Diagnosis of osteochondrosis of the cervical spine

Symptoms of cervical osteochondrosis are acute painful onset and increased pain with active neck movements and with the induction of the phenomenon of the intervertebral foramen (Sterling phenomenon) - forced passive tilt of the patient's head towards the affected root leads to an exacerbation of pain. This phenomenon is based on a decrease in the diameter of the intervertebral foramen with additional compression of the root. Pain may be accompanied by the development of reflex muscle contractures, causing immobilization of the spine and the emergence of a forced position of the head.

During inspection, please pay attention to:

• on the severity of cervical lordosis;
• the height of the patient's shoulders;
• possibility of asymmetry of the supraclavicular regions;
• the possibility of asymmetry in the neck area (for example, as a result of a congenital pathology or a sharp muscle spasm);
• the condition of the muscles of the shoulder girdle and upper limbs (for example, unilateral muscle atrophy may indicate compression of the cervical spinal root);
• position of the chin; the chin should normally be located along the midline;
• neck movement (flexion-extension, tilting to the right-left and rotation).

Palpation is performed in the patient's initial position:

• lying on your back;
• lying on your stomach;
• sitting on a chair.

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Palpation of the back of the neck

• Palpation of the base of the skull.
• Palpation of the mammillary processes.
• Palpation of the spinous processes.
• Palpation of the articular processes:

1. small joints of the vertebrae are palpated approximately 1-3 mm to the side between the spinous processes on each side;
2. when palpating these joints, maximum relaxation of the patient's neck and shoulder girdle muscles is necessary;
3. if the muscle is in spasm, the joints around the belly of the affected muscle should be palpated.

CAUTION: As a transitional vertebra between the thoracic and cervical regions, the body of the C7 vertebra _is usually immobile during flexion or extension of the head.

Palpation of the trapezius muscle:

• The examination should begin from above (cranially), by palpating along each spinous process;
• Bilateral palpation reveals pain, changes in muscle tone, swelling or asymmetry.

Palpation of the intervertebral ligaments when they are damaged causes pain and reflex spasm of the neck muscles.

Palpation of the lateral part of the neck

Palpation of the transverse processes of the vertebral bodies:

• palpation of the transverse processes of the body of C1;
• moving along the lateral surface of the neck from the mastoid process in the caudal direction, palpate the transverse process of the axial cervical vertebra _C2.

ATTENTION! Even slight bilateral pressure on the transverse process of C2 _causes pain.

• palpation of the remaining transverse processes is possible with complete relaxation of the muscles of the neck and shoulder girdle;
• The anterior tubercle of the transverse process of C6 _protrudes most clearly, so it can be palpated at the level of the cricoid cartilage.

ATTENTION! It is not recommended to palpate this formation from both sides at the same time, since the carotid arteries are close to the surface at this point. Bilateral compression of the latter can limit arterial blood flow.

Palpation of the anterior neck

The doctor palpates this area of the neck while standing in front of the patient. The patient's initial position is sitting on a chair:

• at the level of the jugular notch of the sternum, its manubrium is palpated;
• lateral to the manubrium, the sternoclavicular joints are palpated;
• the clavicles are palpated up to the level of the shoulders;
• palpation of the acromioclavicular joint.

The patient's initial position is lying on his back:

• palpation of the sternocleidomastoid muscle (the patient's head should be turned to the opposite side);
• In the supraclavicular fossa (deeper than the subcutaneous muscle), the scalene muscles can be palpated.

The loss of sensitivity is usually accompanied by movement disorders, which are not always detected by the patient. Table 5.1 shows movement disorders and reflex changes at different levels of the cervical spine.

Special research methods

Compression test.

The goal is to identify narrowing of the vertebral openings; compression of the articular surfaces - the occurrence of pain.

• Patient's initial position: sitting on a chair, the doctor applies measured pressure to the patient's head with his hands.

Cervical spine stretch test. Goal: enlargement of the spinal opening - pain reduction.

• The patient's initial position is lying or sitting; the doctor supports the back of the head with one hand, places the other under the chin, then, without jerking, smoothly performs the upward pull, strictly along the vertical axis.

Spinal foramen stenosis test:

• the patient's initial position is sitting; the doctor tilts the patient's head to the right or left with some effort. This movement causes an even greater narrowing of the spinal foramen, which leads to compression of the nerve root and the occurrence of pain.

