Overview Neck & Upper Extremity Spine Exam Root Primary Motion Tested Muscles Sensory Reflex C4 Scapular stabilization (winging) Upper portion of serratus anterior (significant variation in innervation) Upper shoulder, over clavicle - C5 Shoulder abduction Elbow flexion (palm up) Deltoid Biceps Lateral arm below deltoid Biceps C6 Elbow flexion (thumb up) Wrist extension Brachioradialis ECRL Thumb and radial hand/forearm Brachioradialis C7 Elbow extension Wrist flexion Triceps FCR Fingers 2, 3, 4 Triceps C8 Finger flexion, hand grip, thumb extension FDS Finger 5 - T1 Finger abduction Interossei muscles Medial elbow - Brachial plexus illustrations Nerve root anatomy key difference between cervical and lumbar spine is pedicle/nerve root mismatch cervical spine C6 nerve root travels under C5 pedicle (mismatch) lumbar spine L5 nerve root travels under L5 pedicle (match) extra C8 nerve root (no corresponding C8 pedicle) allows transition horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root due to the vertical anatomy of lumbar nerve root, a paracentral and foraminal disc herniation will affect different nerve roots due to the horizontal anatomy of cervical nerve root, a central and foraminal disc herniation will affect the same nerve root Inspection, Palpation, ROM Inspection alignment in sagittal and coronal plane (e.g. kyphotic cervical spine) prior surgical scars (e.g. prior ulnar nerve transposition or carpal tunnel surgery) skin defects (e.g. café au lait spots associated with neurofibromatosis) muscle atrophy (e.g. in a palsy, can see a decrease deltoid and biceps mass) Palpation palpate local tenderness on the spinal axis, asymmetric ROM document range of motion in flexion, extension, rotation, and lateral bend may give absolute degrees or relative to anatomic landmark (e.g. chin rotates to right shoulder) normal range of motion of cervical spine: flexion: 50° extension: 60° rotation: 80° lateral bend: 45° Motor Testing Grade key muscles groups from 0-5 using American Spinal Injury Association (ASIA) grading system include at least one muscle from each nerve root group (C5 to T1) Motor Testing of Upper Extremity Muscles Primary Motion Primary Muscle Innervation Nerve Root Scapular stabilization Serratus Long thoracic nerve C4 Shoulder abduction Deltoid Axillary nerve C5 Shoulder internal rotation Subscapularis Subscapular nerve C5 Shoulder external rotation Infraspinatus Suprascapular nerve C5 Elbow flexion (palm up) Biceps & brachialis Musculocutaneous nerve C5 Elbow flexion (thumb up) Brachioradialis Radial nerve C6 Wrist extension ECRL Radial nerve C6 Wrist supination Supinator PIN C6 Elbow extension Triceps Radial nerve C7 Wrist flexion FCR & PL Median nerve C7 Wrist pronation PT & PQ Median nerve C7 MCP & PIP finger flexion FDS Median nerve C8 DIP finger flexion FDP Ulnar nerve & AIN C8 Thumb extension EPL PIN C8 Finger abduction Interossei Ulnar nerve T1 Sensory Exam Grade sensation in C5 to T1 dermatomes score using ASIA grading system score major sensory types in all patients pain (prick with sharp object such as paper clip, broken cotton swab) light touch (stroke lightly with finger) score minor sensory types for focused exam vibration temperature two-point discrimination Provocative Tests Spurling's test foraminal compression test that is specific, but not sensitive, in diagnosing acute radiculopathy performed by rotating head toward the affected side, extending the neck, and then applying and axial load (downward pressure on the head) test is considered positive if pain radiates into the ipsilateral arm when the test is performed for 30 seconds Hoffman's test a positive test is sensitive, but not specific, for cervical myelopathy performed in one of two ways: hold and secure the middle phalanx of the long finger, and then flick the distal phalanx into an extended position Involuntary contraction of the thumb IP joint is a positive test hold and secure the distal phalanx of the long finger, and then flick the distal phalanx into an extended position Involuntary contraction of the thumb IP joint is a positive test Lhermitte sign a positive test is specific, but not sensitive, for cervical spinal cord compression and myelopathy test is positive when cervical flexion or extension leads to shock-like sensation radiating down the spinal axis and into arms and/or legs Gait Antalgic gait caused by guarding for pain in affected extremity due to hip and knee pathology severe radicular symptoms Trendelenburg gait caused by painful arthritis of hip or gluteus medius weakness wide-based shuffling gait due to a neurologic disorder, including myelopathy steppage or lateral swing gait a method of gait compensation for a foot drop (weakness of ankle dorsiflexion and toe extension)