Diagnosis of cervical spine osteochondrosis

Symptoms of the osteochondrosis of the cervical spine - acute painful debut and pain intensification with active neck movements and when the phenomenon of the intervertebral hole is triggered (the phenomenon of Sterling) - the forced passive inclination of the patient's head towards the affected root leads to aggravation of pain. This phenomenon is based on a decrease in the diameter of the intervertebral foramen with additional compression of the rootlet. Pain can be accompanied by the development of reflex muscle contractures, which determine the immobilization of the spine and the emergence of the forced position of the head.

When viewing, you should pay attention to:

• on the severity of cervical lordosis;
• height of the shoulders in the patient;
• the possibility of asymmetry of supraclavicular areas;
• the possibility of asymmetry in the neck region (for example, a consequence of congenital pathology or a sharp muscle spasm);
• the condition of the muscles of the shoulder girdle and upper limbs (for example, one-sided muscle atrophy may indicate compression of the cervical spine root);
• the location of the chin; the chin should normally be located along the middle line;
• movement of the neck (flexion-extension, right-left inclinations and rotation).

Palpation is performed in the patient's starting position:

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

[1], [2], [3], [4], [5], [6]

Palpation of the back of the neck

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

1. small joints of the vertebrae are palpated approximately 1 to 3 mm apart between the spinous processes on each side;
2. when palpation of these joints, the maximum relaxation of the muscles of the neck and shoulder girdle of the patient is required;
3. provided that the muscle is spasmodic, joints around the abdomen of the affected muscle should be palpated.

ATTENTION! As a transitional vertebra between the thoracic and cervical divisions, the body of the C ₇ vertebra is usually immovable with flexion or head extensions.

Palpation of the trapezius muscle:

• the examination should be started from the top (cranial), after palpation along each spinous process;
• bilateral palpation reveals soreness, changes in muscle tone, swelling, or asymmetry.

Palpation of intervertebral ligaments during their lesion causes soreness, reflex spasm of neck muscles.

Palpation of the side of the neck

Palpation of transverse processes of vertebral bodies:

• palpation of the transverse processes of the body 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 C ₂.

ATTENTION! Even a slight bilateral pressure on the transverse appendix C ₂ causes soreness.

• palpation of other transverse processes possible with complete relaxation of the muscles of the neck and shoulder girdle;
• the anterior tubercle of the transverse process C ₆ is most pronounced, so it can be palpated at the level of the cricoid cartilage.

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

Palpation of anterior part of neck

The doctor palpates this area of the neck, standing in front of the patient. The starting position of the patient is sitting on a chair:

• at the level of the jugular notch of the sternum, its handle is palpated;
• lateral to the arm are palpable in the sternoclavicular joint;
• clavicles are palpated to the level of the shoulders;
• palpation of the acromioclavicular joint.

The starting position of the patient is lying on the back:

• palpation of the sternocleidomastoid muscle (the patient's head should be turned in the opposite direction);
• in the supraclavicular fossa (deeper than the subcutaneous muscle), stair muscles can be palpated.

Loss of sensitivity is usually accompanied by motor disorders, which are not always detected by the patient himself. Table 5.1 shows motor disorders and changes in reflexes at various levels of the cervical spine.

Special research methods

Compression test.

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

• I.p. The patient - sitting on a chair, the doctor performs the dosage pressure on the patient's head.

A test for stretching the cervical spine. The goal is to increase the vertebral opening - to reduce pain.

• I.p. Patient lying or sitting; the doctor with one hand supports the back of the head, the other leads under the chin, then without jerks, smoothly pulls upward, strictly along the vertical axis.

A trial with a narrowing of the vertebral foramen:

• i.p. Patient - sitting; the physician with some effort tilts the patient's head to the right or left. With this movement, there is an even narrower narrowing of the vertebral aperture, which leads to compression of the nerve root and the onset of pain.

Pressure test on shoulder area:

• i.p. Patient sitting on a chair; the doctor with one hand presses on the patient's shoulder, while simultaneously with the other hand makes the slope of his head in the opposite direction.

