THE CERVICAL SPINE

THE CERVICAL SPINE

Posture

Note the symmetry of the head on the neck, and the neck relative to the thorax. The chin should be at 90 degrees to the anterior aspect of the neck. There should be no obvious horizontal skin creases posteriorly. A plumbline from the tragus of the ear should fall behind the clavicle. Assess the cervical lordosis. A decreased lordosis predisposes the vertebral bodies and discs to bear more weight. An increased lordosis increases the compressive loads on the zygapophyseal (facet) joints and posterior elements. Observe for muscle hypertrophy, hypotrophy, spasm, tightness or general asymmetry. An acute wry neck (torticollis) presents as a combination of flexion and rotation or side flexion away from the painful side. Patients with chronic pathology often have a poking chin posture which consists of excessive upper and middle cervical extension and lower cervical/cervicothoracic flexion. This results from a weakness of the deep cervical flexors and overactivity of sternocleido-mastoid and levator scapulae muscles. Note that cervical posture is influenced by lumbar posture and, hence, the poking chin posture is exaggerated by lumbar and thoracic flexion. Cervical and shoulder posture should, therefore, be viewed in both the sitting and standing postures. The shoulders should, ideally, be level, but this is often not the case because of handedness. For example, in a right-handed person the right shoulder is often held slightly lower than the left.

Movements

It is important to not only assess the range of movement occurring in the cervical region but also the quality of that movement. Note, in particular, the motion segments where the movement is occurring. Hinging may be

observed, which indicates areas of hypermobility or instability. Conversely, areas of hypomobility or stiffness are observed as areas of plane or straight lines.

Active movements

Flexion

The movement should be performed to either the patient’s pain or the limit of movement. During flexion the cervical lordosis should be obliterated and the spine appears to be flexed or neutral. The spinous process of C7 should be the most prominent – C6 and T1 less so. The chin should approximate the chest. Common faulty patterns are the upper cervical spine remaining in extension or chin poke. Loss of range, areas of give and restriction should be

noted, as well as the pain response, muscle spasm and crepitus.

Extension

The entire cervical spine should extend, and the face should be almost parallel to the ceiling. A vertical line should be observed from the chin to sternum. Common faulty movement patterns include a loss of lower cervical

extension and the head does not move posteriorly to the shoulders. Furthermore, excessive hyperextension of the upper and mid cervical spine may occur earlier on in the movement and the chin pokes forward.

Side flexion

Often this movement is the most restricted in degenerative spinal pathologies. Tightness in the contralateral sternocleidomastoid and trapezius may be observed. Common faulty patterns include coupling with rotation owing to tightness in anterior flexor musculature. Observe range, pain response and areas of give or restriction. Compare the sides for symmetry.

Right and left rotation

Observe the range of movement available and the patient’s pain response, muscle spasm and crepitus. Common faulty patterns include coupled movements with side flexion and the eyes not moving in a purely horizontal

plane. Compare the right and the left sides.

Overpressures repeated and combined movements

If the plane movements are full range and pain-free, then overpressure may be applied. At the end of the available range the physiotherapist may apply a small oscillatory movement to feel the quality and end-feel of the movement, and the range of further movement. The pain response is also noted. Combined movements may be examined in an attempt to reproduce the patient’s pain or restriction of movement. The patient should if possible

perform repeated movements, as this may alter the quality and range of the movement and may give rise to latent pain (McKenzie 1990).

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