3.13. Movements (7): If lateral flexion cannot he carried out without forward flexion, this is indicative of pathology involving the atlantoaxial and atlanto-occipital joints.
3.14. Movements (8): Rotation (1): Ask the patient to look over the shoulder. The movement may be encouraged with one hand and movement of the shoulder restrained with the other. Normally the chin falls just short of the plane of the shoulders.
3.15. Movements (9): Rotation (2): Again a spatula may be used as a pointer for measurement.
Normal range = 80° to either side. About a third of this occurs in the first two cervical joints. Rotation is usually restricted and painful in cervical spondylosis.
3.16. Crepitus: Spread the hands on each side of the neck and ask the patient to flex and extend the spine. Facet joint crepitus is normally detectable in this fashion, and is a common finding in cervical spondylosis; if in doubt, auscultate on either side of the spine while the patient flexes and extends.
3.17. Thoracic outlet syndrome (1): This may result from involvement of the space between scalenus anterior, scalenus medius and the first rib. so that the subclavian artery and/or the anterior primary rami of the lower cervical and first thoracic nerves may be affected. Begin by looking for evidence of ischaemia in one hand (e.g. coldness, discoloration, trophic changes). Bilateral changes are more in favour of Raynaud's disease.
3.18. Thoracic outlet syndrome (2):
Palpate the radial pulse and apply traction to the arm. Obliteration of the pulse is not diagnostic, but when the test reveals no change when repeated on the other side it is suggestive. Note that the syndrome occurs most commonly when the space is narrowed with fibrous bands or other pathology, such as a cervical rib or a Pancoast tumour.
3.19. Thoracic outlet syndrome (3):
Adson '.v test: Abduct the shoulder to about 30° and locate the radial pulse (which is assumed to be present). Now ask the patient to turn his head fully to the affected side. He should then be asked to take and hold a deep breath.
3.20. Thoracic outlet syndrome: Adson \ test ctd: The patient should then exhale, look forward, and lower the arm to the side. The pulse obtained in the first position should be compared with the second. Obliteration or reduction, especially if there is duplication of the patient's symptoms, is usually significant, but compare the sides. The test may also be tried with the head rotated to the opposite side.
3.21. Thoracic outlet syndrome (4): The
Roos test: The shoulders should be abducted and externally rotated, and the elbows flexed to a right-angle. (In this position the arms are in the aptly named 'surrender' position.) The hands should be repeatedly and slowly clenched for up to 3 minutes. Neurological and/or vascular symptoms, and early disappearance of the radial pulse on the affected side, are highly significant.
3.23. Cord compression and cervical myelopathy (1): In this condition dysfunction in the cervical cord results from local compression. It may be seen where there is developmental narrowing of the spinal canal, or follow old ununited fractures of the dens, or spinal subluxations It may occur in cervical spondylosis (from osteophytes protruding posteriorly from the vertebral bodies or from the uncovertebral joints) or from cervical disc prolapses. The main finding is of muscle weakness which is greater in the upper than in the lower limbs. In the arms lower motor signs at the level of the compression predominate (although there may be a mixed lesion). In the legs there is a lower motor lesion, which may include exaggerated lower limb reflexes, clonus, an extensor plantar response, loss of proprioception, and often a broad-based or ataxic gait. Extensor plantar responses are late in onset, and the sensory deficit is not dermatomal. The differential diagnosis includes multiple sclerosis (where there are usually abnormal cranial nerve findings), amyotrophic lateral sclerosis (where there is no alteration in sensation), syringomyelia, subacute combined degeneration (where the difference between the findings in the upper and lower limbs is less striking), spinal cord or cerebral tumour, and hydrocephalus.
3.24. Cervical myelopathy (2):
(a) Hoffmann's test: Rapidly extend the distal phalanx of the middle finger by flicking its anterior surface (i.e. the pulp): the test is positive (indicating corticothalamic dysfunction) if it results in flexion of the IP joints of the thumb and index, (b) Dynamic Hoffmann test: Repeat while the patient flexes and extends the neck, which often facilitates the response.
3.22. Thoracic outlet syndrome (5):
Look for neurological disturbance, paying particular attention to myotomes and dermatomes. Note any hypothenar or. much less commonly, thenar wasting. Note any disturbance of the pattern of sweating in the hand. (6): Auscultate over the subclavian artery. A murmur is suggestive of a mechanical obstruction, but repeat on the other side. (7): Examine radiographs for the presence of a cervical rib.
L'hermitte's test: Flexion or extension of the neck produces electric shock-like sensations, particularly in the legs, (d) Inverted radial reflex: This highly specific test is positive if the fingers flex when the radial reflex is elicited, (e) Clonus, (f) Myelopathy hand (indicative of pyramidal tract damage). This has two elements: (i) Kinetic: there is inability to rapidly flex and extend the fingers. Time the patient over 10 seconds. The normal is in excess of 20 cycles.
3.26. Cervical myelopathy (4):
Myelopathy hand: (ii) Postural: There is deficient adduction, and often extension, of the ulnar fingers 1-3. In the mildest cases, when the fingers are extended the little finger lies in a slightly abducted position (a); if it can adduct, this position cannot be held for long. The power of abduction is normal, distinguishing it from ulnar nerve palsy. In more severe cases the little, ring (b), and sometimes the middle finger (e) may abduct, and/or the same fingers may flex (d) and lose their power of extension.
3.27. Radiographs (1): The standard projections are the lateral and anteroposterior views of the lower and upper cervical vertebrae. Illustrated: normal lateral projection, with a small non-significant opacity lying anterior to the body of C5. Note the well defined pharyngeal shadows.
3.28. Radiographs (2): Begin your study of the lateral projection by noting the cervical curve, which is normally slightly convex anteriorly: (A) normal, regular curve; (B) loss of curvature: this can be a positional error, but in those with chronic neck pain (especially postural in origin) it may be due to protective muscle spasm. This is, however, a rather unreliable sign; (C) kinking (from a local lesion such as a subluxation, or from intense local muscle spasm).
3.29. Radiographs (3): Now look at the general shape of the bodies of the vertebrae, comparing one with another. Note for example, (A) congenital vertebral fusion, such as occurs in the Klippel-Feil syndrome; (B) vertebral collapse, from tuberculosis, tumour or fracture.
3.30. Radiographs (4): Note the relationship of each vertebra to the ones above and below. It is often helpful in doubtful cases to trace the posterior margins of the bodies. Displacement occurs in dislocations, and may be small when the facet joints on one side only are involved.
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