David Lintonbon DO PG Cert (clin ed) www.theartofhvt.

com

Chapter 2

The Cervical Spine

Examination

Evaluation

&

Treatment

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Cervical Spine & Upper Extremity Evaluation

Causes of neck pain

 Facet-Capsular irritation –most common generally affects active side
bending/rotation and extension more than flexion, which unless very acute is
relatively unaffected. Positive on extension/compression test. Rarely root pain
but typically facet referral pattern.
 Disc injury (Uncommon) Flexion commonly markedly affected while side
bending may be relatively unaffected. Pain on coughing (acute) positive
anterior compression test.
 Facet degeneration/spondylo-arthrosis - late stage. Tends to lead to more
chronic neck pain.
 Postural fatigue - muscle ischaemia will be aggravated primarily by sustained
static postures such as sitting at computer, desk, etc. and relieved by activity.
 Fracture - History of trauma unless pathological fracture
 Soft tissue injury - secondary to trauma i.e. whiplash, which results in both
over sprain to anterior and posterior longitudinal ligaments, plus associated
muscle hypertonia. In severe hyper flexion the ligamentum nuchae can tear
around C5/6 6/7 7/T1.

Causes of neck and arm pain

 Capsule irritation with referred pain - from C5-T1 (NB Referred, not root
irritation) Referred pain may spread down to hand (rarely) but more commonly
only into upper arm.
 Disc injury with nerve root irritation - (Uncommon) NB Dermatomal arm
pain and often though not invariable neurological symptoms and signs.
 Foraminal encroachment with nerve root irritation - more common over 50
years (may occur in younger people if history of significant trauma i.e.
whiplash). Neurological symptoms not uncommon though not invariable, but
motor signs rare.

NB There may be separate causes of the neck and shoulder/arm pain

Causes of shoulder/arm pain
 Disc injury with nerve root irritation (Uncommon) As above without neck
pain

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 Brachial plexus irritation or subclavian artery compression from thoracic

inlet/outlet syndrome
Cervical rib
Scalene syndrome
Claviculo-costal syndrome
Pectoralis minor syndrome
NB Neurological symptoms in medial arm, hand or even in lateral hand if middle
or upper trunks affected.
 Rotator cuff dysfunction - tendinitis, paratendinitis - Relationship to specific
active, active resisted and passive shoulder movements
 Bursitis Subacromial- Relationship to specific active, active resisted and
passive shoulder movements ie painful arc syndrome (80120)
 Adhesive capsulitis - Night pain, plus severe pain and limitation of a number
of passive as well as active movements especially abduction, flexion and
internal rotation i.e. cannot reach behind back
 A-C joint strain-Pain on external rotation.

Causes of shoulder/arm pain, cont’d.

 (Medial arm angina -heart ischaemia - exercise related, not neck or shoulder
movements)
 Usually left shoulder, arm, and hand. (occur left side of jaw & face) via the left
phrenic nerve.
 Hepatitis, gall bladder inflammation refers to the right shoulder and neck.
Pressure from both of these structures press up onto the diaphragm and hence
the phrenic nerve. (C3/4/5) “ 3 4 5 keep the diaphragm alive”

Non-mechanical causes
 Psychological - not consistent with mechanical pattern. Sometimes associated
with minor neck tremor or tendency to repeatedly turn neck to one way.
 Spinal metastasis
 Pathological fracture secondary to osteo-porosis, tumour, secondary CA
 Ankylosing Spondylitis, RA
 Polymyalgia Rheumatica (PMR)
 Neurological disorders such as MS may cause neck pain but there are
generally limb (upper and maybe lower) symptoms. There may also be intra-
spinal neurological disease such as a cord tumour, motor neurone disease or
syringo-myelia, which would also cause limb symptoms.
 Marked - severe degeneration may cause spinal cord compression with or
without root compression (cervical myelopathy) thus causing symptoms in 1-
4 limbs usually at least associated with obvious neck stiffness and some
aching. In severe cases cervical rotation can result in pain/weakness in the

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lower extremities, due to direct compression on the tracts. In the absence of

obvious signs of neck restriction cervical myelopathy from marked
degeneration is unlikely.
NB Anterior neck structures rarely cause posterior neck pain in the absence of
anterior neck pain. Thus, oesophageal and tracheal problems may cause anterior
pain and rarely posterior pain.
 Thyroid problems do not, as a rule, present with pain. Most will cause
generalised systemic symptoms rather than local pain.

