🦴 Cervical Syndromes & Anatomy
Cervical Syndromes
Cervical Syndrome
Painful stiffness of the neck, varying from mild to acute spasmodic torticollis. Defined as contraction of SCM on affected side with stretching of SCM on opposite side. Can affect facial & jaw muscles. Mainly affects the mid-section of the neck.
Shoulder & Arm Symptoms
Painful stiffness of cervical spine plus symptoms in the shoulder girdle & upper extremity. Results from altered functional capacity in the brachial plexus or altered vascular function. Associated dysfunctions of thoracic inlet, 1st & 2nd ribs, thoracic spine & ribcage as far as T5/T6.
Head & Neurological
Pain & restriction of motion in the upper cervical spine (C1-C4 cervical plexus). Demonstrates functional alteration in vision, vertigo, dizziness & nystagmus.
Cervical Spine — Acute Injuries
The cervical spine is subjected to:
- Acute injuries: Whiplash injury
- Chronic repetitive injury: Improper posture, abnormal positions of the head & neck
Most commonly, there is rotary torque included in the trauma, giving rise to multiple motion restriction possibilities & different vectors of soft tissue injuries.
Forward Head Carriage & Posture
Chain of events:
- Forward head carriage → poor posture
- Increase in upper cervical lordosis
- Flattening of the lower cervical spine
- Imbalance of the head on the neck
- Muscle imbalance → tightness of the cervical spine extensors
Forward head carriage occurs in ~90% of the normal population.
Cervical Plexus (C1-C4)
Cutaneous branches: Greater auricular, lesser occipital, transverse cervical, supraclavicular
Muscular branches: Supply deep cervical muscles, infrahyoid, diaphragm (phrenic nerve C3-C5)
Dysfunction in this region can cause Cervicocephalic syndrome — pain, restriction of motion, vision changes, vertigo, dizziness & nystagmus.
Injuries to the Brachial Plexus
| Type | Mechanism | Outcome |
|---|---|---|
| Compression | Pressure on nerves | Nerve injury or ischaemia (local anaemia) due to interference with nerve supply |
| Stretch/Traction | Stretching of nerves | Damage to epineurial vessels — most common etiology. Nerves withstand considerable stretching, severity depends on pressure, stretch & duration |
| Friction | Excessive friction over nerve bundle | Damage similar to excessive heat. Severe trauma may produce nerve root avulsion — not surgically repairable |
Nerve Injury Grades
Neuropraxia
Transitory cessation of function in some nerve fibres. May result in some muscular weakness. Total recovery quickly.
Axonotmesis
Significant motor weakness. Sensory loss more severe. Wallerian degeneration may occur. Recovery possible with proper treatment.
🔬 Vertebral Artery & Motion Testing
Vertebral Artery Test
Purpose: Assesses flow of blood through the vertebral artery
Position: Patient supine. Practitioner's hands support the head bilaterally.
Procedure: Head is slowly extended, rotated & laterally flexed. Hold position and observe for symptoms.
Positive signs: Dizziness, slurred speech, loss of consciousness — indicates partial or complete occlusion of the vertebral artery.
Alternative (Less Aggressive) Vertebral Artery Test
Have the sitting patient look up at the ceiling, then turn the head both left & right. Observe for nystagmus & adverse symptoms (dizziness). This is a hands-off test — patient induces normal active movement.
⚠️ Best sign of impending cerebral anoxia: Acute anxiety & panic in the patient. If this occurs — STOP immediately and institute evaluation & treatment for potential vascular complications.
Signs of Vertebral-Basilar Insufficiency
Testing for Fracture of the Cervical Spine
- Use 128 MHz tuning fork
- Place on spinous process
- Patient feels extreme pain that continues after the tuning fork is removed
- If inconclusive → use ultrasound
- Refer for X-ray / MRI
Cervical Motion Testing — C1 (Atlas)
Tissue texture & symmetry: Slide fingers laterally along the occipitoatlantal sulcus until behind mastoid processes & transverse processes of atlas. More prominent posteriorly → rotation dysfunction in that direction.
