REIDER PART 245

Chapthr 8 Cervical and Thoracic Spine 305

the various movements are painful. Any difficulties dur-ing the arc of motion, such as hesitation or midrange pain, shouid be noted. Midrange pain is typically due to instability of the structure being moved. Whcn midrange pain is present, the total rangę of motion may be normal, but the movement is not conducted smoothly or with a constant velocity. This pain most commonly occurs in cases of subacute or chronię instability, such as would be produced by degenerative disk disease. For example, if the disk is painful when the neck is in a neutral position, the patient would be obscrved to hesitate in the neutral position when moving from fuli flexion to fuli extension. Flexion and Extension. To assess flexion, the examiner asks the patient to attempt to touch the chin to the chest. A patient with a normal cervical spine shouid be able to make firm contact between the chin and the chest or come very close to it (Fig. 8-11). Measuring the distance between the chin and the chest at the point of maximal flexion is the most useful way to quantify this movemcnt for futurę comparison.

To assess extension, the patient is asked to tilt the head back and to look up toward the ceiling (Fig. 8-12). Maximum extension is a combination of cervical, tho-racic, and occipitocervical motion. If normal extension is present, the patient shouid be able to tilt the head back until the face is parallel with the ceiling. Approximately 50% of flcxion-cxtension motion occurs between the occiput and Cl. The amount of extension may be reduced in the presence of degenerative arthritis or a

Figurę 8-11. Active cervical flexion.

Figurę 8-12. Active cervical exten$ion.

fixed deformity such as scoliosis or kyphosis. In addition, acute cervical nerve root compression may also limit extension owing to pain.

Laterał Rotation. Lateral rotation to both the right and the left shouid be assessed. To measure lateral rotation, ask the patient to rotate the chin laterally toward each shoulder, in turn (Fig. 8-13). The spinous processes are seen to rotate away from the side to which the chin points. Normal lateral rotation is typically about 60° in each direction, but it may reach close to 90° in sonie indi-viduals. This is best assessed by standing in front of or directly behind the patient and observing the arc of rotation as the head moves. Approximatcly 50% of normal rotation occurs between Cl and C2, the atlas and the axis. Lateral Bending. Lateral bending to both the right and the left sides is assessed by asking the patient to attempt to touch each ear to the ipsilatcral shoulder (Fig. 8-14). When combined with a normal shoulder shrug, maximal lateral bending shouid permit the shoulder to nearly touch the ear. The amount of motion may be ąuantitated by measuring the distance between the shoulder and the ear at maximal effort or by estimating the angle that the midline of the face makes with the vertical.

Thoracic Spine

Flexion and Extension. In dramatic contrast with the cer-vical spine, the thoracic spine permits lit tle motion. What is present consists of a smali amount of flexion and extension. To assess flexion and extension of the thoracic spine, the patient is seated against a straight-backed chair in order to eliminate lumbopelvic motion. The patient is asked first to flex and then to extend the thoracic spine (Figs. 8-15 and 8-16). The smali amount of motion present may be detected by observing the change in relationship between the thoracic spine and the yertical chair back. In the presence of ankylosing spondylitis, the rangę of flexion and extension of the spine is limited.