Cervical Spine Examination OSCE — Systematic Approach, Special Tests, and Red Flags

Why Cervical Spine Examination Is Examined

Neck pain is the fourth most common cause of disability globally. The cervical spine station tests systematic musculoskeletal assessment combined with neurological screening — making it one of the more complex MSK stations. Examiners mark the LOOK/FEEL/MOVE framework, correct nerve root level identification, Spurling's test technique, and recognition of red flags requiring urgent investigation.

Applied Anatomy — Dermatomes and Myotomes

Systematic Examination — LOOK, FEEL, MOVE

LOOK

Observe from front, side, and behind with patient standing/seated:

• Posture: head position — forward head posture, torticollis, head tilt
• Cervical lordosis: normally present; loss = muscle spasm, disc prolapse
• Muscle bulk: trapezius and paravertebral muscle wasting or hypertrophy
• Scars: surgical (posterior fusion, anterior discectomy)
• Skin: cafe-au-lait spots (neurofibromatosis), psoriatic plaques, hair patches (dysraphism)

FEEL

• Temperature: warmth over spinous processes or paraspinals (infection, inflammation)
• Spinous process tenderness: midline — fracture, discitis, malignancy
• Paravertebral muscle tenderness: bilateral = muscle spasm; unilateral = myofascial pain
• Palpate for step deformity: (spondylolisthesis — forward slip of vertebra)
• Lymph nodes: posterior cervical chain (posterior triangle)
• Supraclavicular fossa: Pancoast tumour in apical lung cancer can cause referred neck pain

MOVE

Active movement — ask patient to perform:

Passive movement: only if restricted on active movement and no red flags.

Overpressure: gentle overpressure at end of range to assess pain provocation.

Special Tests

Spurling's Test (Cervical Foraminal Compression)

• Examiner places both hands on top of the patient's head
• Patient laterally flexes the head toward the symptomatic side
• Examiner applies gentle downward axial compression
• Positive: reproduction of radicular arm pain (not just neck pain) on the ipsilateral side
• Indicates nerve root compression — sensitivity 30-50%, specificity 90%

Distraction Test

• Examiner places one hand under the patient's occiput and other under the chin
• Lifts the head upward (tractioning the cervical spine)
• Positive: relief of radicular arm pain — indicates nerve root compression being temporarily unloaded

Lhermitte's Sign

• Ask patient to flex the neck forward rapidly
• Positive: electric shock-like sensation radiating down the spine or into the limbs
• Indicates cervical spinal cord pathology — demyelination (MS), compression, spinal cord tumour, posterior column involvement

Upper Limb Tension Test (ULTT) — Neurodynamic Test

• Extends the arm, depresses shoulder girdle, externally rotates/supinates forearm, extends wrist and fingers
• Positive: reproduction of neural symptoms (tingling, electric shock) — suggests neural tension/radiculopathy

Neurological Examination of Upper Limb

After identifying the affected dermatome/myotome, perform:

1. 1Power — MRC grading (0-5) for the relevant myotome
2. 2Sensation — light touch and pinprick over each dermatome
3. 3Reflexes — biceps (C5/6), brachioradialis (C5/6), triceps (C7)
4. 4Coordination — finger-nose test (if cerebellar involvement suspected)

Upper vs lower motor neurone signs in cervical pathology:

• At the level of compression: lower motor neurone signs (wasting, reduced reflexes at that level)
• Below the level: upper motor neurone signs (hyperreflexia, Babinski, clonus — myelopathy)

Red Flags in Neck Pain

Common Conditions

Frequently Asked Questions

"What is the difference between cervical radiculopathy and myelopathy?"

Radiculopathy is nerve root compression, causing dermatomal pain, numbness, or weakness in one arm — LMN signs at the level of compression. Myelopathy is spinal cord compression, causing long-tract signs below the lesion: spastic gait, hyperreflexia, Babinski, bladder dysfunction, and bilateral arm or leg symptoms. Both can coexist. Myelopathy is a surgical emergency (or urgent) — further compression risks permanent cord injury.

"Which imaging should be requested for neck pain?"

Plain cervical spine X-ray: limited use but can show degenerative change, fracture (post-trauma), and alignment. MRI cervical spine: gold standard for soft tissue, disc, spinal cord, and nerve root assessment — first-line if neurological signs, red flags, or radiculopathy. CT cervical spine: superior for bony detail — fractures, facet joint disease, bony canal stenosis. CT with contrast or gadolinium MRI if infection or malignancy suspected.

"What is C6 radiculopathy and how does it present?"

C6 nerve root compression (typically from C5/6 disc prolapse) presents with: pain radiating from the neck down the lateral forearm to the thumb and index finger; weakness of wrist extension (radial deviation) and elbow flexion; reduced brachioradialis and biceps reflexes; numbness and tingling in the thumb and index finger. Spurling's test may be positive on the ipsilateral side.

"How does torticollis present and what causes it?"

Torticollis (wry neck) is involuntary unilateral contraction of the sternocleidomastoid, causing head tilt toward the ipsilateral side and chin rotation to the contralateral side. Causes: acute (muscle spasm from sudden movement, sleeping awkwardly, poor posture) — most common and self-limiting; congenital (SCM fibrosis in infants); spasmodic torticollis (cervical dystonia — adult-onset, neurological, treated with botulinum toxin); secondary (atlanto-axial rotatory subluxation post-infection in children — Grisel's syndrome).

"When should you perform neurological examination in a cervical spine OSCE?"

Neurological examination is mandatory whenever the patient has arm symptoms (pain, numbness, tingling, weakness), or when special tests (Spurling's, Lhermitte's) are positive. In a station with neck pain and no upper limb symptoms, a full neurological exam may not be required — but always state you would assess for neurological deficit as part of your complete examination. Examiners often specifically ask for the neurological findings.

Related Posts

• Shoulder Examination OSCE — differentiating shoulder pathology from cervical referred pain
• Neurological Examination OSCE — upper limb neurological assessment in detail
• Musculoskeletal History OSCE — history taking for neck pain and upper limb symptoms