Updated: 6/27/2021

Neck & Upper Extremity Spine Exam

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https://upload.orthobullets.com/topic/2001/images/dermatomes arm_moved.jpg
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
https://upload.orthobullets.com/topic/2001/images/illustration cervical vs 4_moved.jpg
https://upload.orthobullets.com/topic/2001/images/muscle grading system.jpg
  • 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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