An increase in pain or a change in sensitivity indicates a compression of the nerve root.

Test for vertebral artery failure:

• i.p. Patient - lying on his back;
• the doctor with one hand puts pressure on the patient's shoulder (in the caudal direction!), with the other hand gently turns his head in the opposite direction.

A positive symptom reveals compression of the nerve or inadequacy of the vertebral artery, which is indicated by nystagmus or dizziness.

Adson's test is specific for the syndrome of the anterior staircase:

• i.p. Patient sitting or lying on his back.

The patient is offered to slowly turn his head to the affected side. In this case, the doctor slightly sips the patient's head upwards (strictly along the vertical axis!). The attenuation or disappearance of the pulse on the radial artery is the result of compression of the stair muscles. Valsalva test:

• i.p. Patient - sitting, lying on his back.

The patient is offered to take a deep breath, then hold his breath and strain.

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

The symptom of Lermont:

• i.p. Patient - sitting on the edge of the table, legs lowered down.

The patient with the help of a doctor performs a passive head tilt forward (flexion) and simultaneously bends the legs in the hip joints.

Positive test - these movements cause severe pain, spreading along the spine, due to irritation of the dura mater.

Examination of the volume of neck movements

The study of the volume of movements is carried out in the starting position of the patient sitting on a chair (for the purpose of fixing other parts of the spine).

Distinguish the following basic movements in the cervical region:

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

Approximately half the volume of flexion and extension occurs between the occiput, vertebrae C1 and C2. The rest of the movement is due to the underlying vertebrae, with a large swing motion in C ₅ -S ₇ vertebrae.

Lateral slopes are distributed evenly between all vertebrae.

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

Initially, a study should be carried out with the help of a doctor, as with passive movements the muscles are completely relaxed, which makes it possible to evaluate the condition of the musculoskeletal system. Then, active movements and movements with dosed resistance (usually a physician's hand) are examined.

Movement with resistance provided by the doctor's arm is an isometric test for certain muscle groups (MMT).

[7], [8], [9], [10], [11]

Methods of investigating the volume of movements in the cervical spine

The study should begin with a passive rotation of the cervical region.

Features of biomechanics of the cervical spine:

• turn of the head begins with segment C _1-2;
• only after rotation of joints C1-2 to 30 ° the lower segments are included;
• rotation C ₂ begins only when turning the head at least 30 °.

ATTENTION! If the palpation of the spinous process C ₂ shows that it begins to rotate earlier, this indicates a rigidity or functional blockade of the PDS

Normally, the patient can perform a head rotation of 90 ° (for example, chin to get his shoulder).

Study otsipito-atlanto-axial complex: the doctor passively bends the cervical part of the patient (maximal flexion); while segments C ₂ -C _{7 are} "locked", and rotation is possible only in segment C1-2. Normally, the head rotation should be at least 45 ° to the right and to the left.

Study of the rotation of the lower-necked PDS: the doctor, having grasped the head of the patient with his hands, performs the extension of the neck (maximum extension); in this case, "upper" segments are closed, and the passive rotation of the head to the sides is carried out at the expense of the lower spine. Normally, the volume of movements to each side is at least 60 °.

Investigation of the mobility of the underlying cervical PDS: the doctor has fingers of one hand on the spinous processes of the vertebrae under study, and with the other hand performs a passive rotation of the head.

Study of lateral inclinations:

• i.p. Patient - lying on his back, his head hangs from the couch;
• With one hand, the doctor supports the patient's head and tilts to the side; the distal phalanx of the index finger of the other hand densely contacts the interstitial interval, the middle one with the intervertebral joint and the adjacent transverse processes;
• By this method, all segments, starting from C ₀ _, to C ₆ _ ₇ from both sides, are studied consecutively .

1. Flexion:

• the maximum slope is possible within 70-85 °;
• active movement must be carried out without sharp efforts and strains;
• with the passive movement of the patient's chin should touch the chest.

Pain occurs:

• with active bending of the neck may be of muscle or tendon origin; as a consequence of intervertebral disc damage;
• with the passive movement of the neck can be due to the stretching of ligamentous elements.

