Updated: 6/27/2021

Neck & Upper Extremity Spine Exam

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https://upload.orthobullets.com/topic/2001/images/Brachial Plexus with sensory 566_moved.jpg
https://upload.orthobullets.com/topic/2001/images/brachial plexus dissection_moved.jpg
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  • 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 C8 pedicle) allows transition
        • horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
          • because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots
          • because of horizontal anatomy of cervical nerve root a central and foraminal disc 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., cafe au lait spots associated with neurofibromatosis)
      • muscle atrophy (e.g., palsy will see decrease deltoid and biceps mass)
    • Palpation
      • palpate local tenderness on the spinal axis, asymmetic
    • ROM
      • document range of motion in flexion, extension, rotation, and 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 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 n.
      C4
      Shoulder abduction
      Deltoid
      Axillary n.
      C5
      Shoulder internal rotation
      Subscapularis 
      Subscapular n.
      C5
      Shoulder external rotation
      Infraspinatous
      Suprascapular n. 
      C5
      Elbow flexion (palm up)
      Biceps & Brachialis
      Musculocutaneous n.
      C5
      Elbow flexion (thumb up)
      Brachioradialis
      Radial n.
      C6
      Wrist extension
      ECRL
      Radial n.
      C6
      Wrist supination
      Supinator
      PIN
      C6
      Elbow extension
      Triceps
      Radial n.
      C7
      Wrist flexion
      FCR & PL
      Median n.
      C7
      Wrist pronation
      PT & PQ
      Median n.
      C7
      MCP & PIP finger flexion
      FDS
      Median N.
      C8
      DIP finger flexion
      FDP
      Ulnar n. & AIN
      C8
      Thumb extension
      EPL
      PIN
      C8
      Finger abduction
      Interossei
      Ulnar n. 
      T1
  • Sensory Exam
    • Grade sensory in C5 to T1 dermatomes
      • score using ASIA Sensory Grading System
      • score major sensory types in all patients
        • pain (prick with sharp object such as paper clip, broken cue tip)
        • light touch (stroke lightly with finger)
      • score minor sensory types for focused exam
        • vibration (focused exam)
        • temperature (focused exam)
        • two-point discrimination (focused exam)
  • Provocative Tests
    • Spurlings Test
      • foraminal compression test that is specific, but not sensitive, in diagnosing acute radiculopathy.
      • it is performed by rotating head toward the affected side, extending the neck, and then applying and axial load (applying downward pressure on the head)
      • the 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 cervical flexion or extension leads to shockline sensation radiating down 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 neurologic disorder including myelopathy
    • steppage or lateral swing gait
      • a method of gait compensation for a foot drop (weakness ankle dorsiflexion and toe extension)

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