Motion testing: Place fingers behind the transverse processes. Flex occiput on atlas (lock position). Rotate head bilaterally — decreased rotation indicates restriction on that side.
C2-C7 Motion Testing
Position: Patient supine, head relaxed. Practitioner seated at head of table.
Tissue texture: Palpate spinous processes & ligaments (midline). Slide laterally to palpate articular pillars. Have patient gently sidebend — feel sliding motion.
Lateral sidebending test: Introduce lateral sidebending until motion felt at fingertips. Greater motion to one side = sidebending restriction on the side of decreased motion.
Flexion-extension: With fingers on pillars, flex neck until motion felt. Then extend. Note asymmetries.
MET Sequence (Cervical)
Steps: (a) Engage restrictive barrier in sidebending, rotation & flexion (or extension). (b) Patient rotates head toward freedom against isometric resistance (3-5 sec). (c) Patient relaxes, physician stops counterforce (3-5 sec). (d) Engage new motion barriers in all 3 planes. (e) Repeat ≥3 times. (f) Return to neutral & reassess.
🫁 Evaluation of the Thoracic Spine
Observation
↑ A-P curvature
Increase in normal antero-posterior curvature — Dowager's hump in osteoporosis. Flattening may occur with muscle spasm or somatic dysfunction.
Lateral curve
Abnormal lateral curvature of the spinal column.
Inspection
Trauma, surgical scars, skin lesions. Perform erythema test & skin drag test as indicators of somatic dysfunction.
Bony Landmarks — The "Rule of 3's"
| Level | Spinous Process | Transverse Process |
|---|---|---|
| T1-T3 | Same level as vertebral body | Same level as spinous process |
| T4-T6 | 1 level below vertebral body | ½ level above spinous |
| T7-T9 | 2 levels below vertebral body | 1 level above spinous |
| T10 | Same as vertebral body | — |
| T11-12 | Same as lumbar pattern | — |
📌 Scapula landmarks: Inferior angle = T7. Spine of scapula = T3. 12th rib identifies T12. Vertebra prominens (C7) locates T1.
Palpation
Soft tissues: Skin, fascia, subcutaneous tissues, muscle — palpate for texture changes. Large muscle hypertonicity or small localised areas of tension.
Bony landmarks: Asymmetries of spinous processes & transverse processes. Rules of 3's for accurate identification.
Intersegmental Motion Testing — T1-T4
Flexion/Extension: Physician places fingers on transverse processes. Patient bends forward/backward (direction of least motion). Compare symmetry.
Rotation: Patient bends forward/backward to level in question. Rotate head left then right. Dysfunction named for direction of greater rotation.
Sidebending: One finger on each side of spinous process. Patient bends forward/backward then laterally to both sides. Named for direction of greater sidebending.
Intersegmental Motion Testing — T5-T12
Flexion: Downward & slightly anterior force on both shoulders
Extension: Caudal & slightly posterior force on both shoulders
Rotation: Rotate the shoulders in the desired direction
Sidebending: Caudal force to one shoulder + translatory force to opposite side
📌 Key: In Type 1 (neutral, group curves): sidebending opposite rotation. In Type 2 (single): sidebending same direction as rotation. Sidebending limitation relies on asymmetries in flexion-extension and rotation.
