1. Cervical Spine Anatomy and Clinical Evaluation
Orthopedic Assessment III – Head, Spine, and Trunk with Lab
PET 5609C

2. Clinical Anatomy Cervical Spine: Greatest range of motion
↑ risk of injury
Vertebral bodies:
Smaller than other vertebral sections
7 vertebrae:
1st – Atlas
2nd – Axis

3. Clinical Anatomy Cervical Spine: Atlas: No vertebral body
Transverse processes
No true spinous process
Supports the weight of the skull through 2 facet surfaces (atlanto-occipital joint or C0-C1 articulation)
Flexion and extension (primary movement)
Lateral flexion (slight)

4. Clinical Anatomy Atlanto-occipital joint dislocation:
(15% of all fatal spinal trauma)
MOI: high speed motor accident; Pt. unconscious at the scene, respiratory arrest en route to hospital
Lateral cervical spine radiograph:
Prevertebral soft-tissue swelling (white arrow)
Malalignment between the skull and the cervical spine with widening of the atlanto-occipital joints (black arrow)

5. Clinical Anatomy Cervical Spine: Axis: Atlanto-axial joint:
2nd cervical vertebrae
Small body with a superior projection (Dens)
Atlanto-axial joint:
Dens and atlas articulation
Rotation of the skull

6. Clinical Anatomy Cervical ligaments:
Anterior and posterior longitudinal ligaments:
Limit extension and flexion
Ligamentum nuchae:
Limits flexion
Interspinous ligaments:
Between spinous processes
Limit flexion and rotation
Ligamentum flavum:
Connect laminae
Limits flexion and rotation

7. Clinical Anatomy Brachial Plexus: C5 – T1 7 cervical vertebrae
8 cervical nerves:
1st 7: exit above the corresponding vertebrae
C8: exits below the 7th cervical vertebrae

9. Clinical Anatomy Muscular Anatomy:
Cervical extension and flexion → bilateral contraction of cervical muscles
Side bending and rotation → unilateral contraction
Superficial cervical musculature:
Splenius capitis
Splenius cervicis
Upper trapezius
Sternocleidomastoid

10. Clinical Anatomy Splenius capitis: Splenius cervicis:
O: Lower half of ligamentum nuchae
I: Mastoid process and adjacent occipital bone
A: Lateral bending
Splenius cervicis:
O: C7 spinous process through T6
I: Transverse processes of C2 – C4
A: Rotation, extension

11. Clinical Anatomy Upper trapezius:
O: Occipital protuberance, nuchal line, upper portion of ligamentum nuchae
I: Lateral 1/3 of clavicle, acromion process
A: Cervical extension, cervical spine bending, scapular elevation, upward scapular rotation

12. Clinical Anatomy Levator scapulae:
O: Spinous process of C7, transverse processes of C1 through C4
I: Superior medial border of scapula
A: Extension of cervical spine, scapular elevation and downward rotation

13. Clinical Anatomy Scalenes: Anterior scalene: Middle scalene:
O: Anterior portion of transverse processes C3-C6
I: Sternal attachment of 1st rib
Middle scalene:
O: Anterior portion of transverse processes C2-C7
I: Lateral to insertion of anterior scalene on 1st rib
Posterior scalene:
O: Anterior portion of transverse processes C5-C6
I: Medial portion of 2nd rib
Action: Lateral bending of cervical spine

14. Clinical Anatomy

15. Clinical Anatomy Sternocleidomastoid:
O: Medial clavicular head, superior sternum
I: Mastoid process
A: Flexion of cervical spine, rotation to opposite side, lateral bending

16. Clinical Evaluation History: Location of pain: Onset of pain:
Localized pain:
Muscle strain, ligament sprain, vertebral fracture, facet syndrome
Radiating pain:
Trauma to cervical nerve root or spinal cord
Onset of pain:
Acute, chronic, insidious

17. Clinical Evaluation History: Mechanism of Injury: Insidious onset:
Overuse and postural conditions
Acute onset:
Axial load (compression fracture)
Flexion (compression of anterior vertebral body and intervertebral disc; facet joint sprain; posterior muscle strain)
Extension (compression of posterior vertebral body and intervertebral disc; anterior longitudinal ligament sprain)
Lateral bending (nerve root compression, facet joint compression)

18. Clinical Evaluation History: Mechanism of Injury: Acute onset:
Rotation (disc trauma, ligament sprain, vertebral dislocation)
Consistency of pain:
Inflammatory induced pain: consistent pain
Mechanical pain (i.e. nerve compression): varies in intensity, moving spine may ↑ or ↓ pain
Previous injury
Scar tissue formation
Injured disc
Osteophyte within intervertebral foramina

19. Clinical Evaluation Inspection: Cervical curvature:
Lordotic curvature – normal
Lateral bending posture - ↓ pressure on nerve roots away from the bend

20. Clinical Evaluation Inspection: Position of head on the shoulders:
Unilateral spasm – lateral flexion of head towards involved side
Torticollis: Wry neck
Rotation of chin opposite the side of the tilt
Congenital or acquired spasm of the SCM

