Inspection should begin by noting the position of the head in relation to the line of gravity, which passes through the external auditory meatus; odontoid process; the cervical, thoracic, thoracolumbar, and lumbosacral spine; and the sacral promontory. The results of these tests should be considered in the context of the patient’s complaints and in conjunction with the remainder of the examination. Additionally, studies have shown that palpation is useful for assessing for hypersensitivity to pain and other nonorganic causes of pain. However, the criterion standard used was spinal cord deformity on magnetic resonance imaging (MRI) in 65 patients. This can proceed to passive range of motion in the supine position if an abnormality is identified. It may be associated with a particular inciting event, or the disorder may manifest with an acute-on-chronic history of rapid worsening of symptoms that were already present in a less severe form. Complete evaluation of the cervical spine requires that all seven vertebrae, including the C7/T1 junction, be visualized. Sensitivity ranged from 43% to 50%, and specificity ranged from 80% to 100%. Cervical spine injuries (CSI) have the potential to cause severe morbidity in children. They originally described “the neck compression test” as follows: Tilting the head and neck toward the painful side may be sufficient to reproduce the characteristic pain and radicular features of the lesion. Reviewers also found that the level of clinical experience did not improve the reliability in that experienced clinicians fared no better than students in terms of palpatory reliability. Similar to the Spurling maneuver, the literature seems to indicate high specificity with low sensitivity for the shoulder abduction relief test. Davidson and associates described 22 patients who presented with severe cervical radicular pain, sensory and motor symptoms, initially unresponsive to outpatient measures. 12 Cervical radiculopathy is relatively common and is the most frequent indication for cervical spinal surgery. It also fails to identify the correct target tissue in a significant percentage of cases. Generally, the changes in coordination and weakness are symmetric, although this is not always the case. Relevant diagnostic tests are described. Axial neck pain is relatively common, although the severity of the condition varies widely. (3) Of crucial concern for any examination of the cervical spine is the ability to differentiate pathologies that merely cause pain from those that adversely affect sensitive neural tissues associated with the cervical spinal cord and its nerve roots. The forward-head posture thus increases the work requirements of the capital and cervical musculature. The surgeon should be aware of the possibility of a less classic presentation of radicular pain such as isolated parascapular pain or atypical chest pain. In most cases, the symptoms are self-limited. To do this there are three essential elements of the examination: 1. Clinical presentation: Patients will have minimal distal motor function because of damage to the lateral corticospinal tracts Breathing assessment Breathing is assessed by observing adequate movement of the chest. There are 10 degrees of total flexion and extension at the AA joint with a negligible amount of lateral bending. Evaluation of the Cervical Spine after Trauma. Assessment is performed when the patient is awake and alert by allowing the child to freely move their neck whilst they are observed carefully for restricted movement (s) or torticollis. Patients often note that the pain is worse with neck flexion, extension, or rotation. In their experience, the sign is “frequently not present” with cervical radiculopathy, though no statistical data were presented. This course is designed to enhance the participant's knowledge and understanding of the cervical spine to become a more efficient, effective, and knowledgeable practitioner of cervical pathologies ! Degenerative changes within the spine are ubiquitous in asymptomatic individuals. Twenty-six patients showed occult fractures on initial … A positive test result was considered to be the appearance or aggravation of pain, numbness, or paresthesias in the shoulder or upper extremity. This process can take place in the emergency department or in the field by appropriately trained EMS personnel. Many physical therapists are hesitant to perform a cervical spine evaluation due to a lack of confidence. Additional concerns with the reliability of the cervical spine palpatory examination have been highlighted in a systematic comprehensive review of the literature, which showed overall poor interexaminer reliability for all palpation. Cervical spine and neck evaluation for Kinesiology 442 at Sonoma State University done by a student and Professor Winter. The criterion standard used was myelography combined with neurologic exam findings. The goal is not necessarily to learn every examination maneuver performed for neck pain but rather to understand the limitations, reliability, and scientifically proven validity of some of the commonly used tests. The superior articular processes of each vertebra articulate with the inferior articular processes of the next higher vertebra to form hyaline cartilage–covered synovial z-joints. Anterior cord syndrome results from damage to the anterior 2/3 of the spinal cord. The AA joint articulates at three locations creating a medial atlantodental and two lateral AA joints. Rarely, a patient may have a more rapid neurologic decline, particularly in the setting of trauma. The patient’s neck was passively flexed laterally and slightly rotated ipsilaterally, and the head was then compressed with approximately 7 kg of pressure. Studies have addressed the accuracy of palpation in identifying the structure or level of the spine and interexaminer … Evaluation of subaxial cervical spine injuries is nuanced, and improper management of these injuries can lead to significant patient morbidity and even death. Spurling and Scoville first described the Spurling neck compression test, also known as the foraminal compression test, neck compression test, or quadrant test, in 1944 as “the most important diagnostic test and one that is almost pathognomonic of a cervical intraspinal lesion.” Their observations were