Spine Exam: Neck and Upper Extremity

 Written by Ryan Jones with Dr. Nabil Ebraheim

Neck and upper extremities spine examination or cervical spine physical examination involves assessment of vertebrae C3-T2, cranial nerve roots C4-T1, and all the muscles innervated by these nerve roots along with the muscles associated with basic neck movement. This examination follows the typical pattern of orthopedic examination of inspection, palpation, range of motion, neurological evaluation, and special tests1.

Inspection

Check for any visual deformities or abnormal anatomical alignments in the coronal and sagittal plane including typical cervical lordosis and thoracic kyphosis1. Also, look for any surgical scars, skin defects like café au lait spots, or muscular atrophy2. Muscular atrophy can present as shoulder imbalance, scapular winging, or a general unilateral reduction in size of muscles of the upper extremities.

Palpation

Palpate for local tenderness along the spinal axis while also looking for any asymmetry2. This includes palpations of the spinous processes and facet joints of the vertebrae along with palpation of the scapula to look for any asymmetry. Palpate the paraspinal muscles while looking for any tenderness or asymmetry. The muscles of importance include the trapezius, rhomboids, and levator scapulae muscles1,3.

Range of Motion

Range of motion for the cervical spine involves checking cervical flexion (normal = 50), extension (normal = 60), rotation (normal = 80), and lateral bending (normal = 45)2. A thorough range of motion examination should also be done for the shoulder due to the extensive nerve root innervation. Shoulder range of motion involves testing abduction (normal = 180), adduction (normal = 45), flexion (normal = 90), extension (normal = 45), internal rotation (normal = 55), and external rotation (normal = 45)4. Any abnormalities in range of motion can be indicative of muscular or neurological pathologies.

Neurological Examination

Test the motor ability and strength of the muscles associated with each cranial root for strength by grading it 0-V based on the muscle manual testing grading system2,3. Any weakness is a sign of muscular or neurological pathology. Next, test for sensory function for pain (with a paper clip) and light touch (finger) sensation at the dermatome for each cranial nerve1. Any abnormalities may be a result of neurological pathologies. Test the biceps reflex for C5, brachioradialis reflex for C6, and triceps reflex for C7 cranial nerve root abnormalities1.

Special Tests

Use the following provocative test to differentiate neck pathologies from other upper extremity:

·         Spurling’s test is indictive of acute radioculopathy2.

·         Hoffman’s test is indictive of cervical myelopathy2.

·         Lhermitte’s test is indicative of compression and myelopathy of the cervical spine2.

·         Stretch test is indicative of brachial plexus pathology.

·         Compression test is indicative of narrowing of the neural foramen, facet joint pressure, or muscle spasms from the paraspinal muscles3.

·         Observation of steppage, lateral, or wide-base gait are all indicative of myelopathy or neurological pathology2.

Remember that an MRI may be required to confidently differentiate between shoulder and neck pathologies1.

References

1.       Ebraheim N. Spine Exam & Upper Extremity – Everything You Need to Know – Dr. Nabil Ebraheim [Internet]. Toledo (OH): University of Toledo Medical Center, Department of Orthopedics; 2021 Aug 4 [cited 2021 Oct 23]. Available from: https://www.youtube.com/watch?v=hIiV-xi2TiE.

2.       Moore DW. Neck & Upper Extremity Spine Exam [Internet]. Santa Barbara (CA): Santa Barbara Orthopedic Associates; 2021 June 27 [cited 2021 Oct 23]. Available from: https://www.orthobullets.com/spine/2001/neck-and-upper-extremity-spine-exam

3.       Iyer KM. Examination of the Cervical Spine. In: Clinical Examination in Orthopedics. London: Springer; 2012. pp 97-107.

4.       Iyer KM. Examination of the Shoulder. In: Clinical Examination in Orthopedics. London: Springer; 2012. pp 9-18.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: