REIDER PART 253

Charter 8_Cervical and Thoracic Spine 313

to push against the examiner s palm as forcefully as possi-ble (Fig. 8-27). In a normal case, the examiner is unable to overpower the patient s inherent lateral bending strength.

Neurologie Examination

A thorough neurologie examination is a basie part of cer-vical and thoracic spine evaluation. A neurologie exami-nation should include a search for motor or sensory deficits, absent or abnormal reflexes, and root tension signs. Neurologie function is best evaluated in a system-atic examination organized by dermatomes. The sensory, motor, and reflex tests for each dermatome are summa-rized in Table 8-1. Because the most common neurologie deficit associated with cervical spine disorders is a radicu-lopathy, sueh a systematic examination allows the clini-cian to identify the specific nerve root involved. In the case of morę extensive deficits associated with spinał cord injuries, this same examination allows the clinician to determine the neurologie level of deficit.

TABLE 8-1	PHYSICAL FINDINGS IN CERYICAL AND THORACIC RADICULOPATHIES
Dermatome	Sensory Testing	Motor Testing	Reflex Testing
C4	Lateral neck
C5	Area over the middle deltoid	Deltoid Biceps brachii (secondary)	Biceps reflex
C6	Dorsum of the first web	Biceps Brachii	Brachioradialis retlex
	space and thumb	Wrist extensors	Biceps reflex (secondary)
C7	Long finger	Wrist flexors	Triceps reflex
		Long finger extensors Triceps brachii
CS	Little finger and ulnar side of hand	Long digital flexors (grip)
Tl	Medial arm at the clbow	Finger abduction and adduction
		(interossei)
T2	Media! upper arm and adjacent chest
T4	Nipple linę
T10	Umbilicus	Trunk flexion (Beevor’s sign)	Abdominal muscle reflex

P* 1 8-1 • When the Patient Complains of Neck Pain after Trauma

Major Diagnostic Possibilities Include:

• Fracture

• Ligamentous injury

• Cervical strain/sprain

• Disk injury

May be necessary to rule out underlying pathologic lesion of the vertebra such as tumor, infection, or osteoporosis

Ask the Patient to Describe the Original Injury Episode:

• Major trauma such as a motor vehicle accident or a fali from a height with immediate pain

- Exclude fracture or ligamentous injury

• Minor trauma such as a lifting or twisting injury, fali from Iow height

-Consider cervical strain/sprain, fracture in osteoporotic patients, or herniated interverte-bral disk

Ask the Patient to Describe Current Symptoms:

• Constant neck pain, madę worse with any activity

- Exclude fracture or major ligamentous injury.

• Neck pain, madę worse with bending or twisting

-Suggestive of a cervical strain/sprain

- Herniated disk, fracture, or ligamentous injury remain possibilities

• Neck pain associated with radiating arm pain, paresthesias or weakness

- Indicates possible neural compression arising from:

- Herniated disk

- Fracture or ligamentous injury with neural encroachment or injury

• Neck pain associated with arm pain and weakness, and gait disturbance

- Suggestive of spinał cord compression

Relevant Physical Examination:

General:

If suspicious of spinał fracture, ligamentous injury, or

dislocation, immobilize patient and assess for hemody-

namic stability and other associated injuries:

• Inspection for swelling and ecchymosis at the level of injury

• Palpation for midline point tenderness at the level of injury

• Palpation for step-off at site of injury

• Neurologie testing for associated upper or lower motor neuron deficits

Cervical strain:

• Palpation for paraspinal muscle tenderness or spasm

• Rangę of motion typically painful

• Neurologie examination typically normal

Herniated disk:

• Flexion of cervical spine may reproduce symptoms of upper extremity pain

• Nerve root tension signs (Spurling's, Lhermitte's, upper limb tension tests)

• Neurologie testing for deficit in the distribution of the involved cervical nerve root