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Cervical Spine Anatomy
and Clinical Evaluation
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Clinical Anatomy
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Cervical Spine:
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Greatest range of
motion
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↑ risk of injury
Vertebral bodies:
Smaller than other
vertebral sections
 7 vertebrae:
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1st – Atlas
2nd – Axis
Clinical Anatomy
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Cervical Spine:
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Atlas:
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No vertebral body
Transverse processes
No true spinous process
Supports the weight of
the skull through 2 facet
surfaces (atlanto-occipital
joint or C0-C1
articulation)
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Flexion and extension
(primary movement)
Lateral flexion (slight)
Clinical Anatomy
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Atlanto-occipital joint
dislocation:
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(15% of all fatal spinal
trauma)
MOI: high speed motor
accident; Pt. unconscious at
the scene, respiratory arrest
en route to hospital
Lateral cervical spine
radiograph:
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Prevertebral soft-tissue
swelling (white arrow)
Malalignment between the
skull and the cervical spine
with widening of the
atlanto-occipital joints
(black arrow)
Clinical Anatomy
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Cervical Spine:
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Axis:
2nd cervical vertebrae
 Small body with a
superior projection
(Dens)
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Atlanto-axial joint:
Dens and atlas
articulation
 Rotation of the skull
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Clinical Anatomy
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Cervical ligaments:
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Anterior and posterior
longitudinal ligaments:
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Ligamentum nuchae:
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Limits flexion
Interspinous ligaments:
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Limit extension and flexion
Between spinous processes
Limit flexion and rotation
Ligamentum flavum:
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Connect laminae
Limits flexion and rotation
Clinical Anatomy
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Brachial Plexus:
C5 – T1
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7 cervical
vertebrae
8 cervical nerves:
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1st 7: exit above
the corresponding
vertebrae
C8: exits below
the 7th cervical
vertebrae
Clinical Anatomy
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Muscular Anatomy:
Cervical extension and flexion → bilateral
contraction of cervical muscles
 Side bending and rotation → unilateral
contraction
 Superficial cervical musculature:
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Splenius capitis
 Splenius cervicis
 Upper trapezius
 Sternocleidomastoid
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Clinical Anatomy
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Splenius capitis:
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O: Lower half of
ligamentum nuchae
I: Mastoid process and
adjacent occipital bone
A: Lateral bending
Splenius cervicis:
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O: C7 spinous process
through T6
I: Transverse processes of
C2 – C4
A: Rotation, extension
Clinical Anatomy
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Upper trapezius:
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O: Occipital
protuberance, nuchal
line, upper portion of
ligamentum nuchae
I: Lateral 1/3 of clavicle,
acromion process
A: Cervical extension,
cervical spine bending,
scapular elevation,
upward scapular rotation
Clinical Anatomy
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Levator scapulae:
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O: Spinous process of
C7, transverse processes
of C1 through C4
I: Superior medial
border of scapula
A: Extension of cervical
spine, scapular elevation
and downward rotation
Clinical Anatomy
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Scalenes:
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Anterior scalene:
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Middle scalene:
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O: Anterior portion of transverse processes C2-C7
I: Lateral to insertion of anterior scalene on 1st rib
Posterior scalene:
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O: Anterior portion of transverse processes C3-C6
I: Sternal attachment of 1st rib
O: Anterior portion of transverse processes C5-C6
I: Medial portion of 2nd rib
Action: Lateral bending of cervical spine
Clinical Anatomy
Clinical Anatomy
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Sternocleidomastoid:
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O: Medial clavicular
head, superior
sternum
I: Mastoid process
A: Flexion of cervical
spine, rotation to
opposite side, lateral
bending
Clinical Evaluation
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History:
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Location of pain:
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Localized pain:
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Radiating pain:
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Muscle strain, ligament
sprain, vertebral fracture,
facet syndrome
Trauma to cervical nerve
root or spinal cord
Onset of pain:
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Acute, chronic, insidious
Clinical Evaluation
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History:
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Mechanism of Injury:
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Insidious onset:
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Overuse and postural conditions
Acute onset:
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Axial load (compression fracture)
Flexion (compression of anterior vertebral body and
intervertebral disc; facet joint sprain; posterior muscle
strain)
Extension (compression of posterior vertebral body and
intervertebral disc; anterior longitudinal ligament sprain)
Lateral bending (nerve root compression, facet joint
compression)
Clinical Evaluation
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History:
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Mechanism of Injury:
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Acute onset:
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Consistency of pain:
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Rotation (disc trauma, ligament sprain, vertebral dislocation)
Inflammatory induced pain: consistent pain
Mechanical pain (i.e. nerve compression): varies in intensity,
moving spine may ↑ or ↓ pain
History:
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Previous injury
Scar tissue formation
Injured disc
Osteophyte within intervertebral foramina
Clinical Evaluation
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Inspection:
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Cervical curvature:
Lordotic curvature –
normal
 Lateral bending
posture - ↓ pressure
on nerve roots away
from the bend
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Clinical Evaluation
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Inspection:
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Position of head on the
shoulders:
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Unilateral spasm – lateral
flexion of head towards
involved side
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Torticollis: Wry neck
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Rotation of chin
opposite the side of the
tilt
Congenital or acquired
spasm of the SCM
Clinical Evaluation
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Inspection:
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Position of the head on
the shoulders: Torticollis
18 years age male with congenital torticollis