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

Pain occurs:

• with active movement reflects the pathological processes in the muscles of the neck and shoulder girdle;
• with defeat of arched joints.

3. Head incline to the right and left - the maximum inclination in each direction is possible within 30-45 °.

Pain occurs:

• when the muscles of the neck and shoulder girdle are affected;
• when the small joints of the cervical spine are affected; as a consequence of the volatility of the PDS;
• with lesions of intervertebral discs.

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

Pain occurs in the muscles of the neck and shoulder girdle, both during contraction and when stretching.

5. Neck bending:

• if the rotation is carried out with a straight neck, then the entire cervical and upper thoracic spine (to level Th ₄ ) is involved in movement ;
• with slight inclination of the head and rotational motion, predominantly C ₃ -C ₄ segments are involved ;
• at the maximum forward inclination rotational movements are carried out due to C, -C ₂ segments (Table 5.7).

6. Unbending the neck:

• from the rotational movement, the cervico-occipital articulation is excluded;
• C ₃ -C ₄ segments are involved in the movement .

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

Determination of the volume of movements in the cervical spine (in cm)

Movement of flexion and straightening in the sagittal plane. In the position of the examinee - standing with a direct eye, determine the distance from the occiput to the spinous process of the 7th cervical vertebra. With maximum neck bending forward, on average, this distance increases by 5 cm, and when moving in the opposite direction decreases by 6 cm.

Lateral slopes are movement 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 shoulder process of the scapula

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

Rotational motions in the transverse plane. Determined by measuring the distance from the shoulder process of the scapula to the lowest point of the chin in the starting position (see above) and then after the movement. With rotational movements of the cervical region, this distance increases on average by approximately 6 cm.

[12], [13], [14]

Research of the muscular system

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

Function: with one-sided cutting - tilts the head back and to the side, with the bilateral - back.

Test: when the patient's head is unbent, the doctor's hands are given a measured resistance to this movement.

• Chest-clavicular-mastoid muscle. Function: with bilateral contraction of the muscle, the head throws back, with the bilateral - tilts the head in the same direction, with the patient's face turning in the opposite direction.

Test: the patient is offered to tilt his head to the side while turning his face opposite to the inclination of the head; the doctor renders the measured resistance to this movement and palpates the contracted muscle.

• Trapezius muscle. Function: the reduction of the upper fascicles raises the scapula, the lower one - lowers it, the whole muscle - brings the scapula closer to the spine.

The test for determining the strength of the upper portion of the muscle: the doctor's hands have a measured resistance when the patient attempts to lift the shoulders.

The test for determining the strength of the average muscle portion: the hands of the physician resist when the patient attempts to move the shoulder back.

Test to determine the strength of the lower portion of the muscle: the patient is invited to withdraw the arm raised upward back.

• Large pectoralis muscle. Function: leads and rotates the shoulder inside (pronation).
• Small pectoralis muscle. Function: pulls the scapula forward and down, and with a fixed scapula lifts the ribs, being an auxiliary respiratory muscle.

Tests to study the strength of pectoral muscles:

• to examine the clavicular part of the large pectoral muscle, the patient is invited to lower and bring the hand raised above the horizontal plane, the doctor at the same time exerts resistance to movement;
• for the examination of the breast-ribbed part of the large pectoral muscle, the patient is offered to lead a 90-degree arm, the doctor is resisting this movement;
• To determine the strength of the small pectoral muscle, the patient withdraws his arms slightly bent at the elbow joints and fixes them in this position. The doctor's task is to increase the distance of the arms to the sides.

• Deltoid. Function: the front portion of the muscle lifts the raised hand forward, the middle one - withdraws the shoulder to the horizontal plane, the rear one - pulls the shoulder back. When the entire muscle is contracted, the arm is retracted to about 70 °.

The test to determine the strength of the muscle: the patient raises his straight arm to a horizontal level (from 15 ° to 90 °), the doctor's hands have a measured resistance to this movement.

