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Palpation Examination of the Posterior Cervical Spine: the Ideal, Average and Abnormal

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Palpation Examination of the Posterior Cervical Spine: the Ideal, Average and Abnormal PALPATION EXAMINATION OF THE POSTERIOR CERVICAL SPINE: THE IDEAL, AVERAGE AND ABNORMAL The two purposes of this paper relate to Man in or GEOFFREY D MA1TLAND beyond his fifth decade The first purpose is to detail the 'abnormalities' which can be found by palpation Geoffrey Maryland, MB.E, A.U A., F.CS.P, FA.CP, S.A SP,MM T.A.A , is well-known for his study, writing examination of the cervical spine posteriorly, and the and teaching of manipulative therapy in the post-graduate second is to try to explain what the findings indicate. area, he is also a private practitioner in North Adelaide. The 'Ideal' spine, the 'Abnormal' spine and three groups of the 'Average' spine are defined. The method of examining the cervical spine by Tins paper was presented at the 2nd National Congress of the M T A A, Adelaide, South Australia, November, 1980 palpation techniques is detailed. Discussion centres around what is normal for an ideal spine and the average spine and what it is that changes when the average spine becomes 'abnormal'. The associated 'new' and 'old' tissue changes are discussed in relation to the common findings in the Upper, Middle and Lower Cervical Spine. Palpation examination of the posterior from the skull to the third cervical Average elements is the most informative single vertebra, The 'Average' spine is not TdeaF. It does section of physical examination of the • the middle cervical spine (C3-C5), being not consist of a series of ideal motor cervical spine (excluding examination for from the third vertebra to the fifth, and serious disorders of the Central Nervous • the lower cervical spine (C5-C7), being Syitim, the Penpheral Nervous System from the fifth to the seventh cervical and the Vascular System). Frequently, vertebra (See Figure 1). examination of a patient's physiological Before embarking on the body of the movements provides inadequate text it is necessary l o explain and define information when related to the what is mean by the 'Ideal' spine, the complaint. Examination by palpation 'Average' spine and the 'Abnormal'spine techniques, on the other hand, is always informative. This paper is related to Man in his fifth The Ideal, Average and decade and beyond, and has two Abnormal Spine purposes The first purpose is to detail the abnormalities which may be found by Ideal palpation examination of the cervical The ideal1 spine refers to a series of spine posteriorly, and the second is to try intervertebral motor segments (te to explain what the findings might interbody and zygapophyseal joints with indicate. To achieve these goals, while all their supporting hgamentous and discussing the routine of the palpation motor structures) which are normal in examination of the posterior aspect of the every respect, that is, none is cervical spine, the spine will be disadvantaged in any way by injury, wear descriptively divided mto three sections and tear, structural anomaly or disease; • the upper cervical spine (C1-C3), being each motor segment is perfect Figure 1: Divisions of the cervical spine The Australian Journal of Physiotherapy Vol 28, Number 3, June 1982 3 Examination of the Cervical Spine segments. One or more of them is which is not uncommon Such comparable signs will be evident on 'abnormal' in some way, even if they are anomalies are, of themseKes, palpation at the appropriate inter• not causing any symptoms of major painless but they do indicate either vertebral level The title 'Abnormal' is consequence The joint or joints may be asymmetry, or that more stress is used to signify an abnormal degree of imperfect because of placed on adjacent intervertebral symptoms rather than abnormal joints ® congenital or acquired structural segments which, as has been stated, may be totally anomalies, u) Despite the presence of interver• painless • degenerative changes or tebral degenerative changes due to This labelling into groups highlights ® disease processes or changes resulting wear and tear, old trauma, or old important clinical connections between from trauma disease processes which are not symptoms and examination findings Though the 'Average1 spine has been totally inactive, some people do not which can be assessed by the palpation defined as having no symptoms of major have any symptoms whatsoever examination The value of the different consequence, this needs qualification Within this group some spines, when groupings lies in our ability to recognise Some people have no symptoms palpated or stretched, are painless the differences between palpation findings whatsoever while others have minor and some have a minor degree of which relate to a patient's symptoms, and symptoms of a kind which they accept as pain or discomfort those which are not necessarily related being 'normal1 Also within this same group of Such differentiations can then also be The three kinds of imperfection in the degenerative intervertebral joints related to treatment