CERVICAL ORTHOPEDICS

Test/Sign Procedure (+) IND

Bakody Sign Pt. Places the palm Decreased stretching Cervical nerve root
of her affected of the compressed compression
arm/hand on top of nerve root
the head, raising the
elbow to the height
level with the head
Bikele Sign This movement Brachial Plexus
meets with resistance Neuritis, Meningitis
and increases
radicular pain

Brachial Plexus 1.Examiner passively Reproduction of C5 nerve root

Tension Test elevates the pts symptoms syndrome/
through abduction compression
2.Elbows are
extended to a point
just short of the onset
of pain and
maintained in that
position
3.then examiner
supports the patient
in this position

Dejerine Test Sneezing, coughing, Pain (radicular) Herniated or

bearing Protruding IVD,
down/straining Spinal cord tumor,
compression fracture
Distraction Test With the patient Increased Cervical Nerve Root
seated, the Pain=muscle spasm Compression, IVF
examiner exerts
upward encroachment, Facet
 pressure on the Relief of pain=IVF Capsulitis
patient's head. encroachment or
• This pressure
removes the facet capsulitis
weight of the
patient's head
from the neck.
Examiner continues
the distraction for up
to 30-60s

Foraminal With the pt in the Radicular Cervical nerve root

Compression Test seated position, the pain=pressure on encroachment
examiner rotates the nerve root
patient’s neck while Localized
exerting strong pain=foraminal
downward pressure encroachment
on the head
*pressure is first
applied with the head
in a neutral position,
and then with the
head rotatated to the
side of complaint
Jackson 1.Head is slightly Pain that radiates Cervical Nerve Root
Compression Test rotated to the down the arm Compression from
involved side Space-Occupying
2. examiner places lesion, edema,
downward pressure exostosis of
on head degenerative joint
disease, IVD, Tumor,
Lhermitte Sign Pt seated Sharp radiating pain Myelopathy of the
**like Brudzinski & 1.head passively down the UE or LE Cervical Spine
Kernig for flexed (space occupying
Meningeal lesion of the cord)
Inflammation
Maximum Cervical Pt seated is Concave=nerve root Concave Testing:
Compression Test instructed to or facet involvement Cervical Nerve Root
approximate chin to Syndrome or Facet
the shoulder and Vs. Syndrome
extend the neck Convex Testing:
*perform bilaterally Convex=Muscular Cervical Muscle
strain Strain
O’Donoghue Test Isometric (AROM):
Cervical Muscular
Strain
PROM: Cervical
Ligamentous Sprain
Rust Sign Severe Cervical
Spine Sprain, Upper
Cervical RA, Upper
C-spine fracture
Shoulder Depression Reproduction of Cervical Dural
Test Radicular Pain or Sleeve/Nerve Root
Aggravation Adhesion (nerve
root) & Shoulder
Adhesive Capsulitis

Soto-Hall Sign Localized pain Cervical Spine

subluxation,
exostoses, IVD
lesion, muscular
strain, ligamentous
sprain, vertebral
fracture, meningeal
irritation (febrile)
Spurling Test Pain or paresthesia Cervical Nerve Root
and distribution Compression
Syndrome
Swallowing Test Seated Presence of pain Space Occupying
Exactly how it (dysphagia) or Lesion, Ligamentou
sounds difficulty swallowing
Valsalva Maneuver Space-Occupying
lesion, IVD,
Osteophytes

