Overview of Cervical Spine Assessment

Original Editor - Jacquie Kieck based on the course by Shala Cunningham
Top Contributors - Jacquie Kieck, Jess Bell and Kim Jackson

Introduction

Neck pain is one of the most common musculoskeletal conditions with a high personal and economic burden. Clinicians will often encounter patients with neck pain and other cervical spine conditions. It is, therefore, essential that they can confidently perform a thorough assessment of the cervical spine. This page provides a step-by-step overview of the key elements of the cervical spine evaluation, including the subjective assessment (history taking) and the objective assessment (observation and tests). It also introduces the Proposed Classification System for the Cervical Spine.

Subjective Assessment

History

The mnemonic L-M-N-O-P-Q-R-S-T can be used to cover the key aspects you should consider when taking a patient’s history.

L: Location of symptoms and level of functional impairment

This table summarises the likely source of symptoms based on the area of symptoms.

Table 1. Likely source of symptoms based on area of symptoms

Area of Symptoms	Possible Source of Symptoms
Head / occipital region	Upper cervical spine
Localised pain without radiation / referral	Muscle pain Facet pain Facet impingement
Radiating pain	Nerve root irritation

M: Medical factors (medications) and mechanism of injury

In the assessment, find out exactly when and how the injury occurred, what forces were applied, and the position of the head at the time of the trauma. Also, ask about any neurological symptoms associated with the trauma.

Red flag symptoms related to the mechanism of injury: sudden onset of severe pain in the absence of an incident or accident.

N: Neurological examination

A neurological examination is performed to establish neurologic function and to help form a diagnosis. It is important to establish if the patient has numbness, tingling, burning or electrifying symptoms, as these symptoms indicate neurologic involvement. Be specific about the location of these symptoms, i.e. is the distribution of these symptoms dermatomal? The clinician should also note if the symptoms are constant or intermittent and if they are associated with the position of the head.

O: Occupation, including limitations

Establish if there are any work- or activity-related factors that are relevant.

P: Palliating and provocating symptoms

Establish what increases and decreases the symptoms. Also, note how long it takes for symptoms to calm down once aggravated.

Red flag symptom: constant/unrelenting pain independent of position or activity.

Q: Quality of symptoms/pain

Consider the description of symptoms. Are symptoms described as sharp, dull, stabbing, aching or electric / shock-like?

R: Radiation of symptoms

Be specific about where the symptoms radiate to, how long the radiating symptoms last, and whether they are constant or position / activity related.

Red flag symptom: radiating symptoms that cover multiple dermatomes.

S: Severity of symptoms

Note how symptoms impact function and activity.

T: Timing of symptoms

Ask about the sequence and progression of symptoms.

Red flag symptoms: pain is interrupting sleep or constant / unrelenting pain.

Be sure to check the patient's age and include questions about history of neck pain, constitutional symptoms (i.e. dizziness / lightheadedness, drop attacks and vertigo), paraesthesia, numbness, weakness, or stiffness.

Red Flags

Red flags are symptoms that suggest the presence of serious pathology. International guidelines recommend using red flags to identify serious pathology. Below is a list of red flags to screen when assessing the cervical spine:

• severe loss of range of motion (ROM) with sudden onset of symptoms
• changes in balance / gait
• hyporeflexia/hyperreflexia
• constant pain
• severe radiating pain
• moderate to severe occipital headache
• facial pain
• psychological changes
• cranial nerve symptoms
• dizziness
• Horner's syndrome
• hemiparaesthesia
• bowel and bladder changes
• ataxia
• nystagmus
• drop attacks
• hemifacial paraesthesia
• dysphagia

The History can be Suggestive of Certain Conditions

History suggesting cervical spondylosis

A history suggestive of cervical spondylosis would include a person over the age of 45 years with gradual, slow onset of symptoms (no specific incident). The pain is usually unilateral and radiates in a facet joint referral pattern. Pain usually increases with extension ('closing down' of the joint) and reduces with flexion ('opening' of the joint). The most commonly affected cervical spine levels are C5, C6 and C7.

Figure 1. Facet Joint Referral Pattern

History suggesting disc involvement

A history suggestive of cervical disc involvement would include a person under the age of 60 years, with sudden onset of symptoms. Symptoms may be associated with a specific incident, such as a motor vehicle accident, or simply moving "strangely". Pain is usually unilateral and radiates in a dermatomal referral pattern. Pain usually increases with flexion. Tingling and other neurological symptoms may be present. The most commonly affected levels of the cervical spine are C5 and C6.

Figure 2. Dermatomes of the Upper Limb

Self-Assessment Questionnaires

Useful self-assessment questionnaires in the assessment of the cervical spine include:

• Neck Disability Index (NDI)
• Patient Specific Functional Scale (PSFS)
• Fear-Avoidance Belief Questionnaire (FABQ)
• Numeric Pain Rating Scale (NPRS)

Objective Assessment

Observation

It is important to complete a general observation of posture, including the head, neck, and shoulder position. Also, observe for any signs of torticollis.

Instability Testing

The Sharp-Purser Test is used to assess the integrity of the transverse ligament. However, there are concerns about the reliability, validity, and safety of this test. See the video below for a demonstration of the Sharp-Purser Test.