with the left SCMM tight as a band unabeling
him to turn his head to the right
Infant with torticollis: The attitude of the
head and neck results from a combination of
head tilt and rotation. A tight SCM muscle
causes head tilt towards the tight side with
rotation of the chin to the opposite side
Clinical Evaluation
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Inspection:
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Bilateral soft tissue
comparison:
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Trapezius and other
musculature:
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Hypertrophy, atrophy
Level of the shoulders:
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Height of acromioclavicular
joints
Deltoids
Clavicles
Clinical Evaluation
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Palpation:
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Anterior Structures:
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Hyoid bone:
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Thyroid cartilage:
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Have patient swallow
noting superior and
inferior movement
Level of 3rd cervical
vertebrae
Adam’s apple
Level of 4th and 5th
cervical vertebrae
Cricoid cartilage:
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Level of 6th cervical
vertebrae
Clinical Evaluation
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Palpation:
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Anterior structures:
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Sternocleidomastoid:
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Have patient rotate
head
Scalenes:
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Posterior to SCM (C3C6 level)
Carotid artery
 Lymph nodes
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Clinical Evaluation
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Palpation:
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Posterior and Lateral
Structures:
Occiput and superior
nuchal line
 Transverse processes
 Spinous processes:
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Have patient flex cspine
C7 and T1
Trapezius
Clinical Evaluation
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Range of Motion:
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Active neck flexion and extension:
Test position: patient can be standing or seated
 Motion: Atlanto-occipital joint
 Flexion: patient touches chin to chest (450)
 Extension: patient looks up towards ceiling (450)
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Active neck lateral flexion:
Test position: patient seated or standing
 Patient takes ear to shoulders (450)
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Clinical Evaluation
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Range of Motion:
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Active rotation:
Test position: patient seated, head held upward and
facing forward
 Patient attempts to look over each shoulder
 Motion: Atlanto-axial joint (450)
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Clinical Evaluation
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Range of Motion:
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Passive flexion:
Patient position: supine
 ATC: grab patient’s head (under occiput) and
attempt to bring chin to chest
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Passive extension:
Patient position: supine, head off end of table
 ATC: grasp patient’s head and move into extension
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Clinical Evaluation
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Range of Motion:
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Passive lateral flexion:
Patient position: supine, head in neutral position
 ATC: one hand under occiput, tilt head/neck to
bring ear to shoulder
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Passive rotation:
Patient position: supine
 ATC: grasp patient’s forehead and occiput, rotate
head and neck
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Clinical Evaluation
Clinical Evaluation
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Range of Motion:
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Resisted range of motion: Flexion
Patient: supine with cervical spine and head in
neutral position
 Stabilization: superior aspect of sternum
 Resistance: to the forehead
 Muscles tested: SCM and anterior scalenes
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Clinical Evaluation
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Range of Motion:
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Resisted range of motion: Extension
Patient: prone with cervical spine and head in
neutral position
 Stabilization: superior aspect of thoracic spine
 Resistance: to the skull over the occiput
 Muscles tested: trapezius (upper 1/3, levator
scapulae, cervical paraspinal muscles)
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Clinical Evaluation
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Range of Motion:
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Resisted range of motion: Lateral flexion
Patient: seated with cervical spine and head in
neutral position
 Stabilization: over the AC joint on the side toward
the motion
 Resistance: over the temporal and parietal bones on
the side toward the motion
 Muscles tested: SCM, scalenes, paraspinal muscles
on the side being tested
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Clinical Evaluation
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Range of Motion:
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Resisted range of motion: Rotation
Patient: seated with cervical spine and head in
neutral position
 Stabilization: over the anterior shoulder on the side
toward the rotation
 Resistance: over the temporal bone on the side
toward the motion
 Muscles tested: SCM, multifidus, rotators
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Clinical Evaluation
C1-C2
Neck flexion
C3
Neck lateral flexion
C4
Shoulder shrug
C5
Shoulder abduction, ER
C6
Elbow flexion, wrist extension
C7
Elbow extension, wrist flexion
C8
Thumb extension
T1
Finger abduction and adduction
Clinical Evaluation
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Neurological
Screening:
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Nerve root: C5 (Biceps
brachii)
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Patient: seated and
relaxed
ATC: thumb placed
over biceps tendon,
strike the thumb nail
with reflex hammer
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Clinical Evaluation
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Neurological
Screening:
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Nerve root: C6
(Brachioradialis)
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Patient: seated and
relaxed
ATC: taps the
brachioradialis with
reflex hammer
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Clinical Evaluation
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Neurological
Screening:
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Nerve root: C7
(Triceps)
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Patient: seated and
relaxed
ATC: support arm in
position of extension
and abduction, tap the
triceps tendon with
reflex hammer
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Clinical Evaluation
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Babinkski Test:
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Athlete: Supine with shoes and
socks removed
ATC: At the foot of the athlete
holding a blunt tool
Procedure: ATC runs the tool up
bottom of athlete’s foot starting at
the calcaneus and ending at the
great toe
Positive test: Great toe extends
while other toes splay
Implications: Lesion of upper
motor neurons, may be caused by
trauma to the brain
Comments: This reflex occurs
naturally in newborns. However,
this reflex should cease quickly
after birth
Clinical Evaluation
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Oppenheim Test:
Test: Upper motor neuron lesions
 Patient position: supine
 ATC: at patient’s side
 Procedure: examiner’s fingernail is run along
the crest of the anteromedial tibia
 Positive test: great to extends and the other toes
splay
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