based on the presentation of 12 patients with “ruptured cervical discs” verified during surgery in 1943 at Walter Reed Army Hospital. Degenerative changes within the spine are ubiquitous in asymptomatic individuals. The results are presented in a manner making interpretation difficult. Motor vehicle collisions are the predominant mechanism in children under 8 years old; older children most commonly sustain sports-related injuries [].Child abuse should also be considered in the young child with a suspected whiplash mechanism of CSI. Average : rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star. Paired superior and inferior articular processes project from each pedicle–lamina junction. However, the only available prospective study examined a small number of subjects for this test. Additionally, palpation for soft tissue had very low reliability in all regions tested. However, diminished range of motion may also be found in the asymptomatic population. The diagnostic process begins with the taking of a thorough medical history. In 1995, Sandmark and Nisell found in a study of 75 patients with self-reported pain that palpation over the facet joints was the most appropriate screening to corroborate self-reported neck dysfunction. Suprascapular nerve entrapment can cause aching shoulder or periscapular pain that may be noted on physical examination to be associated with atrophy of either the supraspinatus or infraspinatus muscles and confirmed by electromyography (EMG). TSPT Cervical Spine Course. Last modified 02/04/2015. Fifteen (68%) of these patients experienced relief of their radicular symptoms with ipsilateral shoulder abduction. Myelopathy may be painless or may be associated with symptoms of neck or arm pain, depending on the specific neural tissues involved. 3.1 ). Trauma multidisciplinary QI project: evaluation of cervical spine clearance, collar selection, and skin care. Viikari-Juntura conducted a prospective study assessing the interexaminer reliability of common tests performed in the clinical examination of patients with neck and radicular pain. Cervical spine injury (CSI) is rare in children, accounting for only 1–2% of pediatric trauma. High-energy mechanism of injury 4. It should be systematic and focus on palpation of the midline spinous processes, the paraspinal musculature, and the underlying zygapophyseal joints (z-joints), as well as the associated cervical spinal musculature. Results found that maneuvers 5 and 6 were associated with the highest elicited pain and paresthesia, respectively. Axial neck pain, by definition, consists of pain without associated pain down the extremity or neurologic findings. This may lead to error in both the technique and the interpretation of findings. The only investigation of interexaminer reliability concluded the test to be “fair.” Interestingly, incorporation of the abduction maneuver into a nonsurgical treatment program is reported as beneficial for patients with a positive test result. The atlantooccipital (AO) and atlantoaxial (AA) joints are not true z-joints. Currently, this test is performed by extending the neck and rotating the head and then applying downward pressure on the head ( Fig. One should carefully assess not only the upper cervical region but also the relative curvature of the thoracolumbar and lumbosacral spines because the relative positioning of the cervical spine may be influenced by the curvature below. Palpation is a common component of cervical spine evaluation. Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts. The authors concluded that the test is highly specific for cervical radiculopathy with low sensitivity. Imaging modalities and laboratory tests provide useful confirmatory data to substantiate and quantify the clinical impression gained from the history and physical examination. If the child demonstrates pain free and normal neck movement, the cervical spine can be cleared. Multiple imaging studies are used during evaluation of CSIs but come at a cost, both financially and in radiation exposure. The forward-head position can also be the direct cause of the loss of cervical motion. (2)Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA. As the disease progresses, the neurologic symptoms generally worsen, although this occurs classically in a slow, stepwise fashion with long periods of stability between changes in neurologic functioning. Learn More! Patients with axial neck symptoms may complain of associated posterior headaches or constitutional symptoms. The neuromuscular screen is perhaps the most important portion of the examination and should be performed on all patients with neck complaints. A primary goal of diagnosis is to match the patient’s clinical presentation with the most efficacious treatment approach. Palpation is a common component of cervical spine evaluation. Updated by Robert Morgan, MD November 2010 . In 1989, Viikari-Juntura and coworkers published a prospective study assessing the validity of the Spurling neck compression test in diagnosing cervical radiculopathy, along with the axial manual traction and shoulder abduction tests. The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. When available, a thorough history (from either the patient or witnesses) and physical examination can be crucial in raising or lowering the suspicion for unstable cervical spine injury. Today, evaluation of cervical spine trauma consists of patient-reported symptoms, a thorough physical exam, and radiographic imaging—primarily with a CT scan (See Fig. Because many nonspinal sources of pain and disability can have a presentation similar to that of cervical spine disease, the spinal surgeon must always be attentive for features of the patient’s history that suggest an alternative diagnosis. Two blinded expert examiners, who were trained together in the identical performance of the clinical tests, independently examined 52 patients referred for cervical myelography. 