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The cervical spine provides the greatest range of motion (ROM) among the segments of the spinal column. However, the spinal cord is the most vulnerable in this location of the spinal column. Because of the important role of the cervical vertebrae in protecting the spinal cord and spinal nerve roots, injury to this area can have catastrophic results. Noncatastrophic injury to the neck region can also impact daily life. Similar to low back pain, the origin of cervical spine pain is frequently nonspecific in that the involved structure cannot be identified. Because approximately one-third of the population will experience cervical pain during their lives, a systematic examination that leads to specific treatment options is required for proper patient care.1 Serving as the posterior attachment site for the ribs, the thoracic spine provides exceptional protection of the spinal cord, but at the expense of ROM.

This chapter describes the clinical evaluation of cervical and thoracic spine and thorax pathology. Chapter 20 describes the on-field evaluation and management of patients with potentially catastrophic cervical spine trauma. The procedures described in this chapter assume that the possibility of spinal fracture and dislocation have been ruled out.

Clinical Anatomy

Cervical Spine

Carrying only the weight of the head, the vertebral bodies of the cervical vertebrae are much smaller than the other sections of the spinal column. The cervical transverse processes include a transverse foramen through which the vertebral artery and vein pass, a structure not found in the thoracic or lumbar vertebrae (Fig. 14-1). Each vertebra articulates with its adjacent vertebrae via an interbody articulation and superior and inferior facet (zygapophyseal) articulations that project from the pars interarticularis. The uncinate processes on the posteromedial margin of the body's endplates give the superior surface a concavity and increase the joint surface of the vertebral body. The uncinate processes on the inferior vertebrae articulate with the uncus process on the superior vertebrae to form the uncovertebral joints from C3 to C7.


C4 and C5 cervical vertebrae. 1, uncinate process; 2, intervertebral foramen (spinal nerve foramen); 3, superior intervertebral notch; 4, transverse foramen; 5, posterior tubercle of transverse process; 6, anterior tubercle of transverse process; 7, C4–C5 disc; 8, spinous process.

The first two vertebrae of the cervical spine are unique. The first cervical vertebra, the atlas, has no vertebral body and supports the weight of the skull through two concave facet surfaces articulating with the occiput, forming the atlanto-occipital joint. The primary movement at the junction between the atlas and the skull (the C0–C1 articulation) is flexion and extension, such as when nodding the head "yes." A slight amount of lateral flexion also occurs at the C0–C1 articulation. At the C1 vertebrae, the transverse processes are exceptionally long, and no ...

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