tests and MeasuresTests and Measures– ObservationObservation

A major contributor to cervicogenic pain A major contributor to cervicogenic pain is a lack of postural control due to poor is a lack of postural control due to poor neuromuscular functionneuromuscular function

Static observation of general posture, as Static observation of general posture, as well as the relationship of the neck on well as the relationship of the neck on the trunk, and the head on the neck, is the trunk, and the head on the neck, is observed while the patient is standing observed while the patient is standing and sitting, both in the waiting area, and sitting, both in the waiting area, and in the examination roomand in the examination room

ExaminationExamination

AROMAROM– The clinical examination of the mobility of The clinical examination of the mobility of

the cervical spine should consist of a the cervical spine should consist of a comparison between active and passive comparison between active and passive ranges and coupled movements of the ranges and coupled movements of the cervical spinecervical spine

Active motion induced by the contraction of the Active motion induced by the contraction of the muscles determines the so-called physiologic muscles determines the so-called physiologic ROMROM

Passively performed movement causes stretching Passively performed movement causes stretching of non-contractile elements, such as ligaments, of non-contractile elements, such as ligaments, and determines the anatomic ROMand determines the anatomic ROM

ExaminationExamination

Key Muscle TestingKey Muscle Testing – During the resisted tests, the During the resisted tests, the

clinician looks for relative strength clinician looks for relative strength and fatigabilityand fatigability

ExaminationExaminationSpecific key muscles for the various levels

C 2C 3C 4C 5C 6C 7C 8-T 1

ExaminationExamination

Combined motion testingCombined motion testing– Using a biomechanical modelUsing a biomechanical model

A restriction of cervical extension, side bending A restriction of cervical extension, side bending and rotation to the same side as the pain is and rotation to the same side as the pain is termed a termed a closingclosing restriction. This restriction is restriction. This restriction is the most common pattern producing distal the most common pattern producing distal symptoms. However, a limitation in cervical symptoms. However, a limitation in cervical flexion accompanied by the production of distal flexion accompanied by the production of distal symptoms can also occursymptoms can also occur

A restriction of cervical flexion, side bending A restriction of cervical flexion, side bending and rotation to the opposite side of the pain is and rotation to the opposite side of the pain is termed an termed an openingopening restriction restriction

ExaminationExaminationNeurological examination

MOTOR LOSS Spinal nerve root Peripheral nerve

Long thoracicThoracodorsalSubscapularSuprascapularDorsal scapularMedial pectoralLateral pectoralAxillaryMusculocutaneousRadialMedianUlnar

ExaminationExaminationNeurological examination

SENSORY LOSS Spinal nerve root Peripheral nerve

MusculocutaneousAxillaryRadialMedianUlnar

ExaminationExamination

PalpationPalpation– Palpation is performed to:Palpation is performed to:

Check for any vasomotor changes such as an Check for any vasomotor changes such as an increase in skin temperatureincrease in skin temperature

Localize specific sites of swellingLocalize specific sites of swelling Identify specific anatomical structures and their Identify specific anatomical structures and their

relationship to one anotherrelationship to one another Identify sites of point tendernessIdentify sites of point tenderness Identify soft tissue texture changes or myofascial Identify soft tissue texture changes or myofascial

restrictionrestriction Locate changes in muscle tone resulting from, Locate changes in muscle tone resulting from,

trigger points, muscle spasm, hypertonicity, or trigger points, muscle spasm, hypertonicity, or hypotonicityhypotonicity

ExaminationExamination

Stability (Stress) testingTransverseAnterior - posteriorTorsionVerticalLateral shear

ExaminationExaminationSpecial Tests

Foraminal compressionAxial distractionUpper limb neural tension

Median Ulnar Radial

ExaminationExaminationSpecial Tests

Thoracic Outlet SyndromeVascularNeurologicalTraction

Intervention Intervention StrategiesStrategies Physical therapy interventions Physical therapy interventions

that have included postural that have included postural re‑education, neck‑specific re‑education, neck‑specific strengthening and stretching strengthening and stretching exercises, and ergonomic exercises, and ergonomic changes at work, have been changes at work, have been shown to be beneficial in reducing shown to be beneficial in reducing neck pain and improving mobilityneck pain and improving mobility

Intervention Intervention StrategiesStrategies Acute PhaseAcute Phase

– Goals:Goals: To encourage patient involvementTo encourage patient involvement To provide mechanoreceptor To provide mechanoreceptor

stimulationstimulation To control pain and inflammationTo control pain and inflammation To promote healingTo promote healing To maintain the newly attained rangesTo maintain the newly attained ranges To provide neuromuscular feedback To provide neuromuscular feedback

Intervention Intervention Strategies Strategies Functional PhaseFunctional Phase

– Goals:Goals: Correction of imbalances of strength Correction of imbalances of strength

and flexibilityand flexibility Incorporate neuromuscular re-educationIncorporate neuromuscular re-education Strengthening of entire kinetic chainStrengthening of entire kinetic chain Postural correction and retrainingPostural correction and retraining