Pressure test on the shoulder area:

• patient's initial position - sitting on a chair; the doctor presses on the patient's shoulder with one hand, while at the same time tilting the patient's head in the opposite direction with the other hand.

Increased pain or changes in sensitivity indicate compression of the nerve root.

Vertebral artery insufficiency test:

• patient's initial position - lying on his back;
• The doctor applies pressure to the patient's shoulder with one hand (in the caudal direction!), and with the other hand smoothly turns the patient's head in the opposite direction.

A positive symptom reveals nerve compression or vertebral artery insufficiency, which is revealed by nystagmus or dizziness.

Adson's test is specific for anterior scalene syndrome:

• patient's position - sitting or lying on his back.

The patient is asked to slowly turn his head to the affected side. At the same time, the doctor slightly pulls the patient's head upwards (strictly along the vertical axis!). Weakening or disappearance of the pulse on the radial artery is the result of compression of the scalene muscles. Valsalva's test:

• patient's initial position - sitting, lying on back.

The patient is asked to take a deep breath, then hold it and strain.

With a positive test, intrathecal pressure increases, manifested by pain at the level of compression of the nerve root.

Lhermitte's symptom:

• Patient's initial position: sitting on the edge of the table, legs down.

With the help of a doctor, the patient performs a passive forward tilt of the head (flexion) and simultaneously bends the legs at the hip joints.

Positive test - these movements cause sharp pain spreading along the spine, caused by irritation of the dura mater.

Neck range of motion testing

The range of motion examination is performed with the patient in the initial position, sitting on a chair (in order to fix other parts of the spine).

The following basic movements in the cervical spine are distinguished:

• bending;
• extension;
• tilts to the right and left;
• rotation.

Approximately half of the flexion and extension occurs between the occiput and C1 and C2 vertebrae. The remainder of the movement occurs in the underlying vertebrae, with a greater range of motion in _C5 - _C7.

Lateral tilts are distributed evenly between all vertebrae.

Rotation occurs in combination with lateral movement. Almost half of the rotational movements occur between the atlas and the axis vertebra, the rest are evenly distributed between the underlying vertebrae.

First, a doctor should conduct a study, since during passive movements the muscles are completely relaxed, which allows assessing the condition of the muscular-ligamentous apparatus. Then a study of active movements and movements with dosed resistance (usually the doctor's hand) is carried out.

Movements with resistance provided by the therapist's hand are an isometric test for specific muscle groups (MMT).

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Methodology for studying the range of motion in the cervical spine

The examination should begin with passive rotation of the cervical spine.

Features of biomechanics of the cervical spine:

• head rotation begins with segment C _1-2;
• only after the C1-2 joints have rotated by 30° are the underlying segments included;
• _C2 rotation begins only when the head is turned at least 30°.

ATTENTION! If palpation of the spinous process of C2 _reveals that it begins to rotate earlier, this indicates rigidity or functional blockade of the PDS.

Normally, the patient can turn his head 90° (for example, touch his shoulder with his chin).

Examination of the occipito-atlanto-axial complex: the doctor passively flexes the patient's cervical spine (maximum flexion); in this case, segments C2 _- C7 _are "locked", and rotation is possible only in the C1-2 segment. Normally, the head rotation should be at least 45° to the right and left.

Study of rotation of the lower cervical PDS: the doctor, grasping the patient's head with his hands, extends the neck (maximum extension); in this case, the upper cervical segments are "closed", and passive rotation of the head to the sides is carried out due to the lower spine. Normally, the range of motion in each direction is at least 60°.

Examination of the mobility of the underlying cervical spinal joints: the doctor places the fingers of one hand on the spinous processes of the vertebrae being examined, and with the other hand performs passive rotation of the head.

Lateral tilt study:

• patient's initial position - lying on his back, head hanging off the couch;
• with one hand the doctor supports the patient's head and tilts it to the side; the distal phalanx of the index finger of the other hand is in close contact with the interspinous space, the middle one - with the intervertebral joint and adjacent transverse processes;
• This method examines all segments sequentially, starting from C ₀ _ to C ₆ _ ₇ on both sides.

1. Flexion:

• the maximum tilt possible is within 70-85°;
• active movement must be carried out without sudden efforts and tensions;
• During passive movement, the patient's chin should touch the chest.

Pain occurs:

• with active flexion of the neck, it can be of muscular or tendon origin; as a result of damage to the intervertebral disc;
• with passive movement of the neck it may be due to stretching of the ligamentous elements.

