Cervical Spine

Cervical Spine Classifications

  • Date and Course Information: 1/18/25, Cervical Spine Classifications, exam techniques and special tests, MSK III PHTH 676/679, Erin Futrell, PT, PhD, MPT, OCS, Updated January 2025

Cervical Spine Anatomy

  • Anatomical Joints:

    • C0-1 (Atlanto-occipital joint, OA): Mainly responsible for flexion and extension.

    • C1-2 (Atlanto-axial joint, AA): Primarily responsible for rotation (approximately 50% of total cervical rotation).

    • C2-C7: Enables flexion, extension, rotation, and side bending (SB).

  • Coupling:

    • For C3-C7: Rotation and side bending occur in the same direction. For example, right rotation involves a small amount of right side bending, and vice versa.

    • For C0, C1, C2: Rotation and side bending occur in opposing directions. For example, right rotation involves a small left side bending and vice versa.

  • Muscles of the Cervical Spine:

    • Reference Tables 1 & 2 in CCOPT 5th ed and Tables in Magee show shared muscles with the thoracic spine (T/S) and glenohumeral (GH) joint.

Neck Pain Classifications

Categories of Neck Pain

  • Neck Pain with:

    • Mobility deficits

    • Movement coordination impairments (WAD)

    • Cervicogenic headaches

    • Radiating (Radicular) pain

ICD-10 Codes and Conditions

  • M54.2: Cervicalgia

  • M54.6: Pain in thoracic spine

  • R51: Cervicogenic headache

  • M53.0: Cervicocranial syndrome

  • M53.1: Cervicobrachial syndrome

  • M53.2: Spinal instability

  • S13.4: Sprain of ligaments of cervical spine

  • S13.8: Sprain of joints and ligaments of other parts of neck

  • M47.2x: Cervical spondylosis with radiculopathy

  • M47.1x: Cervical spondylosis with myelopathy

  • M50.x: Cervical disc disorder

Common Outcome Measures

  • Neck Disability Index (NDI)

  • Patient Specific Functional Scale (PSFS)

  • Fear Avoidance Beliefs Questionnaire (FABQ)

  • Cervical Spine Specific Functional Questions:

    • Turning head

    • Looking up (e.g., in shower)

    • Looking down (e.g., reading, tying shoes)

    • Driving

    • Sleeping

    • Sitting

    • Upper extremity (UE) symptoms?

    • Dizziness?

    • Headache?

Subjective Exam

  • The subjective exam provides a working hypothesis to plan the physical exam.

Screening for Red Flags and Yellow Flags

Red Flags (Indicate Serious Pathology)

  • Fractures

  • Vascular pathologies* (as discussed in the Rushton article)

  • Ligamentous instability

  • Malignancy

  • Myelopathy

  • Headache, dizziness, concussion

Yellow Flags (Psychosocial Factors)

  • Depression

  • Anxiety

  • Other psychosocial factors

Screening for Fractures

  • Screening details coming soon (refer to the Spinal Imaging Lecture).

  • Included in the Neck Pain Clinical Practice Guideline (CPG).

Screening for Vascular Pathology

  • Thorough history-taking is crucial due to the limited physical examination tests available.

  • Common risk factors similar to Cardiovascular Disease (CVD):

    • History of smoking

    • Hypertension (HTN)

    • Hyperlipidemia

    • Family history of vascular conditions

    • Other risk factors: recent trauma, vascular anomaly, migraine, recent infection, use of oral contraceptives.

  • Determine if patients have underlying predispositions to vascular pathology.

Physical Exam Techniques for Vascular Pathology

  • Observation: Identify red flags or observable signs (e.g., gait disturbance, slurred speech, confusion, signs of Upper Motor Neuron (UMN) lesions, ptosis, drowsiness).

  • Vitals: Monitor blood pressure; palpate and auscultate carotid arteries.

  • Neurological Examination: Neuro exam if responses warrant it.

Specific Screening for Vascular Pathologies

  • Vertebral Artery (Vertebrobasilar) Dissection or Occlusion

    • Causes: Whiplash, minor sport trauma, sneezing, vomiting, atherosclerosis.

