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Cervical Spine
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Anatomy
Osteology
Arthrology
Ligaments
Muscles
Nerves
Patient History
Initial Hypotheses Based on Patient History
Cervical Zygapophyseal Pain Syndromes
Reliability of the Cervical Spine Historical Examination
Diagnostic Utility of Patient Complaints for Cervical Radiculopathy
Physical Examination Tests
Neurological Examination
Screening for Cervical Spine Injury
Range of Motion
Cervical Strength and Endurance
Passive Intervertebral Motion
Palpation
Postural and Muscle Length Assessment
Spurlings and Neck Compression Tests
Neck Distraction and Traction Tests
Shoulder Abduction Test
Neural Tension Tests
Sharp-Purser Test
Compression of Brachial Plexus
Combinations of Tests
Interventions
Outcome Measures
Appendix
Quality Assessment of Diagnostic Studies Using QUADAS
References
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The utility of patient history has only been studied in identifying cervical radiculopathy. Subjective reports of symptoms were generally not helpful, with diagnoses including complaints of weakness, numbness, tingling, burning, or arm pain.
The patient complaints most useful in diagnosing cervical radiculopathy were (1) a
report of symptoms most bothersome in the scapular area (LR [likelihood ratio]
2.30) and (2) a report that symptoms improve with moving the neck (LR 2.23).
Physical Examination
Traditional neurological screening (sensation, reex, and manual muscle testing
[MMT]) is of moderate utility in identifying cervical radiculopathy. Sensation testing
(pin prick at any location) and MMT of the muscles in the lower arm and hand are
unhelpful. Muscle stretch reex (MSR) and MMT of the muscles in the upper arm
(especially the biceps brachii), exhibit good diagnostic utility and are recommended.
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Screening
Range of
Motion and
Manual
Assessment
Special Tests
Interventions
Both the Canadian C-Spine Rule (CCR) and the NEXUS Low Risk Criteria are excellent at ruling out clinically important cervical spine injuries that require radiography.
Because both methods are simple and have been shown to be superior to both a
general clinical examination and physician judgment, we recommend use of the CCR
because it has been consistently shown to have perfect sensitivity (LR 0.0).
Measuring cervical range of motion is consistently reliable, but is of unknown diagnostic utility.
The results of studies assessing the reliability of passive intervertebral motion are
highly variable but generally report poor reliability when assessing limitations of
movement and moderate reliability when assessing for pain.
Assessing for both pain and limited movement during manual assessment is highly
sensitive for zygopophyseal joint pain and is recommended to rule out zygopophyseal involvement (LR .00 to .23).
Mul iple studies demonstrate high diagnostic utility of Spurlings test to identify cervical adiculopathy, cervical disc prolapse, and neck pain (LR 1.9 to 18.6).
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Patients with neck pain for 30 days have a high probability of rapid improvement if
treated with thoracic manipulation (LR 6.4). Other factors associated with improved thoracic manipulation, especially in combination are (1) no symptoms distal
to the shoulder, (2) low fear avoidance behavior,(3) patient reports that looking up
does not aggravate symptoms, (4) cervical extension ROM 30, and (5) decreased
upper thoracic spine kyphosis (LR 12 if any four of six factors present).
Because the risks of thoracic manipulation are minimal, we recommend such
treatment be considered a rst-line intervention for patients with neck pain (and
no contraindications).
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Arthrology
Dens
C2
Atlas (C1)
Cervical curvature
AL
Intervertebral foramina
for spinal nn.
Spinous processes
Dens
Axis (C2)
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C3
C4
Articular pillar
formed by articular
processes and
interarticular parts
C4
Upper cervical
vertebrae, assembled:
posterosuperior view
C5
C6
Zygapophyseal joints
C7
C3
Intervertebral joint
(symphysis)
(disc removed)
Costal facets (for 1st rib)
C3
C4
T1
C5
Interarticular part
Zygapophyseal
joint
Intervertebral
foramen for
spinal n.
Figure 3-3
Joints of the cervical spine.
