Evaluation of cervical spine disorders

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How does the evaluation of a patient with a spine complaint begin?

A complete history and physical examination are performed. The purpose of the history and physical examination is to make a provisional diagnosis that is confirmed by subsequent testing as medically indicated.

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What are some of the key elements to assess in the history of any spine problem?

• Chief complaint: pain, numbness, weakness, gait difficulty, deformity

• Symptom onset: acute versus insidious

• Symptom duration: acute, subacute, chronic, recurrent

• Pain location: Is the pain primarily axial neck pain, arm pain, or a combination of both?

• Pain quality and character: sharp versus dull; radiating versus stabbing versus aching

• Temporal relationship of pain: Night pain, rest pain, or constant unremitting pain suggests systemic problems such as a tumor or infection. Morning stiffness that improves throughout the day suggests an arthritic problem or an inflammatory arthropathy.

• Relation of symptoms to neck position: increased arm pain with neck extension suggests nerve root impingement

• Aggravating and alleviating factors: Is the pain mechanical (activity-related) or nonmechanical (not influenced by activity) in nature?

• Family history: inquire about diseases such as ankylosing spondylitis or rheumatoid arthritis.

• Concurrent medical illness: diabetes, peripheral neuropathy, peripheral vascular disease

• Systemic symptoms: a history of weight loss or fever suggests possibility of tumor or infection

• Functional impairment: loss of balance, gait difficulty, loss of fine motor skills in the hands

• Prior treatment: include both nonoperative and operative measures

• Negative prognostic factors: pending litigation, Workers’ Compensation claim

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What disorders should be considered in the differential diagnosis of neck/arm pain?

• Degenerative spinal disorders: discogenic pain, radiculopathy, myeloradiculopathy, myelopathy, facet joint-mediated pain

• Soft tissue disorders: sprains, myofascial pain syndromes, fibromyalgia, and whiplash syndrome

• Rheumatologic disorders: rheumatoid arthritis, ankylosing spondylitis

• Infections: discitis, osteomyelitis

• Tumors: metastatic versus primary tumors

• Intraspinal disorders: tumors, syrinx

• Systemic disorders with referred pain: angina, apical lung tumors (Pancoast tumor)

• Shoulder and elbow pathology: rotator cuff disorders, medial epicondylitis

• Peripheral nerve entrapment syndromes: radial, ulnar, or median nerve entrapment, suprascapular neuropathy

• Thoracic outlet syndrome or brachial plexus injury

• Psychogenic pain

• Cervicogenic headache

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What are the basic elements of an examination of any spinal region?

• Inspection

• Palpation

• Range of motion (ROM)

• Neurologic examination

• Evaluation of related areas (e.g., shoulder, elbow, and wrist joints; scapula; supraclavicular area)

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What should the examiner look for during inspection of the cervical region?

During the initial encounter, much can be learned from observing the patient. Assessment of gait and posture of the head and neck is important. Patients should undress to allow inspection of anatomically related areas, including the neck muscles, shoulder, elbow and wrist joints, scapula, and supraclavicular area.

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What is the purpose of palpation during assessment of the cervical region?

To examine for tenderness and locate bone and soft tissue pathology. Specific areas of palpation correspond to specific levels of the spine:

• Hyoid bone C3

• Thyroid cartilage C4–C5

• Cricoid membrane C5–C6

• First cricoid ring C6

• Carotid tubercle C6

Spinous processes should be palpated and checked for alignment. If tenderness is detected, it should be noted whether the tenderness is focal or diffuse, and the area of maximum tenderness should be localized.

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