2. Extension - maximum extension is possible within 60-70°.

Pain occurs:

• with active movement reflects pathological processes in the muscles of the neck and shoulder girdle;
• in case of damage to the facet joints.

3. Tilt your head to the right and left - the maximum tilt in each direction is possible within 30-45°.

Pain occurs:

• in case of damage to the muscles of the neck and shoulder girdle;
• in case of damage to small joints of the cervical spine; as a consequence of instability of the cervical joint;
• in case of damage to intervertebral discs.

4. Rotation is the maximum possible movement, carried out within 75°.

Pain occurs in the muscles of the neck and shoulder girdle both when they contract and when they stretch.

5. Neck flexion:

• if the rotation is performed with a straight neck, then the entire cervical and upper thoracic spine (up to the level of Th ₄ ) is involved in the movement;
• with a slight tilt of the head and rotational movement, predominantly C3 _- C4 _segments are involved;
• at maximum forward tilt, rotational movements are carried out due to the C, -C ₂ segments (Table 5.7).

6. Neck extension:

• the cervico-occipital joint is excluded from the rotational movement;
• Segments _C3 - _C4 take part in the movement.

ATTENTION! Above the cervical and Th1 vertebrae, 8 cervical nerves emerge. The first three or four of them form the cervical plexus, the remaining five and the first thoracic nerve form the brachial plexus.

Determination of the range of motion in the cervical spine (in cm)

Flexion and extension movement in the sagittal plane. In the position of the subject - standing with the gaze directed straight ahead, the distance from the occipital protuberance to the spinous process of the 7th cervical vertebra is determined. With maximum forward flexion of the neck, this distance increases by 5 cm on average, and with movement in the opposite direction, it decreases by 6 cm.

Lateral tilts are movements in the frontal plane. Their volume is determined by measuring the distance from the mastoid process of the temporal bone or from the earlobe to the humeral process of the scapula

In the position - freely standing, as well as after performing bends in the frontal plane (without the rotation component). The difference in centimeters is a measure of the mobility of this section of the spine.

Rotational movements in the transverse plane. Determined by measuring the distance from the humeral process of the scapula to the lowest point of the chin in the initial position (see above) and then after the movement is performed. With rotational movements of the cervical spine, this distance increases by an average of approximately 6 cm.

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Study of the muscular system

• The posterior group of head muscles includes the deep and short muscles of the cervical spine.

Function: with unilateral contraction - tilts the head back and to the side, with bilateral - backwards.

Test: when the patient straightens the head, the doctor's hands provide measured resistance to this movement.

• Sternocleidomastoid muscle. Function: with bilateral contraction of the muscle, the head is thrown back, with bilateral contraction, it tilts the head to the same side, while the patient's face turns in the opposite direction.

Test: the patient is asked to tilt his head to the side, while simultaneously turning his face in the opposite direction to the tilt of the head; the doctor provides measured resistance to this movement and palpates the contracted muscle.

• Trapezius muscle. Function: contraction of the upper bundles raises the scapula, the lower ones lower it, the whole muscle brings the scapula closer to the spine.

A test to determine the strength of the upper portion of the muscle: the doctor's hands provide measured resistance as the patient attempts to raise his shoulders.

A test to determine the strength of the middle portion of the muscle: the examiner's hands provide resistance as the patient attempts to move the shoulder backward.

Test to determine the strength of the lower portion of the muscle: the patient is asked to move his raised arm back.

• Pectoralis major muscle. Function: adducts and rotates the shoulder inward (pronation).
• Pectoralis minor. Function: moves the scapula forward and downward, and when the scapula is fixed, elevates the ribs, being an auxiliary respiratory muscle.

Tests to examine the strength of the pectoral muscles:

• to examine the clavicular part of the pectoralis major muscle, the patient is asked to lower and bring the arm raised above the horizontal plane, while the doctor resists the movement;
• to examine the sternocostal part of the pectoralis major muscle, the patient is asked to bring his arm abducted at 90°, the doctor resists this movement;
• To determine the strength of the pectoralis minor muscle, the patient abducts his arms slightly bent at the elbows and fixes them in this position. The doctor's task is to increase the abduction of the arms to the sides.

• Deltoid muscle. Function: the anterior portion of the muscle lifts the raised arm forward, the middle portion abducts the shoulder to the horizontal plane, the posterior portion abducts the shoulder back. When the entire muscle contracts, the arm is abducted to approximately 70°.

