Neck Examination

Neck problems are common in general practice, either chronic discomfort, such as with cervical spondylosis, or following acute trauma, e.g. whiplash injuries following road traffic accidents. Evaluation of neurological symptoms in the upper limbs must also include an assessment of possible causes in the neck. Spinal cord compression in the neck may lead to lower limb problems and abnormal gait, as well as bladder and bowel disturbance.

• Deformity: may be seen in cervical spondylosis or acute torticollis.
• Instability of the cervical spine: check that the patient can easily support their head (obvious if mobile but instability may be missed in a supine patient).
• Abnormal head posture may be due to neck problems but also other causes, e.g. weakness of the ocular muscles.
• Asymmetry e.g. of scapulae, or supraclavicular fossae (e.g. Pancoast tumour - apical lung cancer).
• Torticollis (affected side and chin often tilted to opposite side) or sternomastoid 'tumour' in infants. Causes of acquired torticollis include upper respiratory tract infection, vertebral malalignment or trauma.
• Arms and hands: for wasting, fasciculation, motor abnormalities (tone, power), sensory deficits and any indication of thoracic outlet syndrome.
• Lower limb weakness: cord compression.

• Palpate for tenderness and masses; posterior in the midline, lateral, supraclavicular (cervical rib, lymph glands, tumours) and anterior.
• Midline tenderness in the cervical spine: may be due to supraspinous damage following whiplash injuries or may also indicate more major neck trauma.
• Midline tenderness localised to 1 space is common in cervical spondylosis.
• Palpate lateral aspects of vertebrae for masses and tenderness (the most prominent spinous process is T1).
• Paraspinal tenderness radiating into trapezius is common in cervical spondylosis.
• Crepitation: facet joint crepitus may be detectable with flexion and extension of the neck by either palpation or auscultation on either side of cervical spine; facet joint crepitus is common in cervical spondylosis.
• Palpate supraclavicular fossae for tumours and enlarged lymph nodes. A cervical rib may cause localised tenderness.
• Palpate anterior neck, including thyroid examination.

• Flexion: normal range is 80 degrees with chin able to touch region of sternoclavicular joint.
• Extension: normal range 50 degrees so normal for full flexion to full extension is 130 degrees, primarily involves the atlanto-axial and atlanto-occipital joints.
• Lateral flexion: normal range is 45 degrees to both sides; restriction of lateral flexion is common in cervical spondylosis. Inability of lateral flexion without forward flexion at same time suggests atlanto-axial and atlanto-occipital joint abnormalities.
• Lateral rotation: normal range is 80 degrees to both sides; normally just short of plane of shoulders at full rotation. Rotation is restricted and painful in cervical spondylosis.

• Spinal cord compression may result from developmental narrowing of the spinal cord, spinal fractures or subluxations, cervical spondylosis or cervical disc prolapse.
• Lower motor signs at the level of the compression predominate in the arms. In the legs, there is evidence of an upper motor lesion, with exaggerated reflexes, clonus, extensor plantars, loss of proprioception and often a broad-based or ataxic gait.

• Flexion or extension of the neck may produce electric shock like sensations, particularly in the legs.
• Clonus.
• Myelopathy hand test: indicates pyramidal tract damage. There is an inability to rapidly flex and extend the fingers (the normal is more than of 20 cycles in 10 seconds). There may also be deficient adduction and extension of the ulna fingers.

• Root lesions may cause weakness in the upper limbs in a segmental distribution, with loss of sensation in a dermatome distribution and altered reflexes.
• If cervical cord compression is suspected, the lower limbs should also be examined.

Myotomes

• Shoulder: abduction C5,6; adduction C6,7,8; lateral rotation C5; medial rotation C6,7,8
• Elbow: flexion C5,6; extension C7,8
• Radio-ulnar: supination C6, pronation C7,8
• Wrist: flexion and extension C7,8
• Fingers: long flexors and extensors C7,8
• Hand: small muscles T1.

Upper limb dermatomes

See article on Upper Limb Examination (and dermatome diagrams):

• C4: shoulder tip
• C5: outer part of the upper arm
• C6: lateral aspect of the forearm and the thumb
• C7: middle finger
• C8: little finger
• T1: medial aspect of the forearm.

Reflexes

• Biceps C5,6
• Brachioradialis C6
• Triceps C7
• Finger flexion C8.