Joint
Capsular Pattern
Atlanto-occipital
Synovial: plane
Not Reported
Not Reported
Atlanto-odontoid/dens
Synovial: trochoid
Extension
Not Reported
Atlantoaxial
Apophyseal joints
Synovial: plane
Extension
Not Reported
Synovial: plane
Full extension
Limitation in sidebending
rotation extension
Amphiarthrodial
Not applicable
Not applicable
3 CERVICAL SPINE 69
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Muscles
Scalene and Prevertebral Muscles
Jugular process of
occipital bone
Basilar part of
occipital bone
Mastoid process
Styloid process
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Posterior tubercle of
transverse process
of axis (C2)
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Longus capitis m.
Longus colli m.
Slips of origin of
post rior scalene m.
Anterior
Scalene
Middle
mm.
Posterior
Middle
Scalene mm.
Posterior
Posterior tubercle of
transverse process
of C7 vertebra
Phrenic n.
Anterior scalene
m. (cut)
Brachial plexus
1st rib
Subclavian a.
Subclavian v.
Internal
jugular v Common
carotid a.
Figure 3-8
Scalene and prevertebral muscles
Muscle
Proximal Attachment
Distal Attachment
Action
Longus capitis
Anterior tubercles of
transverse processes
C3-C6
Longus colli
Anterior tubercle of
C1, bodies of C1-C3,
and transverse processes of C3-C6
Anterior aspect of
lateral mass of C1
Transverse process of
C1
3 CERVICAL SPINE 75
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PATIENT HISTORY
Initial Hypotheses Based on Patient History
Initial Hypotheses
Cervical radiculopathy
Cervical myelopathy
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History
C2/3
C3/4
C4/5
C5/6
C6/7
Figure 3-11
Pain referral patterns. Distribution of zygapophyseal pain referral patterns as described by Dwyer and
colleagues.3
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Range of Motion
Diagnostic Utility of Pain Responses during Active Physiologic Range of Motion
Interpretation
LR
10
5.0-10.0
2.0-5.0
1.0-2.0
Large
Moderate
Small
Rarely important
0.1
0.1-0.2
0.2-0.5
0.5-1.0
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LR
Figure 3-19
Overpressure testing.
Test and
Measure
Population
Reference
Standard
Sens
Spec
LR
LR
Active
exion and
extension of
the neck22
75 males (22
with neck pain)
Patient
reports of
neck pain
.27
.90
2.70
.81
98
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AL
ICC or
.81-1.0
.61-.80
.41-.60
.11-.40
0.0-.10
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Figure 3-20
Cervical exor endurance.
Population
Reliability
Neck exor
muscle endurance
test23
21 p tients with
postural neck
pain
Inter-examiner ICC
.93 (.86, .97)
With patient supine, subject tucks the chin and lifts the head
approximately 1 inch. The test w s timed with a stopwatch
and terminated when the p tients position devi ted
22 patients with
mechanical neck
pain
Inter-examiner ICC
.57 (.14, .81)
Cervical exor
endurance24
With patient supine, knees exed, and chin maximally retracted, subject lifts the head slightly. The test was timed with
a stopwatch nd te minated when the subject lost maximal
retraction exed the neck, or could not continue
27 asymptomatic subjects
Intra-examiner ICC
0.74 (.50, .87)
Inter-examiner
Test #1 ICC .54
(.31, .73)
Test #2 ICC .66
(.46, .81)
20 asymptomatic subjects
Intra-examiner ICC
.82.91
Inter-examiner ICC
.67.78
20 patients with
neck pain
Inter-examiner ICC
.67
Cervical exor
endurance25
With pa ient supine with knees exed and chin maximally retracted, subject lifts the head approximately 1 inch. The test
was timed with a stopwatch and terminated when the subject
lost maximal retraction
Craniocervical
exion test26
10 asymptomatic subjects
Intra-examiner
.72
Cervical exor
endurance27
30 patients with
grade II whiplash-associated
disorders
Inter-examiner ICC
.96
3 CERVICAL SPINE 99
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Palpation