TEST POSITIVE FINDING/INDICATION PROCEDU VISUAL

RE
SPURLING •Spurling's
’S A  A : Patient
AND is seated,
SPURLING the neck is
’S B sidebent
toward the
ipsilateral
side, and 7
kg of
overpressur
e is applied.
Positive if
symptoms
are
reproduced
•Spurling's
B: Patient
seated.
Extension
and
sidebending
/rotation to
the
ipsilateral
side and
then 7 kg of
overpressur
e is applied.
Positive if
symptoms
are
reproduced
DISTRACT • With the
ION TEST • Cervical spondylotic radiculopathy is a
patient
common degenerative problem associated
seated, the
with neck and arm pain.
ASSESSME • The pathogenesis of spondylotic examiner
NT FOR  exerts
radiculopathy often relates to foraminal
Cervical upward
narrowing resulting from uncovertebral and
Nerve Root facet joint hypertrophy, as well as disc height pressure on
Compressio collapse  the patient's
n, head.
Intervertebr • The distraction test not only indicates the • This
al Foraminal nature of the patient's complaint but also pressure
Encroachme identifies the merit of cervical traction in the removes
nt, and treatment regimen. the weight
Facet of the
• Notably, the higher the poundage of static
Capsulitis patient's
cervical traction required for relief is, the
head from
more unstable the nerve compression
the neck.
syndrome will be.
•
• Indeed, the higher poundage requirement is Generalized
often an indicator of the need for surgical , increased
resolution. pain
indicates
muscle
spasm.
• Relief of
pain
indicates
intervertebr
al
foraminal
encroachme
nt or facet
capsulitis.
• The
examiner
continues
the
distraction
for up to 30
to 60
seconds to
relax the
involved
tissues
completely.
• This test
provides
some
prediction
of the effect
of cervical
spine
traction in
relieving
pain or
paresthesia.
• Nerve
root
compressio
n may be
relieved,
with
disappearan
ce of the
symptoms
and signs,
if the
intervertebr
al foramina
are opened
or the disc
spaces
extended.
• Pressure
on the joint
capsules of
the
apophyseal
joints is
also
decreased
by
distraction. 
ARM • Examiner
• Diagnostic Utility of the Arm Squeeze Test
SQUEEZE squeezes
in Distinguishing Cervical Nerve Root
TEST the middle
Compression from Shoulder Pain
third of the
•Reference Standard: 305 patients with
patient’s
cervical nerve root compression, 903 patients
upper arm
with rotator cuff tear, and 350 healthy
with thumb
volunteers. Diagnosis of cervical nerve root
on patient’s
compression (C5-T1) based on clinical
triceps and
examination, electromyography, x-rays, and
fingers on
MRI. Sens/Spec +LR/−LR
patient’s
•.96 (.85, .99) .96 (.86, .98) 24 .04 biceps with
•The rationale is that compression provokes a moderate
response from the relatively superficial compressio
peripheral nerves (musculocutaneous, radial, n (5.9 to
ulnar and median) that arise from 8.1 kg).
hypersensitized lower cervical nerve roots Positive if
(C5-T1). patient
reports 3
•Gumina S, Carbone S, Albino P et al. Arm points or
squeeze test: a new clinical test to distinguish higher on
neck from shoulder pain. European Spine VAS with
Journal 2013; 22: 1558-63. pressure on
middle
third of
upper arm
compared
with
acromiocla
vicular
joint and
subacromia
l area
SHARP- •Patient sits with neck in a semiflexed •Patient sits
PURSER position. Examiner places palm of one hand with neck
TEST on patient's forehead and index finger of the in a semi
other hand on the spinous process of axis. flexed 15
When posterior pressure is applied through DEGREES
the forehead, a sliding motion of the head • Examiner
posteriorly in relation to axis indicates a places palm
positive test for atlantoaxial instability of one hand
on patient's
forehead
and index
finger of
the other
hand on the
spinous
process of
axis. When
posterior
pressure is
applied
through the
forehead, a
sliding
motion of
the head
posteriorly
in relation
to axis
indicates a
positive test
for
atlantoaxial
instability

UPPER A positive response is defined as: With

LIMB
1. Patient symptoms reproduced patient
TENSION supine,
TEST A 2. Side-to-side differences in elbow examiner
extension > 10° performs
3. Contralateral cervical sidebending the
increases symptoms or ipsilateral following
sidebending decreases symptoms  movements
:
1.Scapular
 depression
2.Shoulder
abduction
3.Forearm
supination
4.Wrist and
finger
extension
5.Shoulder
lateral
rotation
6.Elbow
extension
7.Contralat
eral and
ipsilateral
cervical
sidebending

UPPER Positive response defined by any of the With

LIMB following: patient
TENSION
1.Patient symptoms reproduced supine and
TEST B
patient's
2.Side-to-side differences in wrist flexion > shoulder
10° abducted
3.Contralateral cervical sidebending 30°,
increases symptoms or ipsilateral examiner
sidebending decreases symptoms performs
the
following
movements
:
1.Scapular
depression
2.Shoulder
medial
rotation
3.Full
elbow
extension
 4.Wrist and
finger
flexion
5.Contralat
eral and
ipsilateral
cervical
sidebending

UPPER
•Starting
LIMB
with patient
TENSION
in supine
TEST C
position:
•Same
position as
ULTTA
•Wrist
extended
and
forearm
supinated
•Elbow
fully flexed