expectations For Average' spine are explained as follows there are people who do have the example, it is possible to recognise, 1) There are people whose spine is degree of symptoms which are through the interpretations of the disadvantaged by a congenital or classed by them as being normal palpation findings, that the realistic goal acquired structural anomaly When their spines are palpated or of treatment may be a minimally Examples are a bifid spmous process stretched they always have a degree symptomatic 'Average' state or a pairtfree lacking one of its processes, a of pain (as compared with the 'Average' state rather an ideal' state spinous process inclining towards previous group which are either Unfortunately very few people over the the left or the right (see Figure 2), or a painless or complain only of dis• age of forty have a total complement of congenital fusion between the comfort). ideal' intervertebral joints. Most people, second and third cervical vertebrae, Of these subdivisions, Group i) (w for one reason or another, fit into one of the ones with congenital or acquired the 'Average' groups If a group of 40- structural anomalies), is quite year-old people, who have no pain or different in kind to Group n) (those discomfort and consider their necks to be with anomalies associated with normal, were examined by palpation, degenerative disease or traumatic abnormalities would be found in nearly changes), and should be thought of all and seen to be so. They are only The question is, when such a person has 'disadvantaged1 because in all other a spontaneous onset of neck pain and regards the individual segments fit seeks treatment for it, how does the the ideal' group examiner differentiate between the in) This group includes people whose findings which relate to the present cervical spines show evidence of joint problem and the findings which were changes due to disease process or present before the spontaneous onset of 9 trauma and who do have symptoms, the neck pam A similar difficulty arises for which they may or may not have when attempting to determine the degree had adequate treatment, yet who of disability which can be attributed to a accept these symptoms as being their recent injury and the degree which is normal despite the fact that they attributable to pre-existing yet painless interfere with their normal life On 'average'joint findings examination their joint movements are painful when stretched and New or Old Tissue palpation findings are obvious Changes Abnormal If an intervertebral joint suddenly The 'Abnormal' spine is a symptomatic becomes painful for no obvious Figure 2: Spine disadvantaged by deviant spine for which the person seeks discernible reason, it is still most likely lumbar spinous process treatment On examination, significant that tissue changes have occurred. 4 The Australian Journal of Physiotherapy Vol. 28, Number 3, June 1982 Examination of the Cervical Spine ® If these recent tissue changes have in the hardness of the leathery feel An 'old' hypomobility has a hard end- occurred in an 'Ideal' joint, the only Thickening from more recent stresses will feel at the limit of the range, with findings which will be detected by be softer or more spong\ and this may movement before the limit of the range palpation examination will be of the overhe an older leathery feel. Thickening being a smooth friction-free movement A 'new1 or 'recent1 kind as with, for within the muscular tissue is usually more 'new1 hypomobility on the other hand has example, a sprained ankle diffuse and never feels like hard leather stiffness occurring earlier in the range ® If these recent tissue changes have Nevertheless, when thickening is present, building up in strength of resistance until occurred in an asymptomatic 'average' it has a stringy feel if it is 'old1 and if it is the end of range is reached, that is, there is cervical joint, then, on examination by 'new' the thickening feels smoother. 'resistance through range1 When crepitus palpation, there will be new tissue Bony anomalies is present during movement it will be changes superimposed on the older Under this heading the features which painless if it is unassociated with 1 'average tissue changes can be determined by palpation are presenting symptoms, and painful if it is Success in differentiating between the abnormal deviation of a spmous process associated. new and old changes makes prognosis, from the central line without or with In 'ldeafjomts, when the synovial joint related to both the success of present vertebral rotation, absence of one process surfaces are strongly compressed and treatment and to the likelihood of future of the bifid spinous process, abnormal moved, the movement will be painless recurrences, easier to assess This is an position of one cervical vertebra relative {Maitland, 1980). There are circumstances examination skill which can be taught to its neighbour; osteoarthntsc osteophyte when pain is experienced during a large • If these recent tissue changes ha\e formation of the margins of the amplitude of the range, and it is occurred in a symptomatic 'average' apophyseal joints.
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