Examination

Adson’s test
There is significant variation in the protocol of this test between different sources.
Most agree that the arm should be raised while the radial pulse is palpated.
Additional movements of the shoulder or neck are then added to see if the radial
pulse can be obliterated. A number of sources are quoted here to demonstrate the
variability of the protocol. In practice it is worth attempting more than one test
including trying rotation to either side since in theory each rotation will have
some effect on the thoracic inlet. Loss of radial pulse is not necessarily indicative
of the thoracic inlet as the cause of symptoms, since subclavian artery
compression may occur in non-symptomatic people. Reproduction of symptoms is
a more useful indication
Magee
Affected arm is abducted while the operator palpates the radial pulse. Patient
Turns their head away from the affected side patient is asked to breathe in. This
tests both 1st rib and scalene hypertonicity and tends to be more reliable as it is
putting a torsion through the thoracic triangle therefore any reduction in the
thoracic outlet is usually picked up.
DiGiovanna
Affected arm is abducted while osteopath palpates radial pulse. Patient turns head
towards affected side and extends neck, then takes a deep breath. If nothing
happens, patient turns head away from affected arm.

Adson Test Positive if pulse decreases or disappears, or if symptoms are reproduced.

(Hyper abduction test - radial pulse monitored. Full 180 degrees of
abduction. Positive if pulse dimishes or symptoms reproduced.)

Costo-clavicular test - Patient is asked to assume a military posture - chest

out, shoulders back and down while radial pulse is palpated. Positive if
pulse diminishes or symptoms reproduced.)

Merc Manual
Test involves elevation of the arm (how far?) and contra-lateral rotation of the
neck while the pulse is palpated.

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Corrigan and Maitland

Patient stands with the arm loose by the side. He rotates the head towards the
affected side, breathes in and holds his breath while the osteopath passively
abducts the shoulder to just beyond 90, while avoiding extension.
Positive if pulse obliterated.

Caillet
Patient rotates towards the affected side and then extends the cervical spine. He
then is asked to abduct the arm (how far?) and takes a deep breath.
Positive if pulse dimishes or symptoms (parasthesia) reproduced.

Phillips and Grieve

Adson’s - Extending and turning the head and neck towards the affected side and
deeply inspiring compromises the radial pulse (no abduction!)
(Hyper abduction - Prolonged periods of hyper abduction with the elbows
flexed will cause a diminution of the radial pulse in normal subjects, but if
symptoms are reproduced easily compression may be suspected.
Exaggerated military posture as above)

Facet joint problems

Examination

If the onset is recent there may be a spinal deviation, due to reflex contracture of
overlying muscle, but this usually subsides as the acute inflammation decreases
and is not likely to persist for weeks unless the patient is not managing the
problem sensibly.

Commonly side-bending is most affected in association with restriction of

extension and less frequently, flexion.

Facet joint involvement is considerably more likely if extension is markedly

limited while flexion is reasonably comfortable. Flexion may, however, be painful
also.

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Unless very acute, on passive palpation there is usually some movement possible
once the patient is relaxed, and the restriction is worse in one or more ranges,
especially side bending towards the side of dysfunction & extension.

Facet or Disc?

Use of compression/quadrant/Spurling’s test.

With the patient seated compress head anterior left and right usually indicates
disc.
Posterior/extension/sidebend usually indicates facet.
If in doubt ref for X-ray/MRI.