🌀 Visceral Referral Patterns
| Organ Condition | Referred Pain Area (Back) |
|---|---|
| Angina Pectoris | Upper back or scapula |
| Myocardial Infarct | Between scapula (also left shoulder) |
| Pericarditis | Between scapula |
| Aortic Aneurysm | Area depends on location |
| Pleurisy | Between scapula |
| Basilar Pneumonia | Right subscapular |
| Empyema | Mid thoracics |
| Biliary Colic | Between scapula (also left shoulder) |
| Cholecystitis | Right subscapular, mid thoracics |
| Gallbladder | Right upper back or scapula |
| Oesophagitis | Between scapula |
| Liver Disease | Right subscapular |
| Pancreatic Cancer | Mid thoracic (also lumbar spine) |
| Pancreatitis | Mid thoracic (also lumbar spine) |
| Gastric Ulcer | 5th-10th thoracic vertebra |
| Duodenal Ulcer | Costovertebral angle |
| Renal Colic | Lower thoracics |
| Pyelonephritis | Lower thoracics |
| Ureteric Colic | Costovertebral angle |
📌 Exam tip: Visceral pain can mimic MSK pain. Always consider referred patterns when back pain doesn't fit mechanical presentation. Liver/Gallbladder → Right subscapular. Heart → Between scapulae. Pancreas → Mid thoracic + lumbar. Kidney → Costovertebral angle + lower thoracics.
🦵 Lumbar Spine Evaluation
Segmental Range of Motion (Lumbar)
| Motion | Range (each segment) |
|---|---|
| Flexion | ~12° per segment |
| Extension | ~2° per segment |
| Lateral Flexion | ~6° per segment |
| Axial Rotation | ~2° per segment |
History for LBP
Thorough history: association with activity (sports, occupation, posture, lifting, bending, stretching). Always consider visceral or other causes. Seek exact location of pain — lumbar spine vs sacral region.
Physical Examination
Observation
Redness, discolouration, blemishes, hairy patches
"Faun's beard" → congenital anomaly (spina bifida). Birthmarks → bony pathology. Masses (lipomata). Surgery/trauma scars.
View from side & back
↑ lumbar lordosis? Flattening? Scoliosis? Gait observation.
Gross Motion Testing
~160°
Bend forward as if to touch toes, keep knees straight. Observe fluidity & areas of restricted motion.
~30°
Slowly bend backward — most motion above waist. Stop when motion felt at ASIS.
~30°
Slide hand down lateral thigh without flexing/rotating. Compare R vs L.
~45°
Turn body from waist up, feet planted. Stop when pelvis begins to rotate.
Hip Drop Test (Lateral Lumbar Flexion)
Position: Patient standing, weight equal, feet 4-6" apart. Physician kneels behind at lumbar level.
Procedure: Patient bends one knee & lets hip drop while keeping the other leg straight. Repeat contralateral.
Interpretation: The iliac crest that drops the most is the side that bends the most → the side of greatest drop = restricted sidebending.
Palpation
Best performed: Patient prone, physician at side of table.
Skin: Erythema test & skin drag test.
Soft tissues: Subcutaneous, fascia, fibro-lipomata (firm benign masses at lumbosacral junction). Paraspinal muscles (larger in lumbar). Quadratus lumborum (T12, spinal column, iliac crest).
Bony: Spinous & transverse processes. Iliac crests in line with L4-L5 interspace. 12th rib → T12 → L1 below.
📋 Lumbar Special Tests & Neurological Exam
Dermatomes & Myotomes — Lower Limb
| Segment | Sensory | Motor | Reflex |
|---|---|---|---|
| L1 | Bikini line | — | — |
| L2 | Front pockets (mid thigh) | — | — |
| L3 | Knee | — | — |
| L4 | Inside leg / medial ankle | Tibialis anterior (inversion of foot) | Knee Reflex |
| L5 | Outside leg / big toe | Extensor hallucis longus (big toe extension) | None |
| S1 | Little toe / lateral foot | Peroneus longus/brevis (eversion) | Achilles Reflex |
| S2 | Back lower leg | — | — |
| S3 | Back of pelvis | — | — |
| S4 | Inner gluts | — | — |
| S5 | Anus | — | — |
📌 Walk tests: Walk on heels = L5 (foot drop). Walk on toes = S1 (gastrocnemius). Walk in straight line = Cerebellum/Vestibular.
Special Tests
Straight Leg Raising
Supine, lift leg with knee straight. Normal ~80°. Painful: determine sciatic vs hamstring. At pain point, lower slightly + dorsiflex foot to stretch sciatic nerve. +ve = leg pain reproduced.
