Spine Exam, Neck & Upper Extremity

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

 

Cervical Spine & Upper Extremity Examination

Overview

The cervical spine examination follows the usual orthopaedic sequence:

Inspection – Palpation – Range of motion – Strength – Neurovascular examination – Specific tests – Gait

The aim is not only to identify cervical pathology, but also to distinguish it from shoulder and peripheral nerve disorders.

1. Inspection

Inspect the patient for:

• Cervical alignment and deformity in coronal and sagittal planes
• Shoulder imbalance
• Scapular winging
• Rib prominence
• Surgical scars
  • Cervical spine
  • Shoulder
  • Carpal tunnel
  • Cubital tunnel
• Skin abnormalities, including café-au-lait spots in neurofibromatosis
• Muscle wasting/atrophy

The speaker gives normal sagittal alignment as:

• Cervical lordosis: 20–40°
• Thoracic kyphosis: 20–45°

Muscle Wasting

Deltoid + biceps wasting may suggest C5–C6 pathology.

Also look for:

• Abducted little finger — Wartenberg sign
• First dorsal interosseous wasting

These may indicate ulnar nerve dysfunction/hand muscle weakness in the speaker’s discussion.

2. Palpation

Palpate systematically from proximal to distal.

Bony structures

Start from the:

Occiput – cervical spinous processes

Assess for:

• Asymmetry
• Local tenderness

Soft tissues

Palpate:

• Paraspinal muscles
• Scapula
• Ribs
• Trapezius
• Rhomboids
• Levator scapulae
• Trigger points/spasm

3. Cervical Spine Range of Motion

Assess:

Movement	ROM stated by speaker
Flexion	~45°
Extension	~70°
Lateral bending	~45°
Rotation	~75°

During flexion, the speaker notes that the chin approaches/touches the chest.

A shoulder examination should also be performed.

4. Provocative Tests

The transcript discusses:

• Spurling test
• Hoffmann sign
• Lhermitte sign
• Shoulder abduction test
• Shoulder impingement testing
• Carpal tunnel compression test
• Tinel sign at the cubital tunnel

These help differentiate cervical spine disease from shoulder and peripheral nerve pathology.

5. Spurling Test

Purpose

Assess for cervical nerve-root irritation/compression.

Technique

• Patient seated.
• Turn the head toward the affected side.
• Examiner applies downward compression over the head.

Positive Test

Radiating pain down the patient’s arm produced by cervical compression.

This supports cervical radicular pathology.

Viva

Head toward symptomatic side + axial compression – radiating arm pain = positive Spurling test.

6. Hoffmann Sign

Technique

The examiner flicks the nail of the:

• Middle finger, or
• Ring finger

A positive response produces flexion involving the index finger/thumb region, as described in the transcript.

Significance

Positive Hoffmann sign suggests an upper motor neuron lesion associated with spinal cord compression.

7. Lhermitte Sign

Also called the Lhermitte phenomenon.

Positive Finding

Flexion/movement of the neck produces:

An electric shock-like sensation radiating down the spine.

It may extend into:

• Legs
• Arms
• Occasionally the trunk

Quick Recall

Neck flexion – electric shock down spine = Lhermitte sign.

8. Shoulder Abduction Test

Technique

Ask the patient to:

Place the hand over the head, abducting the shoulder.

Positive Test

The patient’s radicular symptoms are relieved.

According to the speaker, relief occurs because shoulder abduction:

Decreases tension on the nerve roots.

Therefore, relief favors cervical nerve-root irritation rather than intrinsic shoulder pathology.

Exam Pearl

Shoulder abduction RELIEVES radicular pain – cervical nerve-root pathology.

9. Carpal Tunnel Compression Test

The transcript refers to the carpal tunnel compression test.

Technique

• Apply even pressure using both thumbs directly over the median nerve at the carpal tunnel.
• Maintain for approximately 30 seconds.

Positive Test

Reproduction of symptoms in the:

Median nerve distribution

supports carpal tunnel syndrome.

The speaker describes this as a highly sensitive test.

10. Tinel Sign at the Elbow

Tap over the ulnar nerve at the cubital tunnel.

Reproduction of ulnar nerve symptoms suggests:

Ulnar nerve entrapment at the cubital tunnel.

11. Gait Examination

Gait should not be forgotten during cervical spine examination.

The transcript associates a:

Wide-based/shuffling gait with neurological disease and myelopathy.

It also mentions gait disturbance associated with foot drop.

12. Neurological Examination

The neurological examination includes:

Motor + Sensory + Reflexes + Upper motor neuron signs

The speaker recommends testing at least one key muscle from each C5–T1 nerve-root group.

