Cervical Spine Examination

Commonly Tested

The cervical spine examination must differentiate between radiculopathy (nerve root) and myelopathy (spinal cord). Examiners expect you to identify red flags, perform provocative tests (Spurling's), and complete a thorough neurological assessment. Always exclude the shoulder as a source of referred pain.

Exam day cheat sheet

Cervical Spine Examination Summary

Look

Posture (forward head, loss of lordosis)
Muscle spasm (torticollis)
Scars, skin changes
Deformity (kyphosis, scoliosis)

Feel

Spinous processes (C2-C7)
Paraspinal muscles
Facet joints (lateral)
Supraclavicular fossa

Move

Flexion 0-50°
Extension 0-60°
Rotation 0-80° each side
Lateral flexion 0-45° each side

Special Tests

Spurling's (radiculopathy)
Lhermitte's (myelopathy)
Hoffman's (UMN)
Upper limb neurological exam

Introduction and Setup

Before You Start

Patient Positioning: Seated for most of examination, standing for gait assessment

Exposure: Neck and upper back exposed, arms exposed for neurological examination

Consent Script: "I'm going to examine your neck. I'll look at the posture, feel the spine, and test the movements. I'll also check the nerves in your arms. Please tell me if anything causes pain or unusual symptoms."

Key Anatomy:

7 cervical vertebrae (C3-C7 have similar structure)
C1-C2 (atlantoaxial) provides 50% of rotation
8 cervical nerve roots (C1-C8)
Nerve root exits ABOVE corresponding vertebra (C6 root exits at C5-C6 level)

Red Flags (Screen First)

Must Know

Red Flags in Cervical Spine Pain - Exclude Before Proceeding:

Myelopathy symptoms: Gait disturbance, hand clumsiness, urinary symptoms
Trauma: Any significant mechanism, especially in elderly
Constitutional symptoms: Fever, weight loss, night sweats (infection, malignancy)
Progressive neurological deficit: Increasing weakness or sensory loss
Severe unrelenting pain: Not relieved by rest (tumor, infection)
Age over 50 with new onset: Consider metastatic disease
Known malignancy: Spinal metastases
Immunocompromised: Infection risk

Look (Inspection)

Head position: Forward head posture, tilt, rotation
Shoulder height: Asymmetry (torticollis, scoliosis)
Supraclavicular fossae: Fullness (Pancoast tumor, nodes)
Thyroid: Enlargement
Muscle bulk: SCM, scalenes

Key Concept

Loss of Cervical Lordosis: Often indicates muscle spasm from acute injury or disc pathology. May also be seen in ankylosing spondylitis (where entire spine becomes kyphotic) or post-laminectomy.

Feel (Palpation)

Systematic Palpation Sequence

Posterior Midline:

Occiput: Nuchal ridge, occipital nerves
C2 spinous process: First palpable spinous process
C3-C6: May be difficult to distinguish individually
C7 (vertebra prominens): Most prominent spinous process
T1: For reference

Posterior Lateral:

Facet joints: 1-2cm lateral to midline
Paraspinal muscles: Spasm, tenderness, trigger points
Trapezius: Upper fibers
Levator scapulae: Scapular angle

Anterior Lateral:

SCM muscle: Spasm, tenderness
Scalene muscles: Trigger points
Lymph nodes: Cervical chain
Thyroid: Enlargement
Carotid pulse: Assess before mobilization

Special Palpation:

Supraclavicular fossa (Pancoast tumor, nodes, brachial plexus)
Spinous process step-off (spondylolisthesis, fracture)

Move (Range of Motion)

Flexion

normalRange: 0-50°
technique: Chin to chest
keyPoints: Should touch chest or within 2 finger breadths

Extension

normalRange: 0-60°
technique: Look at ceiling
keyPoints: Face should be nearly horizontal

Rotation (each side)

normalRange: 0-80°
technique: Chin toward shoulder
keyPoints: Chin should nearly reach shoulder; 50% at C1-2

Lateral Flexion (each side)

normalRange: 0-45°
technique: Ear toward shoulder
keyPoints: Don't allow shoulder to rise

movement	normalRange	technique	keyPoints
Flexion	0-50°	Chin to chest	Should touch chest or within 2 finger breadths
Extension	0-60°	Look at ceiling	Face should be nearly horizontal
Rotation (each side)	0-80°	Chin toward shoulder	Chin should nearly reach shoulder; 50% at C1-2
Lateral Flexion (each side)	0-45°	Ear toward shoulder	Don't allow shoulder to rise

During Movement Assess:

Pain: Location, reproduction of arm symptoms
Crepitus: Degenerative changes
Apprehension: Instability
Arc of pain: Specific position that causes symptoms

Key Concept

Combined Movements: In cervical radiculopathy, extension combined with rotation toward the affected side (Spurling's position) compresses the foramen and reproduces symptoms. This is more sensitive than individual movements.

