Evaluation and treatment of the cervical spine

Assistive devices collars, braces

Pain behavior hand over painful area

slow cautious movements

verbal and facial clues

Handshake

Head tilt, rotation

Forward head posture

Rounded shoulders

CT junction

Spinal curves

Muscle atrophy

Muscle hypertone

Performed if subjective examination suggests any possibility of craniovertebral instability or vertebral basilar insufficiency

Should be performed on every patient who presents with spinal problems.

Upper vs. lower motor neuron

Nerve root vs. peripheral entrapment
Are nerve root signs increased or decreased

Hyper vs. hypo

Indicates type of pathology: compression

irritation

combination

Does not indicate exact level of pathology

Purpose: Establish pattern of pain and limitation

Estimate range

Develop baseline for improvement

Most painful movement done last. Try not to do residual pain carry over

Over pressure may be applied, but carefully and only if motion appears to be full and painfree.

Usually do rotation first. Chin should nearly reach plane of shoulder.

Sidebend next. Ear to shoulder.

Flexion next. Chin to chest without opening mouth, or at least within 2 fingers.

May be limited by: CT junction or upper thoracic spine problems

Adaptive shortening

Cervical disc

Extension last. Face should get close to horizontal plane.

Eliminates contractile tissue

Compare AROM/PROM

Check endfeel

Assess strength and pain behavior

Check for worsening/improving pain or increasing decreasing pain

Repeat up to 10 times
Cervical distraction and compression

Compression gradually load cervical spine

pressure through top of skull

test in neutral, flexion, extension

lift up under occiput

test in neutral, flexion, extension
Quadrant test

Assess signs and symptoms by using combined movement of rotation, sidebending, flexion or extension.

anterior left and right

Perform posterior quadrant test passively. If this is negative for reproduction of symptoms, carefully add vertical compression.

Valuable when relevant signs and symptoms are not reproduced with active/passive/resisted movements.

Assess pain behavior with prolonged posture in flexion and extension.
Segmental mobility testing

Shoulder abduction test

Patient seated or lying. Put hand on top of head. Decrease of symptoms is indicative of C5-6 nerve root compression.

Patient seated. Passively rotate head left, right. Then hold head still, while patient turns his trunk left, right. If dizziness occurs in both cases, suspect vertebral artery insufficiency. If dizziness only occurs with passive rotation of the head, suspect inner ear problems.

NEUROLOGICAL EVALUATION

Cervical reflexes

C5 Biceps

Cervical cutaneous innervation

C6 Posterior thumb

Cervical myotomes

Level Resisted movement Muscles

Wrist extension Extensor carpi radialis longus/brevis

Wrist flexion Flexor carpi radialis

Quick test for: median nerve

radial nerve

ulnar nerve

• 
  Level C 4 - C 5
  
• 
  Pain distribution: Extends outward from scapular area to anterolateral area and forearm as far as the radial side of the hand.
  
• 
  Cutaneous innervation: lateral arm
  
• 
  Reflex: biceps
  
• 
  Myotome: deltoid, biceps
  

• Level C 5 - C 6

• 
  Pain distribution: spreads down from the front of arm to radial side of the hand, thumb and index finger
  
• 
  Cutaneous innervation: posterior thumb
  
• 
  Reflex: brachioradialis
  

• Myotome: wrist extensors, biceps

• Level C 6 - C 7

• 
  Pain distribution: from scapula down back of arm and forearm to index, middle and ring finger
  
• 
  Cutaneous innervation: posterior middle finger
  
• 
  Reflex: triceps
  
• 
  Myotome: wrist flexors and triceps
  

• Level: C 7 - T 1

• 
  Pain distribution: lower scapular area, back or inner side of arm and forearm, 4^th and 5^th finger
  
• 
  Reflex: none
  
• 
  Cutaneous innervation: ulnar aspect of 5^th finger
  
• 
  Myotome: thumb extension and finger flexion
  

• Level: T 1 - T 2

• 
  Pain distribution: medial arm and forearm
  
• 
  Cutaneous innervation: medial arm
  
• 
  Reflex: none
  
• 
  Myotome: hand intrinsic musculature
  

We think it’s prudent to test for upper cervical instability prior to testing the vertebral artery, as this involves sustained endrange rotation, which can possibly compromise the spinal cord if there would be underlying instability.

• 
  Bilateral or quadrilateral limb paresthesiae, either constantly or reproduced/aggravated by head or neck movements.
  