13. Manual Muscle Power

The transcript uses the 0–5 grading system:

Grade	Finding
0	No evidence of contraction
1	Minimal contraction
2	Movement with gravity eliminated
3	Movement against gravity
4	Movement against some resistance
5	Normal power

14. Cervical Root Motor Testing

Root	Key muscles/functions stated in transcript
C5	Deltoid, biceps
C6	Biceps, wrist extensors
C7	Triceps, wrist/finger extension*
C8	Finger flexion
T1	Hand intrinsic muscles — abduction/adduction

*The C7 phrase is somewhat distorted by speech-to-text; this table preserves the speaker’s intended framework without adding details not clearly present.

Quick Recall

C5 – Deltoid

C6 – Wrist extension

C7 – Triceps

C8 – Finger flexion

T1 – Interossei / finger abduction-adduction

15. Sensory Examination

Test the C5–T1 dermatomes for:

• Pain
• Light touch

The speaker suggests:

• Paper clip for pain
• Finger for light touch

Temperature and proprioception may be added in a focused examination.

Dermatomal Landmarks

Root	Sensory area stated
C5	Upper outer arm
C6	Thumb
C7	Long/middle finger
C8	Little finger
T1	Medial forearm

16. Reflexes

Reflex	Root stated
Biceps	C5
Brachioradialis	C6
Triceps	C7

Easy Viva Sequence

C5 – Biceps – C6 – Brachioradialis – C7 – Triceps

17. Long-Tract / UMN Signs

These are particularly important when evaluating cervical myelopathy.

The transcript specifically mentions:

• Hoffmann sign
• Clonus
• Babinski reflex

Therefore, cervical examination should not stop after evaluating radiculopathy.

Radiculopathy – nerve root

Myelopathy – spinal cord – look for UMN/long-tract signs + gait abnormality

18. Neck Pain vs Shoulder Pain

The transcript emphasizes that neck and shoulder pathology can coexist and their symptoms can overlap.

Cervical pathology, including disc disease, can produce referred shoulder pain.

Pain Location

According to the speaker:

Neck-origin pain

Often felt:

Over the top of the shoulder/trapezius region

Shoulder-origin pain

Often felt:

Around the upper arm

Palpating the exact area of tenderness is therefore important.

19. Shoulder Movement as a Differentiator

The speaker gives a useful practical point:

If the shoulder moves freely without pain, the neck is more likely to be the source.

However, differentiation may still be difficult because cervical pathology can coexist with:

• Rotator cuff weakness
• Shoulder stiffness
• Shoulder impingement

The speaker notes that MRI may sometimes be required when the clinical distinction remains unclear.

High-Yield Cervical Examination Table

Test/Finding	Suggests
Spurling	Cervical radicular pathology
Shoulder abduction relieves pain	Cervical nerve-root irritation
Hoffmann	UMN/spinal cord involvement
Lhermitte	Cervical cord-related phenomenon
Clonus	UMN lesion
Babinski	UMN lesion
Carpal tunnel compression	Median nerve/carpal tunnel
Tinel at elbow	Ulnar nerve/cubital tunnel
Wide-based/shuffling gait	Myelopathy/neurological disorder
Pain-free shoulder ROM	Favors cervical source in speaker’s framework

Practical Examination Sequence

INSPECTION
Alignment – deformity – shoulder level – scapular winging – scars – wasting

 

PALPATION
Occiput – spinous processes – paraspinals – trapezius -scapula/ribs

 

ROM
Flexion – extension – lateral bending – rotation

MOTOR C5–T1

SENSORY C5–T1

REFLEXES
C5 biceps -C6 brachioradialis – C7 triceps

RADICULOPATHY TESTS
Spurling – shoulder abduction

MYELOPATHY / UMN SIGNS
Hoffmann – clonus – Babinski – gait

RULE OUT PERIPHERAL/SHOULDER CAUSES
Shoulder examination – carpal tunnel compression – cubital tunnel Tinel

Key Take-Home Points

• Examine the cervical spine using a systematic orthopaedic sequence.
• Always include the shoulder and upper extremity neurological examination.
• Spurling reproduces radicular arm pain.
• Shoulder abduction relieving symptoms favors cervical nerve-root irritation.
• Hoffmann, clonus and Babinski are important when cervical myelopathy is suspected.
• Test motor power, sensation and reflexes from C5–T1.
• Remember C5 biceps, C6 brachioradialis, C7 triceps for reflexes.
• Gait examination is essential when considering cervical myelopathy.
• Neck and shoulder disorders can coexist and overlap, so localization requires the complete examination.

Exam Pearls

Spurling – reproduces radicular pain

Shoulder abduction – relieves radicular pain

Hoffmann + clonus + Babinski + abnormal gait ? think cervical myelopathy

C5 = deltoid

C6 = wrist extension

C7 = triceps

C8 = finger flexion

T1 = interossei

C5 = biceps jerk | C6 = brachioradialis jerk | C7 = triceps jerk

 

Spine Exam Neck & Upper Extremity