Cervical Spine Assessment: A Complete Guide for Physiotherapists
The cervical spine is one of the most complex regions to assess in MSK physiotherapy. It is a source of significant morbidity, a common cause of referred symptoms to the upper limb, and a region where serious pathology — including vascular compromise and spinal cord involvement — must be carefully screened for. This guide provides a systematic approach to cervical spine assessment, from the initial subjective history through to objective examination and differential diagnosis.
Subjective Assessment: Key Questions for the Cervical Spine
The subjective assessment should establish the nature, distribution, and behaviour of symptoms, and screen for red flags and serious pathology.
Area and distribution of symptoms — Localised neck pain suggests facet joint, disc, or muscular pathology. Pain radiating into the upper limb in a dermatomal pattern suggests cervical radiculopathy. Bilateral upper limb symptoms, lower limb symptoms, or gait disturbance raises concern for cervical myelopathy.
Onset and mechanism — Acute onset following trauma (road traffic accident, fall) raises the possibility of fracture, ligamentous injury, or whiplash-associated disorder. Insidious onset is more consistent with degenerative pathology or postural dysfunction.
Dizziness and headaches — Dizziness associated with neck movement may indicate cervicogenic dizziness or, more rarely, vertebrobasilar insufficiency. Headache originating from the suboccipital region and radiating to the frontal area is characteristic of cervicogenic headache.
Red flag screening — Always ask about: bilateral upper limb symptoms, lower limb symptoms or weakness, bladder or bowel dysfunction, difficulty walking, dysphagia, diplopia, drop attacks, and history of cancer, inflammatory arthritis, or osteoporosis.
Neurological Examination: Dermatomes, Myotomes, and Reflexes
Neurological examination is essential when upper limb symptoms are present. It allows you to identify the level of nerve root involvement and screen for spinal cord compression.
| Level | Dermatomal Area | Key Muscle | Reflex |
|---|---|---|---|
| C5 | Lateral upper arm | Shoulder abduction (deltoid) | Biceps |
| C6 | Lateral forearm, thumb, index finger | Wrist extension, elbow flexion | Brachioradialis |
| C7 | Middle finger, dorsum of hand | Elbow extension (triceps), wrist flexion | Triceps |
| C8 | Medial forearm, ring and little finger | Finger flexion | None reliable |
| T1 | Medial upper arm | Finger abduction (interossei) | None reliable |
Document any sensory changes, weakness, or reflex changes and compare bilaterally. Hyperreflexia, clonus, or a positive Babinski sign suggests upper motor neurone involvement (myelopathy) rather than nerve root compression.
Special Tests for the Cervical Spine
Spurling's Test (Foraminal Compression Test) The examiner laterally flexes and rotates the head toward the symptomatic side, then applies gentle downward compression. Reproduction of radicular symptoms is a positive finding. - Sensitivity: 30–50% | Specificity: 74–93% - Low sensitivity means a negative test does not exclude radiculopathy, but a positive test is clinically meaningful.
Cervical Distraction Test The examiner applies gentle upward traction to the head. Relief of radicular symptoms is a positive finding, suggesting nerve root compression. - Sensitivity: 40–44% | Specificity: 90–100%
Upper Limb Tension Test (ULTT) The ULTT assesses neural mechanosensitivity in the upper limb. ULTT1 (median nerve bias) is the most commonly used. Reproduction of symptoms with sensitising manoeuvres (contralateral cervical lateral flexion, wrist extension) is a positive finding. - Sensitivity: 72–97% | Specificity: 33–69%
Sharp-Purser Test Used to screen for atlantoaxial instability (particularly in rheumatoid arthritis). The examiner stabilises the C2 spinous process and applies a posterior force to the forehead. A positive test (reduction of symptoms or a clunk) indicates instability — stop the examination and refer urgently.
Vertebrobasilar Insufficiency (VBI) Screening Prior to cervical manipulation, screen for VBI using the sustained end-range rotation test. Sustained rotation for 10 seconds in each direction — if this reproduces dizziness, nausea, nystagmus, diplopia, or dysarthria, cervical manipulation is contraindicated.
Differential Diagnosis: Common Cervical Conditions
| Condition | Key Features |
|---|---|
| Cervical radiculopathy | Dermatomal arm pain, positive Spurling's/ULTT, neurological deficit |
| Cervical spondylosis | Insidious onset, older patient, reduced range of movement, no neurological deficit |
| Cervical myelopathy | Bilateral symptoms, lower limb involvement, hyperreflexia, gait disturbance |
| Whiplash-associated disorder | Post-traumatic, acute onset, variable symptom distribution |
| Cervicogenic headache | Suboccipital pain radiating frontally, reproduced by cervical movement |
| Thoracic outlet syndrome | Arm symptoms with vascular or neurogenic features, provoked by overhead activity |
| Facet joint dysfunction | Unilateral neck pain, restricted rotation and lateral flexion, no neurological deficit |
Always consider the shoulder as a source of referred pain to the neck and upper limb — a cervical screen should be part of every shoulder assessment, and vice versa.
Red Flags and When to Refer
The following presentations require urgent investigation or referral:
- Cervical myelopathy — Bilateral upper limb symptoms, lower limb weakness or spasticity, gait disturbance, bladder dysfunction. Refer urgently to spinal surgery.
- Fracture — History of significant trauma, osteoporosis, or cancer. Immobilise and refer to emergency services.
- Atlantoaxial instability — Rheumatoid arthritis, Down syndrome, positive Sharp-Purser test. Refer to spinal surgery.
- Vertebrobasilar insufficiency — Dizziness, diplopia, dysarthria, dysphagia, drop attacks with cervical movement. Refer to neurology or vascular surgery.
- Malignancy — History of cancer, unexplained weight loss, constant progressive pain, night pain. Urgent imaging and oncology referral.
- Infection — Fever, recent infection, immunosuppression, constant severe pain. Urgent investigation.