    • Symptoms: Neck pain, occipital headache (HA), Transient Ischemic Attack (TIA), cranial nerve (CN) palsy.

  • Internal Carotid Artery Dissection or Occlusion

    • Mechanisms include whiplash or other major trauma, atherosclerosis, stenosis, thrombosis, aneurysm.

    • Symptoms: Neck pain, facial pain, headache, CN signs, Horner’s syndrome, TIA.

Screening for Ligamentous Instability

  • Mechanisms: May result from whiplash or major trauma, down's syndrome, rheumatoid arthritis (RA), Ehlers-Danlos syndrome (EDS), and others.

  • Patients may report: catching, locking, giving way, or fear/anxiety with movement.

  • Symptoms may include sub occipital muscle spasm.

  • Passive range of motion (PROM) may show excessively free end-feel.

Special Tests for Ligamentous Stability

  • Sharp-Purser Test: Tests stability of C1 on C2 by assessing transverse ligament's integrity.

  • Alar Ligament Test: Checks the integrity of the alar ligaments connecting the dens (C2) to the occiput (C0).

  • C1-C2 Relationship Videos: Provided resources for understanding.

Screening for Malignancy and Myelopathy

Malignancy Screening Parameters

  • History of cancer

  • Pain at night

  • Unexplained weight loss

  • No change in pain with rest

  • Symptoms such as sore throat, ringing in ears, and dysphagia.

Myelopathy Screening

  • Compression of the spinal cord or reduction of vertebral canal space; most commonly seen in individuals over age 70.

  • Signs of Myelopathy Include:

    • Loss of disc height

    • Disc bulging

    • Thickening of ligaments

    • Formation of osteophytes.

  • History or Neuro Screen Findings:

    • UMN lesion signs such as hyperreflexia, clonus, +Lhermitte sign, +Hoffman sign, possible bowel/bladder dysfunction, multisegmental weakness, and sensory changes.

    • Symptoms also include intrinsic hand wasting and unsteady gait.

Myelopathy Cluster (CCOPT 5th ed.)

  1. Age > 45 years.

  2. Positive Babinski sign.

  3. Positive inverted supinator sign (brachioradialis reflex).

  4. Positive Hoffman sign.

  5. Gait dysfunction (spastic, wide base of support, or ataxia).

  • Result: 3 or more positive signs indicate high probability of myelopathy (likelihood ratio = 30.9).

Neurological Screen

  • Use in cases of suspected neural involvement.

  • Watch for numbness, paresthesias, loss of sensation, radicular pain, weakness, bowel/bladder dysfunction, balance/gait dysfunction, and ataxia.

  • Differentiate between Central Nervous System (CNS) vs Peripheral Nervous System (PNS) involvement:

    • Upper Motor Neuron (UMN) signs:

    • Hyperreflexia, clonus, +pathological reflexes (Hoffman's, Babinski).

    • Non-dermatomal/non-PNS sensory changes.

    • Often bilateral symptoms.

    • Gait changes.

    • Lower Motor Neuron (LMN) signs:

    • Hyporeflexive or absent deep tendon reflexes (DTR).

    • Corresponding muscle weakness/wasting with usually no sensory changes.

    • Peripheral Nerve Lesion Signs:

    • Pain, sensory changes, weakness, hyporeflexive/absent DTRs.

Goals of Physical Examination

  1. Reproduce symptoms.

  2. Assess the impact of posture, movement, work, and recreational activities on the patient’s issue.

  3. Establish treatment thresholds for diagnostic or impairment-based classifications by identifying clusters of signs and symptoms.

  4. Establish baseline and outcome measures to evaluate and monitor the progression of interventions.

Components of Physical Exam

  • Observation: Look for posture, functional activity performance, gait, and balance.

  • Neurological exam as necessary.

  • Palpation: Involves a screen of the upper extremities (UE), thoracic spine (T/S), and temporomandibular joint (TMJ), can be integrated into ROM and joint/muscle testing.

  • Range of Motion (ROM):

    • Active Range of Motion (AROM)

    • Passive Range of Motion (PROM)

    • Segmental ROM (e.g., PPIVMs/segmental mobility tests).

    • Repeated ROM testing.

  • Joint Play (PAIVMs): Assess joint mobility including joint glides and slides.