BAKODY • While in
SIGN • Differentiates Thoracic outlet syndrome the seated
SHOULDE from cervical nerve root compression. position,
R the patient
• Annular fissures, or rents, develop in a actively
ABDUCTI degenerating disc and may coalesce,
ON RELIEF places the
ultimately allowing nuclear material to palm of the
SIGN/TEST extrude into the neural canals
CERVICAL affected
• When the extruded nucleus pulposus forms extremity
FORAMIN a broad-based extension of the disc beyond
AL on top of
the peripheral confines of the vertebral end- the head,
COMPRES plate, it is bulging.
SION TEST raising the
• When focal asymmetric nuclear material elbow to a
Assessment extends beyond the end-plate but is still height
for Cervical contained by the posterior longitudinal approximat
Nerve Root ligament, the nucleus is protruding. ely level
Compressio • With further expulsion of nuclear material, with the
 head.
n: disc extrusion occurs. With disc extrusion, •By
free or sequestered disc fragments may elevating
migrate away from the parent disc level the
• Patients with moderate to severe radicular suprascapul
symptoms usually do not have to be directed ar nerve,
into the Bakody sign position because it also traction of
is an antalgic pain–relieving posture. The the lower
more difficult it is for the patient to lower the trunk of the
arm, the more difficult the condition will be brachial
to treat conservatively. plexus is
• If the patient cannot lower the arm without relieved.
severe exacerbation of pain, surgery is • Overall,
probably indicated.  this
maneuver
decreases
stretching
of the
compressed
nerve root.
• The sign
is present
when the
radiating
pain is
lessened or
disappears
with this
maneuver.
• The test is
as reliable
as Spurling
test and is
less painful
for the
patient to
endure.
• A cervical
nerve root
compressio
n is
suggested
by a
positive
Bakody
sign. 
BARRE- • Rotation of the neck to one side usually
• The
LIEOU decreases circulatory flow in the atlantoaxial
examiner
SIGN portion of the contralateral VA.
instructs
• When kinking of the artery, atheromata, or
the patient
ASSESSME encroaching osteoarthritis occurs, such
to rotate the
NT FOR movement reduces the circulation even more.
head slowly
VERTEBR • Other mechanisms that can alter the blood
from side to
AL supply to the brainstem are carotid sinus
side while
ARTERY compression, use of a cervical collar,
in a seated
SYNDROM fighting (boxing, wrestling, contact sports,
position
E  etc.), manipulation of the neck that causes
the release of emboli from atheromatous • Rotating
plaques in the great vessels, and thrombosis the head
with infarction of the cerebellum or causes
brainstem. compressio
• The patient with a positive Barré-Liéou n of the
sign is a poor risk for aggressive cervical VAs
spine manipulation. • Vertigo,
• Such manipulation should not be dizziness,
undertaken until all vascular causes have visual
been investigated. disturbance
• Aggravation of the sympathetic ganglia of s, nausea,
the cervical spine can produce many, if not syncope,
all, of these symptoms (vertigo, dizziness, and
visual disturbances, nausea, syncope, and nystagmus
nystagmus), in which case cervical spinal are signs of
manipulation is not contraindicated. a positive
• The examiner must be able to distinguish test
between vascular and neural origins before • A positive
manipulation is performed. finding
strongly
suggests a
buckling of
the
ipsilateral
VA,
constituting
vertebrobas
ilar
insufficienc
y. 
BIKELE •The most common and least understood • With the
SIGN cervical neural injury is neurapraxia of the arm held
nerve roots and brachial plexus. upward and
ASSESSME •Brachial plexus lesions result in motor and backward
NT FOR sensory syndromes of muscles of the upper and the
Brachial extremities. elbow fully
Plexus •The brachial plexus is made up of the flexed, the
Neuritis and anterior primary rami of the four lower patient
Meningitis cervical nerves, C5 through C8, and the extends the
greater part of T1. elbow.
•The C5 and C6 rami form the upper trunk,
• If this
the C7 ramus forms the middle trunk, and the
movement
C8 and T1 rami form the lower trunk.
meets with
•The brachial plexus lies in the
resistance
supraclavicular fossa distal to the anterior
and
scalene muscle. Each trunk splits into an
increases
anterior and posterior division, with
radicular
derivation of three cords from them.
pain from
•Injury to the C8 and T1 roots, the lower
the
trunk, or the medial cord of the brachial
cervicodors
plexus may be caused by tumors, disease of
al region,
the pulmonary apex, or a fractured clavicle
the test is
or cervical rib.
positive.
•Aneurysm of the arch of the aorta, fracture
or dislocation of the humeral head, or • This
unusually abrupt and severe upward traction finding
of the arm may also injure the nerves. suggests
brachial
plexus
neuritis or
meningitis
because
this
maneuver
stretches
the brachial
plexus
nerve roots
or their
coverings. 
BRACHIA • The
L PLEXUS • A direct traumatic insult to the nerve roots
examiner
TENSION causes inflammation in the dural sleeves and
passively
TEST perineural tissues, which may result in
elevates the
fibrosis.
ASSESSME • Adhesions may occur between the dural patient's
NT FOR  shoulders
sleeves and the adjacent capsular tissues.
cervical through
• Normally, the nerve roots are free in the
nerve root abduction.
intervertebral canals and can move ¼ to ½ of
syndrome or an inch. • The
compression • Nerve roots that are injured or compressed elbows are
(C5) by capsular thickening or bony extended to
encroachments cannot move within the a point just
intervertebral canals. short of the
• Nerve roots subjected to compressive onset of
forces by osteophytic encroachments have pain and
varying amounts of distortion and perineural are
fibrosis. maintained
• Although the brachial plexus tension test in that
involves shoulder joint movement, it also position.
provides maximal stretch on the brachial • The
plexus, which affects the lower branches of shoulders
the cervical spine (C5) the most. are
• If this test is positive, the early stages of a externally
C5 nerve root disorder may be present along rotated to
with the subtle signs of a positive doorbell the point
sign (pain that occurs at the superior just short of
scapulovertebral border and radiates with the onset of
deep palpation to the C5 segment) and pain pain and
in the deltoid area. maintained.
• The deltoid pain is often misconstrued as an
articular problem of the shoulder. • The
examiner
supports
the
shoulders
and
forearms in
this
position as
the patient
flexes the
elbows.
•
Reproducti
on of
 symptoms
suggests
cervical
spine
disorders,
most likely
the C5
nerve root.
• In
addition,
from this
challenge
position,
symptoms
increase
when the
cervical
spine is
flexed. 