Special Tests

Radiculopathy Tests

Special test

Spurling's Test

Cervical radiculopathy (foraminal compression)

Technique

1Patient seated, neck extended
2Rotate and laterally flex toward affected side
3Apply axial compression through top of head

Positive Sign

Reproduction of radicular pain or paresthesias into the arm (dermatomal pattern)

Indicates

Cervical radiculopathy (foraminal stenosis or disc herniation)

Diagnostic Accuracy

Sensitivity50%

Ability to detect true positives

Specificity86%

Ability to exclude false positives

Special test

Distraction Test

Relieve foraminal compression

Technique

1Patient seated
2Place hands under occiput and chin
3Apply gentle upward traction (distraction)

Positive Sign

Relief of arm symptoms with distraction

Indicates

Cervical radiculopathy (confirms foraminal origin)

Diagnostic Accuracy

Sensitivity44%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

Special test

Shoulder Abduction Test (Bakody's Sign)

Cervical radiculopathy

Technique

1Patient places hand of affected arm on top of head

Positive Sign

Relief of arm symptoms

Indicates

Cervical radiculopathy (reduces tension on nerve root)

Diagnostic Accuracy

Sensitivity43%

Ability to detect true positives

Specificity80%

Ability to exclude false positives

Myelopathy Tests

Special test

Lhermitte's Sign

Spinal cord pathology

Technique

1Patient seated or supine
2Flex the neck (chin to chest)

Positive Sign

Electric shock sensation radiating down spine or into limbs

Indicates

Spinal cord pathology (myelopathy, MS, cervical stenosis, tumor)

Diagnostic Accuracy

Sensitivity27%

Ability to detect true positives

Specificity99%

Ability to exclude false positives

Special test

Hoffman's Sign

Upper motor neuron lesion

Technique

1Hold patient's middle finger loosely between your thumb and finger
2Flick the nail of the middle finger (quick flexion of DIP)

Positive Sign

Reflex flexion of thumb and index finger

Indicates

Upper motor neuron lesion (myelopathy, corticospinal tract dysfunction)

Diagnostic Accuracy

Sensitivity58%

Ability to detect true positives

Specificity78%

Ability to exclude false positives

Special test

Inverted Radial Reflex

Cervical myelopathy at C5-6 level

Technique

1Test brachioradialis reflex as normal
2Observe finger response

Positive Sign

Finger flexion in addition to or instead of normal elbow flexion

Indicates

Cervical myelopathy at C5-6 level (combined LMN at level + UMN below)

Diagnostic Accuracy

Sensitivity51%

Ability to detect true positives

Specificity87%

Ability to exclude false positives

Special test

Grip and Release Test

Myelopathy (hand function)

Technique

1Ask patient to make a fist and release as fast as possible
2Count cycles in 10 seconds

Positive Sign

Less than 20 cycles in 10 seconds (normal is 20 or more)

Indicates

Cervical myelopathy (hand clumsiness from corticospinal dysfunction)

Diagnostic Accuracy

Sensitivity75%

Ability to detect true positives

Specificity69%

Ability to exclude false positives

Vascular Tests

Special test

Vertebrobasilar Insufficiency Test

Screen for vertebral artery compromise

Technique

1Patient supine with head off end of bed
2Extend and rotate neck to one side
3Hold for 30 seconds, observe for symptoms
4Repeat to other side

Positive Sign

Dizziness, nystagmus, visual disturbance, drop attack

Indicates

Vertebrobasilar insufficiency (IMPORTANT: perform before any manipulation)

Diagnostic Accuracy

Sensitivity0%

Ability to detect true positives

Specificity0%

Ability to exclude false positives

Neurological Assessment

Motor Testing - Myotomes

Muscle: Deltoid, Biceps
Action: Shoulder abduction, elbow flexion
Test: Resisted abduction, flex elbow

Muscle: Wrist extensors (ECRL)
Action: Wrist extension
Test: Resisted wrist extension

Muscle: Triceps, Wrist flexors
Action: Elbow extension, wrist flexion
Test: Resisted elbow extension

Muscle: Finger flexors (FDP)
Action: Finger flexion
Test: Grip strength, finger flexion

Muscle: Hand intrinsics
Action: Finger abduction
Test: Spread fingers against resistance

Root	Muscle	Action	Test
C5	Deltoid, Biceps	Shoulder abduction, elbow flexion	Resisted abduction, flex elbow
C6	Wrist extensors (ECRL)	Wrist extension	Resisted wrist extension
C7	Triceps, Wrist flexors	Elbow extension, wrist flexion	Resisted elbow extension
C8	Finger flexors (FDP)	Finger flexion	Grip strength, finger flexion
T1	Hand intrinsics	Finger abduction	Spread fingers against resistance

Sensory Testing - Dermatomes

Area: Top of shoulder (cape distribution)

Area: Lateral arm (deltoid patch)

Area: Lateral forearm, thumb, index finger

Area: Middle finger

Area: Medial forearm, ring and little fingers

Area: Medial arm (axilla to elbow)

Root	Area
C4	Top of shoulder (cape distribution)
C5	Lateral arm (deltoid patch)
C6	Lateral forearm, thumb, index finger
C7	Middle finger
C8	Medial forearm, ring and little fingers
T1	Medial arm (axilla to elbow)

Testing Method:

Light touch comparison side-to-side
Pin prick if abnormal
Ask "Does this feel the same on both sides?"

