Comprehensive cervical spine examination including neurological assessment, myelopathy screening, radiculopathy evaluation, and recognition of red flags in neck pain.
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.
High-Yield Exam Summary
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:
Red Flags in Cervical Spine Pain - Exclude Before Proceeding:
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.
Posterior Midline:
Posterior Lateral:
Anterior Lateral:
Special Palpation:
| 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:
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.
Cervical radiculopathy (foraminal compression)
Reproduction of radicular pain or paresthesias into the arm (dermatomal pattern)
Cervical radiculopathy (foraminal stenosis or disc herniation)
Ability to detect true positives
Ability to exclude false positives
Relieve foraminal compression
Relief of arm symptoms with distraction
Cervical radiculopathy (confirms foraminal origin)
Ability to detect true positives
Ability to exclude false positives
Cervical radiculopathy
Relief of arm symptoms
Cervical radiculopathy (reduces tension on nerve root)
Ability to detect true positives
Ability to exclude false positives
Spinal cord pathology
Electric shock sensation radiating down spine or into limbs
Spinal cord pathology (myelopathy, MS, cervical stenosis, tumor)
Ability to detect true positives
Ability to exclude false positives
Upper motor neuron lesion
Reflex flexion of thumb and index finger
Upper motor neuron lesion (myelopathy, corticospinal tract dysfunction)
Ability to detect true positives
Ability to exclude false positives
Cervical myelopathy at C5-6 level
Finger flexion in addition to or instead of normal elbow flexion
Cervical myelopathy at C5-6 level (combined LMN at level + UMN below)
Ability to detect true positives
Ability to exclude false positives
Myelopathy (hand function)
Less than 20 cycles in 10 seconds (normal is 20 or more)
Cervical myelopathy (hand clumsiness from corticospinal dysfunction)
Ability to detect true positives
Ability to exclude false positives
Screen for vertebral artery compromise
Dizziness, nystagmus, visual disturbance, drop attack
Vertebrobasilar insufficiency (IMPORTANT: perform before any manipulation)
Ability to detect true positives
Ability to exclude false positives
| 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 |
| 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:
| Reflex | Root | Technique |
|---|---|---|
| Biceps | C5,6 | Tap biceps tendon |
| Brachioradialis | C5,6 | Tap radial styloid |
| Triceps | C7 | Tap triceps tendon |
Grading:
Motor:
Reflexes:
Gait:
Romberg Test:
Always state to the examiner:
"To complete my examination, I would like to:
"48-year-old man with 6-week history of right arm pain and numbness in the thumb and index finger."
| 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 |
| 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 |
High-Yield Exam Summary