● C4–C5 pain pattern . Pain at this level tends to be more focal and is centered in the lower posterior quadrant of the neck. It may spread inferiorly into the proximal shoulder girdle or su- periorly into the suboccipital areas. Typically, it does not refer to the head. ● C5–C6 pain pattern . This level has pain that is often centered around the junction of the base of the neck and the top of the shoulder. It can extend up into the suboccipital area and/or laterally across the top of the shoulder girdle. Infrequently, it may cause pain in the scapular region. It does not cause pain in the head. ● C6–C7 pain pattern . Facet joint dysfunction at this level is typically focused on the junction of the neck and shoulder girdle. It tends to spread inferiorly and medially to the central and medial aspects of the scapula. It does not refer to the head. Self-Assessment Quiz Question #35 The two levels of the spine that are most frequently involved in facet joint dysfunction are:
should be noted. In addition, the patient should report any pain response elicited by these maneuvers. ● Extension–rotation testing. For this test, the patient is seated and asked to fully extend their head followed by rotation to both sides. Patients are asked to report any pain occurring at end range. When painful, this is considered a positive test for facet joint dysfunction ● Manual spine examination . With the patient prone and the spine in neutral, a posterior-to-anterior directed force is ap- plied over the articular pillars from C2–C3 to C6–C7 on each side. This test is considered positive when the patient reports pain or when resistance to motion is noted at any of the seg- ments. ● Palpation for segmental tenderness . With the patient prone, the segmental muscles overlying the facet joints from C2–C3 to C6–C7 are palpated bilaterally. These muscles have the same nerve supply as the painful joint, and joint dysfunction can cause tenderness and spasm in these muscles. This test is positive if the patient reports pain when the joint (or joints) is palpated. Pain patterns C2–C3 to C6–C7 facet joints The referral pain patterns from the facet joints at various levels in the cervical spine have been mapped out. In general, dysfunction at a specific level can refer pain both superiorly and inferiorly, with the upper levels also referring into the head: ● C2–C3 pain pattern . The pain pattern from this level is a band of pain in the posterior neck from the C2 to C3 level with extensions superior into the inferior aspect of the skull and inferiorly to the mid portion of the neck. It may extend later- ally toward the mastoid region. Pain may also extend from the occiput across the parietal and upper temporal regions of the skull to the forehead or orbit. C2–C3 pain typically does not encompass the ear (Cooper et al., 2007). ● C3–C4 pain pattern . The pain pattern from this level includes the posterolateral neck from occiput to shoulder. Pain may also be referred into the suboccipital and occipital regions or into the forehead of the cranium. Cervical radiculopathy Cervical radiculopathy involves neurological dysfunction that is caused by compression and inflammation of the spine nerves or nerve roots in the cervical spine. Peak incidence of this problem occurs in the fifth decade of life, with the most common cause being cervical disc disease and cervical spondylosis (Kang et al., 2020). A classic epidemiological study of cervical radiculopathy found the average age of onset for men and women to be 48, with a range of 13 to 91 years of age. Interestingly, only 14.8% of patients with a diagnosis of cervical radiculopathy had a history of physical exertion or trauma (Radhakrishan et al., 1994). Depending on which level of the spine is experiencing neural compression, cervical radiculopathy can cause neck pain as well as pain, numbness, weakness, and altered reflexes in the upper extremity (Kang et al., 2020). According to Taso et al. (2020), in- volvement at the C6 or C7 roots is most common and occurs at those levels in 80% of patients with this condition. Red flags in differential diagnosis of radicular neck pain Red flag symptoms of myelopathy, malignancy, and spinal ab- scess should be considered during differential diagnosis of neck pain (Childress, 2016). All of these situations can produce neuro- logic symptoms. Malignancy can produce unilateral neurologic findings if the tu- mor is compromising a proximal neural structure or structures. Examination might also reveal gait abnormalities. Past medical history should be assessed for fever, history of cancer, night pain, and weight loss. Myelopathy can cause radicular neck pain. However, in addition to this finding, the evaluating therapist should check hyperreflex- ia, ataxia, clonus, decreased dexterity, and urinary urgency. These symptoms might also be present with cervical myelopathy.
a. C1–C2 and C5–C6. b. C1–C2 and C6–C7. c. C2–C3 and C5–C6. d. C2–C3 and C6–C7.
Self-Assessment Quiz Question #36 When the C5–C6 facet joints are involved, where might you ex- pect the client to report the location of their pain? a. A band of pain in the posterior neck from the C2 to C3 level with extensions superiorly into the inferior aspect of the skull and inferiorly to the mid portion of the neck. b. The posterolateral neck from occiput to shoulder. c. The lower posterior quadrant of the neck. d. The junction of the base of the neck and the top of the shoulder. A spinal abscess can cause neurologic deficits, and the patient’s history should be assessed for fever, history of intravenous drug use, and immunocompromised status. Case Study: Rita Reese Ms. Reese presents to physical therapy complaining of pain in the right arm. The patient states that the pain occurs in the lower neck and intrascapular area. Upon further questioning, she states that she also has pain in the right posterior forearm and middle finger. Question What cervical spine level is typically involved when pain is present as described? What further tests might be used to confirm the involvement of this cervical spine level? Discussion The cervical spine level typically involved when pain is present in the lower neck, intrascapular area, posterior forearm, and middle finger is C7. Myotome and reflex testing can be used to confirm this suspicion. Myotome testing involves elbow extension, fore- arm pronation, wrist flexion, and finger extension. Changes in the triceps reflex may indicate C7 involvement. Relevant anatomy The cervical nerve roots exit the spine laterally via the neural foramina. Each of these foramina is bordered by joints that are prone to degeneration or spondylosis (Childress et al., 2016). This includes the uncovertebral joint anteriorly and the facet joints posteriorly. The intervertebral disc lies anterior and medial to the neural foramen, and a disc herniation has the capacity to pro - trude onto the exiting nerve root, causing compression. When disc herniation or spondylosis is present, these issues can cause
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