Vertebral Artery Testing

Symptoms of vertebral insufficiency include dizziness/vertigo, nausea/vomiting, inability to stand, blurred vision/diplopia, headache, facial paraesthesia/facial palsy/difficulty swallowing.

Following a thorough subjective assessment of the cervical spine, clinicians should carefully plan the physical examination and consider any precautions and contraindications related to vertebral insufficiency.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention International IFOMPT Cervical Framework - Physical Examination

In addition, the clinician should reflect on their ability to perform certain tests and seek additional training if needed.

The following tests can be included for the assessment of vertebral artery insufficiency:

• Hautant Test
• Cervical Quadrant Test
• Pre-manipulative Position Test

Canadian C-Spine Rule

The Canadian C-Spine Rule is a decision-making tool used to determine when radiography should be utilised in patients following trauma. This tool has a very low negative likelihood ratio. This means that if you get a negative finding for the test, there is only a very small chance that the patient would still have the condition (i.e. for the Canadian C-Spine Rule, that the patient would still need a radiograph).

Functional Screening

Typically, a functional screen will include a chin tuck action, cervical flexion, extension and rotation, and shoulder movements.

Palpation

Palpation includes palpation of the relevant musculature of the cervical spine, namely the trapezius, sternocleidomastoid, suboccipital muscles, and the scalene muscles. Also include palpation of the spinous processes and facet joints.

Range of Motion

When assessing range of motion of the cervical spine, take note of symptoms associated with the movements. Generally, over-pressure is not applied when testing the range of motion of the cervical spine, as the weight of the head is sufficient for testing.

Muscle Testing

Neck pain is often associated with weakness of the cervical deep neck flexors, which results in a lack of endurance and decreased ability to hold the neck in position. The Deep Cervical Flexion Test (also known as the Cranial Cervical Flexion Test) and neck flexor endurance testing can be performed to assess the strength and endurance of the deep neck flexors.

Neurological Testing

A neurological screen includes testing of reflexes, dermatomes and myotomes. It is important to also include a cranial nerve screen and upper limb tension tests (i.e. neurodynamic testing).

Joint Mobility Testing

Passive physiological intervertebral mobility testing, passive intervertebral testing and intervertebral glides are included in the cervical spine evaluation to assess joint mobility.

Special Tests

• Cervical Compression Test:
  • pain with this test may indicate an intervertebral disc issue, vertebral fracture, or nerve root irritation (if there are radiating symptoms)
  • this test can be modified to stress specific tissues; applying compression with the neck in a more flexed position will stress the disc and vertebral body while applying compression with the neck in a more extended position will stress the facet joint and the nerve as it exits the formina
• Cervical Distraction Test:
  • decreased pain with distraction may indicate disc pathology, nerve root compression or facet joint pathology
• Spurling's A Test
  • this test is used when looking for cervical nerve root compression causing cervical radiculopathy
  • the test has a good specificity, but a low sensitivity, and is most useful when used in conjunction with other tests
• Test Item Cluster:
  • when combined, a test item cluster of Spurling's Test, Upper Limb Tension Test 1, Cervical Distraction Test and Cervical Rotation Test has high diagnostic accuracy when compared to EMG studies
• Shoulder Abduction Test or Bakody Sign
  • this test was designed to assess radicular pain - it can suggest cervical nerve involvement, but is not diagnostic
  • the client is asked to place the affected extremity on their head. If symptoms reduce, the test is positive

Classification of Cervical Spine Pain

A classification system identifies groups with common characteristics. Classification systems help to determine the intervention(s) that would produce optimal clinical outcomes within specific groups. Fritz et al. found that when subjects were matched to interventions using the Proposed Treatment-Based Classification System, they had greater disability reduction than those unmatched to interventions.

Table 2. Proposed Classification System for the Cervical Spine

Classification	Key Feature	Examination Findings	Intervention Focus
Neck pain with mobility deficits	Mobility	Recent onset Absence of referred symptoms Restricted ROM in rotation and / or side bending Restricted cervical and thoracic segmental mobility	Spinal mobilisation / manipulation Active range of motion exercises
Neck pain with radiating pain	Centralisation	Radicular / referred symptoms in the upper quarter Peripheralisation and / or centralisation of symptoms with range of motion Signs of nerve root compression present May have a medical diagnosis of cervical radiculopathy (Test Item Cluster)	Mechanical / manual cervical traction Repeated movements to centralise symptoms Manual therapy Home exercise programme of cervical spine retraction and deep cervical flexor training
Neck pain with movement coordination impairments	Conditioning exercise	Lower pain and disability scores Longer duration of symptoms No signs of nerve root compression No peripheralisation / centralisation during range of motion	Strengthening and endurance exercises for the muscles of the neck and upper quarter Aerobic conditioning exercises
Neck pain	Pain	High pain and disability scores Recent onset of symptoms Traumatic onset May have referred pain Poor tolerance to examination and / or interventions Medical diagnosis may be whiplash associated disorder	Gentle active range of motion as tolerated Range of motion for adjacent regions Modalities Activity modification
Neck pain with headache	Headache	Unilateral headache with onset preceded by, or associated with, neck pain Typically, has limitations to cervical active range of motion May be limited cervical / thoracic segmental mobility Tends to have poor performance on the Cranial Cervical Flexion test	Spinal manipulation / mobilisation Deep cervical flexor training Soft tissue / muscle trigger point treatment Postural education and training

Resources

• International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical