Inspection of the neck begins upon meeting the patient. Look to see if the patient moves the shoulders when he or she turns the neck, a sign of decreased range of motion, or if he or she winces with certain motions. Take note of the patient's relaxed posture as changes to improve poor posture can be easily addressed in therapy. As the examination proceeds, the clinician should make sure that the neck is properly exposed for evaluation. Look at the muscle bulk and symmetry of the neck, upper back, and shoulders. Also look at the skin for scarring or discoloration. You will be surprised at the details left out by patients. It is not uncommon to learn about a patient's previous surgery during the exam.
The next step involves palpation of the neck and upper thoracic region. Begin in a systematic fashion, either starting from the front or back. From the back, the paraspinal muscles and the nuchal ligament can be palpated. Working down, the upper and middle trapezius muscles should also be palpated for tender or trigger points (2). Palpate for the spinous process of the seventh cervical vertebrae, which should be larger than the superior segments in a neutral position of the cervical spine.
Place the patient in the supine position with the patient's head near the end of the table. Sit with your stool directly behind the patient's head, and continue palpation. Rotate the patient's neck 45 degrees, palpate each zygapophyseal joint, and note whether the patient feels discomfort at a joint that is greater than the opposite corresponding zygapophyseal joint. From this position, the anterior muscles, most notably the sternocleidomastoid and more laterally the scalenes, can be palpated. Palpate the sternocleidomastoid muscle from its origin at the sternoclavicular joint to the insertion on the mastoid process. Rotate the neck from side to side to make the muscle more prominent if it is initially difficult to find. Look for symmetry and bulk.
Range of Motion
Range of motion should be tested both actively and passively. Both are important in the evaluation of the neck. Guarding due to pain, muscle tightness, and muscle imbalances can reduce range of motion to one side during active testing, but the motion may often be full when tested passively. Osteophytes and zygapophyseal joint arthritis can also lead to fixed restrictions. This would be confirmed when the same loss of range of motion found actively is also demonstrated passively.
Range of motion should be checked in flexion, extension, rotation, and lateral or side bending. Motion is not divided equally between the vertebrae. Approximately 50% of flexion and extension come from the atlanto-occipital joint. At the atlantoaxial joint, approximately 50% of the rotation takes place (3).
Guidelines for normal motion are as follows: Normal flexion allows the patient to touch his chin to his chest, and extension allows the patient to look up at the ceiling. In normal rotation, the patient should be able to bring her chin over the acromion. Side bending done toward the ipsilateral shoulder should be approximately 45 degrees. Always begin with active range of motion, particularly in the injured patient. The patient may guard, and this will reduce the range. Forcing motion may make the patient uncomfortable and can injure a patient with zygapophyseal joint dysfunction (4).
Included in any examination of the neck is a full neurologic examination of the upper limbs. Radiculopathies can be very subtle, and all components of the examination, manual muscle testing, sensory examination, and reflexes must be addressed to find these subtle changes. The order to proceed is examiner dependent. Manual muscle testing should also be confirmed with additional muscles when subtleties exist, as the muscles of the upper limb have two or more levels of innervation. Table 2-1 shows what should be included in manual muscle testing.
Reflexes can be addressed next. Table 2-2 shows what should be included in reflex testing.
Finally, sensation can be tested for both pinprick (lateral spinothalamic tract) and light touch (dorsal columns). If there is a concern about carpal tunnel or double crush, two-point discrimination may be more sensitive (5). Table 2-3 shows what should be included in sensation testing.
Examination of the neck should also include a compression test or Spurling's maneuver (6) (Fig. 2-1). The test assesses the mechanical neuroforaminal narrowing of the C4-5, C5-6, and C6-7 with ipsilateral oblique extension (7). The objective of the test is to compress an irritated nerve with the following motion: The neck is brought into slight extension and side bending followed by an axial compression. A positive result reproduces pain along a dermatome below the shoulder. Finally, as with the joints, it is always important to examine the adjacent joints. In the case of the cervical spine, a full examination of the shoulder should be performed to rule out underlying or contributing shoulder pathology.