import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Cervical Spine Examination 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. ## Quick Reference One-Pager ## Introduction and Setup **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) **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 - **Cervical lordosis**: Normal, flattened (spasm), kyphosis - **Forward head posture**: Ear anterior to shoulder - **Chin position**: Poked chin posture - **Thoracic kyphosis**: May affect cervical mechanics - **Spinous processes**: Alignment, step-off - **Paraspinal muscles**: Spasm, wasting - **Scapular position**: Winging, asymmetry - **Scars**: Previous surgery **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) **Posterior Midline:** 1. **Occiput**: Nuchal ridge, occipital nerves 2. **C2 spinous process**: First palpable spinous process 3. **C3-C6**: May be difficult to distinguish individually 4. **C7 (vertebra prominens)**: Most prominent spinous process 5. **T1**: For reference **Posterior Lateral:** 1. **Facet joints**: 1-2cm lateral to midline 2. **Paraspinal muscles**: Spasm, tenderness, trigger points 3. **Trapezius**: Upper fibers 4. **Levator scapulae**: Scapular angle **Anterior Lateral:** 1. **SCM muscle**: Spasm, tenderness 2. **Scalene muscles**: Trigger points 3. **Lymph nodes**: Cervical chain 4. **Thyroid**: Enlargement 5. **Carotid pulse**: Assess before mobilization **Special Palpation:** - Supraclavicular fossa (Pancoast tumor, nodes, brachial plexus) - Spinous process step-off (spondylolisthesis, fracture) ## Move (Range of Motion) **During Movement Assess:** - Pain: Location, reproduction of arm symptoms - Crepitus: Degenerative changes - Apprehension: Instability - Arc of pain: Specific position that causes symptoms **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 ### Myelopathy Tests ### Vascular Tests ## Neurological Assessment | 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:** - Light touch comparison side-to-side - Pin prick if abnormal - Ask "Does this feel the same on both sides?" | 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) **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 **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 ## Cervical Radiculopathy Summary ## Common Conditions Table flexion", specialTests: "Crepitus, may have radiculopathy/myelopathy" }, { condition: "Torticollis", look: "Head tilt + rotation", feel: "SCM spasm", move: "Unable to correct", specialTests: "Assess for underlying cause" } ]} /> ## Examiner Tips