DEJERINE • Coughing,
SIGN • The symptoms of a cervical disc injury vary
sneezing,
according to the status and site of the injury.
and
• Acute disc protrusions typically have
ASSESSME radicular symptoms down one arm; the pain straining
NT FOR  during
can be bilateral if the spinal canal is
Herniated or compromised and the protrusion is central or defecation
Protruding may
large.
Intervertebr • Motor, reflex, or sensory changes are a aggravate
al Disc and distinct possibility, and the examiner should radiculitis
Spinal Cord examine the patient regularly for such symptoms.
Tumor or • This
changes during the first 2 weeks of care.
Spinal aggravation
• The presence of Dejerine sign (pain on
Compressio coughing, sneezing, or straining) suggests a results from
n Fracture the
space-occupying lesion.
• Compression tests with the patient in mechanical
various positions are informative. obstruction
• The position of the disc bulge or the site of of spinal
the canal-nerve root compromise of the fluid flow.
cervical spine causes pain in patients with • Dejerine
disc and nerve root lesions; distraction sign is
maneuvers are usually palliative. present
• Patients with radicular symptoms and when one
pronounced Dejerine sign, especially if it is of the
 following
in the lumbar spine, should be told to bend
exists:
the knees and lean into a wall during a cough
herniated or
or sneeze.
protruding
• This maneuver reduces intradiscal pressure
intervertebr
and minimizes the effect of the cough or
al disc,
sneeze on the nerve root.
spinal cord
• A more worrisome situation is the sudden,
tumor, or
unexpected absence of Dejerine sign when
spinal
all other clinical findings indicate an active
compressio
nerve root compression.
n fracture.
• The loss of the sign indicates fragmentation
of the disc with momentary decompression • The
of the nerve. course of
the
radiculitis
helps
identify the
location of
the lesion. 

DEKLEYN
• The VA is often the first and largest branch • With the
TEST
of the subclavian artery. patient in
• It passes upward to enter the foramen in the the supine
ASSESSME sixth cervical transverse process. position
NT FOR • It continues to course upward, encased by and the
Vertebral the bony rings formed by the transverse patient's
Artery foramina. head off the
Syndrome • After emerging from the transverse table, the
foramen of the atlas, the VA proceeds to examiner
wind posteriorly and medially around the instructs
lateral mass of the atlas. the patient
• The VA then passes through the foramen to
magnum and at the lower border of the pons hyperexten
unites with the VA of the opposite side to d and rotate
form the basilar artery. the head
• The posterior inferior cerebellar arteries and hold
leave the VAs just before they join each this
other  position for
15 to 45
seconds.
• The
patient
repeats this
 maneuver
with the
head
rotated and
extended to
the
opposite
side.
• Vertigo,
blurred
vision,
nausea,
syncope,
and
nystagmus
are signs of
a positive
test. 

FORAMIN • With the

AL • Radiculopathy can result from disc or patient in
COMPRESSI osteophyte encroachment on one or several the seated
ON TEST cervical nerve roots, especially C6 (C5–C6 position,
disc) and C7 (C6–C7 disc). the
ASSESSME • Such encroachment may result in pain or examiner
NT FOR  paresthesias affecting the upper limb rotates the
cervical dermatomes at the involved levels, with patient's
nerve root weakness and hyporeflexia. neck while
encroachme • This test, as well as other compression exerting
nt maneuvers, often produces a cervical strong
collapse sign in addition to radicular downward
complaints. pressure on
• In the presence of capsular sprain with the head.
radicular components, compression
overcomes the modicum of muscular • Pressure
strength that remains in the neck and is is first
required for postural control. applied
• This condition means that the neck will with the
collapse or buckle during the test. This head in a
collapse is found in grade II or greater sprain neutral
syndromes. position,
and then
with the
head
 rotated to
the side of
complaint. 
• When the
neck is
rotated and
downward
pressure is
applied,
closure of
the
intervertebr
al foramen
occurs.
• Localized
pain
indicates
foraminal
encroachme
nt.
• Radicular
pain
indicates
pressure on
the nerve
root.
• If nerve
root
involvemen
t is
suspected,
the
neurologic
level must
be
evaluated 