Reliability of Assessing Pain with Palpation
ICC or
.81-1.0
.61-.80
.41-.60
.11-.40
0.0-.10
Population
.47
.52
32
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Inter-examiner
Reliability
AL
Interpretation
Substantial agreement
Moderate agreement
Fair agreement
Slight agreement
No agreement
32
Suprascapular area32
(Right) .42
(Left) .44
(Right) .34
(Left) .56
Scapular area32
Zygapophyseal joint
pressure21
High
cervical
Middle
cervical
Low cervical
Occiput21
(Right) 0.00
(-1.00, 0.77)
(Left) 0.16 (-0.31,
0.61)
No details
Mastoid process21
Sternocleidomastoid
(SCM) muscle21
Inse tion
Ante ior
(Right) 0.35
(-0.17, 0.86)
(Left) 0.55 (0.10,
0.99)
Middle
Posterior
104
.24
No details given
.78
.32
.72
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Combinations of Tests
Diagnostic Utility of Clusters of Tests for Cervical Radiculopathy
Wainner and colleagues7 identified a test item cluster, or
LR
10
an optimal combination of clinical examination tests, to
5.0-10.0
determine the likelihood of the patient presenting with cer2.0-5.0
vical radiculopathy. The four predictor variables most likely
1.0-2.0
to identify patients presenting with cervical radiculopathy
are the upper limb tension test A, Spurlings A test, distraction test, and cervical rotation less than 60 to the ipsilateral side.
Upper limb
tension
test A
Spurlings
A test
Distraction
test
Cervical rotation 60
to the ipsilateral side7
All 4 tests
positive
Population
Any 3 tests
positive
Any 2 tests
positive
.1
82 consecutive
patients referred to an
electrophysiologic laboratory with suspected
diagnosis of
cervical radiculopathy or
carpal tunnel
syndrome
99
Spec
LR
0.24 (0.05,
0.43)
0.99 (0.97,
1 0)
30.3 (1.7,
38.2)
0.39 (0.16,
0.61)
0.94 (0.88,
1 0)
6.1 (2.0,
18.6)
0.39 (0.16,
0 61)
0.56 (0.43
0.68)
.88 (1.5,
2.5)
Sens
LR
.5
2
5
10
20
30
40
50
60
70
80
90
95
1000
500
200
100
50
20
10
5
2
1
90
80
70
60
50
40
30
.5
.2
.1
.05
.02
.01
.005
.002
.001
20
Not
reported
Percent (%)
Figure 3-33
Fagans nomogram. Considering the 20% prevalence or pretest
probabi ty of cervical radiculopathy in the study by Wainner and
colleagues,7 the nomogram demonstrates the major shifts in probability that occur when all four tests from the cluster are positive.
(Reprinted with permission from Fagan TJ. Nomogram for Bayes
theorem. N Engl J Med. 1975;293:257. Copyright 2005, Massachusetts Medical Society. All rights reserved.)
.2
Percent (%)
Reference
Standard
0.1
0.1-0.2
0.2-0.5
0.5-1.0
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Description
and Positive
Findings
LR
Large
Moderate
Small
Rarely important
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Test and
Study
Quality
Interpretation
10
5
2
1
.5
95
.2
99
Pretest
Probability
Likelihood
Ratio
.1
Post-test
Probability
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APPENDIX
Uitvlugt 1988
Viikari-Juntura 1987
Uchihara 1994
Sandmark 1995
Lauder 2000
Hoffman 2000
Stiell 2001
Tong 2002
Wainner 2003
1. Was the spectrum of patients representative of the patients who will receive the
test in practice?
AL
4. Is the time period between reference standard and index test short enough to be
reasonably sure that the target condition
did not change between the two tests?
5. Did the whole sample or a random selection of the sample, receive verication
using a reference standard of diagnosis?
8. Was the execution of the index test described in sufcient detail to permit replication of the test?
11. Were the reference standard results interpreted without knowledge of the results
of the index test?
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Jull 1988
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Fair quality (Y - N 5 to 9)
Poor quality (Y - N 4)
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Cleland
ch03-065-130-9781437713848.indd 126
978-1-4377-1384-8/00012
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