OnExam

Inspection

  • Inspect patient in standing and sitting, anteriorly, posteriorly and laterally
    • Gait
    • Posture
    • Muscle atrophy, hypertrophy, spasm or increased tone (eg. torticollis), trigger points
    • Cervical spine posture and normal lordotic curve (observe for neutral positioning or forward head posture
    • Thoracic spine and shoulders for potential causes of cervical spine dysfunction
  • Assess for ankylosing spondylitis: Occiput to Wall Distance Test
  • Assess for MS, cervical nerve impingement, and B12 deficiency: Lhermitte’s Sign
  • Assess for impingement of cervical root and radicular pain

Palpation

  • Note areas of pain, swelling, spasm, atrophy, deformity or crepitus in:
    • Each cervical spinous process
    • Facet joints deep in trapezius muscle from C2-C7
    • Paraspinal muscles
    • Trapezius muscle
    • Sternocleidomastoid muscles
    • Thoracic spine
    • Shoulders including scapula

Percussion

  • Percuss each vertebra from C1-C7 with the hypothenar aspect of a closed fist to suggest (or detect possible) malignancy, degenerative disease or osteomyelitis
  • Malignancy
    • Post-test probability if positive: 86%
    • Specificity for malignancy: 60%
  • Osteomyelitis
    • Post-test probability if positive: 10.0% (LR+ = 2.1)
    • Post-test probability if negative: 1.2% (LR- = 0.2)

Range of Motion

  • Forward flexion (normal = 45°), “Chin to chest”
  • Extension (normal = 50°), “Look up at ceiling”
  • Lateral flexion (normal = 45°), “Ear to shoulder”
  • Rotation (normal = 70°), “Turn head from side to side”

References

  1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2009.
  3. Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
  4. Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
  5. Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.