Orthopedics Book

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Neck Exam

Aka: Neck Exam, Neck Exam in Cervical Disc Disease, Cervical Disc Provocative Test, Shoulder Abduction Relief Sign, Upper limb Tension Test, Cervical Radicular Pain Localization
  1. See Also
    1. Neck Pain
    2. Neck Pain Causes
    3. Neck Pain Imaging
    4. Cervical Disc Disease
  2. Signs: General
    1. Range of Motion
      1. Neck flexion and extension (45 degrees in each direction)
      2. Neck lateral bending to right and left (45 degrees in each direction)
      3. Neck rotation to right and left (80 degrees in each direction)
    2. Neck hyperextension elicits cervical disc related pain
    3. Localized C-Spine tenderness in Cervical Disc Disease
  3. Signs: Cervical Disc Provocative Tests
    1. Vertex Compression Test (Spurling Test)
      1. See Spurling Test
      2. Bend neck to ipsilateral side (lateral flexion and neck extension) with axial load
      3. Pressure against top of head reproduces arm pain (by compressing neural foramina)
      4. High Test Sensitivity and Specificity
      5. Shah (2004) Br J Neurosurg 18(5): 480-3 [PubMed]
    2. Shoulder Abduction Relief Sign
      1. Patient places their palm of the affected arm on top of their head
      2. Considered a positive test if this positioning relieves radicular pain
      3. Tandeter (1997) Canadian Family Physician 43:511-2
    3. Upper limb Tension Test
      1. Patient supine with neutral Shoulder at side with flexed elbow and wrist
      2. Examiner places counter pressure at anterior Shoulder and abducts the Shoulder to 90 degrees
      3. Examiner extends the elbow, wrist and fingers and supinates the Forearm
      4. Patient lateral deviates the neck to either side
      5. Considered a positive test if positioning provokes the pain
      6. Nee (2012) J Orthop Sports Phys Ther 42(5):413-24
  4. Signs: Cervical Myelopathy
    1. See Spinal Cord Syndrome
    2. See Central Cord Syndrome
    3. See Transverse Myelitis
    4. See Amyotrophic Lateral Sclerosis
    5. Lhermitte Sign
      1. Passive neck flexion results in electrical sensation down spine or arms
    6. Hoffman Sign
      1. Flick the distal tip of the third or fourth finger
      2. Results in thumb abduction and flexion at the distal phalanx
    7. Upper Motor Neuron Deficits suggestive of myelopathy
      1. Positive Babinski Reflex
      2. Hyperreflexia
      3. Clonus
      4. Clasp-knife spasticity
      5. Muscle Weakness
      6. Ataxia or other Abnormal Gait
      7. Bowel or Bladder dysfunction
      8. Tremor
  5. Signs: Motor Exam and Sensory Exam Localization of Radicular Pain
    1. Background
      1. See Motor Exam
      2. See Sensory Exam
      3. See Neuroanatomy of the Arm
      4. Diminished Deep Tendon Reflex is most common objective neurologic finding
        1. Loss of Triceps Reflex is most common
      5. Motor weakness may also be identified
    2. C3-4 Disc (C4 nerve root): : Accounts for <10% of Cervical Radiculopathy cases
      1. Pain at lower neck or trapezius muscle
      2. Sensory change only (no motor or reflex changes)
        1. Cape distribution
        2. Includes lower neck and upper Shoulder girdle
    3. C4-5 Disc (C5 nerve root): : Accounts for 10% of Cervical Radiculopathy cases
      1. Pain
        1. Base of neck
        2. Shoulder
        3. Anterolateral arm
      2. Numbness
        1. Deltoid
      3. Motor weakness and atrophy
        1. Deltoid muscle
        2. Biceps muscle
      4. Reflexes decreased
        1. Biceps Reflex
    4. C5-6 Disc (C6 nerve root): : Accounts for 20-25% of Cervical Radiculopathy cases
      1. Pain
        1. Neck
        2. Shoulder
        3. Medial Scapula
        4. Dorsolateral arm
      2. Sensory change
        1. Dorsolateral thumb
        2. Index finger
      3. Motor weakness and atrophy
        1. Biceps muscle
        2. Extensor pollicis longus
      4. Reflexes decreased
        1. Biceps Reflex
        2. Brachioradialis Reflex
    5. C6-7 Disc (C7 nerve root): Accounts for 45-60% of Cervical Radiculopathy cases
      1. Pain same as C5-6 Disc (C6 nerve root)
      2. Sensory change
        1. Index finger
        2. Middle finger
        3. Dorsal hand
      3. Motor weakness and atrophy
        1. Triceps muscle
      4. Reflexes decreased
        1. Triceps Reflex
    6. C7-8 Disc (C8 nerve root): : Accounts for 10% of Cervical Radiculopathy cases
      1. Pain
        1. Lower neck
        2. Medial Forearm
        3. Hand
      2. Sensory change
        1. Distal, medial Forearm to medial hand
        2. Fourth and fifth fingers
      3. Motor weakness and atrophy
        1. Wrist flexion
        2. Finger and thumb abduction and adduction, extension and flexion
  6. Signs: Referred Pain and Non-Musculoskeletal Cause Evaluation
    1. Lymphadenopathy (infection, malignancy)
    2. Upper Motor Neuron Deficit
      1. See Myelopathy Findings as above
    3. Central Nervous System Exam
      1. Carotid Dissection
      2. Vertebral Dissection
      3. Thoracic Dissection
    4. Cardiopulmonary Exam including pulses
      1. Pneumothorax
      2. Coronary Artery Disease
    5. Abdominal Exam
      1. Right upper quadrant tenderness (Biliary Colic)
    6. Skin Exam
      1. Herpes Zoster
  7. References
    1. Childress (2016) Am Fam Physician 93(9): 746-54 [PubMed]
    2. Eubanks (2010) Am Fam Physician 81(1): 33-40 [PubMed]
    3. Polston (2007) Neurol Clin 25(2): 373-85 [PubMed]
    4. Rhee (2007) J Am Acad Orthop Surg 15(8): 486-94 [PubMed]

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