Well Leg Straight Raising
Raise uninvolved leg. If pain on involved side = space-occupying lesion (e.g. herniated disc).
Bear Down
Patient bears down as if moving bowels. ↑ intrathecal pressure reproduces back/leg pain → pathology involving theca or ↑ intrathecal pressure.
Malingering Test
Hand under calcaneus of opposite foot. Genuine effort to raise leg → downward pressure on opposite heel. No pressure = not trying.
Meningeal Irritation
Supine, hands behind head, flex head onto chest. Pain in cervical or low back/legs → meningeal irritation / nerve root involvement.
Upper Motor Neuron
Stroke lateral plantar surface from calcaneus across forefoot. +ve = great toe extends, other toes flex & splay. Indicates UMN lesion (brain damage, tumour). Normal in newborns.
Patrick's Test
Foot of involved side on opposite knee. Hip flexed/abducted/externally rotated. +ve hip pathology = ↑ inguinal pain. +ve SI = ↑ back pain.
Femoral Nerve Stretch
Prone, flex knee → ↑ anterior thigh pain = L2-L4 nerve root irritation.
Deep Tendon Reflex Grading
| Grade | Response | Interpretation |
|---|---|---|
| 0 | No response | Always abnormal |
| 1+ | Slight but present | May or may not be normal |
| 2+ | Brisk response | Normal |
| 3+ | Very brisk | May or may not be normal |
| 4+ | Repeating (clonus) | Always abnormal |
📌 Hyporeflexia (absent/diminished) = disease of the 2-neuron reflex arc (LMN). Hyperreflexia (hyperactive/clonic) = interruption of corticospinal pathways (UMN / suprasegmental lesion). Asymmetry is key — suggests abnormality.
🦴 Evaluation of the Pelvis
Bony Landmarks for Pelvic Assessment
Initial assessment standing barefoot. Reassessed prone & supine after 'reseating' of pelvis (see LLDs).
Standing Flexion Test (SIFT) — Iliosacral Evaluation
- Patient stands barefoot, feet parallel, hip-width apart
- Practitioner kneels behind, eyes level with PSISs. Palpate inferior aspect bilaterally
- Patient bends forward from waist toward toes (no knee bending)
- Observe PSIS movement: Ilium on Sacrum
+ve result: PSIS that rises 1st & furthest = ipsilateral iliosacral dysfunction
📌 Theory: Spinal flexion carries sacral base anteriorly → induces SI motion. After joint play, sacrum carries ilium into anterior rotation (PSIS rises). Restriction causes premature locking → ipsilateral PSIS rises prematurely.
Seated Flexion Test — Sacroiliac Evaluation
- Patient seated on stool, feet flat, arms on thighs
- Practitioner behind, eyes level with PSISs. Palpate inferior aspect bilaterally
- Patient bends forward toward floor
- Observe PSIS movement: Sacrum on Ilium
+ve result: PSIS that rises 1st & furthest = ipsilateral sacroiliac dysfunction
📌 Theory: When seated, innominates are locked by ischial tuberosities contacting floor. Sacroiliac portion of joint becomes involved as sacrum engages, rotating in flexion & elevating PSIS. Restriction → premature locking → PSIS rises earliest.
Reflex Arc & Physiology
Golgi Tendon organs detect: length of muscle, rate of contraction, muscle tension.
Eliciting a reflex: Patella hammer → sudden rapid lengthening of tendon & muscle → Golgi detects → spinal cord → reflex protective spasm/contraction (to prevent injury). This message does NOT go to the brain (would take too long & delay could cause injury).
LMN injury: Reflex arc reduced → reduced DTR (e.g. peripheral neuropathy)
UMN injury: Inappropriate reaction → hyper-reflex → stronger contraction (e.g. Parkinson's, MS)
Dermatome Map
Lower limb dermatomes quick reference:
L4 = medial leg/ankle · L5 = lateral leg / big toe · S1 = little toe / lateral foot · S2 = back lower leg · S3 = back of pelvis
💪 Lumbar MET & Thrust Techniques
Lumbar Intersegmental Motion Testing — Prone (Mitchell)
Position: Patient prone. Physician standing on one side, facing patient.
Neutral: Palpate transverse processes for A-P symmetry
Hyperextension: Patient lifts upper body (hands/elbows). Compare TPs.
Flexion: Patient seated, forward-bends with arms between knees. Compare TPs.
Interpretation: If right TP moves more posteriorly in hyperextension → flexion SD with right sidebending & rotation. If asymmetrical in flexion → extension SD with rotation & sidebending to the posterior TP side.
Rotoscoliosis Motion Testing
Principle: A Type 2 somatic dysfunction has a restriction to motion in ALL THREE planes. If a barrier is reached in flexion/extension, the vertebra will tend to rotate & sidebend towards its ease of motion.
Rotation Testing
Patient prone. Apply downward pressure on one TP → feel ventral motion of contralateral TP. Easier ventral motion on right = vertebra rotates to the left more easily = restriction in right rotation.
Sidebending/Rotation Testing
Patient sidelying. Flex hips/knees until motion at monitoring finger. Lift ankles upward (creates sidebending with convexity nearest table). Note posterior rotation of TP indicating Type 1 or 2 dysfunction.
Flexion/Extension Testing
Patient sidelying. Flex/extend lumbar spine, monitoring spinous process. Ease of flexion + barrier to extension = flexion SD. Ease of extension + barrier to flexion = extension SD.
Lumbar MET — Type 1 (Neutral Group Curve)
Side-lying with concavity toward table. Physician monitors apex of curve. Flex patient's hips ~90°. Sidebend lumbar spine to apex by elevating ankles. Patient pushes feet toward floor (3-5 sec) against isometric resistance. Relax → engage new barrier → repeat ≥3×.
Lumbar MET — Type 2 (Flexed)
Mnemonic "FDR": Flexion, posterior facets Downward, Recumbent. Posterior TP down toward table. Flex hips/knees until motion at level below dysfunction. Lock top leg. Bring patient into lateral recumbent position (pull lower arm fwd/up). Patient inhales → exhales → reaches toward table edge. Resist → relax → engage new barrier. Repeat ≥3×.
Lumbar MET — Type 2 (Extended)
Mnemonic "SUE": Sims, posterior facets Upward, Extension dysfunction. Posterior TP faces upward. Modified Sims position (arm behind, rotate chest toward table). Lower legs off table to create sidebending. Patient pushes feet toward ceiling (3-5 sec) against resistance. Engage new barrier by further lowering legs. Repeat ≥3×.
HVLA / Thrust Techniques
Sidelying
Roll patient toward you. Heel of hand on ilium. Produce rotation & extension. Fix patient's thigh with your thigh. Use combined leverage & thrust.
Sidelying
Downward pressure through pelvis. Hand on vertebra at apex. Other arm compresses thorax through shoulder. Final thrust = compression + rotation + sidebending.
Sidelying
Initial flexion positioning. Apply compressive, rotary & flexion force to pelvis. Patient's lower leg off table edge. Produces flexion gapping force — useful in hyperextended patients.
Articulation Techniques
Lumbar
Treat transverse processes with pads of fingers/thumbs. Direct sideshifting force side to side. Movement of whole body around vertebra. Least useful in antalgic sidebent posture.
Sidelying
Flex hips until gapping at target segment. Rock foot to foot. Most useful in most cases. Least useful in extremely large patients or hip disorders preventing flexion.
Sidelying
Overlap hands, pull on area to introduce extension. Patient's knees fixed by your thigh (counter-force). Hips at 90°. Most useful where strong force is desired.
Prone Flex
Press sacrum caudally. Fix thoracolumbar area. Flex sacrum using elbow. Add rotary movement as preliminary. Most useful in tight lumbar fascia. Least useful if prone problematic.
Pelvis & Lumbar Supine
Take up slack with pressure on table. Oscillate alternating pressure on ASISs. Try traction as additional movement. Most useful in smaller patients.
🎯 Exam Quiz
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