HALLPIKE •The
MANEUVE •Rotation of the cervical spine to the extent Hallpike
R of 45 to 50 degrees occurs chiefly at the
maneuver
atlantoaxial joint.
is an
ASSESSME •This rotation is approximately one half of enhanced
NT FOR  the total cervical spine rotation. The VA is
DeKleyn
Vertebrobas held fast at the C1 and C2 transverse test and
ilar Artery foramina by fibrous tissue.
must be
Insufficienc performed
y. •During head rotation, the VA is stretched,
with
compressed, and torqued. Decreased flow or
extreme
even cessation of flow through one VA (the
caution.
vertebrobasilar artery [VBA]) can occur
•The
when the head is turned.
patient lies
•The atlantoaxial joint is the probable site of
in the
vessel compression 
supine
•Cervical spine manipulation and adjunctive position,
therapeutic techniques are safe to use. with the
Nevertheless, the patient's welfare is always head
of prime concern, and screening tests will extending
help identify patients who may be off the end
predisposed to cerebrovascular problems. of the
•During these procedures, symptoms of examinatio
vertigo, nystagmus, dizziness, fainting, n table.
nausea, vomiting, visual blurring, headache •The
(onset), or other sensory disturbances may examiner
identify a possible vertebrobasilar provides
insufficiency. support for
•Problems in the cervical spine apart from the weight
the VAs may cause the same signs and of the
symptoms. patient's
•In suspected VA constriction, resisted neck skull.
extension may be painful, and prolonged •  The
cervical extension may produce a feeling of examiner
faintness. brings the
•The transverse processes of the atlas are patient's
often tender on the side of involvement. head into
•These symptoms may improve significantly positions of
by using manipulative procedures. reclination
•Therefore, manipulation should not (extension),
necessarily be abandoned; rather, the rotation,
manipulative technique should be modified and lateral
so that simultaneous extension and rotation flexion.
are not used. •  The
patient's
eyes are
open so that
the
examiner
may look
for
nystagmus
and other
neurovascul
ar signs.
•The test is
repeated for
the
opposite
side these
positions
are held for
15 to 45
seconds.
•In a final
maneuver,
the patient's
head is
allowed to
hang freely
in extreme
extension
(hyperexten
sion) off
the end of
the
examinatio
n table.
•Vertigo,
blurred
vision,
nausea,
syncope,
and
nystagmus
are signs of
a positive
test. 
HAUTANT
• VA syndrome often occurs as a result of • While
TEST
spondylotic changes in the cervical spine. seated, the
patient
ASSESSME • Osteophyte formation in combination with extends the
NT FOR  reduced cervical height and a forward head arms out in
vertebral position may cause encroachment on the front with
artery vertebral foramina. the palms
syndrome
• This encroachment, which may be further up.
irritated by cervical position, results in • With eyes
decreased blood flow through the VA to the closed, the
brain. patient
extends and
rotates the
head to one
side.
• The
patient
repeats this
maneuver
with the
head
extended
and rotated
to the
opposite
side.
• Drifting
of the arms,
vertigo,
blurred
vision,
nausea,
syncope,
and
nystagmus
are signs of
a positive
test.
• The test
indicates
vertebral,
basilar, or
carotid
 artery
stenosis or
compressio
n. 

JACKSON •Cervical
COMPRESSION • Degenerative
compression is
TEST processes
commonly
affecting the
performed by
cervical spine are
ASSESSMENT having the
a common
FOR Cervical patient sit up and
affliction.
Nerve Root bend the head
• The secondary
Compression obliquely
effects of
Resulting From a backward while
Space-Occupying
degeneration may
the examiner
Lesion, include
applies
Subluxation, degenerative disc
downward
Inflammatory disease, primarily
pressure on the
Edema, Exostosis leading to effects
vertex.
of Degenerative on the adjacent
end-plates and •However, with
Joint Disease,
central canal. the Jackson
Tumor, or
• Degeneration cervical
Intervertebral Disc
affecting the facet compression test,
Herniation
and unco- the head is only
vertebral slightly rotated to
articulations may the involved side.
lead to osteophyte •In either case,
formation, the sign is
synovial cysts, positive if
and soft-tissue localized pain
effects, including radiates down the
ligamentum arm.
flavum
hypertrophy. •A positive sign
• Stenosis (central, indicates nerve
lateral, or both) involvement
may be the result from a space-
of either hard occupying lesion,
degenerative subluxation,
changes such as inflammatory
osteophyte swelling,
formation or soft exostosis of
degenerative
 joint disease,
degenerative
changes affecting tumor, or disc
herniation. 
the soft-tissue
structures such as
the ligamentum
flavum or facet
joint capsule, both
of which can
hypertrophy.
• MRI may be also
used to
demonstrate
complications
such as spinal
cord edema and
additional spinal
cord lesions
• Closure of the
intervertebral
foramina occurs
on the side of
flexion in this
maneuver.
• This test should
be performed
without excessive
discomfort.
• The cervical
collapse sign may
be present.
LHERMITTE • The patient is
SIGN • Cervical seated on the
myelopathy examining table.
results from
ASSESSMENT • The patient's
spinal cord
FOR  Myelopathy head is passively
injury caused by
of the Cervical flexed.
a cervical spine
Spine. pathologic • A sharp pain
condition, such radiating down
as spondylitic the spine and into
spurs, central the upper or
disc herniation, lower limbs is a
tumors, and positive finding.
dislocation of the
cervical spine. • Dural irritation
in the spine is
• Although indicated.
Lhermitte sign is
often construed as • The test is
a pathognomonic similar to a
test for multiple combination of
sclerosis, it is not. other meningeal
irritation
• However, challenges. 
Lhermitte sign
does reveal or
suggest
myelopathy
resulting from
multiple sclerosis,
stenosis, tumor, or
disc herniation.
MAXIMAL • Often associated
• While in the
CERVICAL with cervical
COMPRESSION
seated position,
muscular strain,
TEST the patient is
myofascial trigger
instructed to
points refer dull,
approximate the
ASSESSMENT aching pain.
chin to the
FOR Cervical • This deep pain
shoulder and
Nerve Root ranges from
extend the neck.
Syndrome or Facet uncomfortable to
Syndrome incapacitating. • The test is
(Concave Testing) • Active trigger performed
and Cervical points are bilaterally.
Muscular Strain hyperirritable
• Pain on the
(Convex Testing) areas of skeletal
concave side
muscle tissue that
indicates nerve
cause pain.
root or facet
• Latent trigger
involvement.
points cause
weakness and • Pain on the
restriction of convex side
movement but are indicates
not painful. muscular strain. 
• Active trigger
points
demonstrate a
jump sign.
Stimulation of the
affected trigger
point will cause
the musculature to
react.
• The patient with
lower cervical
nerve root
compression
syndrome has
already
discovered that
looking up or
down with the
head rotated is
uncomfortable
and produces neck
and arm pain.
• If these positions
 are already
producing pain,
then attempts to
use manipulative
procedures
incorporating
these positions
will be difficult
for the patient to
tolerate.