Test to determine muscle strength: the patient raises his straight arm to a horizontal level (from 15° to 90°), the doctor’s hands provide measured resistance to this movement.

• Rhomboid muscle. Function: brings the scapula closer to the spine, slightly raising it.

Test to determine muscle strength: the patient places his hands on his waist and brings the shoulder blade together, while pulling the elbow back; the doctor resists this movement.

• Serratus anterior. Function: the muscle contracts (with the participation of the trapezius and rhomboid muscles) to bring the scapula closer to the rib cage. The lower portion of the muscle helps to raise the arm above the horizontal plane, rotating the scapula around the sagittal axis.

Test to determine muscle strength: the patient raises his arm above the horizontal level. Normally, the scapula rotates around the sagittal axis, moves away from the spine, the lower angle turns forward and laterally and is adjacent to the chest.

• Supraspinatus muscle. Function: promotes shoulder abduction up to 15°, being a synergist of the deltoid muscle. Pulls the capsule of the shoulder joint, protecting it from pinching.

Test to determine muscle strength: the patient abducts the shoulder at 15°, the examiner resists this movement and palpates the contracted muscle in the supraspinatus fossa.

• Infraspinatus muscle. Function: rotates the shoulder outward (supination) and retracts the capsule of the shoulder joint.

A test to determine muscle strength involves the patient turning his arm outward, bent at the elbow, and the doctor resisting this movement.

• Latissimus dorsi. Function: adducts the shoulder toward the body, rotating the arm inward (pronating).

Test to determine muscle strength: the patient lowers the shoulder raised to a horizontal level, the doctor resists this movement.

• Biceps brachii. Function: flexes the shoulder at the shoulder joint and the arm at the elbow joint, supinating the forearm.

Test to determine muscle strength: the patient flexes the arm at the elbow and supinates the previously pronated forearm. The physician resists this movement.

• Triceps brachii. Function: together with the elbow muscle, it extends the arm at the elbow joint.

Test to determine muscle strength: the patient straightens the previously bent forearm, the doctor resists this movement.

• Brachioradialis muscle. Function: pronates the forearm from supination to the midline position, flexes the arm at the elbow joint.

Test to determine muscle strength: the patient flexes the arm at the elbow joint, simultaneously pronating the forearm from a supinated position to a position midway between supination and pronation. The examiner resists this movement.

• Pronator teres. Function: pronates the forearm and promotes its flexion.
• Pronator quadratus. Function: pronates the forearm and hand.

Test to determine the strength of the pronator teres and quadratus: the patient pronates the previously extended forearm from a supinated position. The doctor resists this movement.

• Flexor carpi radialis. Function: flexes the wrist and abducts the hand laterally.

Test to determine muscle strength: the patient flexes and abducts the wrist, the doctor resists this movement and palpates the tense tendon in the area of the wrist joint.

• Flexor carpi ulnaris. Function: Flexes the wrist and adducts the hand.

Test to determine muscle strength: the patient flexes and adducts the wrist, the doctor resists this movement.

• Superficial flexor of the fingers. Function: flexes the middle phalanges of the II-V fingers, and with them the fingers themselves; participates in flexion of the wrist.

Test to determine muscle strength: the patient bends the middle phalanges of the II-V fingers while fixing the main ones, the doctor resists this movement.

• Extensor carpi radialis longus and brevis. Function: extends and abducts the wrist.

Test to determine muscle strength: the patient extends and abducts the wrist, the doctor resists this movement.

• Extensor carpi ulnaris. Function: adducts and extends the wrist.

Test to determine muscle strength: the patient extends and adducts the wrist, the doctor resists this movement.

• Extensor digitorum. Function: extends the main phalanges of the II-V fingers, as well as the hand.

Test to determine muscle strength: the patient extends the main phalanges of the II-V fingers with the middle and distal ones bent, the doctor resists this movement.

• Supinator. Function: rotates the forearm, supinating it.

Test to determine muscle strength: the patient supinates the previously extended forearm from a pronated position, the doctor resists this movement.

CAUTION! When testing muscles, the physician should palpate the contracted muscle when resistance is exerted on the movement of the limb segment.

Interosseous muscles, flexor muscles of the fingers, extension of the thumb.

Function:

• bringing the fingers together and spreading them apart;
• clenching fingers into a fist;
• extension of the thumb;
• turning the brush inward.

All movements are performed with measured resistance provided by the doctor’s hand.