1, Fig. The symptoms often wax and wane in severity and may be aggravated by repetitive function, prolonged positions, or an awkward sleeping position. Hogan BJ, Blaylock B, Tobian TL. Kappa scores were poor to fair and ranged from 0.21 to 0.40. Common complaints include a loss of fine dexterity in hand function (inability to fasten buttons), nondermatomal finger numbness, changes in balance, urgency with bladder control, and increasing muscle atrophy (particularly involving the hand intrinsics). Therefore, the history and physical examination make up the key components of establishing a diagnosis. Most cases are created through highly case-specific and verified reasons involving structural change to the surrounding c-spine anatomy that is developed as an adult. Arm pain is the classic symptom and is generally more severe than neck pain (which may or may not be an associated symptom). However, it still has utility in determining anatomic regions of pain and establishing rapport with the patient. Communication is an essential component for successful cervical spine trauma evaluation and initiation of management. The amount of motion that occurs between contiguous vertebrae in the cervical spine is dictated mainly by the anatomic orientation of the z-joints. Patients may complain of difficulty walking at night when they have fewer visual clues or may note problems navigating uneven terrain. Peripheral nerve entrapment commonly creates sensory deficits (with or without associated pain) that may be similar in distribution to patterns of radiculopathy. June 2017; Turkish Journal of Medical Sciences 47(3):806-811; DOI: 10.3906/sag-1601-179. In a clinical setting where spinal instability is not a concern, range of motion should ideally be initially assessed actively with the patient standing or in a seated posture. The Evaluation of Cervical Spinal Angle in Patients with Acute and Chronic Neck Pain. Unfortunately, additional studies that compare a palpatory examination to known cervical spine pathology are few; thus, evaluation of the validity of this test is limited. Tong and Haig reported a sensitivity of 30% and specificity of 93% utilizing electrodiagnostic studies as a criterion standard in 224 patients. Tweet. When formulating a diagnostic impression, the physician must understand the natural history of common cervical conditions. Although nerve roots have stereotypic patterns of associated motor, sensory, and reflex functions, the examiner must keep in mind that overlap between adjacent root distributions is common. The pain may be described as radiating across the shoulders (along the trapezius muscle distribution) or to the posterior occipital region (where it may be associated with occipital region headaches). Relief or reduction of ipsilateral cervical radicular symptoms is indicative of a positive test ( Video 3-2 ).” History alone may predict a positive test result because patients often describe raising their arms to alleviate radicular symptoms. Though traditional and long the mainstay of cervical spine evaluation, radiographs of the cervical spine now have a limited role in the initial assessment of cervical spine trauma. Alternate modes of communication, such as walkie-talkies, ham radios, and land lines, should be available if necessary. This chapter provides a comprehensive overview of the physical examination of the cervical spine. Purpose. Patients commonly complain of associated sharp parascapular pain. The decrease or disappearance of radicular symptoms indicated a positive test. It was performed in the seated position with the patient instructed to “lift” the hand above the head. Information is from an athletic training textbook. This was based on a reported sensitivity of 82% and a specificity of 79%, in which a single-blinded physiotherapist performed palpation over the cervical z-joints on subjects with and without neck pain. The clinician asks the patient about theoretically known easing factors for structures that could be a source of the symptoms. In summary, there are few methodologically sound studies that assess the interexaminer reliability, sensitivity, and specificity of the Spurling neck compression test. The origin of this maneuver is uncertain, but it is well described in the current literature: To perform the distraction test, the examiner places one hand under the patient’s chin and the other hand around the occiput, then slowly lifts the patient’s head. The National Spinal Cord Injury Statistical Center estimates that about 17,700 Americans suffer spinal cord injuries each year, and approximately 288,000 people are living with the disorder today and require some type of orthopedic care . Careful selection of patients is critical and relies heavily on the history and physical examination. This is one of the only studies in the literature assessing interexaminer reliability for the Spurling neck compression test and other provocative test maneuvers of the cervical spine. For the sitting position, κ values ranged from 0.40 to 0.77, which was considered to be “fair to excellent,” and the proportion of specific agreement was found to be 0.47 to 0.80, which was also considered to be “fair to excellent.” For the supine position, κ values ranged from 0.28 to 0.63, which was considered to be “poor to good,” and the proportion of specific agreement was found to be 0.36 to 0.67, which was also considered to be “poor to good.” The author concluded that this test has good reliability when performed in the sitting position. Cervical radiculopathy generally manifests with pain along a dermatomal distribution as the primary symptom and may be associated with sensory or motor complaints related to the involved nerve root. Other musculoskeletal disorders that can masquerade as cervical spine disease include shoulder disorders, especially rotator cuff disease, which may manifest with shoulder pain radiating to the upper arm and is not relieved by shoulder elevation. A moderate level … Cervical and Thoracolumbar Spine Injury Evaluation, Transport and Surgery in the Deployed Setting. However, the results are analyzed according to the area of symptom radiation (eg, “right shoulder or upper arm,” “right forearm or hand,” “left shoulder or upper arm,” “left forearm or hand”), instead of classifying the test result as positive or negative. For example, symptoms from the upper cervical spine may be eased by supporting the head or neck. Filed under Neurosurgery. If the patient is obtunded, i.e. However, in the patient who is alert, oriented and can participate, a focused physical exam can greatly assist with the initial assessment. 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