NAFFZIGER • A herniated The Naffziger

TEST cervical disc compression test
causing nerve root is performed by
compression that having the
ASSESSMENT
is unresponsive to patient sit erect
FOR Space-
conservative while the
Occupying Mass in
treatment may examiner holds
the Cervical Spine
require surgery. digital pressure
or Canal
• Disc herniation over the jugular
commonly occurs veins for 30 to 40
at the high-motion seconds.
segments of C4–
C5, C5–C6, and • The patient is
C6–C7. then instructed to
• As the cough deeply.
intradiscal • Pain along the
contents leave the distribution of a
annulus, they may nerve may
migrate around indicate nerve
the adjacent nerve root compression
root, resulting in • Although this
radiculopathy. test is more
• If the herniated commonly used
disc displaces into for lower back
the epidural space, involvement,
cord compression cervical or
may result. thoracic root
• Free fragments compression may
of disc material also be
may occasionally aggravated.
be found in the • Local pain in
epidural space. the spine does
• Patients usually not positively
complain of indicate nerve
severe radicular compression but
pain involving the may indicate the
upper extremity site of a strain or
and shoulder sprain injury or
girdle area. other lesion.
• Disc herniation
of C4–C5 results • The sign is
in numbness always positive
around the in the presence of
shoulder and cord tumors,
weakness of the particularly
deltoid muscle. spinal
• Deep-tendon meningiomas.
reflexes are not • The resulting
altered. With C5– increased spinal
C6 disc fluid pressure
herniation, the above the tumor
patient loses the causes the
biceps reflex and growth to
biceps muscle compress or pull
strength. on certain
• Numbness along sensory nerve
the dorsal aspect structures, which
of the thumb and produces
index finger is radicular pain.
typical. • The test is
• Herniations of contraindicated
the C6–C7 disc for a geriatric
cause depression patient, and
of the triceps extreme care
reflex, weakness should be taken
of the triceps when performing
muscle, and this test on
numbness of the anyone suspected
long and ring of having
fingers. atherosclerosis.
• This test is not a
• In all cases, the
good one for a
patient should be
geriatric or
alerted that
atheromatous
jugular pressure
patient to endure.
may result in
• The resulting
light-headedness
increase in
or dizziness. 
cerebrospinal
fluid pressure is
uncomfortable,
 and the
momentary
circulatory
obstruction may
result in
significant
syncope.

O’DONOGHUE • While the

MANEUVER • Patients with patient is sitting,
whiplash the cervical spine
ASSESSMENT frequently remark is actively moved
FOR Cervical on their belief that through resisted
Muscular Strain significance exists range of motion
(Isometric) and to their head and then through
Cervical position at the passive range of
Ligamentous time of impact. motion.
Sprain (Passive
• Some believe • Pain during
Range of Motion)
that the fact that resisted range of
they “saw it motion, or
coming” because isometric
they were looking contraction,
to their right at the signifies muscle
time of a right strain.
lateral impact, for • Pain during
example, passive range of
protected them motion signifies
from more serious ligamentous
injury. sprain. 
• Others believe
that having their
neck twisted at the
time of impact is
the reason they
have unilateral
neck pain 
• This maneuver
can be applied to
any joint or series
of joints to
determine
ligamentous or
muscular
 movement.
• By remembering
that resisted range
of motion stresses
mainly muscles
and passive range
of motion stresses
mainly ligaments,
the examiner
should be able to
differentiate
between strain and
sprain and should
be able to
determine whether
a combination of
both is present.

RUST SIGN
• Assessment for • If the patient
Severe Cervical spontaneously
Spine Sprain, grasps the head
Upper Cervical with both hands
Rheumatoid when lying down
Arthritis, Upper or when arising
Cervical Spine from a recumbent
Fracture, and position, this is a
Severe Upper positive sign that
Cervical Spine indicates severe
Subluxation sprain,
rheumatoid
• No other arthritis, fracture,
physical finding is or severe cervical
as important or as subluxation 
revealing as Rust
sign.
• The presence of
this sign mandates
that (1) no further
passive or active
testing be
undertaken, (2)
imaging be
performed
immediately, and
 (3) the neck be
adequately
supported by
using a cervical
collar.
• Rust sign has
never been
observed in
conditions of
minor
consequence.