• 
  Hyperreflexia
  
• 
  Clonus
  
• 
  Positive Babinski or Hoffman’s
  
• 
  Arm and leg weakness
  
• 
  Lack of coordination bilaterally
  

Anatomy

The vertebral artery arises from the first part of the subclavian artery and passes upward on the longus colli to enter the transverse foramen of C6. Occasionally it may enter the bone at the 5^th, 4^th or 7^th cervical transverse foramen. It then ascends from C6 to C1. After emerging through the transverse foramen of C1, it winds around the articular pillar and together with the 1^st cervical nerve and veins pierces the posterior atlanto-occipital membrane to enter the cranium through the foramen magnum. On the anterior side of the brainstem it joins its fellow to form the basilar artery, before entering the foramen magnum.
The vertebral arteries contribute about 11 percent of the total cerebra blood flow, the remaining 89 percent being supplied by the carotid system. Asymmetry in the size of the two VA’s is common. Indeed, complete interruption of blood flow in one VA may be asymptomatic as long as there is a normal configuration in the circle of Willis and adequate flow through the other VA. Symptoms will occur when the blood supply to an area is critically reduced. This will depend ultimately on a balance between compensatory and compromising factors.
Provocative positional testing is frequently used in practice. It is intended to provide a challenge to the vascular supply to the brain, and the presence of signs or symptoms of cerebrovascular ischaemia during or immediately post testing is interpreted as a positive test.
Despite endorsement by guidelines and common clinical usage, current research does not support the contention that provocative positional testing can accurately identify patients at risk for cervical artery disease. Vertebral artery testing procedures have a sensitivity and specificity that approximates zero. This indicates a high likelihood of false negative findings.
Test procedures for the vertebral artery also hold a certain risk, and screening tests will not identify all patients at risk of suffering adverse reaction to cervical manipulation. There is also disagreement on what constitutes a clinically meaningful change in blood flow on cervical movement. It should be reiterated that there is no known method for testing the intrinsic anatomy of the vertebral artery. Doppler studies (Arnold, 2004) have shown that only full range cervical rotation and a pre-manipulative hold at C1-2 stresses the vertebral artery sufficiently to demonstrate reduction of bloodflow. Therefore the Clinical Guidelines of the Australian Physiotherapy Association recommend that only rotation be used to test for VBI.
Risk factors associated with cervical arterial dysfunction

• 
  History of trauma to cervical spine / cervical vessels
  
• 
  History of migraine-type headache
  
• 
  Hypertension
  
• 
  High cholesterol levels
  
• 
  Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischaemic attack
  
• 
  Diabetes mellitus
  
• 
  Blood clotting disorders
  
• 
  Anticoagulant therapy
  
• 
  Long-term use of steroids
  
• 
  History of smoking
  
• 
  Recent infection
  
• 
  Immediately post partum
  
• 
  Trivial head or neck trauma
  
• 
  Absence of a plausible mechanical explanation for the patient’s symptoms.
  

Signs/symptoms suggestive of vertebral/basilar artery insufficiency:

Early presentation:

• 
  Mid-upper cervical pain
  
• 
  Pain around ear and jaw
  
• 
  Head pain (front- temporo-parietal)
  
• 
  Occipital headache
  
• 
  Acute onset of pain described as "unlike any other”
  

Late presentation:

• 
  Drop attacks
  
• 
  Dizziness
  
• 
  Dysphagia (difficulty swallowing)
  
• 
  Dysarthria (speech change, either slurred or slowed)
  
• 
  Diplopia (double vision)
  
• 
  Nausea
  
• 
  Nystagmus
  
• 
  Facial lip paresthesiae/ facial numbness
  
• 
  Cranial nerve dysfunction
  

Differential diagnosis

1. 
   Vertebral artery insufficiency
   
2. 
   Alar ligament insufficiency
   
3. 
   Transverse ligament insufficiency
   
4. 
   C 1 - 2 instability
   
5. 
   Jefferson fracture
   
6. 
   Balance difficulty, due to loss of proprioception secondary to immobilization of cervical spine
   
7. 
   Symptom magnification
   
8. 
   Autonomic reactions
   

Craniovertebral scan

Scan performed with patient seated, minimal hands on required.

1. 
   Neck rotation
   
2. 
   Upper cervical sidebending
   
3. 
   Upper cervical flexion
   
4. 
   Upper cervical extension
   
5. 
   Compression
   
6. 
   Distraction
   

Stability tests
Alar ligmanent

Patient sitting. Palpate C 2 with index finger while sidebending head to the right. Normal: should feel immediate movement of C 2 to the opposite side of sidebending.

Transverse ligament
Patient supine. Anterior movement of occiput and C 1 on C 2. Normal: C 2 should follow immediately.




Transverse plane stability.

Medial pressure on TP of C 1 while stabilizing the opposite TP. Should be no movement or crepitus (Jefferson fracture).

Upper motor neuron tests

1. 
   Babinski
   
2. 
   Hoffman’s. Flick patient’s middle finger. Positive when there is a flexion pattern of thumb and index finger.
   
3. 
   DTR’s
   
4. 
   Clonus
   

Examination
Performed when stability tests are negative and there are no upper motor neuron signs
Minimal testing recommended includes the following:

• 
  Sustained end range cervical rotation to the left and the right. Maintain each position with overpressure for 10 seconds 9 or less if symptoms are provoked) and on release, a period of 10 seconds should elapse to allow for any latent response to the sustained position. The patient is asked about dizziness during each test, and the eyes are observed for the presence of nystagmus
  
• 
  The position or movement that provokes symptoms as described by the patient.
  
• 
  Sustained mobilization position
  

Specific questioning re. production of symptoms suggestive of VBI is essential and should be done

• 
  Immediately before and after a cervical manipulation
  
• 
  During and immediately after a technique involving endrange rotation
  

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