  • Muscle Testing: Testing both strength and length.

  • Special Tests: Conduct as necessary to draw further conclusions on patient conditions.

Arthrokinematics Review

Cervical Spine Movement Mechanics

  • C1 and C2 Movements:

    • For Right rotation: The left facet slides up (upglide/opening) while the right facet slides down (downglide/closing).

Types of Passive Movements

  • PPIVMs (Passive Physiological Movements):

    • PROM to individual motion segments from C0 to T4.

    • Exam involves flexion, extension, side bending (L/R), and rotation (L/R).

  • PAIVMs (Passive Accessory Movements):

    • Assess joint play, glides, and slides focusing on joint mobility from C2 to T4. This involves:

    • Posterior-anterior glides for extension and general mobility.

    • Side glides for side bending and rotation assessment.

    • Special tests for C0, C1, C2 to assess headaches and mobility at OA joints.

Neck Pain Classifications Related to Specific Findings

  • Mobility Deficits Classification:

    • Common clinical findings include patients younger than 50 years, with recent onset, acute neck pain lasting less than 12 weeks, often linked to awkward positions or movements.

    • Symptoms typically include central and/or unilateral neck pain, potential referred pain, restricted neck range of motion, and reduced segmental mobility with provoked symptoms.

    • Common interventions within this classification include cervical or thoracic spine mobilizations/manipulations, stretching, and strengthening protocols.

  • Movement Coordination Impairment Classification:

    • Pain often relates to trauma (such as WAD) or longer duration pain (> 12 weeks). Symptoms might include shoulder girdle pain, concussive signs, and tenderness or trigger points along with altered muscle activation or proprioception.

    • Recommended interventions here include mobilization/manipulation, neuromuscular re-education, and modalities for pain management,

    • Methods like cervical and scapulothoracic stretching/strengthening exhibit importance in this classification.

  • Cervicogenic Headaches Classification:

    • Symptoms include neck pain accompanying unilateral headaches, particularly aggravated by neck movement or static postures, and present with restricted segmental mobility or active trigger points.

    • Treatment options include upper cervical spine mobilizations/manipulations and soft tissue treatments.

  • Neck Pain with Radicular Pain Classification:

    • Presenting symptoms of upper extremity (UE) pain, paresthesias, and weakness characterized by certain cluster tests (e.g., Spurling's, +ULTT).

    • Treatment primarily focuses on management strategies for cervical mobility, joint mobilization, and neural mobilizations to alleviate symptoms.

Special Tests for Neck Condition Assessments

  • Ligamentous Stability Tests: Sharp-Purser and Alar Ligament Tests

  • Mobility Tests: Cervical rotation lateral flexion test.

  • Headache Assessment: Cervical flexion-rotation test,

  • Muscle Performance Tests: Neck flexor muscle endurance test and craniocervical flexion test.

  • Neural/Radicular Tests: Spurling’s, cervical distraction, Valsalva maneuver, and upper limb tension tests (ULTT).

Treatment Summary by Classification

  • Approach focuses on individualized interventions such as mobilization, stretching, strengthening, and management techniques tailored to the results obtained from special tests and physical examinations.

Case Studies and Classifications

Case 1: Rhea Curran

  • Demographic: 35-year-old female, real estate agent.

  • History: 2-month history of neck, periscapular, shoulder, and arm pain; diagnosed with cervical radiculopathy.

  • Findings: Pain radiating down the right UE, positive tests (e.g., Spurling’s), poor neck flexor endurance.

Case 2: Shanda Lear

  • Demographic: 38-year-old female, executive.

  • History: 4 weeks post motor vehicle accident (MVA), neck pain diagnosed as cervicalgia s/p whiplash injury.

  • Findings: Negative medical screen, multiple joint mobility deficits, and poor craniocervical test results.

Case 3: Lynn O. Liam

  • Demographic: 32-year-old male, sales representative.

  • History: 6-week onset of sharp neck pain, right versus left.

  • Findings: Mobility dysfunction and varying results on diagnostic tests (similar to above cases).

Conclusion

  • The cervical spine presents a complex arena requiring extensive assessment and examination through classification, thorough testing, and tailored interventions.