SHOULDER
DECOMPRESSION • After trauma, • With the patient
TEST scar formation seated, the
(epidural fibrosis)examiner
occurs with depresses the
ASSESSMENT regularity around patient's shoulder
FOR Cervical the dura and nerve on the affected
Dural Sleeve root. side and laterally
Adhesion (Nerve flexes the
Root) and Shoulder • As with cervical cervical spine
Adhesive distraction testing, away from that
Capsulitis this maneuver shoulder.
helps predict the
viability of • This sign is
cervical traction in positive if
therapy. radicular pain is
produced or
• A sharply aggravated.
positive finding
usually means that • A positive sign
the patient will indicates
not tolerate adhesions of the
cervical traction. dural sleeves,
spinal nerve
• The traction may roots, or adjacent
aggravate the structures of the
dural sleeve joint capsule of
adhesion instead the shoulder. 
of relieving it.
SOTO-HALL • The patient is
• ASSESSMENT
SIGN placed supine.
FOR  Cervical
Spine • The examiner
Subluxation, places one hand
Exostoses, on the sternum of
Intervertebral the patient and
Disc Lesion, exerts slight
Muscular Strain, pressure so that
Ligamentous no flexion can
Sprain, Vertebral take place at
Fracture, or either the lumbar
Meningeal or thoracic
Irritation (Febrile) regions of the
• The neck is at spine.
risk for injury in
contact sports • The examiner
because of the places the other
inability to pad, hand under the
brace, or protect patient's occiput
the cervical spine and flexes the
while maintaining head toward the
its function. chest.
• The cervical • The test is used
spine must be primarily when
flexible enough to fracture of a
allow the head vertebra is
and eyes to move suspected.
to the right place • The flexion of
at the right time. the head and
• The spine also neck on the
serves as a sternum
conduit for the progressively
central nervous produces a pull
system. on the posterior
• The spinal cord spinous
and the cervical ligaments.
nerve roots pass
through the • When the
cervical spine, spinous process
making injury to of the injured
the neck a vertebra is
potentially reached, the
catastrophic event. patient
• Soto-Hall sign is experiences a
often misapplied noticeable local
 in the assessment pain.
of fractures and • A positive
sprains for the result indicates
entire spine. subluxation,
• The sign is a exostoses, disc
nonspecific test lesion, sprain or
with limited strain, vertebral
capacity to fracture, or
localize meningeal
conditions of the irritation (an
cervical and upper elevated
thoracic spine. temperature must
• The use of this exist for
sign to draw corroboration). 
conclusions below
T8 is largely
guesswork.
• With the Kernig-
Brudzinski
phenomena in this
test, the patient's
temperature must
be assessed.
• A febrile patient
with Kernig or
Brudzinski sign'a
variation of Soto-
Hall sign—is a
high-risk
candidate for
meningitis.

SPINAL • With the patient

PERCUSSION • Compression
seated and the
TEST fractures resulting
head slightly
from axial loading
flexed, the
may be stable or
ASSESSMENT examiner
unstable.
FOR Osseous or percusses the
• Stability depends
Soft-Tissue Injury spinous processes
on the degree of
and associated
displacement and
musculature of
associated soft-
each of the
tissue injury.
cervical vertebra
• Axial cervical
with a neurologic
burst fractures are
reflex hammer.
usually unstable
 • Evidence of
and result in
localized pain
neurologic
indicates a
damage.
possible fractured
• Dislocation of
vertebra.
the cervical facet
joints may occur • Evidence of
unilaterally or radicular pain
bilaterally in indicates a
association with possible disc
forward lesion.
displacement of a • Because of the
vertebral body on nonspecific
the one below. nature of this
• Injuries to the test, other
upper cervical conditions will
spine may result also elicit a
in C1–C2 positive pain
instabilities as a response.
result of rupture to
the transverse and • A ligamentous
alar ligaments. sprain will cause
• These ligaments pain when the
stabilize or fix the spinous processes
odontoid process are percussed.
to C1. • Percussing the
• When soft-tissue paraspinal
percussion musculature will
reproduces the elicit a positive
pain, the examiner sign for muscular
may expect the strain.
same phenomenon
from applications
of ultrasound to
the tissue.
• This pain
represents
spasmophilia, and
the uses of such
therapies may
need to be delayed
until the soft
tissue is no longer
reactive to
percussion.
SPURLING TEST • The test is
• Narrowing of the
performed with
intervertebral
ASSESSMENT the patient
foramina, pressure
FOR Cervical seated.
and shearing
Nerve Root
forces on the Z • The examiner
Compression
joint surfaces, places one hand
Syndrome
intervertebral disc on top of the
compression, and patient's head and
pressure on stiff gradually
ligamentous and increases
muscular downward
structures may all pressure.
cause pain. • The patient
• A pain pattern notes any pain or
may be perfectly paresthesia and
reproduced, which the distribution
allows for thereof.
identification of
the neurologic • Pressure may
level. also be applied
• If radicular pain while the head is
or paresthesia laterally flexed to
with referral to the either side and
upper extremity extended.
occurs, nerve root • Pressure should
irritation is be maintained.
present.
• If the pain is • This maneuver
confined to the closes the
neck, soft, intervertebral
connective tissues foramina on the
or joints are more side of the
likely to be the flexion and
pain-sensitive reproduces the
structures. familiar pain or
• Spurling test is paresthesia.
an aggressive
cervical
compression test,
and the patient
should be
informed of each
step as it is
introduced.
• However, the
 examiner should
not cue the patient
for pain
responses.
Spurling test
elicits cervical
collapse sign quite
easily.
SWALLOWING
• ASSESSMENT • While seated,
TEST
FOR Space- the patient is
Occupying Mass, instructed to
Ligamentous swallow.
Sprain, Muscular
Strain, Fracture, • Presence of
Cervical pain or difficulty
Intervertebral swallowing
Disc Lesion, indicates a space-
Tumor, or occupying lesion,
Osteophyte at the ligamentous
Anterior Portion sprain, muscular
of the Cervical strain, or
Spine fracture, such as
• Dysphagia may disc protrusion,
be of prognostic tumor, or
significance and is osteophyte at the
often indicative of anterior portion
esophageal injury, of the cervical
pharyngeal spine. 
hemorrhage or
edema, or
retropharyngeal
hemorrhage
• Dysphagia is
often observed
after
hyperextension
trauma of the
cervical spine.
• Coupled with
other sympathetic
nervous system
phenomena, the
patient attributes
 the sore throat or
hoarseness to a
cold.
• The dysphagia is
fleeting but serves
as a more
conclusive sign as
to the extent of
soft-tissue
involvement in the
injury.