Reflex Testing

Biceps

Root: C5,6
Technique: Tap biceps tendon

Brachioradialis

Root: C5,6
Technique: Tap radial styloid

Triceps

Root: C7
Technique: Tap triceps tendon

Reflex	Root	Technique
Biceps	C5,6	Tap biceps tendon
Brachioradialis	C5,6	Tap radial styloid
Triceps	C7	Tap triceps tendon

Grading:

0: Absent
1: Diminished
2: Normal
3: Brisk (may be normal)
4: Clonus (always abnormal)

Lower Limb Assessment (Myelopathy Screen)

Quick Myelopathy Screen

Motor:

Hip flexion (L2)
Knee extension (L3,4)
Ankle dorsiflexion (L5)
Ankle plantarflexion (S1)

Reflexes:

Knee jerk (L3,4)
Ankle jerk (S1)
Babinski sign (plantar response)
Clonus (ankle clonus)

Gait:

Broad-based, ataxic gait (posterior column)
Spastic gait (corticospinal tract)
Tandem walking (heel-to-toe)

Romberg Test:

Proprioceptive loss from posterior column dysfunction

Complete the Examination

Must Know

Always state to the examiner:

"To complete my examination, I would like to:

Examine the shoulder to exclude referred pain
Examine the thoracic spine if indicated
Complete lower limb neurological assessment if myelopathy suspected
Perform gait assessment
Obtain X-rays (AP, lateral, oblique, flexion-extension if instability suspected)
Consider MRI if radiculopathy or myelopathy suspected"

Summary Presentation

Viva scenarioStandard

Presenting Your Findings

Clinical prompt

“48-year-old man with 6-week history of right arm pain and numbness in the thumb and index finger.”

Cervical Radiculopathy Summary

motor: Deltoid, Biceps
reflex: Biceps
sensory: Lateral arm
disc: C4-5

motor: Wrist extension, Biceps
reflex: Biceps, Brachioradialis
sensory: Lateral forearm, thumb, index
disc: C5-6

motor: Triceps, Wrist flexion
reflex: Triceps
sensory: Middle finger
disc: C6-7

motor: Finger flexors, Grip
reflex: None reliable
sensory: Ring, little finger, medial forearm
disc: C7-T1

root	motor	reflex	sensory	disc
C5	Deltoid, Biceps	Biceps	Lateral arm	C4-5
C6	Wrist extension, Biceps	Biceps, Brachioradialis	Lateral forearm, thumb, index	C5-6
C7	Triceps, Wrist flexion	Triceps	Middle finger	C6-7
C8	Finger flexors, Grip	None reliable	Ring, little finger, medial forearm	C7-T1

Common Conditions Table

Cervical Radiculopathy

look: May be normal
feel: Paraspinal tenderness
move: Reduced extension/rotation
specialTests: Spurling's +, dermatomal sensory loss, weakness

Cervical Myelopathy

look: May be normal
feel: Normal
move: May be normal
specialTests: Hoffman's +, Lhermitte's +, hyperreflexia, gait ataxia

Mechanical Neck Pain

look: Loss of lordosis
feel: Paraspinal spasm
move: All directions reduced
specialTests: No neurological deficit, no radicular pattern

Cervical Spondylosis

look: Loss of lordosis
feel: Facet tenderness
move: Reduced extension > flexion
specialTests: Crepitus, may have radiculopathy/myelopathy

Torticollis

look: Head tilt + rotation
feel: SCM spasm
move: Unable to correct
specialTests: Assess for underlying cause

condition	look	feel	move	specialTests
Cervical Radiculopathy	May be normal	Paraspinal tenderness	Reduced extension/rotation	Spurling's +, dermatomal sensory loss, weakness
Cervical Myelopathy	May be normal	Normal	May be normal	Hoffman's +, Lhermitte's +, hyperreflexia, gait ataxia
Mechanical Neck Pain	Loss of lordosis	Paraspinal spasm	All directions reduced	No neurological deficit, no radicular pattern
Cervical Spondylosis	Loss of lordosis	Facet tenderness	Reduced extension > flexion	Crepitus, may have radiculopathy/myelopathy
Torticollis	Head tilt + rotation	SCM spasm	Unable to correct	Assess for underlying cause

Examiner Tips

Exam day cheat sheet

Scoring High in the Cervical Spine Examination

Do

Screen for red flags first
Perform Spurling's test correctly
Complete upper AND lower limb neurology if myelopathy suspected
Examine the shoulder
Correlate myotome, dermatome, and reflex for each root

Don't

Forget myelopathy screening (Hoffman's, lower limbs)
Miss vertebrobasilar screening
Confuse C6 and C7 radiculopathy
Forget to examine shoulder for referred pain
Rush the neurological assessment