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How to Examine the C-Spine

December 19, 2023

Written by Jacob Altholz

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While the majority of neck-related health care visits are self-limiting, in the correct context, a focused history and physical exam could unearth an undiagnosed cervical spinal cord compression potentially circumventing permanent disability.

A real pain in the neck
This article seeks to summarize important components of a thorough exam of the cervical spine which may clue providers into common conditions such as cervical disc herniations and degenerative spondylosis that could lead to future debility.

Thorough clinical examination begins with a detailed history and obtaining details regarding pain location, neurological symptoms, duration, and red flags for serious conditions. General physical exam findings such as spine curvature, skin abnormalities, and systematic palpation of bony and soft tissue structures are all part of a good exam in the correct context.

A detailed neurological assessment inclusive of range of motion, gait, sensory perception isolated to exact dermatomes, as well as motor strength and deep tendon reflexes are imperative when concern for compression. While often overlooked, an abnormal deep tendon reflex exam could hone you in on a myelopathy at a particular level. Deployment of the Spurling test in the correct context will also aid in confirming nerve root compression.

Untreated, herniations and degenerative spondylosis could cause myelopathies presenting as gait instability, numbness, and motor difficulties. Radiculopathies can also cause arm pain, numbness, and weakness. In these patients, early recognition will result in proper imaging utilization and referral, which may be crucial to prevent irreversible damage and permanent disability.

For those interested or hoping to seek more information, this article is a supplemental summary to a video that NEJM has posted to the DOI below.

How will this change my practice?
Refreshers on these core topics are important to ensure that we’re all doing the best we can with our patients while still being efficient. While I admit I probably won’t be doing reflex testing or looking for Hoffman’s sign on all my patients, knowing what’s available when there’s a high degree of suspicion can ensure that quick tests aren’t forgotten that would reveal concerning pathologies.

Peer Reviewed by Dr. Ketan Patel

Another spoonful: Don’t be too worried by a little tenderness, it’s prevalent and not always pathological. Prevalence of Midline Cervical Spine Tenderness without Traumatic Injury.

Source
Clinical Examination of the Cervical Spine. N Engl J Med. 2023 Oct 26;389(17):e34. doi: 10.1056/NEJMvcm2204780.

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