UNDERBURG The patient is

TEST • The blood
standing and is
supply of the vital
instructed to
neck structures,
ASSESSMENT outstretch the
including bony
FOR arms, supinate
spine, spinal cord,
Vertebrobasilar the hands, and
nerve roots,
Artery Syndrome close the eyes.
coverings, and
posterior cranial • The patient
fossa and cerebral marches in place
visual cortex, is and extends and
derived from the rotates the head
VAs. while continuing
• The tortuous to march.
course these • The test is
arteries take and repeated with the
the susceptibility head rotated and
of their intimate extended to the
coverings to opposite side.
structural change
places them in a • The examiner
vulnerable watches for a loss
position. of balance,
• In most dropping of the
instances, the arms, and
protective pronation of the
mechanism is hands.
amazingly • If any of these
adequate. events occurs, the
However, when examiner should
changes such as suspect vertebral,
atheromatous basilar, or carotid
cracks develop artery stenosis or
within the vessels, compression. 
 circulation may be
compromised or
temporarily
obstructed.
• Doppler
examination is
useful in
establishing
changes in
vertebrobasilar
arterial flow
• If the patient
loses equilibrium
at any time while
the eyes are
closed, cerebellar
circulation must
be evaluated.
• In this procedure
the patient may
lose equilibrium
as soon as the
head is rotated to
one side.
• The examiner
must be prepared
to prevent the
patient from
falling.

VALSALVA ASSESSMENT • The patient

MANEUVER FOR Space- takes a deep
Occupying breath and holds
Lesion, Tumor, it while bearing
Intervertebral down
Disc Herniation, abdominally 
or Osteophytes   • A positive test
is indicated by
increased pain
caused by
increased
intrathecal
pressure.
•Increased
intrathecal
 pressure is
usually caused by
a space-
occupying lesion
(herniated disc,
tumor,
osteophytes).
• The test should
be performed
with care and
caution because
the patient may
become dizzy
and pass out
while or shortly
after performing
this test because
the procedure can
block the blood
supply to the
brain. 

Vertebrobasilar • With the patient

The major signs
Artery Functional in a seated
and symptoms of
Maneuver position, the
vertebrobasilar
assessment for examiner
insufficiency are
vertebral, basilar or palpates the
as follows:
carotid artery carotid and
stenosis or 1. Dizziness, subclavian
compression vertigo, giddiness, arteries and
light-headedness auscultates for
2. Drop attacks, pulsations and
loss of bruits
consciousness • If neither of
these possibilities
3. Diplopia (or exists, the patient
other visual is instructed to
problems) rotate and
4. Dysarthria hyperextend the
(speech head to one side
difficulties) and then the
other
5. Dysphagia •This second
6. Ataxia of gait maneuver should
(walking be performed
 only if ini-tial
difficulties,
palpation and
incoordination of
auscultation did
the extremities,
not reveal bruits
ataxia, falling to
or pulsations.
one side)
• The test is
7. Nausea (with considered
possible vomiting) positive if either
8. Numbness on maneuver reveals
one side of the pulsations or
face or body bruits.
• The rotation
9. Nystagmus  and
hyperextension
of this test places
motion-induced
compression on
the VAs.
• Vertigo,
dizziness, visual
blurring, nausea,
faintness, and
nystagmus are all
signs of a
positive test,
which indicates
vertebral, basilar,
or carotid artery
stenosis or
compression.