21. Clinical Evaluation Inspection:
Position of the head on the shoulders: Torticollis
Infant with torticollis: The attitude of the head and neck results from a combination of head tilt and rotation. A tight SCM muscle causes head tilt towards the tight side with rotation of the chin to the opposite side
18 years age male with congenital torticollis with the left SCMM tight as a band unabeling him to turn his head to the right

22. Clinical Evaluation Inspection: Bilateral soft tissue comparison:
Trapezius and other musculature:
Hypertrophy, atrophy
Level of the shoulders:
Height of acromioclavicular joints
Deltoids
Clavicles

23. Clinical Evaluation Palpation: Anterior Structures: Hyoid bone:
Have patient swallow noting superior and inferior movement
Level of 3rd cervical vertebrae
Thyroid cartilage:
Adam’s apple
Level of 4th and 5th cervical vertebrae
Cricoid cartilage:
Level of 6th cervical vertebrae

24. Clinical Evaluation Palpation: Anterior structures:
Sternocleidomastoid:
Have patient rotate head
Scalenes:
Posterior to SCM (C3-C6 level)
Carotid artery
Lymph nodes

25. Clinical Evaluation Palpation: Posterior and Lateral Structures:
Occiput and superior nuchal line
Transverse processes
Spinous processes:
Have patient flex c-spine
C7 and T1
Trapezius

26. Clinical Evaluation Range of Motion:
Active neck flexion and extension:
Test position: patient can be standing or seated
Motion: Atlanto-occipital joint
Flexion: patient touches chin to chest (450)
Extension: patient looks up towards ceiling (450)
Active neck lateral flexion:
Test position: patient seated or standing
Patient takes ear to shoulders (450)

28. Clinical Evaluation Range of Motion: Active rotation:
Test position: patient seated, head held upward and facing forward
Patient attempts to look over each shoulder
Motion: Atlanto-axial joint (450)

29. Clinical Evaluation Range of Motion: Passive flexion:
Patient position: supine
ATC: grab patient’s head (under occiput) and attempt to bring chin to chest
Passive extension:
Patient position: supine, head off end of table
ATC: grasp patient’s head and move into extension

30. Clinical Evaluation Range of Motion: Passive lateral flexion:
Patient position: supine, head in neutral position
ATC: one hand under occiput, tilt head/neck to bring ear to shoulder
Passive rotation:
Patient position: supine
ATC: grasp patient’s forehead and occiput, rotate head and neck

31. Clinical Evaluation

32. Clinical Evaluation Range of Motion: Resisted range of motion: Flexion
Patient: supine with cervical spine and head in neutral position
Stabilization: superior aspect of sternum
Resistance: to the forehead
Muscles tested: SCM and anterior scalenes

33. Clinical Evaluation Range of Motion:
Resisted range of motion: Extension
Patient: prone with cervical spine and head in neutral position
Stabilization: superior aspect of thoracic spine
Resistance: to the skull over the occiput
Muscles tested: trapezius (upper 1/3, levator scapulae, cervical paraspinal muscles)

34. Clinical Evaluation Range of Motion:
Resisted range of motion: Lateral flexion
Patient: seated with cervical spine and head in neutral position
Stabilization: over the AC joint on the side toward the motion
Resistance: over the temporal and parietal bones on the side toward the motion
Muscles tested: SCM, scalenes, paraspinal muscles on the side being tested

35. Clinical Evaluation Range of Motion:
Resisted range of motion: Rotation
Patient: seated with cervical spine and head in neutral position
Stabilization: over the anterior shoulder on the side toward the rotation
Resistance: over the temporal bone on the side toward the motion
Muscles tested: SCM, multifidus, rotators

37. Clinical Evaluation C1-C2 Neck flexion C3 Neck lateral flexion C4
Shoulder shrug C5
Shoulder abduction, ER C6
Elbow flexion, wrist extension C7
Elbow extension, wrist flexion C8
Thumb extension T1
Finger abduction and adduction

38. Clinical Evaluation Neurological Screening:
Nerve root: C5 (Biceps brachii)
Patient: seated and relaxed
ATC: thumb placed over biceps tendon, strike the thumb nail with reflex hammer

39. Clinical Evaluation Neurological Screening:
Nerve root: C6 (Brachioradialis)
Patient: seated and relaxed
ATC: taps the brachioradialis with reflex hammer

40. Clinical Evaluation Neurological Screening: Nerve root: C7 (Triceps)
Patient: seated and relaxed
ATC: support arm in position of extension and abduction, tap the triceps tendon with reflex hammer

41. Clinical Evaluation Babinkski Test:
Athlete:  Supine with shoes and socks removed
ATC:  At the foot of the athlete holding a blunt tool
Procedure:  ATC runs the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe
Positive test:  Great toe extends while other toes splay
Implications:  Lesion of upper motor neurons, may be caused by trauma to the brain
Comments:  This reflex occurs naturally in newborns.  However, this reflex should cease quickly after birth

42. Clinical Evaluation Oppenheim Test: Test: Upper motor neuron lesions
Patient position: supine
ATC: at patient’s side
Procedure: examiner’s fingernail is run along the crest of the anteromedial tibia
Positive test: great to extends and the other toes splay