• The rhomboid muscle. Function: brings the shoulder blade closer to the spine, lifting it slightly.

Test to determine the strength of the muscle: the patient puts his hands on the waist and leads the shoulder blade, while pulling the elbow back, the doctor is resisting this movement.

• Anterior toothed muscle. Function: The muscle, contracting (with the participation of trapezius and rhomboid muscles) brings the scapula closer to the chest. The lower portion of the muscle helps lift the arm above the horizontal plane, rotating the scapula around the sagittal axis.

The test for determining the strength of the muscle: the patient raises his hand above the horizontal level. Normally, the scapula rotates around the sagittal axis, moves away from the spine, turns in the lower corner and moves laterally and fits to the chest.

• Tough muscle. Function: helps to divert the shoulder to 15 °, being a synergist of the deltoid muscle. Delays the capsule of the shoulder joint, protecting it from infringement.

Test to determine the strength of the muscle: the patient leans his shoulder at 15 °, the doctor is resisting this movement and palpating the contracted muscle in the supraspinum.

• The subordinate muscle. Function: rotates the shoulder from the outside (supination) and pulls the capsule of the shoulder joint.

The test to determine the strength of the muscle patient turns to the outside of the arm bent at the elbow joint, the doctor is resisting this movement.

• The widest muscle of the back. Function: brings the shoulder to the body, rotating the hand inside (penetrating).

The test to determine the strength of the muscle: the patient lowers the shoulder raised to the horizontal level, the doctor is resisting this movement.

• The biceps brachii of the shoulder. Function: flexes the shoulder in the shoulder joint and the arm at the elbow joint, suppinging the forearm.

The test for determining the strength of the muscle: the patient flexes the arm in the elbow joint and supplements the pre-penetrated forearm. The doctor is resisting this movement.

• The triceps brachialis muscle. Function: Together with the elbow muscle it extends the arm at the elbow joint.

The test for determining the strength of the muscle: the patient unbends the pre-bent forearm, the doctor is resisting this movement.

• Bronchial muscle. Function: penetrates the forearm from the supination position to the medial position, flexes the arm at the elbow joint.

Test to determine the strength of the muscle: the patient flexes the arm at the elbow joint while simultaneously penetrating the forearm from the supination position to the position average between supination and pronation. The doctor is resisting this movement.

• Round pronator. Function: penetrates the forearm and promotes its bending.
• A square pronator. Function: penetrates the forearm and brush.

Test for determining the strength of a round and square pronator: the patient from the supination position penetrates the pre-expanded forearm. The doctor is resisting this movement.

• Radial wrist flexor. Function: bends the wrist and pulls the brush to the lateral side.

The test to determine the strength of the muscle: the patient bends and retracts the hand, the doctor is resisting this movement and palpating the strained tendon in the area of the arm-wrist joint.

• The ulnar flexor of the wrist. Function: bends the wrist and brings the brush.

A test to determine the strength of the muscle: the patient flexes and leads the brush, the doctor is resisting this movement.

• Superficial flexor of fingers. Function: bends the middle phalanges of II-V fingers, and with them the fingers themselves; participates in the bending of the brush.

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

• Long and short radius of the extensor carpus. Function: unbends and retracts the brush.

The test for determining the strength of the muscles: the patient unbends and withdraws the hand, the doctor is resisting this movement.

• The ulnar extensor of the wrist. Function: Brings and unbends the brush.

The test for determining the strength of the muscle: the patient unbends and leads the brush, the doctor is resisting this movement.

• Extensor of fingers. Function: unbends the main phalanges of the II-V fingers, as well as the brush.

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

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

The test for determining the strength of the muscle: the patient from the position of pronation supinutes the pre-bent forearm, the doctor is resisting this movement.

ATTENTION! When performing muscle testing, the doctor must palpate the contracted muscle when resisting the motion of the limb segment.

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

Function:

• reduction and dilution of the fingers of the hand;
• clenching fingers in a fist;
• extension of the thumb;
• turn the brush inside.

All movements are performed with dosed resistance performed by the doctor's arm.