REIDER PART 249

Chapter 8_Cervical and Thoracic Spine 309

Figurę 8-20. Palpation of the cervical spine. A, Supine position. B, Seated position.

Cervical Spine

Spinous Processes. Palpation of the cervical spine usu-ally begins at the inion, located at the base of the skuli (see Fig. 8-2). The examiners palpating fingertips pro-ceed distally in the midline, attempting to identify each spinous process. The first identifiable spinous process should be that of C2. Palpation proceeds distally toward the morę prominent C7 and Tl spinous processes. The examiner should ask the patient whether gentle pressure on each of the spinous processes is painful. Such tenderness may signify an injury localized to that particular yertebra. In the emergency situation, documentation of localized tenderness is sufficient reason to consider the cervical spine potentially unstable and to immobilize and transport the patient accordingly.

In addition to palpating each of the spinous processes for tenderness, the examiner should also use palpation to evaluate their alignment. Normally, the spin-ous processes should be arranged in a perfectly linear fashion and regularly spaced. An acute lateral shift between two spinous processes may be due to a unilateral facet joint dislocation or fracture. An inerease in the space between two otherwise normally aligned spinous processes raises the possibility of a posterior ligamentous disruption or fracture.

The nuchal ligament connects the ccrvical spinous processes, beginning at the base of the skuli and extend-ing to C7. Its prominence inereases as the neck flexes. Conversely, the proximal spinous processes are easier to palpate when the cervical spine is cxtcnded.

Posterior Facet Joints. After palpating in the midline, the cxaminers fingers should move laterally about 2 cm to the region of the posterior facet joints. Owing to the overlying musculature, firmer palpation is needed to appreciate the resistance of the underlying bony struc-tures. The examiner palpates from proximal to distal in a systematic manner. Although the specific outlines of the individual joints cannot usually be appreciated, the iden-tification of localized tenderness over one of these joints may allow the examiner to identify the site of arthritic degeneration or ligamentous injury.

Posterior Cervical Musculature. While palpating lateral to the midline, the examiner also is able to evaluate the posterior cervical musculature, consisting of the upper portion of the trapezius and the underlying intrinsic neck musclcs. Occasionally, a localized mass owing to a hematoma or other lesion may be palpable. Muscle spasm may indicate injury to the muscle itself, or it may be an iiwoluntary reaction to pain in an adja-cent structure. Cervical spine pain may be referred to portions of the trapezius, either superior to the spine of the scapula or between the thoracic spinous processes and the medial border of the scapula. Palpation of these areas may reveal localized tender nodules, or trigger points.

The splenius capitis and other members of the trans-versocostal group are partly covercd by the upper trapezius, but they may be palpatcd morę distinctly in the proximal neck where they are exposed lateral to the trapezius. The deeper transversospinal group is not distinctly palpable but may contribute to the apparent tenderness of the overlying musculature.

Deep to the trapezius at the base of the skuli lie the suboccipital muscles, the rectus capitis (posterior) major_ythe rectus capitis minor, and the obliąuus capitis superior and inferior. The greater occipital nerve, also known as the suboccipital nerve, traverses the triangle formed by these muscles. Tenderness in this area may be due to occipital neuritis, muscle strain, or, in cases of rheuma-toid arthritis, potcntial C1-C2 instability.

Thoracic Spine. The thoracic spine is stabilized by the associated ribs. Because of this, major injuries here require substantially morę cnergy than in the cervical